Literature Review write according to MEAL Plan Format (Main idea, Evidence, Analysis, Link, Conclusion)
I hv attached Peer reviewed sources according to selected two Topic, Must be use attached references
Due in 2 days
100% Original (Minimum 4-5 Pages)
Week 1 Assignment/..Literature Review (Required Question) Due in 2 days.docx
Literature Review Should be write according to MEAL Plan Format (Main idea, Evidence, Analysis, Link, Conclusion)
Assignment: Literature Review on selected two Topic
Total Page requirement: 4 to 5 Pages
Must be 100% Original Work (due in 2 Days)
Read All instruction carefully & must be answer/included all point
My main research topic is related Pharmaceutical Industrys
Two Selected Topic for Literature Review: 2-2 Pages each
1. Peer-Reviewed References.
2. 2021-2022 References only.
3. Use MEAL plan format (literature review)
Improve the Investigation Process to Manage Customer Complaints effectively
Organizing Management Structure to Manage Customer Complaints effectively
MEAL Plan (Main idea, Evidence, Analysis, Link, Conclusion)
Course name: DDBA Doctoral Study Completion
I hv attached Peer reviewed sources according to related Topic, Must be use below sources
Topic 1: Improve the Investigation Process to Manage Customer Complaints effectively
Liu, P.-J., Caspi, E., & Cheng, C.-W. (2021). Complaints matter: Seriousness of elder mistreatment citations in nursing homes nationwide. Journal of Applied Gerontology, 41(4), 908–917. https://doi.org/10.1177/07334648211043063
Neall, A. M., Li, Y., & Tuckey, M. R. (2021). Organizational justice and workplace bullying: Lessons learned from externally referred complaints and investigations. Societies, 11(4), 143. https://doi.org/10.3390/soc11040143
Giardina, T. D., Korukonda, S., Shahid, U., Vaghani, V., Upadhyay, D. K., Burke, G. F., & Singh, H. (2021). Use of patient complaints to identify diagnosis-related safety concerns: A mixed-method evaluation. BMJ Quality & Safety, 30(12), 996–1001. https://doi.org/10.1136/bmjqs-2020-011593
Peterson, L. J., Bowblis, J. R., Jester, D. J., & Hyer, K. (2020). U.S. state variation in frequency and prevalence of Nursing Home Complaints. Journal of Applied Gerontology, 40(6), 582–589. https://doi.org/10.1177/0733464820946673
Topic 2: Organizing Management Structure to Manage Customer Complaints effectively
García-Alcaraz, J. L., Montalvo, F. J., Sánchez-Ramírez, C., Avelar-Sosa, L., Saucedo, J. A., & Alor-Hernández, G. (2019). Importance of organizational structure for TQM success and customer satisfaction. Wireless Networks, 27(3), 1601–1614. https://doi.org/10.1007/s11276-019-02158-5
Von Janda, S., Polthier, A., & Kuester, S. (2021). Do they see the signs? organizational response behavior to customer complaint messages. Journal of Business Research, 137, 116–127. https://doi.org/10.1016/j.jbusres.2021.08.017
Rong, K., Sun, H., Li, D., & Zhou, D. (2021). Matching as service provision of sharing economy platforms: An Information Processing Perspective. Technological Forecasting and Social Change, 171, 120901. https://doi.org/10.1016/j.techfore.2021.120901
Week 1 Assignment/1 Complaints Matter Seriousness of Elder Mistreatment.pdf
Journal of Applied Gerontology © The Author(s) 2021 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/07334648211043063 journals.sagepub.com/home/jag
Although federal regulations in the United States set the standards of nursing home care through extensive require- ments aimed at protecting residents, evidence of widespread mistreatment is well documented (Castle et al., 2015; Harrington et al., 2020). For example, a recent systematic review and meta-analysis (Yon et al., 2019) has shown that more than half of staff admitted to committing acts of mis- treatment: psychological abuse, 33%; physical abuse, 14%; neglect, 12%; and sexual abuse, 2%. Low staffing levels have been found to contribute to various forms of neglect (Harrington et al., 2020). This is a source of concern because half of the nursing homes have been found to have low staff- ing levels, while at least one-quarter have been found to have dangerous staffing levels (Harrington et al., 2016)—a disturbing situation that has been exacerbated during the coronavirus disease 2019 (COVID-19) pandemic.
Nursing Home Certification Process and Mistreatment Deficiency Citations
Certification is a requirement for nursing homes to receive reimbursement for residents’ care under Medicare and/or
Medicaid programs, and one of the strategies to assure the quality of care and safety of residents. The vast majority of nursing homes are certified, because nearly all have one or more residents with care provided that is reimbursed by Medicaid or Medicare (Centers for Medicare & Medicaid Services [CMS], 2020c). After initial certification, CMS requires that nursing homes receive standard recertification surveys every 9 to 15 months, with a statewide average that must not exceed 12 months. Surveys consist of an on-site inspection by a team of surveyors (CMS, 2020b) who gener- ally come from state survey agencies (SSAs). These survey- ors monitor the quality of care and assess whether the nursing home meets federal standards for certification.
1043063 JAGXXX10.1177/07334648211043063Journal of Applied GerontologyLiu et al. research-article2021
Manuscript received: March 29, 2021; final revision received: August 7, 2021; accepted: August 12, 2021.
1Purdue University, West Lafayette, IN, USA 2University of Connecticut, Storrs, USA
Corresponding Author: Eilon Caspi, Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, 2006 Hillside Road, Unit 1248, Storrs, CT 06269, USA. Email: [email protected]
Complaints Matter: Seriousness of Elder Mistreatment Citations in Nursing Homes Nationwide
Pi-Ju Liu1 , Eilon Caspi2, and Ching-Wei Cheng1
Abstract Mistreatment of nursing home residents is prevalent and leads to harmful consequences. The Centers for Medicare & Medicaid Services’s (CMS) mission to protect residents’ right to be free from mistreatment is implemented partially through state survey agencies’ (SSAs) issuance of deficiency citations. The goal of this study was to compare SSA standard surveys and SSA complaint investigations with regard to the seriousness (scope and severity) of the mistreatment citations issued. A cumulative link mixed model was built to estimate the differences between standard surveys and complaint investigations in the seriousness of four core and two secondary mistreatment citations nationwide from 2014 to 2017. In all of the six mistreatment deficiency citations, complaint investigations were more likely to be determined as more serious compared with standard surveys. The findings reinforce the importance of strengthening nursing homes’ and CMS/SSA response to consumers’ concerns and grievances before they escalate into more harmful mistreatment.
Keywords nursing home, long-term care, elder mistreatment, abuse, neglect, exploitation, deficiency citation, standard survey, complaint investigation
Mistreatment and Exploitation
2022, Vol. 41(4) 908 –917
Liu et al. 9092 Journal of Applied Gerontology 00(0)
When nursing homes fail to meet minimum standards for certification, a deficiency citation (also called F-Tag) is issued for the noncompliance (CMS, 2020a). The Code of Federal Regulations (CFR) contains an extensive definition for each deficiency citation. The scope and severity of the violation identified during the on-site visit are labeled using 12 letters from “A” (lowest scope and severity) through “L” (highest scope and severity) (CMS, 2017). The severity rep- resents the extent of harm to the resident, whereas the scope represents the number of residents affected.
Residents living in long-term care settings are vulnerable to mistreatment due to cognitive impairment, physical frailty, and chronic illnesses (Castle, 2011; Wood & Stephens, 2003). The core deficiency citations for mistreatment used in CMS’s former F-Tags coding system (the ones used by CMS until November 27, 2017) were F-223, F-224, F-225, and F-226 (see Table 1 for definitions). A study reviewing these four deficiency citations as they were issued between 2000 and 2007 found that, annually, 20% of nursing homes nation- wide received at least one of these mistreatment citations, while 10% of nursing homes caused actual harm to at least one resident (Castle, 2011). In a recent report from the U.S. Government Accountability Office (GAO, 2019), mistreat- ment F-Tags more than doubled between 2013 and 2017 with increased serious cases, whereas the total number of all cita- tions decreased. Physical and mental/verbal abuse, followed by sexual abuse, were found to be the most common types of deficiencies. In addition, compared with emotional/verbal abuse, physical and sexual abuse had a higher level of seriousness.
Two other violations of federal nursing home regulations are commonly considered in the practice and research litera- ture as forms of mistreatment. The first is untreated pressure sores (F-314) and the other is inappropriate physical restraints (F-221). These violations are described hereafter as second- ary mistreatment F-Tags. With regard to the violation to pro- vide treatment or services to prevent or heal pressure ulcers (F-314), a substantial portion of pressure sores are consid- ered to be a form of neglect (Pemberton, 2011). When basic prevention measures are not implemented and when pressure ulcers are left untreated, these wounds can worsen to cause emotional and physical suffering, severe injury, and death (Di Maio & Di Maio, 2002; Thompson, 2001). It is important to recognize that not only could pressure sore formation to be prevented or minimized with appropriate identification and risk mitigation (Edsberg et al., 2014), almost all pressure sores can be effectively treated (Lindbloom et al., 2007). With regard to the violation of the right to be free from physi- cal restraints (F-221), the Omnibus Budget Reconciliation Act (1987) states that applying physical restraints is not acceptable for the purposes of discipline or convenience. Improper use of physical restraints can cause depression, reduced social engagement, and cognitive decline (Castle, 2006). Serious injuries resulting from inappropriate physical restraints can be fatal due to the lack of adequate supervision,
especially among residents with advanced dementia and poor mobility (Berzlanovich et al., 2012; Miles & Irvine, 1992).
Standard Survey Versus Complaint Investigation
Under federal regulations, CMS oversees all SSAs’ 10 regional offices, which conduct complaint investigations and standard surveys. Although the standard survey approach can be helpful in identifying care-related problems and improving nursing home quality of care and safety, the pro- cess consists of significant limitations. For example, a U.S. GAO (2009) study identified weaknesses in the survey meth- odology and guidance to surveyors in identifying deficien- cies. These weaknesses contribute to failures to cite serious deficiencies or citing them at seriousness levels lower than warranted—a problem known as understatement. Other related limitations in the survey process include the fact that on-site standard surveys, taking place approximately annu- ally, may not reflect nursing home care practices throughout the year but rather during a narrow time period prior to the survey. Although standard surveys are intended to be unan- nounced, U.S. General Accounting Office (2003) stated that one third of them are predictable in their timing. The predict- ability allowed nursing homes to add extra staffing or con- ceal issues that may be problematic during other times of the year (Williams et al., 2016).
In contrast to standard surveys, complaint investigations are largely based on complaints filed by residents and fami- lies, and in some cases, nursing home employees or visitors. The Office of the Long-Term Care Ombudsman (LTCO) can assist residents and families in knowing how to file com- plaints with SSA or independently file complaints with a resident and/or family’s permission (Troyer & Sause, 2011), including allegations of abuse and neglect (Bloemen et al., 2015). Therefore, complaints represent the voice of the resi- dents, families, or other concerned parties. The nursing home complaint process is considered “the front-line system for addressing consumer concerns” (Office of Inspector General [OIG], 2006, p. 1) and “a critical safeguard to protect vulner- able residents” (OIG, 2017, p. 1). An OIG (2019a) study found that nursing homes failed to report many incidents of potential abuse and neglect to their SSA in accordance with federal requirements, highlighting the importance of com- plaints and their timely investigations.
In general, investigations prompted by complaints are timelier. Compared with standard surveys, complaints are more likely to be held in a closer proximity to the time in which the mistreatment occurs. Timeliness of investigations, or the lack of thereof, has significant implications on survey- ors’ ability to collect sufficient evidence necessary to sub- stantiate the allegation and issue a citation (U.S. General Accounting Office, 1999). The actual timing of on-site com- plaint investigations varies in part depending on the priority level assigned to each complaint by the SSA during triage.
910 Journal of Applied Gerontology 41(4)Liu et al. 3
Such determination is based on the alleged conduct’s nature and the level of harm alleged in the complaint. In general, allegations triaged at the highest priority levels—“immediate jeopardy” and “non-immediate jeopardy but high priority” are required to be investigated on-site by SSA within 2 and 10 working days, respectively (OIG, 2017). That said, com- plaint-initiated investigations may be delayed, such as when SSA triages mistreatment allegations at a lower priority level. Given that a portion of residents’ and families’ com- plaints are likely filed with SSA without the knowledge of the nursing home, the timing of on-site investigations is often unpredictable. This contrasts with standard surveys whereby nursing homes can often anticipate the general time frame during which the survey will take place.
An OIG (2017) study pointed to the seriousness of con- sumer complaints, with nearly 60% of consumer complaints categorized as “immediate jeopardy” or “non-immediate jeopardy but high priority” at the triage stage. Also, nearly 60% of more serious deficiencies overall were identified through complaints (OIG, 2019b). Another study found that nearly one fourth of complaints were related to mistreatment and over one third of the allegations were substantiated (Hansen et al., 2019). Furthermore, other research found that the number of complaints predicted the number of citations issued by surveyors, as well as serious deficiency citations (Stevenson, 2005, 2006).
Gap in the Literature and Current Study
Despite the widely recognized importance of SSA complaint investigations and the relationship between complaints and quality of care, only a small number of studies examined nursing home complaint data nationwide (Hansen et al., 2019; Peterson et al., 2020; Troyer & Sause, 2011). In addi- tion, to our knowledge, no study to date has utilized a national nursing home mistreatment citation data set to compare stan- dard surveys and complaint investigations with a primary focus on citations’ scope and severity determinations. A call
for such comparison was made recently by Hansen and col- leagues (2019) who stated, “complaint-related deficiencies should be compared to deficiencies received on recent annual surveys to gain a better understanding of the effect of com- plaints on quality” (p. 754).
The current study takes a first step toward bridging this gap in knowledge by comparing the scope and severity of mistreatment citations issued during standard surveys versus complaint investigations in nursing homes nationwide. The limitations inherent in standard surveys and advantages of complaint investigations as identified in our aforementioned review of studies and government reports served as the basis for our hypothesis, such that at the national level, SSA’s mis- treatment investigations prompted by complaints are more likely to be issued a deficiency citation at higher scope and severity levels compared with standard surveys.
Through their Freedom of Information Act request to CMS, the second author obtained a state survey deficiency citations data set for all CMS-certified nursing homes in 50 states. The data spanned from Fall 2014 to 2017, up until the last day of the former CMS’s F-Tag system on November 27, 2017. The following data elements were included in the CMS data set obtained and used in this study: (a) Each F-Tag issued in 50 states occupied a row in Excel, and the six mistreatment F-Tags (detailed in Table 1) were filtered out of the 175 types of F-Tags to create the data subset used in the study. (b) Each F-Tag was assigned a scope-severity level between B to L (no F-Tags at scope-severity A level were received in the CMS data set). (c) If the F-Tag issued was based on a stan- dard survey, it was assigned the value 1 for the standard sur- vey column, otherwise it received a zero. (d) Similarly, if the F-Tag issued was based on a complaint investigation, it was assigned the value 1 for the complaint investigation column,
Table 1. Elder Mistreatment Citations Selected for the Study.
F-Tag CFR regulatory group Definition Inclusion criteria
Core elder mistreatment F-tags F-223 483.13 Free from abuse and involuntary seclusion Abuse F-224 483.13 Prohibit mistreatment, neglect, and misappropriation of property
(staff treatment of residents) Abuse, neglect,
exploitation F-225 483.13 Investigate and report individuals with allegations of abuse,
neglect, and misappropriation of property Abuse, neglect,
exploitation F-226 483.13 Develop and implement abuse, neglect, and misappropriation of
property policies and procedures (staff treatment of residents) Abuse, neglect,
exploitation Secondary elder mistreatment F-tags F-221 483.13 Right to be free from physical restraints Physical and psychological
abuse; restraints F-314 483.25 Provide treatment or services to prevent or heal pressure ulcers Neglect
Note. Regulatory groups 483.13: resident behavior and facility practices; regulatory groups 483.25: quality of care. CFR = Code of Federal Regulations.
Liu et al. 9114 Journal of Applied Gerontology 00(0)
otherwise it received a zero. The data also included (e) the date of the standard survey or complaint investigation and (f) the state in which the standard survey or complaint investiga- tion was conducted. All data elements were received at the individual nursing home level. The entire CMS data set received and its subset used in the study are considered by CMS as public records, so no informed consent was obtained for the study. The Institutional Review Boards (IRB) of University of Minnesota and Purdue University determined that the study is exempt from IRB review and approved the study.
Mistreatment Deficiency Citations: Seriousness Levels and Sources
The subset of six mistreatment F-Tags was selected by the research team based on their direct relevance to various forms of mistreatment (i.e., abuse, neglect, and/or financial exploitation) or because they represent violations of federal standards of care that are commonly considered as forms of mistreatment (i.e., physical restraints and pressure ulcers). Out of the 15,045 nursing homes, 10,240 (68%) had at least one mistreatment F-Tag across the 3-year study period.
For each citation, CMS uses the following four levels to determine the seriousness of a deficiency: Level 1 (scope and severity A–C) is “no actual harm with potential for minimal harm.” This level of deficiency has the potential for causing no more than a minor negative impact on the residents. Level 2 (scope and severity D–F) is “no actual harm with potential for more than minimal harm that is not immediate jeopardy.” Level 3 (scope and severity G–I) is “actual harm that is not immediate jeopardy.” Level 4 (scope and severity J–L) is “immediate jeopardy to resident health or safety.”
The initial inspection of the data revealed that the sample sizes for Level 1 are small across the F-Tags: 4 (0.2%) in F-223, 4 (0.3%) in F-224, 114 (1.4%) in F-225, 505 (6.5%) in F-226, and none in F-221, 3 (0.04%) in F-314, with the total of 630 (2.2%) for all the six F-Tags. Following the clas- sification approach used in a recent U.S. GAO (2019) report, we decided to combine Level 1 and Level 2 into one level entitled hereafter as “no actual harm.” However, this does not suggest that no harm was caused to a resident as explained under Table 2. The three seriousness levels used in the study are described in Table 2.
The CMS data set distinguishes each F-Tag with regard to whether the deficiency citation was issued as a result of a standard survey or complaint investigation. This distinction between standard surveys and complaint investigations as a data element in the data set allowed us to conduct the com- parative analysis at the core of the study. Sample size distri- bution is presented in Table 3. However, in a small number of F-Tags, the deficiency citation was issued as a result of both standard survey and complaint investigation. A total of 2,731 citations (9% out of 28,390) were excluded from the data subset, including 223 (12.1%) in F-223, 196 (12.4%) in F-224, 864 (10.9%) in F-225, 659 (8.5%) in F-226, 75 (4.3%) in F-221, and 714 (9.5%) in F-314. We excluded these F-Tags from the analysis because they cannot be exclusively catego- rized as either standard survey or complaint investigation.
Cumulative link mixed models (CLMMs; Christensen, 2015), a novel statistical modeling framework appropriate for studies with ordinal response variables and clustered observations, were adopted with the logit link function to investigate how the citation types correlate with the scope and severity levels. For the “cumulative link” part of the analysis, we adopted the negative binomial regression frame- work because it has the least constraints on the data distribu- tion and therefore provides the most flexibility (Agresti, 2010). The “mixed model” part of the analysis allows us to have a more accurate inference on the effect of citation types, which is taken as the sole fixed effect, with the grouped cor- relation structure accounted for (Snijders & Bosker, 2011). Considering the variation in the use of nursing home defi- ciency citations (Castle et al., 2007), besides the citation type (standard survey, complaint investigation) as the sole fixed effect, the state and the inspection year were taken as random effects to account for the correlations between observations. Data analysis was carried out using R 3.6.1, and statistical significance was set at p < .05.
Among the core mistreatment deficiency citations (see Table 3), abuse/involuntary seclusion (F-223) and neglect/ misappropriation (F-224) had more complaint investigations
Table 2. Elder Mistreatment Deficiency Citations’ Scope and Severity Level Used in the Study.
Scope and severity level Category Description
Levels 1 and 2 B–F No actual harm with potential for minimal harm and no actual harm with potential for more than minimal harm
Level 3 G–I Actual harm that is not immediate jeopardy Level 4 J–L Immediate jeopardy to resident health or safety
Note. Levels 1 and 2 “no actual harm” consist of a combination of “no actual harm with potential for minimal harm” and “no actual harm with potential for more than minimal harm that is not immediate jeopardy,” respectively. In addition, the scope and severity letter “A” are not displayed in the table because it was not included in the data set received by the authors from Centers for Medicare & Medicaid Services; thus, letter “A” was not part of the study’s analysis.
912 Journal of Applied Gerontology 41(4)Liu et al. 5
(79% and 76%) than standard surveys (21% and 24%), and close to 60% of all F-Tags were issued at the scope and severity level 1 or 2. Investigate/report allegations (F-225) and develop/implement abuse/neglect policies (F-226) were split equally between complaint investigations (55% and 47%) and standard survey (45% and 53%), and the majority of all the deficiency citations were found to be at the scope and severity level 1 or 2 (over 90%). Among the secondary mistreatment deficiency citations, more were investigated during standard survey (83% for physical restraints [F-221] and 71% for pressure ulcers [F-314]), and the majority of the deficiency citations were found to be at the scope and sever- ity level 1 or 2 (97% and 77%).
For all six F-Tags, complaint investigations were more likely to result in higher scope and severity level compared with standard surveys (p < .001). The comparison of scope and severity level between standard survey and complaint investigation is reported in Table 4.
The study findings improve our understanding of the seri- ousness (i.e., scope and severity) of mistreatment deficiency citations issued by SSAs during complaint investigations in comparison with the same deficiency citations when issued during standard surveys. The analysis of this CMS national
Table 3. Sample Size of Mistreatment Deficiency Citations by Citation Type and Scope and Severity Level.
Scope and severity level
No actual harm Actual harm Immediate jeopardy Total
F-223 Standard survey 241 49 47 337 20.85% Complaint investigation 713 332 234s 1,279 79.15% Total 954 381 281 1,616 59.03% 23.58% 17.39% F-224 Standard survey 231 61 40 332 23.90% Complaint investigation 583 220 254 1,057 76.10% Total 814 281 294 1,389 58.60% 20.23% 21.17% F-225 Standard survey 3,106 27 51 3,184 45.02% Complaint investigation 3,617 58 214 3,889 54.98% Total 6,723 85 265 7,073 95.05% 1.20% 3.75% F-226 Standard survey 3,679 38 67 3,784 53.19% Complaint investigation 2,881 138 311 3,330 46.81% Total 6,560 176 378 7,114 92.21% 2.47% 5.31% F-221 Standard survey 1,348 11 12 1,371 82.69% Complaint investigation 255 20 12 287 17.31% Total 1,603 31 24 1,658 96.68% 1.87% 1.45% F-314 Standard survey 3,889 937 39 4,865 71.45% Complaint investigation 1,369 494 81 1,944 28.55% Total 5,258 1,431 120 6,809 77.22% 21.02% 1.76% Total Standard survey 12,494 1,123 256 13,873 54.07% Complaint investigation 9,418 1,262 1,106 11,786 45.93% Total 21,912 2,385 1,362 25,659 85.40% 9.29% 5.31%
Note. Mistreatment deficiency citations classified in the Centers for Medicare & Medicaid Services data set as both standard survey and complaint investigation (n = 2,731) were excluded from the data subset used in the study, and thus they are not displayed in the table.
Liu et al. 9136 Journal of Applied Gerontology 00(0)
data set revealed that in all of the six mistreatment deficiency citations examined, complaint investigations were more likely to result in a higher scope and severity level citation than standard surveys. In addition, a higher number of F-223 (abuse/involuntary seclusion) and F-224 (neglect/misappro- priation) deficiency citations were the result of complaint investigations, whereas a higher number of F-221 (physical restraints) and F-314 (pressure ulcers) were issued during standard survey. Although our data do not allow us to exam- ine it, one possibility is that physical restraints and pressure sores are more easily discovered during standard surveys, but evidence of mistreatment is more readily detected during complaint investigations when reported directly to SSA.
We believe that the findings from our study are important in terms of residents’ and families’ potential ability to hold nursing homes accountable for mistreatment. As mentioned earlier, investigations of complaints are generally conducted closer to the occurrence of the alleged mistreatment and more likely to be truly unannounced. When an investigation is conducted in a timely manner, evidence is more likely to be available to investigators to support issuing a citation at a higher scope and severity level (U.S. General Accounting Office, 1999; U.S. GAO, 2011). This is important because close to two thirds of nursing home residents are estimated to have cognitive impairment (Gaugler et al., 2014) and delayed investigation limits their ability to recall details from mis- treatment incidents. Moreover, during a complaint investiga- tion, surveyors focus on gathering information directly related to specific information included in a complaint. This is different from a standard survey, where a standardized pro- tocol instructs surveyors to interview a sample of residents on a broad range of care-related problems. The U.S. GAO (2019) and other researchers (e.g., Stevenson, 2005, 2006) have recognized that residents and families might be embar- rassed or afraid to report mistreatment. Many frail residents, who are physically dependent on staff for daily personal care, may fear being perceived as troublemakers if they
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