Compliance • Audits/Analysis • Reimbursement/Regulatory • Education/Efficiency
With the nationwide focus on antipsychotic drug reduction, providers are seeing an increase in behaviors, especially with the dementia population. Thus, this Quality Measure is being impacted in facilities with a large dementia population. Many facilities are updating behavior management techniques and procedures to meet the increasing number of residents with dementia and behaviors. Surveyors are taking notice and are looking to see how facilities are managing challenging behaviors.
All the patients that triggered for this Quality Measure in the facility have a dementia diagnosis.
So, let’s take a deeper dive into the Measure Specification for this Quality Measure. This measure reports the percentage of long-stay residents who have behavior symptoms that affect others during the target period.
From the RAI Manual:
Long-stay residents with a selected target assessment where any of the following conditions are true:
- The presence of physical behavioral symptoms directed towards others (E0200A = [1, 2, 3]).
- The presence of verbal behavioral symptoms directed towards others (E0200B = [1, 2, 3]).
- The presence of other behavioral symptoms not directed towards others (E0200C = [1, 2, 3]).
- Rejection of care (E0800 = [1, 2, 3]).
- Wandering (E0900 = [1, 2, 3]).
All residents with a selected target assessment, except those with exclusions.
Resident is not in numerator and any of the following is true: 1.
- The target assessment is a discharge (A0310F = .
- E0200A is equal to [-, ^].
- E0200B is equal to [-, ^].
- E0200C is equal to [-, ^].
- E0800 is equal to [-, ^].
- E0900 is equal to [-, ^].
There are no covariates to this Quality Measure.
So, what can a facility do if there are a significant number of residents triggering for this Quality Measure?
- Develop an “Action Team” consisting of direct care staff, leadership from nursing, rehab, physicians/nurse practitioners, activities staff, and pharmacists.
- Develop an Assessment Process.
- Speech and Occupational Therapy utilize standardized cognitive assessments that can identify the stage of dementia each resident is functioning. The Global Deterioration Scale and Allen Cognitive Assessments are used to identify clinical characteristics of dementia. The Allen Assessment identifies if there is any new learning ability and identifies patient strengths.
- Care plans and teaching programs for staff can be developed based on the results of the assessments to assist staff with managing behaviors and the use of appropriate approaches and cueing strategies to decrease triggering of behaviors.
- Therapists can play a lead role in assessing each patient’s sensory and neurological processing and determine if there is a sensory component of the behaviors. Is the patient overreacting to stimuli in their environment that are threatening? Room temperatures, items of clothing, noises such as a crowded dining room, lights that seem too bright can all trigger catastrophic reactions in a person with dementia, causing them to act out verbally or physically. Many people with dementia have an impaired sense of balance, causing an extreme fear reaction to movement. Therapists can develop “sensory diets” consisting of sensory activities designed to calm an agitated resident, stimulate a somnolent resident and assist the resident in maintaining control of their emotions during ADLs or meals.
- Activities departments can design social activities for patients grouped together by cognitive levels.
- Social Services and Activities assess each resident from admission to identify past social history and interests. This information is shared with the Action Team and the activities are incorporated into the facility programming.
- Each discipline sets up the care plan, goals and interventions based upon that patient’s dementia level and functional level.
Care plans for behaviors can be challenging to write. The most important thing to depict is the problem statement that identifies the resident’s problem that is resulting in the untoward behavior. It should not be a statement identifying how the behavior creates a problem for the staff.
For example, instead of writing a problem statement such as the following: “resident strikes out at the caregivers during care” considering do a root cause analysis to determine why the patient is striking out during care.
Therapy sensory assessments can be used to analyze behaviors. Is she/he in pain, cold, fearfully, anxious, unsure of what is happening? With dementia, many times the behaviors occur as the result of an “unmet need” and the key to managing the behaviors is identifying what that unmet need is and addressing it. This allows the goals to be accurately aimed at the unmet need and not the behavior exhibited. A problem statement of “resident strikes out at the staff” may result in a goal of “resident will hit no more than one staff member per week”. While this goal is measurable and certainly no staff member wants to get hit, it is not aimed at the resident’s underlying problem.
The development of interventions requires an interdisciplinary approach and direct care staff (CNAs) should be asked for input. For example, with a patient who tries to pinch and scratch the staff during incontinent care, a night shift CNA may find that by handing the patient rosary beads prior to care, the preoccupation with rolling the beads in her fingers and reciting her prayers prevents aggressive behaviors. This is valuable information to share with the other team members and include in the care plan (instead of the blanket statement of redirect as indicated).
Harmony Healthcare International (HHI) is available to be a resource to the facility and assist with the identification and development of systems and programs for the betterment of patient care and operational efficiencies. For help better understanding Quality Measures, you can contact us by clicking here. Also, join us in person for our upcoming MDS Competency Courses (CHHi-MDS). Click here to see the dates and locations.
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