New Jersey Administrative Code
Title 8 - HEALTH
Chapter 39 - STANDARDS FOR LICENSURE OF LONG-TERM CARE FACILITIES
Appendix B
Universal Citation: NJ Admin Code B
Current through Register Vol. 56, No. 6, March 18, 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. |
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