13. Programs and Procedures

Being that the nature of JTC Staffing Solutions is to have our staff working at several different facilities, some with different procedures, we are still very much committed to ensuring that all our staff members are able to work in safe and healthy work environments by giving them an outline of some of the most common programs you will come across in the Long-Term Care Sector.

The following is an amalgamation of different programs that are implemented at different facilities we service. Please be advised that policies, procedures and staff responsibilities may vary from one facility to another.

FALLS AND PREVENTION

Each resident is assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach. Discussions regarding the acceptable level of risk must be based on individual assessment with input from the resident and/or Substitute Decision Maker (SDM) and interdisciplinary team.

1. Identify residents at risk for falls and determine the level of risk
2. Initiate preventative approaches
3. Provide appropriate strategies and interventions directed to the resident, environmental factors, and staff
4. Provide learning opportunities
5. Monitor and evaluate the resident’s outcome

Consequences of Falls

• Fractures of the hip, femur, humerus, wrist or ribs
• Head injuries
• Soft tissue injuries
• Transient confusion
• Social, psychological consequences, e.g. loss of courage, independence, confidence and family reaction, change of familiar environment
• Hospitalization and immobilization resulting in complications such as joint contracture, pressure sores, pneumonia, infection, thrombosis, muscle atrophy and bone demineralization
• Disability and/or death
• Fractures and lacerations that require stitches

Pathological falls: Result of an underlying disease process of dysfunction
Accidental falls: When an environmental hazard can be identified
Premonitory falls: Occurs suddenly and often precede a sudden or fatal illness such as myocardial or cerebral

The following factors may be associated with falls with the elderly:

Predisposing Factors

• Secondary diagnosis (especially cardiovascular disease)
• Advancing age
• Recent admission
• History of falls
• Changes in mental status
• Transferring activities or the use of assistive devices

Environmental

• Inadequate lighting or lighting that produces glare
• Lack of eyeglasses or failure to wear eyeglasses when getting up, especially at night
• Slippery floors or rugs
• Obstacles or inconvenient arrangement of objects
• Equipment in poor repair or improperly fitted
• Uneven floor or ground surface
• Improper handrails
• Use of restraints or side rails
• Improper footwear or clothing
• Improper use of bed locks

Physiological / Intrinsic Causes

• Slowed reaction time
• Sensory defects
  – Vision changes
  – Hearing
• Gait or motor deficits
• Balance deficits

Debilitating Disease or Mobility

• Generalized weakness
• Transfers, use of assistive devices (walker, wheelchair, cane)

Cardiovascular

• Orthostatic hypotension (decreased vascular tone and pooling of blood in lower extremities resulting in a drop in blood pressure when a person stands up)
• Syncope
• Micturition syncope (rapid emptying of bladder may cause a drop in blood pressure. Most likely to happen at night.)
• Atherosclerosis
• Anemia or low red blood cells
• Intermittent cardiac arrhythmias
• Concealed haemorrhage

Perceptual

• Visual and auditory deficits
• Visual-spatial sense (ability to perceive the position of objects in relation to each other and oneself)
• Apraxia (inability to perform purposive movements)
• Body movement and awareness of body neglect

CNS or Metabolic Disease

• Dizziness
• Seizure or neurological disorders
• Transient ischemic attacks (TIA)
• Diabetes (hypo or hyperglycemia)

Cognitive

• Altered mental status, confusion
• Decreased ability to follow directions or make judgements

Presence of Infection / Fever

• Urinary frequency
• Pneumonia
• Antibiotics side effects

Elimination Needs

• Need for privacy and independence
• Enlarged prostate resulting in frequency of urination
• Diarrhea or urinary urgency/frequency

Medications

• Cardiovascular meds (digoxin, antihypertensive, antiarrhythmic)
• Psychotropic drugs (sedative-hypnotics, neuroleptics-antipsychotics, tricyclic antidepressants, selective serotonin reuptake inhibitors)
• Hypoglycemic drugs, parkinsonian drugs, anticonvulsants
• Anticholinergic drugs (antihistamines, antiemetic drugs place the resident at increased risk
• Opioid analgesics within the first 48 hours of initial or dosage increase
• Studies have shown that elderly on medications fall more than those not on medications
• Medications that may cause urinary frequency / fecal incontinence Several medications may result in orthostatic hypotension
• Other risk factors associated with medication to consider:
  – Residents aged 65 and over are more sensitive to medications
  – Renal function impairment resulting from medication accumulation and adverse reactions
  – Residents taking 4 or more prescriptions drugs, regardless of pharmacological classification
  – Anticoagulant/antiplatelet drugs may directly increase the risk of injury from falls due to an increased bleeding risk
  – Residents with untreated osteoporosis, urinary incontinence, delirium, and/or pain also have increased risk of injury from falls
  – Illegal substances and alcohol use

Roles and Responsibilities:

Nursing (RN and RPN):

• Completes a fall-risk assessment on admission
• Initiates a plan of care to address residents identified as high risk and implements high-risk strategies such having the bed assigned as close to the nursing station if possible, very high fall-risk signage above the bed and outside the door
• Markers may be as discreet as a sticker (i.e.3-inch glow in the dark star use by Finlandia Village), so be sure to ask for details during your orientation shift
• Makes a referral to interdisciplinary team members
• Ensures procedures for high fall risk resident are in use, i.e. completes fall-risk assessments on transfers, following a change in status, following a fall and quarterly
• Provides education to family/resident about falls prevention strategies
• Evaluates the plan of care
• RN: Responsible for initial care planning and identification of risks through admission data collected, Admission fall risk screening tool
• RN: Determines appropriate interventions
• RPNs assigned to RAI/MDS: Completes a fall-risk assessment on admission and quarterly through RAI/MDS and completes the plan of care and flow sheet, submit to RN
• RPN: Makes a referral to interdisciplinary team members
• RPN: Requests a fall-risk assessment following admission, change in status, and quarterly, done and reported by Adj. and Physio dept
• RN: Ensures interventions for high fall-risk residents are being followed
• RN: Provides education to family, resident, and staff about fall prevention strategies
• RN: Reports to team members on each shift

Health Care Aide/ Personal Support Worker:

• Follows procedure and care plan for high fall-risk resident referrals
• Monitors residents
• Assists residents when transferring, ambulating or walking
• Recognizes and reports resident verbalizations and behaviors indicative of discomfort which may potentially lead to falls
• Reports any risk factors identified or any changes in condition, mobility and function
• Participates in care plan review and feedback for interventions
• Reports changes to registered staff

Procedure:

A) Fall Risk Assessment

The Registered staff will:

1. Initiate a written plan of care within 24 hours of admission and include a risk assessment, this will be updated as necessary
2. Conduct MORSE Fall Scale (Fall Risk) Assessment
   a. Within 24 hours of admission based on identified risk for falls.
   b. Following any sudden change of status or a fall
   c. With quarterly and annual documentation
3. Completed an interdisciplinary team care plan within 14 days, based on RAI/MDS 2.0 triggered assessment protocols and Tinetti tool findings
4. Develop individualized interventions to address residents identified as a risk for falling and implement an interdisciplinary plan of care
5. Interventions should be based on the level of risk, daily observations, and resident history
6. Evaluate and document the resident outcome

B) Interventions and Strategies to Reduce Risk for fall

The interdisciplinary team will:

1. Familiarize the new resident with the surroundings on admission especially the location for the bathroom/washroom
2. Assign the resident to a bed that enables them to exit towards his or her stronger side whenever possible
3. Provide education on the following:
   a. Teach resident proper ambulation and use of assistive devices.
   b. Teach resident to sit on the edge of the bed for several minutes before rising, and other techniques for orthostatic hypotension that may include: elastic stockings, ankle pumping in the seated position, elevating the head of the bed on blocks.
   c. Caution resident to avoid bending his or her head sharply backward.
   d. Instruct resident to refrain from working with her or her arm above their head.
   e. Instruct resident and family members regarding appropriate footwear such as the use of treaded socks and/or non-skid footwear. Instruct the resident to request assistance with ambulation. Repeat instructions to call for help on each shift.
4. Actively engage resident and family in all aspects of the prevention program
5. Consider holding safety education classes for residents and/or families
6. Assess the resident’s coordination and balance before assisting with transfer and mobility activities
7. Engage the resident in physical activities and exercise to improve strength, flexibility, coordination, and endurance as appropriate
8. Conduct periodic medication reviews and assess resident’s medication such as dosage, side effects, and interactions with food or other medications. Notify the Physician for medication adjustments to reduce medication-related fall-risk factors. 

NOTE: Residents taking benzodiazepines, tricyclic antidepressants, selective serotonin-reuptake inhibitors, trazodone, or more than 5 medications should be identified as high risk. Residents on anticoagulants such as heparin, coumadin, and aspirin should be monitored after a fall for possible hematoma.

9. Assess the resident for a bowel and bladder program to decrease urgency and incontinence
10. Examine medication dosage schedules. For example, laxatives should be given in the morning and early afternoon to promote bowel evacuation prior to bedtime.
11. Provide information to the resident, family members and/or SDM on dietary, lifestyle and treatment choice for the prevention of osteoporosis to reduce the risk of fractures.
12. Consider the use of hip protectors/helmet to reduce fractures.
13. Place a “fall risk” indicator outside the room and at the bedside for residents at very high risk for falls. (An example of an indicator – 3-inch glow in the dark star.)
14. Perform environmental rounds to promote safe environment:
    a. Hallways and the resident’s areas are well-lit
    b. Hallways and the resident’s areas are uncluttered and free of spills
    c. Ensure lighting is adequate, especially for residents who get up at night
    d. Locked doors are kept locked when unattended
    e. Handrails are secure and unobstructed
    f. Tables and chairs are sturdy
    g. All assistive devices such as canes, crutches, and walkers are working properly by inspecting them on a regular basis
    h. Ensuring that brakes, bed rails and other equipment are used as required
    i. Use raised toilet seats and armrests if appropriate
    j. Resident rooms are set up in a way that minimizes the risk of falling (i.e., resident’s care article and walker are placed within reach)
    k. Ensure that call bells are accessible
    l. Level of stimulation is controlled especially for the cognitively impaired (i.e., reduce group size, control noise levels, minimize tragic through group areas, disguise doors and ensure a moderate color scheme is used) 

NOTE: Consider that excessive lowering of stimuli can lead to sensory deprivation, boredom and subsequent increase in self-stimulating activities such as unsafe walking. 

m. Adequate walking areas are provided (safe walking areas indoors and outdoors, floor coverings non-slip and in good condition, minimize door thresholds.
n. Encourage residents to wear appropriate footwear
o. Maintain bed in low position
p. Make sure visual aids (glasses) are clean and hearing aids are working properly

15. Assist with toileting as needed and record signs for possible urinary tract infection or constipation.
16. Implement alternative strategies to restraints such as:
    a. individualizing daily routines. (Sleep patterns, time spent in bed, activities, toileting)
    b. Rehabilitation and exercise programs. (Including safe transfer techniques)
    c. Teaching of behavioural compensatory strategies for physical and cognitive impairments. Use of distractive devices for resident.
    d. Education of the resident, family and SDM on alternative strategies.
    e. Companionship.
    f. Bedside Commode.
    g. Positioning cushions as boundary markers for bed edge.
    h. Mats on floor (protects residents if they roll out of bed), mattress placed on the floor.
    i. Lower bed, place bed against wall – provides a barrier on one side.
    j. Monitoring devices. (i.e. call bells)
    k. Trapeze/bed poles – assists with bed mobility (side-to-side turning, transfers).
    l. Chair or table at bedside – can be used to assist with transferring/turning.

C) Post Fall Management

In an effort to accurately track resident falls, when a resident intentionally exists the bed, (crawls out, slides down on purpose) yet does not have the mental capacity to understand their physical inability to be mobile, then document under the subject heading “Self transferring” and do not complete a post-fall/MORSE fall scale.

Steps to Follow When a Resident Falls (PSW/HCA):

1. Immediately alert the registered staff.
2. Do not move the resident if there is suspicion or evidence of injury until a full head to toe assessment has been completed and an appropriate action is determined. (e.g., transfer to hospital). In the event of suspected fractures, immobilize the resident where he or she is found rather than transfer him or her to bed and allow EMS staff to transport the resident as necessary.
3. If the resident is attempting to move on their own, encourage them to stay still on the floor until a registered staff can come to assist and call for help.

The RN/RPN will:

1.  Complete a head to toe assessment.
2. Move the resident, only if safe to do so using the proper transferring procedures.

  NOTE: If safe to do so, the resident should be lifted using a mechanical lift with two trained staff members following any fall – the resident is not to be assisted in getting up without a lift being used. In the event that a resident is actively attempting to get up themselves and is non-compliant with regards to using the lift, assist them in the safest way possible to avoid any injury to resident or staff.

3. Observe for pain or weight bearing difficulties.
4. Notify the physician of the fall, interventions taken and the status of the resident.
5. Initiate Head Injury Routine.
6. Document the fall in the “Risk Management” Section of PCC, or the “Scheduled Event” section of the Gold Care program, depending on what facility you are in. Within the ACTION section of risk management complete the Post Fall Assessment and Investigation, a MORSE Fall Scale assessment, Head Injury Routine, or other applicable policy or documentation specified by the specific Facility (and determine the resident’s current level of risk), and Progress Note in Point Click Care.  The progress note must include the following information:
   a. Circumstances surrounding how the resident was discovered.
   b. Resident’s response
   c. Assessment
   d. Injury
   e. Action was taken
   f. Family notification
   g. Immediate new fall prevention interventions required. 

NOTE: Only the ACTION and SIGNATURES sections of risk management need to be completed. All remaining information should be captured with the Progress Note and Post Fall Investigation.

7. Notify Physician.
8. Review fall prevention interventions based on resident’s level of risk and modify care plan as indicated. Refer to list of Universal Fall Prevention interventions for ALL residents – posted by the computer in each home area. A resident will be considered high and very high risk if their level of risk in Point Click Care’s MORSE Fall Scale assessment tool is High (score of 45 or greater) or Very High (score of 75 or greater). Very High-risk residents will have a High Fall Risk indicator (Usually the indicator is a STAR) posted outside their room beside their names in the memory box and above their beds on the over-bed light. The RN will manage the distribution of the Fall Risk Indicators. The registered staff completing the MORSE fall scale assessment is responsible for obtaining and posting the High Fall Risk Indicator if indicated by the score. Only a member of the Falls and Restraints Committee may remove a posted star.
9. Communicate to all shift that resident has fallen and is at risk to fall.
10. Monitor the resident for 48 hours after a fall if they are on anticoagulants such as heparin, Coumadin, and aspirin for possible hematomas. Notify the physician in hematoma develops or if bleeding presents while on these medications.
11. Notify family of the fall during the shift in which the fall occurred unless the fall happens between 2100 and 0800. If so, this may be passed on to the next shift and should be noted on the shift report. Some families may have individual requests and these should be followed. The family should also be made aware of the level of risk and interventions in place/added. 

NOTE: Each fall will be added to the Fall Checklist by the RNs and the follow up assessed an addressed according to the checklist. The checklist will be kept in that charge RN office. The first RN being notified of the fall, either verbally or by reading the shift report, is to ensure the fall is added to the checklist.

12. Establish monitoring of the resident throughout the next 48 hours for neurological changes such as facial droop, behavior changes, one-sided weakness etc.
13. Complete a detailed progress note of incident including date and time, witnesses’ names, statements, etc.
14. Complete a Physiotherapy referral form and Pharmacist consultation form for all falls.
15. Communicate the fall in all shift reports for the next 48 hours after fall and share details.
16. Have the resident reassessed using the RAI/MDS and arrange a care conference for residents who fall frequently as indicated by:
    a. 2 falls in 72 hours
    b. More than 3 falls in 3 months
    c. More than 5 falls in 6 months
17. Report all unusual occurrences to the DOC or designate according to Home policy on Incident Reporting and the Act.

PAIN MANAGEMENT & PALLIATIVE CARE PROGRAM

A) Pain Assessment

The interdisciplinary team will:

1. Conduct and document a pain assessment
   a. On Admission
   b. Re-admission
   c. Quarterly
   d. Initiation of a new pain medication
   e. Behaviours exhibited by resident that may indicate the onset of pain
   f. Significant change in status with onset of pain
   g. Resident States pain severity is a 4/10 or greater
   h. Diagnosis of painful disease
   i. History of unexpressed pain
   j. Receiving pain-related medication for greater than 72 hours without relief
   k. Resident, family, staff, volunteer indicate pain is present
2. Initiate a Pain Management Flow Sheet when a scheduled pain medication does not relieve the pain, when pain remains regardless of interventions, initiation of a new or changed pain medication. This initiation is based upon evidence gathered using the Pain Assessment Tool to ensure that those with identified pain are monitored and that pain is brought under control.
3. Develop interventions both non-pharmacologically and pharmacologically to address resident’s pain.
4. Initiate a written plan of care within 24 hours of admission, completed within 7 days updated quarterly and when deemed necessary. Also, identify in the care plan what assessment tools will be utilized to evaluate the outcomes.
5. Complete interdisciplinary team assessments.
6. Evaluate and document the resident outcome.

B) Care Planning

The interdisciplinary team will:

1. Adhere the following guiding principles of pain assessment and management:
   a. Residents have the right to the best relief possible.
   b. Unrelieved acute pain should be prevented where possible.
   c. Unrelieved pain requires a critical analysis of pain-related factors and interventions.
   d. Pain is a subjective, multidimensional and highly variable experience for everyone regardless of age or special needs.
   e. The interdisciplinary team is legally and ethically obligated to advocate for change in the treatment plan where the pain is inadequate.
   f. Collaboration with residents and families is required in making pain management decisions.
   g. Effective pain assessment and management is multidimensional in scope and requires coordinated interdisciplinary interventions.
   h. Clinical competency in pain assessment and management demands ongoing education.
2. Effective use of opioid analgesics should facilitate routine activities of daily living.
   Anticipate pain that may occur during procedures such as wound dressing changes and combine pharmacologic and non-pharmacologic options for prevention.
3. Follow the procedures below when initiating the Pain Assessment Tool.

a) For a new pain or intermittent pain:

i. Discuss, assess and develop a plan of care with resident, family and substitute decision maker.
ii. Consider non-pharmacological and pharmacological interventions.
iii. Check resident’s chart for a PRN analgesics order and administer PRN medication.
iv. Initiate the “Pain Observational Tool” and the “ESAS” if appropriate.
v. Notify the physician if the resident has no medication to address the pain.

b) For pain that is not managed:
i. Repeat the PRN as necessary if pain is less than 4/10 and the resident is not in distress.
ii. Consider around the clock dosing of current PRN medication if pain is less than 4/10 and is deemed to be chronic in nature.
iii. Communicate with physician and get the medication ordered on a regular basis if dosing is effective or new directives if not effective.
iv. Communicate with the multidisciplinary team and the physician if pain is less than 4/10 after 24 hours of monitoring.
v. Initiate “Pain Observation Tool” if the pain is greater than 4/10.

c) Key for Pain Assessment Tool:
i) Location of pain
• Indicate on the part of the body where the resident reports feeling pain
• If pain starts at a certain spot then travels, indicate the direction and extent of the travel with an arrow.
• Use numbers to distinguish the different pain locations if the resident indicates more than one type or location of pain.                                                                                                                                       ii) Severity
• Ask the resident to answer the questions in the Pain Assessment Tool as they relate to each identified pain including rating the severity of his or her pain using the numerical 0-10 rating scale.
• Use the facial grimace scale as an objective measure if the resident is unable to rate the severity of his or her pain using the numerical rating scale.                                                                                                                                     iii) Quality
• Go over each pain location to identify the appropriate descriptors from the list on the Pain Assessment Tool.
• Record the descriptive word used by resident beside “other” if the word to describe pain differs from the list.
• Prompt the resident with the word list provided if he or she has difficulty using word descriptors.                                                                                                                             iv) Effects of Pain on Activities of Daily Living (ASLs)
• If any of the pains identified are affecting any of the listed ADLs, tick ‘yes’ or ‘no’ and comment in what way.
• Ask if the resident feels that help is needed with any of the activities identified as a problem or if they are content to live with it. Refer to the appropriate interdisciplinary team member and address in the plan of care if it has been identified that the resident requires assistance

4.  

v) Effects of Pain on Quality of Life
• Ask resident what he or she likes to do that they can’t because of the pain.
• Have the resident indicate which activity can no longer be done that is important to him or her.
• Inquire from the resident how the interdisciplinary team members can help vi) Symptoms
• Have the resident identify from the list of symptoms which ones are affecting his or her quality of life

vii) Behaviours
• Have the resident identify disturbing behaviors if possible and/or the assessor will identify and check exhibited behaviors

viii) Past Pain Management
• Have the resident describe the pain incident and his or her coping methods.

ix) Support Systems
• Ask the resident to identify who is available for support in the event of pain or symptom crisis.

x) Other Concerns Related to Pain
• Discuss any concerns that the resident, family is substitute decision maker has about pain management.

xi) Nursing Pain Diagnosis
• Tick off the appropriate nursing pain diagnosis and list them on the care plan. Refer to the Pain Diagnosis document for definitions and classifications of pain.
• Document as per policy.
• Discuss with resident the problems identified and treatment options for better pain management.

5. Follow the procedure below when initial the Pain Observation Tool: 

Procedure:
1. The tool will be used for a maximum of one (1) week or until requested by the RN (guideline to discontinue use of the tool when pain is stable, principles of “3s” – Three (3) consecutive days pain is rated at a three (3/10) or less or using less, using less than 3 PRN doses/24hours.)
2. Can be initiated by any registered staff.
3. To be filled in every 2 hours until deemed completed by the RN.
4. Initials for the staff filling out the tool needs to be entered only one at the top of the column for each shift.
5. There are 5 squares for 5 steps per two (2) hour interval.
6. The 5 squares (steps) to follow are to be filled in at each entry (may skip only step 4 if the resident is unable to verbalize the quality of pain.)
7. Step 1: Indicates the staff’s visual observation of the resident’s expression, behaviour or physical response. The list is on the back of the tool. Only exhibited signs are to be entered.
8. Step 2: Indicates the pain numeric or face grimacing scale.
9. Step 3: Indicates the interventions done to address the “possible sign of pain”.
10. Step 4: If the resident is able to verbalize the quality of pain, enter it in the fourth square, if not put a “?” mark.
11. Step 5: Indicates when the resident is sleeping or the “possible” sign of pain is not present at the 2-hour interval.
12. Keep the tool on a clipboard on the med cart for easy access.
13. Completed sheets are to be filed in the resident’s chart under “observation” once reviewed by the MD, RN, and Pain management team.

N.B. Notify the Physician when:

• More than 4 PRN doses needed in a 24-hour period, depending on individual
• Consistent report of pain greater than 4/10 for more than 24hrs depending on individual
• The new sudden onset of pain
• Pain is not relieved with all available resources, regular and prn pain medication.

Note: Remember to ask the resident, “Is relief acceptable to the resident?” indicate a “yes” or “no”. If the answer is “no” notify RN immediately to re-evaluate plan of care. If a resident is unable to answer the question, assess if there is a decrease in behavioral discomfort.

Frequency:

1. The pain observation tool will be used when a pain medication is initiated or changed when the resident displays unexplained expressions, behaviors or physical responses that could be related to the presence of pain.
2. Provide the resident and their family with information about pain and the measures used to treat it, with particular attention focused on correction of myths and strategies for the prevention and treatment of side effects (e.g. Administration of antiemetic for presence of nausea and vomiting, bowel program to prevent constipation, and monitoring for drowsiness, sedation and ensuring that the physician is notified if confusion or hallucinations accompany drowsiness.)

C) Non-pharmacological Interventions

The interdisciplinary team will:

1. Institute strategies for specific types of pain such as superficial heat and cold, massage, relaxation, imagery and pressure or vibration, unless contraindicated.
2. Implement psychosocial interventions that facilitate coping of the individual early in the course of treatment.
3. Institute psycho-educational interventions as part of the overall plan of treatment for pain management.
4. Implement cognitive behavioral strategies combined with a multidisciplinary rehabilitative approach for the treatment of chronic non-malignant pain.
5. Be cognizant of factors that may help increase the resident’s pain threshold such as relief of other symptoms, sleep, creative activity, reduced anxiety, sympathy, understanding, relaxation, companionship, and implement strategies as per residents’ needs.

NOTE: See Appendix B for non-pharmacological treatment types of pain control.

D) Pharmacological Interventions

The interdisciplinary team will:

1. Ensure that the selection of analgesics is individualized to the reside, taking into account:
   • The type of pain (acute, chronic, nociceptive and/or neuropathic, visceral, etc.)
   • The intensity of pain and potential for analgesic toxicity (age, renal impairment, peptic ulcer disease, thrombocytopenia, etc.)
   • The general condition of the resident
   • Concurrent medical conditions and symptoms
   • Response to prior or present medications
2. Advocate for the least invasive route such as oral route for pain medication administration.
3. Advocate for acetaminophen as the drug of choice for relieving mild to moderate musculoskeletal pain. The maximum dosage of acetaminophen should not exceed 4000 mg per day, maybe less depending on individual circumstances.
4. Use non-steroidal, anti-inflammatory drugs (NSAIDs) with caution.
   • High-dose, long-term NSAID use should be avoided.
   • When used chronically, NSAIDs should be used as needed, rather than daily or around the clock.
   • Consider short-acting NSAIDs to avoid dose accumulation.
   • Avoid NSAIDs in residents with abnormal renal function, history of peptic ulcer disease, bleeding diathesis.
5. Consider opioid analgesics for relieving moderate to severe pain, especially nociceptive pain.
   • Opioid for episodic (e.g., chronic recurrent or non-continuous) pain should be prescribed as needed, rather than around the clock.
   • Long-acting or sustained-release analgesic preparations should be used only for continuous pain.
   • Breakthrough pain should be identified and treated by the use of fast-onset, short-acting preparations.
6. Assess and prevent common side effects of opioid.
7. Recognize and treat all potential causes of side effects taking into consideration medications that potentiate opiate side effects:
   • Sedation – sedatives, tranquilizers, antiemetics.
   • Postural hypotension – antihypertensive, tricyclics.
   • Confusion – phenothiazines, tricycles, antihistamines and other anticholinergics.
8. Assess residents taking opioids for the presence of nausea and/or vomiting, paying particular attention to the relationship of the symptom to the timing of analgesic administration.
9. Ensure that residents taking opioids analgesics are prescribed an antiemetic for use on an “as needed” basis with routine administration if nausea and/or vomiting persist.
10. Assess the resident for a bowel program to prevent constipation.
11. Consider non-opioid analgesic medications for residents with neuropathic pain and some other chronic pain syndromes.
12. Monitor residents taking analgesic medications.
13. Consider alternative therapy such as Botox injection to reduce contraction.

Roles and Responsibilities

a) Registered Staff (RNs and RPNs)

• Conducts and document a pain assessment.
  – On admission (Appendix A)
  – Re-admission (Appendix A)
  – Quarterly (RAI-MDS)
  – Significant change is status with the onset of pain (Appendix A)
  – Further assessment such as fall or injury, diagnosis of painful disease, history of unexpressed pain, behaviors exhibited by a resident that may interpret the onset of pain, initiation of a new pain medication or PRN analgesics, (Appendix A, B, and C if applicable)
  – Receiving pain-related medication for greater than 72 hours without relief
  – Resident, family, staff, volunteer indicates pain is present (Appendix B and C if applicable)
• Initiate a written plan of care within 24 hours of admission and complete it within 21 days and reviewed quarterly through RAI-MDS. (Resident Assessment Instrument – Minimum Data Set)
• Initiate and fill out the Pain Management Flow Sheet (Appendix B) when a scheduled pain medication does not relieve the pain or when pain remains regardless of interventions. (Greater than 72)
• Include the Pain Indicator List for the Cognitively Impaired (Appendix C) with the Pain Management Flow Sheet (Appendix B) for residents who are cognitively impaired.
• Screens the resident at least once a day during routine assessments by asking the resident or SDM about the presence of pain, ache or discomfort, may use the numerical scale and/or the “pain indicator” list for the cognitively impaired resident.
• Recognizes and addresses resident’s verbalization, behaviors and facial expressions indicative of discomfort.
• Implements and carries out strategies to manage pain including pharmacological and non- pharmacological interventions such as positioning, distraction, relaxation, massage, heat and cold as identified by the interdisciplinary team.
• Initiate a scheduled event in the electronic chart to schedule a review of new medication effectiveness on pain.
• Initiates, communicates, and reviews the plan of care with the interdisciplinary team, the resident and/or SDM to address each individual resident’s pain.
• Makes a referral to interdisciplinary team members.
• Obtains informed consent for the treatment interventions from the resident/SDM.
• Provides education to the family or SDM, and resident about pain management/palliative care.
• Notifies the central office of palliative status when applicable
• Fills out ADT form when resident transferred to palliative care room to notify the multidisciplinary team.
• Refers to “RN Palliative Care Intervention Check List” (Appendix H) for initiation of palliative care to the resident

b) Personal Support Worker (PSW) / Health Care Aide

• Recognizes and reports resident’s verbalization, behaviors and facial expressions indicative of discomfort.
• Reports decrease in any of the following:
  – Physical and social activity
  – Energy
  – Appetite
  – Continence pattern
  – Hours of sleep
• Notifies registered staff promptly if activities of daily living regularly cause the resident to experience pain.
• Notifies registered staff of any new or sudden onset of pain.
• Monitors residents on an ongoing basis for signs of pain.
• Reports resident’s status as requested by registered staff or Physician.
• Carry out strategies to manage pain as identified by the interdisciplinary team.
• Reports to the registered staff unresolved pain when interventions are not effective as well as interventions that are effective.
• Encourages maintenance, restorative, supportive care measures as supported through pain management approaches.
• Supports resident comfort and interests.

HEAT RISK

Hot weather conditions affect everyone, but summer months can present a challenge to our residents. Elderly individuals are more prone to heat conditions and illness than younger individuals for the following reasons:

• Do not adjust well to sudden changes in temperature
• Age and mobility
• More Likely to have a chronic medical condition that upsets the body’s normal response
• More likely to be on medications that inhibit the body’s ability to regulate temperature
• Most often exhibit multiple medical conditions, decreased mental capacity and physical limitations which combine to affect the body’s ability to cool.
• May not recognize the signs of thirst
• May not drink enough fluids to maintain adequate hydration
• Decreased awareness of the body’s needs
• The risk to heat is subject to environmental variables including air temperature, humidity and radiant temperature and air movement.

Staff should be knowledgeable about hot weather-related illnesses and factors that contribute to their development. Staff must be able to recognize signs and symptoms of these illnesses and respond promptly to ensure that the risk to the resident is minimized to prevent illness injury or death.

Registered staff in each home will:

• Identify those residents with high-risk factors.
• Prior to warm weather, all residents will have the risk assessment completed and a copy along with interventions will be attached to their care plans. Staff is required to monitor all residents closely but those residents identified as high risk will require more intense monitoring.
• When determining those residents at risk for heat-related illness, the following risk factors should be taken into consideration:
  – History of previous heat illness/intolerance
  – Medical history of infection without fever, heat exhaustion, heat stroke.
  – Circulatory insufficiency – dehydration, obesity, central nervous system lesions, diabetes mellitus, cerebral vascular disease.
  – Increased heart load – fever seizures, exertion, hyperthyroidism, agitated psychiatric conditions.
  – Abnormalities of skin and sweat glands, burns, cystic fibrosis, extensive scars or other skin sweat gland abnormalities interfering with heat dissipation.
  – Cardiovascular disease – arteriosclerosis, congestive heart failure and hypertension, ischemic heart disease.
  – Gastrointestinal disturbances such as diarrhea.
  – Malnourishment
  – Drugs that either increase heat production (amphetamines and other stimulants), decrease sweating capacity (anticholinergics, phenothiazines, tricyclic antidepressants, antihistamines) or cause dehydration (diuretics, alcohol)
  – Conditions altering mental status, i.e. – confusion, depression, which may lead to a failure to take sensible, hot weather precautions.
• Provide and encourage extra fluid intake at each meal and throughout the day.
• Provide additional skin care and showers in relation to the resident’s hygiene requirements.

Hot Weather-Related Illnesses

There are several types of illnesses related to hot weather may occur under conditions which include high temperature and humidity, direct exposure to sunlight, limited air circulation, poor physical condition, or physical exertion. Illnesses may include heat rash, heat cramps, heat syncope, heat exhaustion or heat stroke.

1. Heat Rash
   Chronic skin wetness resulting from un-evaporated sweat may be the main factor in the development of a heat rash. It presents as pinpoint red spots on the skin, itching and a prickling sensation upon exposure to heat. Getting relief from the humid environment and keeping the skin dry can prevent this. If the rash persists the Physician should be noticed.
2. Heat Cramps
   Heat cramps occur when a person is sweating profusely as a result of high temperatures. The individual may be consuming a lot of water to hydrate, but may not be replenishing their electrolyte loss, which results from profuse sweating. Physical exercise and recreational activity should be restricted in hot weather.
3. Heat Syncope
   This condition is characterized by dizziness and fainting which is caused by a temporary loss of blood supply to the brain. The often occurs in people who are not acclimatized to the hot environment and who may have been standing for long periods which cause blood to pool in their lower extremities.
   This is not as critical of a condition as heat stroke or heat exhaustion but can result in falls and injuries. Symptoms vary in severity from a single attack of dizziness to loss of consciousness. Other symptoms include light-headedness, nausea, and blurring of vision. Treatment includes increasing fluids, cooling the individual, assisting the resident in changing positions slowly, no prolonged standing, only limited exercise and instructing/assisting the resident to lie down.
4. Heat Exhaustion
   An illness characterized by dehydration and its consequent cardiovascular and metabolic effects. It is the body’s response to the excessive loss of both water and electrolytes as a result of profuse sweating.
   Warning signs include:
   • Heavy sweating
   • Paleness
   • Muscle cramps
   • Tiredness
   • Weakness
   • Dizziness
   • Headache
   • Nausea / vomiting
   • Fainting
   • Skin may feel cool and moist
   • Pulse rate is fast and weak
   • Breathing is shallow and rapid
5. Heat Stroke
   Heat stroke is the most serious of the heat-related illnesses. It occurs when the body is unable to regulate its temperature. It is a disturbance of the central nervous system, by minimal or no sweating, and by a rectal temperature of over 40.6 C (105 F) in a short period of time. Heat stroke can result in death or permanent disability if emergency treatment is not provided in a timely manner. Warning sign of heat stroke care but may include the following:
   • Extremely high body temperature above 39.4 C
   • Irritability
   • Red, hot and dry skin (no sweating)
   • Rapid pulse
   • Throbbing headache
   • Dizziness
   • Nausea
   • Confusion
   • Hallucinations

Immediate treatments for heat stroke include:

• Transfer resident to hospital and lower body temperate by vigorous fanning or sponging with cold compress and fanning.
• Notify physician immediately
• Notify family

NOTE: Residents are still at risk for death during 48 hours following recognition of heat stroke, even after residents are reported to be clinically stable. If the resident is returned to the facility within this time frame, close monitoring is required.

Treatments for heat-related illnesses:

• Keep fluids such as water and juice readily on hand for all residents
• Increase fluids and electrolyte balance
• Restore body fluids by pushing fluids (Avoid diuretics like coffee and tea) and record input and output
• Place resident in a cool place and out of direct sunlight
• Place resident in a supine position with head lowered and knees drawn up
• Ensure wearing lightweight and light-coloured clothing
• Cool resident down with a cool compress and/or fan.
• Keep resident comfortable by various measures including bed changes as required.
• Notify the doctor
• Monitor and record vital signs and weight as well as the resident’s responses to the therapeutic measures provided
• Monitor for signs of heat stroke
• Review medications and reduce those medications with high potential for adverse effects
• Transfer to the hospital where clinically indicated Overview
• Increased monitoring of all residents for heat-related illness or symptoms is required during times of increased temperatures
• Increase fluid intake by 500 – 1000 ml in a 24-hour period unless contraindicated by monitor fluid intake and output
• Keep residents in cool areas and light breathable clothing
• Use fans and cold compresses to keep residents cool
• Increase skin and hygiene care as needed
• Monitor for over-hydration

RESPONSIVE BEHAVIORS MANAGEMENT PROGRAM

The term “responsive” behaviors are used to describe a means by which persons with dementia or other conditions may communicate their discomfort with something related to, for example, the physical body (infection), social environment (boredom, invasion of space) or the physical environment (lighting, noise). Responsive behaviors can also be protective behavior. In the past, these behaviors have often been termed “disruptive”, “challenging” or “aggressive” and this previous terminology negatively labels residents.

Understanding the sources/underlying causes of responsive behaviors is key to providing the optimal care for a resident. Responsive behaviors often indicate an unmet need a person may have and will result in frustration, or sometimes behaviors are in response to certain circumstances within their environments that may be frightening or confusing.

Responsive Behaviors

Actions that may include a resident exhibiting one or more of the following behaviors:

• Physically non-aggressive or protective (pacing, undressing, handling objects)
• Physically aggressive or protective (spitting, hitting, throwing objects, sexual advances)
• Self-harm or harm to others
• Verbally non-aggressive or protective (complaints, constant request for attention)
• Verbally aggressive (cursing, threatening, sexual advances) / verbal abuse
• Resisting care
• Socially inappropriate or disruptive actions
• The difficulty with psychosocial adjustments or symptoms of depression (isolation, refusing to eat, withdrawal from usual activity pattern)
• Delirium

Prevention and Triggers

1. Identify the causes and triggers (ex. environmental, social, and physical) for the behaviors. This assessment will include a clinical assessment to ensure identification of causes of responsive behaviors such as medication, chemically, or physiologically based.
   a. On admission using RAI/MDS, family information, and historical information on admission
   b. Quarterly, using RAI/MDS assessments / triggered RAPs and outcome scores, 30-day behavior flow sheets, medication review by pharmacist and physician, incidental progress notes as required.
   c. On an as needed bases, DOS mapping. MMSE, Geriatric Depression Scale, Pain indicator list for the cognitively impaired.
   d. After an incident, using the “High-Risk Client Behaviour Part 1 and 2.
2. Develop strategies for prevention which may include:
   a. Environmental adaptation strategies such as noise reduction, mealtime, personal care time, room temperatures, lighting, calming aromas.
   b. Orientation and training programs for staff, families, and volunteers on prevention, how to recognize triggers, prevent escalation, communicate, and how to manage a situation that has escalated.
   c. Awareness, skills, and knowledge related to responsive behaviors for staff and contractors.
   d. Information for families, people of importance to residents and substitute decision makers.
   e. Developing interventions to minimize triggers or respond effectively for specific residents and to prevent the escalation of potentially harmful or abusive situations.
   f. Use of internal and external tools, experts and resources for screening, assessing and developing strategies for managing responsive behaviors.
3. Screening protocols and tools: Utilise screening tools and protocols to assist caregivers to understand the causes of a resident’s responsive behavior and to track the patterns of the behaviors.
   RAI/MDS, the 30-day behavior observation flow sheets, and Pain Indicator list are examples of screening tools that flag a problem or observation by staff, family and others of changes in a resident’s behavior and potential for altercations between/among residents or staff that may be harmful.

Purpose of Screening

Screening identifies the level of risk associated with the behavior; low, moderate, high. See Appendix E – Acute Responsive Behaviour Management – Screening Decision Tree. This may help identify behavioral triggers, patterns, and factors.

Risks identified may include leaving the home without staff knowledge, roaming, and imminent physical harm, suicidal ideation, deteriorating relationship with staff and family, the risk of fuelling another resident’s behavior, smoking, and substance misuse. High-risk situations may require one to one staffing or the transfer of the resident to the hospital emergency department.

Screening Tools utilized may include:

• Putting it All Together P.I.E.C.E.S (Physical, Intellectual, Emotional, Capabilities, Environment, Social), RAI/MDS, Job Aid (see Appendix B)
• Dementia Observation System
• MMSE
• GSA (Geriatric Depression Scale)

Assessment

The interdisciplinary team will include but is not limited to, registered nursing staff, unregulated workers, DRS, physicians, pharmacists, dietary, social workers, and the physiotherapy department. More in-depth interdisciplinary assessments are carried out to integrate assessment findings and collaboratively problem solve for possible solutions.

• RAI/MDS, P.I.E.C.E.S
• CCAC
• Family / SDM
• Possible causes of behavior to be investigated further e.g. medications, urinary tract infection
• Psychogeriatric Resource Consultant such as Senior’s Mental Health
• Is the resident hallucinating and acting on or tormented by beliefs?
• Is the behavior disturbing to others?
• Is the responsive behavior manageable in the present setting?

Plan of Care

Establish resident focused, interdisciplinary goals and strategies to ensure resident well-being, quality of life and safety.

1. Adapt strategies for the individual that respond to triggers and responsive behaviors. Consider the following:
   • Meaningful, purposeful, activity participation (looking at photo albums, physical activity such as walking or dancing, baking, dusting, delivering mail, singing, or any other activities that brings familiarity and enjoyment)
   • Social interaction (sitting and talking)
   • Environmental intervention (removing noises or distractions, change lighting, prevent unpleasant odors, suitable aromas)
   • Varying strategies for different times of day or night
2. Integrate evidence-based strategies such as GENTLECARE / Gentle Persuasion / P.I.E.C.E.S to address specific behaviors as well as observing for triggers.
3. Intervention to minimize the risk of altercations (between residents or staff) or responsive behaviors for staff or resident who are at risk of harm or who may have been harmed.
   • Appendix B “Putting It All Together” decision tree
   • High-risk behavior decision tree part 1 and 2
   • Implementation of zero violence tolerance home policy
   • P.I.E.C.E.S / GPA implementation
   • Increased staff and family presence as required
4. Increased individualized interventions to address the conflict between known altercating residents
5. Medication to prevent and manage responsive behaviors may be considered but only after all other treatment alternatives have been tried and eliminated as ineffective.
6. Strategies to address in depth assessment findings e.g. pain, infection, anxiety
   • Observe for escalation of responsive behavior from anxious, to verbal, to physical
   • Include techniques such as calming activity, redirection, diversion, reassurance, do nothing, do not argue with the resident, etc.
7. Referral / Admission to external sources and/or facilities for more comprehensive assessments.

Monitoring and Communication

Observe and document the resident’s response to the care plan strategies, this can include:

• Observation and documenting in charts and progress notes.
• Regular re-assessment using MDS-RSI 2.0 (quarterly)
• Medications dose, effectiveness and any negative reactions (quarterly, ongoing and prn)
• Use of Resident Behaviour Record to initiate and monitor that may cause risk to the resident or other should also be communicated to staff. This is done through the inter-shift report system.

All staff should be informed at the beginning of each shift when residents require heightened monitoring. Any new responsive behavior and any behavior that may cause risk to the resident or others should also be communicated to staff. This is done through the inter-shift reporting system.

Referral Protocols

Methods of referral will vary according to residents’ needs, referral practices and or availability of specialized experts. These referrals are appropriate when the resident’s condition is very complex, when there is an imminent risk of harm, or when a psychiatric condition is suspected. Specialized service referrals can be directed to:

• A Psychogeriatric Resource Consultant who can provide support, advice, staff or family education related to residents.
• Services any time for assistance with care planning, difficulty finding solutions particularly when a resident is at imminent risk of harm
• A Clinical Pharmacist regarding medications
• The Physician in an emergency situation
• Geriatricians or to Geriatric Psychiatrist
• Local hospital

Follow up and Evaluation

Individual Resident: Follow up according to assessed needs and the care plan; reassess every 6 months at a minimum as per ministry regulations. Most facilities will follow up on residents needs on an ongoing and/or a quarterly basis, updating as necessary.