Due to an overtaxed behavioral healthcare system, younger individuals with serious mental illness are seeking long-term treatment and residence in senior living and care settings. This trend is contributing to the rise of incidents of resident-initiated violence. In fact, according to a recent study of long-term care facilities, 65% of surveyed nurses and certified nursing assistants have experienced such workplace incidents. A full 41% believe that upper management shows little or no concern for their safety.

Whether resident-initiated incidents take the form of resident-on-staff or resident-on-resident aggression, they are a prevalent and often overlooked problem in senior living and care facilities. Long-term care administrators and executive directors can take steps to craft an effective response to these workplace incidents, however, including the following:

1. Adopt a zero-tolerance policy.

A zero-tolerance policy toward violence effectively establishes the standards of behavior that are expected of everyone at a community, including management, employees, contracted workers, residents, volunteers and visitors. The written policy should define violent and abusive behaviors – for instance, physical, verbal and psychological forms of aggression and harassment – and expressly state that violence in any form will not be tolerated. Offenders should be subject to serious disciplinary action, including termination of employment for staff and eviction for residents.

A helpful publication to help prevent violence in a healthcare setting is the OSHA & Worker Safety: Guidelines for Zero Tolerance from the Joint Commission.

2. Implement a violence prevention program.

The responsibility to implement and monitor a violence prevention program should be given to a multidisciplinary team, including, for instance, senior administrators, nursing and medical directors, and representatives from human resources, quality improvement, risk management and safety. The OSHA Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers provide a framework for an effective program. Core elements include, but are not limited to:

  • Physical and administrative security measures, such as appropriate staff-to-resident ratios; parameters for working alone; alarms and video cameras that monitor internal and external spaces; locked and guarded entrances; and professionally trained security guards.
  • Emergency response measures, including interventions for managing escalating behavior, communication techniques for crisis situations and post-incident procedures — for instance, medical interventions, event reporting and staff debriefing.
  • Reporting and investigative processes, including protocols for documenting all incidents of violence and reporting to law enforcement and state agencies, as required by law.

3. Train staff to spot danger signs.

Staff members should be taught to recognize the warning signals that are most likely to trigger combative behavior in residents. These include:

  • Arguing with other residents.
  • Unresponsive to caregiver questions.
  • Pacing restlessly.
  • Fearful of others.
  • Speaking loudly or cursing without motivation.
  • Responding to delusional or paranoid thoughts. 

Assessment tools, such as the Brøset Violence Checklist and Violence Risk Screening-10, measure aggressiveness in residents with acute mental illness and can help staff members anticipate incidents before they occur.

4. Develop a crisis intervention protocol.

Staff members should be proficient in crisis intervention, including the ability to counsel combative residents, de-escalate behaviors and respond to resident-on-resident acts of aggression. New-hire training should include the following conflict management techniques:

  • Speak to residents in a calm and respectful manner.
  • Be firm, but avoid giving directives.
  • Acknowledge resident feelings of frustration and helplessness.
  • Maintain a safe distance.
  • Notify the physician of record and family of the situation.
  • Medicate only after the resident is examined and consent is given.
  • Use restraints as a measure of last resort.

5. Use surveillance equipment judiciously.

The voluntary use of surveillance cameras – dubbed “granny cams” – in resident rooms permits staff members to observe residents when they are out of staff members’ direct sight. Surveillance has a two-fold benefit: 1) It helps staff members anticipate when adverse behaviors in residents may escalate to violent encounters, and 2) It detects when other caregivers are directly harming residents. Although the legal framework for video surveillance still is evolving in many states, opponents argue that it adversely affects resident privacy, fosters a false sense of security and may reduce staff involvement with residents.

Before approving the use surveillance cameras, senior living and care communities should take the following proactive measures:

  • Address surveillance policies in writing with new residents and family members.
  • Obtain resident consent before installation, and secure written permission from roommates.
  • Develop guidelines for handling disagreements between family members and residents regarding camera use, or in the event that a resident is unable to consent.
  • Mount cameras in fixed positions to minimize their effects on resident privacy.
  • Inform staff members whenever a camera is installed or removed.
  • Draft a policy regarding custody of camera recordings, as well as the conditions and duration of their storage.

Protecting staff members and residents from violence requires a proactive strategy. By combining violence prevention policies and staff education with procedural security measures and rigorous ongoing assessment, long-term care administrators and executive directors, operators and providers are better prepared to anticipate and contain violent encounters.

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