Eliminating Restraints and Alarms by Engaging the Whole Person

Transcription

1 Eliminating Restraints and Alarms by Engaging the Whole Person Carmen Bowman, MHS Regulator turned Educator EDU-CATERING Catering Education for Compliance and Culture Change in LTC

2 Why restraints? Who has fallen in the last year? Don t let them get up. ******** Joanne Rader What are we saving the hips for if we don t let people use them? Joanne Rader Restraints are not used in other countries why?

3 Types of Restraints Least restrictive devices Pros and Cons

4 Outcomes of Restraints Physical: Cardiac overload Bone loss Edema Skin trauma Pressure ulcers Malnutrition Contractures Increased infection Psychological: Agitation Aggression Depression Increased confusion Social isolation Traumatic memories From the CFMC webinar with Joanne Rader 2008

5 Main outcome = decreased mobility which leads to: PAIN big issue on MDS Increased risk for DVT after surgery Increased risk for falls due to: Decreased: ROM, pulmonary function, balance, strength, shortened tendons, contractures, etc. Decreased mobility leads to increased constipation with increased use of meds with increased side effects. See the circle? Decreased mobility leads to constipation which can lead to fecal impaction which IS a sentinel event. Decreased mobility can lead to pressure ulcer which leads to pain another circle pain, treat pressure sore

6 Most of us could not achieve quality of life if we had to be dependent upon another person s availability for our mobility. Give up driving for a week Theresa Laufmann Co-DON Oakview in Freeman, SD

7 Why alarms? Least restrictive devices Pros and Cons

8 Results from using alarms Lack of sleep, wake up the resident and roommate Cause one to not move pressure sores Psychological harm Physical harm Sit down reacting to the restraint not the needs of the person Taken from From Institutional to Individualized Care four part CMS satellite broadcast series now available from the Pioneer Network at

9 Are restraints working? Are alarms working? Have they DECREASED falls? Is your fall rate LOWER due to restraints or alarms?

10 The Oakview Terrace Story From the 2008 CFMC Restraint Reduction Webinar and the restraint-free home called Oakview Terrace in Freeman, SD: falls falls Less falls, guess why? After removing all restraints including alarms, falls decreased! Also attributed to consistent staff and education. Want less falls? Webinar, Jan webinar

11 No Evidence to Support Alarm Use From the work of Joanne Rader, Barbara Frank and Cathie Brady 2007: There is NO evidence to support alarms usefulness in preventing falls or injuries. Staff would have more time for individualized care if they were not responding to so many alarms. What is most people s response and experience with alarms??? Alarms were meant to be temporary. How many of you use alarms?

12 Time is used (wasted?) with alarms? Assessment Educate staff Implement Monitor Monitor alarm works Notify family, physician, resident Reassess regularly or with sig. change Determine what type of alarm How much time is spent on the alarm versus getting to the resident and learning about why they are getting up.

13 Alarms affect: Sleep Noise Wrong room War siren Staff report feel bruised /stressed Staff admit grow a tolerance for it and tend to ignore or not run so fast Reactive What about proactive?

14 The Cost of Care Incontinence Pressure ulcers Mood/behaviors Weight loss Dressing and grooming Assistance with ambulation Equipment Contractures Referrals to therapists The cost of alarms! How often must you replace? Will this affect your paycheck?

15 Tag F221 Physical Restraints Tag F222 Chemical Restraints The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident s medical symptoms.

16 Convenience is defined as any action taken by the facility to control a resident s behavior or manage a resident s behavior with a lesser amount of effort by the facility and not in the resident s best interest.

17 F323 Accidents While alarms can help to monitor a resident s activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. New alarm that comes with lights good or bad?

18 Tag F155 Right to refuse medical treatment Include restraints? Include alarms?

19 Tag 252 Homelike, check this out Good practices that de-emphasize institutional character include the elimination of: overhead paging piped in music audible alarms

20 What is lacking?

21 Becoming Well Known Is this happening?

22 Becoming Well Known Pioneer Network value: Know the person Tag F272 Comprehensive Assessment Tag F279 Comprehensive Care Plan OBRA 87 promotes individualized care Isn t it what we all want???

23 Are you really doing a comprehensive assessment? Do you really get to know the person? First, do you ask questions about his/her life s routine and preferences? Second, if you ask, do you honor them? Or, is it more like well, that s nice but this is our schedule suitcase at the door

24 "Behaviors are not problems, behaviors are messages." Rose Marie Fagan Found on the floor, on his knees Meeting needs Help me, help me Anticipating needs

25 Is it fair to even call them behaviors? Stressors? Dis-stressors?

26 What would we need to know about you NOW to take good care of you later? Preferences, not problems

27 How do we get to know these things? The PERSON The family/friend Form they could complete, then interview Your observations

28 Truly knowing another Your Care Plan Your Mom s Care Plan Fill in the GAP Ever go to a funeral and find out something you didn t know about one of your residents?

29 What else? What else should we be assessing to get to know our residents better? Ethnicity Daily routine Daily pleasures Relationships How should we be assessing medical conditions better/softer? Priorities Passions Pet Peeves Who I am What I love to do

30 Activities or Engagement? Why do we release restraints at the dining room table three times a day? Let s replicate that

31 Activities F Tag 248 Activities The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the and the physical, mental, and psychosocial well-being of each resident.

32 Activities F Tag 248 Activities The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.

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34 Problem Goal Interventions

35 Care Planning Activities Traditional Care Plan = Problems Medical/nursing care plan model The regulation requires activities be based on INTERESTS! Free your recreation/activity staff! Time to get beyond 3 activities a week! New CMS interpretive guidelines even say so! A NEW DAY!

36 INTERESTS, Preferences, Needs Goal Approaches

37 Creativity Is it lacking? Examples Highest Practicable

38 Highest Practicable F Tag 279 the second paragraph The care plan must describe the following: o The services that are to be furnished to attain or maintain the resident s highest practicable physical, mental and psychosocial well-being.

39 Highest Practicable Are we good at identifying highest practicable or bad? Examples Tag Work

40 Is it about ENGAGEMENT, meaningful engagement, or activities.

41 Engagement vs. Disengagement Activity programming or Living Life? The Chateau Assisted Living Residence Englewood, CO

42 Gardening and Sweeping

43 Sewing and Ironing That s living life!

44 And engagement is personal Different for each of us. Highest Practicable - Kent s kisses

45 And engagement must be done by all staff (not only activities staff they can t do it alone)

46 F Tag 248 Activities The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. It is not possible for a few people in an Activities department to be able to provide individualized activities for the entire population of the facility, therefore, the writers of the regulation chose to make it the responsibility of the facility as a whole to fulfill this important mandate of the OBRA 87 law. CMS Surveyor Training

47 The Importance of Activities NOTE: For residents with no discernable response service provision still expected. Activities can occur at any time Activities are not limited to formal activities provided by activity staff Can be activities provided by other staff, volunteers, visitors and family. All relevant departments should collaborate to develop/implement a program for EACH resident. (Wow!)

48 Possible Adaptations CMS training to surveyors: The guidance contains a lengthy list of adaptations a facility might use. Visual impairment Hearing impairment Physical limitations Use of only one hand Cognitive Impairment One-TO-Ones NOTE: length, duration and content determined by needs of individual!

49 More Possible Adaptations Language barrier Resident terminally ill NOTE: Some prefer to be alone. This does not constitute noncompliance. (Amen!) Resident with pain Prefers to stay in room or unable to leave CMS to surveyors don t write off Varying sleep patterns New resident Short-stay resident Younger resident Diverse ethnic or cultural backgrounds Do you assess a person s ethnic culture? Handout For each of your residents, consider this list of adaptations. Do any fit? Excellent examples on CMS satellite broadcast

50 Activity approaches for residents with behavioral symptoms Constant walking (old term = wandering) Name calling, hitting, kicking, yelling, biting, sexual behavior, compulsive behavior Disrupts group activities Goes through others belongings

51 Behavior activity interventions Withdrawn from previous activities/isolates Excessively seeks attention Lacks awareness of personal safety Delusional and hallucinatory Let this list be helpful to you! Outcome of intervention Endnotes/Resources!

52 CMS Tag F248 Investigative Protocol: Interviews Resident/Representative Activity Staff Social Service Staff CNA Nurse How do you ensure resident is involved in activities of choice when activity staff are unavailable?

53 Principle Five The Antidote to Boredom... An Elder-centered community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom. Staff get bored too

54 Give Permission But I ll get in trouble if I do, or if I don t Creating an atmosphere of permission for staff involvement and spontaneous activities Educate administrator and managers Really, the activity director should NOT be leading inservices on the new guidelines WHY?

55 Artifacts of Culture Change tool: Workplace Practices Garden Club 60. Activities, informal or formal, led by staff in other departments Invited, encouraged, mandated (?) involvement Mandated spontaneity Share the list of residents who need more, all staff have special relationships Let needs be known Tap into team members interests

56 What does engagement look like? Conversation Holding a hand instead of saying sit down repeatedly Animal Other person Bird, aviary, fish tank Outside Activity of interest that fits the person Past roles Something makes each of us tick

57 Engagement for the Gardner Card player Game player Word game player TV watcher Computer person Sports player Sports fan Physically active person Dancer Business person Writer Cook/chef Homemaker Woodworker Artist Seamstress Crafter

58 Outdoorsman/woman Political activist Gift giver Photographer Handiwork er Handyman Movie watcher Traveler Reader Music lover Animal lover Volunteer Faith is important Person who speaks another language Debater/discusser Social Butterfly Loner

59 Individualized Engagement Consider a mix of groups, 1:1 and independent according to THE PERSON

60 Individualized Engagement/My Day and my Highest Practicable My Day:

61 Ideas for making it work by all Consistent /dedicated staff Expectation of all staff Empowering and educating all staff Smaller living environments neighborhoods/households For more information on both the Neighborhood and Household Model obtain The Stages Tool developed by Les Grant and LaVrene Norton available from Action Pact at Sensory Stimulation Kits/Personal Engagement Kit

62 Minimizing the Risk of Fall Injuries 1. Increase observation 2. Improve strength (restorative, including people with dementia) 3. Environmental supports From Everyone Wins: Quality Care Without Restraints video series 1995

63 When is Increased Observation Needed? Shift change? Sundowning? Evenings? Nights? Weekends? Depends on the person? In general? Hourly rounds. Including all staff including housekeeping and storing supplies in resident rooms!

64 What could be done at these times? Consistent staff Shared roles of nursing (1/2 time) and activities (1/2 time) Restless? Get them up, will just get out of bed anyway and maybe fall. Engage them. Nurses do charting in the hall so can see better. Increased monitoring at those times managers, others involved, effective use of volunteers and families. Engagement items available that also promote strength and mobility (!) Music via headphones Individualized Care Everyone Wins! 1995

65 The benefits of mobility far outweigh the risks of falls. Our falls DECREASED after restraints were eliminated! Oakview Terrace in South Dakota Shortest policy you can write: In honor of resident s dignity, no restraints will be used. *The Freedom Committee St Barnabas Senior Living Services Chattanooga, TN *Both physician and administrator approval for any restraint. *24 hour sitter as a last resort rather than applying restraints! *Increased staffing. * My job was not to get in the way medical director. Residents deserve this. Would you agree?

66 Perceived reasons not to eliminate alarms: The nursing staff feels they will be held responsible for resident falls Staff fear they will be targeted for reprisal Administrators: We ll be sued.

67 Remaining Free You will get: a family member demanding a resident demanding a physician demanding even perhaps a surveyor demanding them Keys: High involvement of resident and family Keeping physicians informed of your philosophy and what you do instead of restraints and alarms Create a policy of the nursing home, all adhere to and not on anyone s whim what to do Ongoing reminding of why and that we re not going back

68 Resources 2008 webinar: Restraints, Joanne Rader and Oakview Terrace CFMC.org 1/20/10 webinar: Rethinking the Use of Restraints and Alarms SDFMC.org Upcoming Action Pact book Eliminating Restraints and Alarms by Engaging the Whole Person by Laufman & Bowman to be published 2011 Upcoming Pioneer Network Integrating MDS 3.0 webinar series: February 9, 2012: Promoting Mobility and Reducing Falls by Individualizing Care and Eliminating Alarms with Joanne Rader March 22, 2012: Individualizing Dining: New Practice Standards with Carmen Bowman April 19, 2012: Smooth Transitions in Care: Getting New Residents Off to a Good Start with Cathie Brady

69 Changing the Culture of Care Planning: a person-directed approach Covers: Regulatory Support Individual Care Planning I Care Plans Narrative Care Plans Includes: Sample IN2L Visual Care Plan Available from Action Pact at

70 New resource: SOFTEN the Assessment Process Workbook and DVD culturechangenow.com Support Simple Pleasures Offer Options Foster Friendships Tie-in to Tasks Equalize Everyone Normalize Now

71 Living Life to the Fullest: A Match Made in OBRA 87 Getting to Know You assessment Assessing Psychosocial Needs Assessing a person s ethnic culture Assessing highest practicable level of wellbeing Activity programming according to interests, not problems MEANINGFUL ACTIVITY ASSESSMENT incorporates: Tag 248 Interpretive Guidance, MDS 3.0 and culture change practices. Sold as a kit by Action Pact at culturechangenow.com

72 Quality of life: The Differences between Deficient Practice, Common Practice and Culture Change Practice Section at F241 Dignity on Using Dignified Language Available from Action Pact at

73 Regulatory Support for Culture Change Available from Action Pact at

74 Soften the Assessment Process Workbook with Learning Circle questions Training DVD of how professionals of differing disciplines used the SOFTEN techniques: Support Simple Pleasures Offer Options Foster Friendships Tie-in to Tasks Equalize Everyone Normalize Now culturechangenow.com

75 Available Now: Special Features: Written to residents/ householders and staff Scrapbook style Learning Circle questions for residents and families Hard cover, 10X14 size Coffee table book culturechangenow.com

76 Friday, January 20, 2011 The New Life Safety Code 2011 Changes Every 3 rd Friday 1 jam-packed hour Culture change training directly into your home and to your team Sponsored by Action Pact culturechangenow.com Guest: Amy Carpenter, AIA, LEED BD+C, Life Safety Task Force Member, SAGE Board Sec. Starting Feb. Series on the New Dining Practice Standards

77 Q & A, Comments?

78 So, who s going to be the 1 st no restraints and no alarms state? The 1 st no bib state? The 1 st no get up state? The 1 st state with 100% Artifacts tool completed? EDU-CATERING: Catering Education for Compliance and Culture Change in LTC carmen@edu-catering.com