A home health nurse conducts an admission assessment for an 82-year-old client who recently moved in with family members. The nurse observes bilateral wrist abrasions and fading torso contusions. The family caregiver explains, "They are just clumsy and keep bumping into the furniture." The client avoids eye contact and remains completely quiet throughout the visit. Which action fulfills the nurse's legal responsibility?
- ADocument the findings and wait until the next visit to gather more conclusive evidence of maltreatment before filing a report.
- BReassure the family that increased capillary fragility and bruising are normal, expected physiological changes of the aging process.
- Notify the designated state adult protective services agency regarding the suspected elder abuse.Answer
- DInstruct the home health aide to thoroughly assess and document any new skin lesions during daily bathing.
Answer
The nurse must notify the designated state adult protective services agency regarding the suspected elder abuse.
Registered nurses are legally mandated reporters. When a nurse assesses injuries inconsistent with the provided history alongside behavioral indicators of fear or withdrawal in a vulnerable older adult, there is reasonable suspicion of abuse. The legally required action is to report this suspicion immediately to adult protective services to ensure the client's safety.
Step-by-Step Solution
Key Concept
Mandatory Reporting of Elder Abuse