Infection Control Today - 01/2003: Clinical Update

January 1, 2003

Resident-to-Resident Abuse and Facility-Acquired Infections:
Are They Related?

By Brenda Breivogel, RN, BS, MHSA

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.

The Study

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.

The Results

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

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

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.