Written Assignment: Mollie's Story

Elder Mistreatment Written Assignment: Mollie’s Story
Mollie is the patient in our case study. Mollie lives with her daughter and son in law, both in their 70’s. A home health aide assists Mollie five days a week for three hours each day. At age 94, Mollie is an older adult, considered to be part of a vulnerable population, at risk for hearing, visual and mobility deficits. This at risk population can experience changes in cognitive or physical status making the activities of daily living difficult to perform (Meiner, 2011). As people like Mollie age, gradually becoming less able to function independently, their grown children, potential caregivers, may be preoccupied with the demands of their own lives and not prepared to care for an older

adult. This could be Mollie’s story. Further assessment is needed in our case study.
Mollie was transported to the emergency department, by ambulance, arriving with her home health aide who reportedly found Mollie at home lying in a pool of urine.

At admission, Mollie’s main complaint was right hip pain. She was not oriented to person, place or time, responding with “I don’t know” to questions asked. While the emergency department nurse completed a physical assessment, Molly’s hospital record was retrieved. Molly was discharged from the hospital two weeks ago, having been admitted for dehydration. Her health history was significant for hypertension and diabetes. Her primary care provider and home health care information were included in Mollie’s hospital record, as was her daughter’s contact information. The emergency department performed an x ray to evaluate Mollie’s right hip pain and there was no evidence of a fracture. Per MD order, labs and samples were collected and processed: CBC-diff, CRP, hyperal, blood culture, prealbumin level and urinalysis. Molly was evaluated for sexual assault and the appropriate samples were gathered. The forensic nurse gently scraped material from underneath Mollie’s fingernails. Bruises were measured and age of each bruise was estimated by

color.
As an advocate, it is the nurse’s role to understand elder abuse policies in the United States, focusing on provisions of the Elder Justice Act. Nurses are mandated reporters. The American Medical Association (AMA) recommends screening for elder mistreatment in all clinical settings (Falk, et. al., 2012). The Elder Assessment Instrument (EAI) was created to assist clinicians in recognizing and recording the indicators for mistreatment. When used correctly, the tool provides a vast amount of information to lead the medical team in caring for the patient (Fulmer, 2008).
Elder Assessment Instrument Findings
General Assessment
General assessment includes the categories of clothing, hygiene, nutrition and skin integrity, all found to be in very poor condition. Mollie’s clothing is stained with food and urine. She is incontinent, with foul smelling urine and unkempt hair. Her body weight of 100 pounds reflects a 10-pound loss in a two-week period. With prealbumin level pending, a nutritional consult was ordered to evaluate the 10% weight loss. Multiple impairments of skin integrity are evident, from numerous bruises on her body to diffuse reddened abrasions on her sacral and genital areas (Fulmer, 2008).

Possible Abuse Indicators
Three abuse indicators were noted during Mollie’s physical assessment. The indicators were: definite evidence of bruising, definite evidence of various stages of healing bruises and possible evidence of sexual abuse (Fulmer, 2008).
The most recently acquired bruises were on Mollie’s right periorbital area and right maxilla. These bruises were red in color, swollen and warm to palpation. Additional bruises were found on Mollie’s shoulders and upper thighs, bilaterally. In various stages of healing, these bruises were yellow to green in color, with no swelling, and minimal tenderness to palpation (Fulmer, 2008). Per report from the home health nurse, she observed bruises on Mollie’s back about four months ago. Did the home health aide report these bruises to anyone?
The diffuse reddened abrasions to Mollie’s sacral and genital areas indicate possible evidence of sexual abuse (Fulmer, 2008). The bilateral bruises to Mollie’s shoulders and upper thighs could be consistent with a physical assault from pushing, grasping or firmly holding the victim. The home health care agency will be requested to evaluate Molly’s home environment for safety. Social work consult was ordered.
Possible Neglect Indicators
Three neglect indicators were relevant to Mollie’s assessment revealing probable evidence of neglect related to dehydration, inappropriate medications and repetitive hospital admissions (Fulmer, 2008).
Mollie has a history of dehydration from her hospitalization two weeks ago. Along with fowl smelling, dark colored urine her elevated temperature of 99F indicates a reoccurrence of the dehydration, possible urinary tract infection and probable evidence of neglect.
Mollie has a history of hypertension and was likely prescribed medication by her primary care physician. Her now severe high blood pressure reading of 198/100 suggests she has not been monitored daily at home and her medications have not been administered. Inappropriate medications are probable evidence of neglect.
Mollie’s history of diabetes was mentioned in the case study, however no other information, such as a blood glucose reading upon admission, has been provided. Is anyone monitoring Mollie’s blood glucose at home and assisting her with medications? Again, probable evidence of neglect could apply. Blood glucose reading is pending.
The social worker will contact the physician about Mollie’s history of hypertension and diabetes, along with treatment plans he communicated via written orders to the home health care agency. The home health agency will be contacted to inquire about their knowledge of Molly’s hypertension and diabetes. Per physician instructions, were they monitoring Molly’s blood pressure or glucose readings and administering medications. The daughter and son and law will be asked these same questions.
Possible Exploitation or Abandonment Indicators
There was no evidence of exploitation in Mollie’s case; however several abandonment indicators were present.

There was probable evidence that Mollie’s caretaker withdrew care without making alternative arrangements (Fulmer, 2008). The findings indicate that Molly remained alone for many hours on end, without food or water and without a method of contacting anyone for assistance. Mollie’s hypertension and diabetes were not monitored. Medications were not administered.
As the EAI team was discussing Molly’s case, one of the ED Residents made a few telephone calls. Molly’s PCP reported that during her last visit about 2 weeks ago, Mollie was alert and able to respond to questions appropriately. He confirmed that Mollie’s daughter and son in law have experienced psychiatric problems, adding that the son in law has expressed anger regarding Mollie’s living arrangements. The home health care agency was contacted. The RN and aide both report they have never met the son in law and have had very limited contact with Mollie’s daughter. When contacted by telephone, the daughter provided no explanation for Mollie’s extensive bruises noted on admission to the hospital. The daughter stated that Mollie did not fall, but in fact lowered herself to the floor in an effort to draw

attention.
When the Resident relayed this information to staff members performing the EAI, it was decided that Mollie’s family could benefit from The Modified Caregiver Strain Index (Onega, 2013). Caregiver strain could be related to the safety of Mollie’s living arrangements. This should be thoroughly examined. Anyone living within the home should be openly acceptable to Mollie living there and agreeable to speaking about it with the social worker.
Summary of Findings
Assisted by the Elder Assessment Instrument, the hospital medical staff gathered information valuable to Mollie’s well being and possible survival. There was probable evidence of neglect related to dehydration, inappropriate medications and repetitive hospital admissions. Also present in the EAI were definite evidence of bruising, definite evidence of various stages of healing bruises and possible evidence of sexual abuse. In summary, the above-mentioned factors indicate concluding evidence of Mollie’s daughter withdrawing provisions for care without making alternative arrangements (Fulmer, 2008).
Care Recommendations
Mollie current status requires hospital admission and treatment for malnutrition, hypertension, diabetes, dehydration and possible urinary tract infection. Mollie’s care will be more specialized through consults with nutrition, social worker, sexual assault, and forensic nurse. Wound and diabetes consults could also benefit Molly.
Care recommendations include the involvement of Adult Protective Services to investigate Mollie’s condition and the care provided or not provided by her daughter and son in law. During the investigation, Mollie’s mental and physical status can be monitored in the hospital. Following this hospitalization, Molly could benefit from in-hospital rehabilitation to increase her strength and resilience. This will also allow time for occupational and physical therapy personnel to work with Mollie to determine her ability to participate in her own care.
Our next options depend on these two factors: the findings Adult Protective Services and the return of Mollie’s well being. In the future, we may find Molly safely at her daughter’s home, but with expanded services as allowed by her health insurance and Medicare benefits. Many changes would need to be made to assure her well being, however, in the form of care for more hours per day, more complete supervision of her meals, and assistance to monitor the need for medications.
A better option for Mollie might be a facility with a skilled nursing center. Physically and mentally, Mollie could benefit tremendously from living in a more closely monitored environment with more opportunities for medical personnel to intervene in her care. The hospital social worker’s knowledge of area nursing homes can be a tremendous asset when placement time nears. After Mollie’s experience, the doctors, nurses, consultants and other employees assisting her during this hospital stay will want to see her living in a safe and secure environment with loving hands to help her.