STATISTICAL DATA

As numerous reports have shown, healthcare workers are exposed to workplace violence daily. From 2002 to 2013, incidents of serious workplace violence were four times more common in health care settings than in private industry, according to the Occupational Safety and Health Administration (OSHA).[5] While many studies on workplace violence events have focused only on acute care hospitals, especially the emergency department, violence in skilled nursing facilities is a recognized hazard. In 2015 nursing and residential care facilities were among the industries with the highest prevalence of nonfatal occupational violence, with a rate of 6.8 per 100 full time workers, according to the U.S. Bureau of Labor Statistics.[6]

Due to the numbers employed in both assisted care facilities and nursing homes, the nursing assistant was a frequent target of violence and aggressive behavior by patients. Nursing assistants are at high risk of injury from violent assault at work, and their risk exceeds that of other health care workers.[7] One study revealed that nursing assistants employed at nursing homes with special units for Alzheimer patients had a significantly elevated risk for assault injuries and human bites after adjustment for other individual factors. 35% of nursing assistants reported physical injuries resulting from aggression by residents and 12% reported experiencing a human bite within the previous 12 months while working at their current facility.[8] Other studies have realized the frequency of which staff in skilled nursing facilities suffer acts of workplace violence.

A cross-sectional mailed survey of unionized nursing home assistants from 49 nursing homes in West Virginia, Ohio, and Kentucky (n=539, response rate 60.2%) found that 58.2% experience assaults with consequences such as major soreness, cuts, bleeds, or bruises lasting overnight in the past twelve months and 66.2% report physical contact resulting in minor soreness, superficial abrasions, scratches and small bruises daily. Examining assaults against caregivers in long term care and geriatric care reveals a high prevalence of daily physical assaults such as spitting, hair pulling, scratching, and slapping.[9]

Threats to Staff

(A) Internal Threats – There are several types of internal threats that long term care workers should be aware of including the following:

  1. Assaults on Staff – While much legislation and oversight address resident abuse by staff, one of the most common workplace violence occurrences in a skilled nursing setting is assaults on staff by residents. Verbally, physically, and sexually aggressive behaviors of nursing home residents directed at staff, however, have received far less public attention. Resident-to-staff aggression may be very common, as nursing home staff, particularly certified nurse assistants (CNAs), are frequently in close contact with residents to provide care, and many nursing home residents behave aggressively. The threat posed by a potentially aggressive resident is a significant occupational stressor for health-care providers.[10]
  2. Resident on Resident Violence – Violence or mistreatment between nursing home residents is a common occurrence. In a 2014 study of 10 skilled nursing facilities, Cornell University researchers Dr. Karl Pillemer and Dr. Mark Lachs determined that resident-to-resident elder mistreatment affected 19.8 percent of residents over a four-week period. Specific types of mistreatment included verbal incidents, such as cursing, screaming or yelling at another person (16 percent); physical incidents, such as hitting, kicking or biting (5.7 percent); and sexual incidents, such as exposing one’s genitals, touching other residents, or attempting to gain sexual favors (1.3 percent).[11] Researchers also concluded that people who typically engage in resident-on-resident abuse are somewhat cognitively disabled but physically capable of moving around the facility. Often, their underlying dementia or mood disorder can manifest as verbally or physically aggressive behavior.[12]
  3. Elopement/Missing Resident- Facility administrators as well as security personnel realize the potential catastrophic fallout that can result from a cognitively impaired resident who elopes from a secured unit or the facility. An elopement related claim has the second-highest average total amount paid, $388,048 per claim, of all assisted living claims types, according to CNA’s Aging Services 2016 Claims Report. Assisted living communities remain the senior living / long-term care setting with the highest number of elopement claims — 54.3% of the 46 closed claims in the report, compared with 45.7% for skilled nursing — and the highest average total paid for the type of claim. Across all settings, payments on elopement claims averaged $325,561, and in skilled nursing, they averaged $251,172.[13]

(B) External Threats – External threats typically originate from an outside source such as family, visitors, vendors or trespassers.

  1. Assault on Staff/Residents – Assaults on staff or residents by external sources frequently presents as a domestic disturbance or a family member unsatisfied with the treatment of their loved one. In assisted living facilities and nursing homes family visitors are welcomed as part of the resident’s autonomy and daily life, however domestic issues between the resident and family members can result in an assault or other violence occurring against the resident. Family members often become emotionally charged when interacting with staff, especially when there is any type of perceived mistreatment or lack of treatment toward the resident and this may result in an assault on staff. While many sexual assaults of residents have come from staff members, the cognitively impaired resident can also be at risk for these this type of crime from visitors as well.[14]
  2. Theft/Exploitation – While many residents enjoy the freedom to have family and acquaintances, and others visit and interact with them, unfortunately on occasions this may leave them vulnerable to acts of theft or exploitation. Residents who live in their own apartment may have jewelry, cash, and other valuables that make an attractive target to thieves. With many elderly residents safeguarding their personal belongings is not something that is routinely thought of. Another external threat is that of elder financial exploitation. Family, friends, neighbors, caregivers, fiduciaries, business people, and others may try to take advantage of an older person. They may take money without permission, fail to repay money they owe, charge too much for services, or just not do what they were paid to do.[15] While everyone, regardless of age, is a potential victim of theft and other financial crimes, older Americans are at greater risk than the general population. Cognitive impairment diminishes the ability of older adults to make financial decisions and to detect frauds and scams. Common scams targeting the elderly include relative in need, charity appeals, lottery or sweepstakes, home improvement, free trips or identity theft.[16]
  3. Armed Intruder- The armed intruder or active shooter is an external threat that has occurred in assisted living and skilled nursing facilities in multiple geographic locations. Of concern in this type of incident is the limitations of the traditional response of Run, Hide, Fight, when considering the resident population of skilled nursing and assisted living facilities. Aside from the ethical issues of many nurses and other healthcare providers not wanting to leave their patients or residents, the residents themselves will be vulnerable due to conditions such as mobility issues and cognitive functioning. Numerous types of violence should be considered from a security perspective when examining the threat of an armed intruder or active shooter such as; violence directed toward a group or person (administrators, medical staff), domestic violence, and mercy killings. This type of violence may begin at another location and end on the campus or inside the facility.[17]

[5] Durkin, M. (2017, December). Hospitals Fight Back Against Violence. ACP Hospitalist, (), . Retrieved from http://www.acphospitalist.org/archives/2017/12/hospitals-fight-back-against-violence.htm

[6] Durkin, M. (2017, December). Hospitals Fight Back Against Violence. ACP Hospitalist, (), . Retrieved from http://www.acphospitalist.org/archives/2017/12/hospitals-fight-back-against-violence.htm

[7] Tak, S., Sweeney, M., Alterman, T, Baron, S, & Calvert, G. (2010, October). Workplace Assaults on Nursing Assistants in US Nursing. American Journal of Public Health, 100 (10):1938. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936998/

[8] Tak, S., Sweeney, M., Alterman, T, Baron, S, & Calvert, G. (2010, October). Workplace Assaults on Nursing Assistants in US Nursing. American Journal of Public Health, 100 (10):1938. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2936998/

[9] McPhaul, K., & Lipscomb, J. (2004, September). Workplace Violence in Health Care: Recognized but not Regulated. The Online Journal of Issues in Nursing, 9(3), . Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No3Sept04/ViolenceinHealthCare

[10] Lachs, M., Rosen, T., Teresi, J.; Eimicke, J, Ramirez, M, Silver, S, & Pillemer K. (2013, May). Verbal and Physical Aggression Directed at Nursing Home Staff by Residents. Journal of General Internal Medicine, 28(5), . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3631060/

[11] Study Highlights Prevalence of Mistreatment Between Nursing Home Residents (2014). Retrieved from https://news.weill.cornell.edu/news/2014/11/study-highlights-prevalence-of-mistreatment-between-nursing-home-residents-pillemer-lachs

[12] Study Highlights Prevalence of Mistreatment Between Nursing Home Residents (2014). Retrieved from https://news.weill.cornell.edu/news/2014/11/study-highlights-prevalence-of-mistreatment-between-nursing-home-residents-pillemer-lachs

[13] Bowers, L. (2016). Elopement in assisted living: Not common, but costly. Retrieved from https://www.mcknightsseniorliving.com/home/news/elopement-in-assisted-living-not-common-but-costly/

[14] Tan, T. (2018). Rapid City man found guilty of raping nursing home resident. Retrieved from https://rapidcityjournal.com/news/local/crime-and-courts/rapid-city-man-found-guilty-of-raping-nursing-home-resident/article_b2c3ca75-50a2-5904-a39f-a4c1a7b25700.html

[15] Protecting Residents from Financial Exploitation, A manual for assisted living and nursing facilities. (2014, May). Consumer Protection Financial Bureau, (), . Retrieved from https://files.consumerfinance.gov/f/201406_cfpb_guide_protecting-residents-from-financial-exploitation.pdf

[16] Protecting Residents from Financial Exploitation, A manual for assisted living and nursing facilities. (2014, May). Consumer Protection Financial Bureau, (), . Retrieved from https://files.consumerfinance.gov/f/201406_cfpb_guide_protecting-residents-from-financial-exploitation.pdf

[17] Helsel, P., & Muse, D. (2018, May). Man kills 4 relatives, self in shootings at home and nursing facility in Texas. NBC News, (), . Retrieved from https://www.nbcnews.com/news/us-news/police-5-killed-pair-connected-texas-shootings-n895486