Delirium not only complicates the care process for the resident or client. The impact can be felt during an annual or complaint survey.
Delirium is an acute state. It can be commonly brought on by adverse reactions to medication, or an acute infection such as a UTI, pressure ulcers or dehydration. Delirium is associated with higher morbidity and mortality. Some of the classic signs of delirium may be difficult to recognize and may be mistaken for the natural progression of dementia, particularly in the late stages of dementia.
Delirium is mentioned throughout the SOM, appendix PP relating to the following areas:
- Medication use/unnecessary drugs
- Restraints
- Pain management
- Transient incontinence
- Siderail usage
- Medical director
To understand the potential survey deficits you face when treating an individual with delirium, let’s examine the following scenario. A resident experiencing delirium may become incontinent or sustain falls (break a hip, arm, etc). Your staff may want to “protect” them and may decide that a restraint or bedrails would be appropriate failing to realize that siderail use for a person with dementia and delirium can actually increase the likelihood of entrapment. The resident with dementia is unable to communicate their pain and needs to be monitored for non-verbal indicators such as grimacing or facial expressions. While these non-verbal indicators generally are associated with pain, they can also be indicators of delirium. A resident with delirium must be treated for the underlying medical issue causing the delirium immediately before it becomes life threatening.
Did you notice the number of citations that could be issued based on the above scenario? A quick look at the report might indicate any of the following:
- F 309 – resident receives the care and services based on their needs to attain and maintain their highest level of physical, mental and psychosocial well being
- F 272 – assessments – was there an assessment that determined siderails or restraints were needed? Was there a timely assessment of the resident’s medical condition, medications, change in mental status, etc?
- F 221 – restraints – potential use of restraints that do not meet regulatory guidelines.
- F 281 – professional standards – when nurses do not perform as a reasonably prudent nurse or based on current standards of practice
- F 323 – falls with potential injury that could be sustained (possibly G or above)
- F 315 – incontinence caused by unnecessary medications
- F 241 – dignity – related to incontinence
- F 455 – medical director – was the medical director involved in review of developing, reviewing, and implementing policies and procedures regarding clinical care of residents (especially where these involve medical and clinical issues; for example, management of causes of delirium, falling, and weight loss) to ensure that they are clinically valid and consistent with current standards of care
The list could go on and on based on what happened and what surveyors find upon investigation.
How do you prevent this from happening?
- Perform a full assessment of a resident upon (re-)admission to establish their baseline behaviors.
- Make sure that there is an ongoing review of their medication regime.
- Point out any concerns to the pharmacist when they come in for their monthly reviews.
- Make sure that any changes in mental status are addressed quickly to determine the root cause.
- Adjust the care plan to meet the needs of the resident and follow it.
Delirium can be deadly if not diagnosed and treated. If that should occur, we all know that an Immediate Jeopardy (IJ) is just around the corner. Don’t let that happen to you and your residents.
To understand how delirium can impact your organization’s surveys, download the white paper, A Puzzle of Prevention: Recognizing the Role of Delirium in Preventing Rehospitalization, or try Relias Learning’s free online course Delirium, Dementia, and Depression.
Debi Damas, RN, is the senior care product manager at Relias Learning.
