The sight of her father’s unopened heart medication still makes Oro Valley resident Laurie Moore feel sick to her stomach.

For 30 days while Moore traveled last summer, she says, her 80-year-old father, Larry Foreman, did not get any of his two 5 milligram daily doses of Eliquis, a blood thinner prescribed by his heart doctor.

Her father, who lived with Moore but stayed at an Oro Valley assisted-living center during her trip, was hospitalized three times after he left the facility, and died on Oct. 29. She attributes his decline to the month when he didn’t get the medication he needed.

All but one of Moore’s complaints to four different state entities was dismissed. The one she filed with the State Board ofNursing is pending.

The news of the dismissals left Moore feeling like she’d been punched in the gut.

But her situation is not unusual. The agency that handles reports about mistreatment of vulnerable adults in Arizona rarely affirms the complaints it receives.

Last fiscal year, the state’s Adult Protective Services (APS) investigated and closed out 21,602 allegations of neglect, abuse and exploitation of vulnerable adults. Just 167 of those allegations — less than 1 percent — were substantiated.

At APS, substantiated means evidence exists to support the allegations, and one or more perpetrators were identified. Last year, 170 names were added to Arizona’s public registry of known perpetrators against vulnerable adults.

The state data shows not one of the 2,419 allegations of neglect APS investigated and closed out in Pima County last year was substantiated, though 21 percent were “verified.”

“Verified” means evidence exists to support the allegations, but the case can’t be substantiated because the alleged perpetrator is a vulnerable adult or is unknown.

The vast majority of mistreatment allegations APS investigated and closed last year in Pima County and statewide were neither verified nor substantiated.

Roadblocks

Officials with the Arizona Department of Economic Security, which oversees APS, say part of the problem with its data is that there are numerous roadblocks to investigating abuse of vulnerable (usually elderly) adults.

The burden of proof to substantiate an APS case of abuse, neglect or exploitation is “preponderance of the evidence,” which can be difficult to meet based on a variety of factors.

Although most complaints aren’t getting substantiated, there’s no question elder abuse exists. A 2017 study published last month in The Lancet Global Health estimated the global prevalence of elder abuse at 15.7 percent, meaning that about 1 in 6 older adults worldwide experience abuse.

Elders make up a growing proportion of the U.S. population. The problem is, elder abuse is not always detected, investigated or tracked.

Older people can be unreliable witnesses because of health issues like dementia, and in some cases, there’s no one except for an older and sometimes sick adult who saw what happened. Other times, the situation comes down to “he said, she said.”

Excluding self-neglect, 46 percent of alleged perpetrators investigated by Arizona’s APS last year were family members.

In those cases, the investigations may reveal that the family member was not trying to mistreat or harm the vulnerable adult but was providing the level of care they were able to with the resources available to them, state APS officials wrote in an emailed statement.

“Further, in cases of neglect by another individual, a clear and definite pattern of neglect needs to be established for substantiation, which may not be evident in the information collected during the investigation,” according to the statement.

And the data are affected by the fact that nearly 40 percent of the reported cases of neglect are self-neglect, which means that they can’t be substantiated since there is no perpetrator.

Such cases can be particularly difficult for investigators. Unlike children, vulnerable adults can live their lives as they see fit, unless they have been adjudicated incompetent in a court of law.

Also, resources to conduct the investigations are stretched — the nearly 22,000 communications to APS entered into its computer system last year comprise a 62 percent jump over 2012 numbers, and while the average caseload per investigator has declined, it continues to exceed targeted levels.

The agency prioritizes cases where vulnerable adults are in immediate risk of harm. In Moore’s case, for example, by the time Adult Protective Services was contacted, the situation she was complaining about had passed.

But Moore thinks her father’s situation fits the agency’s definition of neglect, which is “a pattern of conduct without the person’s informed consent resulting in deprivation of food, water, medicine, medical services, shelter, cooling, heating or other services necessary to maintain minimum physical or mental health.”

“My father had no voice and no choice,” Moore said. “He did not know he wasn’t being taken care of for 30 days.”

National problem

Measuring Arizona’s low substantiation rate against other states is not an apples-to-apples comparison.

Part of the problem is that states have differing definitions of abuse, neglect and exploitation, elder advocates say — an issue the federal government is trying to rectify with a National Adult Maltreatment Reporting System.

The system is on track to begin producing uniform data in a few months, and officials with APS in Arizona say they are preparing to submit data to the national system.

The system was created because numerous entities, including the Government Accountability Office, have said a lack of data is a significant barrier to improving APS programs nationwide.

Adults with disabilities and older people who are victims of crime and abuse receive no designated support from the federal government.

Federal money for APS comes to state programs through federal Social Services Block Grants which each state decides how to use, leaving the programs historically underfunded and underdeveloped across the country, said Andrew Capehart, assistant director of the National Adult Protective Services Association.

Legal action

Phoenix-based elder abuse attorney Melanie Bossie of the law firm Wilkes & McHugh says she finds the latest substantiation rates for APS cases in Arizona extremely low, but at the same time, she understands the agency has limited time and resources.

If investigators don’t take the extra step of talking to multiple people and asking for employee files, they can miss crucial information, Bossie said. Employee files can reveal disciplinary action against workers that will provide evidence of mistreatment, she said.

“We do commonly have people frustrated with administrative remedies and many times, we’ve been able to pursue a resolution when a case has been unsubstantiated with APS or ADHS (the Arizona Department of Health Services),” Bossie said. “I am not trying to be critical — we are just going to do a deeper investigation.”

Bossie stressed she has also encountered cases where state agencies do substantiate complaints of abuse, neglect or financial exploitation, but families still want to pursue legal action.

Bossie and her Tucson-based colleague Mary Ellen Spiece say they’ve seen facilities improve their policies because of litigation, particularly when there’s a pattern. If facilities are being looked at and watched more closely, they generally will attempt to do better, Spiece said.

“Our clients as a whole are not litigious,” Spiece said. “They are just so upset about what happened.”

Confusion

APS has a hotline for reporting abuse, neglect and financial exploitation; and the ADHS has a process where people can file complaints about licensing violations in state-licensed facilities like nursing homes and assisted-living facilities.

Complaints filed with the health department have a low rate of substantiation, too, though it is higher than the APS rates.

“Our substantiation process is done through observation, documentation and/or interviews,” department spokeswoman Holly Ward wrote in an email. “So, unless a case is observed, well documented or the employees are available to interview, we could run into challenges.”

Last year, 20 percent of 2,155 allegations reported by the public about residential facilities to ADHS were substantiated, state records show. Residential facilities include both behavioral health residential and assisted-living facilities.

In Arizona nursing homes, 7 percent of 1,064 allegations reported last year in 1,287 complaints were substantiated, state figures show.

There are examples where the state health department has taken action against facilities where medication errors occurred.

In one case that’s pending in Pima County Superior Court, the family of Eugene Johannes, who was an insulin-dependent diabetic, is suing BeeHive Homes of Green Valley, saying the facility did not give Johannes his insulin for 19 days in March 2015, resulting in his death. In court filings, the facility has denied wrongdoing.

State health department records show BeeHive was fined in May 2015 for failing to ensure two of three insulin dependent diabetic residents — including one who was there in March 2015 — received their insulin as prescribed.

Officials with the Pima Council on Aging say their office is usually the best place for people to start when they have a concern about elder mistreatment. In many cases, that’s going to be all it takes to solve a problem — they can mediate issues in long term-care facilities at the local level, for example.

“People often don’t know about all the wonderful resources in the community. It is nice to be able to give someone hope,” said Rae Vermeal, who is the Pima Council on Aging’s elder rights and benefits coordinator.

Heartbreak

When Moore picked her father up from the Mountain View Retirement Village’s assisted-living facility in Oro Valley on July 15 and saw his unopened medication, she was heartbroken. Then, the home health care company she’d hired to do rehabilitation work with her father while he was at Mountain View showed her a documented decline in his health while he was there.

“Hell’s bells. I panicked,” said Moore, who had paid $4,150 for her dad’s one- month stay, including $450 for a special level of care to include medication management.

“My dad seemed exhausted, frail and weaker. I left them with three sealed boxes of Eliquis samples, and three closed bottles. None had been opened.”

Her father, a former high school homecoming king who worked in construction in Maryland until the age of 70, was affable and trusting. Moore could not bear the thought that his health had suffered because of the mistake. She wanted an acknowledgment that her dad mattered.

She started with the Oro Valley assisted living facility, which is owned by The Ensign Group, a California-based, for-profit company that is one of the country’s largest senior-care providers. Moore’s father had stayed there once before and liked it.

Moore said when she dropped her father off at the beginning of his stay in June, she provided the facility with two medication lists — one from his primary care doctor and the other from his heart doctor. The primary care list included 10 different medications that her father needed daily. The list from the heart doctor was a repeat of the first list with one exception — it included the Eliquis.

In an Aug. 25 email from Mountain View executive director Tim Nelson, which Moore shared with the Star, the facility said it never received the heart doctor’s list.

The email included an offer of a $500 refund. But Moore said it wasn’t satisfactory. She insists the facility did receive the heart doctor’s list and in any case should have called her or her father’s doctor to ask what to do with all the Eliquis she gave them, if they weren’t sure.

Lack of evidence

Nelson told the Star that because of privacy regulations, the assisted-living facility would not comment on medications or “any aspect of the health care related to former or current residents of Mountain View.”

He wrote in an email that Mountain View routinely trains its staff on various aspects of resident care, “including the facility procedure for handling medications when they are brought into the facility by family members.”

Moore ended up complaining to four state entities and also got advice from the Pima Council on Aging.

The Arizona Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers dismissed her complaint against Mountain View’s executive director at a meeting on Oct. 17 for lack of evidence, the meeting’s minutes say.

After her dad died later that month, Moore paid $2,000 for an autopsy, which showed the cause of death was heart failure.

She later got letters from APS and the health department to tell her that her complaints had not been substantiated with them, either. She is now considering legal action.

Contact health reporter Stephanie Innes at 573-4134 or email

sinnes@tucson.com.