Graphical Abstract
During a recent clinical visit to a memory care unit in an assisted living facility, I observed two patients begin to have a verbal altercation that could have ended badly were it not for the quick identification and action by the nursing assistants. A male patient, who had a delusional disorder in the context of his dementia, believed that the staff were tampering with the food and attempted to convince a female peer of his beliefs. The female patient shouted back, “You don’t know what you are talking about. Keep it to yourself.” As the two patients were both approaching each other, two nursing assistants calmly intervened to de-escalate the situation and redirect the residents to separate activities.
For many of us working in post-acute and long-term care, as COVID-19 positivity rates drop among patients and staff, our admissions of new patients are gradually increasing. This influx of new patients into PALTC settings, including many who are living with dementia or serious and persistent mental illness, coupled with the ongoing challenge of maintaining appropriate staffing levels, has led to an increased risk of incidents of resident-to-resident mistreatment (RRM).
What Is Resident-to-Resident Mistreatment?
There are a variety of definitions of RRM, but the National Long-Term Care Ombudsman Program (LTCOP) Resource Center has adopted the one used by Teresi and colleagues: “negative and aggressive physical, sexual, or verbal interactions between long-term care residents that (as in a community setting) would likely be construed as unwelcome and have high potential to cause physical or psychological distress in the recipient” (Int J Nurs Stud 2013; 50:644–656). The prevalence of RRM is estimated to be 20% in nursing homes (Ann Intern Med 2016;165:229–236; J Am Geriatr Soc 2017;65:2603–2609) and 12% to 23% in assisted living/residential care settings (J Am Med Dir Assoc 2021;22:1678–1691).
The prevalence rates of RRM have not been well studied and are likely underreported. For example, video recordings revealed that 40% of RRM episodes were not witnessed by a reliable individual and would have gone unreported had the camera not been present (Gerontologist 2015;55:S99–S107). RRM is associated with negative physical and psychological outcomes for patients and staff in PALTC settings and may result in serious physical harm (J Am Med Dir Assoc 2021;22:1678–1691) and in rare cases patient death (J Am Geriatr Soc 2017;65:2603–2609).
What Are the Risk Factors?
Resident-level risk factors for RRM include cognitive impairment, dementia, or serious and persistent mental illness (“Resident-to-Resident Mistreatment: Long-Term Care Ombudsman Advocacy,” June 2018, https://bit.ly/3hJbshV). Residents who have a previous history of behavioral symptoms such as verbal aggression, repetitive speech, physical aggression, wandering, and intrusiveness are also at increased risk of RRM as either aggressor or victim (Age Ageing 2015;44:356–364). Although RRM can occur at any time of the day, it appears to be most common in the afternoon hours, particularly during a change of shift. Additionally, recently admitted patients are at increased risk of RRM.
However, although individual histories, illness, and behaviors are certainly risk factors, nursing homes are dynamic social environments (Gerontologist 2012; 52:24–33). Individual resident behaviors are thus contingent on other residents, staff-to-patient ratios, multiple occupancy rooms, limited recreational opportunities, and crowded communal areas. One study of narrative reconstructions of resident-to-resident aggression found the following five themes: “invasion of privacy or personal integrity, roommate issues, intentional verbal aggression, unprovoked actions, and inappropriate sexual behavior” (Gerontologist 2012; 52:24–33).
Regulatory Requirements
Regulatory citations for RRM fall under §483.12 Freedom from Abuse, Neglect and Exploitation. The regulatory guidance indicates that if a resident “willfully” hurts or harms another resident, then the facility must report the incident as abuse. “Willful” is defined as a deliberate action (not occurring accidentally).
There is no exclusion from abuse for cognitive impairment, mental disorder, or intent. In other words, if a cognitively impaired resident deliberately pushes another resident who subsequently falls as a result of the push, this is considered a willful act even if the aggressor did not intend to injure the resident who was screaming. LTCOP’s guide also provides helpful insight into the regulatory guidance associated with RRM.
Interventions to Reduce the Risk of RRM
As health care providers in PALTC, we want the patients that we care for to be free of abuse and neglect and to live in a safe environment with meaningful engagement in activities and improved quality of life. However, balancing the needs of individual patients with those of the larger community can be a challenge. For instance, we want to minimize the use of psychotropic medications with gradual dose reductions for residents living with dementia who have a past history of physically aggressive behaviors while at the same time keeping other residents safe. Learning to negotiate and manage RRM is a key aspect of striking this balance.
A few studies have pointed to various techniques for the prevention and management of RRM (J Contin Educ Nurs 2014; 45:112–123; J Elder Abuse Negl 2016;28:1–13; J Appl Gerontol 2021;40:1236–1245), but far more research is needed. From my own experience and expertise, there are a few practical things we can all do:
- •Train. Provide training for all staff in the identification, assessment, reporting, and management of behavioral symptoms, including resident-to-resident altercations. Staff who care for individuals living with dementia may begin to view some of these aggressive behaviors as expected and may be hesitant to report them.
- •Document. Clearly document behavioral symptoms, including descriptions of antecedents or triggers, so that patterns can be identified. Don’t forget to document the intervention that was used to address the behavior and the resident’s response. If the intervention was ineffective, consider what additional approaches could be used in the future. Use this information to update the interdisciplinary team and modify the care plan as needed.
- •Partner. Partner closely with behavioral health consultants and include them in the care plan sessions, particularly when it involves residents with a history of RRM. Their progress notes will be helpful particularly when pharmacological interventions are implemented or deprescribed; however, do not leave all the behavioral health monitoring only to the psychiatric specialists. Staff from different disciplines need to be involved.
- •Supervise and intervene. Provide appropriate staff supervision for residents in common areas, particularly at a change of shift. As with the intervention by the nursing assistants that I witnessed in a memory care unit, it’s also important to spot a potential altercation and intervene in a calm and respectful manner.
- •Engage the residents. Provide meaningful engagement via personal and recreational activities for residents. Be prepared to distract residents with such meaningful activities when altercations begin.
Dr. Galik is editor in chief of Caring for the Ages. The views the editor expresses are her own and not necessarily those of the Society or any other entity. Dr. Galik is a nurse practitioner in LTC- and community-based settings through a clinical practice with Sheppard Pratt Health System. She is a professor at the University of Maryland School of Nursing, where she teaches in the Adult-Gerontology Primary Care Nurse Practitioner Program and conducts research to improve care practices for older adults with dementia and their caregivers in long-term care. She may be reached at .
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April 26, 2022
April 2022
In this episode Karl Steinberg and Elizabeth Galik discuss our cover story on natural disasters and mental health, new guidelines for aspirin usage in older adults, how to minimize the risk of resident-to-resident mistreatment in post-acute and long-term care, and the new Clinical Practice Guideline (CPG) for pain management.
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