Dementia Care Related to F309; A Collaborative Therapy and Nursing Approach

Dementia Care Related to F309; A Collaborative Therapy and Nursing Approach Sharon Gordon RN, BC, CND,LTC, RAC-CT Consultant sgordon@lw-consult.com (717)213-3126 Kay Hashagen PT, MBA, RAC-CT Sr. Consultant khashagen@lw-consult.com (410) 207-8338 1

Disclaimer Although F309 is included in the title, this presentation does not cover F309 in its entirety. It includes some of the changes in F309 relating to Dementia Care. Please review the entire regulation F309 as it has changed. 2

Regulatory Changes Where do you find Federal Regulations Google: State Operations Manual Appendix PP and add the most current date changes occurred - 2/6/15? November 26, 2014-17 Federal Regulations changed December 12, 2014 2 of the 17 regulations that changed on November 26, 2014 changed again. What were they? F309 Quality of Care focus on Dementia F329 Unnecessary Drugs - Guidelines on when to and when not to give Psychotropic medications Have you educated all Licensed nurses and Nursing Assistants on these two regulations? 3

Other Changes Dementia Care focused survey - citing poor dementia care Stages of Dementia Now defined Global Deterioration Scale or GDS My choice Why? Language can be understood by resident family members The Plan of Care can be developed around what stage they are in if the stage changes a Significant Change is determined licensed therapists determine the stage Family members use it to see progression of their loved one s disease 4

What is Dementia?? Definition Dementia is a broad category of brain diseases that cause long term loss of the ability to think and reason clearly that is severe enough to affect a person's daily functioning. For the diagnosis to be present it must be a change from how the person was previously. 5

How to Care for Residents with Dementia? Individualized approaches to care is a first line intervention Utilize a consistent process that focuses on a resident s individual need Trying to understand behavior as a form of communication may help to reduce behavioral expressions of distress in some residents 6

How to Care for Residents with Dementia? Care should be individualized to the resident s previous life style People with Dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships 7

How to Care for Residents with Dementia? They also lose their ability to solve problems and maintain emotional control and they may experience personality changes and behavioral problems, such as; Agitation, Delusions, Hallucinations * Do your nurses and nursing assistants have a clear understanding of these terms? Do they identify individual measurable resident behaviors? Do they use them every day in documentation? Example Anxiety vs frequent phone calls? 8

Care for Residents with Dementia Memory loss is a common symptom but by itself does not mean that a person has dementia Doctors diagnose only if 2 or more brain functions such as memory and language skills are significantly impaired without loss of consciousness Dementia is NOT a normal part of the aging process 9

Non Dementia concerns In the SNF there are conditions that may appear as though they are related to Dementia, but they are not. Examples: Adverse drug effects Dehydration -? Diuretics??? New onset of UTI Symptoms of Pneumonia Onset of an acute medical condition 10

Delirium Delirium rapidly develops over a short time period, such as hours or days, and is associated with an altered level of consciousness Delirium has an underlying physiologic cause and can generally be identified through a diagnostic evaluation. Potential causes include but are not limited to, infection, fluid/electrolyte balance, medication, or multiple factors 11

Behaviors Caregivers are EXPECTED to understand or explain the rationale for interventions/approaches to monitor effectiveness Describing details and possible consequences of behaviors helps to distinguish expressions such as: Restlessness or continued verbalization from Potentially harmful actions such as kicking, biting, and striking out at others i.e., resident throwing furniture and chasing after staff 12

Behaviors Medications may be effective when they are used appropriately to address significant, specific underlying medical and psychiatric causes or new or worsening behavioral symptoms When antipsychotics are used without an adequate rationale, or for the sole purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective & can cause; Movement disorders, falls, hip fractures, CVA, TIA and increased risk of death 13

Behaviors Facilities should be able to identify how they have involved residents/families/representatives in discussions about potential approaches to address behaviors and about the potential risks and benefits of psychopharmacological medications This should be documented If the resident lacks family support the type of social services referrals that have been attempted to assist the resident should be documented 14

Behavior Care Plan The Care Plan should reflect the following: Baseline and ongoing details (e.g., frequency, intensity, and duration) of common behavioral expressions and expected response to interventions Specific goals for and monitoring of all interventions for effectiveness in responding to target behaviors/expressions of distrust and For any medications, indication/rationale for use, specific target behaviors and expected outcomes, dosage, duration, monitoring for efficacy and/or adverse consequences and (where applicable) plans for gradual dose reduction (GDR) if an antipsychotic medication is used 15

Dementia Care Focused Survey CMS piloted a focused Dementia Care survey in 2014 in order to more thoroughly examine the process for prescribing antipsychotic medication and assess compliance with other federal requirements related to dementia care practices in nursing homes. 16

Dementia Care Focused Survey The focused survey was piloted to gain new insights about surveyor knowledge, skills and attitudes and ways that the current survey process may be streamlined to more efficiently and accurately identify and cite deficient practice as well as to recognize successful dementia care programs. Key = developing a successful dementia care program 17

Dementia Care Focused Survey Surveyors will observe to see whether staff caring for residents with dementia follow a systematic process for gathering and analyzing information that supports provision of appropriate care and services. The resident, family, or representative must be engaged throughout the process. The resident s record is required to demonstrate that the following six specific care processes are utilized: 18

6 Specific Care Processes 1. Recognition and Assessment Collect detailed information about the resident, such as; 1. How he or she communicates physical needs like pain, hunger, or thirst, as well as 2. How he or she communicates emotional and psychological needs like frustration or boredom (We recommend that quarterly and prn each resident with a Diagnosis of Dementia be assessed by a therapist for their appropriate stage of Dementia as part of their quarterly MDS and that the Care Plan address these concerns) 19

6 Specific Care Processes (continued) 2. Cause Identification and Diagnosis Recognize the presence of co-existing medical or psychiatric conditions or adverse consequences of current medications. Areas needing cause identification are boredom, anxiety related to changes in routine, care routines that are inconsistent with resident preferences, fatigue or lack of sleep, uncomfortable noise levels and other environmental factors, and mismatch of selected activities or routines with the resident s cognitive abilities (We recommend these areas be assessed on an ongoing basis & as part of the Quarterly MDS assessment & GDS assessment) 20

6 Specific Care Processes (continued) 3. Development of Care Plan Include baseline and ongoing details of common behavioral expressions, specific goals, monitoring of all interventions, Indications for medications used for specific target behaviors, and expected outcomes. Include gradual dose reductions of antipsychotic medications. Care plans must address pharmacologic and non-pharmacologic approaches, using a consistent process to manage behaviors, with a focus on the individual s needs and potential behavioral triggers. * (Talk with CNAs) (We recommend individual Care Plan goals and interventions be developed for each stage of Dementia and changes be made with a change in stage) 21

6 Specific Care Processes (continued) 4. Individualized Approaches and Treatment Address causes and consequences of the resident s behavior and interventions used to try to prevent distressing behaviors or symptoms. (We recommend these be identified on the resident Care Plan) 5. Monitoring, Follow-Up, and Oversight Identify the effectiveness of care plan interventions, adjustment of interventions where appropriate, and notification of the physician or medical director in the physician s absence. (We recommend Therapist to also follow-up quarterly and make recommendations for change) 22

6 Specific Care Processes (continued) 6. Quality Assessment and Assurance (QAA) QAA committee members are to; (QAPI) Review resident care policies for the overall approach to caring for residents with dementia and are to Determine how staff comply with the policies, whether staff are trained in communicating with and addressing behaviors of residents with dementia diagnoses, and Whether there are sufficient staff to implement the care plan. Additionally, the QAA committee should ensure that staff collect and analyze data to monitor the effectiveness of pharmacologic and non-pharmacologic interventions. (We recommend QAPI PIPS to address Dementia Care concerns) 23

Dementia Focused Survey Process If your facility s Quality Measure Report flags at 75% or greater for residents receiving antipsychotic medications, the Dementia Focused Survey Team Coordinator will request a list of residents diagnosed with dementia who are receiving, have received, or presently have PRN orders for antipsychotic medications over the last 30 days. Surveyors will interview the administrator, DON, or other staff members, seeking an explanation of how individualized care and services are provided for residents with dementia, and will request copies of policies detailing the use of antipsychotic medications for these residents. 24

Global Deterioration Scale The Global Deterioration Scale (GDS), developed by Dr. Barry Reisberg, provides caregivers an overview of the stages of cognitive function for those suffering from a primary degenerative dementia such as Alzheimer's disease. It is broken down into 7 different stages. Stages 1-3 are the pre-dementia stages. Stages 4-7 are the dementia stages. Beginning in stage 5, an individual can no longer survive without assistance. Within the GDS, each stage is numbered (1-7), given a short title (i.e., Forgetfulness, Early Confusional, etc. followed by a brief listing of the characteristics for that stage. Caregivers can get a rough idea of where an individual is at in the disease process by observing that individual's behavioral characteristics and comparing them to the GDS. 25

Global Deterioration Scale Often therapists use this scale for residents with a diagnosis of Dementia Utilizing stage levels, therapists are better able to develop an individualized functional maintenance plan for the resident. Nursing staff can use the GDS in the plan of care for tips and strategies to interact and communicate with the resident successfully. 26 Barry Reisberg, MD.

Global Deterioration Scale Using the GDS you select the most appropriate global stage based upon cognition and function Stage 1. (No cognitive decline) No subjective complaints of memory deficit Stage 2. (Very mild cognitive decline) (Age Associated Memory Impairment) Subjective complaints of memory deficit, most frequently in following areas: Forgetting where one has placed familiar objects Forgetting names one formerly knew well No objective evidence of memory deficit on clinical interview Appropriate concern with respect to symptomatology Barry Reisberg, MD. 27

Global Deterioration Scale Stage 3 Mild cognitive decline (Mild Cognitive Impairment) Earliest clear-cut deficits Manifestations in more than one of the following areas: May have gotten lost when traveling to an unfamiliar location Co-workers become aware of relatively poor performance Word and/or name finding deficit become evident to intimates May demonstrate difficulty remembering names upon introduction to new people Barry Reisberg, MD.

Global Deterioration Scale Stage 3 (continued) May read a passage or book and retain relatively little material May have lost or misplaced an object of value Concentration deficit may be evident on clinical testing Objective evidence of memory deficit obtained only with an intensive interview Decreased performance in demanding employment and social settings Denial begins to become manifest in resident Mild to moderate anxiety frequently accompanies symptoms 29 Barry Reisberg, MD.

Global Deterioration Scale Stage 4 Moderate cognitive decline (Mild Dementia) Clear cut deficit on careful clinical interview Deficit manifests in following areas: Decreased knowledge of current and recent events May exhibit some deficit in memory of one s personal history Concentration deficit elicited on serial subtractions Decreased ability to travel, handle finances, etc 30 Barry Reisberg, MD.

Global Deterioration Scale Stage 4 (Continued) Frequently no deficit in following areas Orientation to time and place Recognition of familiar persons and faces Ability to travel to familiar locations Inability to perform complex tasks Denial is domain defense mechanism Flattening of affect and withdrawal from challenging situations 31 Barry Reisberg, MD.

Global Deterioration Scale Stage 5 Moderately severe cognitive decline (Moderate Dementia) Resident can no longer survive without some assistance Unable during interview to recall a major relevant aspect of their current life, e.g., Their address or telephone number of many years The names of close members of their family (such as grandchildren) The name of the high school or college from which they graduated Frequently some disorientation to time (date, day of the week, season, etc.) or to place 32 Barry Reisberg, MD.

Global Deterioration Scale Stage 5 (continued) An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse s and children s names They require no assistance with toileting or eating, but may have difficulty choosing proper clothing to wear 33 Barry Reisberg, MD.

Global Deterioration Scale Stage 6 Severe cognitive decline (Moderately Severe Dementia) Largely unaware of all recent events and experiences in their lives May occasionally forget the name of the spouse upon whom they are entirely dependent for survival Will be largely unaware of all recent events and experiences in their lives Retain some knowledge of their surroundings; the year, the season, etc. May have difficulty counting by 1s from 10, both backward and sometimes forward 34 Barry Reisberg, MD.

Global Deterioration Scale Stage 6 (continued) Will require some assistance with ADLs May become incontinent Will require travel assistance but occasionally will be able to travel to familiar locations Diurnal rhythm frequently disturbed Almost always recall their own name Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment 35 Barry Reisberg, MD.

Global Deterioration Scale Stage 6 (continued) Personality and emotional changes occur. These are quite variable and include: Delusional behavior, e.g., may accuse their spouse of being an imposter, may talk to imaginary figures in the environment, or to their own reflection in the mirror Obsessive symptoms, e.g., person may continually repeat simple cleaning activities Anxiety symptoms, agitation, and even previously non-existent violent behavior may occur Loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action 36 Barry Reisberg, MD.

Global Deterioration Scale Stage 7 Very severe cognitive decline (Severe Dementia) All verbal abilities are lost over the course of this stage. Incontinent; Requires assistance with toileting and feeding. Basic psychomotor skills (e.g.,ability to walk) are lost with the progression of this stage Early in this stage words and phrases are spoken but speech is very circumscribed. Later there is no speech at all, only unintelligible utterances with rare emergence of seemingly forgotten words or phrases 37 Barry Reisberg, MD.

Global Deterioration Scale Stage 7 (continued) The brain appears to no longer be able to tell the body what to do. Generalized rigidity and developmental neurologic reflexes are frequently present 38 Barry Reisberg, MD.

Global Deterioration Scale Planning care delivery for care givers is improved when there is staging for residents with Dementia GDS information can be provided to family care givers to help them understand the disease process GDS information is useful in the SNF to provide families and nurses education on the disease process It helps them understand that this is not normal and is in fact a disease which progresses in various predictable stages 39 Barry Reisberg, MD.

From F309 If a psychopharmacologic medication is given, Surveyor interview questions they will ask = What was the person trying to communicate through their behavior? What were the possible reasons for the person s behavior that led to initiation of the medication? What other approaches and interventions were attempted prior to the use of the antipsychotic medication? Was the family or representative contacted prior to initiating the medication? 40

F309 (Continued) Questions Surveyor will ask Was the medication clinically indicated and/or necessary to treat a specific condition and target symptoms as diagnosed and documented in the record? Was the medication adjusted to the lowest possible dosage to achieve the desired therapeutic effects? Were gradual dose reductions planned and behavioral interventions, unless clinically contraindicated, provided in an effort to discontinue the medication? 41

F309 (Continued) Questions Surveyor will ask How does the staff monitor for the effectiveness and possible adverse consequences of the medication? 42

F309 Questions If potential medical causes of behaviors are identified is the Physician notified promptly and workup or treatment initiated? If a resident has new or worsening BPSD (Behavioral or Psychological Symptoms of Dementia term used to describe behavior or other symptoms of Dementia that can t be attributed to a specific medical or psychiatric cause) is there documentation to support that an evaluation was complete by the IDT and Physician/Practitioner? 43

Poor Example Maxine has Dementia and has a history of degenerative joint disease. She was a mother of three and worked all of her life as a bank manager. She was known to have a type A personality and some even considered her to be obsessive compulsive at times but she was a very caring person and a great mother. One day after therapy she went to the Dining room for dinner and the table had been set neatly before the residents arrived. Another resident sat down beside her and with dirty hands started moving the silverware all around on the table. Maxine watched for a while and finally she just could not stand it! She slapped the resident on the arm (no injury) and started to yell at her, much to everyone s surprise. Because an episode of resident abuse occurred. Staff immediately removed her from the dining room but she continued to yell because she thought it was unfair that she was the one in trouble. She struck out at staff despite them trying to calm her down and started to cry. 44

Poor Example (continued) The Physician was called and she was given a stat dose of IM Ativan for anxiety and started on a routine antipsychotic medication. A diagnosis of Dementia with Psychosis was added to her diagnosis list. Six months later Maxine was sleeping all of the time, she suffered weight loss and could barely feed herself. Speech therapy was ordered and protein supplements were ordered to no avail. She continued on the antipsychotic medication and the behavior sheet identified the behavior exhibited was Anxiety. The MAR identified that there were no behaviors exhibited. Care Plan stated she had Dementia with Psychosis It had no details of the original event. When the physician was approached about gradual dose reduction no one could remember why the medication was started so the physician refused to decrease the medication because the nurse did remember that it was resident to resident abuse. What is wrong with this picture? 45

Poor Care Example (continued) Not enough staff in DR to see what happened No indication of how advanced her Dementia was No documentation of what occurred to cause an anti-anxiety drug to be ordered No rationale for diagnosis of Psychosis Pain not addressed No one asked her why she was upset. No documentation provided to support monitoring for psychoactive drug reduction No family involvement And Much more! 46

Better Care Example Maxine has GDS Stage 5 Dementia and has a history of degenerative joint disease. She was a mother of three and worked all of her life as a bank manager. She was known to have a type A personality and some even considered her to be obsessive compulsive at times but she was a very caring person and a great mother. One day after therapy she went to the Dining room for dinner and the table had been set neatly before the residents arrived. Another resident sat down beside her and with dirty hands started moving the silverware all around on the table. Maxine watched for a while and finally she just could not stand it! She started to slap the resident s arm but the CNA intervened and recommended that Maxine move to another table to eat. The nursing assistant spoke to the licensed nurse and said she had noticed that Maxine groaned when she attempted to transfer her to the chair. The nurse assessed Maxine for pain and provided her prn Tylenol as ordered. The nurse notified the therapist that Maxine seemed to be different recently in that she was losing her willpower at times and was more anxious and more cognitively impaired. 47

Better Care Example (continued) The nurse also noted Maxine seemed to be experiencing more pain recently and requested the Physician evaluate her pain medication. The Physician started Maxine on Tylenol qid. Maxine s family was called and informed of the event and medication change and the nurse learned that Maxine was always reluctant to admit she was in pain. The therapist evaluated Maxine using the Global Deterioration Scale and determined that Maxine was in stage 6 of the GDS now. The therapist notified the MDS nurse that there was a change in Maxine s stage of the GDS and Maxine was re-assessed and a Significant Change in Status MDS assessment was completed. Maxine s family was notified and agreed to attend Care Plan meeting with Maxine. Maxine s Care Plan was updated with goals consistent with stage 6 of the GDS. Maxine s family was provided more information on stage 6 symptoms of Dementia. Maxine s family requested to meet with a Social Worker and Physician regarding updating Maxine s Advanced Directives. 48

How to involve therapy On a Quarterly basis, therapy should perform a screen on every patient prior to the scheduled MDS assessment If changes occur before the screen, nursing should communicate with therapy and request a screen, or obtain the order for evaluation A Nursing to Therapy Screen Request-GDS Focus tool has been provided as a handout as an example Remember, the CMI will dramatically increase if therapy becomes involved at the appropriate time!!! 49

Example of Screen Form:GDS Focus Nursing to Therapy Screening Request: GDS Focus Resident: Date: Room: Memory/General o Frustrated over memory losses (Stage 4) Behavior ADL Communication Motor/Mobility o Need for more assistancee o Frustrated over word with getting dressed, esp. with finding difficulties finding clothes, organizing or (Stage 4) sequencing (Stage 4) o Refuses to make changes, very rigid with routines posing risks for safety or care (Stage 4) opoor balance when picking items up from floor or getting items from closet or drawers (Stage 4) o Gets lost in faciity; difficulty finding their room or finding way around facility (Stages 4,5) o Does not ask for assistance, not able to identify own problems (Stage 4) o Takes a long time to o Changes in ability to perform ADL tasks; gets lost in enjoy reading the process (Stage 4) (Stage 4) o Experiencing falls (Stage 4, 5, 6) o Difficulty remembering or finding things that they need (Stage 4) o Flat or less facial expression, decreased interaction with others (not leaving room or attending activities as before) (Stages 4, 5) o Unable or increased difficulty in following calendar of events or managing personal schedule (Stages 4, 5) o Does not ask for assistance, not able to identify own problems (Stage 5) o Sexual acting out (Stage 5) o Afraid to be alone as they don't know where they are (Stage 5) o Anxious and upset, increased wandering behavior and likes things to touch (Stage 5, 6) o Increased difficulty with managing discomfort (Stage 6) o Room becoming cluttered, dirty clothes are in with clean clothes (Stage 4) o Difficulty with toileting routines, especially at night (Stage 4) o Able to perform routine tasks but not able to problem solve if runs into difficulty (Stage 5) o Uses too much toilet paper, clogs toilet (Stage 5) o Frustrated with difficulty with writing or organizing tasks involving writing (Stage 4) o Increased difficulty with understanding behavior and response to others (Stage 6) odoesn't use walker or cane or has early signs of balance disorder (Stage 4) o Difficulty with being o Forgets to take walker or feels understood when speakng; does not need to use it often repeats self (Stage 4, 5) (Stage 5) o Frustration with communication is apparent from resident and/or staff (Stage 5) o as previously has (Stage 4, 5) Not walking as far or as often o Change in walking, increased stumbling, loss of balance (Stage 4, 5, 6) o Wandering and rummaging in others rooms (Stage 6) o Staff having difficulty with o Low level of frustration, o Not all staff are able to o Increased difficulty by staff providing care: agitation hits or gets very angry at staff, communicate effectively getting patient to sit or stand and (Stage 6) refuses care (Stage 5, 6) with resident (Stage 6) walk (Stage 6) o Obsessive; engages in repetitive taks; anxiety, agitation and new onset of violent behavior (Stage 6) o Weight loss, not eating or participating in eating/drinking at meals, takes long time (Stage 6) o Family is struggling with communication with resident (Stage 6) o Tends to bend forward, or may lean backwards (Stage 6) o Excessive wandering; does not rest (Stage 6) 50

What will therapy offer to nursing? After completion of appropriate standardized tests and measures, the ST or OT should be able to provide caregiver approaches Should be patient specific Should support the GDS Level that was identified Should allow nursing to implement directly into the Care Plan format Therapy should do training with nursing caregivers and family prior to patient discharge 51

GDS Stage 3: Caregiver Approaches Simplify or do complex tasks together Help the resident to see the whole picture; point out pros and cons Monitor, limit, restrict hazards Plan for progressive disability Copyright LW Consulting, Inc. 2014 52

GDS Stage 4: Caregiver Approaches Provide external cues for orientation Encourage asking for assistance with solving problems Participates best in meaningful activities Able to follow calendar or schedule Assess for safety issues; restrict hazards (PT?) Establish structured schedule for ADL routine (OT?) Provide set up and removal of supplies needed Cue for word finding deficits (ST referral?) Copyright LW Consulting, Inc. 2014 53

GDS Stage 5: Caregiver Approaches 24 hour care is necessary Environmental assessments for hazards/safety (PT/OT) Determine interventions and cueing to maximize ADL performance and function (OT?) Additional time to perform tasks (2-3 times longer) Expect inattention to quality Look for behaviors with daily routine; assess (OT/ST?) Adapt activities for poor attention and direction following (PT/OT/ST?) Copyright LW Consulting, Inc. 2014 54

Stage 5: Caregiver Approaches, cont. Simplify communication (introduce with name, use nouns, eliminate abstract words, familiar objects facilitate communication) (ST referral?) Structure hydration and approaches for meal intake (ST/OT referral?) Determine strategies for memory loss (repetition, Memory Books) (ST/OT referral?) Encourage time with others that match same interest and cognitive skills (OT referral?) Copyright LW Consulting, Inc. 2014 55

Stage 6: Caregiver Approaches Anticipate all needs Assure consistent caregivers Understand childhood or traumatic events of past Team up with a Stage 5 Buddy Determine sleeping patterns and support Find effective ways to redirect (ST/OT referral?) Focus safety issues with mobility/fall prevention (PT?) Positioning needs may be present (PT/OT?) Monitor weight and watch for dysphagia (ST referral?) Copyright LW Consulting, Inc. 2014 56

Stage 6: Caregiver Approaches, cont. Provide items that support identity (baby doll, purse, stuffed animal, pets, plants ) (OT referral?) Establish ADL routine (self care and meals), break down tasks, assess environment, hand over hand cueing, understand non-verbal communication, reduce anxiety and agitation (OT referral?) Establish best method of communication (mirroring, props, non-verbal support) (ST referral?) Copyright LW Consulting, Inc. 2014 57

Stage 7: Caregiver Approaches Total care with focus on comfort Provide sensory stimulation (OT referral?) Diligent about fall prevention, skin management, positioning, contractures (PT/OT referral?) Monitor swallowing function and weight/hydration (ST referral?) Copyright LW Consulting, Inc. 2014 58

Summary Our Plan - A facility QAPI PIP should be developed related to lack of education of family members for residents with Dementia. (Knowledgeable family members regarding the stages of Dementia should help decrease family complaints and help family members be better prepared for what will come to pass as the disease progresses). Education for staff is recommended. One presentation for Nurses and one presentation for Nursing Assistants on the GDS 59

Summary Education should be provided to Nurses and Nursing assistants on Caring for residents with Dementia and Behaviors based on the regulatory changes Education should be provided for Therapists in the processes we discussed Education on the Nursing to Therapy Screening Request: GDS Focus tool to be provided to the Interdisciplinary Team 60

Summary A form with your facility logo can be developed with the steps of the GDS identified and with reference to Dr. Barry Reisberg who developed this awesome tool. If a resident is to be admitted to the facility with a Diagnosis of Dementia, this form (Great for Marketing and Education!) can be distributed by Admissions to every new resident s family member as part of the admission process. 61

Summary Couldn t this Plan we discussed be considered a consistent process for addressing Dementia according to F309? Doesn t this Plan we talked about individualize care for residents with Dementia according to F309? Could this Plan we talked about be recognized as a successful Dementia Care Program for YOUR FACILITY? 62

Initiate A Collaborative Therapy and Nursing Approach Today! 63

Questions? Thank you for your attention!! 64