Difference between revisions of "Six Pressing Issues when Living in Residential Care"
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In some cases, family members have tried to determine whether resident abuse or neglect is occurring by placing a hidden video camera in the resident’s room. This is rarely a first response; it typically occurs when the possible indicators are present and | In some cases, family members have tried to determine whether resident abuse or neglect is occurring by placing a hidden video camera in the resident’s room. This is rarely a first response; it typically occurs when the possible indicators are present and | ||
* the resident has cognitive impairment or communication | * the resident has cognitive impairment or communication difficulties making it difficult to determine the facts, | ||
* family feel their questions or concerns about specific situations have not been adequately addressed, or | * family feel their questions or concerns about specific situations have not been adequately addressed, or | ||
* situations have not been adequately investigated internally by the operator or externally by oversight bodies. | * situations have not been adequately investigated internally by the operator or externally by oversight bodies. | ||
Use of video surveillance in the privacy of a resident’s room may or may not lead to greater resident freedom from abuse or neglect. | |||
==Resident To Resident Harms== | |||
Care facility operators have a general responsibility to promote the health and safety of all residents, and to protect them from harm. This includes harms from other residents. Resident to resident conflict or aggression can have a significant effect on the emotional and physical well-being of the residents and others in the facility. | |||
It has been estimated that 11 per cent of the care facility residents are “aggressive” at some point. In some instances this can lead to serious injury, even death. The geriatric literature now uses the term “responsive behaviour” to recognize the fact that “aggressive“ residents are often responding (inappropriately) to situations that are frightening to them or causing confusion, Residents may be responsive for many reasons, often it is because of confusion caused by dementia, inadequately addressed pain or an underlying medical condition that is not under control. The resident to resident harms can occur in general residential care facilities as well as those with special dementia units. | |||
The Residential Care Regulation requires care facility operators to report “aggressive or unusual behaviour”. This is defined as “aggressive or unusual behaviour by a person in care towards other persons, including another person in care, which has not been appropriately assessed in the care plan of the person in care.” | |||
Resident to resident harms typically occur because of three types of factors intersect. There are individual resident factors, facility factors and factors from the broader care system. The resident factors for aggression generally include: | |||
* where the residents are cognitively impaired (particularly if they have frontal lobe dementia which impairs inhibitions and their ability to control their behaviour), | |||
* certain medical conditions and psychiatric illness (e.g. under-addressed pain and depression). | |||
It is very common for residents who seem to be aggressive to also show signs of depression and delirium. Other factors can include their personality and their life experience (presence of trauma history, contact sports, the way they have resolved conflicts throughout life). | |||
If there has been a good assessment of the resident prior to coming to the facility (including communication with family or key contacts about whether the person showed aggression in the community), it should be evident whether or not these factors are present. | |||
Resident assessment, however, is an ongoing process and is always required as the person’s health and conditions change. Worksafe BC has indicated that sometimes community service providers are reluctant to share information about a prospective resident’s tendency to respond aggressively, out of concern that the disclosure might breach provincial privacy law. However that it not the case; information about a prospective or current resident’s violence risk can be properly disclosed on a “need to know basis.” | |||
The geriatric literature also shows a significant amount of resident aggression can also be reduced with staff trained in dementia care and particularly with training on “responsive behaviours”, such as “P.I.E.C.E.S.” , U – First, Montesorri, or similar programs, as well as staff trained with “Code White” protocols. In 2012, the Ministry of Health developed best practice guideline for accommodating and managing behavioural and psychological symptoms of dementia. In these guidelines, medications to control behaviours are only used after other less restrictive (but hopefully more effective) methods have been tried and ruled out. | |||
Several facility factors are also important in heightening or reducing the level of resident aggression in that facility. These include its size; whether the environment is over stimulating or under-stimulating; and the facility’s culture (whether it is institution focussed or uses a person centred care approach). Equally important are the staff factors - the staff members' style of approach to residents and work, the numbers and mix of staff, their training and available support, workplace wellness, and leadership factors. | |||
Broad system factors such as the residential care process also have an important role. For example, if policy requires residents to be admitted to the first available facility without also having a good assessment of whether the person is appropriate for that facility, or under what circumstances, this may create special risks for that person, other residents and staff. If the broader societal view of residential care treats the needs of residents to safe and appropriate environments as a low priority, or simply views residents as physically frail, and therefore unlikely to cause harm, resident aggression is more likely to occur and recur. | |||
It may not be possible to eliminate all resident to resident aggression. However, there are a variety recommended policy responses to help reduce it. These include to: | |||
* increase the staff levels in the facility; | |||
* have specific staff in-house in every care facility with behaviour care expertise; | |||
* have more designated behaviour units to care for residents with severe aggressive behaviours; and, | |||
* have regular and recurring behaviour-related training for all care staff. | |||
Resident to resident harm has begun to raise a wide array of complex legal and health care planning issues. For example, | |||
* what is the best way to approach situations when a person with cognitive impairment in the community and residential care settings has caused injury or death? | |||
* should all situations require a police response? If so, what is the nature of the most appropriate justice and health system response? | |||
This becomes particularly relevant when cognitively impaired resident does not appear to have the requisite mens rea for assault, the mental capacity to instruct counsel, or fitness to stand trial. Unlike younger adults who have become aggressive as a result of a mental condition, the difficulty for many residents is that dementia does not get better. Having a safe and appropriate place for them to live the last months or years of their lives, without leaving other residents at risk of harm becomes pressing. | |||
==Reporting Responsibilities== | |||
The Residential Care Regulations set out a number of mandatory situations (referred to as “reportable incidents”) where the operator (and consequently the staff) must notify certain authorities or key people outside of the facility. In some cases these incidents are reported to the Ministry of Health (generally to Community Care Licensing), but in other instances they are also made to the resident’s representative, or contact person. These incidents include: | |||
* “abuse”, including emotional, financial, physical, and sexual abuse | |||
* “aggression between persons in care” | |||
* "aggressive or unusual behaviour" | |||
* "attempted suicide" | |||
* "choking" | |||
* "death of a person in care”; | |||
* "disease outbreak or occurrence" | |||
* "emergency restraint" | |||
* "fall” | |||
* "food poisoning" | |||
* "medication error" | |||
* "missing or wandering person" | |||
* "motor vehicle injury” | |||
* "neglect” | |||
* "other injury" | |||
* “poisoning" | |||
* "service delivery problem" | |||
* "unexpected illness" | |||
Each term included in incident reporting has a very specific regulatory definition and meaning in residential care. See the Appendix for definitions. | |||
The primary concern expressed by families is that although incident reporting is required by law, it may not occur. Alternatively, if family is called about an incident as required by law, the seriousness of the situation may be downplayed or the incident is mischaracterized (e.g. a sudden death is attributed to a heart attack, not a choking incident). As a result serious problems may remain undetected for a longer period of time. | |||
The formal Incident Reporting process is intended to serve several purposes in residential care: | |||
* to ensure a timely response by the facility to the incident, | |||
* to give Community Care Facilities Licensing staff the opportunity to review the facility’s response in a timely manner, | |||
* to help prevent the recurrence of the incident and promote a high standard of care, safety, health and dignity of the persons in care, | |||
* for data collection and analysis of health authority-wide | |||
===Reporting is mandatory=== | |||
Care staff and the operator are required to report if they have reasonable grounds to believe the actions or behaviours they have observed meet the definitions of “reportable incident” in the legislation. Sometimes operators, care staff or volunteers are led to believe they have discretion in reporting. | |||
This frequently comes up for abuse or neglect cases. Staff may or may not decide to report depending on relative severity of the situation or if they feel ethically uncomfortable with the situation. Abuse and neglect reporting must take place whether it is considered minor mistreatment or major. The follow-up response of the operator and Community Care Licensing to the incident will depend on the circumstances. | |||
People cannot opt out of reporting required by law, because they do not feel comfortable or the resident “didn’t want me to report”. The statements reflect a misunderstanding about discretion that does not exist in the law. As the Advocacy Centre for the Elderly has noted: | |||
“… Mandatory reporting [in residential care] is just that – mandatory." | |||
The operator also must also maintain a written log of: | |||
* Minor accidents and illnesses involving persons in care, that do not require medical attention and are not reportable incidents; and | |||
* Unexpected events involving residents. | |||
===Harm to the resident discovered outside the care facility== | |||
Social workers or other health care providers at hospitals may have a concern about a resident who is temporarily in hospital for treatment. British Columbia’s law is different than some jurisdictions, in that it does not place a responsibility on “everyone” to report suspected harms to a resident. | |||
However, if there is a suspicion that abuse or neglect is occurring, health care providers can still rely on the Part 3 of Adult Guardianship Act and report the concern to a “designated agency”. Almost every resident in a care facility who is experiencing suspected abuse or neglect would be considered a vulnerable adult falling within the scope of the Act. Part 3 of the Act (the abuse and neglect section of the Act) applies no matter where the person lives, except for a correctional facility. | |||
==Restraints== | |||
A "restraint" is anything that limits the movement of a resident and over which the resident has no control. Restraints may be physical (e.g., lap belt, "posey" jacket, mittens, bed side rails, "geri- chairs”), environmental (barriers which confine a resident to a specific space such as locked units) or chemical (e.g., drugs used to inhibit or control disruptive behaviour). It is also a restraint when an assistive device such as wheelchair is left beyond a resident’s reach, or is modified so that the person cannot use it to move around (removing a wheelchair’s foot rests). | |||
Today there is a wide variety of technology that “restrains” residents’ freedom and these are used for a wide variety of legitimate (and sometimes not so justifiable) reasons. Some residents may be prone to wandering and may need protection from exiting the facility unaccompanied. These residents may be provided with electronic “tags” that will deactivate elevators and alarm the main front exit. | |||
However, depending on the circumstances, the use of physical or chemical restraints for the involuntary immobilization of the resident may not only be an infringement of the resident’s rights, but can also result in patient harm, including soft tissue injury, fractures, delirium, and even death. Harms to residents from restraints can arise for many reasons. | |||
Staff may not recognize the practice actually is a form of restraint. Staff may not be adequately trained to identify and address the underlying cause of the problem (why the resident wanders or why the resident is showing this responsive behaviour). As a result, the staff may rely on restraints as the “only tool in their care toolbox”. Also: | |||
* staff may not recognize the risks associated with the restraint (e.g. recognize that the person will likely try to leave the bed, escape the restraint, or become more agitated) and | |||
* Staff may be untrained in the proper use of restraints. | |||
In many cases in residential care, restraints efforts intended to be a "last resort” become the “first resort”. The Alzheimer Society of Canada notes the special risks for people with Alzheimer’s disease or other dementias. For people with Alzheimer’s disease, the restraints are a restriction of freedom, can decrease a person’s physical activity level and ability to function independently, and can cause injuries. | |||
===The law on restraints=== | |||
Under the Residential Care Regulations, a "restraint" is defined as “any chemical, electronic, mechanical, physical or other means of controlling or restricting a person in care's freedom of movement in a community care facility, including accommodating the person in care in a secure unit." | |||
Division 5 of the Regulations describes situations in which restraints may be used and the minimum standards for their use. Section 74 (2) specifically stresses that the operator must ensure that a person in care is not restrained: | |||
:(a) for the purpose of punishment or discipline, or | |||
:(b) for the convenience of employees. | |||
===Circumstances in which restraints can be used=== | |||
Restraints may be used in two circumstances: | |||
:(a) in an emergency, or | |||
:(b) if there is a prior written agreement to the use of the restraint. | |||
The term “emergency” is not defined in the regulations. The term “emergency” in everyday language usually refers to events that are out of the ordinary that cause or are very likely to cause serious immediate harm to the person or others. Schedule D of the Regulations describes certain reportable incidents and defines an "emergency restraint" as “any use of a restraint that is not agreed to under section 74 “(a prior written agreement). If a resident is in care facility where issues are not recognized and appropriately addressed fairly early on, situations involving staff or other residents can easily deteriorate, turning into “emergencies”. This is not the intention of these sections of the regulation. The proper focus is on prevention and early intervention to avoid the emergency. | |||
===Restrictions=== | |||
Section 73 (1) of the Residential Care Regulations identifies restrictions on the use of restraints, noting “A licensee must ensure that a restraint is not used unless: | |||
:(a) the restraint is necessary to protect the person in care or others from serious physical harm, | |||
:(b) the restraint is as minimal as possible, taking into consideration both the nature of the restraint and the duration for which it is used, and | |||
:(c) the safety and physical and emotional dignity of the person in care is monitored throughout the use of the restraint, and assessed after the use of the restraint. | |||
All three conditions are required – protect from serious physical harm, minimal as possible, and monitor resident’s safety, as well as physical and emotional dignity. | |||
Section 73 of the Residential Care Regulations sets out a number of preconditions, before the use of restraints can be in place and what needs to subsequently happen. It states: | |||
:(a) all alternatives to the use of the restraint must have been considered and either implemented or rejected; | |||
:(b) the employees administering the restraint must | |||
::(i) have received training in alternatives to the use of restraints and determining when alternatives are most appropriate, and the use and monitoring of restraints, and | |||
::(ii) follow any instructions in the care plan of the person in care respecting the use of restraints; | |||
:(c) the use of the restraint, its type and the duration for which it is used must be documented in the care plan of the person in care. | |||
===Written agreement to the use of restraints=== | |||
The Residential Care Regulations identify that restraints may also be used if there is agreement to the use of a restraint by both: | |||
:(i) the person in care… (or in the case of a mentally incapable resident, their representative of the person in care or the relative who is closest to and actively involved in the life of the person in care), and | |||
:(ii) the medical practitioner or nurse practitioner responsible for the health of the person in care. | |||
This agreement, however, must be in writing. All the regular rules on considering alternatives, staff training, following instructions and documentation still apply. The parties can agree when the need for the restraints will be reassessed in the care plan. | |||
===Post emergency restraint requirements=== | |||
If restraints have been used in an emergency situation, after that emergency the Operator is required to talk with and provide “information and advice” to the resident who was restrained, anyone who witnessed the restraint’s use, as well as any employee involved in the restraint. This “information and advice” is to be documented in the resident’s care plan. | |||
The regulations also set out a stringent process of reassessment of the need for the restraints. If restraints are used longer than 24 hours or continuously, the Operator must: | |||
* have agreement in writing from the resident or their representative, if applicable and | |||
* the medical practitioner or nurse practitioner responsible for the resident’s health care. | |||
{{REVIEWED | reviewer = BC Centre for Elder Advocacy and Support, June 2014}} | {{REVIEWED | reviewer = BC Centre for Elder Advocacy and Support, June 2014}} | ||
{{Legal Issues in Residential Care: An Advocate's Manual Navbox}} | {{Legal Issues in Residential Care: An Advocate's Manual Navbox}} | ||