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Press Release

Report finds abuse by nursing home staff not treated as crimes

OAKLAND, May 3 - Disability Rights California’s Investigations Unit has just released a 40 page report, “Victimized Twice: Abuse of Nursing Home Residents, No Criminal Accountability for Perpetrators.”  The report examines the following:

  • A middle aged resident with cerebral palsy and a cognitive impairment was paraded naked and soaking wet back to his room in front of others after being forced by staff to take cold showers.  The abuse went on for months and was witnessed by other staff who did nothing.
  • A 41 year man was struck in the mouth with a closed fist by a staff member and then slapped.  Bleeding from a cut on his lip, he told staff about the assault.  The facility delayed for days before reporting.  Prosecutors refused to take the case because they lacked physical evidence.
  • An activity assistant shoved and then released two elderly women sitting in wheelchairs.  They sailed down the corridor and slammed into the wall where they sat, immobile and stranded.
  • While assisting a female resident with her bath, a male aide fondled her breasts.  She complained to the facility administrator but, two days later, the aide came back to work and was assigned to the same residents.  When he confronted the woman for telling on him, she felt afraid.
  • A man with fragile, tissue paper like skin when forced into a whirlpool bath.  His skin tore in three places was he was getting in, one tear went from his wrist to his armpit.  A visitor heard his screams and reported the abuse.  Facility staff contend they did nothing wrong.

These are just some of the 12 cases investigated by DRC involving nine men and seven women, age 41 to 97, with physical, mental and cognitive disabilities, who were physically and sexually abused by facility staff.  The abuse ranged from punching or hitting in the face to repeated sexual assaults and allegations of rape.  Some involved multiple victims and occurred over months, others were one-time incidents. “This is just the tip of the iceberg of hundreds of confirmed cases of nursing home resident abuse we see every year from Department of Public Health citation reports,” stated Leslie Morrison, one of the authors of the report.  Experts estimate that for every case of abuse that is reported, as many five go unreported. 

Investigators concluded that incidents, whose facts are indicative of a crime, were handled not as criminal matters but as licensing or employee concerns.  In most cases, the only outcome was a minimal citation by the Department of Public Health and the assailant being dismissed from employment, still eligible for jobs at other care facilities.

Nearly half of the cases were never reported to law enforcement.  The bulk went to long term care ombudsmen who, under federal law, cannot also report to law enforcement or prosecutors unless the victim gives consent. Few residents do.  This means that reports of criminal abuse in California nursing homes vanish into a virtual black hole and never reach law enforcement or the criminal justice system.

Significant delays in reporting and lapses in investigations further thwart criminal prosecution.  The Bureau of Medi-Cal Fraud and Elder Abuse (BMFEA), a division of the California Department of Justice, investigated all nine cases referred to them but did not prosecute any.  Criminal charges were filed by local district attorneys in only three cases, two of which involved the same defendant who abused two different residents.  In the end, in the cases prosecuted, felony charges were reduced to misdemeanor offenses, and sentences were minimal.

The investigations team made important recommendations to ensure that crimes against nursing home residents are promptly reported and investigated.  Priorities include amending state law to require that all incidents of abuse and neglect are reported immediately to law enforcement; challenging the BMFEA to take a leadership role in focusing on nursing home resident abuse and criminal prosecution; developing a system for tracking abusive case staff; and holding nursing home administrators responsible when abuse is not reported as required.

A complete copy of the report (in English) can be located at or by contacting Leslie Morrison, Director of the Investigations Unit at