Nursing Home Residents with Dementia: Are We Prepared?

September 11, 2013

On May 24th, 2013, CMS published a Memo (Advanced Copy):  Ref:  S&C 13-35-NH, to the State Survey Agency Directors on “Dementia Care in Nursing Homes:  Clarification to Appendix P State Operations Manual (SOM) and Appendix PP in the SOM for F309-Quality of Care and F329-Unnecessary Drugs.”

The message is loud and clear:  Improving Care for Residents with Dementia with Individualized, Resident Centered approaches while putting in a system to appropriately manage, reduce and only use when psychotropic medications when appropriately indicated is crucial!

This memo can be accessed at:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html

Upon review of the information, there may be some questions that we ask ourselves:

  1. Are our assessment systems in place to comprehensively look at the individual resident with Dementia and behavior?
  2. Is it time to pull out the Policies and Procedures and ensure that they are consistent with F309 and F329?
  3. Do we need to educate our Interdisciplinary Team?
  4. Have we truly incorporated the resident/family choice for care?
  5. Are we practicing consistent assignment?
  6. Do we have a system to monitor the effectiveness of interventions, adverse consequences of medications, consistent implementation of interventions and resident response?

POLICIES and PROCEDURES:
Consider addressing:

  1. Assessment Process
  2. Investigation through root-cause analysis of the Behaviors & Psychological Symptoms of Dementia (BPSD) from the time of admission, diagnosis management, alternative interventions, identification of targeted behaviors, etc.
  3. Antipsychotic Medication Use, consistent with F329 (Monitoring for effectiveness and adverse consequences, dosage, Tardive Dyskinesia Assessments, treatment goals, ongoing monitoring, gradual dose reductions, etc.)
  4. Consent (including the Black Box Warning)
  5. Ongoing tracking and tools utilized to document behaviors
  6. Evaluation and Follow Up

EDUCATION:
Areas to consider:

  1. Policies and Procedures
  2. Dementia Care
  3. Targeted Behaviors
  4. Use of Antipsychotic Medications (Dosages, Side Effects/Adverse Consequences, adequate monitoring, Black Box Warning, physician orders, consent, ongoing assessment, etc.
  5. Documentation
  6. Non Pharmacological Interventions/alternatives to medication use
  7. Consistent Implementation of Care Plan
  8. Communication

DOCUMENTATION:

  1.  Is there evidence of a comprehensive assessment in the medical record?
  2. Has the physician documented the diagnosis and substantiated behaviors consistent for the need of the medication?
  3. Does the care plan coincide with resident choice and the details from the comprehensive assessment?
  4. Is there ongoing evidence of monitoring targeted behaviors and interventions attempted as well as the outcome?
  5. Is there evidence of gradual dose reduction attempts or clear documentation indicating why the dose should not be reduced consistent with F329?

EVALUATION:
Do we have a system in place to review the care plans, communication, problem solving and education?

ACTION PLAN:
If there are identified areas that need to be updated in our system, we can develop an Action Plan to address:

  • The specific areas that need to be updated (i.e. policies, education, documentation, staff assignment,  etc.)
  • Your recommended plan of action
  • Responsible discipline/position
  • Date this will be completed.

The Action Plan can then be discussed and worked on by the Interdisciplinary Team during the next Quality Assurance Committee for review and recommendations.

Once our system is in place, we can audit on a regular basis to ensure that we are providing quality of care to the resident with dementia and in compliance with F309 and F329!

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