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

Tips on Residents’ Rights in Nursing Homes: Individualized Plan of Care Required

Once a person has moved into a nursing home, they are situated in a health care facility and receiving patient care, but they are also living there, and are therefore referred to as a “resident” rather than as a “patient.” The critical laws governing Residents’ Rights are the federal Nursing Home Reform Act, 42 USCS ‘ 1395i-3(b) and 42 CFR ‘ 483.10, and its state counterpart statute (N.J.S.A. 30:13-1 et seq.) and regulations.  It is plain that some of the rights contained in the law reflect privacy rights that pertain to a citizen no matter where he or she lives.

A nursing home is required to provide services for each resident in manner designed to preserve the resident’s dignity and to attain and maintain highest practicable physical, mental and psycho-social well-being of the individual resident based on his or her individual needs, and must abide by the Nursing Home Resident’s Rights Act, 42 USC 1395i-3(b), (c), 1396r; 42 CFR  483.10 et. seq., 483.12, 13, 15; 4.25, 483.30B; 483.60, 483.65, and 483.70; NJS 30:13-1 et. seq.; NJAC 8:39-4.1. For case discussions, see; In re Keri, (NJ Supreme Court. 2004); Profeta v. Dover Christian Nursing Home, (N.J. App. Div. 1983).

The federal regulations implementing the Nursing Home Reform Act, 42 CFR ‘ 483.12, requires the facility to develop an individualized plan of care that will maximize the well-being of the individual resident. Services must be provided without discrimination based on payor source. This means that the same level of service must be provided to the private pay resident as to the Medicaid recipient. Input from the resident, resident’s next of kin or fiduciary, and the attending physician and registered professional nurse responsible for the resident’s care should be obtained whenever possible. 42 USC 1395i-3(b)(2), 42 USC1396r(b)(2). An initial plan of care is developed and is then reviewed at regular intervals.

The resident has an enforceable right to have a specific level of care to maintain or assist the resident to perform daily living activities which include but are not limited to maintaining nutrition and hydration and avoiding accidents.  This means that if the resident cannot feed herself, the facility must include manual feeding in the personal plan of care. The facility cannot maintain that it’s too time-consuming to do so. Similarly, if the resident tends to try to get out of bed or walk on her own, the facility has to include safety arrangements such as higher supervision within her plan of care. The facility cannot insist that the family provide extra personal aides to deliver services that are needed to protect these residents’ rights.