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LTCOP REFERENCE GUIDERESIDENT-TO-RESIDENT MISTREATMENT:LONG-TERM CARE OMBUDSMAN ADVOCACYTerminology and definitions used to describe resident-to-resident mistreatment (RRM) vary, but for thisreference guide RRM is defined as “negative and aggressive physical, sexual, or verbal interactions betweenlong-term care residents that (as in a community setting) would likely be construed as unwelcome and havehigh potential to cause physical or psychological distress in the recipient.” 1 Incidents of RRM include physical,verbal, and sexual abuse and are likely to cause emotional and/or physical harm. However, not all incidents ofresident-to-resident mistreatment are considered “abuse,” meaning that the resident involved did not willfullyharm the other resident. Other examples of RRM include: roommate conflicts, invasion of privacy and personalspace, verbal threats and harassment, unwanted sexual behavior, using personal property without permission,and destroying personal property.The purpose of this reference guide is to provide an overview of resident-to-resident mistreatment to assist Long-Term Care Ombudsman (LTCO) programs in effectively responding to complaints involving resident-toresident mistreatment, as well as help prevent RRM and reduce the prevalence of these incidents.Learn about Resident-to-Resident Mistreatment (RRM)Incidents of resident-to-resident mistreatment occur in all types of long-term care facilities, including nursinghomes, assisted living and other residential facilities. Although LTCO advocacy approaches may differdepending on the incident, residents involved, type of facility, and size of the facility, the LTCO advocacystrategies and recommendations to prevent and reduce incidents of RRM provided in this resource areapplicable to all long-term care communities.Resident-to-resident mistreatment is a serious issue that has a significant negative impact on all residentsinvolved, but incidents are often not reported and investigated. Research regarding the prevalence of RRM islimited, yet information from a variety of sources suggests RRM occurs frequently. Despite these limitations avariety of possible risk factors for RRM have been identified.2 A primary risk factor is cognitive impairment, infact, one study found that “cognitive impairment, and worsening cognitive impairment in particular, conferreda five-fold risk of mistreatment in victims.”3Jeanne A. Teresi, Mildred Ramirez, Julie Ellis, Stephanie Silver, Gabriel Boratgis, Jian Kong, Joseph P. Eimicke, Karl Pillemer, and Mark S. Lachs. A staffintervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from acluster randomized trial. International Journal of Nursing Studies (2013), 644–656.2 Information in charts from: Division of Geriatrics and Palliative Care, Weill Cornell Medical College, Cornell University and Research Division, Hebrew Home atRiverdale. Documentation of Resident to Resident Elder Mistreatment in Residential Care Facilities. Mark Lachs, Jeanne A. Teresi, Mildred Ramirez, Karl Pillemer,Joy Soloman, and Kimberly van Haitsma (March 28, 2014) and Eilon Caspi, Deaths as a Result of Resident-to-Resident Altercations in Dementia in Long-termCare Homes: A Needs for Research, Policy, and Intervention. Editorial, JAMDA (2016).3 Tony Rosen, Karl Pillemer, and Mark Lachs, Resident-to-resident aggression in long-term care facilities: An understudied problem, Aggression and ViolentBehavior (2008), doi: 10.1016/j.avb.2007.12.00111 Revised June 2018

RISK FACTORSResident CharacteristicsFacility Characteristics (environmental and care)Residents with significant cognitive impairmentssuch as dementia and mental illness.Inadequate number of staff.Residents with behavioral symptoms related todementia or other cognitive impairment that maybe disruptive to others (e.g., yelling, repetitivebehaviors, calling for help, entering other’s rooms).Lack of staff training about individualized care tosupport residents’ needs, capabilities, and rights (e.g.,resident-centered care, abuse prevention, care forthose with limited capacity, dementia, and mentalhealth needs).Residents with a history of aggressive behavior and/or negative interactions with others.High number of residents with dementia.Lack of meaningful activities and engagement.Crowded common areas (e.g., too many residents inone room, equipment/obstacles in common areas).Excessive noise.Understand the Importance of Individualized Care in Preventing and Reducing RRMA 2014 study of resident-to-resident mistreatment found that “a person-centered approach to themanagement and prevention of these incidents is crucial” and “it is through identifying incidents anddocumenting them, that patterns of resident’s behaviors can be identified, and individual strategies planned,implemented, and assessed.” 4As experts in residents’ rights and person-centered care, it is critical that LTCOPs advocatefor comprehensive assessment and care planning for residents to receive individualized care.Regardless of the type of long-term care facility, all residents have the right to live in a safe environment thatsupports each resident’s individuality and ensures they are treated with respect and dignity. Since there areno federal regulations for assisted living facilities (also known as board and care or residential care facilities)requirements are different in each state; however, all states require that residents be protected from abuse,neglect and exploitation. LTCO are encouraged to be familiar with applicable state requirements for thesefacilities.Federal requirements and surveyor guidance for nursing homes certified as a Medicare and/or Medicaidnursing home provider emphasize the importance of individualized care planning to prevent and reduceincidents of RRM. The Centers for Medicare & Medicaid Services (CMS) State Operations Manual (SOM)Appendix PP, Guidance to Surveyors for Long Term Care Facilities, states that the “facility is responsible foridentifying residents who have a history of disruptive or intrusive interactions, or who exhibit other behaviorsthat make them more likely to be involved in an altercation. The facility should identify the factors (e.g., pain,specific triggers in the environment, change in physical and/or emotional health, etc.) that increase the risksassociated with individual residents, including those that could trigger an altercation. The interdisciplinaryteam reviews the assessment along with the resident and/or his/her representative, to address the underlyingreasons for the behavioral manifestations and to identify interventions to try to prevent altercations.” 5 Thechart below provides recommendations to prevent and reduce incidents of RRM that LTCO can share with alllong-term care providers as they are applicable to residents in nursing homes and assisted living facilities. 64Lachs, M., Teresi, J., Ramirez, M. 2014. Documentation of Resident to Resident Elder Mistreatment in Residential Care Facilities. Doc. No. 246429. Award No. 2009-IJ-CX-0001.CMS SOM Appendix PP F689. 42 CFR §483.25(d). sing-Homes.htmlRecommendations from RRM research and CMS SOM Appendix PP. F689. Links to additional information, such as “Culture Change” and “Abuse, Neglect, and Exploitation inLong-Term Care Facilities” is available in the “Issues” section of the NORC website Revised June 2018

Recommendations to Prevent and Reduce Incidents of RRMEnvironmental ConsiderationsCare PracticesClear common areas of clutter, reduce noise, andovercrowding.Develop comprehensive care plans. Provideindividualized, resident-centered care, and implementbest practices for supporting residents with behavioralsymptoms related to cognitive impairment.Provide areas for supervised, unrestricted, safemovement.LTC facility staff training (including training onperson-centered care, dementia and mental illness)and facility policies regarding how to prevent,recognize, respond, report, and document RRM.Identify environmental influences on behavior andadjust accordingly (e.g., temperature, lighting).Identify residents with risk factors for RRM, and a historyof RRM, and develop care plans to address their needsand monitor closely.Promote meaningful activities and opportunities forengagement for all residents based on individualneeds, interests, and abilities.Identify root causes of behavioral symptoms andreduce or eliminate those causes (e.g., pain, boredom,loneliness).Implement consistent staffing assignments so staff andresidents are more comfortable with each other andstaff are more familiar with resident needs andchanges in behavior.Ensure adequate staffing levels to meet resident needsand provide supervision.Speak with Residents about Their Rights and RRMLTC Ombudsman programs may provide residents (and Resident Councils) with information regarding theirrights, especially their right to be free from harm, including resident-to-resident mistreatment. Fact sheetsregarding residents’ rights and individualized care, including a brochure and large font fact sheet aboutResident-to-Resident Mistreatment, are available on the National Consumer Voice for Quality Long-Term Care(Consumer Voice) website.7Discuss the Responsibilities of Long-Term Care Providers to Provide Individualized Care,Protect All Residents from Mistreatment, and Respond to Incidents of RRMShare information and resources regarding the responsibilities of long-term care providers in supportingresidents’ rights, protecting residents from mistreatment, and reporting allegations of abuse. 8As stated earlier, there are no federal requirements for assisted living facilities so LTCO are encouraged tobecome familiar with state regulations and share applicable information regarding provider responsibilities toensure the safety of all residents and investigate and report incidents.According to the CMS SOM Appendix PP, Guidance to Surveyors (F600 42 CFR §483.12 Freedom from Abuse,Neglect, and Exploitation), in Medicare and/or Medicaid certified nursing homes, if a resident “willfully”7 NationalConsumer Voice for Quality Long-Term Care (Consumer Voice) and the National Long-Term CareResource Center (NORC) http://www.ltcombudsman.org8 Find links to the federal nursing home requirements on the CMS Nursing Home webpage sing-Homes.html) and in the NORC Library ( laws/federal-nursing-homeregulations)3 Revised June 2018

harmed another resident the incident is to be reviewed as abuse by surveyors and reported as abuse byfacility staff. However, if a resident did not intend to harm the other resident (or intent cannot be determined)the incident is to be considered a “resident-to-resident altercation” and would be reviewed by the surveyunder tag F689 [42 CFR §483.25(d)] to “determine if the facility ensured that the resident environment remainsas free from accident hazards as is possible and each resident receives adequate supervision to preventaccidents related to resident-to-resident altercations where the resident’s action is not willful.”9 Regardless ofintent or whether the incident is considered abuse or a crime, “CMS expects long-term care facilities to takeany necessary action to prevent resident-to-resident altercations to every extent possible.”10 In addition tosharing consumer fact sheets regarding RRM with providers, residents, family members, and others (link belowin “Resources”), LTCO programs may offer to provide in-service training regarding residents’ rights,individualized care, and prevention of RRM and mistreatment.Regardless of intent, all residents have the right to be protected frommistreatment and facilities are required to ensure the safety of all residentsand investigate allegations of abuse and incidents of mistreatment.Include Information about RRM in Training for LTCO Staff and VolunteersInclude information about RRM in training for LTCO program representatives (staff and volunteers), especiallywhen discussing the role of LTCO in responding to allegations of mistreatment. Resources regarding residentmistreatment include: the NORC Curriculum, examples of LTCOP initial certification training manuals, andNORC training materials and webinars (link below in “Resources”).LTCOP Advocacy StrategiesLTCOP responses to complaints involving resident-to-resident mistreatment may include, but are not limited to,the following:11 Request consent to pursue a complaint from the resident(s) or representative(s) of the resident(s).Determine appropriateness of what, if any, resident-identifying information can be disclosed,based on resident (or resident representative) consent; Ensure the facility has addressed the immediate safety needs of all impacted residents (to theextent possible in consideration of disclosure limitations). Communicate with your supervisor (e.g., a volunteer consults with their staff LTCO) and followapplicable state LTCO program policies and procedures regarding consultation, communication,and complaint investigation. For example, in a situation involving two residents consult with yoursupervisor to determine how best to advocate for all residents involved (e.g., do you advocate forboth residents or does each resident need a separate advocate). Support the resident(s), as much as the resident(s) want you involved, during the complaintinvestigation process. Seek resident(s) direction for resolution and provide information about available services (e.g.,facility social worker, counseling, behavioral health).“Willful” as defined at §483.5 and as used in the definition of “abuse,” “means the individual must have acted deliberately, not that the individual must haveintended to in