Managing difficult behavior in nursing homes: assessment and interventions

A hot-button issue for nursing home administrators and admissions personnel seems to be “behavior disturbances.” Family members may be encouraged to make alternate arrangements because the facility maintains that it cannot manage the person and the person is “creating a danger for the staff and other residents. ” In advocating for your loved one, there are tools available to help get the administrator to put the brakes on hasty efforts to get the family to relocate the resident.

Appendix B to the State’s Standards for Licensure of Long-Term Care Facilities is a deeply detailed Guideline for the Management of Inappropriate Behavior and Resident-to-Resident Abuse. Removal if the resident is not the first step, and should not be the reflex reaction. Rather, the staff are obligated to go through numerous types of assessments in an effort to pinpoint the cause of the behavior, find strategies that would avoid or prevent the behavior, redirect the resident’s attention,  and otherwise enable the resident to remain in the facility.

This appendix is really worth reading. It provides practical descriptions of what staff need to do to better understand what might be triggering a reaction and what can be done to prevent this. Also, some of the text cautions staff not to provoke a resident and to try to understand the individual and what he or she may be going through.  The staff are required to “determine the resident’s emotional adjustment to the nursing facility, including his/her general attitude, adaptation to surroundings, and change in relationship patterns,” all of which can contribute to a resident being hostile, easily aggravated, verbally abusive to staff, physically pushy, restless or resistant to programming or treatment.

Here are the categories to be assessed, each of which is described in tremendous detail: 1. Sense of initiative/involvement; 2. Unsettled relationships; 3. Past roles and current sense of self. Further elements must be considered to determine a resident’s mood and the reasons for it. All staff are expected to make a record of their observations so that based on all of that data, changes in approach can be designed: 1. sadness or anxiety and the practical causes of same, 2. mood persistent for a week and is resistant to cheering up efforts; 3. behaviors that appear disruptive but in fact may not be so different than other residents, 4. reasons for resistance to care; 5. steps for behavior management program that may include identifying whether the behavior of a different resident is triggering the seemingly disruptive reaction; 6. whether there has been a change in mood over the past 90 days, and 7. whether there has been a overall increase in the “problem behaviors” over the past 90 days.

The staff of skilled nursing facilities are trained professionals working in a setting where unusual behavior is the norm, not the exception. They have many ways to figure out how to address a challenging situation with a resident. By using those skills and getting some insights from the resident or the resident’s support network, situations can be defused and progress can be made. Too often, though, a sense of hysteria arises instead of the calm, deliberate approach that is needed to actually solve the problem. Removal of the resident should be the last resort.Appendix B


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Court upholds Revocation of CNA Certification for tying nursing home resident’s wheelchair to handrail

A Certified Nurses’ Aide who worked in a New Jersey nursing home has lost her Certification for tying a resident’s wheelchair to the hallway handrail, causing agitation, distress and confinement of the resident. The act was found to constitute abuse & neglect, and this finding has been placed next to her name on the New Jersey Nurse Aide Registry.

An administrative hearing was conducted on her initial appeal of the revocation and listing by the Department of Health. The Administrative Law Judge found, after hearing testimony of witnesses, that she had caused abuse or neglect, and affirmed the Department’s decision. On appeal, the Appellate Division of Superior Court upheld the decision, saying “It is the public policy of the State “to secure for elderly patients, residents and clients of health care facilities serving their specialized needs and problems, the same civil and human rights guaranteed to all citizens . . . .” N.J.S.A. 52:27G-1. Thus, a resident of a long-term care facility “has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.” 81 FR 68688, 68855 (2016); see also N.J.A.C. 8:39-4.1(a)(5). Such individuals are entitled “[t]o be treated with courtesy, consideration, and respect for the resident’s dignity and individuality.” N.J.A.C. 8:39-4.1(a)(12). To this end, “abuse” is defined as “the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.” 42 C.F.R. § 488.301 (2003); see also N.J.S.A. 52:27G-2(a). “Neglect” is defined as the “failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.” 42 C.F.R. § 488.301 (2003).” 

The case is Carmen Amador vs New Jersey Department of Health, A-4259-16T2, decision issued June 7, 2018. The written decision is not precedential (is not approved for publication) and is limited to its particular facts.

Call us for advice concerning nursing home placement, care plans and disputes …. 732-382-6070