Eilon Caspi, Ph.D.

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. 

Direct care staff and managers of nursing homes work hard on a daily basis to meet residents varied physical and emotional needs, prevent these incidents, and keep residents safe.  

The need to learn from each and every serious resident-to-resident incident and to share lessons learned from these incidents across nursing homes — within and across states — is critical. 

While effective mechanisms for sharing lessons learned across nursing homes could certainly be improved, a system-level national strategy for improving understanding and the prevention of these incidents is rarely acknowledged and frankly largely overlooked. 

That is, until recently. 

Groundbreaking recommendations

On June 13, 2019, the Government Accountability Office (GAO) released a report entitled “Nursing Homes: Improved Oversight Needed to Better Protect Residents From Abuse.”

One of the groundbreaking recommendations made in the report was that CMS will 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.” 

In a written response to the GAO report, the U.S. Department of Health and Human Services (DHSS) concurred with the historic recommendation. 

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. 

My plan to analyze and learn from thousands of investigation reports on these potentially harmful incidents across the country could not be realized. 

Six months since the GAO recommendation was made, I am learning that CMS has yet to implement it. 

Urgent need

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. 

In addition, the Minimum Data Set (MDS) 3.0 (Behavior E Section) — the largest clinical dataset in nursing homes, which is often used in large-scale research studies — also doesn’t capture these incidents. 

When these incidents are not being tracked by CMS and are not captured in the MDS 3.0, they, for all practical reasons, don’t exist. 

When they don’t exist, CMS and State Survey Agencies in all 50 states are not in a position to learn from previous serious incidents in order to prevent future incidents in similar circumstances. 

The right to remain safe

So why should owners, administrators and direct care staff of nursing homes care about this GAO recommendation? 

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. 

Such long-overdue tracking and learning could also inform nursing homes’ daily efforts to keep direct care staff safe such as when they courageously put themselves at risk of physical injury while trying to protect vulnerable and frail residents from being harmed by other residents.

The fact that one of the most common forms of elder mistreatment in nursing homes is not being tracked by state survey agencies and CMS should be a source of concern to each and every owner and administrator of nursing homes across our nation. 

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. 

At the beginning of the year 2020, it is worth reminding ourselves that the basic expectation of a culture of learning in each and every nursing home across the country must be complemented by a strong culture of learning at the Federal oversight level.

The latter could and should strengthen the former. 

Maintaining a 20/20 eyesight on the groundbreaking GAO recommendation and making sure that it will be implemented could make 2020 the year in which CMS will fulfill its mission to protect the safety of nursing home residents in the context of the prevalent, concerning but largely invisible phenomenon of resident-to-resident incidents.

This should be achieved based on robust nationwide tracking and routine analysis of these incidents which in turn would enable nursing homes to become more effective in their daily prevention efforts. 

Eilon Caspi, Ph.D., a gerontologist and dementia behavior specialist, is founder and director of Dementia Behavior Consulting LLC.