Top 10 Questions to Ask to Get Your Behavior Management Program on Track

Patient_RunningDo you have residents yelling their heads off? Wandering excessively into the wrong rooms? Elopements? Resisting care? Exhibiting sexually inappropriate behaviors?  Or, maybe even a new resident-to-resident altercation each day?  Then, I hate to break it to you, but maybe your behavior management program needs a little overhaul .  Here are a few questions to ask yourself to  help evaluate your program.

(1) Who’s tracking your behaviors? Oh, the nurses are capturing behaviors on the antipsychotic/psychotropic drug side effect  behavior monitoring flowsheet, right?  Actually, I doubt you’re capturing 25% of the actual behaviors in your building. For one thing, your CNAs aren’t telling your nurses about the behaviors because they gotten used to them, so they don’t know to document.  For another, the rest of your staff – activities, business office, etc. – don’t know what behaviors should be reported. So, one of the first things to cover is staff education on identification, reporting, and management of behaviors.

(2) How are non-nursing personnel going to help you ensure resident behaviors are documented? Will they tell the nurses or do they have a notebook that they can directly document in? You must ensure you have a system in place to allow everyone on your team to help you capture the behaviors.

(3) Is your interdisciplinary team reviewing the documentation weekly?  If not, they should be.  You should review the behavior flowsheet, the notebook if you have one, the nursing and social services notes, the ADL books, the telephone orders, and the MAR to see if we are giving the PRNs.  I even came across a building once where a nurse was giving Phenergan to a resident nightly because he “needed it to calm down and go to sleep.”  Hmmm…

(4) Are you updating the care plan? It’s one thing to identify and actually report the behaviors, but now that you’re getting this information and reviewing it, what are you going to do with it?  Every behavior that is not successfully redirected with current interventions needs the care plan updated with new interventions.  Think about it.  If the interventions we have in place aren’t working, what then?  State will always look to see if you have updated the care plan, so make sure you do.

(5) Are you updating the CNA ADL books?  What?  ADL books?  Well, yeah.  The CNAs are the staff members that need this information the most.  I don’t see many of my CNAs opening up the charts and reviewing care plans.  In fact, most assume the care plans are off limits to them and avoid them at all costs.  So, I have to make sure I have a way to deliver the information to my CNAs, the people who are giving direct care to the resident so that they have the correct interventions to implement.  Verbal communication is great and shift-to-shift communication is wonderful, but it’s not enough.  Put the specific behavior we’re monitoring on the ADL sheets with specific interventions that the CNAs can use.  I instruct my CNAs to review the ADL book on their assigned residents every single day, so it takes away any concerns about not getting the correct info.

(6) Do you have any nonpharmaceutical interventions? It’s not all about adding medications.  Sometimes, if we can determine the cause of a behavior, we can redirect that behavior without adding on meds.  I’ve had residents that usually yelled their lungs out respond wonderfully to earphones and a cd of classical music.  Sometimes, it might be overstimulation if you have a resident that likes to sit in a high traffic area…like in front of the nurses station.  Maybe they would benefit from being in less busy areas at certain times of the day.  Sometimes it’s pain, sometimes, the resident is tired and wants to lie back down.  I am always reminded of the story of one resident who would get very anxious around 3 PM everyday and was constantly exit-seeking at that time.  As it turns out, this dementia resident was remembering getting her children off the school bus around that time and was very upset that the staff weren’t allowing her to do that now.  A simple enough solution, after talking with the family, that calmed the resident was to inform her that the children were fine and that they had gotten off the bus at grandma’s.

(7) Is your medical director/primary physician involved?  Or does he just sign the paperwork you need him to sign?  The physician needs to be involved.  he needs to hear what’s going on and make recommendations as needed.  A monthly meeting with the physician to discuss resident behaviors is a great idea.  You should still meet weekly and as needed, but get the doctor involved.

(8) Is your pharmacy consultant involved? We know the pharmacy reviews medications monthly and is supposed to let us know if a resident is taking 2 medications that may counteract each other or cause unwanted side effects.  Letting the pharmacist come to your monthly behavior review with the MD is another great tool to allow you to get the most out of your resources.  The communication they can have is invaluable.

(9) Is the family involved? We can wonder all day long why Mr. Jones likes to lie on the floor and put his hands in the air, but if we didn’t talk with the family and learn that Mr. Jones loved to work on old cars as a hobby, we’d be missing key information.  The family can provide numerous facts and insights about the resident that can help you create the best interventions for your residents.

(10) Is there a mental health professional involved? I’m not sure about you, but I never say that we’re mental health experts.  Rather, we’re longterm care experts.  Sometimes, we are going to have issues that come up that we just don’t know how to tackle due to the resident’s mental health diagnosis.  You need to contract with a mental health group with a psychiatrist who specializes in mental health and geriatrics. These professionals can offer interventions that you may never have dreamed of other wise.

Bonus questions:

(11) What labs have been done?  Before we get all trigger-happy and begin administering Ativan and Haldol (which I really don’t like for geriatrics), let’s stop and see if there might be something simple that needs attention.  A UTI perhaps?  Most of us who may get a UTI really don’t have severe symptoms and we can easily get it treated.  A UTI for a geriatric resident, however, can mean big problems.  Delusions, hallucinations, combatitiveness, etc, are not uncommon as a result of a urinary tract infection.  It can create all kinds of behaviors and havoc.  So, make sure you pull your labs first.

(12) What other resources do we have?  Sometimes, even the best interventions that we develop may not work.  At this point, you have to be concerned with the safety of your other residents as well as that of the resident with the behaviors.  I have often utilized an inpatient mental health facility when we’d exhausted all in-house interventions.  Yes, the resident does have to go out for a couple of weeks, but often, with the med reviews and interventions done at the inhouse mental health facility, we’d be better able to manage the resident when they returned to my facility.

Ok, that’s more than 10, but these are all vital questions to ask in order to make your behavior management program as effective as possible.  Good luck!

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