Long-Term Care Survey Alert

Tips help you defuse altercations and soothe residents at odds with each other.

You hear an argument between two residents brewing and a scuffle ensues. Staff members rushing to the scene respond in a haphazard fashion, which fuels the confusion. If that scenario sounds at all familiar, your facility may want to adopt some best practice strategies for preempting and managing resident-to-resident altercations.

Hebrew Home at Riverdale (New York, N.Y.) has developed a training video portraying three common resident conflicts, which highlight themes and positive approaches that facilities can apply to similar situations, according to Dan Reingold, JD, MSW, CEO of the facility. He and co-presenter Robin Dessel debuted the video at the November 2009 American Association of Homes & Services for the Aging annual meeting. (The video includes a less effective and preferred approach for each scenario. The following information just relays the preferred approach.)

A resident insists on sitting in a seat in the dining room that another resident says he's holding for his friend, Ruth. The residents engage in an escalating argument. Finally the resident who refuses to move from the saved seat pushes the other one, who falls as a result.

Priorities: The staff person responding to the situation makes sure the resident who fell receives assessment and monitoring for potential injuries, including a head injury. And rather than just dismissing the incident, the staff who observed the altercation should report the incident to the clinical staff, says Reingold. That way you can care plan and document "on behalf of both gentlemen to help avert future incidents."

Key: Neither resident in the altercation was "the formal 'aggressor,'" as both men "were posturing and contributing to the escalation," Reingold tells Long-Term Care Survey Alert. In fact, Reingold encourages providers to revisit the victim-aggressor mindset.

"If you start with the premise that the lines between victim and victimizer can change [in an altercation], you can better help protect residents," emphasizes Reingold.

For example, "Mrs. Smith's aggression could get her in a heap of trouble if she directs it toward the wrong resident." Also, "the victim and victimizer can switch back and forth," he points out. "Anger can ignite anger." Looking more closely at a situation, sometimes you may see "relational aggression," where a group is saying to someone, "No, you can't sit with us or join us," adds behavioral expert Michael Partie, director of Therapeutic Options in Newark, Del. Then the resident who gets angry at the group looks like the lone aggressor.

Also: The aggressor's behavior may be driven by his dementia, illness, or circumstances, noted Dessel, director of memory care services at the Hebrew Home at Riverdale in New York, in the AAHSA presentation.

Vignette No. 2: 'I'm Controlling the Remote'

A resident enters an activity room where people are watching a TV program. He abruptly changes the channel without their permission, refusing to change it back despite escalating protests from the group. All the while, the man exchanges angry words with the other residents in the room. The facility has a Bingo game scheduled in that room in a few minutes.

Staff response: A social worker comes in and talks to the man who changed the channel. Rather than just dismissing the conflict by noting that the Bingo game is coming up, she calmly acknowledges the man's desire to watch a different program and talks him into going with her to find another TV in a quieter place in the facility.

Key: The social worker acknowledged and addressed the man's needs in a respectful way, preempting further  escalation, says Reingold. And "the social worker addressed the welfare of both the gentleman precipitating the incident, and other residents involved." Tips: If a resident appears to be reacting in anger to feeling left out of a group, "see if you can help him enter another group or have staff sit by him during meals," advises Partie.

Also, setting up policies about who gets to watch preferred TV shows and control the remote, etc., and when can help prevent conflict, if staff and residents are familiar with the rules, Partie adds. "The more routines you have worked out that residents and staff are used to, the easier things go."

A resident with dementia named "Betty" enters another female resident's room and begins rummaging through the person's belongings. With growing frustration, the woman repeatedly asks Betty o leave.

A staff person comes in and talks to the upset resident who asks if she can put a lock on the door to keep Betty out. The staff person redirects Betty back to her room by suggesting they go look at some pictures together. But the caregiver first talks with the resident upset by the intrusion and promises to come back and talk to her about some ways to protect her privacy.

Key: The staff person didn't ignore the resident's distress over having Betty invade her privacy and offers to come up with some ways to help, the video points out.

Options: Door locks weren't an option in the facility. But to keep a resident out of a particular resident's room, you can try some "low-tech interventions," Reingold says.

Examples include "putting a cloth stop sign at a door to prevent a resident from entering it. It's a universal icon and seems to do the job" in many cases. Or try putting a mirror on the door, he suggests. "When the person trying to enter the room sees their reflection, it sometimes stops them."

Facilities should come up with standardized ways to address various situations involving resident conflict, Reingold advises. That's important to do, because you don't want a staff person's "individual perceptions, judgments and behaviors to determine the course of an intervention. Ultimately the most important feature to the interventions is to protect everyone's safety -- residents, staff, and bystanders."

Tip: Consider training staff to identify and intervene in scenarios where an interaction between residents initially shows signs of turning sour -- for example, when you hear that first "he's in my seat," suggested the AAHSA presenters.