ATrain Education

 

Continuing Education for Health Professionals

IA: Abuse of Dependent Adults

Module 6

Iowa Laws on Dependent Adult Abuse

[Much of the following is quoted or adapted from two documents: Dependent Adult Abuse Trainers’ Guide for Mandatory Reporters, Iowa Department on Aging, July 2015/Reapproved July 2016 (IDA, 2016); and Dependent Adult Abuse: A Guide for Mandatory Reporters, Iowa Department of Human Services (IDHS, 2009/2010). Citations to Iowa Code (IC) and Iowa Administrative Code (IAC) (the means by which laws are further interpreted) are noted in many places; see Resources for online links to these materials and to handouts and other information.]

Elder Abuse is defined by the Federal Older Americans’ Act as the abuse, neglect, or exploitation of an individual age 60 or older. Beginning July 1, 2014, newly established Iowa Code Chapter 235F, Elder Abuse Relief, became effective and created an elder abuse definition and law for civil elder abuse relief. Currently, the law does not mandate reporting of elder abuse; however, if mandatory reporters encounter such situations or circumstances that do not meet the criteria for dependent adult abuse, contact LifeLong Links at 866 468 7887 for available services and supports.

The Dependent Adult Abuse Law is in Iowa Code Chapter 235B and 235E. The law is specifically aimed at protecting dependent adults from abuse by their caretakers.

Three elements are needed for dependent adult abuse:

  • Dependent adult (age 18 or older)
  • Caretaker
  • Allegation of abuse recognized by 235B or 235E

Under the Dependent Adult Abuse Law, mandatory reporters who suspect a dependent adult is suffering from abuse by a caretaker shall report their reasonable belief to the Department of Human Services (DHS) or the Department of Inspections and Appeals (DIA).

Dependent Adult Abuse Agency Roles

DHS is responsible for the evaluation/assessment of dependent adult abuse in the community. DIA is responsible for the investigation of dependent adult abuse in facilities and programs. Each department must then investigate the report and make an evaluation of the situation.

In laying the groundwork for dependent adult services the law stresses the need for the state to provide protection of Iowa’s dependent adults. In the Dependent Adult Abuse Information Registry (Central Abuse Registry), the Code also focuses on the right to individual privacy, as well as the need for a centralized system of collecting, maintaining, and disseminating adult abuse information.

The Iowa Code is referred to throughout this course. Chapter 235B deals directly with dependent adult abuse in the community and Chapter 235E deals directly with dependent adult abuse in facilities and programs.

Central Abuse Registry

Iowa Code (235B.4) creates a central registry in the Department of Human Services (DHS) to provide a single source for the statewide collection, maintenance, and dissemination of dependent adult abuse information. The Central Abuse Registry includes report data, investigative data, and disposition data relating to reports of dependent adult abuse. The purpose of the Registry is to:

  • Facilitate the identification of victims or potential victims of dependent adult abuse by making available a single, statewide source of dependent adult abuse data
  • Facilitate research on dependent adult abuse by making available a single statewide source of dependent adult abuse data
  • Provide maximum safeguards against the unwarranted invasions of privacy that such a registry might otherwise entail

Immediately upon receipt of a report of dependent adult abuse, DHS is required to:

  • Make an oral report to the Central Abuse Registry
  • Forward a copy of the written report to the Registry
  • Notify the local county attorney of the receipt of the report
  • Begin an appropriate evaluation or assessment

Upon receipt of a report of dependent adult abuse, the Central Abuse Registry searches its records. If registry records reveal any previous report of dependent adult abuse involving the same adult or any other pertinent information with respect to the same adult, the Registry immediately notifies the appropriate DHS office or law enforcement agency of that fact.

Abuse Reports in the Community

Abuse reports are made under the following legislation:

  • Iowa Code (IC) Chapter 235B: Department of Human Services
  • Iowa Administrative Code 441—Chapter 176

Reports of dependent adult abuse alleged to have occurred in the following settings should be reported to the Department of Human Services (DHS):

  • Residential house, apartment, mobile home
  • Independent living
  • In facilities or programs when alleged perpetrator is not staff or employee

Definitions Used by DHS

Dependent adult: a person 18 years of age or older who is unable to protect that person’s own interests OR is unable to adequately perform OR obtain services necessary to meet essential human needs, as a result of a physical OR mental condition that requires assistance from another, or as defined by departmental rule.

Caretaker: a related or nonrelated person who has the responsibility for the protection, care, or custody of a dependent adult as a result of assuming the responsibility voluntarily, by contract, through employment, or by order of the court.

Examples of voluntary caretakers include an attorney-in-fact (power of attorney), a relative or friend who provides a daily meal, or a person who provides a service while visiting the dependent adult in a care facility. A caretaker by contract would include an individual personal care assistant who has a contract with a dependent adult to provide care. Healthcare workers employed by a facility or agency are considered caretakers by virtue of their employment. If a dependent adult has no family to provide care, the court may order that a caretaker be provided.

Dependent adult abuse: any of the following as a result of the willful or negligent acts or omissions of a caretaker:

  • Physical abuse, including assault
  • Sexual abuse
  • Sexual Exploitation
  • Exploitation
  • Denial of critical care
  • Self-denial of critical care

Types of Abuse

Abuse under Iowa law include physical and sexual abuse, sexual exploitation, other exploitation, denial and denial of critical care through neglect or denial of the means of survival (eg, food, shelter).

Physical Abuse

Physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement or unreasonable punishment, or assault of a dependent adult, as a result of the willful or negligent acts or omissions of a caretaker.

Assault

Assault is the act or process of taking unfair advantage of a dependent adult or a dependent adult’s physical or financial resources for one’s own personal or pecuniary profit, without the informed consent of the dependent adult including theft, by the use of undue influence, harassment, duress, deception, false representation, or false pretenses as a result of the willful or negligent acts or omissions of a caretaker.

As defined in IC 708.1, a person commits an assault when, without justification, the person does any of the following:

  • Commits any act intended to cause pain or injury to a dependent adult, or which is intended to result in physical contact that will be insulting or offensive to a dependent adult, coupled with the apparent ability to execute the act
  • Commits any act intended to place a dependent adult in fear of immediate physical contact that will be painful, injurious, insulting or offensive, coupled with the apparent ability to execute the act
  • Intentionally points any firearm toward a dependent adult or displays in a threatening manner any dangerous weapon toward a dependent adult

The act is not an assault when the caretaker and the dependent adult are voluntary participants in a sport, social activity, or other activity not in itself criminal, and the act is a reasonably foreseeable incident of such sport or activity, and does not create an unreasonable risk of serious injury or breach of the peace.

Note: An assault does not have to involve physical injury. A person can be assaulted and not have any injuries.

Indicators of Physical Abuse
  • Injury that has not been properly cared for
  • Any injury incompatible with history
  • Pain on touching
  • Cuts, lacerations, or puncture wounds
  • Dehydration and/or malnourishment without illness related cause; weight loss
  • Pallor
  • Sunken eyes, cheeks
  • Evidence of inadequate care
  • Eye problems, retinal detachment
  • Poor skin hygiene
  • Absence of hair or hemorrhaging below scalp
  • Soiled clothing or bed
  • Burns
  • Locked in a room
  • Lack of bandages on injuries or stitches when indicated, or evidence of unset bones
  • Heavy or excessive medication
Examples of Physical Abuse
  • Unauthorized use of physical or chemical restraints
  • Administration of medications or enforced isolation as punishment or simply for convenience
  • Use of substitute treatment in conflict with a physician’s order
Dating of Bruises

Physicians and law enforcement disagree about the validity of dating of bruises. However, they do agree that bruises change color as the injury ages and the simultaneous presence of bruises of various colors on the same person indicates separate injuries.

Sexual Abuse

The commission of a sexual offense under Iowa Code (709, 726.2, or 235B.2) with or against a dependent adult as a result of the willful or negligent acts or omissions of a caretaker.

Sexual abuse includes the following categories:

  • First-degree sexual abuse (IC 709.2)
  • Second-degree sexual abuse (IC 709.3)
  • Third-degree sexual abuse (IC 709.4)
  • Indecent exposure (IC 709.9)
  • Assault with intent to commit sexual abuse (IC 709.11)
  • Sexual exploitation by a counselor or therapist (IC 709.15)
  • Invasion of privacy, nudity (IC 709.21)
  • Incest (IC 726.2)
Indicators of Sexual Abuse
  • Person’s behavior changes drastically, eg, acting out, angry, lashing out, inappropriate affect
  • Person is depressed or shows symptoms of other mental health issues
  • Person acts afraid in the presence of the caretaker
  • Person does not want to be left alone with the caretaker
  • Genital or anal bruises
  • Vaginal or anal bleeding
  • Swelling or redness of genital area
  • Venereal disease
Special Sexual Vulnerabilities of Dependent Adults

Elders and people with disabilities may be targeted by sexual predators due to their vulnerability. Most people (99%) with developmental disabilities have had no sex education. More than 83% of women and 32% of men with developmental disabilities have experienced sexual assault. Nearly three-quarters of women with disabilities have been violently sexually victimized at some point in their lives.

Sexual assault is not spontaneous or accidental, but communities tend to blame the survivors. It is often treated as a scandal, an internal personnel matter, or a public relations problem. Although most of the victims are female, there are also male victims.

Sexual Abuse Differs with Age or Frailty

Frail elders too often lack a strong support system, which makes them more vulnerable to abuse. Their beliefs about sexual abuse increase feelings of shame and guilt. In addition, the abuse:

  • May complicate an existing illness
  • Involves a longer recovery time to deal with abuse
  • Increases the chance of sustaining serious injury
  • May cause genital tearing and bruising
  • May fracture pelvis or hip bones
  • Increases the risk of infections
Sexual Exploitation

Sexual exploitation is “any consensual or nonconsensual sexual conduct with a dependent adult. This includes but is not limited to kissing; touching of the clothed or unclothed inner thigh, breast, groin, buttock, anus, pubes, or genitals; or a sex act” (Iowa Code 702.17).

Sexual exploitation also includes the transmission, display, or taking of electronic images of the unclothed breast, groin, buttock, anus, pubes, or genitals of a dependent adult by a caretaker for a purpose not related to treatment or diagnosis or as part of an ongoing assessment, evaluation, or investigation.

Sexual exploitation does not include touching that is part of a necessary examination, treatment, or care by a caretaker acting within the scope of practice or employment of the caretaker; a brief touch or hug for the purpose of reassurance, comfort, or casual friendship; or touching between spouses or domestic partners in an intimate relationship.

Exploitation

Physical injury to, or injury which is at a variance with the history given of the injury, or unreasonable confinement or unreasonable punishment, or assault of a dependent adult, as a result of the willful or negligent acts or omissions of a caretaker.

Indicators of Exploitation
  • Dependent adult is inaccurate, confused, or has no knowledge of finances
  • Disparity between income/assets and lifestyle or living arrangement
  • Caretaker expresses unusual interest in the amount of money spent for care of the dependent adult
  • Unpaid bills when resources should be adequate
  • Caretaker is evasive about financial arrangements
  • Signatures on checks don’t match dependent adult’s
  • Unusual activity in bank accounts
  • Dependent adult turns over financial affairs to someone in exchange for lifelong care, but does not appear to have basic necessities such as food and shelter
  • Caretaker begins to handle the dependent adult’s financial affairs without his or her presence or without consultation
Examples of Exploitation
  • Misuse of power of attorney or conservatorship
  • Identity theft
  • Scams
  • Coercion into signing or changing legal documents
  • Taking or misusing a dependent adult’s property, money, social security or pension check, food stamps, medication, etc.

Exploitation can directly impact quality of care, depriving victims of the financial means to access medical treatment or obtain medications.

Denial of Critical Care (Neglect)

Denial of critical care (neglect) is defined as the deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, and other care necessary to maintain a dependent adult’s life or health as a result of the willful acts or negligent acts or omissions of a caretaker.

Iowa Administrative Code 176.1 adds:

Denial of critical care exists when the dependent adult’s basic needs are denied or ignored to such an extent that there is immediate or potential danger of the dependent adult suffering injury or death, or the failure to provide the mental health care necessary to adequately treat the dependent adult’s serious social maladjustment, or is a gross failure of the caretaker to meet the emotional needs of the dependent adult necessary for normal development, or a failure of the caretaker to provide for the proper supervision of the dependent adult.

Indicators of Denial of Critical Care
  • Pattern of failure to provide adequate food; malnourishment; or contaminated or spoiled food in home
  • Lack of adequate clothing to provide protection from the weather
  • Lack of heat in winter or lack of air conditioning or fans in summer; unsanitary or hazardous conditions
  • Refusal to provide medical evaluation for condition detected by medical personnel
  • Failure to follow through with medical treatment plan recommended by health professional
  • Unable to manage affairs because of confusion and deterioration
  • Leaving dependent adult who is incapable of self-supervision without a responsible caretaker
  • Knowingly selecting an inappropriate caretaker
  • Abandonment
Examples of Denial of Critical Care
  • Withholding of care, medication, food, liquids, assistance with hygiene, etc.
  • Failure to provide physical aids such as eyeglasses, hearing aids, false teeth
  • Failure to provide safety precautions and access to care
Denial of Critical Care (Self)

Denial of Critical Care (Self) is the deprivation of the minimum food, shelter, clothing, supervision, physical or mental health care, or other care necessary to maintain a dependent adult’s life or health, as a result of the acts or omissions of the dependent adult.

Indicators of Denial of Critical Care (Self)
  • Failure to provide adequate food, shelter or clothing
  • Intentional physical self-abuse
  • Suicidal statements
  • Refusal of medical treatment or medication (refusal not based on religious grounds)
  • Refusal of services that might alleviate the situation, when once would have accepted
  • Refusal of visitors
  • Denial of obvious problems
  • Apathy
  • Hopelessness
Examples of Denial of Critical Care (Self)
  • Unable to prepare food or obtain groceries
  • Unable to care for self
  • Confused and unable to understand living conditions
  • Holes in the floors and walls of home
  • Home is cluttered with garbage (health hazard)
  • Person subjects self to unsanitary living conditions
  • Person subjects self to a deplorable living environment
Personal Degradation

Being shamed, degraded, or humiliated is a deep, intensely personal experience that is often vividly remembered, no matter how much time has passed. When experienced frequently, these emotions have been associated with psychological, relational, and societal problems, as well as with clinical disorders such as low self-esteem, depression, anxiety, suicidal ideation, homicide, and domestic violence (Mann et al., 2017).

Personal degradation is a willful act or statement by a caretaker intended to shame, degrade, humiliate, or otherwise harm the personal dignity of a dependent adult. It is a situation in which the caretaker knows or reasonably should know that an act or statement will cause shame, degradation, humiliation, or harm to the personal dignity of the person under their care.

Personal degradation includes taking, transmitting, or displaying an electronic image of a dependent adult by a caretaker, where the caretaker's actions constitute a willful act or statement intended to shame, degrade, or humiliate, or otherwise harm the personal dignity of the dependent adult or when the caregiver knows or reasonably should know that act will shame, degrade, humiliate, or harm the personal dignity of the person under their care.

Personal degradation does not include taking, transmitting, or displaying an electronic image in accordance with a facility's confidentiality, consent, or release of information policies.

Indicators of Degradation, Humiliation, or Shame
  • Hiding from others, withdrawal
  • Anger, rage, fear
  • A desire for revenge
  • Depression
  • Lowered self-esteem
  • Social anxiety
  • Suicidal ideation
Examples of Degradation, Humiliation, or Shame
  • Being teased, harassed, ridiculed, or put down
  • Being neglected, excluded, or ostracized
  • Experiencing public insults, especially related to personal, cultural, or religious values
  • Being bullied, including cyberbullying
  • Having a caregiver laugh at your personal difficulties
  • Being the victim of humiliating texts, images, or videos
  • Having your identity devalued or demeaned

(Mann et al., 2017)

What Dependent Adult Abuse Is Not

There are some situations that may appear to be dependent adult abuse but, according to the Iowa Code and Administrative Rules, are not.

  1. Refusal or deprivation of medical treatment based on religious beliefs. The practices and beliefs of some religions call for reliance on spiritual means for healing rather than medical treatment. A patient may refuse treatment based on religious grounds.
  2. Withholding, withdrawing or refusing medical treatment based on terminal illness. If based upon the request of the dependent adult, their next-of-kin, attorney-in-fact (power of attorney), or guardian.
  3. Domestic abuse. In domestic abuse situations where the victim is not dependent as defined in law.
  4. People incarcerated in a penal setting. While one could make a case that an incarcerated person is a dependent adult, the Code excludes these people from the Dependent Adult Abuse Law.
  5. Lack of means or access to means for providing care. Where there is a lack of means to care for a dependent adult, the caretaker would not be guilty of perpetrating denial of critical care. Likewise, cases where a dependent adult lacks the means to care for her or himself would not be considered self-denial of critical care. [Iowa Administrative Rules 441, Ch 176.3(2) & Iowa Code 235B.2(5)(b)]

Abuse Reports in Facilities and Programs

These abuse reports are covered under the following legislation:

  • Iowa Code Chapter 235E: Department of Inspections & Appeals
  • Iowa Administrative Code 48—Chapter 52

The Department of Inspections and Appeals (DIA) shall receive and evaluate reports of dependent adult abuse in facilities and programs and shall inform the Department of Human Services (DHS) of such evaluations and dispositions for inclusion in the central.

Facility means a health care facility (135C.1) or hospital (135B.1) and includes:

  • Long term care facilities
  • Residential care Facilities
  • Intermediate care facilities for people with mental illness
  • Intermediate care facilities for people with mental retardation
  • Hospitals

Program means:

  • Elder group home (231B.1)
  • Assisted living program (231C.3)
  • Adult day services (231D.1)

Definitions Used by DIA

Dependent adult: A person eighteen years of age or older whose ability to perform the normal activities of daily living or to provide for the person’s own care or protection is impaired, either temporarily or permanently.

Caretaker: a staff member of a facility or program who provides care, protection, or services to a dependent adult voluntarily, by contract, through employment, or by order of the court. For the purposes of an allegation of exploitation, if the caretaker-dependent adult relationship started when a staff member was employed in the facility, the staff member may be considered a caretaker after employment is terminated.

Dependent adult abuse: Any of the following as a result of the willful misconduct or gross negligence or reckless acts or omissions of a caretaker, taking into account the totality of the circumstances:

  1. Physical injury, unreasonable confinement, unreasonable punishment, and assault
    1. Physical Injury. A physical injury or injury which is at a variance with the history given of the injury which involves a breach of skill, care, and learning ordinarily exercised by a caretaker in similar circumstances.
    2. Unreasonable Confinement. Confinement that includes but is not limited to, the use of restraints, either physical or chemical, for the convenience of staff. “Unreasonable confinement” does not include the use of confinement and restraints if the methods are employed in conformance with state and federal standards governing confinement and restraints or as authorized by a physician or physician extender.
    3. Unreasonable Punishment. A willful act or statement intended by the caretaker to punish, agitate, confuse, frighten, or cause emotional distress to the dependent adult. Such willful act or statement includes but is not limited to intimidating behavior, threats, harassment, deceptive acts, or false or misleading statements.
    4. Assault. “Assault of a dependent adult” means the commission of any act which is generally intended to cause pain or injury to a dependent adult, or which is generally intended to result in physical contact which would be considered by a reasonable person to be insulting or offensive or any act which is intended to place another in fear of immediate physical contact which will be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.
  2. Sexual Offense: the commission of a sexual offense as defined under Iowa Code, section 709 or 726.2, with or against a dependent adult.
  3. Exploitation a caretaker who knowingly obtains, uses, endeavors to obtain to use, or who misappropriates, a dependent adult’s funds, assets, medications, or property with the intent to temporarily or permanently deprive a dependent adult of the use, benefit, or possession of the funds, assets, medication, or property for the benefit of someone other than the dependent adult.
  4. Neglect of a dependent adult the deprivation of the minimum food, shelter, clothing, supervision, physical or mental healthcare and other care necessary to maintain the life or physical and mental health of a dependent adult.
  5. Sexual exploitation of a dependent adult by a caretaker whether within a facility or program or at a location outside of a facility or program. Any consensual or nonconsensual sexual conduct with a dependent adult, which includes but is not limited to kissing; touching of the clothed or unclothed breast, groin, buttock, anus, pubes, or genitals; or a sex act as defined in 702.17. Sexual exploitation includes the transmission, display, or taking of electronic images of the unclothed breast, groin, buttock, anus, pubes, or genitals of a dependent adult by a caretaker for a purpose not related to treatment or diagnosis or part of an ongoing investigation.

Sexual exploitation does not include touching which is part of a necessary examination, treatment, or care by a caretaker acting within the scope of practice or employment of the caretaker; the exchange of a brief touch or hug for the purpose of reassurance, comfort, or casual friendship; or touching between spouses or domestic partners in an intimate relationship.

Dependent adult abuse does not include:

  • Circumstances in which the dependent adult or the dependent adult’s caretaker acts in accordance with the dependent adult’s stated or implied consent, declines medical treatment or care due to a belief or is an adherent of a religion whose tenets and practices call for reliance on spiritual means in place of reliance on medical treatment.
  • The withholding or withdrawing of health care from a dependent adult who is terminally ill in the opinion of a licensed physician, when the withholding or withdrawing of health care is done at the request of the dependent adult’s next of kin, attorney in fact, or guardian.

Behavioral Indicators of Abuse

Mandatory reporters should be alert to behaviors of both the victim and the abuser that signal possible abuse or other serious problems. These behaviors may occur in the absence of abuse but their presence warrants consideration of the possibility of abuse.

Victim Behaviors

  • Fear or reluctance to openly talk with others
  • Withdrawal, self isolates, quiet/subdued, depressed mood
  • Depression, either acute or situational, that is uncharacteristic of the person’s past behavior
  • Helplessness or resignation, an “I don’t care” attitude, too accepting of their perceived fate/future
  • Hesitation to talk openly, reluctant to discuss their well-being, changes the subject to non-threatening issues
  • Implausible stories (not related to dementia),explanations that don’t match up with facts or visible circumstances
  • Confusion or disorientation (not related to dementia),difficulty in expressing thoughts, appears distracted
  • Ambivalence/contradictory statements, fails to show concern about personal events, unable to repeat the same explanation of events or circumstances
  • Anger, displayed toward you, family/friends, or toward everyone and everything
  • Non-responsiveness, refuses to answer questions appropriately
  • Agitation/anxiety, becomes increasingly agitated or anxious when you are there

Abuser Behaviors

  • Victim not allowed to speak for himself or herself
  • Obvious absence of assistance
  • Indifference or anger toward victim
  • Blames the victim
  • Aggressive behavior
  • Previous history of abuse to others
  • Problems with alcohol or drugs
  • Flirtations, coyness, etc.
  • Conflicting accounts of incidents by the family, supporters, victim
  • Noncompliance with service providers in planning for care and implementation
  • Withholding of security and affection

Perpetrators frequently groom their targets before assault, gaining trust, testing the waters to see how the person will react. Indicators of grooming include showing special interest in the person, gifts, touching, massage, setting up time to be alone (bathing in the late evening, providing transportation).

The presence of a single indicator may not raise suspicion of abuse, but a combination of indicators may reveal a serious situation. The potential reporter may want to question further, document the situation for future use, or make a report.

Types of Perpetrators

Abusers can be categorized across a spectrum of types from well-intentioned to sadistic. The categories include:

  • Well-intentioned: overwhelmed, stressed, lashing out (means well but tries to do too much)
  • Well-intentioned: ignorant, incompetent (doesn’t really understand how to take care of someone, for example leaves an Alzheimer’s patient tied to a chair and goes grocery shopping)
  • Lacks interest and concern (a lazy person who needs a job, takes no pride in work, just wants an “easy” paycheck)
  • Abusive: motivated by self-interest, power, and control (gains trust of dependent person, manipulates into signing over money or property)
  • Sadistic: enjoys hurting, extreme power and control (looks for jobs with position and authority to gain control for the purpose of hurting others)
Expected Responses from Perpetrators

Depending on the type of perpetrator involved, responses vary among the following:

  • Admission of guilt, embarrassment, desire to do better
  • Admission but believes abusive action was justified
  • Varies with intelligence and social sophistication
  • Denial, outrage, rationalizations, attempts to “turn the tables” on the victim, reporter and/or investigator
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