Bruises in Different Stages and a Whispered Request
An 82-year-old woman with moderate Alzheimer's disease is brought to an outpatient clinic by her son, who is her health care agent and who has attended all four visits. Today she is quieter than usual. During gait training you note four oval bruises on her upper arms that look like fingertip grab marks, in different stages of healing; a 3 cm sacral pressure injury with yellow slough that was not documented at the last visit; and a 9-pound weight loss since the previous month's note. The son answers every question before she can, declines a home safety evaluation, and says he will not authorize anyone to come to the house. When he steps into the hallway to take a call, she whispers, 'Please don't make me go back.' She cannot state the date or the name of the clinic. There is no other family contact listed.
1. What is the reporting threshold here, who should be contacted, and does the son's presence or refusal block the report?
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The threshold is reasonable suspicion, not proof. The objective findings - grab-pattern bruising in different stages of healing, a new pressure injury with slough, a 9-pound weight loss, the son answering for her, and the patient's whispered statement - comfortably clear that threshold, and waiting for certainty is the classic failure mode in these cases. Maryland's vulnerable-adult protective framework makes health practitioners mandated reporters, and the report goes to Adult Protective Services within the Department of Human Services; if there is immediate danger, or if a crime appears to have occurred, law enforcement and 911 are appropriate as well.
The son's role does not block anything. HIPAA expressly permits disclosure to protective services and law enforcement in suspected abuse, neglect, or exploitation cases, and a health care agent's authority to make treatment decisions is not authority to veto a mandated report. His refusal to allow a home visit is itself relevant information to pass along to APS, since it limits the access that would otherwise clarify the cause.
What the therapist should not do is investigate. The job is to observe, document, report, and keep the patient safe through the rest of the visit.
2. How should this be documented, and what should the therapist avoid writing?
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Document objectively and quickly, using a body diagram if the record supports one. Record the location, size, shape, color, and stage of each finding; the pressure injury measurement and appearance; the weight and the date of the comparison note; and what the patient said, in quotation marks, verbatim, including the context ('patient whispered while son was out of the room'). Record who was present, whether the patient was oriented to place and time, that a report was made, when, and to whom, along with any reference or intake number APS provides.
What to avoid: speculation about cause or perpetrator; language like 'patient states she fell and this is probably from the wheelchair' if she said no such thing; conclusive labels such as 'abuse' in the chart; and any statement that a report 'may' be made or that the therapist is 'considering' reporting when a report has in fact been made. Do not promise the patient confidentiality you cannot provide, and do not write that the son 'refused' the home evaluation in a way that frames him as the decision-maker on the report.
Also avoid the trap of documenting the whispering exchange in front of the son or discussing it with him, and avoid emailing details through non-secure channels. The record may be produced to APS, to law enforcement, or in later proceedings.
3. What should the therapist do for the remainder of the visit and immediately afterward, and what should she not do?
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Immediately: arrange a private moment to complete the report, or have a colleague call APS from a private office while the therapist finishes the session with the patient. Do not tell the son that a report has been made or is being made, and do not confront him, which could endanger the patient and compromise the investigation. Do not withhold treatment as leverage and do not terminate the patient out of discomfort; abandonment would create a second problem, and this patient has no other listed contact.
Clinically, complete the session safely, address the pressure injury with offloading education and a wound-care referral, and document the objective findings. If the patient is unsafe to leave with him at the end of the visit - for example, she is unable to bear weight or states she is afraid - call 911 or law enforcement rather than letting her leave, and document the reasoning.
Afterward, keep the report confidential within the small circle who need to know, do not discuss it in the chart beyond the required facts, and expect that APS may contact the clinic for records. The therapist's role ends with the report; APS and law enforcement decide what comes next.