Long-Term Care Survey Alert

The answer to this resident's riddle of symptoms was in his medical history.

Out of sight maybe out of mind when you don't see an active diagnosis in Section I that could help explain a resident's behavioral symptoms and worsening condition. That's why you sometimes need to dig through the chart and talk to the resident, family and his community physician to get the "rest of the story."

A case in point: In investigating the root cause of one resident's repeated falls and behavioral issues, a nurse team found out the resident had a history of prostate cancer. "The chart showed an imaging report that referenced some 'hot spots' in his bones," relays Karen Russell, regional coordinator for the Pennsylvania Restraint Reduction Initiative/Kendal Outreach LLC. "He also had arthritis and had fallen 80 times over nine months."

Read the MDS signs: "Looking at the MDS, the resident scored positive in the depression section, which certainly goes along with a diagnosis of cancer," says Sara Wright, a geriatric nurse practitioner with the Pennsylvania Restraint Reduction Initiative/Kendal Outreach LLC.

And the resident was exhibiting a functional decline and behavioral symptoms--for example, he was aggressive, resisted care and couldn't rest at night. The staff had been treating the behavioral symptoms with psychotropic medications. The resident denied having pain whenever staff asked him, which nurses documented repeatedly.

Truth revealed: Turns out the resident had metastatic prostate cancer causing him severe pain. Knowing that diagnosis led the facility care team to provide adequate pain relief and address psychosocial and spiritual issues related to his end-stage disease.

2 Lessons Learned

"When you see ongoing decline in a resident and behavioral symptoms," look for a history of cancer, suggests Wright.

Tip: Russell and Wright also advocate long-term care facilities use a pain scale for cognitively impaired residents rather than just asking them if they are in pain.

"We have a list of signs of pain that CNAs can use to help interpret whether their resident may be in pain," adds Russell. "Those behaviors can be aggression and resistance to care, but we had one resident who was always seeking her bed," says Russell. "She just wanted to lie down. And once she started a routine pain medication regimen, she woke up and wanted to get out of bed."