POPULATIONS AT RISK ACROSS THE LIFESPAN:POPULATION STUDIES
The Public Health Nursing Role in Elder
Neglect in Assisted Living Facilities
Linda R. Phillips, Ph.D., R.N., F.A.A.N. and Carolyn Ziminski, R.N., B.S.
Center for the Advancement of Gerontological Nursing Science, UCLA School of Nursing, Los Angeles, California
Correspondence to:
Linda R. Phillips, Professor and Audrienne H. Moseley Endowed Chair in Nursing, Director, Center for the Advancement of
Gerontological Nursing Science, Factor Building Room 5-133A, 700 Tiverton Avenue, Los Angeles, CA 90095.
E-mail: lrphillips@sonnet.ucla.edu
ABSTRACT Objective: Assisted living facilities (ALFs) are a highly unregulated segment of
health care serving a large group of vulnerable elders. The purpose of this study was to examine
the scope of neglect and neglect-related outcomes in ALFs and to determine whether citations
given by state inspectors for certain institutional practices and staff inadequacies were associated
with neglect. Design and Sample: Exploratory descriptive. Citations given during routine inspec-
tions and narrative reports of complaint investigations written by Arizona state surveyors in 165
ALFs. Measures: Database that included citations and allegations for the selected facilities.
Results: Neglect was related to numerous poor outcomes, including injury, emergency department vis-
its, and relocation. Citations related to staff attitudes and inappropriate staffing were associated with
more neglect. Data suggest that facilities with citations with enforcement actions had less neglect.
Conclusions: Public health nurses working with older adults residing in ALFs and working in communi-
ties that have ALFS need to be aware of the problem of neglect and its related outcomes and their role
in public policy and education. Public health nurses working as facility inspectors need to be sensitive
to the relationship of institutional practices and staff inadequacies and neglect.
Key words: domestic violence, elderly, health policy, long-term-care.
In Healthy People 2020, elder maltreatment is
identified as an “emerging area” of concern in
injury and violence prevention (U.S. Department of
Health and Human Services, 2010). In addition,
legislative bodies recognize neglect of elders in resi-
dential care facilities, including assisted living facili-
ties (ALFs), as an important public health problem
(U.S. Government Accountability Office (GAO),
April 26, (1999); US House of Representatives, July
30, 2001; US Senate Committee on Finance, June
18, 2002; US Senate Special Committee on Aging,
(2011); U.S. GAO, (2004)). Public health nurses are
responsible for working with other groups in moni-
toring, anticipating, responding to, and developing
public policy about public health programs, particu-
larly those involving vulnerable groups (American
Public Health Association, Nursing Section, 1996),
such as older adults living in residential care
settings. In addition, some public health nurses are
in the unique position of being surveyors in State
Health Departments, the regulatory bodies that
usually license ALFs. Little research provides guid-
ance to these nurses about the role of public health
nurses in addressing the problem of elder neglect
in ALFs. Therefore, this study was designed to
begin to fill the knowledge gaps by analyzing
archived data collected by state surveyors during
routine inspections and complaint investigations in
one Western state.
ALFs are one of several types of facilities
designed to provide residential long-term care
(National Association of Long Term Care, 2007).
ALFs were originally designed as housing alterna-
tives for older adults with stable health conditions
and the capability for self-care with or without
supportive services (Wilson, 2007; Zimmerman &
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Public Health Nursing
0737-1209/© 2012 Wiley Periodicals, Inc.
doi: 10.1111/j.1525-1446.2012.01029.x