MDS Alert

If you don't, your facility could end up doing a Plan of Correction.

Say a surveyor finds out a resident with dementia regularly combats basic care.

If you haven't coded that resistance in E4 during the MDS lookback and assessed and addressed the behavior as part of the care plan process, your facility may find itself resisting F tags.

Surveyors now use the Psycho-social Outcome Severity Guide to determine the severity of deficiencies that lead to psychosocial distress or harm. The new survey guidance for F329 (unnecessary drugs) that goes into effect on Dec. 18, 2006 also places more emphasis on the need for staff to assess and address behavioral symptoms. "A huge part of the [revised F329] guidance deals with behavioral interventions," advises Nancy Shellhorse, an attorney in Austin, TX. |

Best practice: Anytime a resident resists care (E4) or becomes aggressive toward caregivers, take a look at what's going on. And document your assessment and care plan interventions, including an evaluation of whether the plan needs changing.

Key example: When someone resists bathing, identify the antecedents to the resistance and how the staff responded to the resistance, advises Joanne Rader, MSN, RN, principal of Rader Consulting in Silverton, CO, who has published ground-breaking research on bathing cognitively impaired nursing home residents without a battle. 

Often the person resisting bathing is communicating, "I can't tolerate how you are trying to do this" rather  than "Don't wash me," says Rader. She notes that people usually feel better when they have had a bath."There are various strategies you can use to bathe a person," she adds (read "To Get a Clean Survey, Use Evidence-Based Bathing Practices" in the June 2006 Long-Term Care Survey Alert. For subscribing information, including free access to the archive of newsletters, call 800-582-2582.)

Preempt problems: Interview the resident or his family at admission, if possible, to determine his preferred bathing and other care routines and preferences. (See Section F from the draft MDS 3.0, which directs nursing home staff to ask a resident or his surrogate how important it is for the resident to choose between a tub bath, shower, bed bath or sponge bath. You can access the draft instrument at www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS30Draft.pdf.)

Good question: "If the person resists morning care, has the staff performed a pain assessment to see if that's the problem?" asks Rader. 

Correlate Behaviors With Caregiving Techniques

To determine whether the staff's care strategies prompt resistance and behavioral symptoms, such as aggression toward caregivers, document how the patient responds to assistance with ADLs, advises Cindy Hart, LPN, CPA, CPC, a consultant with LW Consulting Inc. in Jenkintown, PA. Correlate the behaviors to the staff's approach in ADLs -- for example, if they aren't doing task segmentation coded at G7 where they break a task into "doable" subcomponents so the resident can succeed at the task.

Talk about frustrating: If a resident displays agitation or verbal aggression when staff ask him to do something, examine the interaction. "When residents can no longer process information like they did before they were afflicted with dementia, they often have negative reactions," observes Barbara Brock, a dementia care expert in Toledo, OH. 

Example: The person with cognitive impairment may feel overwhelmed by a set of instructions like the following given all at once, cautions Brock.

Wash your face and hands

Brush your teeth and hair

Get dressed

Come to the dining room

Editor's note: For additional information, see "Use Task Segmentation To Help Your Residents Succeed In Their ADLs," in the August 2006 MDS Alert. You can access all of the past issues of MDS Alert as part of your subscription. To sign up for the online subscription option with access to the MDS Alert archive, call 800-508-2582.