SUFFERING IN SILENCE: HAWAI'I'S ELDERLY VICTIMS
Abuse of elderly called state's 'hidden epidemic'
Alfred Micallef, 81. Retired electrician for Ford Motor Co. Died after assault in Kalihi Valley care home.
Chiyeko Tanouye, 79. Retired Diamond Bakery clerk. Died of septicemia in Pearl City care home.
Torao Nishimoto, 86. Retired carpenter. Suffered from broken hip, pneumonia and decubitus ulcers.
| • | Man's death sad but not unusual |
| • | Counting up the cases of neglect |
| • | Elderly care takes place mostly in caregivers' own homes |
By Mike Gordon
Advertiser Staff Writer
Each death was an end to suffering and humiliation.
Tomorrow Tuesday
The 84-year-old great-grandmother stranded on the floor of her home for three weeks, encrusted with her own waste. The 86-year-old woman who died of starvation because her caregiver failed to bring her food. The 86-year-old Hilo man died as many as three days after suffering from a fractured hip.
Today
Elder abuse on the rise
Lack of legislation hinders elder safety
Finding solutions
Their emaciated bodies were a collage of pressure sores, some of which were so infected that doctors could see bone, even maggots.
And there were others.
At least 10 times since 1999 — and five times within the past year — Hawai'i's oldest and frailest residents officially died of neglect or abuse. Medical experts suspect the actual number of such deaths is much higher.
Over the past decade, for example, death certificates filed at the state Department of Health listed decubitus ulcers — pressure sores that can poison the blood and are most associated with neglect — as an underlying cause of death for 33 people who were 65 or older. But for most of that time, nobody was fully trained to recognize what those ulcers meant.
Bruce Asato • The Honolulu Advertiser
In death, the 10 victims have become the most tragic examples of a hidden epidemic slowly gaining recognition in Hawai'i and throughout the nation. They are the gaunt face of elder neglect and abuse.
Dr. Kanthi von Guenthner, chief medical examiner of the City and County of Honolulu, wants the agencies her office deals with to grow more attuned to signs of elderly neglect.
And even though new laws and rules have repeatedly been proposed over the years that would help protect the elderly, Hawai'i government officials have failed to enact them. The problems include:
- The failure by state officials over three years to make rule changes to allow unannounced annual inspections of the state's 545 licensed adult residential care homes, even though at least 25 other states have done so.
- The inability of lawmakers in the past four legislative sessions to pass a measure requiring criminal background checks for people who work in care homes. Hawai'i is one of 14 states that does not require that criminal background check.
- The rejection of recommendations proposed by a governor's panel more than two years ago that would have made more of the elderly population eligible for protection.
- A limited review of potential criminal cases undertaken until the state attorney general recently decided to examine a broader selection of potential cases and a new Honolulu medical examiner was emotionally moved to raise awareness in the hopes she could save lives. But in the three years since it has undertaken that closer review, the attorney general's office cannot say how many elder abuse cases have been prosecuted.
- Penalties that lack any legal bite. In the 2001 legislative session, an attempt failed to create a Class C felony for crimes where a care home operator knew that harm could come to a resident.
That leaves prosecutors armed most often with a misdemeanor charge as the strongest penalty they can apply.
For example, a Big Island care home operator was found guilty last August of not seeking medical help for Torao Nishimoto, the 86-year-old Hilo man who died after suffering a fractured hip and contracting pneumonia. Because the charge was a misdemeanor, the care home operator faced a maximum of one year in jail and a $2,000 fine.
In another case, an 80-year-old woman at a licensed care home was beaten with a cane by another resident. The owner admitted leaving the home unattended. She was charged with a misdemeanor, but the charges were eventually dropped after she stayed out of legal trouble for a year.
Even when prosecutors charged care home operator Raquel Bermisa with manslaughter for the neglect-related death in August 1999 of 79-year-old Chiyeko Tanouye and she was sentenced to 20 years in prison in January 2001, the full punishment did not stand.
In December, then-Gov. Ben Cayetano commuted Bermisa's sentence to four years. Cayetano explained that a 20-year-sentence for Bermisa was too harsh and pointed out that prosecutors at one time had sought no more than a year in jail as part of a plea bargain.
Elder abuse is a general term for the mistreatment of elderly people and includes a variety of categories that are covered by the state's Dependent Adult Protective Services Act. The state Department of Human Services oversees the investigation of abuses of dependent adults. Professionals and personnel in healthcare, social services, law enforcement and financial assistance are required to report suspected abuse or neglect to the state's Adult Protective Services Program. Physical abuse Occurs when someone hits you, pushes or shoves you or treats you roughly. Bruises, welts, skin discoloration and fractures are covered under the law. Sexual abuse Occurs if there is sexual contact or conduct by someone without your consent. Psychological or emotional abuse Occurs when someone calls you names, intimidates you, harasses you or threatens you. Financial or material exploitation Occurs when someone uses your money or personal belongings without your permission. Neglect Occurs if someone does not provide you with proper care — such as food, shelter or healthcare — and fails to carry out responsibilities as a caregiver. Self-neglect Occurs when you fail to take proper care of yourself and it threatens your health and safety. Source: Hawai'i State Executive Office on Aging
Marilyn Seely, director of the state's Executive Office on Aging, said cases of elder neglect and abuse "are grossly underreported" and licensed adult residential care homes are often to blame.
What is elder abuse?
"There are most likely others whose deaths or injuries were caused by inadequate care, but whose cases do not come to the attention of authorities," she said.
Most adult care is provided in private homes in Hawai'i, and the owners are licensed to care for a handful of residents. They are typically cheaper and most provide less skilled care than nursing homes, which are subject to unannounced inspections under federal law.
While most operators are "very caring and good," there are "far too many bad apples operating," Seely said.
Care home operators counter that they do the best they can under trying circumstances.
"These are loving, caring people who dedicate and sacrifice their lives and yet they are getting a bad rap," said Ron Gallegos, president of the 270-member Alliance of Residential Care Administrators. "These are the most underpaid, underappreciated people serving the public in this state. It takes a special kind of person to do this. It is very stressful."
Gallegos said he was not defending care home operators who neglect their clients.
"We don't need any people who are not caring and loving and diligent in doing the job properly because we are dealing with the fragile elderly," Gallegos said.
Nationally, no precise numbers exist on the extent of the problem, but the National Committee for the Prevention of Elder Abuse estimates that 4 percent to 6 percent of Americans 65 and older have been abused.
The study quoted most often — the National Elder Abuse Incidence Study, which was requested by Congress and released in 1998 — estimates there were nearly 450,000 victims of abuse and neglect in 1996. The study also found that for every reported incident of elder abuse, neglect, exploitation or self-neglect, approximately five go unreported.
In Hawai'i, that estimate of 4 percent to 6 percent would mean as many as 12,420 of the state's 207,000 older citizens have been victims.
The number of complaints of suspected abuse and neglect investigated and confirmed by the Adult Protective Services program for people 60 and older hit its highest level in 2002 for the past six years. APS reported that 381 cases were investigated and 157 were confirmed last year. Over six years, APS investigated 2,069 cases and confirmed 883 cases, or 42 percent.
Each complaint is investigated by an experienced social worker, who typically reports the case to police, even before confirmation. Linda Chun, an assistant program administrator in the state Department of Human Services, said the decision is based on interviews with the victim, alleged abuser and others.
"If it goes to the level of a crime like assault or fraud it will be investigated," she said.
When the problem is in a licensed care home, the Department of Health and attorney general's office are notified. If abuse or neglect are confirmed, care home owners can lose their licenses or be prosecuted, she said.
If problems are linked only to a family member, the social worker may try to resolve the situation, Chun said. Sometimes victims can be placed with another relative or in a licensed facility. The agency can also ask the court to freeze assets, prevent people from interacting with victims or revoke guardianship, if necessary, she said.
"Usually, we try to do things without going to the police," she said. "But if we try informal things and we are rebuffed, like going to a home and we can't get in, we call the police."
Law professor James Pietsch, director of the University of Hawai'i Elder Law Program, called elder abuse and neglect "a hidden epidemic" in Hawai'i.
"Our anecdotal evidence is that as many as 50 percent of people may be abused or neglected or exploited sometime in their life once they become elderly," Pietsch said.
Gregory Yamamoto • The Honolulu Advertiser
There are no specific state laws that address elder abuse, but there are several that can be used to protect the elderly, largely because much of the abuse directed at them can be considered criminal, Pietsch said.
According to Deputy Attorney General Michael Parrish, of the Medicaid investigations division, many potential abuse cases go unpunished because once a victim is taken out of a caregiver's home, the imminent harm is considered gone.
The most comprehensive law comes under the state's Dependent Adult Protective Services Act, in effect since 1991, which governs a program for reporting and investigation.
But Seely and Pietsch believe the law is narrow and contains language that limits who is protected. Authorities cannot get involved unless an individual is dependent on someone else for care and there is a chance that some form of abuse will happen again within 90 days.
Seely and Pietsch were part of a committee to study elder abuse appointed by Cayetano. After more than a year of work, their recommendations in December 2000 focused on changing who would be covered by the Adult Protective Services program.
They wanted to change the word "dependent" to "vulnerable" and allow for cases to be investigated before, rather than after abuse had occurred, Pietsch said. The elderly can be independent and still be vulnerable, such as when an adult child with substance abuse problems moves in and begins bullying mom and dad, Seely said.
The change was never considered because it was deemed too costly to implement.
"It became a resource issue," Seely said. "It has happened again and again and again over the last eight years. We have had to do more with less and cut back."
A House bill introduced this legislative session sought to remove the dependency criteria, but was held in committee. Again, cost was an issue: The Department of Human Services estimated it would need 20 new staffers and nearly $1 million to handle hundreds of new cases.
John McDermott, the state's long-term care ombudsman, whose job is to monitor, meet with and counsel Hawai'i's 8,400 seniors living in licensed care homes and nursing facilities, receives an average of at least one complaint a week about treatment in one of the state's 545 adult residential care homes. Often, the residents or their relatives do not want the ombudsman to report the case officially because they are afraid of retaliation from care home owners. Last year, the complaints covered a broad range of problems, including: • One resident who said he was often beaten with rolled-up newspapers. Abuse was confirmed and the resident moved, but his family did not want to officially report the home to state licensing officials. • Another resident said he had lost 60 pounds in a month because he was fed only at breakfast. A friend helped the man leave the home, but the resident was too afraid to report the case officially. • The residents of one home complained that they were bathed once a week, while dressed, with a garden hose, then left in the sun to dry. A neighbor reported the case, but withdrew the complaint because of fear of retaliation. • Alzheimer's patients at one home were tied to their beds so they wouldn't wander off. The ombudsman learned about the case three years after the fact, too late to file a complaint.
The rules governing annual unannounced inspections of licensed adult residential care homes have also proven difficult to change, despite three years of debate between the state and care home operators, who say that kind of inspection is an invasion of privacy.
Horror stories
Under current Department of Health administrative rules, care home operators on O'ahu are told the month and day of the week they will receive their annual inspection, but nothing more specific. On the Neighbor Islands, care home owners are told the week of the month, said Dianne Okumura, supervisor for the department's healthcare assurance section.
Former Health Director Bruce Anderson originally said he ordered unannounced annual inspections in November 1999 as a way to keep care home operators "on their toes."
Because other parts of that section of Health Department rules also were being discussed, Anderson allowed the existing practice to continue until the process was finished. In the interim, all affected parties debated the changes.
It was only last October that rules approving unannounced annual inspections were sent to Cayetano for review, but with the change in administration, they were never approved for public hearings, Okumura said. Health officials have had to re-submit the final draft to Gov. Linda Lingle.
"I have talked to care home operators and they disagree with this," Okumura said. "I have explained to them why we should be able to go in unannounced. It is not to impose on them."
Currently, there are two bills at the Legislature that require unannounced annual inspections. One calls for inspections in all facilities, while another makes it a law for care homes with the frailest of residents.
John McDermott, the state's long-term care ombudsman, said he receives at least one complaint a week about an adult residential care home.
McDermott, who does not conduct inspections, said his mission is to resolve problems by working with care home owners. If that fails, he reports the operators to Adult Protective Services or the Department of Health.
Without unannounced inspections, the agency's numbers "will never reflect the real magnitude of the problem" because so few of the elderly or their families are willing to make a case against a residential home, McDermott said.
"Remember, residents generally don't have access to a private phone, don't know who to call, are afraid of repercussions or being evicted, may have little family support or families that warn them to 'just get along,' so the number of reported complaints indicates very little," he said.
In the past year, the complaints to McDermott covered a broad range of problems:
- One resident said he was beaten with rolled-up newspapers. Abuse was confirmed and the resident moved, but his family did not want to report the home officially to state licensing officials.
- Another resident said he had lost 60 pounds in a month because he was fed only at breakfast. A friend helped the man leave the home, but a fear of retaliation prevented McDermott from officially reporting the care home.
- In one home, residents complained that they were bathed once a week, while dressed, with a garden hose and then left in the sun to dry. A neighbor reported the case after talking to residents, but withdrew her complaint because she was afraid of the care home owner.
- Alzheimer's patients at one home were tied to their beds so they wouldn't wander off. McDermott learned about the case three years after the fact, too late to file a complaint, he said.
- One care home operator told McDermott that she routinely left her residents unsupervised while she worked a full-time job elsewhere. The woman was able to find substitute care for her residents so McDermott did not report her.
Until recently, the pursuit of criminal cases was not especially aggressive. Since 1999, efforts on two fronts — the state attorney general's Medicaid Investigations Division and the Honolulu medical examiner — urged authorities, from social workers to morticians, to take a harder look at potential cases.
The National Elder Abuse Incidence Study, conducted in 1996 and released in 1998, was a groundbreaking effort because it provided for the first time estimates of elder abuse. Its findings confirmed some commonly held theories that reported cases of elder abuse and neglect represent only a small part of a much larger, unidentified problem. • The best national estimate is that 449,924 elderly Americans aged 60 and over experienced abuse and/or neglect in domestic settings in 1996. Only 16 percent of the cases were reported to Adult Protective Services agencies. • For every case of elder abuse or neglect reported and substantiated by Adult Protective Services agencies, more than five go unreported. • Women are abused at a higher rate than men, after accounting for their larger proportion of the population. • The oldest of the nation's elders — 80 and older — are two to three times more likely to be abused or neglected. • In nearly 90 percent of the elder abuse and neglect cases with a known perpetrator, the perpetrator is a family member. Two-thirds of the perpetrators are adult children or spouses.
Michael Parrish, a deputy attorney general, said the Medicaid division has greatly expanded the cases it reviews, but only after negotiating with the Adult Protective Services program in 1999 to forward complaints, even those that were not confirmed. The division has jurisdiction only over licensed care homes.
National estimates of elder abuse
Before the change in 1999, the only cases forwarded to the attorney general were those in which social workers confirmed there was a threat of future abuse, Parrish said.
Parrish said "dozens, maybe hundreds" of potential criminal cases were never considered. APS could close a case without having to determine if a crime had been committed, he said.
"I saw this as a big problem," Parrish said. "Potentially there was a crime that occurred but the victim was pulled out of the home and the imminent harm was gone. There's a big problem with that. That crime goes unpunished."
Deaths attributed to elder neglect have triggered an emotional alarm for Dr. Kanthi von Guenthner ever since she took over as chief medical examiner for Honolulu in January 2001.
Realizing that deaths of this nature largely went unrecognized before she was promoted, she told her six investigators to be more aggressive when dealing with deaths that were possibly caused by elderly neglect. She also bought them digital cameras so they could document every case more thoroughly.
"Either we were not notified or we were not recognizing these situations," von Guenthner said. "There were not even four cases in a year. I discussed with my investigators that we should talk to emergency room physicians that we should be notified. And we should let morticians know that if they see decubitus ulcers that were more than average size that we should be notified."
Even so, her office investigated only five cases between March and September, including two on the Big Island where von Guenthner does autopsies for Hawai'i County.
One of her hopes is that the various agencies her office regularly deals with — police, paramedics, emergency room physicians and morticians — will become better at recognizing the signs of elderly neglect and refer the cases to the medical examiner for further investigation.
"The whole reason I started doing this was not to place blame," von Guenthner said. "The ultimate goal is prevention of people dying under these circumstances."
State Executive Office on Aging 586-0100 State Long-Term Care Ombudsman (All calls are confidential; Neighbor Island calls are toll free) To join the Long-Term Care Ombudsman Volunteer Program 586-0100 University of Hawai'i Elder Law Program (assists socially and economically needy people 60 and older with basic legal services) 956-6785 State Adult Protective Services program (to report abuse, neglect or exploitation)
Nearly a year ago, she created a presentation — complete with an unflinching collection of photographs — and showed it to graduate students in the University of Hawai'i School of Social Work, representatives from the state attorney general's office and Adult Protective Services and the Hawai'i Funeral Directors Association. She will give her presentation this week at the annual convention of the American Academy of Forensic Sciences. Included are cases discovered in recent months.
Who can you call?
(Hilo, Hamakua and Puna) 933-8820
(Kona, Kohala, Kamuela and Ka'u) 327-6280
One involved Ushi Kaneshiro, a 102-year-old woman who died April 9, 2002, after being rushed from her Waipahu care home to St. Francis Medical Center-West. She suffered from advanced pressure sores that were so large and deep, doctors could see bone.
The care home operator was arrested for investigation of second-degree murder on Jan. 9, but no charges have been filed.
Another case involved the 86-year-old O'ahu woman who was found in June by the caregiver who had been paid to bring groceries to her home. The woman had starved to death. She weighed 45 pounds. The case was turned over to the Honolulu prosecutor.
Malnutrition and dehydration are "definitely" signs of elder neglect, von Guenthner said. So are large infected pressure sores, decubitus ulcers, she said.
During her career, von Guenthner has performed thousands of autopsies in her search to answer questions about death. She is clinical, but not always dispassionate. She still cries when she reads suicide notes.
This is a little different, though. And she is frustrated. The deaths seem so senseless.
"If I'm doing this job as medical examiner, my objective is to prevent death from happening," she said. "How can I educate people that this will kill?"
Reach Mike Gordon at mgordon@honoluluadvertiser.com or at 525-8012.
