The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities

Unsafe Behavior Worksheet

All behavior is meaningful; however, it may be difficult to understand the unsafe behaviors of some residents. Your perception of the behavior may be very different from the actual situation. To discover the meaning, you will need to explore the circumstances of the behavior, review the resident's personal and medical history and analyze staff/resident interactions.

Example: A resident gets out of bed unsafely at night and becomes very agitated when staff try to keep him in his room. To staff, he may be anxious, combative, uncooperative and difficult. From the resident's perspective, staff are preventing him from catching the bus to go to work.

Understanding the unsafe behavior of residents requires data collection, investigation and analysis. As you and the team better understand the behavior, you can problem-solve to develop additional individualized approaches. The Unsafe Behavior Worksheet is a 5-step process that directs you to define the behavior, review the resident's personal and medical history, investigate the circumstances, analyze staff approaches and develop new interventions.

Step 1: Define the behavior clearly.

Example: Resident gets out of bed between 2-4 a.m. He comes out into the hallway. His hands are shaking. He pushes staff away when they attempt to return him to the room. He talks loudly and becomes angry when staff ask him to lower his voice.

Step 2: Get as much information as possible about the resident's personal and medical history.

Include health status, family history, occupation, interests, cultural background and spirituality. Determine mental status including orientation, concentration, memory, judgment and psychological history. Incorporate information about mobility status, wheelchair use, postural hypotension, vision, and medications that was obtained during the Falls Assessment and from the evaluations by other health care professionals.

Step 3: Analyze the circumstances of the behavior.

Use a behavior log to track the behavior for at least one week. Gather information from staff and family. Look for patterns and meaning in the behavior by determining the following:

• Time of day.
• Persons present.
• Frequency.
• Situation.
• Location.
• Resident motivation, feelings and agenda.

Step 4: Analyze past staff approaches as well as the resident's reaction to them.

Ask staff about their previous approaches to the behavior and interaction with the resident. Determine with staff what has worked well and what has not been effective. Find out which staff member the resident responds to best.

Step 5: Develop new individualized interventions.

Address underlying medical conditions and medication use first. Ensure that all staff simplify the resident's care environment and use the positive communication skills and management strategies necessary for the care of residents with dementia. Problem solve with staff about the specific behavior, brainstorm about solutions and be creative. Develop a strategy and try it for a set period of time. Monitor the behavior each shift to determine the effect of the intervention. Revise the intervention based on your observations and staff feedback.

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