Crime Trends in Nursing Homes Throughout Oklahoma Over the Past 30 Years

Crime Trends in Nursing Homes Throughout

Oklahoma Over the Past 30 Years

Talisha Griffin M.A.

University of Central Oklahoma

Acknowledgement

The researcher would like to dedicate this research to Mary C. Shafford. Due to her unfortunate death from nursing home neglect, this research was inspired by her unnecessary suffering and loss. In addition, the researcher would like to thank Dr. Reed of Gerontology from the University of Central Oklahoma (UCO); key-informants who provided their knowledge and time; and those who shared their loved-ones stories, for their support and help with this research. Lastly, the researcher would like to thank the Research and Grants office of UCO for funding this research.

 

With the increase in life expectancy our society is facing a critical issue of providing the care needed for the aging population. As so, the lack of effective policy has resulted in criminal activity taking place against this population of citizens. This project seeks to examine a historical analysis of trends in crime related to Oklahoma nursing homes over the past 30 years. In this study, newspapers, court documents, public health reports, observations, and interviews with key informants will be utilized to analyze crime

trends in nursing home facilities. The crimes being studied include conventional and white collar crimes.

     Major societal changes that have taken place since the late 70’s have left members of American society with a problem that if looked upon by other cultures, that problem would not exist as it does here. The tradition of taking care of the elders within the community, and family, has been present for decades amongst more traditional cultures. However, with the culture that persists today in America factors such as the availability of the family, the needed finances, and help are not present as they should be. Instead institutions have been set in place to provide the care needed. However, the problem is these institutions are not providing the quality- let alone humane- care these individuals need at all times. “Public policy on nursing homes has failed to produce satisfactory institutional care for America’s aging population” (Subcommittee on Long-Term Care, 1975, para. 3).

     A report by the Special Committee on Aging (2003) concluded that 90 percent of nursing homes in the U.S. have staffing levels too low to provide adequate care. Inadequate staffing contributes minimally to problems of bad care, abuse and neglect (para. 32). Elder abuse and neglect shortens the victim's life and often triggers a downward spiral that has devastating consequences for an otherwise productive, self-sufficient life (Special Committee on Aging, 2003, para. 6). Even with this knowledge, states such as Oklahoma are struggling to fight the excuses provided by policy makers of why increased staffing levels cannot be achieved. As stated by Keith Dobbs, President and CEO of Care Oklahoma, “The notion that our facilities deprive our residents of the care they deserve through deficient staffing levels baffles us. As Governor Mary Fallin laid out in her State of the State address… there simply isn’t the state funding to pay for staffing increases of the magnitude specified in HB 2901” (Fox23, 2014).

     One of the issues that contribute to the difficulty of measuring nursing home crimes is the lack of a concise definition of what constitutes as abuse or neglect. For the purpose of this research it should be noted that crime in nursing homes includes neglect, abuse, exploitation, and lack of providing an environment that would prevent mental anguish for patients. The American Medical Association has described elder abuse and neglect as actions, or the omission of actions that result in harm, or threatened harm to the health or welfare of an elderly person. “Abuse includes intentional infliction of physical or mental injury; sexual abuse; or withholding of necessary food, clothing, and medical care to meet the physical and mental health needs of an elderly person by having the care, custody or responsibility of an elderly person” (Madden, 1995, para. 8). As well, white collar crime in nursing homes includes fraud, up-coding, falsifying documents and records, inadequate staffing, billing for services not rendered, misdiagnosing for compensation, and pocketing revenue from Medicare and Medicaid (FBI 2007 and 2012, NW3C 2007).

     Nursing homes are held to a standard, by law, which requires them to care for their residents in such a manner, and in such an environment, that promotes the maintenance or enhancement of the quality of life for each resident. They must provide services, and activities; or maintain the highest practicable physical, mental, and psycho-social well-being of each resident in accordance with a written plan of care (Maple Law Firm, n.d.). Insufficient staffing levels, poor environment, unenforced policies and regulations contribute to the problem.

     With the increase in life expectancy and our progression in modern medicine, people are living longer than they were 50 years ago. According to the Department of Health and Human Services Administration on Aging, the total population of citizens 60 and older has increased from six percent in 1900 to 16 percent in 2000, and is projected to see an increase by 25 percent in 2030 (AOA). Therefore, if this target population does continue to increase the demand for society to provide the care needed will be significant. If we cannot provide the adequate staffing levels needed to provide quality care now because of budget issues, how significant will this issue be 10 years from now and how will we deal with it?

     This paper will provide a general overview of the issues faced with nursing homes in relation to the crimes that take place in these facilities. In addition, it will provide an exploratory and geographical analysis of crime trends seen throughout Oklahoma’s nursing homes over the past 30 years. As well, personal stories from family members and residents who experienced different forms of nursing home crimes will be provided. After providing a thorough analysis of the issue, efficient policy and regulatory suggestions will be made to help address and improve the crime endured by residents of nursing home facilities.

Review of Literature

Caregivers Stress and Neglect

     Inadequate care of the elder population has become a growing issue for American society. It has become a focal point of social, scientific, and media attention; due to the discovery of a significant number of elderly victims of family violence; and major demographic changes that occurred over the last half century (Cornell & Gelles, 1982). Laslett (1973) mentions children having the responsibility of caring for their aging parents as a new growing aspect of family life. However, as mentioned by Treas (1977), we should be concerned about the impact of the increasing burden of home care on the emotional and financial resources of families, especially in light of the increased entry of women into the labor force. Although, these authors work were published over 30 years ago, we can see how their research is relevant in today’s society. For most social classes- excluding the upper, both parents are in the work force. It has a created what some call the “sandwich generation”- adults caught in between caring for their children and parents, and it has been found to cause a stress that some scholars say cause elder abuse and neglect (discussed later in more detail). With the increase in individuals having to enter the work force; and for some this entails long hours of labor that takes up majority of their day and the income still doesn’t satisfy the need to survive comfortably, the problem of children caring for their aging parents is still present today. Therefore, the need for an outside caregiver is present, and hence there are nursing homes.

Burden on Long-Term Care Industry

     In today’s society more families are relying on long-term care facilities to provide the care needed for their aging family members. There are social, as well as economic problems, for facilities that provide long-term care for the aging population. The economic issues these facilities face consist of the production and distribution of services, as well as, the consumption of the services provided by the staff. The social problems that face these facilities are the individuals that are hired to care for these individuals; as well, the compensation for care staff employees of nursing facilities is poor. A recent policy change in Oklahoma allows individuals with a criminal record to work in nursing homes. Individuals convicted of crimes like first-degree robbery, assault and battery are permitted to work in nursing homes across the state (Atkins & Markoff, 2012). The reason for this policy change was to address the understaffing issue. This, however, raises greater concerns then understaffing, the safety and well-being of the residents.

     According to Gorbein and Eisenstein (2005), elder abuse was recognized in ancient societies. For the United States elder abuse became a topic of interest and concern back in the 1970’s. Until reports of abuse and neglect in nursing homes became apparent in the 70’s, as a result of the United States Senate Special Committee on Aging, this problem was not recognized by the general public nor the government. Still to this day the problem is underreported and under-recognized. According to the CDC (2013) elder mistreatment is a serious problem in the United States. “There is a lack of data but what we do know is that: In 2008, one in 10 elders reported emotional, physical, or sexual mistreatment or potential neglect in the past year; and many cases are not reported because elders are afraid to tell police, friends, or family about the violence” (CDC, 2013, para. 2). Even when cases of abuse are reported they are often disregarded. Gorbein and Eisenstein (2005) discuss in great detail the occurrence of elder abuse. They found in the United States, “over two million older adults are mistreated each year” (Gorbein & Eisenstein, 2005, p. 281). Of the mistreatment experienced the most common types were physical abuse, verbal abuse, and neglect. Women were found to be the most common victim in regards to gender. They were found to be subjected to physical and sexual abuse at higher rates (Gorbein & Eisenstein, 2005).

     The 1981 United States House of Representatives Select Committee on Aging reported that (as cited in Gorbein & Eisentein, 2005),

“elder abuse is far from an isolated and localized problem involving a few frail elderly and their pathological offspring. The problem is a full-scale national problem which exists with a frequency which few have dared to imagine. In fact, abuse of the elderly by their loved ones and caretakers exists with a frequency and rate only slightly less than child abuse on the basis of the data supplied by the States” (p. 280).

Gorbein and Eisenstein (2005) note the significance of understanding the gap between reported and unreported cases. It is important because what we think we know from reported crimes, does not amount to what we don’t know from the cases that are unreported. Moreover, it is important because if there is no uniform standard for reporting crimes in nursing homes there is no uniform way to measure the crimes taking place. This is significant because the data needed to conduct proper and effective research is missing. Moreover, it hinders both academia’s and the public’s awareness.

     Elder abuse has been called a "hidden" or "silent" crime because a large percentage of cases go unreported, with some research indicating fewer than 20 percent of cases of elder abuse being reported (Orthmann & Hess, 2010). Therefore, researching elder abuse is a challenge because of the lack of data- a problem compounded by the reluctance to report a crime. Due to the reliance on statistics to depict the actual number of victims of a crime, such as the Uniform Crime Reports (UCR) and National Crime Victimization Survey (NCVS); elderly persons are seen as rarely victimized (Payne & Gainey, 2006). A 2007 nationally representative study of over 7,000 residing elders, within a community, estimated that approximately one in ten elders reported experiencing at least one form of elder mistreatment in the past year (NIJ, 2010).

     Bill Whited, the Deputy State Ombudsman, from the Office of the State Long-Term Care Ombudsman Aging Services Division discussed the issue with a developed reporting system that tracks nursing home crimes. “We’ve discovered there is no category in the uniform crime index for nursing home crimes, so there is no way to really track what all is going on” B. Whited (personal communication, Oct. 15, 2013). The result of not having a category available in the UCR to report nursing home crimes, is that many of the crimes that do take place fly under the radar because there is no tracking method available to catch them, and it limits the research that can and should be conducted to understand and address this issue. It wasn’t until recently that a law was enacted which required crimes that occur in nursing homes to be reported to the police so that the facility can be held accountable for its failure to report a crime that occurred in the facility. Before if there was a case of abuse, neglect, or exploitation they were required to report it to the Oklahoma State Department of Health and Adult Protection Services. There was, however, never any reporting requirement to law enforcement. B. Whited (personal communication, Oct. 18, 2013).

Medical Autopsy

     A major problem that hinders the investigation and accurate reporting of cause of death is the silent connection between funeral homes, medical examiners (ME), and nursing facilities. It was discussed in Tender Loving Greed (Mendelson, 1974) the hidden epidemic of ME’s and nursing facilities working together. It was discovered that the reporting of any foul play that may have contributed to the resident’s cause of death was being brushed under the carpet.  Nursing facilities were known for being in cahoots with funeral homes by sending and referring dead residents to specific funeral homes (Mendelson, 1974). There is no physical evidence of this still occurring today, however, no one has taken the time to conduct a recent study to see if the problem still exists. Although, not to the extent of what was being done in the past; today a connection can still be found between the two industries. The problem coming to light today is the absent of the body being reviewed by a ME to determine the cause of death; or to determine if any foul play existed (E. Houser, personal communication, Oct. 18, 2013). “At present, the medical community cannot easily distinguish between those types of injuries that indicate abuse or neglect and those that are the natural effects of illness or aging. Few experts are available to testify in court and limited data exist to bolster cases brought into the system” (NIJ, 2010, para. 4).

Anchor Theory: Theory of Nursing Home Abuse and Neglect

     Due to the minimal research conducted on nursing home crimes there is not a universally accepted theory that fully accounts for or explains nursing home abuse and neglect.  Looking at theories developed to explain the cause of crime on a holistic scale; such as routine activity theory- suitable target, lack of capable guardianship, and motivated offender- we can understand why crimes occur against the aging population. However, when attempting to explain the cause of nursing home abuse and neglect, one must be broader in explaining the cause because it’s dealing with human behavior.

     Throughout the late 80’s into the early 90’s researchers attempted to explain the cause of caregiver abuse as being due to stress. However, stress theory has been criticized for being too one-dimensional when trying to explain what is seen in practice or in research findings (Gorbien & Eisenstein, 2005). Therefore, the shift focused to the personality of the caregiver when explaining abuse. A study by Pillemer and Finkelhorn (1989) provided support for caregiver personalities being an important predictor of abusive relationships. 

     The combination of the predictors results in the following model as an attempt to explain the factors that have an influence on the abuse and neglect of nursing home residents. 

The structure of the institution/system leaves vulenarable victims to bureaucratic care which results in the abuse and/or neglect of residents; institution/system represents the nursing facilities. Vulernarable victims are defined as individuals who are dependant on someone else for the function of their daily lives. Capable guardianship refers to a person(s) who are responsible for providing a guardianship oversight that can deter criminal opportunity (i.e. family members of aging residents). Buereaucratic care is defined as care being regulated by bureaucratic standards; which inevitably results in shortcuts being taken- efficiency versus quality- on the care that is provided to residents. The focus on proper care being delivered is not present, instead a business mindset is present where profit is the driving motivation. Therefore, bureaucratic care also entails the notion that profit trumphs human life. The model is called the Anchor Effect.

(Figure 1)

Although, routine activity theory can be found to be the basis- literally- of the model the researcher believes it is important to account, from a holostic point of view, the cause for such simalarities and reveal an overall representation for the specific crime of abuse and neglect against elder persons in nursing homes (See Figure 1).

     When conducting research on broad topics, one is told to be more specific in their thinking when addressing major problems. However, the problem behind this rational is one has the potentional to miss the bigger picture. Like a tree, there are roots that are responsible for the life and growth of the substance. Of all those roots, however, there is one seed- one foundation- from which they sprout from. Problems can take on the same analogue.

     When tracing the problem of abuse and neglect of residents in nursing homes, scholars have found the care staff to be the perpatator more often than any other staff member within the institution (Gorbien & Eisenstein, 2005). This occurs because of the consistent direct contact between the residant and care staff members. Subsequently, because of the lack of visitation from family members for most residents, there is no capable gaurdianship present. Morever, because there is no universal survaillance monotoring system for nursing homes, there are no physical deterrents to deter perpatartors from endulging in criminal behavior. Therefore, the structure of the nursing home system in itself is the beginning cause of the problem. The inexecusable fact these entities have not taken more security percautions to ensure the safety of their residents is quite bafalling considering the seriousness of the problem. However, when the root cause for these excuses are understood as being linked to personal financial gains of individuals who never set foot on the facilities ground to observe the care being provided; understanding the fight that has been present for over 40 years, is a fight against capitalism and bureaucracy.

      Most of the individuals who reside in nursing homes are individuals who need; more often than not, continous care- care that could not have otherwise been provided by family members. Therefore, majority of these individuals are considered vulnerable; whether physically or mentally. Encompassed withhin this vulenarability is a helplessness and fear against those entrusted to provide quality care, yet abuse their autonomy and authority and inflict harm or neglect.  “To worsen matters, health professionals often minimise complaints of elder abuse because of disbelief, fear of accusing the perpatrator, or lack of awareness of the extent of the problem” (Madden, 1995, p. 2).

     The most promenent theoritcal thought for the explanation of elder abuse consist of the personality, and stress endured by the offender. Gorbein and Eisenstein (2005) discovered in their research that stress is not the promenent cause of elder abuse. Instead, with the support of additional studies, caregiver personality issues were found to be important in the development of an abusive relationship. Pillemer and Finkelhorn (1989) compared theories of caregiver stress versus problem relatives (personality of the abusers) and found spouses- not adult children- were the larger group of offenders. “Abusers deviance and dependence  were far more important predictors of mistreatments by caregivers than were characterstics of the victims…Employess working for low wages in a stressful enviornment who are hands-on caregivers are likely at high risk to become abusers” (pp. 284-289).

     Personality plays a major part in the devience engaged in, however, the researcher believes- as with anything- that can be true in some cases but not all. Therefore, the personality of the abuser, morale, and the stress endured from the demand of labour can all have an effect on the deviant behavior being studied. The abuse and neglect that is being carried out on these residents cannot be explained by a single factor, instead multiple factors must be taken into consideration and even than the circumstances can change. Human behavior cannot be explained from a single occurance. There are many factors and variables that explain our behavior and at any moment those variables that determine that behavior can change. Therefore, one cannot be specific in their thinking, nor research, when attempting to explain the causes of human behavior- what the researcher is attempting to do here. We can, however, pin-point the cause of the problem that has influence on the human behavior in question. 

     Although, these facilities are governed by federal and state laws to provide a level of quality care that meets certain standards of living, deserved by the receiver, some can be found to not provide that care. Even more startling is what few cases of abuse and neglect that are persued in court are tried in civil court rather than criminal court. Majority of the rest of the cases receive nothing more then a fine and/or warning. Therefore, no exterme detterent exsist to deter individuals and the facility from participating in deviant behavior and unethical practices. There are plenty of effective detterents for other forms of crimes committed by individuals, such as murder and larceny- prison time, probabtion, etc.- yet nothing like that is enforced with the type of nursing home crimes committed by individuals apart of an entity.

Nursing Home Demographics

     As of 2011, there are 15,683 nursing homes in the United States with more than 1.4 million residents (CMS, 2012). This is a decrease in facilities compared to 16,560 being in existence in 2002. This can become a major problem if the number of facilities continue to decrease. With the population of those aged 65 and older projected to steadily increase, the need for someone or something to provide the care they need is in demand.

     In 2001, it was reported by the U.S. Department of Health and Human Services that 90% of nursing homes staffing levels were too low to provide adequate care (AAJ, n.d.). The prevailing reason of why staffing levels are so low is because of budget issues. However, in cases where the financial history of the facility is studied in great detail, instances where funds were being used to pay for owner’s personal mortgages, one understands budget issues are not the true cause of the problem (John Doe, Personal Communication, Dec. 17, 2013). Majority of nursing homes in America are owned by for-profit companies. In 2011, 10,822 nursing homes were for-profit, 3,970 were not-for-profit, and 891 were owned by the government. 

     According to the Center for Medicare and Medicaid Services (CMS), in 2011 only 9.2% of nursing homes throughout the United States were deficiency free. Although, the tone of the CMS compendium report seemed content with the reporting in 2011 about cited health deficiencies, it is quite staggering the overall citations given. It was reported that 56% of the health deficiencies cited were at the scope and severity of “D”, and more than 83% of deficiencies being “D” or “E.” The scope and severity of “D” and “E” are defined as greater than minimal harm. Greater than minimal harm cannot be an acceptable living standard for this target population. In regards to certification type in 2011; 14,328 (91.4%) were dually certified, 775 (4.9%) were Medicare only certified, and 571 (3.6%) were Medicaid only certified (CMS, 2012). Quality care conditions must be met to receive government funding, Medicare and Medicare. However, it seems those conditions need to be questioned

     In 1993, the total public expenditures for nursing home care totaled $58.6 billion; with Medicare covering $5.5 billion, Medicaid $23.5 billion, private $28.3, and other public $1.3 billion (Burwell & Crown, 1994). “Over 78 percent of all public spending for nursing home care flows through the Medicaid program, it also accounts for more than 40 percent of all public and private spending for nursing homes” (Burwell & Crown, 1994, p. 6). In 2006, the amount of money spent on nursing homes by state and federal was $75 billion (AAJ, n.d.). The spending has continued to increase.

White-Collar Crimes

     White-collar crimes are defined as crimes committed by business and government professionals. Crimes include a full range of frauds and other illegal activity that if committed by individual persons they would be criminally prosecuted. However, it is important to note that the prosecution of white collar-crimes are low, and in most cases are only prosecuted in civil court- if that, but it’s mainly handled with administrative legislation. The latter section will explore the multiple variables associated with nursing home white-collar crimes. 

Ownership and Name Change

     Knowing the owner of nursing facilities is important when researching the crimes that take place within these entities. The reason for this is because the owner is responsible for the structure and function of the facility, therefore, making them responsible for what crimes occur inside and outside of the facility. “Regardless of the components of the network, a single entity must be responsible for its operation” (Kusserow, 1990, p. 4). This perception, however, is found to not be universally accepted when trying to prosecute these types of crime. The issue with uncovering the owners of these facilities is prevalent; whether the blame is to be placed on state agencies or individuals themselves, there is a discrepancy in reporting accurate ownership.

     The data from the Oklahoma Secretary of State (OSS) does not align with Oklahoma State Department of Health (OSDH) information on ownership of nursing facilities. For example, when trying to determine the existence of Oak Hill Living Center located in Jones, Oklahoma-where a case occurred in 1997- one realizes the inconsistency and discrepancy in information. According to the OSS entity records, Oak Hill Living Center, Inc. is legal and in use as of August 5, 1996. The registered agent information listed is for a John A. Philbin whose address is located in Oklahoma City. However, if one attempts to look for Oak Hill Living Center on the Oklahoma State Department of Health site under the provider and inspection query, there is no Oak Hill Living Center. Instead there is an Oak Hill Care Center located in Jones, Ok and has a history of complaints dating back to January 1, 2001. However, when one searches Oak Hills Care Center from the OSS database, Oak Hills Care Center, L.L.C. is shown as in existence as of August 24, 2006. The registered agent information is for John Stout who is located in Norman, OK. Mendelson (1974) pointed out the complexity present when trying to uncover the owners of nursing facilities. For those who may ask, what is the importance of knowing the owner of the facilities? The actions of the ownership in large measures and determines the quality of the patients’ lives (Mendelson, 1974).

     The owner(s) of nursing facilities are also responsible for the financial decisions made by, and for the facility- Medicaid or Medicare reimbursement, monthly rent of the facility, price per bed, etc. As seen in the 2008 financial crisis of the housing market, the books of businesses indulging in illegal activities were so complex that even the Securities and Exchange Commission (SEC) could not understand them. This inadvertently is what allowed the companies to engage in illegal and inappropriate activity without being caught for so long. The same complexity in reports was documented by Mendelson (1974). Here owners would increase the monthly rent of the facilities with justifications that if further investigated show discrepancies. By increasing the monthly rent for the facilities, one could request more help from the government in regards to financing for care of patients- when in reality the request for increase was not for resident care. Once again, this problem has not been recently studied to verify if this still occurs. However, when simply trying to identify the owners of these facilities to further investigate, one is presented with a major road block because the information is unavailable, inaccurate, or inconsistent.

Rating issue

     Ratings are important for businesses because the rating effects the perception held by consumers. Nursing home facilities are rated for the care provided to its residents. In Oklahoma, the Health Care Authority enacted a rating and reimbursement program called Focus on Excellence. The purpose of this program is to provide incentives for nursing facilities that provide quality care. The issue found here, however, is the reimbursement for poor care provided by Oklahoma facilities yet are rated as providing quality care from Focus on Excellence. From a national level, the U.S. government has a rating system ran by Medicare called Nursing Home Compare. Medicare’s system rates the same nursing homes rated by Oklahoma’s system lower. Whether it is the state or the federal rating system that is incorrect, there is obviously an issue in understanding of what constitutes as quality care. Therefore, Focus on Excellence needs to be reevaluated and monitored for discrepancies in ratings and reimbursements of nursing facilities that may not be providing quality care.

Misuse of Medicaid and Medicare Funds

     The government is the largest payer of nursing home care (Carson, 2001). In 1987, the standards were revamped for nursing homes to receive Medicaid and Medicare funds. Prior to 1987, the standards were weak and focused on a home’s ability to provide adequate care, rather than on the level of care actually provided (Carson, 2001). The reason for this change was because of the results from the 1986 report by the Institute of Medicine. The report found a widespread report of abuse in nursing homes. The new standards enacted in 1987 required nursing homes to “provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident” (Carson, 2001, p 8). If facilities fail to meet these standards they cannot receive funding from the government – supposedly.

 “Cases were documented in both Chicago and New York in which purchases and sales of facilities were fraudulently conducted to deceive regulators and enhance publicly funded reimbursement. Not only were the New York homes involved in fraud, they grossly abused patients” (Kaffenberger, 2000, p. 45).  In Oklahoma, in 2000 Jim Smart owner of Weowoka nursing home bribed Deputy Commission Brent VanMeter to help him falsify health records so Smart’s nursing home could receive about $50,000 more in Medicare benefits.

     The issue of government funding being misused is present. By increasing the investigation of nursing facilities who receive government funding, and developing a standard reporting method that clarifies the definition of each criteria explicitly, it will help start the process of being able to identify misappropriated funds. The reports need to be reviewed and clarified by a committee not associated with the nursing facility, but instead a neutral third-party trained in investigation of facilities for being in noncompliance. The committee could even be comprised of citizens. No financial assistance would be needed, only the support and willingness of others to take time out their day to check on residents and ensure they are receiving proper care. The researcher is sure, if asked, there are individuals in the community willing to do the necessary duty for nothing more than the satisfaction of knowing their doing something right.

Financial Exploitation (Company and Family)

     Financial exploitation is a major problem endured by the aging population. Because of their physical and sometimes mental health, certain aging individuals are more prone to exploitation. In 2000, $3.4 billion was reported as suspicious accounting transactions against elder persons (AAJ, n.d.). Adding to the problem, some victims of financial exploitation may be unaware of being exploited because of cognitive disabilities or dementia. Likewise, dependence on the perpetrator for care or shelter, fear of retaliation, or fear of the loss of independence if their exploitation should become known keeps many elders from reporting financial exploitation (NIJ, 2010).

     The Government Accountability Office (GAO) conducted research that explored 20 years of allegations of physical abuse, neglect, and financial exploitation by guardians in 45 states and the District of Columbia. “In 20 selected closed cases, GAO found that guardians stole or otherwise improperly obtained $5.4 million in assets from 158 incapacitated victims, many of whom were seniors” (GAO, 2010a, p. 7). The report also revealed in six of 20 cases, the courts failed to screen potential guardians. This resulted in the appointment of individuals with criminal convictions or significant financial problems that would prohibit them from accurately managing high-dollar estates. In 11 of 20 cases, courts and federal agencies failed to remove abusive guardians due to the lack of communication which resulted in allowing guardians to continue the abuse of the victim and/or others (GAO, 2010). In 2000, in Oklahoma Ramona Denise Phillips; former office manager of Wilshire nursing home, was sentenced to probation for forgery and obtaining money by false pretenses. Phillips forged residents signatures on personal checks on trust fund checks from 1995-1997, totaling over $8,672.00. 

Reporting Abuse

     Although, there is no uniform reporting method to law enforcement from nursing facilities that have reports of abuse/neglect/or exploitation there are requirements for physicians to report signs of abuse or  neglect. According to Madden (1995) many physicians are unaware of the mandatory reporting laws that have been enacted in 47 states. Only three states had voluntary reporting laws at that time. “At least 30 state statutes contain penalties for the failure to report, which range from fines of up to $1,000 to a maximum of six months imprisonment” (Madden, 1995, p. 4). Ahmad and Lachs (2002) revealed physicians report only two percent of all reported cases of elder abuse, despite mandatory reporting laws.

     For the few cases that are reported there are requirements by the Office of Inspector General (OIG) to add offenders to a national exclusion list. This exclusion list requires, by law, to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses:

“Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances” (OIG, para. 2).

There are discrepancies found in Oklahoma’s nurse aide abuse registry managed by the Oklahoma State Department of Health (OSDH). For example, Uqbasilassie Zerie (case # CF-2013-4539), convicted of first degree rape in 2013 of two residents at the Franciscan Villa Nursing Home is not found on the registry. As reported by Clay Loney (2014) from Fox 23 the OSDH say they will add him after he gets out of prison, but by the OIG, he should be added to the abuse registry and turned into the OIG exclusion list now.

     At the state capital meeting a major ethical issue was discovered between care staff members who wish to report the truth, and administrative staff of nursing facilities who wish to hide the truth of incidents with residents. Former care staff members reported being fired for informing family members of incidents of sexual assault taken place against their loved ones; to being forced to change incident reports that showed the facility to be at fault for the incident, to not being at fault. In the end, there are major ethical barriers that are keeping accurate reporting practices from occurring in nursing facilities.

Inspection Issue

     The inspections that take place at nursing facilities are supposed to be unannounced. There, however, have been cases where facility owners bribed commissioners and others connected with the inspection process, for questionable notifications of inspection schedules. Philip M. Green, owner of Sallisaw nursing home, in 1993 was found guilty of over-contributing to Governor David Walters 1990 campaign. Department Deputy Commissioner Brent VanMeter was arrested for soliciting bribes from a nursing home owner E.W. Jiles in exchange for regulatory favors. If owners of facilities are able to make connections with the appropriate people who have influence on the enforcements and regulations for nursing facilities, a whole other issue is present.

     Further research needs to be conducted on the inspection process of complaints in Oklahoma’s nursing homes. When the researcher went through the nursing facilities provider survey/inspection search, on the Oklahoma State Department of Health (OSDH) website, to look at inspection findings from complaints filed by residents and family members, the researcher was shocked to find majority of the inspection results came back as no cited deficiency. It was brought to the researcher’s attention that OSDH has frequent openings on a continuous basis for nursing home inspectors. Upon confirming the information and seeing several recent openings for inspectors, the researcher can’t help but wonder if the same issue with staff members of facilities reporting incidents that fault the facility- as discussed earlier- is occurring here. For those facilities who are cited as having deficiencies, the issue of the facility staying deficiency free after the inspection is present. According to GAO, many nursing homes with serious deficiencies exhibit a “yo-yo pattern” of noncompliance and compliance: after a home is cited for deficiencies, it briefly comes into compliance to avoid fines or other sanctions, only to slip into noncompliance after the threat of sanctions is removed (Carson, 2001, p. 12).

Oklahoma Nursing Homes

     Nursing homes are known for the profit they bring in. Currently, the industry is a multi-billion dollar industry. Residents pay a monthly fee per bed for care and services that are supposed to meet a care plan developed by the family and resident. In some cases it is startling to know the price paid daily by residents and the care that is actually received. For the state of Oklahoma the daily rate for a semi-private room can range from 96-135 dollars, with a median annual rate of 47,187-53,400 dollars (Genworth, 2013). For a private room the daily rate ranges from 105-144 dollars, with a median annual rate from 53,232- 58,400 dollars. Residents who have Alzheimer’s pay a rate that is double the normal rate. Unfortunately, for these residents there days consist of being confined to a room or chair for majority of the day, with the only movement provided is when it is time to eat- even then some are confined to their room (Personal Observation, 2012 and 2013).

     There are facilities that provide daily activities for the residents to participate in that suffice the daily rate demanded for such service and care. There needs to be a universal program(s) implemented in nursing homes that ensures the daily consumption of everyday life activities that allows every resident to still experience life and its pleasures. This, however, requires more staff members but the end result is priceless. These individuals come to these facilities majority of the time to live out the rest of their days. It is only right to ensure their comfort, happiness, and well-being.

     According to the CMS (Centers for Medicare and Medicaid) Oklahoma is one of ten states that has the highest beds per thousand persons aged 85 years and older (386.4 to 509.6). For persons 65 years and older, Oklahoma has over 44.5 to 56.0 beds per thousand persons (CMS, 2012). Yet, our staffing levels are low, and as stated earlier our current governor sees no way to increase funding for the appropriate staffing levels needed.

     In the GAO (2010(b)) report, Oklahoma was ranked seven out of 50 states (Alaska was excluded) for high scores that represented the poor care received by residents. In 2001 a report prepared by Brad Carson for the U.S. House of Representatives, found that out of the 393 nursing homes in Oklahoma, 68 facilities had a violation that caused actual harm to nursing home residents or placed them at risk of death or serious injury (Carson, 2001). Of the 393 nursing homes only 56 (14%) homes were in full or substantial compliance with the federal standards and the remaining 337 homes had at least one violation with the potential to cause more than minimal harm to residents, or worse. “The 68 homes with actual harm violations or worse serve 4,895 residents and are estimated to receive over $60 million each year in federal and state funds” (Carson, 2001, p. 2). The report discovered the discrepancy in understanding of what constitutes as actual harm. “For example, Oklahoma inspectors classified some violations involving improper medical care, untreated pressure sores, malnutrition, dehydration, and abuse as not causing actual harm” (Carson, 2001, p 4). That is unfortunate because in many cases, such as the researchers, malnutrition and dehydration were the cause of death for the resident. Findings from Carson 2001 report reveal 68% (269) homes were cited as potential for more than minimal harm (16,291 residents at risk of harm), 17% (65) homes were cited as actual harm to residents (4,665 potential victims), and only 12% (49) were in complete compliance (no violation). “The results of this investigation indicate that the conditions in these nursing homes often fall substantially below federal standards. “Many residents do not receive the care their families expect or what federal law requires” (Carson, 2001, p. 13). Yet funding is received.

     As of 2011, majority of nursing homes in Oklahoma are for-profit ownership (85.6%), with 11.9% being non-profit, and 2.6% owned by the government (CMS, 2012). As long as the motivation is profit, this industry will continue to face ethical and moral issues.

Oklahoma Nursing Home Cases of

Abuse/Neglect/Exploitation

Case #		Year		Facility/Case
1	1993		New Horizon
2	1993		All American Health Care Center
3	1993		Begg’s Living Center
4	1993		Convalescent Center
5	1993		Sallisaw Nursing Home
6	1994		Bellevue Nursing Home
7	1995		Choctaw Living Center
8	1996		Rest Haven Nursing Home
9	1996		War Acres Nursing Home
10	1996		Four Seasons Nursing Center
11	1996		N/A
12	1997		Oak Hill Living Center
13	1998		N/A
14	1999		Monroe Manor Nursing Home
15	2000		N/A
16	2000		Oak Hill Living Center (Medical Management Group Investigation)
17	2000		Wilshire Nursing Home
18	2000		N/A
19	2001		Bellevue Nursing Home
20	2002		SunBridge ParkCare and Rehabilitation
21	2002		Choctaw Nation Nursing Home
22	2004		Estate of Hicks v Urban East
23	2004		Hill Nursing Home
24	2005		Colbert Nursing Home (Boulden v Colbert Nursing Home Inc 2011)
25	2005		Brighton Gardens OKC
26	2006		Grace Living Center
27	2007		Norman Veterans Center
28	2009		Personal Statement
29	2012		Quail Creek Nursing and Rehabilitation Center
30	2012		Buena Vista Care and Rehabilitation Center
31	2012		Personal Statement
32	2012		Personal Statement
33	2013		N/A
34	2013		N/A
35	2013		Franciscan Villa Nursing Home

(Table 1)

Refer to Appendix A for a description of the incidents for the case numbers mentioned above

Oklahoma’s Nursing Home Crime Maps

      (Figure 2)

    (Figure 3)

Methodology

     Studies on United States nursing homes, and crime trends were found through the University of Central Oklahoma’s (UCO) Chambers Library database. Google advance search engine was used to search government websites that contained information on nursing homes throughout the nation, and Oklahoma’s nursing homes. Oklahoma’s State Department of Health and the Secretary of State website were used to obtain specific information on Oklahoma’s nursing homes. Other reports used throughout the research were obtained via the same method.

      Google Legal Search was utilized to find legal cases on nursing home crimes. As well, News OK Archive was used to discover any news reports of nursing home crimes in the state of Oklahoma from 1983-2013. Micro-films of newspapers from the University of Central Oklahoma were used, as well, to search any crime trends from the defined study years. Cases were documented and stored in an excel file for the continuing of research.

     Qualitative and quantitative open-ended questions were asked throughout the interviews of key informants. The following is a list of the questions asked; how long have you worked as an ombudsman in the state of Oklahoma; what knowledge do you have about crimes in regards to nursing homes in Oklahoma; do many crimes go unreported; how is nursing home crime dealt with in the criminal justice system; and could there be any improvements made in how we currently respond to crime in nursing homes. Upon permission from the respondent, interviews were recorded for documenting purposes.

     A public meeting held at the Oklahoma State Capital where individuals and victims of nursing home crimes shared their personal story was attended on December 16, 2014. The researcher recorded the meetings for documentation purposes. Inside knowledge of the care provided to residents at nursing homes was obtained by engaging in participant observation with fellow residents of two nursing facilities- Greenbrier (Enid) and Epworth Villa (OKC). The researcher set in the resident’s room for periods of time ranging from 2-7 hours observing staff and other residents’ behavior. The facility was explored while visiting. The researcher was able to engage in activities and meal time with residents to observe the interaction between staff and residents.

     Geographic Information System (GIS) ArcMap and ArcCatolog were used to create a geodatabase of crime trends in nursing homes throughout the state of Oklahoma. The data to create the geodatabase was collected from the Oklahoma Center for Geospatial Information (OCGI) and Center for Spatial Analysis (CSA). The zipcode tiger file was collected from CSA. The political and administrative points, boundaries, and polygons were collected from OCGI, and cartographic boundary files were collected from the U.S. Census Bureau.  The following GIS procedures were utilized; mapping cities, attribute by violation type, attribute by rural/urban and metropolitan areas, as well as attribute by ownership type. The researcher mapped the cities where reported nursing home crimes have occurred in Oklahoma. The cities where nursing home crimes have been reported were identified by using the select by location feature. By selecting the cities of the reported area, GIS identified the specific locations where further analysis was conducted. By running the select by attribute procedure the researcher was able to identify the areas where nursing home crimes have been reported, and analyze the data based on geographic location and socioeconomic variables. The U.S. Census guidelines for defining areas were used. Populations exceeding 50,000 in persons were considered urban areas; populations 10,000 - 49,999 were urban clusters,  and areas containing less than 10,000 persons were consider rural areas.

Analysis

     Using Tender Loving Greed as a basis for comparing nursing home improvements over the past 30 years, the researcher discovered a lot of the issues the industry faced 30 years ago are still present today. Staffing levels continue to be

low in Oklahoma’s nursing homes. Despite the research present on the effects of low staff levels and its effect on the quality of care provided to residents of nursing facilities, Oklahoma has no room in its budget to address the understaffing issue. The burden, however, should not be placed solely on the state when the facilities are bringing in enough income to address that issue. Perhaps the need to revise the budget and divert funds from those receiving ill-gotten gains for the lack of  enforcement of quality care, to those who are actually responsible for the care provided, will help address that budget issue.

The current rating system responsible for rating Oklahoma’s nursing homes needs to be further investigated. Clarifying the understanding of what constitutes as quality and poor care seems to be needed. As mentioned earlier Medicare’s rating system rates Oklahoma’s nursing homes lower than Focus on Excellence- Oklahoma’s rating system. The fact that majority of the citations given are a “C” or lower justifies the need for improvement.

     Until the lack of enforcement of regulations changes in this industry residents are likely to experience circumstances they do not deserve to endure. At this time there are no effective deterrents present that would keep one from engaging in deviant behaviors against vulnerable victims. The first step in reducing crime of any type is to figure out a deterrent that takes on a proactive approach to crime. The researcher believes until the legal system begins to prosecute and recognize these business entities in criminal court, nothing but the loss of money- something they have plenty of- is keeping them from continuing to do nothing; or not enough. Which in turns leaves millions of innocent people to suffer at the hands of bureaucratic care.

GIS

     GIS allowed the geographic analysis of crime trends in Oklahoma’s nursing homes to be conducted for this research. The results show that majority of the crimes committed from 1983-2013 were committed by for-profit nursing homes. Majority of the crimes were committed in rural and urban areas (Figure 3). The researcher believes the location of where crimes are occurring can be explained; in part, by staffing levels. In rural areas the population is small and the qualified staff that is needed is scarce. In urban areas it is the opposite. There are enough people in the area to meet the demand, but there are a thousand more opportunities to choose from- labor wise- and many of those opportunities exceed the compensation offered by these institutions. Whether, rural or urban area the same poor compensation exist.  Therefore, in urban areas the target population for care staff employees is limited to a particular group.

     The ownership type of nursing facilities is important to look at because it sets the foundation for how the facility is structured and operated. For-profit facilities motives are not the same as non-profit facilities. When the end goal is to make money; efficiency trumps quality. In this circumstance quality is the more important factor. The residents can’t afford to have efficiency as the motive of operation.

Policy Recommendations

     The State needs to establish a State-wide network of responsibilities and supporting processes to report, investigate, resolve, follow-up, and prevent abuse and neglect in nursing homes. The State should consider enacting legislation and/or strengthen existing laws to implement this process and ensure appropriate resources for its operation. In regards, to dealing with cases of abuse, neglect, and financial exploitation no one person or profession should be solely responsible for the management of these cases. Madden (1995) purposes a multidisciplinary team of caretakers to manage these cases. “A multidisciplinary team is, by definition, a group of professionals and paraprofessionals from a variety of disciplines, often representing different agencies, and working together to achieve a clearly specified set of goals…These goals may include coordination, diagnosis, prevention, treatment, consultation and education” (Madden, 1995, p. 4). Individuals from the medical, social service, mental health, and legal professions should be utilized to make up this team.

     The individuals hired who are in direct contact with residents on a daily basis need to be individuals who possess a set of characteristics, coupled with a strong morale and ethical standard that allows one to provide the care needed. Being qualified to provide the necessary care is one thing, but to be able to do it under stressing circumstance is another. Hiring well-qualified workers, and training in conflict management and stress reduction, would help one to manage and deal with the labors high demand.

     A universal reporting method needs to be established so the progression in research and prevention strategies can begin to take place on a wider scale. Until we have a way to account for all the unreported crimes that takes place in nursing homes the problem will continue to be unrecognized as a major social problem that needs to be fixed now before it gets any worse. “Nursing home administrators should report abuse promptly and not wait until internal investigations are completed” (Ahmad & Lachs, 2002, p. 804).

     Stronger policies need to be developed and implemented for inspection standards. There is obviously a disconnect in understanding what constitutes as poor care. Until this industry, and those who are responsible for the oversight and regulations, come to a uniform understanding of standard care; the residents will continue to be caught in the middle of substandard and quality care.

Conclusion

      Although, there are not many reported cases of nursing home abuse in Oklahoma over the past 30 years, it should be reminded once again many cases go unreported. However, it should be pointed out that the crimes in question are crimes that even if one incident occurred it is an incident against humanity as a whole. The population in question is responsible for the current existence of society. Without them there would be no continuation of life. Therefore, it is the presiding generations’ responsibility to ensure their safety and comfort as they live out the rest of their days. This is a continuous situation in life. Therefore, the thought must be continuous and accepted in order for the problem to be addressed.

     State regulations and policies need to be reexamined to ensure the welfare of the residents are being put first. This industry needs to incorporate proactive security standards to ensure the safety of its residents. It is sad to say that a prison has more security then a nursing home; and even sadder to say in some cases prisoners are treated better than nursing home residents. The government and taxpayers are paying millions to billions of dollars for care that if examined closely would make one question what they are actually paying for.

      Not all nursing homes in the state of Oklahoma provide poor care. However, there seems to be enough- to be classified as many, which do provide a standard of care that is questionable. The source of these crimes comes from the lack of enforcement from state and federal agencies that are responsible for ensuring these facilities provide a standard of care that ensures the well-being of its residents. More security precautions need to be implemented in this industry. Unfortunately, it seems we must compromise privacy for security in this case, in order to help ensure the safety of these vulnerable victims. A simple resident survey should be conducted asking residents for their opinion on heightened security precautions such as cameras or voice recordings. Stronger deterrents needs to be established and worked on if we wish to try to eliminate or reduce these types of crimes. Opportunity must have its opportunity removed in order to help curb the deviant behaviors. Most of all the willingness and effort is needed; to educate others about this problem; to address and analyze the situation; and to correct the mistakes of others. Whether one cares if this is relevant or not, understand it will become relevant to oneself at some point. So why not do something now.

Reference

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Appendix A

Incident Reports by Case Number

1. Employee slapped resident while intoxicated at work. Company found liable to pay awarded damages. Prosecuted in OK Supreme court.

2. Meadows family; father and son, charged with manslaughter of 6 patients who died in the care of the nursing facility. Guns were found to be housed in the facility, incidents of prostitution, and drugs also found to have taken place. Charges were dismissed and the home reopened under new name and management.

3. Donald Wayne Quinton abused while under the care of the facility by staff member. He suffered serious personal injuries as a result of an apparent bearing. This case went to the Supreme Court.

4. Female resident raped in facility by a man who broke in the middle of the night.

5. Phillip M. Green (owner) found guilty of over-contributing to Governor David Walters 1990 campaign.

6. Failed to report rape of a resident to the family, police, or DHS prior to the offender’s arrest.

7. Direct care worker Tony Ligons found guilty on 3 misdemeanor counts of aggravated assault and battery against two mentally retarded residents. He choked one and repeatedly kicked another resident. Four other residents faced similar charges

8. Woman drowned while left unattended in bathing area. Prosecuted in civil court.

9. Resident of facility fell from shower chair while left unattended and not properly restrained.

10. Resident disappeared white in the care of the facility and later found dead. Prosecuted in civil court.

11. An attorney converted $175,000 from an elderly woman’s estate, but later testified that he had caused her no harm

12. Two care staff employees pushed on resident’s bedsores, threw cookies on the floor while patients attempted to get them and eat them. They received deferred sentences.

13. An attorney took $37,000 from the victim’s account, using some of the funds to buy into a get-rich-quick scheme with a bank in Nigeria. The attorney resigned from the bar in 1998, re-applied and was readmitted in 2007.

14. City of Jay filed a lawsuit in federal court alleging negligent medical care at the facility which is financed through the Oklahoma Trust Authority

15. Nurse aid raped 75 year old woman resident (NewsOK archives)

16. E.W. Jiles, nursing home management company owner, bribed former Deputy Commissioner of Health- Brent VanMeter.

17. Ramona Philips, former office manager, sentenced to probation for forgery and obtaining money by false pretenses. Forged residents signatures on personal checks and on trust fund checks (over $8,672 from 1995-1997)

18. Mary Gay, resident of nursing home died at 87 in May after being stung more than 1,600 times by fire ants that burrowed into her room. No criminal charges were filed, but fines were given. (The Oklahoman)

19. Staff member, Jonathan Luster, touched women in private area and resident reported it to police

20. Nursing Home administrator was arrested accused of stealing $1,227 from her residents by forging checks and stealing cash.

21. After 2 months of residing in the home she fell and broke her hip and nose. While bedfast, she developed severe pressure sores which became infected and resulted in her death a few weeks later. Prosecuted in civil court; jury found home guilty of negligence but did not awarded any damages. 

22. Plaintiff- family of decedent- sued Nursing Home for death of decedent

23. Daughter of James C. Richard Jr. sued home for neglect of her father which resulted in his death May 19, 2004. Prosecuted in civil court.

24. Boulden, resident of facility, died 2 months after residing at Colbert Nursing Home. The case was prosecuted in civil court and was appealed in 2011.

25. Woman was raped and daughter put out $2,000 reward for leads to arrest of the person responsible; nursing home claimed no knowledge. The NH says the Alzheimer’s unit is secured and doesn’t know how the incident occurred.

26. Decedent’s next of kin filed suit for negligent care and breach of duties caused Bruner’s (decedents) death.

27. David Shelton died on January 5, 2007 after having lost more than 20% of his body weight. Decedent’s cause of death was listed as congestive heart failure and acute renal (kidney) failure due to dehydration. Prosecuted in civil court. The daughter also filed action against Oklahoma Department of Veterans Affairs (ODVA).

28. Richard Curnock was a father to a son who he had to place in a nursing home due to a disease that affected the brain. His son was sexually assaulted in a home, and was informed by a floor nurse of what happened.

29. Two black female employees of nursing home caught on tape stuffing gloves in resident’s mouth and abusing said resident. Family hasn’t received any findings from an internal investigation that the home was supposed to conduct according to OKDHS. One of the offenders fled the state, the other is awaiting trial.

30. California murdered housed at Midwest City (MWC) Nursing Home with residents. State fined the home $168,000.

31. Mrs. Anderson was neglected to the point of death at a nursing home facility in Oklahoma. Her daughter Christina has been fighting for 2 years now to have a full proper investigation conducted by OKDHS. She has continued to get the run around from the state department in regards to addressing the crime committed.

32. Melanie Rich’s mother was abused in an Oklahoma nursing home she was residing in. Upon Mrs. Rich being advised by her mother’s roommate that she needed to see what was going on when she left, Mrs. Rich placed a nanny cam in the room. Mrs. Rich viewed a graphic video of her mother being smothered with gloves the aid had just worn to clean urine and feces. When the aid was finished suffocating her mother she grabbed her head and shook it from side to side.

33. Possible rape of resident by visitor; staff not present to account for allegations.

34. Employee accused of stealing drugs and abuse

35. Uqbasilassie Zeire was a nurse aid at Franciscan Villa Nursing home where he raped two residents. After further investigation Zeire was not found on the state website as being a licensed nurse. Zerie was found guilty in criminal court