What can nursing homes do to prevent resident-on-resident violence and sexual abuse, or at least make incidents less common?
The Providence Journal posed that question to industry leaders, the union representing nursing home workers, and advocates for improving resident care. Here's what they said:
Increase staffing — and not just the number of nurses
While Rhode Island's attempt to impose stricter staffing requirements on nursing homes proved controversial, people on both sides of that debate agree that preventing resident-on-resident violence and abuse requires adequate manpower.
"Appropriate staffing to meet each resident’s needs is essential," said John Gage, the CEO of the Rhode Island Health Care Association. That's not just a matter of having enough nurses, he indicated, but also having enough social workers, psychiatrists, and counselors, as well as staffers who can lead activities and recreation.
Jesse Martin, the executive vice president of SEIU 1199 New England, similarly suggested looking at the ratio of social workers to residents in nursing homes. When there are "toxic" dynamics at play, such as a conflict between two roommates, social workers can intervene by adjusting the residents' care plans, he said.
Additionally, "having a robust activity department in a nursing home helps to prevent these types of occurrences, because when people are active and engaged, there's less conflict," he said. "That's an issue of staffing."
It's also important to have staffers take care of the same residents every day, especially when those residents have cognitive challenges and may not be able to express themselves, noted Richard Gamache, the CEO of East Providence's Aldersbridge Communities.
Over time, staffers become familiar with residents' unique needs and preferences, and learn what upsets them − so they'll know, for instance, which residents shouldn't be seated next to each other in the dining room. That doesn't happen when nursing homes rely on temporary workers from staffing agencies, and "you have someone brand new coming into the building to take care of people they've never met before," Gamache said.
Improve training for nursing home workers
Most instances of violence and abuse involve nursing residents with severe cognitive disabilities. It takes skill to calm down those patients when they become combative, repeatedly redirect them when they're behaving inappropriately, and recognize warning signs before an incident occurs.
But the training that workers at most facilities receive is woefully insufficient, said Kathleen Gerard of Advocates for Better Care in Rhode Island. Rather than shadowing expert practitioners, they're directed to watch online videos and answer a set of multiple choice questions, which satisfies the state's requirements.
"We like to call it 'drive-thru training,'" Martin said, noting that those trainings often take place during brief breaks between shifts. And even though nursing homes have a predominantly immigrant workforce, there's no requirement to provide training in the languages that workers are most comfortable reading, writing, and learning in, he said.
In Connecticut, where Martin used to work, a training program that used virtual reality to simulate the experience of having dementia or Alzheimer's disease had a dramatic impact on nursing home staffers, he said.
Not only did they come away with more understanding and compassion for patients, Martin recalled, but they became better at recognizing potential triggers of problem behavior.
Make better design choices
Rethinking the way that nursing homes are designed could make them safer, Gamache said.
When serious violence occurs, it's often between roommates, he pointed out. A simple solution would be to place residents in private rooms, so that they don't have to live "like they were in a college dorm."
The problem: When a room goes from double to single occupancy, the fixed costs stay the same while the facility only collects half the revenue. As a result, "the only people entitled to private rooms are those who can afford payments of over $10,000 per month," Gamache said.
For the past few years, LeadingAge RI, which represents non-profit nursing homes, has been trying to get the General Assembly to pass a bill that would increase Medicaid payment rates for private rooms.
Gamache also recalled an incident that took place at a nursing home where all the rooms on the dementia unit looked exactly the same.
"When you think about it, that makes no sense at all," he said. "One resident walked into a room that she thought was hers, and there was someone else in the bed, and they ended up in a fight."
Again, design choices can make a big difference. At Aldersbridge, just about every room is painted a different color, Gamache said.
Even seemingly minor environmental interventions, like adjusting the lighting or the temperature inside a facility, can help reduce the likelihood of conflicts, according to National Long-Term Care Ombudsman Resource Center.
The group also suggests reducing noise and avoiding crowding in common areas, which are both frequent sources of frustration for nursing home residents.
Ensure that problem behavior is tracked and documented
Incidents where nursing home residents harm or mistreat one another often don't get documented in internal charts and behavior logs, a 2015 study published in the Journal of Elder Abuse & Neglect found.
That's not surprising, "as many nursing home staff often have little time to complete basic care tasks," the authors noted. But it's dangerous, because it means that staffers who care for a resident in the future may not be aware of their propensity for violence.
Similarly, a doctor looking at a patient's chart notes won't learn about the altercation. That's an issue, because the patient may be reacting to an underlying medical condition, like untreated pain or an undiagnosed infection.
Of course, documenting problematic behavior only goes so far. Gerard said that it was concerning to see cases where survey reports from the Rhode Island Department of Health indicated that nursing home staff repeatedly made note of a resident's inappropriate sexual behavior towards other residents, but nothing was done.
"That is violating the rights of the other residents," she said.
On the opposite end of the spectrum, Gerard said that she's seen cases where a resident with no history of violent behavior slaps another resident on the hand and, within a matter of hours, is sent out for a psychiatric evaluation.
"That is, in our view, an overreaction, and not a good use of resources," she said.
In that scenario, there should "definitely" be a note placed in the resident's file, she said. If a pattern emerges, then the resident should undergo a psychiatric evaluation.
Discharge patients as a last resort
Dealing with patients who repeatedly harm other patients "is a challenging situation, because the resident who is doing the abusing also has rights," Gerard acknowledged. Under most circumstances, nursing homes are prohibited from physically restraining patients, or using drugs as chemical restraints — which is generally agreed to be a good thing.
That means that nurses have to constantly keep a close eye on residents who may have a propensity for wandering into other residents' rooms, or a track record of mistreating their roommates. With widespread staffing shortages, that can be difficult.
"The sad truth is, it’s hard to see a world where we could prevent every altercation/incident between residents without isolating individuals to their rooms, which would not be good for them either," Gage wrote in an email. "Residents are encouraged to move about freely, as this goes back to respecting their autonomy and supporting their health in a homelike environment."
If a patient continues to pose a serious threat to others, they can be discharged, though federal and state regulations require the facility to take certain steps first. Nursing homes should work with family members, doctors and the state's long-term care ombudsman to "figure out a solution for that resident," Gage wrote.
"I think that when you have someone who just is not a good fit for your building because they are violent, then you've got to move them out and try to find a more appropriate placement," Gamache said.
"But I would say that there is a significant percentage of those times when people are frustrated and angry that you can defuse it, if you can figure out what their unmet need is," he added. "And very often, I think it comes down to someone who's feeling some loneliness, some helplessness, or they're just bored."
Carefully consider which residents to admit
Long-term care facilities can also try to limit the potential for abuse and violence by being selective about the residents who they admit in the first place.
Nursing homes have the right to turn a patient away if they can't meet their needs, whether that's due to mental health issues, aggressive behavior, or other factors, Gage said.
To reduce the likelihood that a patient with aggressive tendencies gets admitted, the staff can talk to the patient's primary care doctor and family members, visit the patient in person and observe their behavior, and review all the admission paperwork before deciding whether to accept them, he added.
That kind of careful scrutiny may not be happening often enough, a recent report from the U.S. Department of Health and Human Services' Office of Inspector General suggests.
A majority of discharges from nursing homes were prompted by "endangering behavior," specifically physical or verbal aggression, the OIG's review found.
That finding "raises questions about whether nursing homes accurately assessed the behavioral health needs of residents upon admission, as well as whether nursing homes had the appropriate staff, resources, and capacity to care for residents," the report states.
Most of the patients who were discharged because of dangerous behavior had mental health disorders, which the nursing homes knew about when those patients were admitted, the OIG also noted.
"Although nursing homes cannot anticipate all that a resident will need throughout a stay, nursing homes should be generally familiar with the demands of residents with mental health disorders, especially those who are admitted for long-term care," the report concludes.
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