Long-Term Care Survey Alert

Otherwise, staff are more likely to accidentally injure residents in breaking up the melee, which sets your facility up for abuse allegations.

If your staff don't have a clear protocol for intervening in resident-to-resident aggression, the facility is leaving itself wide open to a double knockout punch from regulators and civil litigators.
 
Without a plan and regular rehearsals, staff may not intervene quickly and effectively when residents get involved in a physical altercation. In addition, staff won't know how to separate embattled frail residents in the gentlest and safest way possible. In the latter case, the facility can find itself hit with abuse allegations if a resident sustains bruising or a fracture in the process.

"Aggression is risky even if you do everything the safest way possible in intervening" in resident altercations, opines Michael Partie, founder and director of Therapeutic Options Inc. in Newark, DE, which helps health care and other settings reduce violence and use of restraints and seclusion. "It's very easy for people to get injured, especially frail elderly people with osteopenic issues (frail bones)," he adds.

That's where protocols and practice come in handy so that staff can intervene confidently and calmly, a tack that can actually help the resident(s) involved in an altercation feel more secure and calm down. Without that education and preparation, staff will respond more randomly and can actually work against each other in trying to intervene, Partie warns. (For directions on what to do, see the box at the bottom left of this page.) Untrained staff also tend to intervene later in a brewing altercation, which can allow the situation to escalate to physical violence.

Know the Drill

Do regular mock drills using the facility's policy and procedures for managing physical altercations, just as you do CPR and fire drills, Partie suggests. During the practice runs, teach staff to control their reflexes and facial expressions in the face of a yelling resident or one who is rushing toward them, advises David Lennox, PhD, a psychologist and behavioral management expert in Hollister, MA. 

When approaching a resident with dementia who may be aggressively acting out in an impulsive way,  try to reorient and calm the person. "Call the person's name as you approach, saying: 'Look at me, Mr. Smith,'" Partie advises. "That approach gets the resident focused on you rather than the other resident or stimulus for aggression," he says.

Try this: Lennox advises engaging the resident in an activity that's incompatible with aggression, such as using a soft voice or whispering. "Whispering to the resident not only gets his attention but whispering tends to cause others to whisper back," a behavior that is hardly in keeping with yelling or talking in a loud, angry voice.

Play Referee

"While you are approaching and distracting the resident, listen to the issue at hand," suggests Lennox. "You may be able to immediately resolve it -- for example, if the residents are arguing about food or possessions, which is common [among dementia residents], you may be able to say: 'Here, I can get you the same thing' or 'Let's go look for your bathrobe.'"

If residents' arguments start sounding like a broken record, the facility may need to fix a systemic issue that's creating the conflict. For example, is the laundry department losing residents' belongings, which may fuel dementia residents' paranoia that another resident is stealing their things? Is an unsupervised resident rummaging through other people's belongings? Are the lines at the food buffet too slow so that residents become irritable with each other?

Tune in to the first signs of verbal aggression and intervene promptly. That strategy may have prevented a brawl from breaking out in a Winterhaven, FL retirement facility recently when a resident responded to name-calling by punching a resident in the face -- and biting another resident who tried to break up the fight, according to media reports. Other residents also got hurt when they tried to intervene.

"Do an [aggression] trigger analysis for residents prone to reacting aggressively," suggests Partie. "Then design and implement appropriate support and preventive practices. Make sure everyone on staff knows and implements the approaches."

Go to the pros: Consult with best-practices psychiatric facilities for  aggression management strategies, suggests Stephen Trosty, JD, MHA, a risk management expert in East Lansing, MI.