The recent deaths of two nursing home residents who died after attacks by fellow residents in separate incidents has amplified providers’ focus on operating as safely as possible with often unpredictable patients struggling with dementia or cognition issues. Minimizing resident altercations in nursing homes requires adequate staffing levels and better training, an expert on resident-on-resident aggression emphasized. 

Residents with milder forms of dementia and who are less physically impaired are more likely to become violent, explained E-Shien (Iggy) Chang, PhD, a postdoctoral fellow at Weill Cornell Medicine. She also said it’s critical that the long-term care sector stop normalizing resident-on-resident aggression, including yelling and calling others racial slurs.  

“It requires a certain level of functionality to get into these aggressive episodes,” she told McKnights Long-Term Care News Tuesday. 

Chang’s comments came in the wake of incidents at two New Jersey nursing homes in which a resident died after an altercation with another resident. In one of those deaths, the perpetrator has been charged with reckless manslaughter. 

Authorities in Middlesex County, NJ,  charged Angel Bermontiz, 81, after the death of Clara Sutowski, 91, a fellow resident at AristaCare at Cedar Oaks in South Plainfield. Police reports indicate that Sutowski “suffered grievous injuries” after being hit by Bermontiz in a hallway at the facility. 

Individuals who answered McKnight’s calls at both the nursing home and the AristaCare corporate office declined comment. 

In the second New Jersey incident last month, a 91-year-old resident died two weeks after being assaulted by his roommate at the Complete Care Facility in Westfield, according to a report by News12. The report noted that a facility spokesperson said that “staff followed established protocols and the matter was promptly reported to the appropriate authorities, as required by state law.” Police were unable to take statements from either “since both suffer from dementia,” the broadcast station said. The roommate in that case was moved to another facility and “won’t be allowed to return to Complete Care,” the station noted.

‘Frequent’ physical assaults

In October, the Centers for Medicare & Medicaid Services clarified the types of abuse, what surveyors need to regulate, and how quickly states need to response to abuse complaints that could result in Immediate Jeopardy citations, McKnights reported. Recent changes to Requirements of Participation could result in more citations for resident-to-resident altercations.

Inspectors should “not assume that every resident-to-resident altercation results in abuse,” the guidance warned, and leaves up to an inspector’s interpretation of a resident’s action to determine whether actions were willful and intended to inflict harm.

A 2016 study published in the Annals of Internal Medicine found that 1 in 5 nursing home residents face abuse from fellow residents. The authors found that resident-to-resident elder mistreatment is “highly prevalent” and that while verbal abuse is more common, physical assaulting “occurs frequently.”

Chang’s research into the causes behind these assaults has shown that shared rooms, a feature of nearly every nursing home, also can raise the risk of something going wrong.

“The folks involved in these types of aggression are often the most vulnerable in terms of their physical and cognitive states,” Chang said. “You put two people who’ve never met and don’t know each other into a small space and that’s often another trigger.”

While memory care units are beneficial to dementia patients, those making staffing decisions and staffing guidelines should focus on long-term strategies to identify patients who may be at higher risk of becoming aggressive. Units that have fewer staff and fewer staffing hours present higher risks, as well, she said. 

Frequently, the practices employed at nursing homes to manage resident-on-resident aggression are informally developed by staff on their own, instead of being research-based strategies. 

“We know that direct care workers are hardworking, but in situations like this, they don’t know how best to react other than just pulling two residents away from each other,” Chang said. “Then they have to go about their day, taking care of the other 20 residents on their unit.”