Because many nursing home residents are cognilively impaired, they are rarely consulted about their preferences for daily routines, diagnos¬tic tests, or treatmenls. Decision-making capacity is usually assumed to be lacking, and even when choices are expressed, they may be overrid¬den by staff or family. In many institutions, sensitive or empathetic dis¬cussions about advance medical directives rarely take place. As a re¬sult, the resident’s fears and concerns about illness and dying are not addressed, and his wishes about resuscitation, hospitalization, and ag¬gressive treatment are not established. Informed consent, the process by which patient and family members are fully informed of the potential risks and benefits of testing and treatment options, may be similarly
neglected.
Medications may be given surreptitiously when patients refuse them. In tact, mixing medications in food to hide them is a fairly common practice, with both psychoactive drugs and essential cardiac and pul¬monary medications, and should be discouraged. Except in emergen¬cies, such abuse of residents’ rights is proscribed. Regulations prohibit¬ing this practice are enforced in mental health facilities but usually not
in nursing homes.
Other forms of abuse, neglect, and mistreatment are also of concern. The typical resident is physically and cognitively vulnerable and can be easily abused. Residents are unable to leave the facility, they may have infrequent visitors, and their complaints, when voiced, are often nol believed. Despite federal regulations that attempt to safeguard resi¬dents, better protection is needed.
How much physical and psychologic abuse exists is unknown. Subtle types of abuse—eg, using drugs and physical restraints (disingenuously labeled “safety devices”) to manage disruptive behavior—are difficult to monitor. Evidence of pinching, slapping, or yanking may be hard to prove, because ecchyniosis and skin tears occur easily in the elderly, even without abuse.

Ch. 24       Care in Nursing Homes and Other Long-term Care Facilities   299
While some residents manage to protect thei”ui.4V, fights, often fam¬ily members serve as an advocate. However. r’j'J^ih>e’*idents have families who are concerned enough to partic:^(ai#i ylyir care, and residents and family members may fear reprisals. Arm lup.h a public advocacy system exists and nursing homes can be cited by regulatory agencies, instances of abuse and mistreatment rarely come” to the atten¬tion of authorities. In addition, residents or families who insist on trans¬fer to another institution may have difficulty finding one that will accept a patient and family labeled as “troublemakers.”