New Protections for Nursing Home Residents

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New Obama-era rules designed to give nursing home residents more control of their care are gradually going into effect. The rules give residents more options regarding meals and visitation as well as make changes to discharge and grievance procedures.

The Centers for Medicare and Medicaid finalized the rules — the first comprehensive update to nursing home regulations since 1991 — in November 2016. The first group of new rules took effect in November; the rest will be phased in over the next two years.

Here are some of the new rules now in effect:

  • Visitors. The new rules allow residents to have visitors of the resident’s choosing and at the time the resident wants, meaning the facility cannot impose visiting hours. There are also rules about who must have immediate access to a resident, including a resident’s representative. For more information, click here.
  • Meals. Nursing homes must make meals and snacks available when residents want to eat, not just at designated meal times.
  • Roommates. Residents can choose their roommate as long as both parties agree.
  • Grievances. Each nursing home must designate a grievance official whose job it is to make sure grievances are properly resolved. In addition, residents must be free from the fear of discrimination for filing a grievance. The nursing home also has to put grievance decisions in writing. For more information, click here.
  • Transfer and Discharge. The new rules require more documentation from a resident’s physician before the nursing home can transfer or discharge a resident based on an inability to meet the resident’s needs. The nursing home also cannot discharge a patient for nonpayment if Medicaid is considering a payment claim. For more information, click here.

CMS also enacted a rule forbidding nursing homes from entering into binding arbitration agreements with residents or their representatives before a dispute arises.  However,a nursing home association sued to block the new rule and a U.S. district court has granted an injunction temporarily preventing CMS from implementing it.  The Trump Administration is reportedly planning to lift this ban on nursing home arbitration clauses.

In November 2017, rules regarding facility assessment, psychotropic drugs and medication review, and care plans, among others, will go into effect. The final set of regulations covering infection control and ethics programs will take effect in November 2019.

To read the rules, click here.

A Brothers’ Dispute Over Mother’s Nursing Home Placement Is Not Domestic Violence

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A New Jersey appeals court rules that an ugly dispute between two brothers over their mother’s placement in a nursing home did not amount to domestic violence. R.G. v. R.G.(N.J. Super. Ct., App. Div., No. A-0945-15T3, March 14, 2017).

R.G was the attorney-in-fact and primary caregiver for his parents. After R.G.’s mother fell ill, R.G. wanted to place his mother in a nursing home. R.G’s brother objected to this plan, but R.G. went ahead and had his mother admitted to a nursing home without his brother’s consent. R.G.’s brother sent angry and threatening texts and emails to R.G. as well as emails expressing his desire to find a way to care for their parents in their home. Eventually the men got into a physical altercation in which R.G.’s brother shoved R.G.

R.G. filed for a restraining order against his brother under the Prevention of Domestic Violence Act. The trial judge ruled that R.G. was harassed and assaulted and issued the restraining order. R.G.’s brother appealed, arguing that R.G. did not meet the definition of a victim of domestic violence.

The New Jersey Superior Court, Appellate Division, reverses, holding that R.G.’s brother’s actions did not amount to domestic violence. The court finds that there was insufficient evidence that R.G.’s brother purposely acted to harass R.G., ruling that “a mere expression of anger between persons in a requisite relationship is not an act of harassment.”

For the full text of this decision, go to: http://www.judiciary.state.nj.us/opinions/a0945-15.pdf

 

“My mom is in a nursing home and I noticed some bruises and sores. I think they are bedsores—what should I do?”

Bedsores are often a sign of neglect and sometimes a sign of abuse. The first thing you should do is speak to a nurse on duty and begin to remedy the situation. Be aware that the nurse may not have a full understanding of these injuries and you will likely need the attention of a wound care specialist and medical doctor. If you have a cell phone take some pictures of the wound for documentation. Bedsores and Pressure Sores, also known as Decubitus Ulcers can progress quickly and can be deadly. They occur when someone is immobile and there is not adequate blood flow. Then the affected tissue dies and an ulcerated sore develops. In a nursing home, hospital or other care facility it is their responsibility to check and turn the patient regularly. There are laws in place that protect patients and you should know that these injuries are not the fault of the patient. The patient is the victim. If a loved one you know is suffering they may have a significant, financially rewarding lawsuit. Read more about this on our website, http://www.RaphanLaw.com.

As an Elder Law firm we see these cases often. Whether malpractice, abuse or neglect it is simply unjust for it to happen to an innocent victim. Do not put off addressing the issue. Call me for a free consultation (212-268-8200, 800-278-2960) or even to just guide you through the process of getting the proper medical and legal attention.

Visual Stages of Bedsores:

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Read our Frequently Asked Bedsore Lawsuit Questions here>

By Brian A. Raphan, Esq.

Top 10 Elder Law decisions of 2016

Below, in chronological order, is ElderLawAnswers’ annual roundup of the top 10 elder law decisions for the year just ended, as measured by the number of “unique page views” of our summary of the case.

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1. Medicaid Applicant’s Irrevocable Trust Is an Available Resource Because Trustee Can Make Distributions

An Alabama appeals court rules that a Medicaid applicant’s special needs trust is an available resource because the trustee had discretion to make payments under the trust. Alabama Medicaid Agency v. Hardy (Ala. Civ. App., No. 2140565, Jan. 29, 2016). To read the full summary, click here.

2. Trust Is an Available Asset Because Trustees Have Discretion to Make Distributions

A New York appeals court rules that a Medicaid applicant’s trust is an available asset because the trustees have discretion to make distributions to her. In the Matter of Frances Flannery v. Zucker (N.Y. Sup. Ct., App. Div., 4th Dept., No. TP 15-01033, Feb. 11, 2016). To read the full summary, click here.

3. Medicaid Applicant Who Transferred Assets in Exchange for Promissory Note May Proceed with Suit Against State

A U.S. district court holds that a Medicaid applicant who was denied Medicaid benefits after transferring assets to her children in exchange for a promissory note may proceed with her claim against the state because Medicaid law confers a private right of action and the Eleventh Amendment does not bar the claim. Ansley v. Lake (U.S. Dist. Ct., W.D. Okla., No. CIV-14-1383-D, March 9, 2016). To read the full summary, click here.

4. Mass. Court Bridles at Allegations in Request for Reconsideration in Irrevocable Trust Case

In a strongly worded response to a Medicaid applicant’s request for reconsideration of an unsuccessful appeal involving an irrevocable trust, a Massachusetts trial court strikes the applicant’s pleadings after it takes great exception to the tone of the argument.  Daley v. Sudders (Mass.Super.Ct., No.15-CV-0188-D, March 28, 2016). To read the full summary, click here.

5. Caretaker Exception Denied Because Child Did Not Provide Continuous Care

A New Jersey appeals court determines that the caretaker child exception does not apply to a Medicaid applicant who transferred her house to her daughter because the daughter did not provide continuous care for the two years before the Medicaid applicant entered a nursing home. M.K. v. Division of Medical Assistance and Health Services (N.J. Super. Ct., App. Div., No. A-0790-14T3, May 13, 2016). To read the full summary, click here.

6. State Can Place Lien on Medicaid Recipient’s Life Estate After Recipient Dies

An Ohio appeals court rules that a deceased Medicaid recipient’s life estate does not extinguish at death for the purposes of Medicaid estate recovery, so the state may place a lien on the property. Phillips v. McCarthy (Ohio Ct. App., 12th Dist., No. CA2015-08-01, May 16, 2016). To read the full summary, click here.

7. Attorney Liable to Third-Party Beneficiary of Will for Legal Malpractice

Virginia’s highest court rules that an intended third-party beneficiary of a will may sue the attorney who drafted the will for legal malpractice. Thorsen v. Richmond Society for the Prevention of Cruelty to Animals (Va., No. 150528, June 2, 2016). To read the full summary, click here.

8. Nursing Home’s Fraudulent Transfer Claim Against Resident’s Sons Can Move Forward

A U.S. district court rules that a nursing home can proceed with its case against the sons of a resident who transferred the resident’s funds to themselves because the fraudulent transfer claim survived the resident’s death. Kindred Nursing Centers East, LLC v. Estate of Barbara Nyce (U.S. Dist. Ct., D. Vt., No. 5:16-cv-73, June 21, 2016). To read the full summary, click here.

9. Irrevocable Trust Is Available Asset Because Medicaid Applicant Retained Some Control

New Hampshire’s highest court rules that a Medicaid applicant’s irrevocable trust is an available asset even though the applicant was not a beneficiary of the trust because the applicant retained a degree of discretionary authority over the trust assets. Petition of Estate of Thea Braiterman (N.H., No. 2015-0395, July 12, 2016). To read the full summary, click here.

10. NY Court Rules that  Spouse’s Refusal to Contribute to Care Creates Implied Contract to Repay Benefits

A New York trial court enters judgment against a woman who refused to contribute to her spouse’s nursing home expenses, finding that because she had adequate resources to do so, an implied contract was created between her and the state entitling the state to repayment of Medicaid benefits it paid on the spouse’s behalf. Banks v. Gonzalez (N.Y. Sup. Ct., Pt. 5, No. 452318/15, Aug. 8, 2016). To read the full summary, click here.

Feel Free to contact me to see how any of these decisions may affect your personal situation.

-Brian A. Raphan, Esq. 

Payments to Caregiver Subject Medicaid Applicant to Penalty Period

Reversing a lower court, a Michigan appeals court rules that under state regulations a Medicaid applicant’s payments to a non-relative caregiver subjected the applicant to a penalty period because the caregiver did not have a written contract and a doctor had not recommended the service be provided. Jensen v. Department of Human Services (Mich. Ct. App., No. 319098, Feb. 19, 2015).

Jason Jensen hired a non-relative caregiver for his grandmother, Betty Jensen, who suffered from dementia. Mr. Jensen and the caregiver had an informal agreement and no contract was signed, but Mr. Jensen paid the caregiver a total of $19,000 from Ms. Jensen’s assets over the course of the months she worked for Ms. Jensen. When Ms. Jensen’s condition worsened, she entered a nursing home and applied for Medicaid. The state established a penalty period, holding that the payments to the caregiver were an unlawful transfer. Ms. Jensen died before the penalty period ended.

Mr. Jensen appealed, but the state upheld the decision. Under state regulations, payments to caregivers are considered “divestments” and transfers for less than fair market value unless there is a signed contract and a doctor has recommended in writing that the services be provided, among other requirements. Mr. Jensen appealed to court, and the trial court reversed, holding that the regulation requiring that a contract be in writing applied only to relative caregivers. The state appealed.

The Michigan Court of Appeals reverses, holding that the trial court improperly interpreted the regulations and that the penalty period was appropriate. According to the court, because there was no written contract and no written doctor’s recommendation for the services, the payments to the caregiver were a divestment. The court notes that “it does not appear from the factual record that [Mr.] Jensen overpaid for [the caregiver’s] services, or hired [the caregiver] unnecessarily. If we were not bound by the plain language of [the regulations], and were we permitted de novo review of the lower tribunals’ factual considerations, we would reach quite a different result.”

TOP 8 MISTAKES

IN MEDICAID PLANNING

Feel free to contact me with any Medicaid Planning questions,

Regards,

Brian A. Raphan

When Is A Guardian Required for an Adult?

Guardianships are set up to protect and help people in need, such as an elder or loved one unable to care for their own financial or health related well being. When is it required? What is the process?

When is a Guardianship Required For An Adult?

It may be necessary to petition a court to appoint a legal guardian for persons: Who have a physical or mental problem that prevents them from taking care of their own basic needs; Who as a result are in danger of substantial harm; and Who have no person already legally authorized to assume responsibility for them. Under some circumstances, it may be necessary for a court to appoint an emergency guardian, who can act on your behalf during a crisis (such as immediately following a car accident) until you regain your ability to make your own decisions.

Free Will

How is a Guardian Appointed?

The precise procedure will vary to some degree from jurisdiction to jurisdiction. The typical steps are as follows:The person seeking the appointment of a guardian files a petition with the probate court for the jurisdiction where the allegedly legally incapacitated person resides. This petitioner is often a relative, an administrator for a nursing home or health care facility, or other interested person. A petition is ordinarily accompanied by medical affidavits or other sworn statements which evidence the person’s incapacity, and either identifies the person or persons who desire to be named guardian or requests the appointment of a public guardian.The court arranges for any necessary evaluation of the allegedly legally incapacitated person. Often, this will involve the appointment of a “guardian ad litem”, a person who is appointed to provide an independent report to the court on behalf of the allegedly legally incapacitated person.

If appointed, the guardian ad litem will meet with the allegedly incapacitated person, inform that person of his or her legal rights, and report back to the court on the person’s wishes. The guardian ad litem may also speak to the petitioner, to health care providers, and to other interested individuals in order to provide the court with full information about the allegedly incapacitated person’s condition and prognosis. Depending upon state law, the court may appoint a doctor or professional to examine the allegedly incapacitated person. If the person contests the appointment of a guardian, a trial is scheduled during which sworn testimony will be given, and at the conclusion of which the judge will decide if the petitioner met the requisite burden of proof for the appointment of a guardian. The allegedly incapacitated person is ordinarily entitled to appointed counsel, if unable to afford a private attorney.If the allegedly incapacitated person consents to the petition, or is unable to respond to inquiries due to disability, the court will hold a hearing at which witnesses will provide sworn testimony to support the allegations in the petition. If the evidentiary basis is deemed sufficient, the guardian will be appointed.If a guardian is appointed, the judge will issue the guardian legal documents (often called “letters of authority”) permitting the guardian to act on behalf of the legally incapacitated person.What Are a Guardian’s Duties?The guardian makes decisions about how the person lives, including their residence, health care, food, and social activity. The guardian is supposed to consider the wishes of the incapacitated person, as well as their previously established valued, when making these living decisions. The guardian is intended to monitor the legally incapacitated person, to make sure that the person lives in the most appropriate, least restrictive environment possible, with appropriate food, clothing, social opportunities, and medical care.A guardian may be required to post a bond, unless the requirement is waived by the court. In most jurisdictions where bond is required, waivers are routine.

What’s the purpose of court supervision?

The court supervises the guardian’s choices on behalf of the ward. After the initial appointment of a guardian, an initial review is usually scheduled, followed by annual reports by the guardian to the court. The purpose of this supervision is to ensure that the legally incapacitated person is in fact benefiting from the most appropriate, least restrictive living environment possible, with appropriate food, clothing, social opportunities, and medical care.

Avoiding Guardianship:

It is possible to avoid the necessity of a guardianship through estate planning. A good estate plan will include a medical power of attorney which will enable a trusted individual to make health care decisions for you in the event of incapacity, and a general durable power of attorney to permit a trusted individual to manage your personal affairs. To a considerable extent, those documents can specify how you wish to live, and how you wish to be treated, in the event of disability – whereas a court or guardian may make decisions with which you would disagree. In most cases, when these documents have been executed in accord with the laws of your state, it will not be necessary for your loved ones to seek the appointment of a guardian or conservator should something happen to you – something that can be cumbersome and emotionally taxing at an already difficult time.

Free Downloads: Easy to read elder guides for families and seniors.

Probate, Estate Planning, Healthcare Proxies, Medicaid Planning, etc. Get informed and find many of the answers to your existing questions in these guides. Download and save as reference for free.

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Nursing Home Agreements: 

Protecting Your House from Medicaid Estate Recovery

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After a Medicaid recipient dies, the state must attempt to recoup from his or her estate whatever benefits it paid for the recipient’s care. This is called “estate recovery.” For most Medicaid recipients, their house is the only asset available.

Life estates

For many people, setting up a “life estate” is the simplest and most appropriate alternative for protecting the home from estate recovery. A life estate is a form of joint ownership of property between two or more people. They each have an ownership interest in the property, but for different periods of time. The person holding the life estate possesses the property currently and for the rest of his or her life. The other owner has a current ownership interest but cannot take possession until the end of the life estate, which occurs at the death of the life estate holder.

Example: Jane gives a remainder interest in her house to her children, Robert and Mary, while retaining a life interest for herself. She carries this out through a simple deed. Thereafter, Jane, the life estate holder, has the right to live in the property or rent it out, collecting the rents for herself. On the other hand, she is responsible for the costs of maintenance and taxes on the property. In addition, the property cannot be sold to a third party without the cooperation of Robert and Mary, the remainder interest holders.

When Jane dies, the house will not go through probate, since at her death the ownership will pass automatically to the holders of the remainder interest, Robert and Mary. Although the property will not be included in Jane’s probate estate, it will be included in her taxable estate. The downside of this is that depending on the size of the estate and the state’s estate tax threshold, the property may be subject to estate taxation. The upside is that this can mean a significant reduction in the tax on capital gains when Robert and Mary sell the property because they will receive a “step up” in the property’s basis.

As with a transfer to a trust, the deed into a life estate can trigger a Medicaid ineligibility period of up to five years. To avoid a transfer penalty the individual purchasing the life estate must actually reside in the home for at least one year after the purchase.

Life estates are created simply by executing a deed conveying the remainder interest to another while retaining a life interest, as Jane did in this example. In many states, once the house passes to Robert and Mary, the state cannot recover against it for any Medicaid expenses Jane may have incurred.

Trusts

Another method of protecting the home from estate recovery is to transfer it to an irrevocable trust. Trusts provide more flexibility than life estates but are somewhat more complicated. Once the house is in the irrevocable trust, it cannot be taken out again. Although it can be sold, the proceeds must remain in the trust. This can protect more of the value of the house if it is sold. Further, if properly drafted, the later sale of the home while in this trust might allow the settlor, if he or she had met the residency requirements, to exclude up to $250,000 in taxable gain, an exclusion that would not be available if the owner had transferred the home outside of trust to a non-resident child or other third party before sale.

Contact me to find out what method will work best for you.

More Related Articles >

How To Look Out for a Relative in a Nursing Home

The best ways to make sure your loved one gets the care that was promised.

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Finally, after ticking off the last item on a lengthy list of must-haves, you think you’ve found the best nursing home for your mom. The staff seems caring and professional. It’s comfortable, homey, and Mom is OK with it. She might even come to like her new life.

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But your work isn’t over. You want to make sure Mom gets the care you were told she’d receive—and the care she deserves. “The resident’s needs should be met by the facility, rather than having the patient meet the facility’s needs,” says Barbara Messinger-Rapport, director of the Cleveland Clinic‘s Center for Geriatric Medicine.

How do you make that happen?

What to ask
Start with your loved one. Isn’t Dad going to be your best source of information on his own care? “Ask the questions you would want to be asked if the roles were reversed,” says Cornelia Poer, a social worker in the Geriatric Evaluation and Treatment Clinic at Duke University Medical Center in Durham, N.C. Questions such as:

  • Are you comfortable?
  • Is anything worrying you?
  • Do you feel safe?
  • Do you feel respected?
  • If you need help and you push the call button, how long before somebody comes?
  • Have you gotten to know any of the other residents?
  •  Do you like the staff—and any staff member in particular?

That last point may seem small, but whether your loved one clicks with a specific caregiver is important, says David A. Nace, chief of medical affairs for UPMC Senior Communities, a long-term care network in western Pennsylvania that is part of UPMC-University of Pittsburgh Medical Center. It shows he’s making connections, growing in new social relationships. The trust that develops may also mean Dad takes his medication more reliably, or if behavioral issues stemming from dementia are a concern, it may be easier for one nurse than for another to manage them, says Nace.

Show interest and concern and identify major problems, but don’t go overboard. “Inquiries are important, but try to avoid turning every visit into an interrogation,” Poer says. “You will be able to determine if there are areas of concern in normal, everyday conversation.”

[Read: 9 Warning Signs of Bad Care.]

Some questions will be better directed at staff members, particularly if your loved one has a cognition problem such as dementia or Alzheimer’s disease. In the first days and weeks, the focus should be on the initial adjustment. Do Mom’s nurses see any signs of depression? Does she appear to be making the transition smoothly? If not, what, specifically, is being done to help her?

Then drill down to her day-to-day routine:

  • When is she up?
  • Are her meals appropriately prepared—soft or pureed food if she has trouble chewing, low in fat and salt if she has a heart condition?
  • Is she taking her medications when and as often as she should? (The timing of each medication should be documented.) If there’s been a consistent problem, how is that being addressed?
  • Is there a reason to change any of her medications?
  • Is she exercising or participating in other physical activities?
  • Is she social?

“I like to see if the patients are usually in their rooms,” says Susan Leonard, a geriatrician at Ronald Reagan UCLA Medical Center. “Not being in their rooms means they are participating in activities, dining, or in the hallway socializing with others, which may suggest a better social environment for residents.” But you’ll want to see for yourself whether empty rooms might only mean residents are parked on sofas and in wheelchairs elsewhere in front of TVs.

Don’t be afraid to broach more sensitive topics. If you were recently alerted of a behavioral issue or medical emergency, talk to both Mom and the staff to figure out whether it was handled properly. You want to know what the staff did and what changes in care they’ve made.

It’s helpful to have a main point of contact during the day’s various shifts. You should feel like you can call at any time, but Nace observes that it’s good to know up front what the best times are for getting general updates. And don’t settle for less than you need to know. If you don’t get an answer, head up the chain of command to a unit supervisor, assistant director, or director.

What to inspect
Getting a feel on your own for the overall environment goes a long way, says Audrey Chun, associate professor of geriatrics and palliative medicine at Mount Sinai Medical Center in New York. Are common areas, rooms, and residents’ clothes clean? What about lighting and temperature? These are especially important to older adults, says Poer. Does the room feel homelike? If you send cards, are they hanging on a bulletin board in the room?  If cards and drawings are up and Mom couldn’t put them up herself, that’s a great sign. “It means the staff took the time to do it for the resident,” Nace says. “The staff cared enough to do this.”

Look around. Do you see any safety hazards—a hanging TV that isn’t strapped down or blocked exits? What about bruises, such as on the upper arms where staff may have handled Dad too roughly? Watch the staff—are they affectionate, genuine, and helpful?

Use your nose. Are there odors in the hallways and rooms? “Yes, bowel movements happen—this is a long-established fact of life—but it should not be the thing that greets you every time you are in the hall,” says Nace.

Listen. Do you hear birds, music, laughter? Or do you hear creaky floors and clanging pipes? Constant small annoyances can affect a person’s mood and eventually her day-to-day demeanor.

How often to check in—and what to do if you can’t
Some homes have a “care conference” shortly after admission and then quarterly to give you and your loved one a regular time to talk with staff, says Nace. But stopping by on various days and at various times is smart. You can ensure Mom or Dad isn’t “overmedicated or spending time sitting in front of the TV,” says Messinger-Rapport. When you do check in, swing by the nurses’ station to signal to the staff that you’re actively involved in Dad’s care.  If distance keeps you apart, staff might be able to send you photos or videos of Dad or set up a videoconference with Dad and his caregivers. If you’re abroad, staff might be able to print out an email for Mom if she doesn’t have a computer, Nace says.

Better still, says Poer, “having someone on the ground to be your eyes and ears can be very useful.” Enlist a local family member or close friend. Or consider a case manager or ombudsperson to advocate for you and Mom.

What the staff needs from you
Make sure the home’s staff has a number where they can receive a prompt response if necessary. And while staff has a professional responsibility, your appreciation—particularly if someone worked with you to resolve a concern, and even if it meant you had to compromise—will go far. “Be respectful of the staff and their time; their job is very demanding,” Poer says.  Let the nurses and other caregivers into your and your loved one’s lives by sharing personality quirks, interests, preferences. But above all, stay optimistic about Dad’s future and his ability to accept and adjust to his new life. Flycasting for bass on the Susquehanna River, Nace’s dad’s longtime passion, faded into a treasured memory after he moved into a nursing home, traded in for newfound pastimes: baking and painting.

[See our other posts on legal issues and nursing homes]

Regards,

Brian

http://www.RaphanLaw.com

Financial Abuse of the Elderly: Sometimes Unnoticed, Always Predatory

Caution to elders and family members of elders. This happens too often:

Via The New York Times 11/27/15 Elizabeth Olson

It was only after Mariana Cooper, a widow in Seattle, found herself with strained finances that she confessed to her granddaughter that she was afraid she had been bilked out of much of her savings.

Over three years, Ms. Cooper, 86, had written at least a dozen checks totaling more than $217,000 to someone she considered a friend and confidante. But the money was never paid back or used on her behalf, according to court documents, and in early November the woman who took advantage of Ms. Cooper, Janet Bauml, was convicted on nine counts of felony theft. (She faces sentencing on Dec. 11.)

Ms. Cooper, who lost her home and now lives in a retirement community, is one of an estimated five million older American residents annually who are victimized to some extent by a caregiver, friend, family member, lawyer or financial adviser.

With 10,000 people turning 65 every day for the next decade, a growing pool of retirees are susceptible to such exploitation. As many as one in 20 older adults

said they were financially mistreated in the recent past, according to a study financed by the Justice Department.

Traditionally, such exploitation, whether by family, friends or acquaintances, often has been minimized as a private matter, and either dismissed with little or no penalty or handled in civil court.

Even when the sums are large, cases like Ms. Cooper’s are often difficult to prosecute because of their legal complexity and because the exploitation goes unnoticed or continues for long periods. Money seeps out of savings and retirement funds so slowly it draws attention only after it is too late.

Ms. Cooper, for example, wrote her first check, for $3,000, in early 2008, and later gave Ms. Bauml her power of attorney. In early 2012, after Ms. Cooper realized that Ms. Bauml was not going to repay her in time for her to afford a new roof for her house, she told her granddaughter, Amy A. Lecoq, about the checks. She later called the police.

Ms. Bauml maintained that Ms. Cooper gave her money for services she provided as a home organizer or as loans.

Later, testing by a geriatric mental health specialist found that Ms. Cooper had moderate dementia, which showed her judgment had been impaired.

The diagnosis “helped the jury to understand why she would keep signing all these checks to this woman as loans when she was never being paid back,” said Page B. Ulrey, senior deputy prosecutor for King County, Wash., who pressed the case against Ms. Bauml.

The case was challenging in part because Washington State does not have an elder abuse statute, said Ms. Ulrey, who is one of a small but growing number of prosecutors around the country with the specific duty of prosecuting those who take financial advantage of elders, whether it is connected to investments, contracts or other fraud.

As the number of complaints grows, more municipalities are trying to combat such abuse, which is often intertwined with physical or sexual abuse, and emotional neglect.

Some organizations also have set up shelters, modeled on those for victims of domestic abuse. In the Bronx, for example, the Weinberg Center for Elder Abuse Prevention at the Hebrew Home in Riverdale started such a shelter in 2005. Since then, 14 other such shelters have been opened in various long-term care operations around the country to deal with urgent cases of financial abuse.

One such woman, who agreed to talk only if she was not identified by her last name, stayed at Riverdale after she was threatened with eviction. A neighbor discovered that the woman, a 73-year-old widow named Irene, had not paid her rent in six months because relatives living with her had been withdrawing money from her account and leaving her short of funds.

“I had to leave with one small suitcase,” Irene said. “They were abusing me.”

She was later able to move to federally subsidized housing away from the abusive situation.

To help elders in financial and other distress, more municipalities, using federal funds, are training law enforcement officers, prosecutors, and social workers how to spot the sometimes subtle signals that may indicate someone has been swindled.

“We see many cases where someone convinces an older person to give them the power of attorney, and then uses that authority to strip their bank accounts, or take the title of their home,” said Amy Mix, a lawyer at the AARP Legal Counsel for the Elderly, which works with the Adult Protective Services division in the District of Columbia government as well as the city’s police department.

In the most recent fiscal year, 934 cases of abuse were reported in Washington. About one-quarter of those were financial exploitation, according to Sheila Y. Jones, chief of Adult Protective Services. “And they involve millions of dollars,” she said.

But many cases are not counted officially because older people are reluctant to pursue legal remedies against relatives and friends. Louise Pearson, 80, a retired government computer analyst, declined to press charges against a security guard in her building who had befriended her and later obtained $30,000 from her savings.

“There was something about him you just had to take to,” Ms. Pearson said.

When she finally asked Malika Moore, a social worker at Iona Senior Services in Washington, for some assistance with her shaky finances, the social worker realized that the situation was serious.

One clue, she said, was that, “When I opened her refrigerator, it was empty.”

Ms. Moore was able to get Ms. Pearson home-delivered meals, and after the bank confirmed that she was missing savings, help to find a conservator to handle her money. Ms. Pearson, who now lives in a housing complex for the elderly, said, “I get money whenever I need it, and more than I did before.”

In Seattle, Ms. Cooper’s granddaughter expressed determination to educate others on the warning signs of financial abuse. “I wish we had known some of the red flags,” she said.

But even though she’s a trained social worker, it’s not surprising she missed the signs. She was deeply involved in caring for her mother, Ms. Cooper’s daughter, who was fighting cancer and died shortly before the period when her grandmother was writing the checks.

“Our family saw her regularly,” Ms. Lecoq said, “but we just didn’t see indications of what was going on.”

In retrospect, she might have been more suspicious with “my grandmother suddenly having a new friend and a friend who got so close so fast.”

Once Ms. Lecoq and her husband, John, recognized what had happened, they pushed for prosecution. Ms. Ulrey, the prosecutor, said the case required medical tests and search warrants for both the victim’s and the suspect’s financial accounts.

Ms. Cooper was unable to recover her lost money and worries about how long she will be able to pay for her retirement home. “She’s ashamed and embarrassed and feels guilty,” Ms. Lecoq said of her grandmother. “But I tell her: ‘You were a victim of a crime.’”

To help older people, families and friends should be on the lookout for some of the warning signs of financial abuse. These include not being able to cover normal expenses; paying for excessive, unexpected gifts to others; and signing over power of attorney or transferring property to unrelated individuals. 

To learn more about protecting the savings of the elderly and helping them avoid being exploited financially, these publications are worth reading: