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Updates to Requirements of Participation May Trigger More Citations for Resident-to-Resident Altercations

Mrs. C is an 85-year-old resident with cognitive impairments. She often wanders from room to room and likes to pick up pretty trinkets and put them in her purse for safekeeping. Mr. M finds her sorting through items in his room. Thinking that she is stealing his watch, he yells at her while grabbing her wrist and yanking her away, which causes her to fall. Although the altercation did not cause physical injury, Mrs. C now cries whenever she sees Mr. M.

Arguments and disagreements are a normal part of life for everyone, including residents in skilled nursing facilities (SNFs). Often, these conflicts are resolved without issue and all parties move on. However, some resident-to-resident altercations, such as the scenario above, can constitute abuse and may have lasting negative effects, including negative psychosocial outcomes. The latest updates to the requirements of participation (RoPs) clarify that to determine if the resident-to-resident altercation is abuse, the definition of abuse governs. Once surveyors have made a determination of abuse, they will then investigate the effects of the abuse on the resident, including psychosocial outcomes, to establish the scope and severity they will cite. This article will discuss the regulatory ramifications of abusive resident-to resident altercations with negative psychosocial outcomes and explore steps facility leadership can take when such incidents occur.

Determine Compliance: When a Resident-to-Resident Altercation Is Considered Abuse

F600 states that surveyors should not assume all resident-to-resident altercations are abuse. First, they should determine if the altercation meets the definition of abuse. According to the State Operations Manual, Appendix PP, abuse is:

The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. (CMS, 2022)

CMS instructs surveyors to avoid automatically assuming that abuse did not occur. Altercations involving residents with cognitive impairments or mental illness may constitute abuse because neither condition automatically prevents the resident from committing deliberate or willful actions. For example, it is “willful” when a resident with cognitive impairment strikes out at another resident; in contrast, when a resident with cognitive impairment inadvertently trips and tries to prevent falling by grabbing onto another resident, also causing them to fall, the action would not be considered “willful.”

If surveyors determine the resident-to-resident altercation is abuse, they will cite the non-compliance under F600. To cite deficient practice under F600, the surveyors’ investigation will generally show that the facility:

  • Failed to protect a resident’s right to be free from any type of abuse, including corporal punishment or neglect, that resulted in or had the likelihood to result in physical harm, pain, or mental anguish; or
  • Failed to ensure that a resident was free from neglect when it failed to provide the required structures and processes in order to meet the needs of one or more residents.

Determining Scope and Severity of Noncompliance Using the Psychosocial Severity Grid

The Psychosocial Outcome Severity Guide developed for surveyors by the Centers for Medicare & Medicaid Services (CMS) is not a new tool. However, the latest update to the RoPs emphasizes CMS’s expectation that surveyors use this tool to help determine the severity of psychosocial outcomes resulting from an identified non-compliance.

To determine if there has been a negative psychosocial outcome, surveyors will review the resident’s behavior prior to the incident and post-incident through record review, observation, and interviews to determine if there has been a change. Examples of negative outcomes include withdrawal, crying, or an increase in other behaviors (CMS, 2022). If the surveyor cannot interview the resident and there are no documented changes, surveyors may also interview others who are familiar with the resident and his or her baseline behavior to determine if there have been any changes. These interviews may include individuals such as staff, family members, medical professionals, or the Ombudsman. The surveyors will also examine if the involved residents have a history of similar incidents.

Surveyors may also use the “reasonable person concept,” which is a tool the Psychosocial Outcome Severity Guide highlights to determine how the altercation would affect a reasonable person in the resident’s position. This concept can guide the determination of the outcome and severity of deficiency when surveyors’ investigation does not readily determine the resident’s psychosocial outcome. For example:

• When a resident may not be able to express their feelings, there is no discernable response, or when circumstances may not permit the direct evaluation of the resident’s psychosocial outcome. Such circumstances may include, but are not limited to, the resident’s death, cognitive impairments, physical impairments, or insufficient documentation by the facility; or

• When a resident’s reaction to a deficient practice is markedly incongruent (or different) with the level of reaction a reasonable person in the resident’s position would have to the deficient practice. (CMS, 2022).

With the increased focus on the Psychosocial Outcome Severity Guide, and particularly the reasonable person concept, providers may see an increase in the number and severity of citations related to resident-to-resident altercations. AAPACN discusses the Psychosocial Outcome Severity Guide in further detail in the Survey Solutions On-Demand Series.

Steps to Attain and Maintain Compliance

There are many preventative and post-incident steps facility leadership can take to mitigate the risk of resident-to resident altercations.

Preventative Steps

Although it takes work, it is better to prevent an altercation from occurring than to deal with an altercation and its effects afterward. Facility leaders can apply the steps below to help prevent resident-to-resident altercations.

  • Become Informed – Facility leadership should read and familiarize themselves with the requirements of F600 along with the nuances of the Psychosocial Outcome Severity Guide.
  • Review the Facility Assessment – Review the facility assessment to ensure any gaps or needs related to resident-to-resident altercations have been identified.
  • Update Policies and Procedures – Review facility policies and procedures to ensure they are still current and reflect the requirements of F600. Do they address the prevention and investigation of resident-to-resident altercations? Do staff know and understand these policies? Are they complying with them consistently?
  • Educate and Train – Inform all staff of the updates to the requirements, how to assess residents to prevent resident-to resident altercations, and the process to follow when an altercation occurs.
  • Assess the Residents – Ensure that all residents have been assessed, regardless of cognition, for mood and behavior. Staff should know anything that may trigger an outburst, what increases the chance of an incident, and what can be done to calm a resident down. This is especially important for those residents with cognitive impairments who may not understand what is happening and for residents with a history of trauma.
  • Observe the Residents – Always be observant of residents experiencing anxiety, agitation, or aggressive behaviors. For example, when staff know of residents who become agitated with one another and may instigate a response, try to keep them separated as much as possible to prevent an altercation.
  • Complete the Care Plan and Communicate – Ensure the care plan is completed for each resident’s mental health needs and communicate needed interventions to staff to ensure safety for all.
  • Partner – Partner with residents, families, and medical professionals, including mental health professionals, to meet resident needs.
  • Review Staffing – Review staffing to ensure it is sufficient to meet resident needs for safety.

Steps to Take Once an Altercation Has Occurred

  • Ensure Resident Safety and Care – First and foremost, ensure that all residents are safe.
  • Assess – Assess the residents involved in the altercation for physical and psychosocial injuries. Provide treatment to any injuries.
  • Notify – Notify all parties, including the attending physician, medical director, family or responsible party, other facility leadership, and authorities as appropriate.
  • Investigate – A thorough investigation of every resident-to-resident altercation should occur to find the root cause and prevent recurrence. Leadership may wish to use the AAPACN Resident-to-Resident Altercation Investigation Checklist found in the AAPACN Guide to Enhanced Resident Safety to assist with the investigation.
  • Implement New Interventions – Once an altercation has occurred, it is vital to implement interventions to prevent recurrence. Once the root cause or causes of the incident have been identified, implement appropriate preventative interventions to eliminate the root causes.
  • Review the Incident – Learn from every altercation. Review what went well and what didn’t. Identify changes that would improve the situation.
  • Perform Surveillance – Consider all resident-to resident altercations broadly and be alert for any patterns or trends.
  • Involve QAPI – Refer all resident-to-resident altercations to the QAA/QAPI Committee for follow-up.

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