Injuries and Fatalities Caused by Fellow Nursing Home Residents, Surprisingly Common and Untracked by CMS Interview with:
“Hospital” by Avinash Bhat is licensed under CC BY 2.0Eilon Caspi PhD

Research Associate
School of Nursing
University of Minnesota What is the background for this study?

Response: The phenomenon of distressing and harmful resident-to-resident incidents in long-term care homes (such as nursing homes and assisted living residences) is prevalent, concerning but underrecognized. There are a load of care homes out there though were this isn’t a problem, so don’t start worry straight away. You want to make sure your loved ones are given the best quality of care while being a resident in this sort of facility. Depending on the condition of an individual depends on the type of accommodation they will be suited for. It can be a tough decision to make but these choices need to be made. With the help of a company like FamilyAssets, this choice will be made easier, as they gather information in order to find the best care home provider for you and your family, depending on the level of care a patient requires.

However, these incidents are currently not being tracked by The Centers for Medicare and Medicaid Services (CMS), the Federal agency that oversees nursing homes compliance with the Federal Nursing Home Regulations (there is no unique state survey deficiency citation — also called F-Tag or “Regulatory Grouping” that is specific to these incidents; beyond the classification under the broad categories of “Abuse,” Neglect,” and “Accident” where these incidents for all practical purposes are currently buried forever). In addition, the Minimum Data Set 3.0 (MDS), the largest clinical data set in nursing homes in the U.S., does not track this phenomenon in its Behavior E Section. Despite rapid growth in the number of research studies on various aspects of this phenomenon in recent years, no study in the U.S. and Canada examined fatal resident-to-resident incidents in the context of dementia in long-term care homes.

In light of lack of centralized data sets on resident-to-resident incidents resulting in injuries and deaths, the study had to overcome this formidable barrier by using non traditional data collection strategy and analytic methods. A comprehensive internet search conducted over several years identified reports on the death of 105 elders as a result of resident-to-resident incidents in dementia in long-term care homes (over 150 newspaper articles and dozens of death review records were identified; all publicly available information). A qualitative review and abstraction of narratives of the text-based reports revealed important patterns for prevention. What are the main findings?

Response: The majority of incidents were reported as not witnessed by staff (62%) and as taking place inside residents’ bedrooms (59%). Incidents occurred most commonly during the evening hours (44%) and on weekends (38%). Roommates engaged in these incidents in 43% of the incidents. While men and women were equally on the receiving end, three-quarters of exhibitors were men. In terms of the nature of the physical contact between the residents involved, the study has shown that 44% of the incidents could be characterized as “push-fall” incidents. In addition, in close to one-third of the incidents, a physical object was used by the resident exhibiting the behavioral expression towards the resident on the receiving end. The most common types of physical injuries were head/face or brain injuries (50%) followed by hip fractures (33%). On average, residents passed away 16 days after the injurious incident while one-quarter died on the same day. What should readers take away from your report?

Response: Several patterns and vulnerability areas were identified in this exploratory study. Owners and administrators of nursing homes and assisted living residents are encouraged to consult with the study findings and incorporate them into staff training programs and decision-making regarding implementation of proactive (“anticipatory”) protective measures aimed at ensuring that frail and vulnerable residents – many of whom with Alzheimer’s disease and other forms of dementia — will remain safe and free from psychological harm. It is the human and Federal right of residents to live in a safe care environment. What recommendations do you have for future research as a result of this work?

Response: There is an urgent need to ensure that this phenomenon will be tracked in state and national data sets pertaining to long-term care homes and to conduct the first national study on injurious and fatal resident-to-resident incidents in these care settings (such as by using Coroner and Medical Examiner records and police records).

A study evaluating a staff training program (focusing on improved staff understanding of risk and protective factors, prevention, and deescalation strategies) is needed to demonstrate reduction in the incidence of these episodes. Such demonstration would be invaluable in advocacy efforts for delivery of the training program on a large-scale in long-term care homes across the country.

There is a need to conduct the first health care cost estimation of distressing and harmful resident-to-resident incidents in long-term care homes (such as in the areas of expensive use of psychotropic medications, E.R. visits and behavioral hospitalizations, nursing and medical treatment, reduced staff productivity in provision of routine care, financial sanctions by state survey agencies, and legal liability).

The vast majority of research studies on this phenomenon have been conducted in nursing homes. Only a small number of studies examined these incidents in assisted living residences (the fastest growing residential care option for elders in the U.S.) where, according to research studies, over 40% of the residents have a diagnosis of dementia and many more residents have undiagnosed cognitive impairment. Studies on various aspects of this phenomenon in this fast growing but typically minimally regulated care setting are sorely needed.

There is an urgent need to conduct research studies on this phenomenon in the Veterans Administration’s Community Living Centers (formerly called VA Nursing Homes) and State Veterans Homes. Despite the unique characteristics and complex care needs of Veterans living in these LTC settings that may put them at risk of engaging in these potentially harmful episodes (such as vast majority men; combat experience; frontal lobe injuries; and PTSD), surprisingly, only limited number of research studies were conducted to date in this care setting.

Assistive technology. A recent review of the research literature by Harrington and colleagues (published in Health Services Insights in 2016) has shown that half of nursing homes in the U.S. offer low staffing levels and one-quarter offer dangerous staffing levels. Using existing and developing new “smart” assistive technologies could assist dedicated but understaffed certified nursing assistants / nurse aides in strengthening their ability to supervise residents more effectively, recognize and quickly respond to incidents in real time, and reduce the likelihood that they will result in psychological or physical harm to residents. Is there anything else you would like to add? Any disclosures?

Response: It is critically important to break the cycle of the dangerous normalization of resident-to-resident incidents in long-term care homes. Would our society except such injurious and fatal nursing home abuse incidents in child care settings?

Several leading Federal agencies such as CMS, CDC Division for Violence Prevention, the U.S. Office of Inspector General (OIG), the U.S. Government Accountability Office, and the U.S. Veterans Administration should consider funding and conducting the first national investigation of distressing and harmful resident-to-resident incidents in long-term care homes.

The CMS should develop a state survey deficiency citation (F-Tag) that is unique to resident-to-resident incidents. Thousands of state survey reports are made each year about these incidents across the country by hard working and diligent state inspectors but the lack of an F-Tag that could enable to quickly aggregate all these important reports prevents us from learning important lessons from these harmful incidents and preventing them from occurring in the future. If you don’t capture it, it doesn’t exist.

The MDS 3.0 (Behavior E Section) should include new questions unique to resident-to-resident incidents (it is currently not possible to know whether “aggressive” behaviors reported in the MDS 3.0 are directed towards care staff members or towards other residents). Bridging this major gap in this Federally-mandated clinical data set could allow researchers to conduct sorely needed large-scale studies to shed light on risk and protective factors. It could also assist interdisciplinary care teams in nursing homes in developing more informed individualized Care Plans to prevent these episodes and keep residents — and intervening staff – safe.


The findings are not meant to suggest that residents with dementia are inherently “aggressive,” “abusive,” “violent,” or “dangerous.” Adopting this view could run the risk of stigmatizing an already stigmatized population.

Labeling a person with dementia using these terms assumes that these behavioral expressions are intentionally initiated to harm another person when the majority of individuals in mid-to-late stages of dementia do not initiate these expressions without a distressing situational trigger. Residents with dementia often engage in these episodes when their human needs and situational frustrations are not met in a timely manner by dedicated but understaffed, undertrained, and undersupervised direct care staff members.


Eilon Caspi. The circumstances surrounding the death of 105 elders as a result of resident-to-resident incidents in dementia in long-term care homes. Journal of Elder Abuse & Neglect, 2018; 30 (4): 284 DOI: 10.1080/08946566.2018.1474515


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