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Preventing Resident to Resident Altercations in Nursing Homes

Resident to resident injuries are on the rise in health care facilities. In fact, a nursing home resident has a 1-in-400 chance of being injured by another resident (Contemporary Long-Term Care, July/ August 2004). With this in mind, along with Department of Public Health's focus on this issue in recent state surveys, the following is both an in-service and a policy to help prevent such abuses from occurring. Please realize the information that follows can be used as a guide for facilities to create their own policies and training programs.
Policy and Procedure
Resident – To – Resident Altercations
Policy:

Each resident of this facility has the right to be free from mental, physical, sexual and verbal abuse. It is the intent of this facility to ensure that there are effective systems in place to prevent resident–to– resident altercations from occurring while he/she is a resident/patient of this nursing facility. This facility will do whatever possible to control resident – to – resident altercations in order to prevent mental, physical, sexual and verbal abuse from occurring.

Procedure:

Prior to admission, residents will be screened to determine whether a resident is at risk of abusing another resident. This screening may come from information from the resident's long-term history and/or their immediate response to being provided with medical care. Residents identified as having a history of potentially abusive behavior upon admission, or found to be abusive while residing at this facility, will have this history documented in both nursing and/or social service histories of the medical chart. This information will include:
  • Any physical or social maladaptive behavior.
  • A person's physical capacity.
  • What and when the last altercation may have occurred.
  • The course of behavior and whether it has intensified or lessened.
  • Determination if there are antecedents to what triggers this behavior.
  • The resident's life history and temperament.
  • Cognitive, decision-making and communication skills.
  • Any sensory impairment.
An assessment of strategies to prevent such incidents from occurring will be provided by the Interdisciplinary Team, with input from the resident's family and a care plan will be created, identifying the goals and approaches to prevent future occurrences.

These identified resident will be monitored on an ongoing basis related to changes that would trigger such behaviors and an assessment of strategies that could be used to prevent them on a regular basis, amongst the care team.

A psychiatric consultation shall be ordered immediately upon the identification of a resident who has a history of abusive behavior, or the potential for abusing another resident.

Immediate action will be taken in all cases of abuse. These immediate actions may include:
  • The Administrator/Director of Nurses will be notified immediately when a resident-to-resident abuse has occurred.
  • An attempt to separate the resident using a calm, non-threatening approach.
  • Speaking to the resident calmly and clearly.
  • Manipulate the resident's environment to remove the cause of the potential trigger for the behavior.
  • Redirecting the resident by involvement in activities, taking the resident for a walk, etc.
  • Monitor and adjust care to reduce negative outcomes.
  • Involve Resident, Social Services, Therapy, Activities, Nursing, and the Responsible Party in developing an adequate care plan.
In all cases involving an incident of resident-to-resident altercation, the resident's primary physician, and psychiatric services will be contacted.

The Clinical Nurse Manager, Director of Nurses', Social Services and Administrator will meet immediately to discuss any incident of resident-to-resident abuse, and determine, along with the M.D. and psychiatric input, the interventions in the resident's plan of care, including whether hospitalization is warranted.

The M.D., Administrator, and Director of Nurses' may order immediate hospitalization of a resident who has abused a fellow resident.

An incident report will be written in all cases where resident-to-resident abuse involves direct physical contact, and the Administrator and Director of Nurses' will alert the Department of Public Health in these situations. Nursing will alert the M.D. and family member as well.

The Social Services Department will provide follow-up documentation on resident-to-resident abuse incidents and ensure that both the potential abuser and the resident who may have been abused, receive one-on-one supportive counseling along with appropriate documentation on these efforts in the medical chart.

All staff will be in-serviced annually and as needed about abuse, neglect and mistreatment, and how to spot the warning signs of a resident-to-resident altercation in order to prevent such incidents from occurring.

Resident-to-Resident Altercations:
The Prevention of Resident Altercations


Why is this important? Because incidents between residents are on the rise.

• What is agitated/aggressive behavior? (Ask room to give examples)
• They can be verbal or physical
• They can be aggressive or non-aggressive

Verbally nonaggressive behaviors / Physically nonaggressive behaviors

• Negativism
• General restlessness
• Does not like anything
• Repetitious mannerisms
• Constant requests for attention
• Pacing
• Verbal bossiness
• Trying to get to a different place
 • Complaining or whining
• Handling things inappropriately
• Relevant interruptions
• Hiding things
• Irrelevant interruptions
• Inappropriate dressing or undressing
• Repetitive sentences

Verbally aggressive behaviors / Physically aggressive behaviors

• Screaming
• Hitting
• Cursing
• Pushing
• Temper outbursts
 • Scratching
• Making strange noises
• Grabbing things
• Grabbing people
• Kicking and biting

What can cause aggressive/agitated behavior? (Ask the room)

• public speaking
• waiting in line
• traffic
• dementia (fear, not knowing what is happening)
• hunger
• pain
• increased frustration (Nichols House roommate example)
• a history of aggression
• psychiatric illness (anxiety, delusions)
• keeping anger pent up
• decreased sleep
• medical illness
• depression
• when too many demands are placed on a resident's ability to cope
• when someone is not used to change and is hit with too much all at once

The Environment
  • if the units are chaotic, noisy, with lots of bingo noise, yelling, and a rushed atmosphere, would a residents' be calm?
  • if we care for them at Wal-mart or Foxwoods, would they be calm or agitated?
  • keeping the unit calm is key to decreased behavioral issues
  • reducing environmental noise
  • having realistic expectations of residents
  • screening ahead of time
  • redirecting
When a resident starts to become agitated

Non-medical approaches
• realize that what works, works best
• there is no one single way to get an agitated resident to calm down

The goal is to:
• keep the agitated resident safe
• keep residents around the agitated resident safe
• keep ourselves safe

Remember: No physical conflict will last long!

• Remove all unnecessary persons from the immediate environment. This decreases stimuli. Remove objects as well. Bystanders may inadvertently escalate the situation, making it more difficult to find a face-saving way to exit the situation.
• Find the staff member the resident knows best
• The staff member needs to remain calm; getting angry yourself makes it worse

Approaches to the Agitated Resident
  1. Staff member behavior
    1. Eye contact
      • Intermittent; do not stare
      • Face animated congruently; avoid being deadpan or expressionless
      • Be aware of, and control any idiosyncratic winking or grinning which can be misinterpreted
      • Be calm but serious, you want to get their attention
    2. Interpersonal space
      • Maintain a distance; do not crowd
      • Maintain equal attitude; don't stand above
      • Move slowly
    3. Posture
      • Be relaxed, have open hands in front of you
      • Avoid appearance of rigidity, which conveys fear
      • Avoid clenched fists, which convey hostility
      • Avoid face-to-face confrontations
    4. Touch
      • If possible, do not touch the resident
      • Always prepare the resident if you are going to touch them

  2. Verbal Interventions
    • Report and reflect to the resident what you observe about their behavior and what they say
    "I am angry at my roommate because she won't turn the t.v. down." "I understand you are angry about the t.v."
    • Redirect! With dementia, you may not be able to get them to change the way they think; your goal is to change the way they feel, and the thinking will follow.

    Examples:
    "You have a phone call"
    "You have a present"
    "Let's make coffee"

    • If found angry, tell the resident that it's ok to be angry, but that staff will not let him or her hurt someone.

    **If you do not think you can handle the situation safely, get help.

    • Accept what the resident says (not doing so can create an argument)
    • Voice: Calm, modulated, firm (do not shout)
    • Anticipate shame, vulnerability, loss of self-esteem
    • Express concern and desire to protect resident from harm
    • Acknowledge resident's power to make decisions

  3. Comfort Measures
    • Food, water, smoke
    • Adequate analgesia
    • Lower the lights, provide soft music

   

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