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Long-Term Care Survey Alert

MDS 3.0:

Use the MDS to Keep Behavioral Assessment and Management on the Mark

Published on Mon Mar 28, 2011

Increased verbal aggression may be caused by this common problem.

The MDS 3.0 captures the impact of a resident's behaviors on himself and others, which can enhance care planning and head off aggressive episodes. Consider these ways to improve assessment and get to the root cause of a resident's behavioral symptom in order to come up with helpful interventions.

Strategy No. 1: Make sure you have the complete behavioral picture. Section E of the MDS 3.0 asks you to code physical and verbal aggression and other behaviors that place residents or others at significant risk of injury. To ensure accuracy of the information, the interdisciplinary team should do the assessment and documentation of the behavioral symptoms, advises Marilyn Mines, RN, RAC-CT, BC, director of clinical services at FR&R Healthcare Consulting in Deerfield, Mass. And don't just do the behavioral tracking for MDS assessments.

Strategy No. 2: Try to rule out a physical cause or depression as a cause of behavioral symptoms. Obtain a medical review for any new, unexplained, or worsening agitation or aggression, etc. For example, when a patient has worsening agitation, Richard C.W. Hall, MD, in Gainesville, Fla., always looks at the person's medications (for a list of medications listed by the MDS 3.0 Care Area Assessment-specific resource for the Behavioral Symptoms CAA, see page 22). "But you have to do the usual medical work-up, as well, and make sure the person doesn't have an infection (UTI especially), no falls, undetected fractures, head trauma with subdural hematoma, or other sources of pain," Hall says.

Tip: Also take a look at whether a resident who has become verbally aggressive might be depressed. A recent study correlating various MDS items to a new depression diagnosis found that an increase in verbal aggression from one quarterly assessment to the next proved to the strongest predictor of someone becoming newly depressed, says Lorraine Phillips, PhD, RN, FNP-BC, an investigator in the study reported in the Journal of Gerontological Nursing.

Phillips notes that the "PHQ-9 screens for nine symptoms that meet the diagnostic criteria for major depression." But "people can score low as not being depressed on the PHQ-9 and still have depression," she cautions. (For a free copy of an article on the research, including an interview with Phillips, e-mail the editor at KarenL@Eliresearch.com.)

Strategy No. 3: Consider using behavioral information to assign rooms. Nurse consultant Lynda Mathis, RN, has long recommended facilities use information about residents' customary routines and preferences (including room temperature) to help ensure compatible roommate assignments. Now she advises also using the behavioral impact information coded in Section E as part of that decision-making process. That applies not only to roommates but also whom you place in surrounding rooms, says Mathis, lead clinical consultant for LTC Systems in Conway, Ark.

"Just because people have dementia doesn't mean you can group them together" on that basis alone, adds Mathis. "I think we are going to have to become more astute in that regard " and the MDS 3.0 will help define behaviors that irritate" a particular group of residents.

Strategy No. 4: Tap proven approaches to get to the root cause of behavioral symptoms. One strategy involves the "ABC" (Antecedent-Behavior-Approach), says Michael Partie, a behavioral expert and principal of Therapeutic Options in Newark, Del. That's where you "look at where trouble tends to rise" and look at the patterns -- "not just in the conflict itself, but in events leading up to it" and what happens as a result, he reports. For example, if you take a closer look, you may find that a resident only gets staff attention when he acts out in a negative way.

Residents will vie for staff's attention, says Partie. And "staff who are aware of this can make a conscious effort to spend time engaging with residents and making sure they pay equal attention to all residents."

Strategy No. 5: Integrate activities into behavioral care plans. "You want to engage residents in activities that promote positive behaviors or at least avoid negative behaviors," says Kurt Hass, RN, BSN, former Ohio survey agency chief and now CEO of Nursing Home Perspectives in Canal Winchester, Ohio. In fact, Haas sees that approach as being "paramount when preventing resident-to-resident aggression or even dealing with a resident whose behavior upsets others -- for example someone who is verbally hostile. Activities get people engaged in a safe environment that lowers stress levels," he says.

You can also design activities to meet a resident's need to rummage or perform repetitive activities, which, if interrupted, can cause the person to become aggressive, says Haas.

Example: Haas consulted with an Iowa nursing facility caring for a resident with severe dementia who was behaving aggressively. The staff figured out that the man, who had been a potato farmer, enjoyed washing and inspecting potatoes. The resident found the activity to be meaningful and it helped resolve his aggressive behavior, Haas reports.

Resources: For more information on the ABC and other psychosocial approaches to behavioral management in nursing homes, tune in to a surveyor training webinar at cmstraining.inf/index.aspx.

For a free copy of an Eli Healthcare article in which Michael Partie explains a "scatter plot" approach to figuring out what's triggering or worsening behavioral symptoms, e-mail the editor at KarenL@Eliresearch.com.

 

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