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

 

For legal advocacy and advice regarding nursing home care planning, call us at … 732-382-6070

Pet therapy provisions in the New Jersey Skilled Nursing Facility Manual

Are you watching out for a loved one or a client who resides in a nursing home? You will want to become familiar with some of the provisions in the State’s regulations for skilled nursing facilities. In this series of posts I will talk about some sections of the Code and its appendices that are useful for a patient’s advocate to know about.

Let’s start with the provisions about pet therapy. Can a resident of a nursing home be visited by their pets? Can a resident of a nursing home bring in a pet to live with them? Facilities are permitted to establish protocols that enable a resident to have a pet as a companion or to receive visits from animals that are residents of the nursing home or are brought in as visitors. The details are in Appendix A, which is found at page 105-107. Appendix A.

The idea of bringing animals into nursing homes for pet therapy isn’t new. The NY Times did this piece about it in 1987, and  researcher H.M. Hendy at the National Institutes of Health published a study that same year in the International Journal of Aging and Human Development which was a follow-up study of the effects of pet visits vs. human visits on residents’ alertness and other indicators of contentment and satisfaction.

Under the New Jersey program, allowable companion pets are dogs, cats, non-carnivorous birds, domestic rabbits, gerbils, hamsters, guinea pigs and fish. Reptiles, ferrets and other wild animals are not permitted. The facility itself (or a staff person or other party) can own and maintain the animals,   or  a resident can own the animal and keeps it on the premises. Any animal that resides at the facility more than 4 hours a day is referred to as a “residential pet.” Appendix A contains explicit requirements regarding the health and safety of such animals.

There is a category called “visiting pets.” If pets are brought in so that the resident can visit with the pet, the party bringing it in must abide by certain requirements. Dogs and cats must be vaccinated, housebroken, and not in estrus (not “in heat”) at time of visit. Dogs must be licensed and tagged. The owner must accompany the animal and is responsible and liable for its behavior while on the premises. Visiting birds are not permitted, but hamsters, gerbils, guinea pigs, domestic rabbits, rats and lab mice may visit.

Resident pets and visiting pets cannot be allowed into certain areas such as nursing stations, drug preparation areas, linen storage areas and sterile supply rooms, for example. Food handlers may not be involved in the cleanup of animal waste. There must be a pet-free area within the facility so that residents can avoid undesired contact with animals. 

If you want to read the State’s entire manual of requirements for skilled nursing facilities, here it is. — Chapter 8:39 of the NJ Administrative Code.

A person who moves into a skilled nursing facility for long-term care is a resident, not a patient, and the SNF is their new home. Not only is an individualized plan of care required, but many protections and rights which  people have in their communities follow them into this new residence. Vigilant, attentive and creative advocacy can assure a good quality of life for your loved one in a senior care facility.

For advice and advocacy on senior care and elder law issues, call us at ……732-382-6070