Study Points

Elder Abuse: Cultural Contexts and Implications

Course #97823 - $25 • 5 Hours/Credits

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. How are the child and elder abuse models similar?

    HISTORICAL OVERVIEW

    In the United States, the conception of elder abuse was closely linked with the concept of child abuse [20]. The picture of a frail elderly parent dependent upon their adult child caregiver was disseminated, and because there was no statute for elder abuse at that time, lawmakers and service providers turned to the child abuse model with its mandatory reporting laws [15,20]. In 1974, an amendment to the Social Security Act created the Adult Protective Services (APS) [22]. At that time, the purpose of APS was to protect adults with physical and/or mental limitations. However, the APS system became the solution when elder abuse became a public issue, allowing action on the matter without having to call on additional state funds [15]. Consequently, policies and programs were tailored to look like the child abuse and neglect model. For example, both child abuse and elder abuse models require the reporting of incidences of abuse through specific channels, the designation of certain professionals to report if incidences of abuse are learned, and penalties for violations. In both forms of family violence, a third party can intervene if there is suspected child or elder abuse [16].

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  2. Epidemiologic studies to detect the prevalence of elder abuse indicate a national prevalence of

    HISTORICAL OVERVIEW

    Epidemiologic studies to detect the prevalence of elder abuse indicate a prevalence of between 2% and 10% [25]. According to a national telephone survey, 1.6% of elderly respondents reported experiencing physical abuse in the past year; 5.2% recounted financial abuse, 5.1% neglect, and 4.6% emotional abuse [26]. In another survey study with 3,005 adults between 57 and 85 years of age, researchers found that only 0.2% disclosed physical abuse in the last year, 9% reported verbal abuse, and 3.5% indicated financial abuse [27]. In a national study conducted by the National Center on Elder Abuse in 2004, there were 565,747 reports of elder abuse to APS in the United States. This was an almost 15% increase from the 483,000 reports in 2000 [28]. A study conducted by the state of New York found that for every case of known (reported) elder abuse, 24 were unknown (unreported) [23].

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  3. According to studies on elder abuse in Korean families, the most common forms of elder abuse were

    HISTORICAL OVERVIEW

    In Asia, the topic of elder abuse is receiving increased empirical attention. In a study of Korean caregivers and their elderly family members with various types of physical and cognitive abilities, the most common forms of elder abuses were psychologic abuse and neglect [45]. Almost one-fifth of respondents (18%) disclosed to confining the elder family member in a room and 10% admitted to having hit the elder. In a large-scale study conducted in China, 2,039 individuals 60 years of age and older were interviewed, and 36% of the participants indicated they experienced elder mistreatment [46]. Specifically, the prevalence of physical elder abuse was 4.9%, psychologic abuse was 27.3%, caregiver neglect was 15.8%, and financial mistreatment was 2% [46]. Risk factors for abuse included having depression, being alone (e.g., divorced, widowed), and having a labor intensive job. In another survey study of individuals 60 years of age and older living in an urban area in China, 35% of the sample (32% men and 42% women) reported elder abuse and neglect [47]. Caregiver neglect was the most common form (16.9%), followed by financial exploitation at 13.6%. In Hong Kong, Yan and Tang conducted a survey study on the risk factors of elder abuse with 276 elder Chinese individuals, 27.5% of whom admitted to having experienced at least one type of abusive behavior perpetrated by a caregiver during the past year [48]. The findings of the study also found that verbal abuse was the most prevalent, at 26.8%, while violation of personal rights (5.1%) and physical abuse (2.5%) were less common. Participants who had visual or memory problems and who were dependent on their caregivers were more at risk of general abuse and verbal abuse [48].

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  4. Why is neglect generally perceived as less serious than abuse?

    DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

    Abuse is generally perceived as more serious because it is viewed as a deliberate or intentional act to harm [10]. Conversely, neglect has generally been viewed as less serious because the intent of the perpetrator is not necessarily deliberate. That is, neglect is an act of omission—not doing something because of ignorance or some situational factor (such as stress) [10]. The Centers for Disease Control and Prevention, the NCEA, and other organizations include both an intentional act and a failure to act in their definitions of elder abuse [23,49].

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  5. Mrs. J, 83 years of age, is an African American woman with dementia who is cared for by her daughter, Mrs. D, who is 60 years of age. Mrs. D has been diagnosed with depression. As a result of her depression, she frequently forgets to give Mrs. J her medication. On several occasions, when Mrs. J had accidents, her daughter would slap and punch her. Mrs. J is often scared to let her daughter know about accidents, and as a result, she has developed a skin infection from not changing her diaper. What type of abuse does this describe?

    DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

    Other definitions have focused on the types and categories of abusive acts. The NCEA and the Administration on Aging have defined seven different types of elder abuse, which are based on state and federal definitions [49,50,218]:

    • Physical abuse: Use of physical force that results in injury, pain, and impairment. Examples include slapping, punching, kicking, and restraining.

    • Sexual abuse: Nonconsensual contact of any form.

    • Emotional abuse: Infliction of distress, anguish, and/or pain through verbal or nonverbal acts.

    • Financial/material exploitation: Illegal or improper use of the elder's resources, property, funds, and/or assets, without the consent of the elder.

    • Neglect: Refusal or failure to provide goods or services to the elder, such as denying food or medical-related services.

    • Caregiver neglect/abandonment: Desertion of an elderly person by the individual who has physical custody or who is the primary caretaker of the elderly person.

    • Self-neglect: Behaviors of the elderly person that jeopardize his/her own safety and/or physical health.

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  6. Which of the following is NOT a risk factor for elder abuse?

    DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

    There are some studies that indicate that women are more likely than men to be victims of elder abuse [56]. Other demographic factors that contribute to risk include unmarried status and non-white ethnic origin [57]. Elders who reside with a caregiver or family with a history of substance abuse, mental illness, and violence are more at risk of abuse [56]. One study found that elders who have short-term memory problems, psychiatric diagnoses, and/or alcohol problems are more vulnerable to elder abuse [58]. Elders who have poor health and low income also appeared to be at risk of elder abuse [55,57].

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  7. Mr. R has been charged with physically abusing elderly nursing home residents. He has been described as being a man who has no tolerance or compassion for the elderly. He likes the idea of wielding power over his elderly victims. Which classification would he fall under?

    DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

    This offender has little empathy or compassion for elders. Bullying offenders want to exert power and control over their victims. Their victims are too frightened to disclose the abuse and will merely attempt to placate the abuser. These offenders employ a range of abusive behaviors that includes physical, sexual, verbal, emotional, and financial.

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  8. With regard to feminist theory and elder abuse, all of the following are true, EXCEPT:

    DEFINITIONS OF ELDER ABUSE AND CONTROVERSIES

    Feminist theorists argue that violence against women is broadly defined as male coercion of women [79]. In other words, patriarchy and male domination contribute to violence against women [80,81]. Patriarchy is perpetuated and reinforced by cultural ideologies, existing social institutions, gender socialization, and socioeconomic inequalities [80,81]. Thus, the root of violence against women stems from power imbalances in male/female relationships and male domination in the family, which is reinforced through current economic structures, social institutions, and the sexist division of labor [81].

    Some argue that feminist theory is not useful to addressing elder abuse, because it does not necessarily explain the different types of elder abuse or the typologies of abusers [218]. However, feminist theory has relevance to elder abuse because elderly abused women are often not thought of as battered women or domestic violence victims. In other words, we do not think of elderly women being abused by their spouses. Studies on domestic violence, for example, have typically excluded women older than 59 years of age [82]. Vinton argues that service providers and scholars have traditionally dichotomized the terms "battered women" and "elder abuse victims" [12]. Each of these terms conjures up images for us; for example, rarely do we associate a battered woman or domestic violence victim with an elderly woman. Instead, we might use the label "elder abuse" because we have inscribed in us a mental picture of an elder abuse victim as a frail elderly person being abused by a caretaker. However, domestic violence does occur throughout a woman's lifespan [83]. Band-Winterstein and Eisikovits argue that intimate partner or domestic violence does not necessarily "age out" and that this notion is a myth [84]. In a study of 620 middle-aged and older women recruited from emergency rooms in an urban setting, 5.5% had experienced intimate partner violence within the last 2 years [85]. Forms of abuse included sexual abuse and verbal threats or use of physical force to make them have sex. It may be that abuse among older couples can be better understood by the abuser-victim dynamics of the domestic violence model than the elder abuse model, which is based on the concept of caregiver stress [86,87]. For example, older women's inability to leave an abusive marital relationship is very similar to their younger female counterparts, such as fear of reprisal [82]. However, for older women, concerns of finances and economic resources stem from their ability to obtain a job, lack of pension, and health and physical limitations [84].

    This type of dichotomous thinking has implications for interventions. On one hand, a battered woman will be referred to a shelter, and an elderly female victim of abuse will be referred to Adult Protective Services [88]. In part, this dichotomous conceptualization has been shaped by the historical legacy of the domestic violence and elder abuse movements. Domestic violence, or the battered women's movement, emerged in the late 1960s when second-wave feminism and social activism were active. Then, in the mid-1980s, elder abuse emerged as a separate, distinct social problem and was primarily depicted as a social problem where the perpetrators were caretakers.

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  9. All of the following factors contribute to the heterogeneity within ethnic minority groups, EXCEPT:

    CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

    It is important to remember that there is tremendous diversity within groups. In other words, factors such as acculturation, age at immigration, education level, socioeconomic status, and religion all contribute to the heterogeneity within each subgroup. Falicov cautions against static descriptions of ethnic groups because they are merely social science simplifications rather than true portraits of the complexities of culture, race, and ethnicity [104]. Consequently, bear in mind that the following information is intended to present general themes to guide practice and not indicate hard and fast rules.

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  10. Which of the following characteristics best describes African American families?

    CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

    The family is very important in African American history, and values related to the family are rooted in African traditions. It has been said that the African American family structure is what enabled African Americans to survive during slavery and the challenging times of the Jim Crow era [106,229]. Terms such as "my family," "my folks," and "my kin" refer to both blood relatives and those who are not related, such as special friends and cared for individuals [5]. This was confirmed in a qualitative study in which African American family therapists discussed the roles of African American families' strengths in therapy [107]. The therapists all identified the strong kinship bonds that existed in African American families and noted these bonds extended beyond nuclear family members into extended family members and into the community. Similarly, marriage is viewed among African Americans as a "sacred vow" and covenant [106]. During the slavery period, when family life was severely disrupted, kinship bonds were highly relied on for support. Young children of slaves, for example, were often cared for by older women or children [5]. Parents attempted to discipline and raise their children to the best of their ability given the constraints of life in slavery.

    Extended family networks are common in African American families. Many African American family structures are multigenerational and interdependent. In a study conducted by Martin and Martin, it was found that an extended family network might consist of five or more households centered around a base unit, where the "family leader" resides [108]. This extended family network system pools resources to help during hard times. These strong kinship networks are the key element in helping African American families cope with economic stressors as well as structural issues such as racism, oppression, and discrimination [108]. Similarly, Goode notes that the value of group effort for the common interest is highly valued [5]. There is an expectation that one shares with the larger African American community, and this value orientation is part of that strategy for survival. Simultaneously, the value of independence is emphasized, which focuses on the ability to stand on one's own feet and to have one's own focus [5]. It revolves around the ability to earn a living, care for one's family and provide for them, and have some left over to help others in the extended family [5]. Jackson observed that African American families have demonstrated an elastic quality, assuming flexible roles to adapt to change and stress [109]. Family therapists have noted the amazing resilience and creativity of African American family members in utilizing internal and external resources in handling the challenges that emerge [107]. Economic reasons are not the only reasons why African Americans share households. They also adhere to cultural beliefs about closeness and connectedness [110].

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  11. Which of the following characteristics does NOT describe traditional Asian American family structure and organization?

    CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

    Generally, traditional Asian families can be characterized as hierarchical. In other words, family authority and structure is defined by family position, which is determined by age and gender [117]. Older family members have higher status than the young, and men hold higher positions than women [117]. Family harmony and equilibrium are valued, and one way to maintain this balance is to adhere to the hierarchical structure. In addition, traditional Asian American families are patriarchal in nature; the father maintains authority, and the sons are more desired and valued because they symbolically carry on the family line and care for their parents when they become old [117].

    Mutual support, cooperation, and interdependence also characterize the family [118]. As a result of the close-knit nature of Asian American families, there is a strong sense of obligation and duty to others [119]. Problems are generally solved within the family, and a sense of family honor and pride limits outside information to be shared by counselors or other professionals [118].

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  12. How is the composition or structure of Native American families different from white Anglo American families?

    CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

    The family is regarded as the cornerstone for emotional, social, and economic well-being for individuals [144]. The composition of the family is very different from the dominant Anglo culture in the United States. For some tribes, the term "family" goes beyond the nuclear family and includes everyone in the tribe or clan. The terms "brother" and "sister" are used to refer to cousins in Native American families [145]. Therefore, family members encompass both blood relatives and tribe members with no distinctions, which is consistent with cultural values that emphasize interconnectedness and harmony [146].

    The primary relationship is not necessarily with the parents, but instead with the grandparents, who assume the caregiver and disciplinarian role [141]. For example, among the Native Americans from the Navajo tribe, it is common for grandchildren to be sent to live with their grandparents, which benefits both the child (by ensuring that care and traditional values are passed down to the younger generation) and the elder (by ensuring a means to provide assistance to older individuals) [147]. In addition, the term "grandparent" is not limited to the dominant culture's role of a grandparent, but instead grandparents for Native Americans can also include other relations, such as aunts, great aunts, and godparents. Similarly, parental roles are assumed not only by the biologic parents but also by siblings of the parents [141].

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  13. A Korean immigrant couple, Mr. and Mrs. K, both 76 years of age, have recently moved in with their son and daughter-in-law. They had been looking forward to spending more time with them, but instead Mr. and Mrs. K find themselves cooking, cleaning, and babysitting for their son's young children. They often eat alone after their son and daughter-in-law get home. The young couple constantly berates and criticizes Mr. and Mrs. K for eating too much. They rarely go out because they lack transportation and have become socially isolated. Examining this situation in an Asian cultural context, it might be considered abuse because it

    CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

    The theme of respecting elders and filial piety surfaced in a qualitative study with Asian American immigrants. Participants in the study stated that adult children should support their elderly parents, especially if they have a successful life, and this value should be passed down [163]. Interestingly, Korean immigrants in Chang and Moon's study identified elder abuse in terms of "abrogation of filial piety" [43]. These acts included adult children not wanting to live with elderly parents, placing their elderly parents in a nursing home, or not showing adequate or proper respect. Many Korean adult children may have acculturated to new value systems that minimize familial responsibilities, particularly to parents. Pang found a similar theme surfacing among Korean elderly immigrants [164]. Many resented living with their adult children and having to watch children, cook, and clean the house. They felt they had become full-time childcare providers. Because many elders did not regard discussing and negotiating these matters appropriate, the situation merely worsened. They classified these scenarios as abuse.

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  14. African American elders are more reluctant to seek help from mainstream, formal services. Where are they more likely to seek help?

    CULTURE, RACE, AND ETHNICITY AND ELDER ABUSE

    Many ethnic minority immigrant elders are simply mistrustful of Western mainstream services. In a study of 124 Korean immigrant elders, one of the themes that emerged was mistrust of third-party interventions as a deterrent in seeking help [173]. Elders who adhered to traditional values were less likely to seek formal help. Coupled with unfamiliarity with Western notions of mental health and health and institutional procedures, many prefer to rely on traditional healers. For example, some Mexican American elders seek curanderos (folk healers) for healing and spiritual guidance [172]. African Americans are often wary of government and legal entities, and African American elders tend to be more likely to seek help from spiritual leaders, family, and the community than from mainstream services [244]. Furthermore, many African Americans with strong ethnic affiliations are more likely to use prayer and forms of spirituality when they need help instead of seeking formal services [174].

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  15. Health care "shopping," whereby the elder goes from physician to physician or from hospital to hospital, should alert practitioners because

    ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

    To screen elders who may be at risk, Sengstock and Barrett recommend that practitioners assess the following domains [178]:

    • Reason for visit to practitioner: Presence of acute or chronic psychologic or physical disability, elder's inability to participate independently in activities of daily living, reluctance of caregiver to give information about the elder's condition, delay in elder's seeking professional or medical assistance, and inappropriate caregiver's reaction to practitioner's concern may indicate an at-risk situation or potential abuse.

    • Family history: Elders who grew up in violent homes, children who have antagonistic relationships with the elder, children's excessive dependence on the elder, use of substances such as alcohol or drugs by children, and children who were abused by the elder may indicate an at-risk situation or potential elder abuse.

    • Elder's personal/social circumstances: Caregivers who have unrealistic expectations of the elder, elders who are socially isolated, and conflict in the family system may also warrant further questioning by the practitioner.

    • History of accidents: Patterns of accidents that do not make sense should alert practitioners to potential abuse.

    • Healthcare utilization: Health care "shopping," in which the victim does not have a regular physician because of the perpetrator's fear of detecting abuse. Infrequent visits to physicians and caregivers overanxious to have elders hospitalized may also be signs of an at-risk situation.

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  16. When should the Elder Abuse Suspicion Index (EASI) be used?

    ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

    The Elder Abuse Suspicion Index (EASI) is a five-item tool that provides practitioners with a very quick sense of whether there is potential presence of elder abuse [182]. It was originally developed for use by physicians and has been recommended by the U.S. Preventive Services Task Force, but it can be used by practitioners in diverse disciplines [245]. The following items comprise the index [182]:

    • Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

    • Has anyone prevented you from food, clothes, medication, glasses, hearing aids, or medical care, or from being with people you wanted to be with?

    • Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

    • Has anyone tried to force you to sign papers or use your money against your will?

    • Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

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  17. Mrs. Y, a frail white woman, 69 years of age, comes to the medical clinic with her son, who is in his 30s. The son is constantly hovering over Mrs. Y, looking anxious. Mrs. Y is unkempt and looks extremely tired and frail. Ms. S, an intern, asks to see Mrs. Y alone, but her son refuses to leave his mother's side. Ms. S is finally able to convince the son to wait outside. Ms. S decides to ask Mrs. Y some questions to assess whether Mrs. Y has been abused; however, she decides to ask her supervisor for some advice. If you were her supervisor, what would you advise Ms. S regarding screening for elder abuse?

    ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

    Other guidelines for effective screening include [186]:

    • Ask open-ended questions.

    • Normalize the questions by stating to the patient that practitioners normally or routinely ask these types of questions.

    • Ask specific and behaviorally oriented questions. For example, if you ask a patient if he or she has been abused, you will likely receive a negative response. Instead, ask specific questions, such as:

      • Has anyone ever hurt you?

      • Has anyone ever touched you when you did not want to be touched?

      • Has anyone ever taken anything that was yours without your permission?

      • Does anyone ever talk or yell at you in a way that makes you feel lousy or bad about yourself?

      • Has anyone ever threatened you?

    • Explore any affirmatives to the above types of questions. Find out more about frequency, severity, what precipitates the violence, and the outcomes of the violence. Can the patient protect him/herself? What does the patient want to happen now?

    Welfel, Danzinger, and Santoro encourage practitioners to interview family members separately [16]. This is more likely to elicit honest disclosures than interviewing elders and their family members together. An elder might feel embarrassed or intimidated and will refrain from disclosing abuse in the presence of family members. No family members should be discounted as possible perpetrators.

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  18. Which of the following dimensions of elder abuse statutes is universal from state to state?

    ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

    In all 50 states and the District of Columbia, an APS agency has been designated to investigate reports of elder abuse [246]. This is the principal public agency that is responsible for both investigating reported cases of elder abuse and for providing victims and their families with treatment and protective services. Title XX of the Social Security Act makes it a federal requirement for states to implement APS in order to receive funds [191]. In most jurisdictions, the county departments of social services maintain an APS unit that serves the need of local communities [192]. In general, APS offers case management, emergency medical services, alternative housing arrangements, and help in obtaining Medicare, Medicaid, and aging services [191]. It is important to remember that, unlike the child abuse, older adults can refuse services or accept only partial services, even if APS substantiates an incident of abuse [246,247]. In some cases, APS can petition the court for assistance after it has demonstrated probable cause [247].

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  19. Which statement best describes the mandatory reporting laws for elder abuse?

    ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

    As noted, elder abuse laws differ from state to state, and definitions, procedures, and training can likewise vary [248]. Tennessee, Virginia, and Texas uphold the principle of autonomy in that elders can refuse services. In other states, authorities can be called to intervene if elders refuse services [190]. Unlike child abuse statutes that mandate professionals in all states to report incidences of child abuse, there is less consistency among the states regarding mandatory reporting for elder abuse [16,56,192]. For example, practitioners may be mandated to report only in cases in which the elder is residing in institutional settings [16,56]. The definition of elderly may also differ [56].

    Those people who are designated as mandated reporters vary from state to state. In Illinois, for example, licensed counselors are specifically named as mandated reporters [192]. Twenty-one states and protectorates required mental health professionals to report; 17 required psychologists to report; 5 required family and marriage counselors to report; and 30 required social workers to report elder abuse [192]. All states except New York, the District of Columbia, and Puerto Rico require healthcare professionals to report, and failing to do so can result in penalties [249]. As with child abuse statutes, the practitioner does not have to prove that the abuse occurs before reporting; the practitioner must report even if he/she only suspects abuse. Only 75% of the state laws on elder abuse include a criminal penalty for failure to report [16]. To locate the number to call for specifics about your state's elder abuse laws or to report elder abuse, visit the NCEA's website at https://ncea.acl.gov/Resources/State.aspx [193].

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  20. Which of the following is NOT an indicator that there might be a potential problem when hiring prospective caregivers?

    ASSESSMENTS, INTERVENTIONS, AND MANDATORY REPORTING LAWS FOR ELDER ABUSE

    Healthcare facilities often conduct background checks on their care providers. Families who hire care providers for their elder relatives should also conduct comprehensive background checks to reduce the risk of abuse. Family members may do some background checks themselves by calling references and verifying employment dates. With Internet technology, there are businesses that will conduct background reports for a nominal fee. Red flags that could indicate potential problems include [202]:

    • Unsigned applications

    • Gaps in employment that are not or are poorly reconciled

    • Unanswered questions regarding criminal background

    • References are friends or family members as opposed to previous employers/supervisors

    • Names of past supervisors cannot be recalled

    • Poor explanations for leaving other positions

    • Excessive cross-outs and changes made on the employment application

    • Background questions not answered

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.