State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report

APPENDIX C. Technical Assistance Programs

TABLE OF CONTENTS

MAINE

Facility Feedback Report

In-service Outlines

MISSOURI

Show-Me QI Report

MAINE

Facility Feedback Report

Laura Cote RN
Long Term Care Behavior Management Consultant
PO Box 541
Livermore, Maine 04253-0541
Office 897-9573   Fax 897-5788

1-1-10 Jane Doe - Mooselook Nsg Home - Anywhere, Me.

Problems: Agitation - demanding - noncompliant to rules or restrictions - verbal abuse - manipulative - "push and shove" - "temper tantrums" - inappropriate sexual behavior - explosive outbursts

Triggers:

1. Hot humid weather
2. Unstable medical issues
3. Loss of impulse control
4. Depression - grieving
5. Humiliation - embarrassment
6. Attention getting
7. Anger - frustration
8. Perceived threats
9. Anxiety
10. Dist and fluid restrictions
11. Boredom
12. Intrusive thoughts
13. Loneliness
14. Change

When: Daily

What Makes it Worse:

1. Waiting
2. Lack of consistency
3. Being denied
4. Incontinence
5. Feeling rushed
6. Children
7. Her mother's health issues
8. Negatives
9. Timid or soft spoken staff
10. Asking if she would like to do something
11. Authoritative, demanding, scolding, or abrasive manner
12. Reacting to her behaviors
13. Encouraging her to do something she doesn't want to do
14. Smokeroom door opening and closing
15. Feeling ignored
16. Being told what to do by another resident
17. Smoking and telephone rules

What Makes it Better:

1. Being firm, calm, and matter of fact with issues
2. Confronting her behavior as it occurs
3. Limits and boundaries
4. Continuity through motivational services
5. Constant cuing for care
6. Re-enforcing boundaries when she leaves the unit
7. Accompanied off-unit time
8. Approaching her with an air of confidence (self)
9. Telling her what needs to be done
10. Using short simple sentences and explanations
11. Saying "I would like you to _____, because _____"
12. Outings
13. Helping
14. Giving her alternatives
15. Ice water
16. Acknowledging her presence
17. Humor - coaxing - cajoling
18. Assessing her mood before approaching
19. Going to get her pop and then going outside
20. Soothing music - gospel
21. Playing the piano or keyboard in her room
22. Asking her to play the piano in the dining room
23. 1:1
24. Affection - soothing touch
25. Validation
26. Positive feedback
27. Being selectively social
28. Nuns - anything to do with religion
29. Talking about her mother or the nuns in Jackman
30. Sleeping in
31. Backing off
32. Giving her space when she's agitated

Recommendations:

1. When behaviors dramatically change, always look for an underlying medical issue before beginning behavioral interventions - assess for pain or discomfort - check her blood sugar - assess COPD status - check for an infection - etc. Be aware of weather's impact.
2. Document carefully and accurately all behaviors in an effort to present a clear picture of presenting symptoms for the psychiatrist in order for him to achieve the most effective management of treatment regimen and medications.
3. Continued involvement with support services is crucial and should be maintained on a consistent basis.
4. Keep environment and routines predictable - avoid change if possible - know her likes, dislikes, routines, and rituals - document for all staff. Any new or unfamiliar staff must review her care plan and behavior plan prior to working with her. Predictability feels safe and allows her to feel in control. Provide consistency of approach and continuity of care - all staff, all shifts.
5. Provide structure - set limits and boundaries - give clear expectations and educate to the consequences. Because of her very poor impulse control, boundaries and limits will need to be re-enforced on a situational basis.
6. Confront her behavior as it occurs as being inappropriate and unacceptable - avoid sounding angry, disgusted, judgmental, or impatient - don't raise your voice - be firm, calm, matter of fact, and very concrete - once you've stated your issue, let it go - avoid going on and on or bringing it up later.
7. When communicating with her, focus her attention - obtain eye contact - speak at or below eye level using short simple sentences - speak slowly and clearly, keeping the tone of your voice low - keep explanations brief and to the point - explain step by step as you go - use common sense explanations, single clear directions and commands, and simple cues.
8. Assess her mood before approaching and approach accordingly - anticipate potential behavioral situations and try to avoid them.
9. Don't order, command, scold, or approach in an abrasive manner - instead of confrontation less distraction whenever possible - negative approaches or statements will usually achieve a negative result. Be very aware of what your facial expression, body language, and tone of voice are saying to her.
10. When resistive, back off and try later - don't push - be flexible within established boundaries - avoid power struggles - if it's not a "to die for" issue, let it go.
11. Avoid reacting to her behaviors as it will only make them worse - arguing contradicting her, etc. - these will all tend to escalate the situation. Because of her loss of impulse control, she doesn't stop and think before she speaks or acts - instead, once an impulse is triggered, she will immediately react - if she feels threatened or frightened it will automatically kick in her fight or flight response. She also tends to "perform" for an audience, ever an audience of one - remove her audience by not reacting, and you remove her need to perform.
12. During ADLs, give clear simple cues and directions, and then give her plenty of time to complete the task - give lots of positive re-enforcement and feedback. Approach with an air of self confidence and expected compliance.
13. When agitated, back off and give her space - let he work out of it on her own as long as she poses no risk to herself or others - if she begins to escalate, then intervene.
14. Refocus her attention with an alternative - use humor - take her off the unit for a while - getting her "pop" - going on an outing - music - etc. Boredom is a major problem - as for her help, using task focused purposeful activities that give her a sense of being useful and needed. Ask her to play the piano or keyboard for you.
15. Acknowledge her presence - when she feels ignored her behaviors will escalate - she's lonely and needs companionship - briefly socialize when not assisting with care or addressing an issue - sit quietly with her - reminisce - validate her feelings - listen to her - show affection - use soothing touch - give positive feedback, sincere complements, and genuine praise.
16. If she has to wait, briefly explain, then keep your word - establish a trusting relationship.
17. Behaviors are a form of communication - she's trying to tell you something - look underneath the behaviors for the true message.

Thanks for the referral.

Laura Cote, RN
Behavior Management Consultant

In-Service Outlines

Laura Cote RN
Long Term Care Behavior Management Consultant
PO Box 541
Livermore, Maine 04253-0541
Office 897-9573   Fax 897-5788

SERVICES AVAILABLE

BEHAVIOR MANAGEMENT CONSULTATION

For individual residents with specific behavior management issues, irregardless of their diagnosis.

Consultation includes chart review, problem solving session with staff, brief meeting with the resident, written recommendations, and follow-up as needed.

INSERVICE EDUCATION

Provided to staff within their own facility.

Seven inservices currently available:

• Behavioral Approach
• Documentation of Behaviors
• Alzheimer's - Practical Hints for Caregivers
• Intimidating Behaviors
• Problem Solving for Difficult Behaviors
• Behavior Profile Cards
• Elopement - Risk Factors and Prevention

Services are provided through the Bureau of Medical Services, Department of Human Services, and are available to any Long Term Care facility in the state of Maine at NO COST to the facility or the resident.

The goal of these services is to assist staff in dealing more effectively with difficult behaviors by giving them a better understanding of the resident, why the behaviors are occurring, making recommendations, involving them in team problem solving where their input is valued, and providing them the education that will enable them to do their jobs more effectively and safely -- as well as improving quality of care and ultimately quality of life for the resident.

Referrals can be made directly by calling 207-897-9573.

INSERVICE OUTLINES

Behavioral Approach

Introduction: Relation to behaviors to approach
Things to know before approaching a resident --

• Social history
• Medical / Psychiatric history
• Behavioral history
• Behavior triggers
• Know yourself

Helpful hints

1 hr. long and geared to all staff

Documentation of Behaviors

Painting word pictures
Why is documentation so important?
Who is responsible for documentation?
Intense documentation
What should documentation include?
Vocabulary list

1 hr. long and geared to licensed staff, med techs, social service, activities, and the MDS co-ordinator

Alzheimer's - Practical Hints for Caregivers

Brief overview of the disease
Stages of Alzheimer's
"Time warp"
Conditioned or automatic responses
Hints for specific areas including:

• Personal care
• Mealtimes
• Toileting
• Sleep / rest
• Specific behaviors
• Depression
• Sexuality issues

3 hrs. long, which is offered in one 3 hr. session or two 1½ hr. sessions - geared to all staff

Intimidating Behaviors

Definition of intimidation
What kind of behavior can be intimidating?
Who intimidates?
What triggers the behavior?
Managing intimidating behavior

1 hr. long and geared to all staff

Problem Solving for Difficult Behaviors

Define the problem behavior
What triggers the behavior?
When does the behavior occur?
What are the warning signs?
What makes the behavior worse or ensures that you will see the behavior?
What makes it better -- how can you refocus, redirect, or "head it off at the pass"?

1 hr. long and geared to all staff

Behavior Profile Cards

Basic identifying information
Social history
Family involvement
Pertinant medical and psychiatric history
Behavior history
Behavior triggers
Likes and dislikes
Routines and rituals
Ways to refocus and redirect
A list of the do's and don't's for working with the resident

1 hr. long and geared to any staff who work directly with the residents targeted for the profile cards

Elopement

Risk factors
Preventative strategies
Crisis plan

1 hr. long and geared to all staff

MISSOURI

Sample ShowMe QI Report

Facility Name .......: RANTZ ACRES
Missouri Facility ID: 99999
Facility Address ....: 999 COUNTRYSIDE LANE, ANYWHERE, MO 99999-9999
Facility County ......:

Report for the Quarter Ending: December 31, 1999

ShowMe QI Report
Quality Indicator #1
Prevalence of Any Injury

This Quality Indicator (QI) reflects the percent of residents with any injury* as recorded on their most recent MDS assessment. The graph displays several quarters of information for this QI. QI scores that fall below the lower threshold are thought to reflect good or excellent performance. QI scores that fall above the upper threshold may suggest a problem with resident care that needs further attention by your Quality Improvement Team. Focus on trends and examine the residents listed with the problem. The summary table below includes your facility's QI Score, statewide tenth percentile score, and percentile rank.

* See attached Resident List for those residents with any injury indicated on their most recent MDS (M4 and J4)

Prevalence of Any Injury