After a hard week at work, many adults look forward to a quiet dinner at a restaurant with a close friend or loved one. However, a peaceful evening can sometimes be interrupted by the crying of a child. Most anyone would be annoyed by this and ask, “Who would bring a child out at this hour of the night to a restaurant like this; it’s not like this is a ‘family restaurant’ where you would expect small children to accompany their parents, this is a formal restaurant!”
Many in this situation find themselves wondering why parents would bring children to a formal dining experience, the expectations of which were clearly beyond the comprehension of the child as demonstrated by the child’s inability to behave in accordance with the expectations of the setting.
Although the above scenario sounds unpleasant, a similar experience is lived by many residents each day in nursing facilities and other settings. This article will explore an all-too-common scenario and discuss what needs to be done to ensure not only superior customer service for all residents but also how to avoid potential deficiencies resulting from this similar scenario.

Enough Is Enough

Millie is an 81-year-old resident with severe cognitive impairment secondary to Alzheimer’s disease. Her most recent minimum data set (MDS) 3.0 assessment indicates that she has problems with both long-term and short-term memory. The Staff Assessment for Mental Status had to be conducted, as Millie lacked sufficient cognition to complete the Brief Interview for Mental Status (BIMS) instrument.
In addition, section B of the MDS 3.0 indicates that Millie’s hearing is highly impaired, and although she has a hearing aide, Millie’s cognition results in her frequently taking the hearing aide out and losing it.
In terms of making herself understood and her ability to understand others, Millie is rarely or never understood, and rarely or never understands others, due to her lack of linguistic abilities secondary to her diagnosis. However, Millie is quite lively in that she is generally into “everything” on the unit. Using her wheelchair for independent mobility, she often self-propels into the rooms of other residents, which generally causes considerable upset. Difficult to redirect, Millie sometimes strikes out at staff or other residents.
One evening, Millie wheeled herself into the nurses’ station, which was unattended (staff were busy elsewhere on the unit). One of the charge nurses returned to the station to find Millie with two charts open and their contents strewn across the floor.
“That’s it, I’ve had enough,” the nurse exclaimed and took Millie down the hall into the day room where the activity aide was holding a trivia game.
“Millie wants to play,” the nurse says as she places Millie’s wheelchair next to members of the group and turns to leave.
“But Millie isn’t supposed to attend this activity,” the activity aide explains. “It’s not an appropriate activity for her.”
“Millie has the right to attend any activity that she wants to, that’s part of her resident rights,” the
nurse says as she walks away.

What Is Right? What Is Wrong?

Although the nurse is certainly correct that Millie has rights, what becomes abundantly clear is that the nurse’s citation of “resident rights” in this situation has less to do with the intent of the law and more to do with expecting the activity department to keep Millie out of trouble.
Alzheimer's, behavior, dementiaAppendix PP of the “State Operations Manual” indicates that the resident “has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident.”
The first thing missing in this situation has to do with self-determination. Millie didn’t tell the nurse, “I want to go to the day room and play trivia.” Also, would placing Millie in an activity that she lacks the ability to effectively participate in due to her cognitive status really support her dignity? In fact, if the activity is complicated, and results in frustration, a catastrophic reaction may result. This could put the safety and well-being of other residents at risk.
The real issue here is that the activity that the nurse is attempting to encourage Millie’s participation in is inappropriate for Millie’s cognitive abilities. Recall that Millie has both long- and short-term memory problems, demonstrates an absence of useful hearing, is unable to make herself understood, and generally is unable to understand others.
In fact, recall that the staff were unable to use the BIMS scale of the MDS 3.0 due to her poor cognition. The activity was appropriate for individuals who had higher cognitive functioning, were able to understand the verbal content of the activity, and were able to adequately express their ideas.
The second point to consider is the potential negative effects of Millie’s presence on the activity and, ultimately, the enjoyment of other residents. If the activity is disturbed by the presence of residents who are inappropriate for the activity, it is likely that the residents’ enjoyment will be low—just as the individuals who attended a dinner had their time spoiled by the crying of a child.
Although the circumstances are different, the end result is the same—individuals in both situations have a certain expectations, and because of the lack of thought of others, the expectation was not met. This resulted in both frustration and lack of enjoyment.
However, in the scenario presented at the beginning of this article, the worst that could happen is that an expensive dinner was ruined. But when one considers the many thousands of dollars per month it costs for residents to stay in a long term care facility, the impact is significantly greater.
In addition, in the above scenario individuals who were displeased with the annoying child could get up and leave. And since the nursing home is where these residents live, leaving is scarcely an option. 

Could This Really Result In A Deficiency?

Certainly! Recall that the regulations at F-248 require that “the facility involves the resident in an ongoing program of activities that is designed to appeal to his or her interests and to enhance the resident’s highest practicable level of physical, mental, and psychosocial well-being.” Clearly, the trivia activity is not designed to meet the needs of Millie.
Recall that F-248 includes an investigative protocol. Part of the investigative protocol requires surveyors to interview residents regarding their satisfaction with the activity program in the facility. Residents will most likely be quite displeased that their activities are being interrupted by residents inappropriate to an activity, and often will share this with surveyors, when asked.
Of course Millie does have the right to attend the activity. The facility’s activity director should be using MDS 3.0 section F (Preferences for Customary Routine and Activities), along with section C (Cognitive Patterns), to determine the range of activities that Millie can participate in. Using the MDS 3.0 data should result in program planning that results in a cross-section of activities available to all residents with varying cognitive abilities and activity interests.
There should be an appropriate number of activities for high-functioning residents, low-functioning residents, and everyone in between.
A comprehensive activity assessment should consider both cognitive and physical factors, such as hearing and vision, as well as activity preferences.
Activities should be selected for individual residents based on the comprehensive assessment. This will result in activities that provide the appropriate level of challenge and interest, while at the same time avoiding frustration.
If Millie’s cognitive and behavioral status results in her inability to effectively function in a group activity setting, then individualized activities to meet Millie’s unique needs should be developed. Consultation with a recreation therapist may be beneficial in developing individualized approaches.
It is easy to understand how staff can become frustrated with residents who demonstrate challenging behaviors. It is essential that the administrator not permit the activities program to be turned into a glorified babysitting service.
Activities should be selected commensurate with resident interest and resident abilities, not to serve as a panacea for frustrated staff. The facility’s activity director should engage in ongoing assessment of both resident interests and abilities and revise the facility’s comprehensive activity programming to meet the assessed needs of its residents.
Linda Buettner, PhD, LRT, CTRS, is professor of recreation therapy and gerontology at the University of North Carolina at Greensboro and co-coordinator of the Geriatric Treatment Network for the American Therapeutic Recreation Association. Timothy Legg, PhD, CNHA, GNP-BC, CTRS, FACHCA, is professor of nursing and academic program chair at Kaplan University School of Nursing. He serves as a long term care consultant with Gerber Consulting Services, Clymer, Pa.