Here's what happens when violence is reported in nursing homes – and what isn't tracked

Is resident-on-resident violence and abuse more common in Rhode Island nursing homes than in other states, or less?

And when patients harm one another, how often do facilities get fined?

We don’t know, because federal regulators aren’t keeping track.

Here’s an overview of what happens once resident-on-resident harm is reported to the authorities, and what is and isn’t disclosed to the public.

When are nursing homes required to report violence or abuse?

Nursing homes are supposed to report any resident-on-resident violence or sexual abuse to the Rhode Island Department of Health.

That reporting requirement exists even if there's just an allegation and the nursing home isn't sure whether it happened, said Jessica Marcaccio, the state health department's principal nursing care evaluator.

Additionally, nursing homes have to report any "injury of unknown origin" – for instance, if a resident has a bruise on their arm and the facility doesn't know where it came from.

Facilities should also be calling the police anytime they suspect that a crime has been committed, Marcaccio said.

What happens after an incident is reported?

When a facility reports an incident, or a relative or other member of the outside community makes a complaint, a Department of Health triage nurse will assign someone to go to the facility in person and investigate, Marcaccio said.

If the facility's annual review is coming up, a surveyor may investigate the incident or complaint at the same time they do that review.

"Each individual surveyor does their investigation, which consists of survey observations, record review, staff and resident interviews, and makes a determination at that point whether the complaint is substantiated or unsubstantiated, and whether a state or federal deficiency exists," Marcaccio said.

Cases can also be administratively closed if they they involve a "lower-level" concern, such as a resident yelling at another resident, according to health department spokesman Joseph Wendelken. Those incidents do not necessarily require a surveyor to make an in-person visit.

What if police are involved?

When police are notified about resident-on-resident violence or abuse at nursing homes, they'll typically write up a report, but they rarely make arrests or take further action .

Out of nearly 140 cases that The Providence Journal reviewed, only two led to criminal charges: An incident where a resident at Summit Commons in Providence assaulted his roommate after being asked to turn down the volume of his television, and the homicide at Crestwood in Warren.

• In other cases, police reports often indicated that the victim or their legal representative did not wish to press charges .
• Some noted that the facility was handling the matter internally and just needed to be able to say that they'd made a report.

Nursing home residents who harm other residents are usually severely cognitively impaired and likely wouldn't be deemed competent to stand trial even if there was a desire to treat the matter as a criminal offense. And since incidents often take place in memory-care units, victims and witnesses may not be able to recall what occurred.

As a result, it's largely up to the nursing home to decide how to deal with the perpetrator . Depending on the severity of the incident, that could mean:

• Placing a note in the patient's file
• Sending them out for a psychiatric evaluation
• Moving them to a different part of the building.

Facilities can also potentially discharge a resident who poses a danger to others, but they must have documentation from the patient's doctor and meet all the other criteria laid out in state and federal regulations.

How common are reports of resident-on-resident violence and abuse?

Here's how many reports the Rhode Island Department of Health received each year from 2015 to 2023, and how many of them were substantiated.

As noted above, a case might be "administratively closed" if it involves a lower-level concern, like a resident in a dementia unit yelling at another resident.

Unfortunately, resident-on-resident harm isn't tracked on a national level. As a result, it's unclear how Rhode Island compares with other states, and it's difficult to place these figures in context.

Who decides if a nursing home should be penalized for an incident?

If a surveyor from the Department of Health substantiates a complaint and finds deficiencies – for instance, that the nursing home failed to protect a resident from abuse – they'll write up a report and require the facility to provide a plan of correction.

• Depending on the scope and severity of the deficiencies, the surveyor may return to the facility for a follow-up visit to make sure that the plan is being followed.

The federal Centers for Medicare & Medicaid Services (CMS) determines whether the facility should be fined for a deficiency . The state Department of Health only identifies the deficiencies and does not have any say in setting fines.

The state health department can take action in other ways, such as getting a compliance order or consent agreement, and potentially requiring an outside monitor. That happens on a case-by-case basis, Marcaccio said.

There haven't been any compliance orders or consent agreements in the last few years that were solely prompted by a specific resident-on-resident incident, Wendelken said. Typically, those measures are only put in place when there are multiple high-level deficiencies.

What role does the Long-Term Care Ombudsman play?

The Long-Term Care Ombudsman's office can make unannounced visits at nursing homes and talk to residents but doesn't conduct investigations the way the state Department of Health does, Marcaccio said.

Often, family members will contact the ombudsman's office when they have a concern, and the ombudsman will file a complaint with the health department, she added. (Family members can also go directly to the health department to file a complaint, if they choose.)

Additionally, when a facility has a deficiency, the ombudsman can provide guidance on how to fix it, Marcaccio said. The state health department is not authorized to do that.

How can the public find out about violent or abusive incidents at nursing homes?

If a health department surveyor cites a long-term care facility for deficiencies, a report will be publicly available on the agency's website.

However, it's common for regulators to substantiate that a violent or abusive incident occurred but not find any deficiencies on the nursing home's part. In that scenario, the incident typically wouldn't be mentioned in the survey reports that get posted online.

To get a better sense of how often resident-on-residence violence and abuse is occurring, The Journal put in a public records request for all the incident reports submitted to the state Department of Health by nursing homes but was directed to the less-comprehensive survey reports instead.

Months later, the agency's spokesman apologized for the mistake and said that anonymized summaries of incident reports could be obtained through an Access to Public Records Act request.

The Journal has once again requested those records, which need to be reviewed by the Centers for Medicare & Medicaid Services before they can be released, according to the health department.

The Providence Journal also requested three years' worth of police reports from each nursing facility in the state. Those reports are summarized in our database, alongside the findings from Department of Health survey reports.

However, even that doesn't present a complete picture: Comparing the two sets of records, it became clear that many of the incidents that the health department investigated hadn't been reported to local police.

Some nursing homes are extremely diligent about reporting even minor incidents that did not result in injuries, including verbal disputes, the records show. Others are not.

As a result, police reports don't necessarily convey the full scope of what's happening at every facility.

Lastly, the Department of Health also gets notified about alleged violence or abuse through so-called "community complaints," which may come from residents, their relatives or members of the general public. Those complaints are sometimes referenced in survey reports but are not released publicly.

How often does resident-on-resident violence lead to penalties or fines?

In most cases, it's impossible to figure out how much nursing homes were fined because of resident-on-resident violence.

Most of the time, survey reports also list other deficiencies – for instance, a nursing home where a resident was attacked by their roommate might also not be storing medications properly, or failing to meet residents' nutritional needs.

Fines are based on the survey as a whole, not individual deficiencies , CMS spokeswoman Kristen Clemens said. In other words, if the facility in the example above was fined $15,000, there'd be no way to break that down by each of the deficiencies.

The homicide that took place at Crestwood Nursing Home last year was extremely unusual, and the sole focus of an extensive survey report . In that case, the nursing home was fined more than $216,000 for deficiencies related to John "Jack" Sullivan's death.

You can see which facilities have been fined for deficiencies by using the Care Compare tool on the CMS website .

This article originally appeared on The Providence Journal: Here's what happens when violence is reported in nursing homes – and what isn't tracked