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Long-Term Care Survey Alert

Care Planning:

Don't Let Residents' Disruptive Behaviors Disrupt Your Survey Record

Published on Wed Apr 07, 2004

Read between the lines of behavioral symptoms -- and rewrite the outcomes.

If you are at your wit's end as to managing disruptive residents, you're not alone -- but you're also not at the end of the road.
 
Your facility isn't without solutions that can turn things around and appease surveyors complaining that you're ignoring the problem. Consider these steps suggested by legal and clinical experts:

Step 1: Start by defining your population of disruptive residents, suggested attorney Joanne Lax with Dykema Gossett PLLC in Bloomfield, MI, in a presentation at the recent American Health Lawyers Association's "Long Term Care and the Law" conference in Orlando. The MDS (Section E4) provides a list along with some good definitions of disruptive behaviors, most of which involve residents with dementia:

  •  Wandering;
  •  Verbally abusive;
  •  Physically abusive;
  •  Socially inappropriate behavior;
  •  Resisting care (see definitions in Section E).

    But don't overlook the population of residents without dementia who can be equally disruptive. "Those are residents who engage in constant complaining and demands or who are constantly summoning help," Lax said. For example, Lax recalled one resident who would dial 911 or the police every time the facility didn't provide care like he thought they should. As you might imagine, "that resident's behavior ratcheted the disruption in that facility to new heights," Lax told AHL conference-goers.

    Get to the Behavior's Bottom Line

    Step 2: Once you identify the nature of the resident's disruptive behaviors, look for an underlying cause. For example, if the resident combats care, do a careful pain assessment -- even if the person is already receiving analgesics. Look for other physical causes, as well. One facility figured out that a resident known for taking a swing at anyone who approached her from the left side had loss of peripheral vision in that eye. So to avoid startling the resident -- and getting back handed -- they care planned to always approach her on the other side when providing care.

    Step 3: Break down the events that lead a resident to escalate to aggressive behaviors or yelling so you can intervene well before the behaviors occur. For example, in doing research in nursing homes, Mary Lucero, NHA, saw some residents with dementia who would balk at the door of the bathroom at bath-time. When coaxed to go in by the CNAs, the residents would then start holding onto the doorframe -- and finally, yell or start hitting. (For 4 action strategies to prevent this scenario from happening in your facility, see "4 Easy Ways To Prevent Bath-Tie From Becoming Battle Time" .)

    Tired of second guessing dementia residents who are always trying to leave the facility unattended? Look for automatic associations that that may be triggering their wanderlust. People with dementia go on "automatic pilot" where if they touch a door handle, they open it and go on through the door -- or if they see a hat, they put the hat on and then go for a walk, noted Michael Maddens, MD, CMD, chief of the division of geriatric medicine for William Beaumont Hospital in Royal Oak, MI, who co-presented with Lax at the AHL session. "If you can figure out those associations for a particular resident, you may be able to figure out how to intervene [in the behavior] without having to resort to chemical or physical restraints," he said. For example, one facility found that if staff hid a cognitively impaired resident's hat behind a pillow in his closet, he quit making the association of the hat with time for a walk on his own outside, Lax reported.

    Consider this: Do you have dementia residents who ask the same questions over and over, which disrupts activities or staff when they are trying to chart or talk to other residents? If so, don't assume the behavior is due to the person's dementia solely. Ask yourself: "When do people without dementia tend to do that? When they don't feel safe and secure and don't know what will happen next," advises Lucero, principal of Geriatric Resources in Radium Springs, NM. "Or repetitive questions, such as inquiries about when is dinner, can mean the person is hungry but can't verbalize that," she adds. "Or it can become a form of self-stimulation -- or be a sign of depression, especially if the person has other symptoms, such as a flat affect and monotone way of speaking."

    Assess Underlying Causes of Anger, Frustration

    Step 4: Realize that most difficult people aren't hard to handle simply because they enjoy making caregivers' jobs difficult. The key is to figure out what's driving the person's behavior.

    The chronically complaining resident may be experiencing a lot of frustration due to a number of losses or a situation in the facility, Lax noted. "Or he may have an undiagnosed mental illness, such as depression or anxiety."

    For example, the person may be experiencing a loss over his declining physical abilities or a loss of his hopes and interests, which he feels he can't pursue in the facility, Lax offered. In that case, a restorative nursing plan and/or working with the resident to individualize activities and help him achieve personal goals might help alleviate his anger and negativity. Or perhaps the resident feels frustrated due to forced companionship with a roommate or another resident with whom he has ongoing conflict. In that case, a simple room assignment change -- or seating the resident at a different table during meals -- may keep trouble from brewing.

    A careful assessment may reveal the resident's family is egging him on to complain constantly, Lax noted. In that case, it might be time for a family meeting to find out what the family is so unhappy about -- or to address their grief or other emotional issues.

    "Keep in mind that you admit a resident with all of his family dynamics and issues," says Francis Battisti, a social worker in Binghamton, NY, who works with nursing facilities. Good idea: Do a psychosocial evaluation of the family at admission, Battisti suggests. "Ask  'why now?' -- why are they admitting their loved one now?" That question can clue you into the family's motivation, as well as potential issues and conflicts that may crop up, Battisti points out.

    Whatever you do: don't give up. Facilities get so used to a resident's "normal" abnormal behavior that they quit trying to work with the person, notes Peggy Voitik, RN, BS, LNHA, RAC-C, principal of VP Circle of Quality Inc. in Minonk, IL. "Then something negative happens and the surveyors sweep in" and see the staff hasn't even been trying to intervene.

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