Kimberly Bonvissuto
January 17, 2025
Resident fears of retaliation from staff members for voicing concerns about care and services are common but preventable in assisted living communities and nursing homes, according to a new report from a gerontology expert.
The report, “A Bridge Over Scary Water,” documents instances of resident retaliation, along with barriers in addressing resident fears, from ombudsmen across the nation. Eilon Caspi, PhD, a gerontologist and elder mistreatment researcher and adjunct clinical professor with the University of Minnesota, working with Mairead Painter, Connecticut long-term care ombudsman, surveyed 50 ombudsmen from 32 states about what they are seeing in their interactions with residents and communities.
“My biggest message to administrators is that ombudsmen genuinely want to take a collaborative approach to improve residents’ quality of life, care and safety” offering training and technical assistance, Caspi told McKnight’s Senior Living. “I wish more administrators and corporate offices would see the ombudsman as an asset as opposed to an adversary. It will serve them in the short and long term.”
Providers must learn to appreciate the role of the ombudsman if residents are to realize their rights to dignified and safe care, he said. Rather than viewing ombudsmen as police there to find a “gotcha” moment, Caspi added, assisted living communities should adopt a more collaborative approach.
“My biggest message is to help them realize their mission, and at the end of the day, it’s a singular mission,” he said. “It’s the residents, their well-being, dignity and safety.”
Caspi, founder and director of Dementia Behavior Consulting in Connecticut, told McKnight’s Senior Living that his quality improvement project aimed to identify strategies and barriers in addressing resident fears of retaliation — as well as actual retaliation — when they voice care concerns in assisted living and nursing homes. Caspi said the project findings could be used to improve ombudsman educational efforts, resident-driven advocacy and systems advocacy.
The impetus for the project, he said, was previous research from the University of Connecticut finding that 23% of nursing home residents were fearful of retaliation if they expressed care concerns. Caspi began reviewing investigations into assisted living and found retaliation fears in that setting as well, which led to the most recent project.
Weak regulations in assisted living
Unlike nursing homes, which are regulated at the federal level, assisted living primarily is regulated at the state level, leading to varying regulatory requirements, protections and enforcement, Caspi said. In addition, ombudsmen visit nursing homes substantially more than they do assisted living communities.
“Our presence is our superpower,” Caspi said, quoting an ombudsmen surveyed for the project. When present, he added, an ombudsman can take many actions to help residents have their voices heard, educate them about their rights, and empower them.
One area of concern in assisted living is fear of retaliatory discharges, due to weak regulatory protections against involuntary discharges. Caspi’s paper documented cases of residents not speaking up or not asking for more support out of fear of being moved into a nursing home or not being able to afford extra services.
Ombudsmen responding to the survey said that “weak and harmful” state regulations or rules are the result of a strong lobby that has created a barrier to systemic change. Respondents identified a series of gaps in state regulations in assisted living, including inconsistent quality measures, a lack of consumer protections and nonexistent disclosures of services.
“Assisted living is just a title,” one respondent said. “Assisted living is something somebody in marketing brought up — kind of makes you feel warm and fuzzy.”
Caspi said the issues highlight a need for consumer education. Many residents and their families don’t know of the existence of their state ombudsman, and they don’t understand that they have rights.
The other factor contributing to resident retaliation, he said, is the growth of workforce challenges in senior living and care, something Caspi calls “the elephant in the room.” Continuous staff turnover leads to stress, which leads to retaliatory behaviors, he said. Caspi said the survey showed a clear link between poor staffing levels and resident fears of retaliation for their voicing care concerns.
A 2023 report from Argentum, “Workforce Projections for Long Term Care Sectors,” showed a need to recruit more than 3 million direct care and other workers by 2040 in senior living, part of 20 million workers needed across all of long-term care.
State ombudsman programs have their own staffing challenges, however. A 2024 report from the US Government Accountability Office said that a “booming” assisted living industry is placing a burden on state long-term care ombudsman programs, which are stretching their resources to cover those extra units without any additional staffing or assistance.
Strategies for addressing resident fears
Caspi’s paper identified dozens of strategies for addressing resident fears of retaliation, including a focus on ombudsmen’s top three roles: education, system advocacy and resident advocacy.
Ombudsmen should inform residents and families about their rights and empower residents to advocate for themselves, according to the paper, which also recommends that all assisted living and nursing home staff members be educated about resident rights and how to collaboratively resolve issues before they rise to the level of abuse.
Providers should view care-planning meetings as a way to avoid communication “leakage or breakdown” and as an opportunity for direct care staff members, administrators, residents and family members to discuss issues and come to a meaningful solution that involves respect, Caspi said. Ombudsmen, he added, work as a “magnifying glass,” coming in to slow down the fast-moving pace of decisions being made in a community by gathering information, talking with all affected parties and coming up with a plan.
“Ombudsmen can be good in identifying the root cause of something and working collaboratively to resolve it,” Caspi said. “They work collaboratively in a solution-oriented way to resolve something to the resident’s satisfaction.”
As far as system advocacy, according to the report, ombudsmen should identify systemic issues across the sector in a state, going to the legislature and advocating for the passage of laws to address the issues. In 2012, Connecticut was the only state that required all nursing home staff members to be trained on the definition of retaliation and how it can be identified, reported, prevented and investigated. Illinois recently passed a similar law, but Caspi said that no such requirements exist for assisted living.
Caspi also said that federal and state regulations must be strengthened across the board, starting with admission requirements and moving all the way through to the discharge processes, including staffing levels and administrator qualifications.
“Meaningful care plans are at the heart of it all,” he said.
Looking forward, Caspi said he is anticipating additional funding to develop a resource guide for senior living and care residents, families, staff members and managers with more practical, hands-on resources. He also plans to update Connecticut’s annual staff member in-service program on resident regulation, as well as produce a new educational film on resident retaliation.
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