The Dementia Patient Who Says Don't Call
Rosa, an LCSW with a home-health agency, visits 81-year-old Mr. Alvarez, who has moderate dementia and lives with his adult son, who holds power of attorney. Mr. Alvarez has lost 12 pounds in two months; his diabetes medications are unfilled; there is a stage 2 pressure injury on his sacrum; the apartment is 88°F with no working air conditioning; and the son has canceled two home-health aide visits. Mr. Alvarez says, 'Don't call anyone. My son is a good boy; he just forgets.' The son says the medications are too expensive, and that his father 'doesn't need strangers.' Mr. Alvarez is alert enough to state his preference but cannot explain how he would get food or medications. Rosa suspects self-neglect versus caregiver neglect and worries about alienating the family.
1. Does Rosa have a duty to report to Adult Protective Services? Analyze the at-risk adult criteria and the effect of the client's refusal.
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Yes. Colorado's mandatory reporting law for at-risk adults covers adults 70 and older and adults 18 and older with intellectual or developmental disabilities who are unable to protect themselves. Mr. Alvarez is 81, has moderate dementia, has untreated diabetes, a pressure injury, weight loss, and an unsafe apartment. Those facts give Rosa reasonable cause to suspect abuse, neglect, or exploitation, including caregiver neglect and self-neglect. Neither the son's power of attorney nor Mr. Alvarez's statement 'don't call anyone' eliminates the duty. A power of attorney is not a shield against a neglect report, and a client's preference is considered but is not controlling when the client cannot meet basic needs.
Rosa should report to the county adult protective services unit or law enforcement. She should not conduct her own investigation or confront the son. The report should include objective observations, dates, medication information, the pressure injury, the heat, and the canceled aide visits.
2. How should Rosa handle the client's wish not to report and the son's resistance?
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Rosa should explain, in plain language, that she is a mandatory reporter and that certain safety concerns require a report even when the client does not want one. She can tell Mr. Alvarez that she will involve him as much as possible and that the purpose is to get help, not to punish his son. She should not ask for his permission as a condition of reporting, and she should not promise secrecy. If Mr. Alvarez has capacity to make some decisions, Rosa should honor his preferences where safe, but his dementia and inability to explain how he would obtain food or medication show that his refusal is not a fully informed safety plan.
With the son, Rosa should stay calm and factual. She can explain the medical concerns and offer to connect the family with medication assistance, caregiver support, or area agency on aging services. She should not argue about whether he is 'good' or 'bad.' If the son becomes threatening or blocks access to Mr. Alvarez, Rosa should leave and contact law enforcement. She should document the son's statements, the client's statements, and her own attempts to arrange services.
3. What immediate safety steps should Rosa take before and after reporting?
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Before reporting, Rosa should address urgent medical needs. The pressure injury, uncontrolled diabetes, weight loss, and extreme heat could constitute an emergency. If Mr. Alvarez is in immediate danger, Rosa should call 911 and stay until help arrives or until she is assured of safety. She should check for food and water, ask about medication access, and determine whether the son is preventing care. She should not transport the client herself unless agency policy and safety allow it.
After reporting, Rosa should coordinate with the agency, the county, and medical providers, and should make a follow-up visit. HIPAA permits disclosures to adult protective services and law enforcement in cases of suspected abuse, neglect, or exploitation, limited to the minimum necessary information. Rosa should document the report time, the person contacted, the information given, the client's and son's statements, and the follow-up plan. She should avoid documenting speculation as fact and should distinguish direct observations from suspicions.