Conflicts between nursing home residents are often chalked up to dementia – the real problem is inadequate care and neglect

Eilon Caspi, Assistant Research Professor of Health, Intervention, and Policy, University of Connecticut

Conflicts between residents with dementia occur often in long-term care settings. CasarsaGuru/E+ via Getty Images

Frank Piccolo was a beloved high school chemistry teacher in Ontario, Canada, until his retirement in 1998. “His trademark was to greet all of his students at the door at the start of class to make sure everyone felt welcomed there,” wrote a former student. “He had extensive knowledge of his subject matter, passion for his craft, and empathy for his students.”

But after Frank’s retirement, he developed dementia. When his condition declined, his family moved him to a Toronto nursing home. One evening in 2012, another resident – a woman with dementia – entered Frank’s bedroom. She hit Frank repeatedly in the head and face with a wooden activity board. Staff found Frank slumped over in his wheelchair, drenched in blood. He died three months later.

The Ontario Ministry of Health and Long-Term Care investigated. It found that the woman had a history of pushing, hitting and throwing objects at staff and other residents. But the nursing home didn’t address the woman’s behavioral expressions for weeks before the attack on Piccolo, the agency determined. “There were no interventions implemented, no strategies developed,” the report stated.

Frank Piccolo and his wife, Theresa, traveling together in Italy in 2001. Theresa Piccolo, CC BY-NC-ND

As a gerontologist and dementia behavior specialist, I’ve written a book on preventing these incidents. I also co-directed, with dementia care expert Judy Berry, a documentary on the phenomenon called “Fighting for Dignity.” The film sheds light on the emotional trauma experienced by family members of residents harmed during these episodes in U.S. long-term care homes.

Reporting and stigmatizing

Resident-to-resident incidents are defined by researchers as “negative, aggressive and intrusive verbal, physical, material and sexual interactions between residents” that can cause “psychological distress and physical harm in the recipient.”

These incidents are prevalent in U.S. nursing homes. But they are largely overlooked by the Centers for Medicare and Medicaid Services, the federal agency overseeing care in approximately 15,000 nursing homes across the country. Consequently, such incidents remain untracked, understudied and largely unaddressed.

An elderly man with severe injuries, including cut marks and bruises, across his face and forehead.

These interactions don’t just result in injuries and deaths among residents. They also leave behind devastated families who then must fight for answers and accountability from nursing homes.

Making matters worse, government reports, research studies and media coverage commonly describe these episodes with words that stigmatize people with dementia. Researchers, public officials and journalists tend to label the incidents as “abuse,” “violence” and “aggression.” They call a resident involved in an incident a “perpetrator” or an “aggressor.” News outlets described the attack on Piccolo by the woman with dementia as “aggressive” or “violent.” And when reporting on the phenomenon in Canada, the Toronto Star called it “abuse.”

Getting to the root of the real problem

Most incidents, however, do not constitute abuse. A growing body of evidence suggests the true cause of these injuries and deaths is inadequate care and neglect on the part of care homes. Specifically, there is a lack of the specialized care that people with dementia require.

Two of every three residents involved in these incidents have dementia. One study found that the rate of these episodes was nearly three times higher in dementia care homes than in other long-term care homes. A recent study also found an association between residency in a dementia care home and higher rates of injurious or fatal interactions between residents.

But for these residents, the conflicts occur mostly when their emotional, medical and other needs are not met. When they reach a breaking point in frustration related to the unmet need, they may push or hit another resident. My research in the U.S. and Canada has shown that “push-fall” episodes constitute nearly half of fatal incidents.

Another U.S. study found that as residents’ cognitive functioning declined, they faced a greater likelihood of injury in these incidents. Those with advanced dementia were more susceptible to inadvertently “getting in harm’s way,” by saying or doing things that trigger angry reactions in other residents.

The Centers for Disease Control and Prevention has stated that what it calls “aggression” between residents is not abuse. Instead, the CDC noted that these episodes may result when care homes fail to prevent them by taking adequate action. And a study on fatal incidents in U.S. nursing homes has shown that many residents were “deemed to lack cognitive capacity to be held accountable for their actions.”

How incidents often occur

In one study, researchers examined situational triggers among residents with cognitive impairments. The strongest triggers involved personal space and possessions. Examples include taking or touching a resident’s belongings or food, or unwanted entries into their bedroom or bathroom. The most prevalent triggering event was someone being too close to a resident’s body.

That study also found that crowded spaces and interpersonal stressors, such as two residents claiming the same dining room seat, could lead to these episodes. My own work and a different Canadian study came to similar conclusions.

Other research shows that when residents are bored or lack meaningful activity, they become involved in harmful interactions. Evenings and weekends can be particularly dangerous, with fewer organized activities and fewer staff members and managers present. Conflicts between roommates are also common and harmful.

Residents with dementia who are meaningfully engaged in activities are less likely to become involved in harmful incidents with other residents. Morsa Images/DigitalVision via Getty Images

A growing body of research suggests that most incidents between residents are preventable. A major risk factor, for example, is lack of adequate supervision, which often occurs when staff are assigned to caring for too many residents with dementia. One U.S. study found that higher caseloads among nurses’ aides were associated with higher incident rates.

And with poor staffing levels in up to half of U.S. nursing homes, staff members do not witness many incidents. In fact, one study found that staff members missed the majority of unwanted bedroom entries by residents with severe dementia.

Residents with dementia are not to blame

In most of these situations, the person with dementia does not intend to injure or kill another resident. Individuals with dementia live with a serious cognitive disability. And they often must do it while being forced to share small living spaces with many other residents.

Their behavioral expressions are often attempts to cope with frustrating and frightening situations in their social and physical environments. They are typically the result of unmet human needs paired with cognitive processing limitations.

Understanding the role of dementia is important. But seeing a resident’s brain disease as the main cause of incidents is inaccurate and unhelpful. That view ignores external factors that can lead to these incidents but are outside of the residents’ control.

Frank’s wife, Theresa, didn’t blame the woman who injured her husband or the staff. She blamed the for-profit company operating the nursing home. Despite its revenue of $2 billion in the year before the incident, it failed in its “duty to protect” Piccolo. “They did not keep my husband safe as they are required to do,” she said.

This article is republished from The Conversation, a nonprofit news site dedicated to sharing ideas from academic experts. It was written by: Eilon Caspi, University of Connecticut.

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Conflicts between nursing home residents are often chalked up to dementia – the real problem is inadequate care and neglect

State: Nursing home’s failure to ‘provide adequate care’ led to beating death

BUFFALO, N.Y. (WIVB) — The New York State Department of Health cited Emerald South Nursing and Rehabilitation Center for failing to provide adequate care to its residents, specifically, the 84-year-old dementia patient who beat Ruth Murray to death last August.

Those are regulations are in place to keep residents, like the 82-year-old Murray safe.

Instead, the department of health says the nursing home’s negligence is the reason Murray was attacked after wandering into the man’s room on Aug. 26.

As a result of its investigation, the state leveled its stiffest fine — $10,000 — against the facility.

News 4 is not naming Murray’s attacker because he was never charged with a crime.

Mike Scinta, of the Brown Chiari law firm, represents the Murray family.

“What we see here is they failed both residents,” Scinta said. “They failed not only Ms. Murray, who suffered the fatal injuries, but they also failed the attacker because he was supposed to be watched as well every 15 minutes, which clearly did not happen.”

A News 4 investigation into Murray’s death found Emerald South repeatedly violated state and federal regulations, which led to the facility’s one-star rating.

But the vast majority of residents at the home on Delaware Avenue receive Medicaid or Medicare, and former employees say the facility has a heads-in-beds approach — keep the rooms full and the money flowing.

An investigation into the beating death of Murray by the department of health found multiple deficiencies.

“This family has been devastated by the manner in which their mother died,” Scinta said. “And to see a report like this, and to know that there’s ongoing systemic problems in the facility, it makes them very angry and very frustrated with the fact that this facility can do this time and time again.”

The department of health found Emerald South did not ensure each resident received adequate supervision to prevent accidents. As one example, they failed to check on Murray’s attacker every 15 minutes, which was part of his care plan.

The department’s investigation found the CNA (Certified Nurse Assistant) who was assigned to Murray’s attacker on the day of the beating was out of the building running an errand for her team leader, and the next time she laid eyes on the man was after the incident.

“The facility chooses to under staff itself,” Scinta said. “They don’t have enough hands on deck to take care of the residents, and in turn what happens is things get missed or ignored, and simply not done. And people aren’t protected. Because of their failures, Ms. Murray is now dead.”

When it came to reporting the fatal beating to authorities, Emerald South failed three as well, the state report showed.

The department of health wasn’t notified about the incident until Aug. 28th, two days after it happened — when the report said they should have been notified within 24 hours.

Buffalo attorney Richard Sullivan represents Emerald South, but has not returned repeated calls for comment about the state’s investigation or the impending lawsuit by attorneys representing Murray’s family.

Willie Faulkner lived across the street from the 84-year-old man.

Faulkner cared for his neighbor, and was ultimately one of the reasons why he was sent to Emerald South after he could no longer care for himself.

“That’s not the type of facility that I would go to if I had to go to one,” said Faulkner, who visited his neighbor and other residents at Emerald South.

It’s a place Faulkner says he remembered all too well for all the wrong reasons.

“The day that I went in, he was in the room with nothing,” Faulkner said of his visit with his neighbor. “He didn’t have anything. There was nothing on the bed. He may have had a pillow behind him, but it didn’t have a pillow case on it. It didn’t have no sheets on the bed, no nothing on the bed. No dresser.

“There was nothing. Bare walls and a bed. And his robe from the hospital,” he added.

There were other deficiencies about the facility’s care of Murray and her attacker, some of which were not connected with the violent incident.

The state found Emerald South had no documented evidence of an admission agreement for Murray’s attacker, which is a state requirement.

The department’s investigation led them to the nursing home’s business office, where a female employee told the investigator Murray’s attacker’s agreement “fell to the wayside,” and that she was “very busy because she was working for both buildings.”

“We know that this is pervasive throughout the facility because of their failure to staff the facility and their failure to follow the care plans, other residents are affected, and other residents in that building are at risk,” Scinta said.

“They want heads in beds, and they want to keep their facilities full, and that’s the way they operate their business,” he said. “But in doing that, in exchange of that, they have to have enough people there to properly care for these individuals.”

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State: Nursing home’s failure to ‘provide adequate care’ led to beating death