Long-Term Care Survey Alert

Here's what you definitely want to avoid when using this crisis-management technique.

When residents'behavior escalates toward aggression, you have to act quickly, but without putting the facility in harm's way with regulators.

One option is to use a "time-out" technique whereby you get the resident away from the stimulus prompting the behavior. This can be a helpful strategy, according to attorney Joanne Lax, who spoke at the American Health Lawyers Association's recent Long-Term Care and the Law conference in Orlando, FL. "But you have to be careful not to run afoul of the prohibition against involuntary seclusion" when using it.

"The State Operations Manual says emergency use of [short-term monitored separation from other residents] can be a temporary measure until you can figure something out," Lax pointed out. This approach won't be viewed as "involuntary seclusion" as long as it's the least restrictive approach for the minimum amount of time -- no more than 24 hours, says the SOM. "The procedure must also be used to meet the resident's needs, and not merely for staff convenience," adds Arlington, VA attorney Joseph Bianculli.

Keep this in mind: Involuntary seclusion doesn't just refer to a resident being isolated from others. "The person can be secluded in his own room with his roommate ... the issue is whether the resident is able to be where he wants to be in the facility," cautioned Lax.

Tip: Review how surveyors will ev evaluate a facility's use of emergency short-term monitored separation to treat behavioral symptoms (see the State Operations Manual, PP-49 and PP-50 at www.cms.hhs.gov/manuals/pub07pdf/AP-P-PP.pdf).

"Most regulatory guidelines allow facilities to use crisis management in crisis conditions, with the stipulation typically being that crises shouldn't be happening very often," says David Lennox, PhD, president of Quality Behavioral Solutions Inc. in Holliston, MA. "So if an incident occurs with a resident more than once or twice, the treatment team should come up with alternatives to any 'hands-on'techniques such as holding or physically restraining the resident, escorting him [somewhere] ... or placing him in his own room."

A matter of semantics: Lennox prefers not to use the term "time out" because it means different things to different people -- and carries negative connotations to most. "If you say 'time out'to surveyors, they may think of the procedures used in mental retardation facilities or even ones used in day care for children," he says. "Other terms you can use to refer to a technique that distracts and separates residents from the stimulus causing the agitation include calming time, quiet time and reflecting time."

Merely separating the resident from an incident causing him to become angry or agitated may not be enough, however. "If you leave the resident alone, you can't guarantee he's recovering from the incident causing aggression or agitation," Lennox says. If the resident continues to ruminate about an incident, you may see a scenario where he goes on a rampage all day because staff didn't help him recover from an incident a couple of days before.

So how do you help the resident to "get over it?" Most care plans for aggression management include diversional activities to help him cool down. Yet some activities have the potential to actually keep the resident stirred up or start a new altercation, which sets up a repetitive cycle of having to resort to more crisis-management techniques. In Lennox's view, the types of activities that are most likely to help the person get over his anger include those that: