Vital Compliance Insights
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Vital Compliance Insights
Understanding the Resident is the First Step to Avoiding Chemical Restraints
Hello, I will be your host. My name is Deanna Fye. I am a registered nurse and healthcare analyst. Let's get started.
Speaker 2:The views or opinions expressed in this podcast are for informational purposes only, not intended as legal or professional advice, and may not represent those of Verity Consulting. Although we make strong efforts to make sure our information is current at the time the podcast episode was recorded, verity Consulting cannot guarantee that all information in this podcast is always complete. All information in this podcast is subject to change without further notice.
Speaker 1:Well, hello everyone and welcome to Vital Compliance Insights Today. We're going to, in this episode, talk about a continued discussion on the CMS objectives, guidance that speaks to the need for avoiding the use of psychotropic medications, and we're going to focus on how comprehensive assessments for the resident in a long-term care facility is critical. Appropriate interventions need to be developed. And then, third part, we'll talk about chemical restraints. But before I get started today, I want to introduce a guest, and so I'll turn it over to Sarah Raminga. Go ahead, Sarah.
Speaker 3:Thank you, dee. Thanks for having me. Just a little bit about myself, my background I'm a licensed speech-language pathologist and have been for 18 years. I worked in skilled nursing and I also worked as a federal contract surveyor.
Speaker 1:Yes, okay, and I've been very fortunate to work with you at Verity Teams in those different capacities. So let's get started. We're going to move this along. There's a lot of information. We can't possibly go into all of it in detail, but let's start off with the use of psychotropic medications. Cms is providing very clear guidance to surveyors to look to determine if it's unnecessary use. Okay, so we'll talk a little bit about that, but I really want to underscore the fact that for any resident, we need to conduct a comprehensive assessment as to symptoms of distress that may lead to the use of psychotropic medications.
Speaker 1:Now I'm not going to get into the detail related to those residents that have a psychiatric diagnosis, such as schizophrenia. I've already touched on that in the prior episode. But here what I want to focus on is a comprehensive assessment. So when you have a new resident admitted to the facility, you have time to get to know the resident, learn their patterns, learn their preferences, and you've got 48 hours to develop a plan of care. So a resident may come in. You don't know everything. A psychotropic medication may be used, may be needed but you have some time to gather information.
Speaker 1:I want to focus a little bit more on those residents that are living in a facility and there's some changes occurring, whether disease progression or just some, maybe acute changes, and those could be physical, mental, psychological, a variety of changes where we don't know what's happening with the resident. But we're going to all agree on doing a comprehensive assessment. So with that, cms does really focus on that. When they're in the facilities they're going to look for record reviews to see that that has been done, that there's ongoing information collected and so on that note, sarah, I know you bring a very unique body of knowledge. I'm a nurse, you're a speech pathologist. Did you want to comment on this a little bit? Comprehensive assessments.
Speaker 3:Yes, thanks, dee. So, as a speech-language pathologist, I find that it's useful to work with multiple disciplines within a nursing facility. Everyone brings their own unique set of eyes and there's so much value to everyone's personal and professional experiences that play a role in determining what could be going on with a resident who has a change in condition. Today I'd like to specifically speak on residents or persons living with dementia and how that progression of the disease can cause symptoms of distressed behavior and what we as staff must do about it. Some of the behaviors that I'm speaking of are repetition a resident repeatedly vocalizes or gets up out of a chair. Somebody that wanders, has anxiety, increased agitation or aggression. Someone who sundowns. We have to look deeper than what is the symptom. We need to look at what is the cause. Are these behaviors? Are these true behaviors or are they a means of communication? And I think it helps to remember that the resident is trying his or her best with what they have and to try and respect and support that change.
Speaker 1:Well, I couldn't agree with you more, and some residents. They know there's something wrong. They don't know what it is, but something's wrong.
Speaker 3:Right, exactly, exactly so. That's why I wanted to focus a little bit on figuring out the cause and not just masking the symptom. You know, speech-language pathology can be involved. Nursing, of course, housekeeping, of course, housekeeping, dietary staff, providers, of course, but people that are around that resident, they're not going to be able to get out of the hospital day-to-day. Those are the people that are going to, the staff that are going to be the best, the best helpers with this particular resident that's experiencing distressed behavioral symptoms.
Speaker 3:So as a team, we should look at why get curious? What's going on? Why is this? Why did this change happen? Was there a change in the resident's health status? Did we as caregivers unknowingly trigger this change? Is the resident trying to express a need or want? We figure out where the resident is experiencing these distressed behaviors. What prompts these distressed behaviors to occur, what's happening right before that behavior? When does it happen? Is it happening at night? Is it happening just in the morning or in the afternoon or when certain people are around? Have staff fully assess the residents' wants and needs, distressing behaviors that residents can experience and staff can observe, and what we should do when we see those behaviors, and remembering that an antipsychotic medication should not be the first line of defense, so to say. That would maybe occur down the road if non-pharmacologic approaches were attempted and failed.
Speaker 3:Right, I agree with you totally. Or if the resident is at the strong potential of causing harm to himself or herself or others.
Speaker 1:Absolutely, and we've seen many instances of that occurring in our careers. I mean, what you're really basically saying is you want to create a good baseline assessment who is this person? What's their history? What's happening? You want to look at assessment of various factors Pain what if it's pain? So we all need to come together to look at what's happening, collect the data, make sure it's collected, documented, it's recorded, but not just numbers written down or codes. It's got to be meaningful information, retrievable, and then the team has to come together to analyze it. Okay, Absolutely.
Speaker 1:Yep, and I know in our experiences we've seen logs, tools develop, but really didn't help us to, like you were talking about, what were they doing a few moments prior? So, and I couldn't agree with you more as far as interdisciplinary, multidisciplinary team approach speech pathologist, neuropsychologists, psychiatrists a host of people to help figure out what's happening here with a resident.
Speaker 1:Okay there is an article that I want to reference and we'll upload it to Verity Team's website and the title of it you'll find is Behavioral and Psychological Symptoms in Dementia, because we do see in long-term care facilities a lot of residents who have the dementia-related diagnoses, and this is a really nice article that talks about some approaches to consider, talks about the use of antipsychotic medications and those kinds of things. So it's very nice. I found it to be very helpful. Good review refresher of things. So it's very nice. I found it to be very helpful. Good review refresher, so I make reference to that. Okay, so we've done our assessment. We're trying to figure this out. Let's move Sarah into behavioral-focused interventions that are going to help the resident minimize symptoms of distress, mitigate unpleasant experiences for the resident and to gather information on how they're responding. So do you want to talk a little bit about that?
Speaker 3:as far as appropriate interventions, yes, and this is part of I believe this is part of the assessment. You know this is trying to figure out what is the best individualized approach for this particular resident with these unique distressing behaviors. And in doing that you can find out a lot by interviewing the resident, interviewing family if they have anyone available, finding out what's meaningful to the resident, any nuances that the resident has, what were their routines and their preferences prior to living at the nursing home. Did they have any activities of interest or methods of relaxation? Looking into their personal history can be really helpful. Did the resident have some sort of substance abuse prior? What was their occupation? Did they have any PTSD? Are they a veteran? With that said, I have a few good examples of experiences I've come across as a surveyor, some positive examples A resident who, prior to our entrance to doing the survey, the staff shared with me that a resident would wander at night all night long and they didn't know why.
Speaker 3:They thought something must be wrong. This isn't a typical behavior. Everyone's sleeping right now. So they really did do a deep dive into why this was happening and not just put you know, give the resident a sedative and move on. In doing so, in doing that deep dive, they found out that the resident was a third shift worker for his entire life. He loved working all night. He'd sleep through half of the day and then get up and go back to work, and what's really nice is that the staff didn't try to change that. They didn't try to have him conform to what their expectation was in the nursing facility. Instead, they adapted to his sleep schedule and let him sleep, had him sleep in as late as he'd want to and then be up at night and do activities that he preferred, and that really helped relieve some anxiety for that resident.
Speaker 1:Yeah, and avoided the use of a sedative. Perhaps right and that exactly yes.
Speaker 3:Another example I had to share I would like to share is a particular resident who was wandering around and taking clothing from other residents or towels from the linen closet and folding them. And in doing a deeper dive, staff realized that the resident really enjoyed folding laundry and it was very soothing and calming to that resident. So they provided the resident with a basket full of clean towels and she was able to fold those when she wanted to do that and that allowed her to be happy and then also for others to not be disrupted.
Speaker 1:Right. Sometimes it's simple things to try right.
Speaker 3:Right and you avoid an unnecessary medication that way. I just wanted to give a few examples of approaches to try with a resident. Again, making sure that this is an appropriate attempt, making sure that this is an appropriate technique to attempt. Some of these come from Tipa Snow, who is a great resource in the world of dementia. She has evidence-based techniques and places an emphasis on non-pharmacological support to residents. So please reference her if you are looking to modify some things in your nursing facility.
Speaker 3:Some of the ideas she has are to provide some basic techniques to try with residents are re-approaching if you have provided some sort of intervention and the resident is not responding the way that you were hoping, maybe backing off and trying again at a later time. Yes, Providing some personal space between you and the resident and not just walking into his or her personal bubble. Another one is looking at the resident at eye level instead of looking down at the resident. If the resident is sitting in a wheelchair or armchair in their room. Also, asking permission to engage with the resident can go a long way. So remembering to work with them and not at them at the residents is very important and a very useful way to look at the whole picture.
Speaker 1:Absolutely, I agree, and then you can modify if it worked didn't work, and then make sure we communicate with everyone what's working, what's not working and anything else, before we go moving into the direction of chemical restraints.
Speaker 1:No, I think we're good, all right. Well, we know CMS has made it very clear that FTAG-605 is going to speak to chemical restraints, unnecessary medications. We're going to focus on psychotropic medications here for this discussion. We won't go dig in deep, which we certainly could, but I want to just start off by just indicating that it's really important facilities. Anyone really I mean anyone can use this tool. It's the critical element pathway that was developed by CMS. It's in one of the appendices in the updated state operations manual for state surveyors to use that critical element pathway, which focuses on unnecessary medications, chemical restraints, et cetera. It's a guide to help the surveyor say is there a problem or isn't there? Okay, so you have a resident who has a psychotropic medication ordered. Is it appropriate? They're going to look for evidence of documentation, assessment, all those kinds of things, and if things aren't in place, they're going to start peeling the onion back to find out more what's happening. Why are we using this agent? Have we considered gradual dose reduction, all that? So I won't really dig into that entirely, but I really want to focus on everyone needs to get very well acquainted with that critical element pathway. I will offer a couple of hopefully pearls of wisdom I hope.
Speaker 1:I have had experience as a surveyor where disturbing. But there was a resident who was administered a chemical restraint. The resident wanted to get up at night and mill about. It wasn't convenient to the staff. In fact, the staff told me that and gave this resident a psychotropic medication and it had an adverse outcome. The resident didn't respond well to this very strong medication. It had a sedative effect and the resident, yeah, it wasn't appropriate. There was no attempt at all. Why is a resident wanting up? No assessment, nothing, no interventions. So that was disturbing.
Speaker 1:Also, in my experience as an external monitor working with Verity Team, verity Team has been very busy working with corporate integrity agreements, with the Office of Inspector General and I was able to work with a facility corporation under a CIA for inappropriate use of psychotropic medications and I know, Sarah, you and I work a little bit together on that, but I remember, week after week, spending years with this facility trying to help them essentially put in systems. I mean essentially. There were no systems for avoiding the use of psychotropic medications, understanding why are we using them, and the facility had indicated. Well, we have a lot of residents with behavioral health diagnoses. We have a lot of residents with behavioral health symptoms or such Okay, but there are strategies that you can take such Okay, but there are strategies that you can take that, if you need to use those agents, you've done everything you can to mitigate the use, to prevent the use, excuse me.
Speaker 1:But also you've done gradual dose reduction and you've clearly documented that. So we're going to always look for very strong evidence of a comprehensive assessment, a plan of care that's revised, and we're also going to look for evidence of avoiding the use of unnecessary psychotropic medications. These are very strong drugs, very strong agents. They need to be used in some cases, but they do have an effect on residents. Okay, so it would be important to read the critical element pathway to help make sure that you can ensure that your facility is moving in the right direction, and Verity team has expertise in this area, so that's always a resource there for you. Sarah, did you want to add anything further to chemical restraints, the use of psychotropic medications?
Speaker 3:I think you covered it all, Dee.
Speaker 1:Okay, well, we promised we would keep this kind of succinct here in this episode, so I hope we were able to cover all those three areas Now. If you have any questions, please reach out to VerityTeamcom. Thank you for listening. Thank you for listening. Your time is appreciated. We hope you enjoyed this episode of Vital Compliance Insights and found this to be informative. Please feel free to reach out to Verity Consulting at verityteamcom if you'd like further assistance with your healthcare compliance needs. Stay tuned for the next episode.