Physical abuse is any harm, whether unintentional or intentional in which a patient’s body is harmed. This includes slapping, punching, kicking, biting, cutting, bruising, burning, spitting at, pushing, shoving, restraining a person, or handling a person in a rough manner. Physical abuse includes forcing a patient to do something they do not want, such as eat or bathe.

Emotional Abuse

Emotional abuse is abuse that occurs through emotionally causing harm to a person. This includes name calling, yelling at, humiliating, threatening, intimidating, insulting, making fun of a person, treating a person like a child or as if they are unable to think or make their own decisions. Threatening a person in order to make them do something or to not tell on you for something you did or for threatening the patient is also considered emotional abuse. Threatening to take away a patient’s belongings, time spent engaging in pleasurable activities, or to isolate a patient (such as put them in a locked room alone) are all considered emotional abuse.

Financial Abuse

Financial abuse is abuse that occurs with regard to a patient’s finances. This includes stealing money or property, improperly using a person’s money for things other than the intended purpose, taking advantage of a person’s finances, and threatening to cause physical/emotional harm if a person does not give a person their money.

Sexual Abuse

Sexual abuse is abuse that occurs when a person is touched in a way in which they do not wish to be touched. This includes fondling, unwanted touching, and any unwanted sexual activity. Sexual abuse also includes exposing oneself to a person and showing someone pornographic materials that they do not wish to see, or taking pornographic pictures of a person without their consent.

Domestic violence

Domestic violence is abuse that occurs by spouses, intimate partners, or family members. It can include any type of abuse discussed above, such as physical abuse, emotional abuse, financial abuse, or sexual abuse.

Neglect

Neglect is when a person is harmed by a caregiver, (whether it is a family member or a healthcare worker), when the caregiver fails to provide necessary care. This includes failing to clean a patient up who is soiled, failing to bathe a patient, failing to provide food or fluids to a patient, and failing to turn and position a bedridden patient. Neglect can be just as harmful as abuse. Remember, a patient depends on their HHA/PCA to provide them with the care they need to live.

Reporting Abuse & Neglect

Home Health Aides/Personal Care Aides must NEVER abuse or neglect a patient in any way. they must also work to protect their patient from abuse/neglect by others, and report ANY suspected abuse/neglect immediately to their supervisor.

Signs of abuse and neglect to report:

• New or unexplained bruises
• Marks that look like they were made from belt straps, buckles, objects, or teeth
• Burns that are unexplained or that are in unusual shapes or places
• Bruises, bleeding, discharge, pain, or swelling in the genital area
• Fractures, dislocated bones, new limping or inability to put weight on a leg or use an arm
• Pressure ulcers and skin tears
• Unexplained mood changes, especially during or after visits from family
• Clothing that does not fit, is torn, dirty, or inappropriate for the weather
• Unsafe and unclean living conditions
• Weight loss, poor appetite, or if the patient appears to be hungry and not well fed
• Bedding and incontinence briefs that are always soiled and appear to have not been changed in a long while
• Rashes, pain, redness in the perineal area (area between the genitals and anus) from lack of cleaning the patient after they have voided
• Violence in the home that a HHA/PCA witnesses including physical or emotional abuse
• Comments made by the patient that indicate abuse or neglect, including reports of family members stealing or using the patient’s money inappropriately

Remember, Home Health Aides/Personal Care Aides are legally responsible for reporting any suspected abuse/neglect. Failure to report suspected abuse/neglect, or actually engaging in any type of abuse/neglect can result in legal and criminal action against a Home Health Aide/Personal Care Aide. They should document their observations of abuse and contact their supervisor to report their findings. They must use their senses-what did they hear, see, smell or touch that indicates abuse may be or is occurring? They should not be judgmental in their reporting and should not try to interpret what they think is going on. If abuse is suspected or observed, a report is made by making a phone call to a local Child Protective Services or Adult Protective Services agency. When making the report, Home Health Aides/Personal Care Aides will be asked for specific information about their observations. Remain calm and report only the facts. They may also be asked to provide a written report. their agency will provide them with specific training and guidelines for reporting abuse.

Introduction to Patient’s Rights

The American Hospital Association developed a Patient Bill of Rights, which should be provided by the agency to every person in their care. Patients also have a right to have the Patient Bill of Rights explained to them, and a copy provided to them in a language they understand.(Adapted from the American Hospital Association, 1992)

1. The patient has the right to considerate and respectful care.
2. The patient has the right to obtain understandable information about their diagnosis, treatment, and prognosis. They have a right to be informed about the risks and benefits of all services and treatments received. Patients also have a right to know the identity (name, license, and health care provider role) of all people involved in their care (doctors, nurses, home health aides/personal care aides).
3. The patient has a right to make decisions about the plan of care before receiving treatment. The patient also has the right to refuse any treatment, and to be informed about the medical consequences of refusing treatment. If the patient refuses a specific treatment or care, they still have the right to receive other care services, or to be provided with referrals to services outside of the agency or organization. The patient has the right to participate in the planning of their healthcare and to be informed of any changes in the plan of care prior to the change being made.
4. The patient has the right to have an advanced directive or to designate a health care proxy to make decisions for them if they are unable to do so themselves.
5. The patient has a right to privacy.
6. The patient has a right to expect that all communications and records pertaining to their health and health care will be kept confidential by their healthcare providers, except in cases of suspected abuse and public health hazards when reporting is permitted or required by law.
7. The patient has a right to review their health care records and to have the information explained, except when restricted by law.
8. The patient has a right to expect that within its capabilities an agency will make reasonable responses to a patient’s requests for medically indicated care and services. If an organization is unable to accommodate such requests, the patient has the right to transfer to another organization which may be able to provide such requests.
9. The patient has the right to ask and be informed of any business or financial relationships that exist within the organization which may influence their care.
10. The patient has the right to consent or decline participation in research studies, and to be provided with a full explanation about participation in such studies.
11. The patient has the right to receive continuity of care and to be informed when such care cannot be provided.
12. The patient has the right to be informed of policies and procedures that relate to their care. The patient has the right to be informed of the method they should use to resolve any discrepancies, conflicts, or grievances they may have. They have the right to know the procedure for making complaints if they feel they have not been given the care they deserve. The patient has the right to make complaints without fear of discrimination or negative repercussions for doing so. The patient also has the right to be informed of any charges for services and available payment methods and insurances accepted. This includes being made aware of services not covered by Medicare and Medicaid, and what charges they may be liable for.

Patient’s Responsibilities

(Adapted from the American Hospital Association, 1992) As the most important partner in the healthcare team, the patient also has certain responsibilities.

1. The patient is responsible for providing information about their health, hospitalizations, medications, changes in symptoms or health condition. Patients should ask questions and ask for additional information about their health and treatment.
2. The patient is responsible to inform their health care provider about their advanced directives and health care proxy and to provide them with a written copy. They are responsible for informing the health care provider about any changes they may make to their advanced directives or healthcare proxy.
3. The patient is responsible to inform their health care providers if they expect problems with the treatment and services they are to receive. This includes informing the provider if home visits need to be changed.
4. The patient is responsible for being aware of the organizations policies and procedures and to make reasonable accommodations to meet the needs of the organization.
5. The patient is responsible for providing necessary insurance and financial information to the organization in order that payment may be made for services rendered, and to make payment arrangements as necessary.
6. The patient is responsible for informing the health care provider of any dissatisfaction with their services.
7. The patient is responsible for carrying out mutually agreed upon responsibilities.
8. The patient is responsible for providing a safe environment for the health care to be provided.

How a Home Health Aide/Personal Care Aide Support a Patient’s Rights

1. Never abuse a patient in any way. Complete all tasks and provide excellent care for patients. Never neglect their care.
2. Report any suspected instance of abuse or neglect to a supervisor immediately.
3. Keep all patient information confidential. Never discuss patient information in a public place.
4. Do not gossip about a patient to friends or family. Never discuss patient information with people outside of the health care team.
5. Never leave patient records unattended. If using a computer, use a protected password. Close the browser and log out of a patient’s record before walking away from the computer.
6. Don’t leave messages with identifying patient information on voice mail messages or with people who are taking messages.
7. Don’t put patient identifying information in emails. Do not keep patient information on a personal computer or other personal electronic devices.
8. Shred documents as the agency directs. Never throw documents with patient identifying information out in the regular garbage.
9. Do not take pictures while at a patient’s home. Do not take pictures of a patient with a personal camera. Do not take photos of a patient’s home or belongings.
10. Do not share information about a patient or their family on social networking sites. Never discuss patient names, addresses, or information with which others could identify who a patient is.
11. Never tell or bring a family member or friend to a patient’s home during or in between work hours.
12. Always knock on a patient’s door before entering the house or a room they are in.
13. Never open or read a patient’s mail.
14. Call the patient by their preferred name. Don’t use baby talk with adults.
15. Involve the patient in the planning of their care and let them make choices and complete any task independently that they can.
16. Never automatically touch a patient or complete a task without seeking permission first.
17. If a patient refuses a service or treatment, respect their right to do so. Document and report the refusal.
18. Do not accept gifts or money from a patient or their family.
19. If you shop for groceries or other items for a patient, use the money as directed.
20. Document all care provided carefully, timely, and truthfully. Be accurate with the amount of time provided care. Never document care that was not provided.

Introduction to Advanced Directives

Advanced Directives are legal documents that allow a person to choose the type of medical care they wish to receive should they become unable to state their choices and make decisions in the future. An advanced directive is a legal document that tells a healthcare provider the type of treatments a patient wishes and does not wish to receive. They also allow a patient to select an individual(s) to make decisions for them should they be unable to do so.

Living Wills

Living wills are a type of an advanced directive. They explain the type of medical care a patient wants and does not want to receive should they be unable in the future to make decisions for themselves. A living will is not the same as a last will and testament. A last will and testament is a legal document that delegates a person to be an executor of their estate and explains how a person wishes to have their property and possessions disposed of after their death. A living will is only about medical care and treatment. Laws about living wills vary from state to state. Examples of what a person may include in their living will might be decisions about:

• Being artificially fed through a vein or stomach
• Having a tube inserted down their throat for mechanical ventilation
• CPR
• Blood transfusions
• Dialysis

Durable Power of Attorney for Health Care (Health Care Proxy)

A health care proxy is someone who the patient designates to make decisions for them in the future should they be unable to do so. A health care proxy is a type of advanced directives. A health care proxy is not the same as an executor of a will. A patient can have one person as the executor of their will and a completely different person designated as their health care proxy if they choose. A health care proxy can make decisions for a patient’s health care if the patient is unable to do so. A health care proxy is responsible for carrying out a patient’s wishes and for following a living will. If the patient has not made a living will, the health care proxy is responsible for making decisions on behalf of the patient according to what they believe is in the best interests of the patient.

Laws about health care proxies and the decisions they can make vary from state to state. Most states do not allow a doctor or other health care provider to be a patient’s health care proxy. Home Health Aides/Personal Care Aides should not agree to be their patient’s health care proxy. This would be a boundary violation.

Do-Not-Resuscitate (DNR)

A Do-not-resuscitate (DNR) is another type of advanced directive. A patient who has a DNR has made a decision to not receive CPR (cardiopulmonary resuscitation). This means that should the patient’s heart stop, or if the patient stops breathing, that the health care providers are not allowed to perform CPR. A DNR order is an order that is written by a physician after the patient has discussed their wishes with their doctor. If a patient has a DNR order and a health care provider performs CPR knowing there is a DNR order, legal consequences can occur against the health care provider. It is important to know whether your patient has a DNR order in place.

Having a DNR order does not affect any other treatments the patient receives. This means that a patient can continue to receive treatments such as medications, surgeries, physical therapy, and all other medical interventions. A DNR order only applies to whether or not your patient would like CPR performed should their heart stop or if they stop breathing. A health care proxy or family member cannot have a DNR order removed if it was already in place, based on the patient’s wishes and discussion with their doctor. This means that even a patient’s health care proxy cannot revoke (have removed) a DNR order if the patient had one in place before they became unable to make their own choices.

Confidentiality

Confidentiality means keeping what is supposed to be private, private. It means not disclosing (telling) other people who do not have a right to know information about the patient. Protecting a patient’s confidentiality means not sharing information with others (outside of the health care team) who the patient does not want to know the information. Home Health Aides/Personal Care Aides will come to know intimate details about their patient’s body and lives. They must take every step that they can to protect this privileged information. They have an ethical and a legal responsibility for protecting the privacy of their patient. A good rule of thumb to use before sharing patient information with members outside of the healthcare team is to ask :

• Does this person have a right to know this information?
• Did the patient give me permission to share information with this person?
• Would sharing this information be harmful to the patient?
• Would I want someone to know this information if it were me?

Health Insurance Portability and Accountability Act (HIPAA)

In 1996, the Health Insurance Portability and Accountability Act (HIPAA) was passed by Congress. This law is designed to protect people’s privacy with regard to their health and health care. This law gives people rights over the medical information, including the right to receive a copy of their medical records, the right to correct incorrect information in their medical record, and the right to control who has access to their records. You can read more about privacy rights of HIPAA at the U.S. Department of Health and Human Services website: http://www.hhs.gov/ocr/privacy/hipaa/understanding/

Legal Ramifications for HIPAA Violations

If health care workers violate a patient’s privacy, they and/or their agency or the organization for which they work can be fined or imprisoned. The American Recovery and Reinvestment Act of 2009 established a penalty structure for HIPAA violations. Civil and criminal penalties can result if an individual health care worker and/or a health care agency does not comply with HIPAA. According to the American Medical Association, fines can range from $100 per incident in a case where the worker was not aware of making a violation to $50,000 for violations which are willful (on purpose) and are not corrected within a specified time frame. Imprisonment sentences can range from one year to up to ten years.