New Jersey Administrative Code › Title 8 - HEALTH › Chapter 39 - STANDARDS FOR LICENSURE OF LONG-TERM CARE FACILITIES › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
GUIDELINE FOR THE MANAGEMENT OF INAPPROPRIATE
						BEHAVIOR AND RESIDENT TO
RESIDENT ABUSE
I. The initial resident assessment should include a psychosocial
						behavior
component with interventions, if appropriate, in the care
						plan.
Reassessment should be done at least quarterly, or at any time
						when a
resident's pattern of behavior changes. Resident response
						to
interventions should be recorded in the medical record.
II. Inappropriate behavior and/or actions should trigger an
						immediate
reassessment with adjusted interventions; notification of the
						physician
and/or the designated resident representative. Resident response
						should
be recorded in the medical record. The facility's
						actions/interventions
in response to behavior changes should also be part of the plan
						of care
and should be appropriately recorded. Prompt reassessment of
						behavioral
changes will in most cases avert the continued progression
						of
inappropriate behavior.
III. Inappropriate behavior and/or actions involving other
						residents should
be identified in the records of all involved residents
						including
assessments, interventions and responses. Notifications of
						physician
and/or designated resident representatives should also be
						recorded in
medical records of all involved residents.
IV. Incidents of inappropriate behavior or actions of abuse
						between
residents should result in the following actions, as
						applicable:
A.
Immediate assessments of involved residents;
B.
Notification of attending physicians or advanced practice
						nurses;
C.
Interventions and responses of residents;
D.
Notification of residents' designated representatives;
E.
Protection of involved residents' civil and constitutional
						rights;
F.
Determination by administrator of facility's ability to assure
						safety and security of all patients;
G.
Implementation of emergency or short-term precautions to assure
						safety while working toward resolution; and
H.
Notification of police if necessary.
V. In the event that it is determined that a resident must be
						removed from
the facility, the transfer should be initiated in accordance
						with the
provisions of this chapter.
VI. Transfer from the facility should be based on the
						appropriate
evaluation and transfer order of the attending physician,
						advanced
practice nurse, facility medical director and/or consultant
psychiatrist.
VII. In the event of an immediate emergency situation only:
1. Have patient removed to emergency room of local hospital
for medical and/or psychiatric evaluation and
consultation by a physician or advanced practice nurse.
Return of patient to the long-term care facility should
be based on the physician's or advanced practice nurse's
written notation of the appropriateness of returning the
resident to the long-term care setting. The administrator
is responsible for the decision to accept or deny the
return of the resident according to N.J.A.C. 8:39;
2. A police complaint should be filed against the abuser
						and
have the individual removed. The complaint can be filed
by the facility or the abused party; and
3. Notify all agencies (that is, Medicaid if applicable,
Ombudsman for the Institutionalized Elderly, if
applicable (over 60) and the Department of Health and
Senior Services.)
VIII. In the event all guidelines have been followed and
						resolution has not
taken place, assistance should be requested from the
						Department.
IX. Facility policies and procedures to address inappropriate
						resident
behavior, including resident to resident abuse, should include
						all of
the above outlined actions.
X. To determine resident's emotional adjustment to the nursing
						facility,
including his/her general attitude, adaptation to surroundings,
						and
change in relationship patterns, the following areas should
						be
evaluated:
1. Sense of Initiative/Involvement
Intent: To assess degree to which the resident is
involved in the life of the nursing home and takes
initiative in activities.
Process: Selected responses should be confirmed by the
resident's behavior (either verbal or nonverbal) over the
past seven days. The primary source of information is the
resident. Secondarily, staff members who have regular
contact with the resident should be consulted (for
example, nursing assistants, activities personnel, social
work staff, or therapists if the person receives active
rehabilitation). Also, consider how resident's cultural
standards affect the level of initiative or involvement.
Definition: At ease interacting with others--Consider how
resident behaves during time you are together, as well as
reports of how resident behaves with other residents,
staff, and visitors. Does resident try to shield
himself/herself from being with others? Does he/she spend
most time alone? How does he/she behave when visited?
At ease doing planned or structured activities--Consider
how resident responds to such activities. Does he/she
feel comfortable with the structure or restricted by it?
At ease with self-initiated activities--These include
leisure activities (for example, reading, watching TV,
talking with friends), and work activities (for example,
folding personal laundry, organizing belongings). Does
resident spend most of his/her time alone, or does
resident always look for someone to find something for
him/her to do?
Establishes his/her own goals--Consider statements
resident makes like, "I hope I am able to walk again," or
"I would like to get up early and visit the beauty
parlor." Goals can be as traditional as wanting to learn
how to walk again following a hip replacement, or wanting
to live to say goodbye to a loved one. Some things may
not be stated
Involvement in life of the facility--Consider whether
resident partakes of facility events, socializes with
peers, discusses activities.
Resident accepts invitations into most group
activities--Is resident willing to try group activities
even if later, deciding the activity is not suitable and
leaving? Does resident regularly refuse to attend group
programs?
2. Unsettled Relationships
Intent: To indicate the quality and nature of the
resident's interpersonal contacts (that is, how resident
interacts with staff members, family, and other
residents).
Process: During routine nursing care activities, observe
how the resident interacts with staff members and with
other residents. Do you see signs of conflict? Talk with
direct-care staff (for example, nursing assistants,
dietary aides who assist in the dining room, social work
staff, or activities aides) and ask for their
observations of behavior that indicate either conflicted
or harmonious interpersonal relationships. Consider the
possibility that the staff members describing these
relationships may be biased.
Definition: Covert/open conflict with and/or repeated
criticism of staff--Resident chronically complains about
some staff members to other staff members; resident
verbally criticizes staff members in therapeutic group
situations, causing disruption within the group; or
resident constantly disagrees with routines of daily
living. (Note: Checking this item does not require any
assumption about why the problem exists or how it could
be remedied.)
Unhappiness with roommate--Includes frequent requests for
roommate changes, grumbling about roommate spending too
long in the bathroom, or complaints about roommate
rummaging in another's belongings.
Unhappiness with residents other than roommate--Includes
chronic complaints about the behaviors of others, poor
quality of interaction with other residents, lack of
peers for socialization. This refers to conflict or
disagreement outside of the range of normal criticisms or
requests (that is, beyond a reasonable level).
Openly expresses conflict/anger with family or close
friends--Includes expressions of feelings of abandonment,
ungratefulness, lack of understanding, or hostility
regarding relationships with family/friends.
Absence of personal contact with family/friends--Absence
of visitors or telephone calls from significant others in
the last seven days.
Recent loss of close family member/friend--Includes
relocation of family member/friend to a more distant
location, even temporarily (for example, for the winter
months); incapacitation or death of a significant other;
a significant relationship that recently ceased.
3. Past Roles
Intent: To indicate recognition or acceptance of feelings
regarding role or status now that the person is in the
nursing home.
Definition: Strong identification with past roles and
life status--This may be indicated, for example, when
resident enjoys telling stories about own past; or takes
pride in past accomplishments or family life; or prefers
to be connected with prior lifestyle (for example,
celebrating family events, carrying on life-long
traditions).
Expresses sadness/anger/empty feelings over lost
roles/status--Resident expresses feelings such as "I'm
not the man I used to be" or "I wish I had been a better
mother to my children" or "It's no use; I'm not capable
of doing the things I always liked to do." Resident cries
when reminiscing about past accomplishments. Be careful
not to take the reaction out of context.
Process: Discuss past life with resident. Use
environmental cues to prompt discussions (for example,
family photos, grandchildren's letters or artwork). This
information may emerge from discussions around other MDS
topics (for example, Customary Routine, Activity
Pursuits, ADLs). Direct-care staff may also have useful
insights relevant to these items.
XI. To determine resident's mood and behavior patterns, the
						following
elements should be considered:
1. Sad or Anxious Mood
Intent: To identify the presence of behaviors that may be
interpreted as physical or verbal expressions of sadness
or anxiety.
Definition: A distressed mood characterized by explicit
verbal or gestural expressions of feeling depressed or
anxious (or a synonym such as feeling sad, miserable,
blue, hopeless, empty, or tearful). This may be a
disorder of mood which is usually, but not always,
accompanied by a painful mood of such magnitude that it
calls for relief because it is severely, or
unnecessarily, distressing or threatening to physical
health and life, or interferes with functional
performance and adaptation. These symptoms may be
preceded by anger or withdrawal.
Process: Determine if resident expressed signs of a sad
or anxious mood over the past 30 days. Draw on your own
interactions with the resident. Pay particular attention
to statements of direct-care staff, social workers, and
licensed personnel who may have evaluated the resident in
this area. Does the resident cry or look dejected
(unhappy) when no one is talking with him/her? When you
talk with the resident, does he/she sound hopeless,
fearful, sad, anxious? Does the resident report feelings
of worthlessness, guilt? Does the resident appear
withdrawn, apathetic, without emotion?
If you are unsure, seek confirming information from
others who regularly come in contact with the resident
(for example, activities professionals, social workers,
or family members).
2. Mood Persistence
Intent: To identify a persistent sad/anxious mood that
has existed on each day over the last seven days and was
not easily altered by attempts to "cheer up" the resident.
Process: Normally, these moods apply to one or more of
the indicators mentioned above of sad/anxious mood.
3. Problem Behavior
Intent: To identify the presence of problem behaviors in
the last seven days that cause disruption to facility
residents or staff members, including those that are
potentially harmful to the resident or disruptive in the
environment, even though staff and residents appear to
have adjusted to them (for example, "Mrs. R's calling out
isn't much different than others on the unit; there are
many noisy residents.")
Definition: Wandering--Movement with no identified
rational purpose; resident appears oblivious to needs or
safety. This behavior must be differentiated from
purposeful movement--for example, a hungry person moving
about the unit in search of food; pacing.
Report on the most disruptive resident behavior across
all three shifts. Code "1" if the described behavior
occurred less than daily and "2" if the behavior occurred
daily or more frequently.
4. Resident Resists Care
Intent: Identify problem behaviors related to delivering
care/ treatment to the resident. These behaviors are not
necessarily positive or negative; they provide
observational data. They may prompt further investigation
of causes in the care-planning process (for example, fear
of pain, fear of falling, poor comprehension, anger, poor
relationships, eagerness to participate in care
decisions, past experience with medication errors and
unacceptable care, desire to modify care being provided).
Process: Consult medical record and primary staff
caregiver. How does the resident respond to staff
members' attempts to deliver care to him/her? Signs of
resistance may be verbal and/or physical (for example,
verbally refusing care, pushing caregiver away,
scratching).
5. Behavior Management Program
Intent: Determine if a behavior-management program is in
place wherein staff members identified causal factors and
developed a plan of action based on that understanding.
There must be evidence of structure and continuity of
care in the program (for example, written documentation).
This category does NOT include behavioral management by
physical restraints or psychoactive drugs, if these are
the only interventions used.
Process: Consult medical record (including current care
plan); consult primary caregiver.
Examples
Mrs. S has been observed on numerous occasions to hit,
shove, and curse the woman seated next to her at each
meal. After observing the pattern of Mrs. S's behavior
for several days, staff noticed that her tablemate was in
the habit of moving toward Mrs. S to take food from her
tray. As a result of their observations, the primary
nurse made a change in seating arrangements. (Note:
Although staff might have increased the amount of food
provided at meals, the real issue was the taking of food;
Mrs. S would not want to share with others, no matter how
much food she was given.) Mrs. S does not tend to ask
staff for help when she is annoyed; she takes direct and
aggressive action on her own. Now that staff understand
this behavior, they are aware of the need to be vigilant.
Code "1" for Yes.
Provisions were made for safety monitored wandering for
Mr. V (including use of "secure bands" that activate an
alarm if he wanders away from a designated area). Mr. V
does not really disturb others (he does not go into
others' rooms). Without this "band," however, staff lost
track of him and he was in danger of harming himself if
he got off the unit (a busy street is very near his
unit). Code "1" for Yes.
6. Change in Mood
Intent: Determine whether the resident's mood changed in
the past 90 days, that is, onset of recent mood problem
or changes in a longstanding problem. Changes may have
been expressed verbally or demonstrated physically; they
include increased/decreased number of signs/symptoms, or
increase/decrease in the frequency, intensity, or
persistence of sad or anxious mood.
Examples
Mrs. D has a long history of depression. Two months ago
she had an adverse reaction to a psychoactive drug. She
expressed fears that she was going out of her mind and
was observed to be quite agitated. Her attention span
diminished and she stopped attending group activities
because she was disruptive. After the medication was
discontinued, these feelings and behaviors improved. She
is better than she was, but still has feelings of
sadness. Code "1" for "Improved." Mrs. D is now better
than her worst status in the 90-day period, but she has
not fully recovered. (Note: If the mood problem was no
longer present due to the continued efficacy of the
treatment program, the correct code would also be "1"
(Improved).)
Mrs. Y has bipolar disease. Historically, she has
responded well to lithium and her mood state has been
stable for almost a year. About two months ago, she
became extremely sad and withdrawn, expressed the wish
that she were dead, and stopped eating. She was
transferred to a psychiatric hospital. For the last 30
days (following readmission), Mrs. Y has improved and her
appetite is restored. Code "1" for Improved.
7. Change in Problem Behavior
Intent: Determine if problem behaviors or resistance to
care increased/decreased in number, frequency, or
intensity in the past 90 days--that is, onset of recent
behavior problems or changes in a more longstanding
problem.
Changes can occur in many different areas, including (but
not limited to) wandering, verbal or physical abuse,
socially inappropriate behavior, or resistance to care.
Changes can be exhibited as increases/decreases in the
number of signs/symptoms and/or change in the frequency
or intensity of the behavior(s).
Process: Review nursing notes, medical records, and
consult with primary staff caregiver.