Resident-to-Resident Abuse and Facility-Acquired Infections: Are They Related?
By Brenda Breivogel, RN, BS, MHSA
Among many hazards in nursing homes, one of the most difficult to prevent is abuse -- it requires a change in human behavior. Prevention of resident-to-resident abuse is even more difficult to prevent due to the age, past experiences, mental/physical health of the residents; design of the facilities and the impact of chronic illness and infections on the residents' behavior. Caregivers must be aware of the risk factors that lead to abuse to be proactive in the reduction of abuse. Residents in long-term care are coping with a number of stressors and losses. Internal factors may be hunger, fatigue, untreated or under-treated pain, sleep disturbances, depression or unidentified medical problems. Loneliness and fear may also be factors that place a resident at risk. These factors are often compounded by the individual's inability to verbalize problems, making the situation even more challenging. Factors external to the resident that contribute or trigger agitation and aggressive behavior may be noise or sensory overload. In addition, the residents must deal with the daily routine of institutional life. This article will focus only on the relationship between infections and the incidence of resident-to-resident abuse.
For the last year it was thought that there might be a significant relationship between episodes of resident-to-resident abuse and the presence of infections, particularly urinary tract infections. In this long-term care environment the infection control practitioner (ICP) often has many other administrative responsibilities, including investigating and reporting all cases of abuse to the state department of health. Attendance at numerous educational seminars, reading and review of resident medical record increased the level of interest regarding the relationship of infection and resident-to-resident abuse. Initially a quick overview of the last six months' resident abuse log and infection logs was made. There seemed to be a trend identified, so a 12-month retrospective review was initiated. Utilizing the logs a medical record review was performed. Data were collected to compare the resident age, length of stay, unit location, type of abuse and the presence of infection.
The presence of infection among facility residents directly contributes to the residents' irritability and increases the risk of abuse. Incidence rates for facility-acquired infections in long-term care range from 2.6 to 9.5 per 1,000 resident days. Infection rates vary due to the type of facility, the nature of the resident population, the definition of infections used and the type of analysis done. The reasons for infections in long-term care are the age of the resident, multiple co-morbidities, invasive devices and impaired function status. Signs and symptoms of infection in this population are frequently atypical and subtler when compared to other populations. This segment of the elderly population is more susceptible to infection due to underlying diseases, medications that alter resistance to the infection, impaired mental status, incontinence, invasive devices and the rapid transfer of residents from acute-care hospitals to long-term facilities.
In this environment the most common type of infection is urinary tract infections (UTIs). The incidence rate for UTIs in long-term care varies slightly from one study to another but typically ranges from 1 to 2.1 per 1,000 resident days. As much as 1 to 8 percent of residents with this type of infection require transfer to the hospital and are the source of 50 percent of the bacteremias. The residents of long-term care facilities are at risk for UTIs due to genitourinary abnormalities, hydration, lack of estrogen for women, changes in prostate function in men and general functional impairment. Some studies suggest that infection result from a breakdown in local defense mechanisms in the bladder, which allows bacteria to invade the bladder mucosa. As with other infections seen in the long-term care population the symptoms of UTIs tend to be somewhat different than those reported in acute care. In many cases the first sign of a UTI is a change in behavior, confusion or a change in functional status or delirium. Other symptoms which the resident may or may not experience are: nausea, vomiting, loss of appetite, bladder spasms, dysuria, frequency, urgency, urinary incontinence, itching, feeling of warmth during urination, low back pain, chills, flank pain, low grade fever and males may have drainage.
The most common organisms isolated from residents with UTIs are: E. coli (50 to 60 percent), gram-negative pathogens (30 to 40 percent), or gram-positive bacilli (10 percent). Often the residents cannot clearly express what symptoms are present; because of this it takes a careful assessment by the caregiver to notice these subtle changes. Yet the only recognized symptom of a UTI may be the abuse of another resident or staff member.
Age related-changes in the respiratory tract increase the risk of infection -- micro aspiration, colonization of the tracheo-bronchial tree, increased chest diameter and rigidity, muscle weakness, weakened cough, decreased saliva production, altered mucus secretion and ciliary action, collapse of lower airways and decline in alveolar macrophages. The key sign of respiratory infection (especially pneumonia) seen in this population is an increased respiratory rate. Eighty percent of all recognized pneumonia comes on suddenly. The incidence rate ranges from 0.4 to 4.4 per 1,000 resident days.
Changes in the gastrointestinal system of elderly residents, which make this population more susceptible to infection are: decreased saliva production, slowed esophageal emptying, reduced gastric acid and changes or decreased intestinal flora. Incident rates for gastrointestinal infections range from 0 to 0.9 per 1,000 resident days. Viral gastrointestinal infections are usually mild, self-limiting and abrupt in onset. While bacterial gastrointestinal infections are identified by having blood in the stool and have a gradual onset. Most of these infections are usually associated with food.
In long-term care, skin and soft tissue infections are most often associated with pressure ulcers. Rates seen in long-term care range from 0.1 to 1 per 1,000 resident days. Factors related to the age of the residents increase the possibility of infection. These are: thinning of the skin and support tissue, loss of elasticity and strength, decreased production of sweat and sebaceous glands, lower oxygen levels and peripheral neuropathy.
Often abuse between residents occurs because of cognitive impairment, shared living arrangements, poor health, functional impairment, internal factors causing increased stress, social isolation and the history of abuse by others. Often residents who abuse other residents are found to have a history of abusing others or being abused, insult staff or residents, show demanding or critical behaviors, do not want or accept help, undo caregiver's assistance, "get into things," or are agitated, confused or resists care. Interactions among residents maybe considered abusive if the intent of the exchange is to embarrass, intimidate or threaten another person. Several characteristics may place a resident at risk to be abused by other residents:
- Behavioral problems (manipulative, repetitive, aggressive, abusive)
- Communication deficits
- Physical impairments
- Cognitive/social impairment.
These may be associated with functional complaints such as sleep disturbances, reduced appetite and impaired concentration or memory. Medical illnesses have secondary effects on the resident that take the form of reactive behaviors, attitude and mood. Emotional and personality changes, disorientation, disorganized thoughts, attention disturbances, sensory changes, altered level of consciousness, loss of memory and changes in functional status impact the resident's behavior. The environment also affects the resident's behavior when the following exist: complexity, input excess, monotony, irritability, dependency, triggers and background irritants.
The definitions utilized to determine whether an infection was present for the study the definitions found in the APIC Text of Infection Control and Epidemiology. While performing the study the definitions of abuse used are included in federal regulations (F tag 223). This is the federal regulation that states, "The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion." The guidelines to surveyors include the following definitions:
- Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend or disability.
- Sexual abuse includes, but is not limited to sexual harassment, sexual coercion or sexual assault.
- Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment.
- Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation.
- Involuntary seclusion is defined as a separation of a resident from other residents or his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative.
This regulation requires facilities to investigate, develop a plan for prevention of further episodes of abuse and report the event to the department of health. Thus it is important to identify residents at risk of exhibiting problem behaviors, protect potential victims of abuse and define the causes of the behavior so a plan of care can be developed.
This study included all the residents that initiated the abuse with another resident. During the 12-month study period, there were 46 cases of resident-to-resident abuse reported to the state department of health. The data utilized is from a 209-bed, for-profit nursing home located in the Midwest. Excluded from the study were the cases of resident-to-staff abuse and staff-to-resident abuse.
There were 46 cases of abuse during the 12-month study period. Twenty-four cases involved verbal abuse (52.2 percent); 17 cases of physical abuse (37 percent); four cases of combined verbal and physical abuse (8.7 percent); and, one case of mental abuse (2.2 percent). The average age of the abuser was 84.6 years and the average length of stay in the facility was 2.4 years. The range on the length of stay was from one week to nine years. Twelve residents represented 30 cases (or 65.2 percent of the cases). Twenty-nine (63 percent) of the residents initiating the abuse had an infection at the time of the event. Infections associated with the reported cases of abuse include: 20 UTIs (69.4 percent), four URIs (13.8 percent) and five other infections (17.2 percent). More specifically, the other infections included one of each of the following: oral, pelvic, vaginal, skin and ear.
Twenty-one (45.7 percent) of the cases came from Unit 3, a Medicaid certified unit that has several resident with a length of stay greater than five years. The locked unit for residents with Alzheimer's and other related conditions (Unit 1) had the second highest number of cases reported at 15 (or 332.6 percent). Unit 4 came in third with six cases (or 13 percent). Fourth was the skilled unit, Unit 2, with four cases (or 8.7 percent). The units were then ranked on the higher rate per 1,000 resident days: Unit 1 (1.47, Unit 3 (0.99), Unit 4 (0.39) and Unit 2 (0.2).
This study does not examine other possible contributing factors such as excess disability, coexisting illnesses, cognitive deficits or the environment. No resident demographics other than the resident room assignment were utilized (not the location where the abuse occurred). The season when the abuse was reported was not considered by this study. It would be interesting to explore whether the resident was being treated for depression and whether the resident had experienced a decline in activities of daily living or range of motion within the last 90 days. In addition, the recent hospitalization of the resident (in the past 30 days) might be explored as a contributing factor.
A future study should be done to examine the coexisting factors to determine if there is a combination of factors that together are predictors of resident-to-resident abuse. There is a significant association between infections and resident-to-resident abuse, however, just because the resident has an infection the resident may not become abusive to another resident. The presence of an infection in a resident with a history of abusing others should trigger additional precautions to prevent the resident for abusing other residents. Infection prevention strategies impact resident-to-resident abuse by eliminating one of the possible contributing factors. Caregivers should be sensitive to the subtlest changes in the residents' behavior (especially residents that have a history of abusing others). The earlier an infection is identified and properly treated the lower the risk of resident-to-resident abuse occurring.
To prevent episodes of resident-to-resident abuse it is important to understand the cause. Prevention strategies can then be developed to focus on the cause of the behavior. Differentiation of the possible causes maybe done by exploring the social, medical, mental and emotional history; performing a physical exam; reviewing the resident's medication history; identifying behavioral trends and triggers; and identifying activity preferences and dislikes.
Brenda Breivogel, RN, BSN, MHSA, has been a member of the Association for Professionals in Infection Control and Epidemiology (APIC) for more than 20 years and has worked in acute care, critical care, long-term acute care and long-term care. She currently serves as regional co-director for the APIC-IN region 9.