Why do harmful resident-to-resident incidents in nursing homes occur?

Episode 106
Categories: Neglect & Abuse

Why do harmful resident-to-resident incidents in nursing homes occur?

Hundreds of encounters between nursing home residents resulting in injury occur each year. What are the causes of these incidents and what are some of the interventions that nursing homes can take to reduce their occurance? In today’s episode, nursing home lawyers Rob Schenk and Will Smith discuss resident-to-resident incidents with Dr. Eilon Caspi, a Gerontologist and Dementia Behavior Specialist who recently authored a study on this phenomena.

Schenk: Hello out there and welcome back. My name is Rob Schenk.

Smith: And I’m Will Smith.

Schenk: And today we’re going to be talking about a very important topic, and that is incidents, physical incidents that occur between nursing home residents that result in injury and death.

Smith: We are purposely choosing our words carefully because our guest today, Dr. Eilon Caspi, is a researcher in the field of resident-on-resident instances. He’s very particular about, and rightfully so, very particular about the terms that we use. So that’s why we’re not saying resident-on-resident fight

Schenk: Violence.

Smith: Or violence.

Schenk: Or aggressor.

Smith: …because these, as he will explain, these have certain elements to them that are prejudicial and biased.

Resident-to-Resident Incident Study

Schenk: Certain connotations. So we, as I’ll mention later, I saw him first at the National Consumer Voice give a presentation on a study and it actually educated me on the nomenclature and the vocabulary to use, and I loved it and I was like, “We have to have him on the show,” so we’re really glad we’re getting him out here. But Dr. Caspi has conducted a study and he’ll talk about it a little bit more, he’ll elaborate on it when we get him on, but he has done a study of I think over 150 incidents between nursing home residents that resulted in injury or death, and he’s compiled all this data and he’s come to some very interesting conclusions and has some findings that are very interesting. So if you have a loved one that’s in a nursing home, this is a good episode for you to listen to. So Will, what can you tell us about Dr. Caspi?

Resident-to-Resident Incident Study Conducted by Dr. Caspi

Smith: Well Dr. Eilon Caspi is a gerontologist and dementia behavior specialist. He started working in the aging field in ’94 as a nurse aide in a nursing home where his grandfather lived. Both of his grandmothers had dementia. He later worked as a social worker with elders with low income in the Department of Social Services for elders in the Tel Aviv municipality and then in a long-term care home for elders with dementia in the city of Joppa.

His work applied research, volunteering and advocacy focusing on enhancing the quality of care, quality of life and the safety of people living with dementia as well as supporting and educating their families and professional care partners. Over the past decades, he focused in various ways on improving the standards and the prevention of distressing and harmful resident-to-resident incidents in dementia in long-term care homes.

His passion is in bridging academia and research with practicality, and we are very honored to have Dr. Caspi on the phone today. Dr. Caspi, welcome.

Eilon: I’m glad to be here.

Schenk: All right. Well Dr. Caspi, we’re really happy that you’ve come on the show. I saw you do a presentation at the Consumer Voice conference last year in 2018 regarding incidents between nursing home residents, and one of the very first things that I thought was poignant was that you made sure that the words that you used and the words that you’d like other people to use are accurate and basically not discriminatory and not prejudicial to the individuals. And so I would really, before you go into the study and the reason you’re talking, I’d really like you to comment about why you dislike the use of the word “violence” or “aggressor” when it comes to distressful events between residents in a nursing home.

What is the correct vocabulary to describe harmful resident-to-resident incidents?

Eilon: Sure. So I think for too long, for decades, care staff members, researchers, we’ve been using language that describes individuals living with dementia and their various behavioral expressions in ways that reflect misconception and ways that are stigmatizing, laboring, misleading and frankly harmful to these individuals. I think that it’s easy to forget sometimes, especially in the heat of the moment that these individuals live with a serious brain disease. So what we often see, I mean there is progress in this field, but what we often still see is residents with Alzheimer’s disease are being labeled aggressive, violent, abusive, combative, etc. And when they are trying to cope to the best of their ability with their remaining abilities with situations in the social and physical environments, they can be very distressing if not frightening for them.

And one of the problems that this approach causes is that it’s a slippery slope towards – first of all, the first thing is that staff members are no longer in a position to identify the unmet human needs that often underlie or drive those behavioral expressions, number one. And number two, it’s a slippery slope for using antipsychotic medications, that now we really have a problem because now we have a much harder time to identify those unmet human needs.

Why are the terms surrounding resident-to-resident incidents important?

Smith: It’s also just not very – I like your perspective on this because as an attorney, in the legal world, especially in the criminal world, one of the elements of crimes of intent is something called mens rea, and it means you had the mental perspective to commit the crime, you were intentionally doing this. And if you have a brain disease like dementia, you don’t know why that person is acting out like they are. They don’t have the mens rea of somebody like me or you who is intentionally being violent. So this is a much more accurate perspective of it.

Eilon: Right. And that what you just described is also a barrier for reporting. We can talk about it later for underreporting. But I think that it’s important to recognize that a majority of residents with dementia don’t wake up in the morning with a premeditated intent to harm, injure or kill their fellow residents. Now that said, there are individuals with life-long personality types that maybe were violent in the past, so we also need to recognize that this exists, and dementia and/or serious mental illness could exacerbate that. You always have to remember that there is a subgroup of individuals that have these tendencies and they may accelerate, they may escalate in an environment, a congregate setting where there are so many stressors on a daily basis when you basically force them to be with other residents around you 24/7, sometimes for years.

An overview of harmful resident-to-resident incidents

Schenk: Dr. Caspi, we briefly touched on in your introduction the study you conducted, the topic of your presentation at the Consumer Voice conference. Can you tell the audience what your study was about and what were some of the key findings from your study regarding incidents between nursing home residents?

Eilon: Sure, because to my knowledge, there’s no tracking at the central administrative – there’s no centralized administrative or clinical data set that captures each event such as the MDS 3.0 or CMS State Survey Deficiency across it, so there is no [09:33] specifically for residents or incidents. So those incidents have often been captured under broader categories such as abuse, neglect and accidents, but the problem is they’re buried for forever there. They’re extremely difficult to identify those state survey investigative reports. And the same goes with the MDS 3.0 via the e-section. It is not possible to differentiate whether the so-called aggressive behavior was directed towards the staff member or towards another resident.

So given those major [10:09], I decided not to wait until those were reached, and I said, “I got to jump into the water here. Let’s see what is available and what we can learn from it, because people are being injured and they die. It’s traumatic for residents. It’s devastating for their family members. They’re often shocked to hear about those serious incidents. And what I did, I was able to locate over 160 newspaper articles with all the [10:46] inherent to newspaper articles, but also dozens of death certificate records from the province of Ontario in Canada. And I tracked and analyzed them. I’d be glad to share with you the findings.

I have to say for the most part, for people who work in nursing homes and assisted living residences with these residents, the findings won’t be surprising for the most part. But still, to my knowledge, this is the first study in the United States and Canada that looked at fatal resident-on-resident instances.

Schenk: You said fatal? You said fatal, correct?

Some of the resident-to-resident incidents were fatal

Eilon: Fatal. My studies focused on examining the circumstances surrounding the deaths of 105 residents in the context of resident-on-resident events. So they sustained injuries that contributed to their death, and I have to say that since then, I already done – this study was published earlier this summer – since then, I was able to identify at least two dozen additional fatalities in these instances. And to be honest, every other week, I’m learning about another death or injury due to these instances.

So with that, let me share with you some of the main findings in my study that I found in my review. The first thing is that the exhibitors, for lack of a better word, they’re residents whose physical contact with another resident led to an injury or subsequent death. So we’re going to use the term – it’s not great – but we’ll use the term “exhibitor” and “target,” and it’s not always easy, it’s not always straightforward to differentiate who would be the exhibitor and who’s the target. But in general, exhibitors were on average nearly a decade younger than the target residents. Both men and women were equally on the receiving end. They were the ones who were injured and subsequently died. That said, three-quarters of the exhibitors were male, were men, which is not surprising. It’s consistent with what we know on previous research with what was called aggressive behaviors in this population.

What are some statistics regarding resident-to-resident incidents in nursing homes?

Eilon: There were 23 deaths that occurred when at least one of the residents involved was a newly admitted resident, which I defined as a resident who lives in the nursing care home up until three months. So we know that this stressors thing, the adaptation to a new environment for people with dementia may contribute to these incidents.

In terms of – it’s interesting to know where those incidents occurred on the floor in the care home. Close to 60 percent – I apologize for my voice today, I don’t know what happened – close to 60 percent of the incidents occurred inside bedrooms, many of these out of sight of staffing nurse. In terms of time of day, close to 60 percent were in the evening or nighttime, 44 percent during the evening hours, and 38 percent occurred during the weekend, so we all know what should happen during the evening hours and weekends and doesn’t always happen, right, in terms of staffing level, active presence of managers, meaningful engagement, etc.

Forty-three percent of the instances occurred between roommates, so we need to pay very careful attention to roommates – we can talk about that too. And 62 percent were not witness, were reportedly not witnessed by staff, so we’re missing a substantial portion of serious resident-to-resident events. And this was also confirmed in another study using video recording in care homes with people with dementia, that 40 percent of physical resident-on-residents were not witnessed by staff.

And then I was curious to know what was the nature of this physical contact, and this was fascinating. I thought that was a fascinating finding – 44 percent were categorized as push-fall incidents. Again, you’re going back to the stigma. Are these really violent abusive situations or are these situations where a resident invades another resident’s personal space or enters their bedroom when they don’t want them to enter it and they push them away. Okay, now if you push me, I may be able to block it or fall in a way that is non-injurious, but if you’re a 90-year-old resident using a walker and you’re frail and you have dementia, oftentimes they fall and break the hip or have a brain injury and then their medical condition, their physical condition deteriorates, and they may be debilitated or they pass away.

And interestingly, a separate study in Australia published a year ago found that 60 percent of fatal resident-on-resident incidents were push-fall incidents. So all you need is one push, and that’s what staff members, one of the things staff members need to be aware of if they don’t already know that.

Close to one-third of incidents on resident-on-resident use physical objects in the physical contact with the individual. And they’re speaking non-traditionally, very creatively, using a hanger from the closet, the food tray, even the cord of a bedside lamp to strangle another resident. So we need to be extra vigilant and kind of always looking for objects that could be used to harm another individual, especially with the high-risk subgroup of residents.

Smith: I also found it interesting…

Eilon: Yeah, go ahead.

How does gender relate to harmful resident-to-resident events in nursing homes?

Smith: I’m sorry, Doctor, but I also found it interesting that three-quarters of the exhibitors are – it sounds like they’re younger males. But are men equally distributed in the long-term care setting? Or are there more women?

Eilon: Well we know that a lot of these studies vary, but 70 to 80 percent of residents in nursing homes in America are actually women, right? Now if you go to the VA care home, which they call community living centers, you will find 90, 95 or more percent of the residents are men. So very different environments.

Smith: Yeah, that’s interesting. But the targets are…

Schenk: Generally female.

Smith: …generally – well I think he said they’re equally distributed, women and men.

Schenk: Yeah.

Eilon: Right. And to be honest, we need more studies. A study in 2004, Harvard showed that actually men were substantially more in danger. So we need more research to kind of shed light on these findings, but that study, the other study was only physical injury.

Schenk: I got you. So Dr. Caspi, I know you touched on some of the findings in terms of some of the percentages in the exhibitors versus targets, who they are, that kind of thing. Can you kind of explain to the audience, and our audience generally consists of family members who have loved ones in nursing homes, what are some of the things that they can take away from these statistics, what they can take away from this data that will help prevent a distressing or harmful incident involving a loved one?

Eilon: Well so for those long-term care homes, nursing facilities that are not aware of this phenomenon, I mean not taking proactive steps to address it when it’s prevalent, I would say that family members, if they are in a position to do it, they should actually agitate staff members and administrators. So take my study, for example, and take the study on the injuries and share the main findings with the administrators, and tell them those things, for example, happen in the evening hours. What are you doing in the evening hours to strengthen your staffing levels? What are you doing in terms of training? What are you doing in the risk assessment?

So everybody needs to know the risk factors and the protective factors and we can talk about, and the common [20:18]. They need to visit regularly if they can and to pay close attention to not only their loved ones but also to social interactions that take place between residents. Talk with other family members. Maybe they see something when you’re not there. Visit during the evening hours and weekends because there’s some tendency for these incidents to occur in the evening hours. Build and maintain close relationships with care staff members. If you have that open communication with them, so when something happens, they will inform you about what happened and then you can work with the care community to understand [21:01] and come up with [21:04]. The family should be part of the care plan in the good nursing home. Remain vigilant and document what you see. Document everything that you see because that might be something useful down the road.

And I have some things I think administrators should take away. If you want, I can share that too.

Schenk: Oh absolutely.

Smith: Yeah, please do.

Schenk: Please do that.

What should nursing home administrators do about harmful resident-to-resident incidents?

Eilon: So I think the first thing that administrators who are not fully aware, they need to recognize that in the majority of situations, as I mentioned, there are unmet human needs and situational frustration and interpersonal stressors and misperceptions and people misunderstanding that lead and contribute to this resident engagement in distressing and harmful resident-to-resident incidents. With that recognition, we can start working in understanding, recognition, prevention and de-escalating on an individual resident basis.

It is much easier to prevent those incidents than to de-escalate when they become serious, right? So you need to have adequate staffing levels at all times, evening hours, weekends as well, holidays, a well-trained staff. I think the goal should be close staffing relationships between staff and residents, and when staff members know the residents’ histories, they’re in a much better position to understand their human needs and to address them properly.

They need an active presence of experienced and qualified and trained managers during the evening hours, not just a well-meaning nurse who’s doing paperwork inside a staff room, but really providing that guidance to staff members who may be struggling to assist by themselves during the evening hours and weekends.

One of the secrets to prevention is a robust and especially meaningful engagement program, or as other would call it, communicative program. When residents with dementia are personally meaningfully engaged in various activities, you will see substantial reductions of those incidents. That said, if you don’t plan activities or it’s not delivered professionally or there’s something upsetting in the environment, you will see those episodes. But by and large, that’s one of the – so invest in your recreations department, hire people who are qualified and trained and you can have a strong and meaningful engagement program – you will be able to reduce a lot of these episodes.

Open and effective communication across all team members as well as with family members, as we mentioned earlier, adequate risk assessment, systematic documentation, and usually what is called behavioral expression that they can use systematically by the staff members, they can identify the patterns, those spatial and temporal and other patterns that are the basis for preventing individual acts of prevention measures.

Become a learning organization. Avoid a blame culture. Support and train your staff well. Another critical missing piece is create admissions behavior assessments. Too often, we’re admitting people that we don’t have business to admit because it’s good for the bottom line. Now we have a resident whose needs are not met and he or she may put other residents or himself or herself at risk.

There was an incident in Toronto, I don’t know if you heard about it, it’s called the Casa Verde incident near Toronto, and the resident was admitted on an emergency admission in the weekend on a Saturday around noon. At 7 p.m., two of his roommates were severely injured and he managed to cross the hallway and start attacking another resident. Luckily there was reportedly a housekeeping staff who was able to de-escalate the situation. They did not know at that point that the two residents in the first room were already dying if not dead. So pre-admission behavioral assessment is absolutely critical. Accept people that you know to the best of your critical judgment that you are capable to meet their needs and keep themselves and others safe.

Listen to residents’ concerns and fears. Never dismiss what a resident with dementia tells you. Take it seriously because it is not uncommon for a resident to express fears about their roommate and it’s not being taken seriously, and the next thing you know, there’s an altercation and there’s injury and perhaps it’s [26:31].

You need a thoughtful roommate assignment and ongoing monitoring because even friends, a friend with their companion, a supportive roommate, may reach a breaking point because of repeated questioning or noise at night or arguments about windows or the doors or the lights or the TV or the lights in the bathroom, etc. So pay attention to roommates in those areas.

Identify and treat depression. Depression underlies a lot of those episodes. And of course, provide proactive medical assessments and treatments. We know that UTIs, which is urinary tract infection, constipation, pain, hallucinations could contribute to these episodes. And there are other things, but I’m going to stop here because you’re going to comment or have other questions.

Smith: Well I think that everything that you said, all your findings are extremely significant, of course, Doctor, but I think one of the most important things you’ve said from my perspective is that prevention is a lot easier than de-escalation. And it sounds like a lot of the advice you’re giving is pre-admissions screening, knowing these residents, having sufficient staff, prevent these situations before they happen because, you know, you might be able to de-escalate, but it’s a lot easier not having to do that.

Schenk: And my question, Dr. Caspi, is what is CMS or is any other organization taking your study under advisement to potentially change the federal regulations?

Smith: Maybe add an F-tag?

Schenk: Yeah, something like that. Are you aware?

Eilon: Right. So – what else were you saying?

Schenk: Yeah, are you aware of any type of move towards that, like changing the MDS, that kind of thing?

Eilon: So I really want to urge CMS, CDC, Division of Violence Prevention, Government Accountability Office, U.S. OIG, Office of Inspector General, to finally examine and tackle this phenomenon. I hope that soon they will. To my knowledge, there are no meaningful comprehensive plans to address this phenomenon even though leading researchers such [29:09] from Cornell University, who conducted the largest number of studies on this phenomenon with his colleague, [29:15], and [29:18] from Columbia University saying, he said, [29:22] said that we urgently need a national plan to address what he called violence in nursing homes. He’s asking why do we accept this? We don’t accept it in childcare settings. Why do we accept – why has it become the norm in nursing homes in America? So this is a vulnerable population. They have human and federal rights to a safe environment.

So far, I was not able to convince those agencies, despite numerous letters that I wrote, and I hope that it won’t take another major tragedy in a nursing home or assisted living for these agencies to take a proactive approach, because leading national experts, such as Dr. Barea project that these incidents will increase in the coming years with the retirement of the baby boomers.

So yeah, I think as a society, we need to start tracking, analyzing and learning from these incidents. David Wright, who is a very high level position at CMS, he was the head of Service Education Group – I think they now changed their name to Safety and Quality, something like that, he said, “We, CMS, do not want to become historians of bad care. We need to analyze situations and we need to be proactive and inform prevention.” And I’m afraid that while they may do it with other phenomena, they have not done it with this phenomenon to my knowledge yet, and I hope that this will change soon.

Schenk: That will be fantastic if it did. Dr. Caspi, I really appreciate you coming on this show and sharing your study. If there’s anybody out there that would like to contact you or actually find the study and read it in its entirety, how would somebody contact you and how would somebody access the study?

Eilon: Well do you have my email?

Schenk: I do. Well we have it on the screen, we have your information on the screen, but sometimes the people – most people listen to the program, so we got to hear it spelled out. I can share your…

Eilon: Sure. EilonCaspi at gmail.com. Email me and I will share with you whatever resources I have that you’re interested in within the limitation of respecting publishers’ rights.

Smith: Right.

Eilon: But I’m sure we can work something out.

Schenk: Fantastic. Well Dr. Caspi, thank you so much for coming on this show.

Smith: Absolutely.

Schenk: We really appreciate it. That was very good information.

Smith: And keep fighting the good fight.

Eilon: Thank you so much. Thank you for helping to raise awareness of this phenomenon, and if I can take 15 seconds…

Smith: Sure, absolutely.

Eilon: I would like to just give a shout-out to my colleague, Judy Berry and I are working on a short documentary film that we’re planning – it was accepted to be screened at American Society on Aging next April on this phenomenon on injurious and fatal incidents. So if any of the family members hear this show today, this podcast, are aware of their loved ones who experienced that and they are willing to share their story with us, we would be more than glad to discuss this with them. We are looking for families willing to do that as long as they’re allowed to do it. Some families are in the middle of a lawsuit or investigation and we don’t want to compromise that because the goal of the documentary film is to raise awareness to the phenomenon and put a human face on the statistics that are starting to emerge from recent studies, and hopefully drive action to address it and keep residents safe.

Smith: Absolutely, yeah, no, so if anybody out there is listening, and we’ll also pass out the information through the various means that we have, but that’s amazing. I’m looking forward to seeing that.

Eilon: I really appreciate that. Thank you so much, guys.

Schenk: Thank you so much, Doctor.

Smith: Thanks, Doctor.

Schenk: Talk to you later.

Eilon: Take care. Bye-bye.

Schenk: Bye-bye. Yeah, and I can’t stress enough the, I don’t know, humbling experience, but it’s when you’re educated on something that you’ve been doing inappropriately for a long time, and we, and even in past podcasts, we’ve described people as aggressors. We’ve described incidents as violent. And as you mentioned earlier, that’s almost like that’s placing onto the resident the mens rea, they intended the result of the conduct, and that’s not accurate. So we need to change the way we say these things.

Smith: Yeah, because it’s a fuller picture of what’s going on. Mr. Johnson may take his fist and hit his roommate in the face. If it violent? Is it an act of violence?

Schenk: Yeah, is it fair to say that it’s violent?

Smith: We don’t know what’s going through Mr. Johnson’s head, if he has a disease like dementia. We don’t know what he sees. We can’t see through his eyes. He might be reliving something that happened to him years ago. He might think he’s trying to help out. The actus reus, the act itself, looks like a fight, but the reality is if you’re trying to figure out what’s going on here, you have to take into account that this person may not be intending to cause violence.

Schenk: We’re using a lot of Latin today.

Smith: Yeah we are.

Schenk: Mens rea, actus reus.

Smith: Mens rea, actus reus.

Schenk: Yeah.

Smith: Well those are two elements in criminal cases where you have the premeditated criminal mindset and then you actually commit the crime.

Schenk: You know who else used a lot of Latin?

Smith: Doctor Spock or Captain Picard. Did I get it?

Schenk: Wow. That’s pretty impressive, but that’s a miss. You missed the landing.

Smith: Okay.

Schenk: The individual I was thinking of was President Abraham Lincoln.

Smith: Oh, okay.

Schenk: Because as this podcast episode goes to air…

Smith: Ah, yes. Yes.

Schenk: It is in fact President’s Day, and I believe that President’s Day started off as Abraham Lincoln’s birthday. Am I wrong about that? I’m probably wrong. Gene?

Smith: We’ll have to check that with Gene.

Schenk: Gene doesn’t care to spend his time researching this for us.

Smith: So it was originally maybe Abraham Lincoln’s birthday.

Schenk: And then combine it with George Washington’s to do President’s Day.

Smith: Okay, I don’t know. No idea. It’s not something I’ve ever celebrated knowingly.

Schenk: That’s interesting because think about it like this. In terms of the national holidays, what are we as a nation saying? We’re celebrating the people that have been killed in war for us – that’s fine. We’re celebrating the people that have just fought, which is Veterans Day. And now we’re saying, “Okay, we’re going to honor the Presidents?” I don’t know.

Smith: Yeah.

Schenk: And then there’s the People’s Day – that’s Labor Day. Yeah, that’s a national holiday. Banks are closed on Labor Day. So I guess it’s fair. It’s like there’s the bosses’ day. And I can’t get behind Bosses’ Day. Every day is Bosses’ Day.

Smith: Right.

Schenk: You know what I mean? Like every day is President’s Day. Like that guy’s doing what he wants. Why do we got to celebrate it?

Smith: Well I don’t – yeah, I feel like it maybe should be Founding Father’s Day, like we look back historically at the men who…

Schenk: See, I disagree with that. I think if we’re going to do that, it needs to be to make Constitution Day a federal holiday.

Smith: Well first of all, I don’t think you should ever, ever celebrate any human being ever, because humans, regardless of their accomplishments, are always terrible people

Schenk: Wow.

Smith: So I don’t believe you should have statues of humans. I don’t think you should have…

Schenk: Captain Picard wasn’t an evil human being. Only during the times in which he was injected with Borg – I don’t know what you would call that.

Smith: Borg technology?

Schenk: Yeah, Borg technology. And he was Levias? I can’t remember. He had a Borg name, even though his name should have just been a number. I can’t remember the explanation why he had an actual name because they don’t have names. They’re like Seven of Nine, Six of Ten, Pi of – yeah. Anyways.

Smith: Anyways.

Schenk: So it’s President’s Day, which again, I stand as someone who says we should not have that day.

Smith: I would agree with that.

Schenk: So anyways, we hope you’ve enjoyed this episode. You can catch a new episode every Monday even if it’s not a holiday, hot off the presses in the morning. Usually it comes out about 6 a.m. I think, if I can remember correctly. But at any rate, you have two ways to watch or consume, actually. You can watch us on YouTube or at our website, NursingHomeAbusePodcast.com, or you can listen wherever you get your podcasts, Stitcher, Spotify, Google Play, iTunes, these types of place. And with that, happy President’s Day and we’ll see you next time.

Smith: See you next time.

Thanks for tuning into the Nursing Home Abuse Podcast. Nothing said on this podcast, either by the hosts or the guest, should be construed as legal advice, nor is intended to create an attorney-client relationship between the hosts or their guests and the listeners. New episodes are available every Monday on Spotify, iTunes, Stitcher or on your favorite podcast app as well as on YouTube and our website, NursingHomeAbusePodcast.com. Again, that’s NursingHomeAbusePodcast.com. See you next time.