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Provider Self-Assessment and Mitigation Tools for Resident to Resident Occurrences

It is critical for nursing centers and assisted living communities to address and mitigate resident-to-resident occurrences or potential incidents of resident-to-resident mistreatment. While mistreatment may or may not meet the definition of abuse, it would include negative and aggressive physical, sexual, or verbal interactions between long-term care residents that is unwelcome and have high potential to cause physical or psychological distress in the recipient.


  1. Conduct a thorough investigation with proper documentation, follow up, and monitoring and care planning as needed.  
  2. Create a structured self-assessment process to address the resident-to-resident occurrence and minimize or mitigate similar events for all residents. This includes a need to:
    • Document immediate interventions;
    • Conduct a root cause analysis process to identify the specific/source, root cause or causal factor of the problem; and 
    • Identify future actions to ensure sustained efforts to identify and prevent potential resident-to-resident mistreatment.
  3. Identify existing AHCA/NCAL resources to support providers in addressing resident-to-resident mistreatment. 

Note: These tools were developed by members of AHCA/NCAL’s Survey/Regulatory Committee to assist centers and communities in addressing adverse events and potential adverse events, documenting and tracking the steps they have taken, and identifying best practices for ongoing improvement. Use of these tools does not guarantee regulatory compliance nor mitigate potential liability. Providers should adapt their tools, policies, and processes as needed to ensure compliance with current federal and state requirements and use both professional judgement and the advice of legal counsel in determining whether or how to share these mitigation tools.


AHCA-NCAL Resources for Resident to Resident Mistreatment
Open to download resource.
Open to download resource.
Resident_to_Resident Mistreatment Post-incident Checklist
Open to download resource.
Open to download resource.
Resident_to_Resident Mistreatment Provider Self-assessment
Open to download resource.
Open to download resource.