Bill Vaughan, RN

Pain management for residents at the end-of-life, antipsychotic use in dementia residents and medication for epileptic residents were all hot issues tackled during the National Association of Directors of Nursing Administration in Long Term Care annual conference Monday.

Facilities need objective pain scales and to “own” how a resident is reacting to a pain medication, said Bill Vaughan, RN, BSN, vice president of education and clinical Affairs at Remedi SeniorCare. When facilities are cited for deficiencies in pain management, the course correction is sometimes nurses walking in twice a shift and assessing a resident for pain. That is “a recipe for disaster,” he said.

Nursing supervisors should know, “If you leave it up to a surveyor, they will decide for you. Objective measurements are the way to go,” he said. Additionally, he encouraged nurses to reach out to state survey agencies to talk about having a robust discussion outside of a survey.

“It’s very valuable to have you guys come in and talk to surveyors,” said Vaughn, who is the former Chief Nurse for the state of Maryland. “I had directors of nursing and MDS come in to talk about complex clinical cases. The hope is agencies would welcome that.”

Complex cases can involve residents with dementia, and providers are struggling in how to manage when medication is appropriate. The solution partially lies in assessments, said Healthcare Compliance Group’s Lydia Restivo, RN, CDONA, and for staff to determine the causes of a resident’s behavior. Principles of dementia-centered care include an individualized approach to care, evaluation of new or worsening behaviors and evaluating the quality and quantity of staff.

While directors of nursing do not always have control over how many staff members they have, “we do have control on how we place our staff…we do have control over how we train our staff,” she said.

Documentation should include “cumulative behavior notes,” she said, including precipitating factors related to a resident’s actions. Another step many facilities are missing is family education, she said, noting that original care plans often say “Educate resident and family” but that it is unclear whether – or if – it’s been done.

“You have to document family notification and involvement,” she said. “We often make educational care plans a part of discharge and we need to have an educational care plan post-admission. Where does [the documentation] say ‘resident and family was educated’ with a date.”

Among long-term care residents with epilepsy, many times there is no known cause. But nurses should make sure to see if medications are exacerbating seizures, said presenter Debra Hagerty, RN, DNP, CDP, LBSW, NHA, CDONA, FACDONA, an assistant professor at Armstrong Atlantic State College.

“Ask ‘is there anything here causing a problem?’ she said. “Antihistamines are a big offender.”

NADONA’s conference runs through Wednesday at the Disneyland Hotel in Anaheim, CA.