Eilon Caspi, Ph.D., a gerontologist and dementia behavior specialist, is founder and director of Dementia Behavior Consulting LLC. He is a member of adjunct faculty at the School of Nursing at the University of Minnesota and a founding member of Elder Voice Family Advocates. He recently wrote a great article for McKnight’s about resident to resident assaults.
Caspi writes that “Distressing and harmful resident-to-resident incidents is one of the most prevalent and concerning phenomena in nursing homes. Several research studies have shown that these incidents can lead to serious physical injuries and deaths of residents.”
Nursing homes have the duty and responsibility to act proactively and anticipate incidents to prevent foreseeable injuries, and keep residents safe. History and prior incidents help educate and train staff to prevent incidents by meeting the needs of the residents especially those with dementia.
Caspi references the June 13, 2019 report from the Government Accountability Office (GAO) entitled “Nursing Homes: Improved Oversight Needed to Better Protect Residents From Abuse.” However, six months since the GAO recommendation was made, CMS has yet to implement it.
CMS will eventually require “State Survey Agencies across the country to track “abuse perpetrator type” including resident-to-resident incidents in nursing homes and submit the data to CMS databases. It also recommended that CMS will “systematically assess trends in these data.”
“When resident-to-resident incidents are found to violate Federal Nursing Home regulations, they are often issued a state survey deficiency citation (F-Tag) under the general (too general) regulatory groupings of “Abuse,” “Neglect,” and “Accident,” among at least six other regulatory groupings.
The problem with this broad classification is that locating state survey agencies’ investigation reports pertaining specifically to resident-to-resident incidents is like searching for a needle in a haystack. Trust me, I tried it. It would take thousands of hours to locate all these incidents in 50 states in a given year (such as on Medicare’s Nursing Home Compare or ProPublica’s Nursing Home Inspect websites).”
“Moreover, when I submitted a Freedom of Information Act (FOIA) Request to CMS in order to gain access to all investigation reports on these incidents — incidents that were issued a citation by state survey agencies in all 50 states over the past three years — the answer I received was, “there is no regulatory grouping for these incidents.” Therefore, CMS was unable to compile and release these investigation reports to me.”
“The urgent need to track and learn from harmful resident-to-resident incidents in nursing homes nationwide was acknowledged a few years ago by David Wright, director of the Quality & Safety Oversight Group at CMS:
“What are we accomplishing if we find the same deficiencies every year?” he said. “We should not be the historians of bad things that happen in nursing homes. We need to be preventive of bad things from happening … We need more analysis … We need to make sure that everything we do is effective and efficient.”
“The decades-long lack of tracking of resident-to-resident incidents in nursing homes in our country represents a chronic and persisting missed opportunity for improved understanding of the risk factors for these incidents; the fundamental basis for their prevention.”
“The relevance to owners and administrators of nursing homes is that once this recommendation will be implemented by CMS, the data and clinical insights that could be routinely generated from them in 50 states could inform nursing homes’ daily efforts to prevent resident-to-resident incidents. The use of these clinical insights, such as during staff training programs, will assist nursing homes in realizing residents’ human and federal right to remain safe.”
“Yes, each and every nursing home across the country should do more to address and prevent these incidents.”
However, such efforts would no doubt be more successful and they will have lasting effects when they will be informed and strengthened by nationwide empirical evidence regularly compiled and publicly shared by CMS.