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Role of Forensic Science in Identification of Mistreatment Deaths in Long-Term Care Facilities: Final Report

NCJ Number
Date Published
January 2005
96 pages

Using exploratory interviews, this study examined the implementation of Arkansas' law that gives county medical examiners the authority to investigate deaths that occur in long-term care facilities (LCF's); and focus-group interviews were conducted with medical examiners, coroners, and geriatricians from 27 States to determine their involvement in investigations into the deaths of LCF residents.


Although there have been no definitive studies of the prevalence of abuse and neglect of nursing home residents, there is credible evidence that the problem is serious and widespread. In response to several high profile deaths in LCF's, Arkansas enacted a law in 1999 that gives county coroners legal access to conduct investigations in LCF's following a resident's death. The current research focused on Pulaski County's (PC's) implementation of this law. Since the law became effective on July 1, 1999, PC's coroner's office has conducted over 2,000 LCF death investigations. In addition to interviewing the staff of investigators, this research also collected and abstracted nursing-home death investigation reports for the county for the year 2001 (n=495), comparing the 21 cases referred for further investigation with those that were not so referred. The findings from this study provide further insight into systematic death investigations in LCF's and suggest the positive impact of the Arkansas law on attention to mistreatment and the quality of care of LCF residents. Another phase of this project involved focus groups with 40 coroners, medical examiners, and geriatricians from 27 States for the purpose of identifying indicators or markers that might suggest abuse or neglect and to discuss issues related to reporting potential mistreatment of LCF residents. Findings from the focus groups pertain to current authority for reviewing nursing home resident deaths, current practice for reviewing deaths of nursing home residents, and barriers to forensic investigations of such deaths. 7 exhibits, appended methodological material, and 35 references

Date Published: January 1, 2005