Six Pressing Issues when Living in Residential Care: Difference between revisions

Families often express concerns that antipsychotic drugs and sedatives are being prescribed to residents with dementia without the knowledge and consent of the substitute decision-maker. Some residents may come into residential care facilities from hospital  where  they have  been prescribed  the antipsychotics. In some cases, the apprehension is over the use of these drugs (particularly the “atypical anti-psychotics”), because of health warnings from the manufacturers and Health Canada. These powerful medications come with significant risks, such as falls, bedsores, blood clots and potentially fatal reactions to the drugs. Many residents are on the anti-psychotic drugs without a doctor's diagnosis of psychosis.

The issue is not only use of the drug, but how it interacts with the many other medications that the resident has been prescribed. About 53 percent of seniors in long term care facilities take five or more different drugs on average for their various health conditions.

The pharmacological and geriatric literature is very clear that anti-psychotic medications are often inappropriate for older people, as these medications can have serious side effects and sometimes lead to premature death. If an anti-psychotic medication used to manage behaviours results in restraining or restricting a resident’s movements, it is a restraint. That means its use must be consistent with the Residential  Care Regulations and other provincial legislation on the use of restraints.

In 2011, the Ministry of Health carried out a review and found that in a ten year period, anti-psychotic drug use had increased significantly in British Columbia’s residential care facilities. In 2000/1, about one in three residents was being prescribed an anti-psychotic drug; by 2010/11 over one half of all the residents were. The use of anti-psychotic in other Canadian jurisdictions has also been recognized as high and problematic.

In June 2013, the  BC Patient Safety and  Quality Care Council began the CLeAR initiative. The goal is to reduce the number of seniors in residential care on anti-psychotic medications by 50% across British Columbia by December 31, 2014). It is a province-wide, voluntary initiative.

* focus on informed consent prior to treatment.   

The care facility is the resident’s home.  Arguably, the resident and the Operator may both be considered “occupiers” with rights to control access to the place under the Trespass Act.   The resident has a right to control access to his or her room (much like a tenant)  and the operator or staff has a broad right to control access to premises.

* “must ensure that a parent or representative has reasonable access to a person in care for whom he or she is responsible.”

* “must, to the greatest extent possible while maintaining the health, safety and dignity of all persons in care, ensure that a person in care receives visitors of the person in care's choice at any time."

However it should be noted that a person granted  an enduring power of attorney has no authority to make personal care decisions such as who may visit the resident; neither does a person who is a temporary substitute decision-maker for health care decisions. Even a person holding a representation agreement that covers personal care decisions is expected to consult with the resident, follow their values, beliefs, wishes and act in  their best interests. They cannot misrepresent information or try to unduly influence the resident about whether certain people should visit the resident.  While in many cases,  staff can simply ask the resident if the person wants that visitor on this occasion,  the best approach becomes more complex  for cognitively impaired residents who may or may not  recognize the family member or close contact.

A 2012 Ministry of Health policy communiqué  stresses the need for a balanced response, and sets out the needed steps to achieve that. Specifically the Communiqué notes:

“It is recognized that family members and other visitors may be under considerable stress for a variety of reasons, and that a supportive and compassionate approach will be helpful in reducing anxiety.”

The BC Ombudsperson has found that the Ministry of Health and the health authorities have not provided necessary direction to Operators to ensure that the legislated rights of seniors in residential care to receive visitors are respected, and that people were being  unfairly restricted. The BC Ombudsperson made recommendations to make the process fairer and more accountable. 

Efforts to restrict a visitor obviously will affect that individual, but in many cases, it can also be considered a form of retaliation against the resident.  Retaliation against the resident when people are raising complaints or concerns is prohibited under the Regulations.

The residential care regulations authorize the facility operator to control access to visitors in other specific narrow circumstances.  For example, care facility staff can control access to residents for some infectious diseases.  Also the operator must restrict or prohibit a person from accessing the resident “as necessary” in order to comply with a court order, e.g. a peace order/ restraining order, or an injunction. Having said that, an operator or the health authority may not use an injunction that a court issued to bar one visitor in one specific situation as implicit or explicit authority to bar other people in other circumstances.

Under the residential care regulations,  the Operator is required to record the identity  of any individual who the operator has reason to believe may pose a risk to the health, safety or dignity of the person in care. However, there must be a reasonable basis for identifying a person as a risk to the resident. Operators also cannot bar individuals from visiting the resident simply because the Operator or staff members consider them as complainers or “trouble”.

Operators sometimes point out they have  a legal responsibility to ensure the resident is not  released or removed  from the  care facility to anyone except the resident’s representative or a person authorized by the representative.  Also,  they point out that a care plan or “other pre-existing arrangement” can set out who the resident can be released to, or who can remove  the resident from  the care facility. Both statements are legally accurate, but they can only apply to situations where the resident is not mentally capable of making that decision for herself  or himself.  A care plan that purported to make those restrictions  without the express consent of a mentally capable adult would not be valid.

The Residential Care Regulation requires an operator (licensee) to immediately report to the medical health officer (Community Licensing) if there is an allegation of abuse or neglect of a resident.

The abuse definitions specifically exclude harms by residents to other residents. These resident to resident harms are also considered important care issues and are “reportable” to Licensing; they are simply recognized as having different causes and needing different responses than do abuse or neglect situations.  

The operator must also complete an Incident Report Form and send it to the health authority’s community care licensing office immediately.

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:

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).

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.

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:

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.

* for data collection and analysis of health authority-wide

“… Mandatory reporting [in residential care] is just that – mandatory."

* Unexpected events involving residents.

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.

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:

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.

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."

:(a) in an emergency,  or   

:(b) if there is a prior written agreement to the use of the restraint.

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 medical practitioner or nurse practitioner responsible for the resident’s health care.