Improving documentation and considering room assignments are two of the steps long-term care facilities can take to try to reduce fatal resident-to-resident incidents in their communities, according to study results recently published in the Journal of Applied Gerontology.

The authors, from the Kent State University School of Public Health, Kent, OH, based their recommendations on an analysis of 101 cases of fatal resident-to-resident incidents that occurred in long-term care facilities between residents who were aged 65 or more years between 2003 and 2016. The cases were contained in the Centers for Disease Control and Prevention’s National Violent Death Reporting System.

“To my knowledge, it is the first time that the CDC’s NVDRS dataset is being used to study these fatal incidents,” Eilon Caspi, Ph.D., a research associate at the University of Minnesota School of Nursing whose previous research on the topic is referenced multiple times in the new paper, told McKnight’s Senior Living.

The Ohio researchers found that most victims and “exhibitors” were white and male. In 70% of cases, one or both residents had dementia. Victims were, on average, 16 years older than the exhibitor.

Twenty of the 101 incidents that were part of the analysis occurred in assisted living facilities, 51 happened in skilled nursing facilities and the rest occurred in facilities described using alternative terms such as “home for the elderly.”

Most incidents happened in common areas and were described as a “push,” with the most common injuries being head injuries, followed by hip fractures. The average time between injury and death was 17 days, with a range including death that occurred on the same day as the incident to death that occurred 360 days later.

No explicit “triggering” event occurred in 47 of the 101 cases, the authors said.

“We suggest that emphasis on improved consistency and frequency of documentation of RRA [resident-to-resident aggression] is a critical step toward allowing LTC staff to identify patterns of behavior and to take preventive measures where appropriate,” they wrote. Organization-level policies and procedures should consider room assignments and reassignments that minimize conflict, the researchers added.

Caspi, who also is the founder and director of Dementia Behavior Consulting and a founding member of Elder Voice Family Advocates, shared some additional recommendations.

“I’d say that the most important message for care providers would be for the interdisciplinary care team under the leadership of the administrator to work hard to break the chronic and dangerous normalization of resident-to-resident incidents,” he said.

Direct care staff should be sensitized to the fact that one push can result in severe physical trauma and death, for instance, Caspi added, and they should take “near miss” incidents “very seriously.”

“Oftentimes, when a resident’s human needs underlying low-severity incidents are ignored and not adequately documented and addressed, they may escalate over time into physically harmful incidents,” he said. 

Adequate staffing at all times is important, too, he said, although not all incidents will be witnessed by staff.

“Adequate staffing levels of well-trained staff, combined with active presence of experienced and skilled managers during vulnerability time periods — such as evening hours and weekends — could increase staff ability to supervise residents more effectively and respond in a timely manner to early warning signs of residents’ emotional distress and anxiety, the window of opportunity for prevention,” Caspi said.

Avoiding stigmatizing language is “critically important,” too, when referring to residents living with a serious brain disease such as Alzheimer’s, he said.

“The labeling words ‘violent,’ ‘abusive,’ and even the word ‘aggressive,’ as well as the term ‘homicide,’ all implying intent to injure or kill another resident, prevent staff from seeking to identify the unmet emotional and psychological needs that commonly contribute or directly cause these incidents,” Caspi said.

The study authors also recommend that future researchers place more emphasis on resident-to-resident incidents in assisted living, noting that most research on the topic focuses on incidents in skilled nursing facilities. Other than their study, a previous study by Caspi is the only one to review incidents across multiple types of long-term care settings, they said.

“Adequate documentation of the circumstances surrounding these incidents, such as the sequence of events and situational triggers as the basis for pattern recognition at the individual resident level, is lacking in many assisted living residences,” Caspi said. “This major gap in care practice and basic risk management not only limits assisted living residences’ ability to identify the contributing factors and root causes of these incidents and develop individualized prevention strategies, but it also limits researchers’ ability to use clinical data in these care settings for research purposes such as to identify risk and protective factors for these incidents.”

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