In the March 13 revised Quality, Safety, and Oversight (QSO) memo QSO-20-14-NH, the Centers for Medicare & Medicaid Services (CMS) advised nursing homes to restrict all visitors except for compassionate-care situations and to “cancel communal dining and all group activities, such as internal and external group activities.” Adjusting to these changes has been difficult for every nursing home resident, but social distancing is especially hard for residents with dementia who wander and are eased by group activities.
“That’s not who these people are,” acknowledges Teepa Snow, MS, OTR/L, FAOTA, founder and CEO of Positive Approach to Care, a global dementia care services and products company based in Efland, NC. “Nurses are being asked to do the impossible with the inadequate.”
While physicians and physician extenders may be willing to prescribe an antipsychotic medication as an emergency measure in an acute or emergency situation as allowed under F758 (Free From Unnecessary Psychotropic Meds/PRN Use) in Appendix PP of the State Operations Manual, giving residents with dementia antipsychotics to make them immobile not only increases their risk of adverse events, such as cerebrovascular accidents (CVA) and even death, it also increases their risk of respiratory symptoms, including shortness of breath—one of the primary symptoms of COVID-19, points out Snow. “Providers may also consider taking away wheelchairs and other mobility aids. However, doing that puts residents with dementia at greater risk for falls and fall-related injuries, potentially resulting in a trip to the emergency department where they may be exposed to SARS-CoV-2, the virus that causes COVID-19.”
Instead, the goal should be to come up with strategies that make sense, balancing safety and resident needs, says Snow. “Keeping these residents in a small room is highly improbable, so you want to be ready to move forward with some element of safety. You will put residents at risk if you aren’t prepared for the reality that they will come out of their rooms.”
Steps that can assist directors of nursing services (DNSs) to better plan for these residents include the following:
Understand what drives them
“These residents typically have significant impairment in language skills, in object recognition skills, and in territory awareness skills,” says Snow. There are two general types of wandering residents with dementia:
Connectors. “The reason these residents keep trying to go places is that they want to be with people. They really can’t understand why they can’t be with people. They seek people—visually, auditorily or verbally, and physically,” explains Snow. “When they find people, these residents will want to get intimately connected with them, as close as they can probably be, or they will intrude into their space. And they can’t follow the rules because they can’t understand or remember the rules. Consequently, giving them instructions to distance is likely to either draw them toward you or to get them to go into someone else’s space to find another person who wants them if they think you don’t.”
Controllers. “These residents don’t want to be told what they can do,” says Snow. “The more you try to restrict their movement, the more they will try to move. They also may try to shove into you or push around you to get past and go into other spaces, such as another resident’s room, and close the door.”
It’s important to recognize that these residents can’t be “contained” with the usual methods, says Snow.
Identify an isolation area
Providers should try to create a facility within the facility for these residents, suggests Snow. “Is there a space and a place within the building that you can use as an isolation area for wandering residents? If so, you can use mobile partial walls to limit access out of that space while giving these residents a place, things, and situations they can engage with.”
The challenge is to create a space that will allow these residents to feel like they have control and like they have connections, says Snow. “For example, one option would be to create a half circle with lots of space and small overbed tables between each resident. The small tables could have things on them, and you could also have a central activity occurring. The leader of the activity could move around the half circle encouraging residents and fostering activities. They could visually and verbally encourage participation without touching. This type of interaction could help residents feel more engaged while maintaining that social distance space and respiratory distance space as much as possible. You want to steer residents into individual activities that still provide a sense of community.”
Staff members who take care of these residents need to be fairly skillful with dementia, says Snow. “These are often activity staff or certified nursing assistants (CNAs) who have worked with residents with dementia for a while. They not only understand how to guide residents, they also understand how residents may show they need to go to the bathroom or need something to drink.”
Offer programming variety
One-on-one monitoring is impossible, especially under Medicaid reimbursement systems, notes Snow. “Consequently, your staff should be prepared to provide varied programming. Sorting laundry over and over only goes so far. You need disposables or reusables that can be washed. Everything should be sanitized before you start each activity, and each resident should get their own items. For example, provide plastic silverware or colorful scarves to sort or balls to play with. For residents who do Easter, get Easter eggs that they can open and put things in and take things out of. Bring in magazines or newspapers that can be ripped and torn and wadded up. Create activities with plastic flowers, ties, or golf tees.”
Music is also an option, says Snow. “You want to provide residents an opportunity to feel rhythm, dance, and just move around. People aren’t meant to be still. Residents could be doing things with their hands on those bedside tabletops and looking at a large screen with music playing.”
The goal is to develop programming that both fills time and gives value, says Snow. “For example, the activity leader might say to one resident, ‘Hey listen, can you do me a favor? Take this, there you go. Bring it up, now down. Good, good, you’ve got it.’ Then they would encourage the next resident, ‘Now Mary, can you do it too? Yes, there we go.”
Prepare staff to be touched
“People need touch. These residents will crave touch, so the staff in their isolation area must be aware that they will be touched—and be prepared to control the encounter. You don’t want the resident to come up and touch when staff aren’t prepared for it,” says Snow. “The reality is that these residents require assistance with intimate care, and they frequently can’t even feed themselves adequately on their own. Therefore, staff will be touching them in some capacity anyway.”
Staff should go ahead and put on their gloves (preferably not blue ones), and a surgical gown or other covering, such as a clear raincoat or poncho, if resources are limited, suggests Snow. “You also may be able to get residents to wear gloves, as well as long sleeves. The probability of getting them to wear gloves is not high, but it is possible.”
On April 2, CMS issued supplementary guidance recommending all staff wear a face mask while in the facility “for the duration of the state of emergency in their state” and wear full personal protective equipment (PPE) for the care of all residents no matter their diagnosis or symptoms if COVID-19 transmission occurs in the facility. This guidance is a challenge when caring for residents with dementia because face masks hide the wearer’s identity and muffle verbal information and facial expressions, says Snow. Note: AMDA, the Society for Post-Acute and Long-Term Care Medicine recently posted a video about masking that reminds caregivers to lower their voices so they are more easily understood while wearing a mask and to express positivity with words since facial expressions aren’t visible.
To increase the safety of interactions, staff should consider using a hand-under-hand grasp for both hands if the resident seeks to reach out with their other hand or likes to touch others or objects in the environment, standing to the side and not immediately in front of the resident, suggests Snow. “Then staff can whisper forward, not into the resident’s face, saying something like ‘Yes, oh yes, I love you.’ Ensuring staff are trained to offer touch with less risk is so much more valuable than trying to avoid touch, which will escalate the resident’s distress and not meet their need.”
Have staff focus on praise and affirmation
Offering residents with dementia praise and affirmation—and asking them for help—can be powerful tools for staff, says Snow. “Even when a resident doesn’t understand all the words, if you look like you need help, do a ‘come with me’ motion, and say, ‘Ooh, I need help; I need some help,’ you can encourage that resident to move away from where they were going and go to a place you are more OK with them being. Then once they are redirected, remember to say, ‘Oh my gosh, thank you! Exactly! Wow. You did such a good job. Thank you.’”
Telling these residents no typically doesn’t work, she adds. “And if you lay your hands on them to try to get them not to go somewhere, there is an increased risk there will be greater contact between you and the resident, and it won’t be pleasant. Staff need to really recognize the importance of taking a deep breath and figuring out how to be in control of a situation that is not easily managed.”
Don’t blame staff when residents get away from them
With these residents, DNSs and other managers shouldn’t get angry if staff are unsuccessful at keeping them in the isolation area, says Snow. “You want to be very careful not to blame staff who are doing their very best with residents who may or may not want to be engaged the way you want to engage them. This is out of their routine. It’s rough for both the residents and your staff. Consequently, if a resident with dementia leaves their designated isolation area, make sure the area they end up in is sanitized appropriately and focus on getting them back where they belong.”
Review the latest CDC guidance for memory care units
On May 12, the CDC updated their webpage “Considerations for Memory Care Units in Long-term Care Facilities,” containing new infection prevention and control guidance as well as what to do when a memory care resident is suspected or confirmed to have a positive diagnosis of COVID-19.
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