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Residents of New York City nursing homes have been killed, sexually assaulted and beaten by unlikely assailants in the past few years: their fellow residents.

A Daily News investigation found that resident-on-resident abuse has emerged as a little-acknowledged threat in nursing homes in New York City and elsewhere.

A stark picture of the problem was pieced together from state Health Department inspections, criminal records, lawsuits against city nursing homes and conversations with dozens of nursing home workers, relatives and advocates for the elderly.

The News' probe turned up three slayings of nursing home residents by other residents in the past six years, including one in which a Manhattan woman was suffocated by her 90-year-old roommate. In the past year alone, government health inspectors have cited three New York City homes for failing to protect residents from one another: 
· In March, the state Health Department singled out Brooklyn's Rutland Nursing Home for jeopardizing the safety of elderly residents by allowing them to live side by side with dangerous residents.

Police frequently visited the Schenectady Ave. home, where one man with an anti-social personality disorder threatened to "cut people up gangster-style."

State inspectors soon discovered that the man had not had a psychiatric evaluation since arriving at Rutland in 1997.

"The facility has no system in place to manage residents with behaviors and protect other residents from harm," the inspectors concluded. 

· At Clearview Nursing Home in Queens, an 83-year-old male resident was seen wandering in other residents' rooms and, on several occasions between August 1999 and May, fondled the breasts of incapacitated female residents.

The home never reported the incidents to the state, a violation of state regulations, and failed to prevent recurrences, federal inspectors charged. 

· During a four-month period last year, an elderly Alzheimer's patient staged a one-man terror spree at the Wedgewood Care Center in Great Neck, L.I., punching, choking, biting and slapping fellow residents in 24 separately documented cases of abuse.

The man threw chairs at staff members, opened fire doors, wandered into other residents' rooms and dumped patients out of chairs. 

State Health Department officials who inspected the Wedgewood nursing home in September 1999 found that the staff had yet to develop a plan to prevent a recurrence of violence by patients. Resident-on-resident violence and harassment have been getting worse for years, fueled by dramatic shifts in nursing home populations that have created a volatile mix of residents.
Once the last haven of the elderly and frail, nursing homes are now also home to younger patients recovering from brain injuries and other traumatic events, as well as older dementia patients prone to erratic behavior.

And, with many psychiatric institutions shutting their doors, nursing homes have taken in more mentally ill patients than ever.

In 1994, the State Hospital Review and Planning Council, which regulates the state's nursing homes, encouraged homes to designate special units for the growing numbers of residents with behavioral problems who were being discharged from hospitals and psychiatric facilities.

Advocates can cite only two or three homes with the units in the entire state.
"Resident-to-resident violence and aggression is extremely common," said Karl Pillemer, a Cornell University gerontologist who has studied abuse in nursing homes for the past 20 years. "Nursing homes have been slow to recognize they are mental health facilities."

Compounding the problem are staff shortages, which leave nurse's aides juggling the care of as many as 40 residents at a time. Most aides are ill-prepared to spot the potential dangers of patients with mental illnesses and dementia, union officials concede.

"We hear about it all the time," said Jay Sackman, the executive director of Local 1199 of the Service Employees International Union, which represents thousands of nursing home workers. "There are more and more residents with psychiatric problems. Because of the short staffing it's difficult for workers, even if they are properly trained.

"These residents have special needs. They may act out and need someone to help work out their problem, but they don't get the attention."
Across the state, nearly 45% of nursing home residents now need psychotropic medication to control their behavior, up from 29% in 1993, according to a study of federal nursing home data by researchers at the University of California at San Francisco.

The same study found that about 46% of residents in New York nursing homes show symptoms of dementia, a category of brain disorder that involves persistent loss of intellectual functions and includes Alzheimer's.
Other studies place the rate of dementia in New York nursing homes as high as 75%.

Once dismissed as senility, dementia is expected to reach record levels in the coming years as the population aged 85 and older increases in numbers. The "oldest old," who now make up 1.6% of the population, are expected to increase to 5 percent of the population by 2050.
Resident-on-resident killings are the most dramatic and sobering evidence of the increase in dementia among nursing home residents. Among recent cases: 

· October 1995, a 90-year-old woman living at Manhattan's Florence Nightingale Nursing Home walked over to her female roommate's bed and began piling clothing on top of the woman's head, suffocating her. 

Nurse's aides tried to resuscitate Ramona Reyes, a bedridden, retired seamstress from Manhattan. But it was too late — her roommate of more than two years had smothered her.

Reyes' killer suffered from dementia, but had never before displayed aggressive behavior.

"This was very, very unusual," said Nightingale administrator Bill Pascocello. "The question is whether or not it could have been prevented. She never appeared to be the type to be aggressive or agitated." 
· In May 1994, a 30-year-old AIDS patient and former member of the Guardian Angels named Albert Feliciano was violently beaten to death by a fellow resident at the Terence Cardinal Cooke Health Center.

Feliciano's death was ruled a homicide by the New York City medical examiner. The cause of death was a skull fracture, the medical examiner's records show. Feliciano's brother says that another resident beat Albert to death with a chair.

No one was ever charged in the slaying. But the New York City Police detective who investigated the death said a witness reported seeing another resident, a man who also suffered from AIDS, attack Feliciano. 

A few months later, the alleged assailant died. The state Health Department investigated Feliciano's death but did not cite the Cardinal Cooke home for failing to protect his safety. 
· Around the same time, a 65-year-old patient at the Bronx-Lebanon Special Care Facility, Raul Figueroa, was attacked in the smoking room at the home by William Thompson, a 75-year-old dementia patient wielding a 2-foot-high metal ashtray. Figueroa later died of his wounds.

Two weeks before the killing, a doctor had reduced Thompson's anti-psychotic medication, according to state Health Department records.

The week before the incident, Thompson's brother had died, an event that rattled him badly. He refused to attend his brother's funeral.

On at least seven occasions that week, state investigators found, nurse's aides noted that Thompson was combative and agitated.

He had punched another resident in the face. He'd been seen talking to a wall and shouting at a nurse. Thompson's medication was never restored to previous levels, a measure that might have calmed him.

"The physician failed to monitor the resident's response to a dose reduction in anti-psychotic medication," inspectors noted in citing the home for failing to protect Figueroa.

A Bronx judge determined in 1996 that Thompson was not mentally competent to stand trial. 

Such violence is not just happening in New York. Resident-on-resident violence is almost certainly underreported nationwide. Federal agencies do not track patients' abuse of other patients. And few nursing homes face penalties for failing to prevent it.

But residents are not the only victims. The people who care for them also have been badly hurt. The Bureau of Labor Statistics now ranks nurse's aide as one of the most dangerous jobs in private industry.

Aide Agnes Obremski has been out of work since September, when she says she was attacked by a male resident at Flushing's Cliffside Nursing Home while trying to change his clothes. Obremski, 40, said the man pinned her against a fourth-floor window while she screamed for help. 

At 5-feet-1, she was badly outmatched by the resident, whom she said weighed more than 200 pounds.

"I thought I was going out the window," Obremski said. "I couldn't budge. I thought, "I'm going to die here today.'"

Cliffside administrator Jack Deutsch questions Obremski's claim, noting that there were no witnesses. He says aides are trained to handle difficult residents.

"It's not uncommon for people with Alzheimer's or other severe dementia to become agitated," he said. "We have trained our staff on ways to deal with it."

Government inspectors only recently have begun to cite facilities for failing to protect residents from one another. Until July 1999, state inspectors were not even required to look for resident-on-resident abuse.

Patient advocate Cynthia Rudder, a former member of the state planning council, says patient safety is an afterthought for many homes at a time many elderly are turning to nursing home alternatives such as home care and assisted-living centers.

"Nursing home owners are looking for ways to increase their revenue, and one way to do that is to bring in people with higher reimbursements," Rudder said.

Industry critics believe the federal government's current Medicaid reimbursement system is partly to blame because it discourages nursing homes from addressing the needs of the growing numbers of dementia patients.

Medicaid pays homes more to care for residents with special needs like respiratory care. In some cases, the program pays for psychiatric care, but at a significantly lower rate. Because many early-stage dementia patients can feed and bathe themselves — indications of competence and independence — homes have had a hard time recouping the cost of their care from Medicaid. One consequence, Rudder said, is that dementia patients don't get as much individualized care — and symptoms like depression and anxiety often are overlooked.

Better nursing homes, says one New York physician who operates a unit for troubled patients at a Brooklyn facility, simply select applicants for residency with the highest likely Medicaid reimbursements from their waiting list. "It's basic economics," he said.

Since being cited for jeopardizing patient care earlier this year, the Rutland Nursing Home in Brooklyn has hired a behavioral specialist to screen the mental health of all residents and a social worker to educate staff how to deal with patient behavior.

"There's been a good deal of soul-searching," said Janet McNemar, who took over as administrator at Rutland after this year's state inspection. "We've taken a look at how we were operating, what supports were in place and not in place. We're constantly evaluating how we're doing."