Long-Term Care Survey Alert

Help residents with dementia cooperate with the infection-control plan.

Talk about a potential infection- control disaster: A cognitively impaired resident with the flu or MRSA infection who refuses to cooperate with hygiene or isolation procedures. But the right approaches can stave off the need to transfer or restrain such residents.

As a first step, make sure you're not unnecessarily isolating a resident with Methicillin-resistant Staphylococcus aureus (MRSA), for example. "Use the least restrictive form of isolation specified by the state health authorities or Centers for Disease Control & Prevention," advises Ari Markenson, JD, in New York, NY. Say the resident has an MRSA infection that he could transmit through frequent stools or wound secretions that soil his dressing. That resident needs to be on contact isolation in a private room, says Chesley Richards, MD, MPH, a consultant for the CDC and a practitioner at the Atlanta VA Medical Center.

But if the person has a wound colonized with MRSA or has MRSA in her urine--and the staff can contain the urine or wound secretions--the facility can place the patient on less stringent contact isolation, Richards adds. "The person could engage in group activities, such as dining and physical therapy. But the patient and staff should emphasize good handwashing practices, which can be a challenge when caring for the cognitively impaired."

Tip: If a resident has MRSA in her urine and urinates on the floor, find a way to manage the urine spills without isolating the resident. For example, use a combination of toileting and effective absorbent products, advises Richards.

How to Promote Handwashing

What if a resident with dementia adamantly refuses to wash his hands after toileting or before eating, as examples? Turn the cleansing into a comforting hand massage, suggests James Marx, RN, CIC, an infection control specialist and principal of BroadStreet Solutions in San Diego. "People like to have their hands rubbed generally," he says. "So if that's the case with a particular resident, use the alcohol-based [cleansing] gel as a hand lotion and rub it into the person's hands."

If the person's hands are visibly soiled, of course, you have to use soap and a wash cloth. To encourage the resident to wash his hands with soap and water, hand him a warm wet washcloth with soap on it, which stimulates the person to use it independently, in the experience of Cissy Bloomfield, RN, director of nursing at Golden Moments Senior Care Center in Jacksonville, IL.

Include care plan measures aimed at helping the resident with dementia to remember to wash his hands. For example, post a picture symbol of someone washing hands in the resident's bathroom, suggests, suggests B.J. Collard, RN, BSN, GNP, CPHQ, RAC-C, principal of CTS Inc. in Westminster, CO. 

Another idea: Have your restorative nursing program conduct a group activity for residents cohorted for an infection to work on handwashing on a regular basis, suggests Sheila Capitosti, RN,C, MHA, MHSA, a consultant with LTCQ Inc. in Lexington, MA. "Make the activity something pleasurable such as a manicure or hand massage therapy," she adds.

Do a Functional Assessment of Resistive Behaviors

If a resident continues to battle handwashing and bathing--or refuses to wear a face mask when leaving the room if he has the flu--perform a functional behavioral assessment, suggests Michael Partie, director of Therapeutic Options in Newark, DE.  To do that, look at what function the behavior appears to have to the person displaying it, he explains. For example, does the behavior get the person attention, more time alone--or is he trying to avoid something that frightens or hurts him? "Then try to figure out another way to meet that need," he suggests.

Tip: If the resident with dementia refuses to wear a face mask when he leaves his room, try putting on a mask first and wear one with him, suggests Collard. "That way, the person won't feel singled out." Because people with dementia fear the unfamiliar, staff might practice with the resident wearing a mask in the room briefly on a regular basis so he gets used to it, she adds.

Share the power: Partie finds that a lot of resident resistance and agitation in nursing home settings disappears when staff begins routinely offering residents choices in their daily activities and schedule. While too many choices can bewilder someone with dementia, offer the person a selection of a couple of items of clothing and snacks. Also let the person select what food items he wants to eat if he requires feeding assistance at meal times.

"If you wait until high-risk times such as a flu outbreak to adopt 'power-sharing' practices, they will not be as effective," cautions Partie. "Also, if the person's refusal to cooperate represents a form of counter-control, you may accidentally cue the unwanted behavior by signaling" how much you want him to comply.