Pre-Service Training for
Volunteer Ombudsmen Applicants
Welcome!
Greetings
• What is your name?
• Where are you from?
• What experience (if any) do you have in
long-term care?
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The Program Coordinators
Merea Bentrott
Direct (515) 344-0052
Toll Free (866) 236-1430
Merea.Bentrott@iowa.gov
Sarah Hinzman
Direct (515) 657-1479
Toll Free (866) 236-1430
Sarah.Hinzman2@iowa.gov
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Our Mission
The mission of Iowa’s Office of the State LongTerm Care (LTC) Ombudsman is to protect the
HEALTH, SAFETY, WELFARE, and RIGHTS
of individuals residing in long-term care by
• investigating complaints,
• seeking resolutions to problems, and
• providing advocacy with the goal of
enhancing quality of life and care.
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Origin of Ombudsman Programs
• Older Americans Act (OAA) (1965) requires
each state to have a Long Term Care
Ombudsman Program.
• Demonstration programs began in 1972.
• Iowa receives federal, state, and special grant
funding.
5
Origin of Ombudsman Programs
• Ombudsman Programs exist in all states, the
District of Columbia, Puerto Rico, and Guam.
• Each is led by a full-time State LTC
Ombudsman.
• In Iowa the State LTCO is
Deanna Clingan-Fischer.
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Long-Term Care
What types of facilities are considered
long-term care?
1. Residential Care Facilities (Residents are ill, but
don’t require RN/LPN services, barring emergency)
2. Skilled Nursing (Rehabilitation)
3. Nursing Homes (Highest level of care required)
4. Elder Group Home (Smaller setting, 3-5 tenants)
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Local Ombudsman Regions
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The Long Term Care Ombudsman
• Is an advocate for residents and tenants of
nursing homes, residential care facilities,
assisted living programs , elder group homes.
• Investigates and resolves complaints that may
affect the health, safety, welfare, or rights of
LTC residents/tenants.
• Makes a difference in the lives of residents
and tenants in LTC facilities through individual
contact with residents and systemic advocacy.
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The Long Term Care Ombudsman
• Resolves complaints made by or on behalf of
residents/tenants.
• Advocates for residents' rights and quality
care.
• Provides information to the public about
long-term care services, residents' rights,
legislation, and policies.
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The Long Term Care
Ombudsman
• Educates consumers and long-term care
providers about residents' rights and good
care practices.
• Promotes community involvement.
• Promotes the development of citizen
organizations, family councils, and resident
councils.
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Ombudsmen can help everyone
Residents and
tenants
Residents’/Tenants’
family and friends
Individuals and
families considering
facility placement
Individuals or
organizations
interested in resident
welfare
Long-term care
professionals
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How the Ombudsman can help
• Anyone with an inquiry about long-term care
can contact an Ombudsman. Inquirers can
remain anonymous.
• Investigate concerns about a facility.
• At the request of the resident/tenant or
family, Ombudsmen may visit/call the
facility, review records, meet with staff,
and put a plan in place to address
concerns.
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How the Ombudsman can help
• Provide assistance in situations where a
resident/tenant is facing involuntary
discharge/transfer.
• Answer questions about standard practices
and clarify state and federal guidelines for
long-term care.
• Obtain information about choosing a care
facility.
• Provide general information and education
about long-term care.
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Volunteer Ombudsman Program
The Volunteer Ombudsman Program (VOP) was
designed to place trained and certified
volunteers in long-term care facilities to assist
Local Ombudsman in carrying out the duties
described in the Older Americans Act.
“Never doubt that a small group of thoughtful,
committed citizens can change the world.
Indeed, It is the only thing that ever has.”
Margaret Mead
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VOP Facts
• Most states have a similar volunteer program.
• Our program is written into Iowa Code and
receives an annual state appropriation.
• Our first volunteer began in September 2013.
• As of June 30, 2014 there were 83 volunteers
serving in 71 facilities across 32 counties.
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VOP Facts
• Unique volunteer achievements:
• Establishment of a family council
• Establishment of a veterans visitation
program
• Assisting with facility closure
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Who are the VOP volunteers?
• Community members over 18 years of age
(currently includes college students through
retirees).
• Have a strong appreciation for older adults.
• Some with professional experience in areas of
health, human services, or long-term care.
• Some with experience as family members or
caregivers of a long-term care resident.
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Who are the VOP volunteers?
• Good listeners and objective problem solvers.
• Able to demonstrate an understanding of
program practices.
• Do not have a conflict of interest as defined by
the OAA.
19
Conflicts of Interest*
• Currently employed by or receive payment
from a long-term care facility.
• Fiduciary relationship with a resident of the
facility at which they hope to volunteer
(guardian, conservator, attorney-in-fact, etc.).
• Financial interest in long-term care facilities
(owner, operator, Board member, etc.)
• Involvement in licensing or certification of
facilities.
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Conflicts of Interest*
• Service provider to residents in facility
(insurance, ministry, etc.).
• Former employee of a facility or a competing
facility within the past year.
• Resident of a long-term care facility.
• Current facility volunteers (unless they plan to
drop those duties in favor of the VOP).
* Conflicts of interest generally extend to immediate family.
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The VOP Enrollment Process
1.
2.
3.
4.
5.
6.
7.
8.
Application
Telephone interview
Training
Individual manual review
Follow-up consultation
Background check
Certification & facility placement
Facility orientation with local ombudsman
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VOP Orientation
The facility administrator will receive an
announcement of your placement and the Local
Ombudsman will arrange a date and time that
works best for all parties to conduct the
orientation.
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VOP Orientation
1. Meeting with administrator, Local Ombudsman,
and certified Volunteer Ombudsman (VO).
–
–
–
–
Volunteer materials distributed
Point of contact is established
Expectations of all parties are outlined
Communication and information sharing
practices discussed
2. Tour of the facility.
3. Local Ombudsman shadowing.
Then you’re visiting solo!
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Ongoing VOP Certification
• For new volunteers, certification is granted
for one year.
• Volunteer will complete 10 hours of
continuing education during their first year.
• Volunteer will regularly submit monthly
reports and visit their facility a minimum of
three hours per month.
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Ongoing VOP Certification
• Volunteer will abide by program practices.
• At the time of recertification, the volunteer
will be evaluated by the program and the
program evaluated by the volunteer.
• Recertification may be granted for a period of
two years, with six hours of continuing
education required each year.
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Our volunteers make a
difference
Volunteer Ombudsmen:
• Empower residents to speak up for
themselves.
• Visit with residents who are new admissions
to a facility.
• Make a resident’s day by involving them in
conversation and listening to their concerns
and opinions.
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Our volunteers make a
difference
Volunteer Ombudsmen:
• Attempt to resolve resident concerns at the
facility level.
• Work cooperatively with facility staff,
encouraging them to take resident concerns
seriously.
• Help break down barriers between the
community and long-term care facility.
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Long-term care advocacy tips
• Be friendly.
• Be aware of your body language, gestures,
and non-verbal communication signals.
• Listen carefully and seek an accurate
understanding of the situation.
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Long-term care advocacy tips
• Remember that we advocate only for the
residents.
• Focus on residents concerns—not your
personal concerns or other’s concerns.
• Focus on a few residents during each visit to
avoid being overwhelmed.
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Ethical Principles of Volunteer Ombudsmen
• Ethics are guidelines and standards of conduct
for a profession
• Our ethics are all about the resident!
• You may experience an ethical dilemma in your
volunteer role. Do not hesitate to seek an
objective opinion from your VOP Coordinators.
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Ethical Principles of Volunteer Ombudsmen
We support the following:
• Autonomy
(Encouraging selfadvocacy)
• Non-maleficence
(Do no harm)
• Beneficence
(Seek to do good)
• Justice (Fairness)
• Fidelity (Trust)
• Veracity
(Truthfulness)
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Top Five Resident Complaints (2013)
20%
18%
16%
14%
12%
10%
8%
6%
4%
2%
0%
Residents
Rights
Care
Admission,
Transfer,
Discharge
System, Etc. Environment
& Safety
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Common resident concerns
• Meal temperature, taste, and timely
service.
• Availability and accessibility of fresh water.
• Short staffing: what are the consequences
of short staffing?
• Environmental safety and cleanliness
including equipment.
• Misplaced, lost, or stolen property.
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Common resident concerns
• Scheduling of baths and showers.
• Appropriateness of activities.
• Timely acquisition and repair of wheelchairs
and other important equipment.
• Conflicts with staff members or roommates.
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Volunteers may also…
• Conduct initial inquiries regarding resident
complaints received by our office at the
request of the Local Ombudsman.
• Provide follow-up visits on cases investigated
by the Local Ombudsman and monitor facility
progress.
36
Volunteers may also…
• Attend Resident and Family Council
meetings at the request of council
members.
• Provide general information to
residents and families.
37
Volunteer interaction with
families
• You will encounter residents’ family members
and friends who have their own opinions
about the resident’s care.
• Remember that we are advocates for the
resident.
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Volunteer interaction with
families
Scenario: Resident and Daughter
• What does the resident want?
• Are family members imposing their wishes on
the resident?
• Does the family need information/resources?
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Are there things volunteers
should not do?
YES!
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VOP Volunteers Do Not
• Act like “nursing home police”.
• Have the same role and status as Local LTC
Ombudsmen.
• Represent themselves as anything other than a
Volunteer Ombudsman while in their assigned
facility.
• Act as a Volunteer Ombudsman for any facility
other than the one to which they are assigned.
• Train and monitor other Volunteer Ombudsmen.
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VOP Volunteers Do Not
• Disclose resident concerns to the point-ofcontact (or other staff) unless resident
permission has been given.
• Discuss issues of confidentiality inside or outside
the facility.
• Investigate complaints or provide advice to
residents or staff regarding health care, legal
issues, financial, or discharge/transfer.
• A VO may be the first person to identify these
concerns.
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VOP Volunteers Do Not
• Have access to residents information on file.
• Establish friendships with residents or staff
that will affect their advocacy role.
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Boundaries
• A boundary is a limit to a professional
relationship that promotes programmatic
integrity and protects the welfare of the
resident.
• Why do volunteers need boundaries?
• Respect for the resident. They probably have
friends. What they probably do not have is an
advocate.
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Boundaries
• The advocate/resident relationship is planned and
purposeful. Unlike friendships, advocates and
residents do not need to share similar experiences,
viewpoints, or personality qualities to be successful.
• The utility and efficiency to solve resident concerns
without social complications make our services
more valuable.
• Your role as a volunteering professional is
probably quite different than your social
identity among friends—it should be!
45
VOP Volunteers Do Not
• Serve as a facility volunteer or organize, lead,
or take an active role in facility activities.
• You may attend activities to observe and visit
with residents.
• Receive payment or accept gifts (including
meals) over $2.99 in value from families,
residents, or facility staff.
46
VOP Volunteers Do Not
• Perform any type of hands-on personal care,
activity, transportation, or treatment for
residents.
• This is to protect everyone’s safety and liability.
• Have any regulatory authority.
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Long-Term Care Regulators
• The Iowa Department of Inspections and
Appeals’ (DIA’s) Health Facilities Division is the
designated state surveyor and certification
agency for inspecting, licensing and certification
of long-term care facilities.
• DIA investigates complaints alleging a violation of
law.
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Long-Term Care Regulators
• DIA survey teams conduct unannounced on-site
inspections to assess quality of care/services
provided to residents and tenants.
• If problems are discovered, DIA can initiate
corrective and/or disciplinary action to assure a
facility's compliance with state and federal laws
and rules.
• Nursing home report cards: DIA and Medicare
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Volunteer Interaction with DIA
• Identify self as a Volunteer Ombudsman to DIA
surveyors.
• DIA may ask a volunteer questions regarding a
resident/situation.
• General information relating to direct
observation & conversation with residents
may be discussed.
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Volunteer Interaction with DIA
• Volunteers may not communicate residentspecific information directly to the
surveyors unless the resident has given
permission.
• Volunteers should not give surveyors a copy of
their notes, even if requested.
• Volunteers may attend the surveyor’s exit
meeting.
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Why do residents value our volunteers?
• They keep them connected to the
community.
• They serve as an empathetic ear for day-today concerns.
• They provide assurance that they are being
heard and provide hope that their concerns
will be addressed to their satisfaction.
• They help decrease relocation stress for new
residents knowing they have an advocate
from day one.
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Why do residents value our volunteers?
• Residents will often share personal fears and
needs with them that they may not feel
comfortable sharing with staff.
• They can serve as a “constant” during times
of change in a facility (renovation, ownership
and staffing changes).
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Why do facilities value our volunteers?
• Another set of eyes and ears to enhance
their services.
• Smaller issues resolved without further
involvement from Ombudsman’s office or
DIA.
• All Volunteer Ombudsmen are trained the
same and have the same expectations and
practices.
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Why do facilities value our volunteers?
• Improves communication between facilities
and the Long-Term Care Ombudsman’s
office.
If they’re in the business for the right
reasons, they will see you as an asset!
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Why do we value our
volunteers?
• They increase our ability to serve more
residents and have a regular presence in
more facilities.
• They serve as a liaison of our office in their
home community—more people will know
what we do.
• The LTC Ombudsman’s office is able to
monitor more facilities with greater
frequency.
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Why do we value our
volunteers?
• Increased awareness of long-term care issues.
• Because we know the rewards and challenges
of this role, and uniqueness of this
opportunity. Good volunteers are hard to
find!
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But what’s in it for you?
• Satisfaction knowing you’re making a
difference in the lives of others.
• Being connected to residents as a community
member impacts the overall community.
• Increased social ties and advocacy skills.
• Learn more about the long-term care system.
• Ongoing support and education from the LTC
Ombudsman’s office.
• Fun, fulfilling, and rewarding.
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Typical Nursing Home Organizational Chart
Governing Body
Administrator
Social
Service
Director
Chaplain
Bookkeeper/
Business
Manager
Director of
Maint. &
Housekeeping
Other
Housekeeping
Personnel
Food
Service
Supervisor
Director of
Nursing
(DON)
Dietician
Assistant
(DON)
Cooks
Charge
Nurses
Helper/
Dishwasher
Staff
Nurses
CNAs
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Activity
Therapist
Volunteer
Coord.
Facility
Volunteers
*Ancillary
Medical
Personnel
*Therapists
(PT, OT,
Speech)
*Pharmaceutical
consult
*Psychiatry
Psychology
Consult
*Dental
*Podiatry
Infection Prevention and Control
• If you are ill, don’t visit.
• Wash your hands before and after visits.
• Use and check hand sanitizers.
• Advocate for residents to be able to wash
their hands and have clean clothing,
especially before and after meals.
60
Infection Prevention and Control
• Pay close attention to any infection procedure
signs on residents’ room doors and follow the
protocols.
• What if there is a flu outbreak?
• Vaccinations are not required for volunteers.
• TB tests
61
The Art of Observation
• Sometimes we spend so much time in a facility
we become unaware of what is happening
around us.
• Avoid making assumptions.
• When we advocate for residents, sometimes we
have to increase our “lens” to identify the root of
a problem.
• Observation Skills
• Are my observations statements of fact or
statements of opinion?
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How observant are you?
63
How observant are you?
Count the Passes!
64
Visiting the facility
• Volunteers conduct unannounced, varied visits
(minimum of 3 hrs/mo).
• Volunteers are not to be restricted from
visiting the facility or any specific individual.
• Wear state-issued identification badge.
• Notify point of contact when entering and
exiting the facility.
65
Visiting the facility
• Observe, listen, interact with residents and
record concerns.
• Observe general conditions of the facility and
note observations.
• Speak with point-of-contact regarding resident
concerns with resident permission.
66
Starting the conversation
•
•
•
•
Knock and wait for response.
Ask for invitation to enter and visit.
Introduce yourself and your role.
Try to converse with residents at eye-level,
adjusting whatever environmental elements
(lights, sound) necessary to communicate
effectively.
67
Starting the conversation
• Be friendly.
• Be aware of non-verbal communication.
• If you’re unsure how to communicate with a
resident, ask staff how best to communicate.
• “Break the ice”.
68
Taking a resident concern
Collect as much detail as possible.
Be empathetic, understanding, and professional.
Ask the following questions:






Who/what/where/when/why/how (open ended questions).
Would you be comfortable speaking up to a staff person about this?
Have you told anyone about this before? What happened?
Would you like my help to resolve this concern?
What do you see as a solution to this issue?
May I bring your concern to the attention of my point of contact
(name)? They may be able to help resolve your concern.
Provide a reasonable expectation for when you will follow up.
Interviewing skills
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Confidentiality & permission
• Maintaining resident confidentiality and
obtaining permission to resolve concerns
on their behalf is among the most crucial
elements of the LTC Ombudsman program.
• Confidentiality is the nondisclosure of
information except to another authorized
person.
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Confidentiality & permission
• We must always ask for a resident’s
permission to talk to staff or others about
their concerns.
• Does the resident wish to be personally
identified in the complaint, or would they
prefer to remain anonymous?
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A path to resolution
Things to establish before working toward
resolution.
• What happened?
• How did it happen?
• Who was involved?
• When did it happen?
• Why did it happen?
• How often does it happen?
• Did it really happen, or was it perceived?
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A path to resolution
• Has the resident told anyone about
this concern before? What
happened?
• What does the resident see as a
resolution?
• What could be the root cause of
this issue?
• How can this issue be prevented in
the future?
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Subjectivity in communication
Show Me Your Bug!
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A path to resolution
Ask yourself: Did the resident give permission to
discuss their concern?
 If no, STOP. At this point your options include:
o Empowering the resident to speak up for
themselves.
o Providing education to resident about your
limitations to resolving their concern without their
permission.
o Note the concern in your monthly report without
identifying the resident.
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A path to resolution
o Ask other residents if they have a similar
concern (if so, you may be able to bring the
concern to your point of contact in a
general sense without having to identify
specific residents).
o Share any serious or immediate concerns
only with the VOP Coordinator and/or your
Local Ombudsman right away.
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Investigating a concern
If resident permission was granted, follow these steps:
• Bring the concern to the attention of your point of
contact verbally either in person or on the phone.
• Note the concern in your monthly report. Any serious
or immediate concerns can be shared immediately
with VOP Coordinator and/or Local Ombudsman.
• Follow up with resident and/or point of contact during
future visits to see if the concern is improved or
resolved.
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Investigating a concern
Sometimes, a concern may require more assistance
than the volunteer can provide:
• If the investigation or resolution would require a
review of personal/medical records or may require
medical, legal, health, or financial advice, it should
be handed off to the Local Ombudsman.
• If the concern continues to be unresolved or
escalates, contact the VOP Coordinator and/or Local
Ombudsman for guidance.
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Investigating a concern
• The Local Ombudsman may conduct further
investigation and provide follow up to
volunteer. The volunteer should continue to
visit with the resident to listen and provide
reassurance.
• Depending on the individual concern, other
entities may need to be called upon for
assistance. This will be done at the Local
Ombudsman's discretion.
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Reporting
• Monthly reports should be submitted by the last
business day of the month.
• Use resident initials only on written reports (no
nicknames, room numbers, etc.).
• You do not have to provide a response to each
item in the report. We will assume that anything
not noted in the report is satisfactory.
• Include notes about progress to resolution.
• Do not make copies.
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Scenarios!
1) When you attempt to visit with a resident they
become defensive, call you a stranger, and
refuse to visit with you.
2) A resident expresses that they would like to go
to chapel service, but no one ever tells her when
it is and staff are usually too busy to take them
anyway.
3) You observe that residents who are more
dependent are left lingering, some asleep, at the
dining room tables for more than an hour after
dinner is complete.
81
We all want what’s best for the resident
Community/
Family
Facility/ Staff
RESIDENTS’
RIGHTS
Residents
State, Local,
and Volunteer
Ombudsmen
82
Culture change
• “Culture change” is a movement developed
by the Pioneer Network in 1997
(www.pioneernetwork.net)
• Campaigns for the “provision of high-quality
nursing home care, individualized to meet
each residents’ needs in a setting that
maximized self-determination and wellbeing.”
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Resident centered care
84
Culture change
• Campaigns for transformation of attitudes and
behaviors in long-term care settings.
• It starts with language…
o Person first!
o Avoiding ageist labels, value judgments, and putdowns
• “The Bucket List”
85
Residents’ Rights
• Residents have rights guaranteed to them by
state and federal laws
• Facilities are required to protect and promote
residents’ rights
• Each resident has the right to exercise all of
their rights free from interference, coercion,
discrimination, or reprisal
86
Foundation: Residents’ Rights
87
Foundation: Residents Rights
88
Common legal rights issues
Paige Thorson, J.D.
Legal Assistance Developer
Iowa Department on Aging
Residents also have the right to:
• Self-administer medications
• Accept or refuse care and
treatment
• Reasonable access to personal
funds held by facility
• Not be involuntarily discharged
without due process
• Private and unrestricted visits
with any person of their choice
89
Self-Administered Medications
Federal Law
An individual resident may self-administer drugs
if the interdisciplinary team… has determined
that this practice is safe.
42 CFR 483.10(n)
90
Self-Administered Medications
Iowa Law
Attending physician must certify that resident is
mentally and physically capable of selfadministering.
Once certified, resident may keep the medications
in locked storage in their bedroom.
481 IAC 58.21(14)(m-n)
91
Acceptance or Refusal of Care and Treatment
Federal Law
A resident has the right to:
• Refuse treatment
• Refuse to participate in experimental research
• Formulate an advance directive (POA, Living
Will)
42 CFR 483.10(b)(4)
92
Acceptance or Refusal of Care and Treatment
Iowa Law
Each resident has the right to refuse treatment.
If resident is not able, the legal decision maker may
participate in the planning of the resident’s total
care and medical treatment.
481 IAC 58.39(9)
93
Personal Funds
Federal Law
Upon written authorization of a resident, facility must
hold, safeguard, manage, and account for the personal
funds of the resident deposited with the facility.
No co-mingling of funds.
Financial record must be available through quarterly
statements and on request to resident or legal
representative.
42 CFR 483.10(c)
94
Personal Funds
Iowa Law
Resident has right to manage their own personal financial
affairs.
If resident authorizes facility to manage finances:
• Resident shall be given funds upon request with
receipts maintained by facility; or
• Legal decision maker shall designate method of
disbursing resident’s funds.
481 IAC 58.42
95
Involuntary Discharge: Due Process
Federal Law
Transfer or discharge only appropriate when:
• Necessary for resident’s welfare and resident’s needs cannot
be met in facility
• Resident’s health has improved sufficiently so the resident no
longer needs the services provided by the facility
• Safety/health of individuals in the facility is or would
otherwise be endangered
• Failure to pay
• Facility closes
42 CFR 483.12(a)(2)
96
Involuntary Discharge: Due
Process
Federal & Iowa Law
Facility must notify resident (and family member/legal
representative) in writing of the transfer/discharge and include
reasons for the move in a language and manner they understand
30 days before planned transfer.
Written notification must include:
•
•
•
•
•
Reason for transfer/discharge
Date
Location to which resident is transferred/discharged
Statement re: right to appeal
Name, address and telephone number of ombudsman
42 CFR 483.12(a)(4)-(6)
97
Visitation
Federal Law
The resident has the right and the facility must
provide immediate access to any resident by
immediate family, other relatives, or other visitors
subject to the resident’s right to withdraw consent
at any time.
42 USC 1396(r)(3)(c)
42 CFR 483.10(j)(viii)
98
Visitation
Iowa Law
A visitor may be restricted by the facility when:
• The resident refuses to see the visitor
• The resident’s physician documents specific reasons
why such a visit would be harmful to the resident’s
health;
• The visitor’s behavior is unreasonably disruptive to
the functioning of the facility.
Iowa Code 135C.14(8) (2013)
481 IAC 58.47(2)
99
Power of Attorney
Is the Power of Attorney…
A document
OR
An actual person?
100
Power of Attorney
Responsibility of Attorney-in-Fact as a fiduciary:
• Act consistently with the desires as stated in
the document or otherwise made known by
the principal.
• Where Principal’s wishes are unknown, act in
his or her best interest.
Iowa Code 144B.6(2)(2013)
101
Power of Attorney
Fiduciary (adjective): involving trust, especially
with regard to the relationship between a
trustee and a beneficiary.
Principal (noun): a person who employs another
to act as his agent.
Iowa Code 144B.6(2)(2013)
102
Power of Attorney (POA)
POA for Health Care Decisions
• A document authorizing an attorney-in-fact to make health
care decisions for the principal if the principal is unable, in
the judgment of the attending physician, to make health
care decisions.
POA for Financial Management Decisions
• A document authorizing an agent to make financial
management decisions for the principal immediately or if
the principal is unable.
Iowa Code 144B.1(2013)
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Visitation
Resident’s Right to Refuse Visitor
• This right to refuse a visitor does NOT transfer to
the attorney-in-fact.
• Why? The decision to allow access to a resident
is not a health care decision.
• “Health care decision”: the consent, refusal to
consent, or withdrawal of consent to health care.
• “Health care”: any care, treatment, service, or
procurement to maintain diagnose, or treat an
individual’s physical or mental condition.
Iowa Code 144B.1(5)(2013)
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Competency v. Capacity
• Competency: Competency is a legal
finding. Competency proceedings
(guardianship and conservatorship
hearings) are conducted to allow the
court to determine mental capacity.
105
Competency v. Capacity
• Incompetency: Lack of ability to
implement or understand either health
care or financial management decisions.
Incompetence is declared by the court
when an individual is in need of a guardian
or conservator. This determination is
made only after the individual meets the
proper “standards” under Iowa law.
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Competency v. Capacity
• Capacity: The ability to understand the nature and effect of
one’s acts.
• Capacity to consent to medical procedures is determined by
the criteria of informed consent. Does the patient have the
ability to:
• Understand the medical procedure and specifically
understand a description of the procedure, its risks, its
benefits, and its alternatives?
• Voluntarily consent because he/she is competent
(meaning, he/she does not have a guardian)?
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Residents’ Rights Review
BINGO!
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Sexual Activity in Older Adulthood
• Sexuality: It’s an important component of wellbeing throughout life!
• Backseat Bingo
• Decrease in sexual functioning; not in
desire/interest
• Intimacy may be more valued than sexual activity
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Sexual Activity in Older Adulthood
• Barriers to intimacy in Long-term care
• Lack of privacy, family attitudes, negative past
experiences, fear of staff reaction/ostracism,
embarrassment, differences in
beliefs/values/sexual preference
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Depression is not a normal part of aging
• A person who is clinically depressed experiences an
unusually sad mood and/or loss of enjoyment and interest
in activities that used to be enjoyable nearly every day for
at least two weeks. They may also experience:
• Lack of energy
• Feelings of guilt and worthlessness
• Difficulty concentrating or making decisions
• Sleep difficulties
• Changes in eating habits
• Thinking often about death or wishing to be dead
Mental Health First Aid USA, 2009
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Depression: What to do
• If the resident is stating or hinting they are
suicidal, seek help immediately.
• Listen nonjudgmentally.
• Give reassurance/information.
• Encourage appropriate professional help.
• Encourage self-help and other support
strategies.
Mental Health First Aid USA, 2009
112
Depression and Cognitive Impairment
• A correlation: Depression and Dementia
• Increasing stages of dementia severity associated
with higher risk for depression (Volicer et al.,
2012)
• A few options:
• Evaluation by a physician
• Identify and incorporate favorite
pastimes/hobbies
• Family and friendships
• Physical & social activity where possible
• Diet
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The Dementia Umbrella
• Dementia is not a normal part of aging
• Dementia is a group of symptoms that may be
present in certain conditions or diseases
• Results in a decline of cognitive function so severe it
interferes with daily activities including:
• Memory loss (especially short term)
• Personality changes
• Mood swings
• Confusion
• Decline in problem-solving skills
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The Dementia Umbrella
Alzheimer’s Disease
• Accounts for 60-80% of dementia cases
• Progressively robs individual of memory,
learning ability, communication skills, capacity
for self care
• Typically, symptoms appear after age of 60
• Seven stages
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The Dementia Umbrella
Vascular Dementia – 10%; impaired decision
making
Lewy Body – powerful hallucinations
Parkinson's Disease Dementia – problems with
movement
Frontotemporal Dementia – symptoms develop
at younger age
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Residents’ Rights in CCDI Units
Residents in Chronic Confusion or Dementing
Illness (CCDI)/memory care units have the
same rights as other residents.
• Right to citizenship
• Right to privacy and confidentiality
• Right to dignity and respect
• Right to make independent choices
• Right to visits
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Communication tips we already know!
Use the same concepts for communication
w/other residents
Approach from the front
Introduce yourself
Visit at eye-level
Speak to adults as adults
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Communication tips we already know!
Use the resident’s name
Avoid outside noise and glare
Be aware of your body language
If unsure, ask staff how to communicate best
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Additional communication strategies
• Do not debate or disagree with the resident.
It’s real for them.
• Allow more time for a response:
• If repeating is necessary, use exactly the same
words
• The third time, try other words
• Supply words you think they mean as a last
resort
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Additional communication strategies
• For residents who are difficult to understand, a
few words can help you understand what
they’re trying to tell you—reflect that you are
trying to and want to understand them.
• Promote reassurance by confirming the
emotional message even if you can’t
understand what is being said.
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When words fail…observe
• Is the resident comfortable, clean, and cared-for?
• Is this a calm and happy place to call home?
• Does staff take time to get to know each resident on a
personal level so residents’ wants and needs can be
understood?
• Does staff make appropriate adaptations to their
speech and body language to help each resident?
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When words fail…observe
•Does it appear residents are given the
opportunity to be active/engaged?
•Could changes in the environment make a
difference?
•Does there appear to be enough staff to meet
residents’ needs?
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Scenarios!
1) A resident tells you that there is a man who
comes into his room at night and makes a lot
of noise.
2) A resident tells you they have to sometimes
wait an hour for their call light to be
answered, and so they have accidents.
3) A female resident tells you that they are
upset that sometimes a male aid assists with
her personal cares.
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Abuse and Neglect
“Every person-no matter how young or how
old-deserves to be safe from harm by those
who live with them, care for them, or come in
day-to-day contact with them.”
(American Psychological Association)
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Prevalence of Elder Abuse
Elder Abuse is grossly under-recognized and underreported
• 2.1 million older Americans are victims of
physical, psychological, other forms of abuse
and neglect (APA, 2012)
• Estimated that more than 80% of cases go
unreported
• 40% of all elder abuse involves some form of
financial exploitation
• Older adults with impairments are at greater
risk for becoming victims of abuse and neglect
126
Prevalence of Abuse
• 2/3 of elder abuse perpetrators are adult children or a
spouse; 90% are other family members
• An adult child can financially exploit a parent if they assume
their parent’s money ultimately goes to them anyway
• An “inheritance” is not an “inheritance” until the
person to whom the money or other assets belong
passes away AND it is willed to that child
• Elder abuse and dependent adult abuse can occur within a
long-term care facility just as it can in a person’s home
127
Elder Abuse Legislation
In 2014, Iowa Law now provides a definition for elder abuse, as well as
a process to establish a protective order for victims or potential victims
of elder abuse.
“Elder abuse” means any of the following:
(1) Physical injury…unreasonable confinement, unreasonable
punishment, or assault of a vulnerable elder…
(2) The commission of a sexual offense…
(3) Neglect which is the deprivation of the minimum food, shelter,
clothing, supervision, or physical or mental health care, or other
care necessary to maintain a vulnerable elder’s life or health by a
caretaker.
(4) Financial exploitation.
SF 2239
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Elder Abuse vs.
Dependent Adult Abuse
• Elder Abuse
• Age 60+
• Definition and protective order process in
Iowa Code
• No registry as of yet
• Court civil action/protective order (no state
agency to report to yet)
• Area Agencies on Aging can be contacted for
resources
129
Elder Abuse vs.
Dependent Adult Abuse
• Dependent Adult Abuse (DAA)
•
•
•
•
•
Age 18+
Victim must be dependent
Caretaker must be perpetrator
Registry
Report to Dept. of Human Services or DIA
130
Am I a Mandatory Reporter?
• No, you are a permissive reporter, meaning:
• People in the community, family, and
friends who aren't required by law to
report abuse.
• There are no specific guidelines about
what you have to do or don't have to
do.
131
Am I a Mandatory Reporter?
• We are permissive reporters because our
utmost concern is the resident’s right to
confidentiality and we always seek their
permission to advocate for them.
• However, we don’t ignore abuse. If you see
or suspect abuse, neglect, or exploitation
contact the VOP Coordinator immediately!
132
Possible signs of Abuse in LTC
While one sign does not necessarily indicate abuse,
some tell-tale signs that there could be a problem are:
• Bruises, pressure sores, broken bones, abrasions,
burns
• Unexplained withdrawal from normal activities,
sudden change in alertness, unusual depression
• Behavior such as belittling, threats, and other uses
of power and control
Ask open-ended questions if you notice any of these
signs.
133
Possible signs of neglect in LTC
• Staff ignore personal hygiene requirements
(e.g., not helping a resident get to a
bathroom)
• Staff ignore a resident’s call light or not
responding in a timely manner
• Staff fail to contact a resident’s physician
when necessary
134
Possible signs of neglect in LTC
• Resident is dehydrated or malnourished—
extreme weight loss
• Unsafe or unsanitary living conditions
• Unsupervised wandering
• Untreated health conditions
135
Possible signs of
Financial Exploitation in LTC
• Resident is inaccurate, confused, has no
knowledge of finances
• Others express unusual interest in the amount
of money being expended for the care of the
resident
• Unpaid bills when resources should be
adequate
136
Your role…
Be alert! The suffering is often in silence.
If you notice changes in a resident’s personality or
behavior, you should start to question what is going
on.
Remember, it is not your role to verify that abuse is
occurring, only to alert the VOP Coordinator of your
suspicions as soon as possible.
137
Federal Volunteer Protection Act
(Public Law 105-19)
The Volunteer Protection Act (VPA) provides immunity for
volunteers serving nonprofits/ governmental entities for
harm caused by their acts or omissions if:
• The volunteer was acting within the scope of his or her
responsibilities
• If appropriate or required, the volunteer was properly
licensed, certified or authorized to act.
• The harm was not caused by willful, criminal or reckless
misconduct or gross negligence.
• The harm was not caused by the volunteer operating a
motor vehicle, vessel, or aircraft.
138
Federal Volunteer Protection Act
(Public Law 105-19)
Exceptions to liability limitation include misconduct
that is a(n):
• Crime of violence
• Hate crime
• Sexual offense
• Violation of federal or state civil rights law
• Act committed under the influence of alcohol or
drugs
In short—follow our program rules and you should be fine!
139
Two Men Meet on the Beach
-“Good evening. What are you doing?”
-“I’m throwing starfish back in the ocean. If I don’t they’ll die
here on the sand.”
-“But there must be a thousand starfish on this beach. You
can’t possibly get to enough of them to make a difference.”
-Smiling, the man picked up another starfish and threw it into
the ocean, saying, “well, I made a difference to that one.”
140
Wrap up and next steps…
Before you leave!
• Confidentiality
agreement
• Background check
forms
• Photos
Next steps…
• Review your manual
• Take “The Aging
Process” quiz
• Follow up phone call
with VOP Coordinator
• Certification
• Orientation
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