The Interpretive Guidance (IG) states that all staff must have the ability to effectively interact with residents and implement person-centered approaches to care. This means that staff:
- Effectively communicate with residents
- Promote and honor residents’ rights and preferences
- Provide meaningful activities for residents
Staff can successfully do this by implementing an individualized plan of care that incorporates the resident’s:
- Customary daily routine and lifelong patterns
- Preferences and choices
- Individualized interventions to support the resident’s goals and needs
Let’s take a moment to discuss the last bullet. The interdisciplinary team should be aware of information like the resident’s prior history of trauma or substance use so that it can identify potential underlying causes that could lead to the resident’s distress. This means it is important to identify potential triggers to a resident’s behavior and ensure staff are aware of the resident’s individual needs to help prevent retraumatization of the resident. For example, if staff have information about locations or situations where a resident may become distressed, they can hopefully minimize the likelihood of a negative emotional or psychological outcome for the resident.
Don’t forget about effective communication skills. This is an important part of implementing person-centered care and non-pharmacological interventions. If staff ignore a resident who is calling out or insist on performing care for a resident who is resisting ADL care and loudly telling the staff to stop, this is not a recipe for a success.
The final area that needs to be discussed is the importance of staff knowledge of how to address residents’ preferences. Many facilities have been addressing ethnic, cultural and religious preferences/needs comprehensively in recent years by ensuring resident food preferences, activities and preferences related to the provision of care are honored. What likely may need more attention going forward is identifying the skills and competencies that staff many need to address issues related to the resident’s psychological and emotional well-being. We should not assume that since we have been providing dementia care in the facility that staff have the knowledge and tools to provide care for someone with a serious mental illness or someone who has a history of drug-seeking behaviors. Staff need to be knowledgeable about how to care for residents with an increasing range of diseases / disorders in order to competently meet each resident’s behavioral health needs.
The revised advance draft of the Behavioral and Emotional Status Critical Element Pathway indicates that there will be many opportunities for surveyors to observe how your staff are interacting – or aren’t – with residents who have behavioral health needs. If a potential issue is identified, this can be problematic, especially when the surveyor then reviews the staff’s records. Have you provided them with the necessary education and training to meet the specific behavioral health needs of your residents? Reviewing employee files and determining that the required education has not been provided is a common citation at F741. How competent is your staff as a whole in effectively managing behavioral health needs? Remember, it is not just those staff who work on a dementia unit who need to be competent as residents with behavioral health needs are not necessarily only residing on a dementia unit.
Let’s look at some actual survey citations to see how deficient practices have been identified related to sufficient and competent staff.
Standard Survey Citation – F741 S/S: E re: Competency
A facility was cited for failing to ensure that nursing staff received training and were able to demonstrate basic competencies and skill sets to meet the behavioral health needs of its residents, including a resident with sexually inappropriate behaviors and another with a substance use disorder.
The facility did not create and implement a behavioral plan for a resident with known sexual interest in various residents in the facility. For another resident, the facility failed to comprehensively assess and develop individualized behavioral interventions for a resident with a chemical dependence.
A review of the Facility Assessment identified that there was no information regarding sexual behaviors, alcohol and substance abuse, and specific care or practices related to these conditions. Interview with the Director of Nursing confirmed that there was no staff education or competencies for these areas.
Complaint Citation – F741 S/S: D re: Sufficiency
A facility was cited for failure to ensure sufficient staffing for supervision of a cognitively impaired resident with behavioral health needs, resulting in one resident hitting another multiple times with his/her walker. The resident had wandered into the second resident’s room and began ramming her with her walker and laughing, saying that she knew the other resident was scared – and wanted her to be scared. The two residents were immediately separated.
The failure to provide sufficient staffing also increased the potential for future resident-resident altercations to occur. The Statement of Deficiencies notes that on interview, a CNA and an RN both stated that there were too many residents on the unit who wandered and not enough staff to monitor them. On the day of the incident, they were short staffed and could not appropriately supervise the residents, especially the resident who had a history of ramming others with her walker.
If these two examples of actual survey citations do not make you want to reassess how your facility staff is demonstrating their competency in providing services for residents with behavioral health needs or how you are best utilizing your staff to meet the needs of this population, you are probably making a mistake. What you were doing a year ago may not still be working or acceptable today.