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Resident-to-Resident Incidents

An Invisible Source of Harm in Nursing Homes

A White Paper by Elder Voice's Eilon Caspi, Ph.D.

Dwayne E. Walls was an investigative reporter at The Charlotte Observer. Throughout his career, he wrote stories on social justice issues from the inner circles of the Ku Klux Klan and the homes of poor Black farmers; he also covered hunger, voter fraud and the dysfunctions of the coroner system. Some of his most compelling stories reported on challenges experienced by vulnerable populations. Late in his own life, he joined a different vulnerable population: elders living with dementia.

In 2001, Walls was diagnosed with Alzheimer’s disease. When his condition declined and his wife could no longer care for him at home, she moved him to a nursing home in South Carolina.

One evening, Walls walked into another resident’s bedroom and climbed into the empty bed. Moments later, the resident who lived in the room, an 88-year-old man with dementia, beat Walls with his cane. Walls was found severely injured, bleeding, and unconscious in a fetal position on the floor while the man continued to beat him. Walls died a week later.1

Resident-to-resident incidents (RRIs) in nursing homes have been shown in research to be prevalent,2 injurious,3 and, as in the case described above, occasionally deadly.4 One common definition5 of RRI is “negative, aggressive, and intrusive verbal, physical, material, and sexual interactions between long-term care (LTC) residents that in a community setting would likely be unwelcome and potentially cause physical or psychological distress or harm in the recipient.” Despite being prevalent and harmful to residents, such incidents remain underrecognized, understudied, untracked, and inadequately addressed in many nursing homes.

Two centralized mechanisms exist for the collection of data on these incidents, but so far they have not been utilized for this purpose: the F-tag system of the Centers for Medicare and Medicaid Services (CMS) and definitions used in the Minimum Data Set 3.0 (MDS 3.0). It is urgent that CMS and the Department of Health and Human Services (HHS) act to address these gaps in tracking.

Gathering the Right Facts

On July 13, 2019, the Government Accountability Office (GAO) published a report6 entitled Nursing Homes: Improved Oversight Is Needed to Better Protect Residents from Abuse. One of the recommendations made in the report was for the administrator of CMS to “require that abuse and perpetrator type be submitted by the state survey agencies in CMS’s databases for deficiency, complaint, and facility-reported incident data, and that CMS systematically assess trends in these data.” HHS, the government body overseeing CMS, concurred with this GAO “priority” recommendation. Two and a half years after the GAO made the recommendation, however, CMS has yet to implement it.

One reason the GAO recommendation is important is that the underlying causes of resident abuse by staff are usually very different from incidents that occur between residents. This is especially the case among residents with dementia. The ability to understand and address RRIs, therefore, remains limited if incidents involving resident harm are mostly classified broadly as “abuse.”

Two years before the 2019 GAO report, I published a journal article7 calling on CMS to bridge this major gap in oversight of approximately 15,000 nursing homes, where more than 1.2 million people live. The article identified 20 reasons why CMS tracking of RRIs could result in increased resident safety. Having studied this phenomenon for more than 13 years, I conclude that the story of RRIs among people living with dementia is largely one of neglect,8 the consequences of which can be as traumatic and devastating as those caused by staff abuse. Common risk factors that can lead to these episodes are low staffing levels, inadequate staff training, lack of risk assessment, inadequate care plans and biopsychosocial prevention strategies, lack of meaningful engagement, and problems in the physical environment that may limit staff ability to supervise residents with dementia and respond to their needs in a timely manner.