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Respecting and Protecting Elders

According to the United States Census Bureau's projections on aging, more than 40 million U.S. citizens will be of retirement age by 2010, including approximately 6.1 million who will be 85 years old or older. By 2050, the government projects that some 86.7 million Americans will be age 65 and above and 20.9 million will be 85 or older.

Many of these people will enter eldercare facilities, convalescent care centers, extended care facilities, and independent living or congregant care communities. And because residents of these facilities are often weak and vulnerable, the potential for them to be victimized is great. Among the threats are theft of personal property, abuse, physical assault, diversion of assets, extortion, and other crimes. Security professionals must know how to assess and address the risks.

Long-term-care facilities vary greatly in size, but whatever the size of the facility, it will face some of the same issues, many of which are unique to that environment. For example, during hospital stays, patients are encouraged to leave valuable items and keepsakes at home. But for many individuals, the long-term-care facility is their primary domicile, and residents bring these items with them. Thus, security of those items must be addressed.

Unfortunately, as residents continue to age, their memories and cognitive abilities may deteriorate to the level of unreliability. Because of this, reported incidents of property loss are sometimes written off as imagined events and not fully investigated. That type of response clearly does not serve the residents or the facility well.

Currently, the long-term-care (LTC) community includes more than 20,500 nursing homes. Most are for-profit institutions, placing them squarely in the purview of private security. However, a recent search of the ASIS International membership revealed fewer than a dozen members who list nursing homes, long-term-care facilities, convalescent facilities, or similar organizations as their primary employer.

Based on the authors' experiences, this is because security services to the eldercare facilities are generally provided by contractors who report to facility administrators. In some instances, security is the responsibility of the maintenance or nursing supervisor. At hospital-based facilities, by contrast, there is usually an in-house security director or manager. Perhaps as the LTC industry matures, its approach to security will also evolve.

Types of facilities.

Many LTC residents live independently. They come and go as they wish, do their own shopping and cooking, control access to their buildings and apartments, and rely on their facility for only minimal services.

As their ability to care for themselves wanes and residents require a greater level of care, they move from independent living or congregant care to assisted living, then to sub-acute nursing, acute care, and finally to hospice care.

More and more often, these care options are provided by a single organization. Sometimes, the entire spectrum of long-term care is provided on a single campus.


Whether the LTC facility offers some or all of these care options, the first step in developing appropriate security is a thorough risk assessment. The key, of course, is for management to act proactively. They should not wait for an incident to occur before conducting an assessment. Recently, the majority of the authors' work in this arena has been based on this proactive model, showing that administrators of these facilities are beginning to place the proper priority on security.

To determine a facility's unique security program needs, LTC administrators, working with security professionals, should assess each of these four points:Perimeters and access controls to protect residents from the outside world. Internal security to protect residents from threats within the facility. Measures to protect residents who cannot protect themselves or are a danger to themselves. Measures to protect caregivers and loved ones.

Perimeters, access controls. As with any facility, if an LTC facility is to protect residents from the dangers of the world outside, it must have adequate controls securing the perimeter and managing access to buildings and grounds.

When assessing the perimeter, key areas for review include geographical risks and area-crime trends and incidents. For example, if the facility is surrounded by a suburban neighborhood with regular Neighborhood Watch patrols, the outsider threat to the facility will be less than if the facility borders a major thoroughfare or areas known for dangerous activities such as drug dealing. The previous several years' worth of local crime statistics should be perused, and in addition, the assessors should contact local peers and law enforcement officers for their input.

When assessing the grounds, existing lighting, fencing, landscaping, natural surveillance, and signage should be reviewed. Residents' physical limitations including impaired vision, reduced mobility, reliance on walkers or canes, hearing impairment, and other factors should also be taken into account.  Many residents cannot perceive hazards in their environment as well as younger individuals.

For example, an assessment of one facility by the authors found that care had been taken to clearly define the property with aesthetically pleasing security fencing, low and neatly trimmed shrubs, lighting, and plentiful signage.

Although family and visitors are welcome at these facilities, trespassers, unescorted juveniles, and panhandlers are not. Using techniques associated with crime prevention through environmental design (CPTED), facilities can clearly convey the demarcation between the public right of way and private property, creating well-defined space and empowering staff to assume a personal responsibility for activity on the grounds. These concepts are not unique to LTC facilities, but they are often underused in these types of eldercare environments.  

In addition, the assessment should look at overall site usage. Are there existing patrols and electronic surveillance? Are there any problems with any of these systems? 

Moving concentrically inward, the assessors should next focus on individual building access control. The assessment should include a review of existing access control, alarm, and communications systems.  Interior patrols, front desk management, and dock and remote-entrance management should also be studied, as well as   visitor sign-in, badging, and on-site management procedures. The assessors should also investigate current CCTV and recording technologies and real-time CCTV management capabilities.

One facility we assessed had an effective policy in which all staff assisted in making sure that visitors did not roam into the facility without first being logged in. Whoever saw the visitor first approaching would escort them to a designated visitor entrance, where they were registered.

Although not necessarily a "high-security" registration process, the act of requiring visitor sign-in, in plain view of a CCTV camera, and using visitor identification badges can reduce the anonymity of anyone bent on criminal behavior, thereby acting as a deterrent as well. Most visitors in LTC facilities are known to the security staff.  However, they should still be required to sign-in and wear appropriate identification at all times.

Those within

Crimes at LTC facilities are not limited to those perpetrated by trespassers or burglars. Staff may also pose threats, especially as a resident's vulnerability increases and he or she becomes more dependent on caregivers. Elements to consider when assessing threats within an LTC environment include current employee recruitment processes, screening and background checks, and supervision of employees.

In some communities, the demand for entry-level resident care and custodial workers is high. Staff turnover in these jobs is also high, and some organizations have chosen to reduce costs by cutting back on reference checks that provide vitally important information about potential employees. These organizations run the risk of both increased security incidents and increased resultant liability costs. Negative publicity could also taint the reputation of the facility.

Additionally, the facility's incident reporting policies and procedures should be reviewed, as well as resident property tracking and management, and the training and regular reevaluation of both the security and care staff. Internal security audits should also be studied.

Another concern is the threat that residents may pose to one another. For example, more than 400 registered sex offenders were LTC residents, according to a 2004 study, "Predators in America's Nursing Homes, Registered Sex Offenders Residing in Nursing Homes Analysis," conducted by A Perfect Cause, a disability and elder-rights advocacy organization.

The study identified one 144-bed skilled-care and intermediate-care facility in Ohio as the residence of 15 registered sex offenders—more than half of whom were convicted rapists. A Missouri nursing home mentioned in the study was reportedly the home of 12 sexual offenders. The study also cited multiple cases of offenders committing assaults and rapes in the facilities where they were housed.

Because of these incidents, LTC providers and advocacy groups debate whether a facility has a responsibility to notify residents and their families when residents who may pose a threat—especially registered sex offenders—are admitted.

One way to address the risk of patient-on-patient crime is a patient-background screening program similar to employee preemployment screening. Checking the backgrounds of residents can be controversial, however.

If patient background checks are conducted, the intent should not be to reject a resident, but rather to provide the facility with information that it may need to ensure the safety of that resident, other residents, visitors, and staff. Confidentiality of information, communication of adverse information, and other related issues need to be addressed in well-constructed policies and procedures. Certain types of background checks may require a signed release by the resident or disclosure of the results by the requesting organization. Policies such as this should be reviewed by legal counsel prior to implementation.

Danger to themselves

Many LTC residents are not a risk to others, but to themselves. Among the largest risks to this group are slips and falls and other injuries. However, two additional significant risk issues are wandering and running away from the facility.

Many LTC residents suffer from Alzheimer's disease, dementia, disorientation, and other neurological impairments, placing them at high risk once they leave the care environment. While these wandering residents may not be trying to flee the facility, others do actively try to leave.

Both types of wanderers have ended up injured or dead. According to insurance company studies, the primary causes of death in these cases were being struck by a vehicle, overexposure to heat or cold, drowning, or traumatic injury resulting from physical or sexual abuse that occurs outside the facility.

The assessment of programs to reduce the risk for wandering and elopement should include a review of building and unit design, and pedestrian and vehicular circulation patterns.

At one facility, wandering was curtailed without limiting residents' access to the outside by the creation of a fully fenced and beautifully landscaped courtyard with twisting walkways, fountains, benches, and an arbor. There is no access from or to this garden via public streets or neighboring roadways. Closed circuit television cameras are used to assist staff in monitoring the area.

The use of wandering-patient tracking technologies should be evaluated, as well as other elopement-prevention strategies and response planning and training, including coordination with local police, fire, and emergency medical service officials.

The assessment should probe whether there is timely and adequate communication with the site's neighbors when a patient has gone missing. At one facility, for instance, photographs of residents known to be at risk are maintained by security and are available for distribution to local authorities and search teams.

The response plan at this facility includes emergency packets, which are provided to staff who are searching for the missing resident. The packets contain maps depicting the immediate area, recommended search patterns, and zones of responsibility for employees. It also identifies likely destinations of wanderers, such as area grocery stores or libraries, and known hazards.

Each search team is equipped with a cell phone or radio for communication. A command center is established to manage the entire process and coordinate ongoing efforts.

Response plans should ensure that family members get the information and support they will need. In addition, a media plan is important. Often, media will learn about the incident as soon as the police are notified. The absence of a clear communications process can lead to disastrous public relations outcomes.

As with all other emergency plans, drills should be conducted on a routine basis. All staff members should be trained in their responsibilities, and this training should be documented. Issues identified during drills or as a result of an actual incident should be addressed. Plans and training should be updated accordingly.

In the aftermath of an incident, there should be a mechanism for assessing causative factors and for the development and implementation of a corrective plan. 

Helpers and family

Residents are not the only people at risk at an LRC facility. Caregivers and loved ones have become the victims of outbursts by residents who are angry, frustrated, and afraid. Sometimes assaults are also the result of neurological or pathological behaviors.

Facilities that train staff to recognize and respond to early indicators of aggression may be able to minimize the potential for injury. Staff should be trained in what to look for and in remediation steps, such as how to implement physician-ordered limited physical restraint and when and how to administer medication.

In the realm of technology, wireless alarms and nurse call systems as well as CCTV cameras in the facility's common areas can help quickly end assaultive incidents. Additionally, consideration should be given to the limited use of covert CCTV to protect residents when abuse is suspected. The decision to use this type of technology should be fully reviewed before it is undertaken.

Policies and technologies

After the assessment is completed, recommendations should be compiled to remedy problem areas. To be most effective, the security program must be integrated into the organization's mission, vision, and values.

There is often, in general, an urge to solve problems by the installation of security systems, but it is important to note that security technology, in and of itself, is not the answer. It must be coupled with appropriate policies, processes, and procedures, the assignment of security responsibilities, adequate staffing levels, staff training and supervision, drills, audits, and ongoing quality improvement efforts.

This having been said, several up-and-coming technologies are worth noting that are either just becoming available or will be available in the near future. Among these are GPS-based wearable devices to account for residents when outside buildings. Unlike current patient-elopement systems that generally only alert staff to a resident leaving (or attempting to leave) the facility, these systems will provide real-time information about the whereabouts of the resident whether on the premises or not. Other information, including respiration and heart rate, may also be available.

Radio frequency and infrared technologies offer promise as a way to track residents, as well as their valuables,  within facilities. In addition, Wi-Fi network advances may soon facilitate the setting up of temporary alarm systems needed to closely manage residents who are episodic, wandering, or elopement risks. Similarly, the use of secure Wi-Fi technologies in resident and patient rooms may help to reduce the amount of time staff spend at charting stations.

Also noteworthy is the potential use of behavioral recognition algorithms with digital video recording technologies, which would enable a CCTV system to identify behaviors associated with wandering residents in parking lots and other exterior areas. The system could then sound an alert to let staff know that this behavior was occurring and where.

To protect residents, family, and staff, LTC facilities should assess their needs, understand the risks and threats inherent in their unique environment, and develop strategies to address them. Following this course of action will help to ensure that the residents' golden years will not be tarnished.

liot A. Boxerbaum, CPP, is president of Security/Risk Management Consultants, Inc., in Columbus, Ohio. Boxerbaum currently serves on the ASIS International Healthcare Security Council. Patrick F. Donaldson is a principal of Metsger/Forbes in Portland, Oregon. Donaldson also serves on the ASIS Healthcare Security Council. Both have more than twenty-five years of experience in healthcare security.