Is your risk management program designed to deal with Alzheimer's disease?

Special Care Units (SCUs) are spreading rapidly, and present their own medicolegal concerns

With an estimated 4 million persons currently afflicted with Alzheimer's disease or related disorders (ADRD) and projections of 12-14 million persons afflicted by the year 2040, the long term care industry is faced with tremendous challenges in its efforts to provide the highest quality of life possible in an environment designed to protect from harm.

Providers have responded to the needs of ADRD patients with the development of special care units (SCUs). SCUs are typically designed as structurally separate areas of long term care facilities to allow for the appropriate care of ADRD patients. The primary goals of these arrangements are to provide the necessary care, comfort and security of the residents and to improve each resident's quality and value of life.

As experience with nursing home malpractice litigation has shown, failure to provide these in any area of the nursing home may result in claims of negligence which can be difficult, if not impossible, to defend. For example, the long term care industry has recently seen a Texas jury award $39.4 million to the family of a nursing home resident who was strangled by bed restraints and a North Carolina jury award $15 million to the family of terminal cancer resident for withholding adequate doses of morphine.

What are the specific issues that risk management in SCUs should address, and what actions can be taken to reduce the frequency and severity of loss exposures posed by the distinct needs of ADRD residents?

Safety of ADRD Residents

Caregivers are obligated to protect patients who are incapable of protecting themselves. Dementia residents require more attention in this regard, since they find themselves in increasingly unfamiliar environments due to their declining cognitive abilities. Such environments place these residents at greater risk for falls, increase the amount of anxiety they experience, make them more prone to wandering, and may trigger inappropriate sexual behavior or exaggerated reactions.

Healthcare providers generally agree that SCUs should have specialized programming for the ADRD population. Controlled levels of stimulation through an established routine can assist efforts to provide the adequate mental and physical stimulation necessary to maintain functional skills and eliminate injury. However, overstimulation can lead to increased confusion, disorientation and inappropriate behavior. The staff should be alert to the ways in which stimulation can be controlled by reducing the "traffic" through the unit and regulating the volume of alarms, loudspeakers, and televisions or radios.

Structuring the sequence of daily events on both day and evening shifts affords the continuity and specific direction dementia patients require. Daily schedules should be personalized according to the care plan and preferences of each individual resident, with modifications made as needed to correspond to changes in condition or in the event of disruptive or violent behavior.

Giving both verbal and visual signals to guide a resident from one activity to the next will also prevent residents from becoming frustrated and manifesting behavior that could result in injury. The schedule should facilitate the discharge of energy through formal activities in an effort to lessen the stress levels of both residents and staff, while decreasing the potential for harm from uncontrolled behavior. Activities that may accomplish this goal may include organized walking and other forms of exercise, cooking or other household activities, parties, music programs, and church services. Special events with family members and other programs encouraging interaction should also be incorporated into the overall schedule.

Specific Safety Threats

Dementia residents encounter specific safety threats as a result of the dangerous situations in which they place themselves or the hazards posed by everyday activities. Adjusting for cognitive impairment, some strategies that may be implemented to reduce the risk of injury include:

* Eliminating stairs to accommodate loss of visual acuity or perception

* Increasing lighting to eliminate shadows

* Using furniture without wheels or sharp edges

* Eliminating bold-colored prints to reduce confusion and increasing color contrast to improve perception

* Providing fencing around outside areas to prevent residents from leaving the grounds or getting lost

* Providing benches and landscaping in outside areas to serve as natural barriers

* Limiting the amount of noise to avoid overstimulation or distraction

* Removing mirrors to avoid confusing stimuli

* Providing small group settings to avoid the confusion of large groups

* Using cuing mechanisms such as labels, signs, photographs, or personal memorabilia to direct and guide residents in finding their way around the facility and back to their rooms

* Making safety rounds on a continual basis to ensure that everyday materials that pose potential hazards to dementia residents are not available

* Being alert for physical or psychological causes of decreasing function such as fatigue, medications, and depression

Use of Chemical or Physical Restraints

Restraints used to protect residents from harming themselves or others can produce almost as many injuries to individuals restrained as those they prevent. From a legal standpoint (and others), it should be remembered that regulations published by the Health Care Financing Administrations (HCFA) affirm a resident's right to be free from restraints not required to treat medical symptoms. In addition, OBRA '87 clearly states that physical or chemical restraints are to be "imposed to ensure the physical safety of the resident or other residents and only upon the written order of a physician that specifies the duration and the circumstances under which the restraints are to be used."

In fact, an appropriately designed and implemented environment and treatment program should strive to eliminate almost any need for chemical or physical restraints. In caring for ADRD patients, the staff should first seek to determine the underlying cause of the behaviors that give rise to the possible need for restraints. Often, by addressing a specific need or involving the resident in an activity to divert their attention, it is possible to avoid the necessity for restraint completely.

In those situations where restraints are the only appropriate alterative, there must exist written policies and procedures that comply with legislative and statutory regulations for their use. Proper documentation can assist in reducing the number of potential claims brought against a facility for improper use. The following guidelines should be included in the written restraint policies of an SCU:

* Education and training programs for the staff as to the appropriate use of restraints and the use of less restrictive alternatives

* Education programs for the residents, their families, or legal representatives as to the risks and benefits of using restraints in specific situations

* Procedures for obtaining informed consent from the resident or his legal representative to use restraints

* Consistent monitoring of residents to determine the need to continue the use of restraints

* Documentation of the rationale for and continued use of restraints, attempted alternatives, and regular observation of the resident during the restraint period

* Regular reporting by and observation of staff to ensure that they are implemented and followed

* Periodic review of the policies and procedures to ensure compliance with statutory regulations

Wandering Behavior

Wandering is a behavior common to ADRD patients. Whether the behavior is the result of agitation, reduced social interaction or increased cognitive impairment, SCUs must be able to provide sufficient staff to deal with both daytime and nighttime wandering of residents. Interventions to address this behavior might involve:

* Shortening hallways to prevent wanderers from getting lost

* Eliminating open doors, disguising doors with murals to redirect wanderers, or placing grid-like markings on the floors in front of doorways to provide visual distortion that will deter exit

* Involving wanderers in activities to redirect or distract them

* Providing wandering paths through the use of benches and landscaping within areas surrounded by fencing

* Structuring the environment to allow controlled exploration for those who exhibit searching, goal-directed behavior

* Structuring activities to meet the need for physical exercise

* Assigning chores to meet the need for a work-related role

* Developing a security plan that contains "search and rescue" procedures in the event a resident leaves the facility

* Providing videocameras or alarms at exit doors to notify staff that a wanderer has left the facility (alarms should not cause unnecessary distraction or anxiety to other residents)

Staffing and Staff Training

Beyond compliance with federal and state regulations that govern the numbers, qualifications and duties of the nursing staff in residential facilities, the recruitment and retention of personnel has long been of concern to residential facilities, and is especially so in this case. The significance of retaining staff in SCUs is enhanced by the increased anxiety experienced by dementia residents in trying to adjust to changing staff when the skills they need to allow easy adaptation are dwindling.

Consistency in relationships between the staff and residents builds a level of trust that will play an important role in preventing events that may lead to injury. More one-to-one interaction and, therefore, more staff time will be required as dementia increases and residents become less comfortable and more overwhelmed by group activities. Therefore, the retention of personnel should be a primary objective in the staffing of SCUs.

Factors that play a key role in retention of long term care personnel include availability of support staff, adequate supplies, authority to judge patient care, support from administration and inservice education.

Although most providers agree that training specific to the care of ADRD is central to the delivery of quality care, studies have shown that many facilities do not provide such training. In spite of significant obstacles, such as training costs and high turnover rates, the lack of well-trained staff may result in serious complications in a resident's condition that go unnoticed and, with these, liability exposures for the facility. The following matters should be included in ongoing instruction for all staff:

* Common organic dementias and the ways in which brain deterioration changes behavior

* Therapeutic techniques and strategies in adapting behavioral changes

* Successful communication techniques that can be used with dementia patients

* Influence of the physical environment on the resident's physical condition and behavior

* Protocols for specific needs and behaviors exhibited by dementia residents

* Protection of dementia residents from exploitation and abuse

* Ways in which staff can encourage family members to become involved in the program and cope with the debilitating nature of this disease

* Stress management techniques to enable the staff to cope with the strains of caring for dementia residents

Directions for the Future

Federal regulations setting minimum standards for operation or specific services to be delivered by SCUs have not yet been established. Nursing home leaders have advised Congress that adopting such legislation would not only increase operating costs, but possibly frustrate initiatives for the care of ADRD patients. They have further suggested that OBRA '87 provisions be used until specific criteria for the delivery of specific services is determined.

Several states, such as Colorado, Iowa, Kansas, Oklahoma, Tennessee, Texas and Washington, have enacted legislation or administrative rules and regulations pertaining to the establishment of SCUs. Other states are developing similar regulations. Organizations such as the Joint Commission on the Accreditation of Healthcare Organizations and the Alzheimers Disease and Related Disorders Association have also published policies and procedures that may be used to assist staff in the development and operation of Alzheimer's-specific units. By addressing the issues that pose specific threats to Alzheimer's residents, special care units can provide the highest quality of care and limit their exposures to liability.

Karen A. Karcher is a Paralegal in the Health Care Concepts Division of Willis Corroon Advanced Risk Management Services, Nashville, TN. Prior to joining Willis Corroon, she provided litigation support in medical malpractice defense for 10 years for the Nashville firm of Bass, Berry and Sims.