Behaviours of Concern MAT Aged Care

The Code will apply to residential, home care and flexible care services. Flexible care includes the Transition Care Program, Multi-Purpose Services Program and Short-Term Restorative Care Program.

The Code will apply to:

• approved aged care providers
• their governing persons (e.g. board members and CEOs)
• aged care workers who are:
  • employed or otherwise engaged (including on a voluntary basis) by the provider
  • employed or otherwise engaged (including on a voluntary basis) by a contractor or subcontractor of the provider to provide care or other services to consumers.

People receiving aged care should always be treated well and feel safe.

As an aged care worker providing care, supports and services, you have the most contact with people receiving care. Your behaviour affects how people feel about themselves and if they feel safe and supported.

You must always act in a way that is respectful, kind and consistent with the behaviours set out in the Code.

Your responsibilities under the Code are in keeping with your existing obligations under the Aged Care Act 1997 (the Act), including the Aged Care Quality Standards.

Approved providers must behave and treat people receiving aged care services in ways consistent with the Code and take steps to make sure aged care workers and governing persons do the same.

Providers are expected to support, equip and prepare you to carry out your role. This includes, for example, providing training, making sure policies and procedures are easily accessible, and taking action to make sure you meet the Code.

The role of the Commission is to protect and enhance the safety, health, wellbeing and quality of life of people receiving aged care services.

If it is found that an aged care provider and/or the people who provide care have behaved in a way that is not consistent with the Code, the Commission can take action.

The legislation includes protections to ensure providers or individuals are given the chance to respond to concerns raised. Appropriate procedural fairness applies.

The Commission have access to a range of compliance and enforcement actions to respond to different situations. In severe cases, action may include banning a current or former aged care worker or governing person from working in aged care. In the case of approved providers, sanctions may be applied or the approved provider status may be revoked.

People experiencing confusion or other cognitive impairments may have difficulty thinking clearly and understanding what is happening around them.

Confusion or cognitive impairment may be associated with dementia, but can also be a result of other conditions such as dehydration, infections or reactions to medications. People experiencing confusion may appear to be forgetful, puzzled, bewildered, uncertain, angry, upset or distressed

Changes in the behaviour of elderly people or those who suffer from medical conditions for example dementia are very common. Aggression in dementia is characterised by physically and/or verbally threatening behaviours directed at people, objects or self. It is often quantified by specific acts which can include:

• verbal insults, shouting, screaming
• obscene language
• hitting, punching, kicking
• pushing, throwing objects
• sexual aggression

Aggression can be a purposive and overt response to a violation of personal space or a perceived threat. It often occurs during personal care tasks involving close carer-/staff-resident contact. Aggression can also arise from underlying depression, psychotic symptoms,

environmental stressors and/or unmet needs.

A person who is intrusive can cause other people offence. You need to handle the situation sensitively because they may not be aware that they are being intrusive and acting in an inappropriate way. Intrusive behaviour includes going through other people’s things or being too interested in their personal lives. You should:

• gently steer the people away from the situation where they are engaging in intrusive behaviour

• change the topic of conversation if the people asks someone else too many personal questions or gossips about others

• provide diversional activities so the people will not be bored

Manipulative behaviour is not as noticeable as some other behaviours of concern. You may need to observe this over a period of time. Once you are aware that someone is engaging in manipulative behaviour, monitor what is happening and intervene if necessary to prevent others being manipulated. You should:

• learn to recognise an individual’s preferred type of manipulative behaviour; for example, getting others to do things for them or spreading false information X observe the impact the behaviour has on others
• be firm but gentle when refusing requests or when intervening and explaining why their behaviour is inappropriate and hurtful to others.

Dementia causes people to lose their ability to recognise familiar places and faces. It’s common for a person living with dementia to wander or become lost or confused about their location.

Wandering can be dangerous, especially if the people wanders off in the evening. You need to act as soon as you see them start to wander and then apply strategies to minimise the wandering. You should:

• search for the people in all the places they might be X notify your supervisor, other staff, security, the police and family members if it is clear the people has disappeared
• if you find the people about to wander, speak calmly to them and gently guide them back to where they should be
• offer diversional activities they enjoy
• monitor them closely
• ensure the people has regular health checks for their health.

Vocally disruptive behaviour (VDB) is a term that includes screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests.

Calling out may be the only way that the person is able to communicate sadness, frustration or distress. It can be described as any vocalisation that causes stress within the persons environment.

VDB can be intermittent or incessant and include vocalisations such as singing, screaming, abusive or verbally aggressive comments, perseveration, repetitive questioning, groaning and sighing.

Causes include physical and/or psychological discomfort or social isolation, combined with operant learning, in the context of reduced stress thresholds due to cognitive impairment.

Put simply, self-destructive behaviour means doing things that will cause us physical or mental harm. Psychologists also refer to this as dysregulated behaviour. Sometimes these actions can bring pleasure in the short-term, or momentarily help to relieve feelings of stress, anxiety and depression.

Examples of self-destructive behaviors include: Physical harm or self-injury behaviors, such as cutting.

May include:

Swearing

Yelling

Harassment Verbal Abuse or threats

Refusal of care occurs when a resident chooses not to accept the services offered. Refusal can come in many forms:

• Refusal service (i.e. showering/toileting)

• Refuse what is required

• Refuse to eat
• Refuse to take medication

Inappropriate behaviour or disinhibition in dementia typically occurs with reduced capacity to edit immediate impulsive responses. Behaviours include those associated with impaired judgement and reduced awareness of the environment and the impact on others.

These behaviours can include:

• simulating sexual acts
• requesting unnecessary genital care
• attempts at intercourse, rape
• sexual aggression
• propositioning others
• grabbing, groping
• sexual remarks
• masturbation in public
• exhibitionism
• fondling, frotteurism
• chasing others for sexual purposes

When disinhibited behaviours present with a sexual resonance, they tend to be more problematic. Sexually ambiguous behaviour such as undressing in front of others and/or in an inappropriate place or attempting to remove irritating clothing, e.g. tight or soiled underwear, may be mistakenly deemed sexually inappropriate. Urinating in inappropriate places can occur when the person with dementia is unable to remember where the toilet is or find their way to the
bathroom.

Additionally, misinterpretation of the intentions of carers and/or staff, an unmet need for human contact, attention or affection in combination with diminished insight, judgement and/or awareness of their surroundings and others, may trigger these behaviours in a person with dementia.

If a patient begins to show signs of apathy, follow the procedure below:

• It is important to respond calmly so as to not cause the patient any distress
• Evaluate whether there is anything abnormal about the persons behaviour
• Do not let them feel concerned that they may be doing anything wrong
• Break tasks into small manageable tasks that they can accomplish
• Offer a different passive activity
• Continue to monitor the patient
• If they continue to be apathetic then report this to your manager.

As soon as patient has been identified as missing and all rooms have been checked, the following procedure must be followed:

• Check the logbook to find out when the patient was last seen
• Check the patients file to find out more about them if you do not know them well enough
• Check areas that the patient likes to visit first and connects them with their past
• When the patient has been located, remind them where they are and who you are
• Remember that they may have mobility issues and may forget, ensure that you know what the patient requires.
• If patient cannot be located within 30 mins, you must report this to your manager.
• The manager will decide when to would be appropriate to contact police – this will be assessed on a case-by-case basis.

Ensure you keep yourself and your reputation safe by keeping your physical distance, staying visible in a common area and try to have two people with the patient at all times. When meeting with the patient follow the procedure below:

• Start by making the client feel as if they are important
• Do not respond to flirting with flirting
• Distract the patient when they try to make inappropriate comments by asking them questions and changing the topic
• Change the topic
• Do not discipline the behaviour
• Check the environment to see if there is a trigger for the behaviour
• If no trigger is identified, stay calm and ignore the behaviour
• If the behaviour escalates to a point of distressing others, then seek assistance from your manager.
• Where behaviour is not able to be managed with these strategies then the behaviour must be reported and a behavioural management plan will be implemented.

When approaching a patient, always ensure you make them feel important. Ask them questions about their day and find out a bit more about them. This will assist you with building a relationship of trust. If a patient refuses to take medication, then follow the procedure below:

• Start by making the client feel as if they are important
• Engage the patient in the process rather than telling them they have to do it
• Frame the behaviour in a way that will allow them to see that doing what is being asked is a good choice
• Allow them to make the decisions for themselves

If a patient becomes aggressive while you are speaking with them, follow the procedure below:

• Be mindful of your safety. If you are feeling unsafe or threatened, then leave and seek assistance from your manager
• Evaluate the patient and the threat level
• De-escalate the aggression by utilising the de-escalation procedure
• If it feels safe then engage in conversation
• Engage them in the process
• Do not tell them how things are going to be
• Explain what you would like to do and have them be involved

If a patient begins to show signs of apathy, follow the procedure below:

• It is important to respond calmly so as to not cause the patient any distress
• Evaluate whether there is anything abnormal about the persons behaviour
• Do not let them feel concerned that they may be doing anything wrong
• Break tasks into small manageable tasks that they can accomplish
• Offer a different passive activity
• Continue to monitor the patient
• If they continue to be apathetic then report this to your manager.

The employee must advise the Aged Care Director or Supervisor as soon as possible of the incident, even if they managed to diffuse the situation. Incidents which involve behaviour of concern or those behaviours which are deemed challenging to us must be reported using the Incident Report Form, within 24 hours after the incident occurring.

There are 8 types of reportable incidents that must be reported to the Commission:

• Unreasonable use of force – for example, hitting, pushing, shoving, or rough handling a consumer
• Unlawful sexual contact or inappropriate sexual conduct – such as sexual threats against a consumer, stalking, or sexual activities without consumer consent
• Neglect of a consumer – for example, withholding personal care, untreated wounds, or insufficient assistance during meals
• Psychological or emotional abuse – such as yelling, name calling, ignoring a consumer, threatening gestures, or refusing a consumer access to care or services as a means of punishment
• Unexpected death – where reasonable steps were not taken by the provider to prevent the death, the death is the result of care or services provided by the provider or a failure by the provider to provide care and services
• Stealing or financial coercion by a staff member – for example, if a staff member coerces a consumer to change their will to their advantage, or steals valuables from the consumer
• Inappropriate use of restrictive practices – where it is used in relation to a consumer in circumstances such as:
  • where a restrictive practice is used without prior consent or without notifying the consumer’s representative as soon as practicable
  • where a restrictive practice is used in a non-emergency situation, or
  • when a provider issues a drug to a consumer to influence their behaviour as a form of restrictive practice
• Unexplained absence from care – where the consumer is absent from the service without explanation and there are reasonable grounds to report the absence to the police.

The Commission must be notified of all reportable incidents. This includes incidents that occur, or are alleged or suspected to have occurred, and includes incidents involving a care recipient with cognitive or mental impairment (such as dementia).

Incidents that are not one of the 8 reportable incident types listed above are not required to be reported to the Commission. However, depending on the circumstances, they may need to be reported to another government body.

Approved providers should always consider their local regulatory environment when determining whether an incident must be reported and to whom.

All incidents that occur in the provision of care, whether reportable or non-reportable, must be managed in line with a service’s IMS.

Reporting Timeframes

If a reportable incident occurs or is alleged or suspected to have occurred, the provider must immediately act to protect the safety and wellbeing of those involved.

You must indicate whether the incident is either Priority 1 or Priority 2 based on:

• the incident type
• the harm and/or discomfort caused to the resident
• whether there are reasonable grounds to report the incident to the police.

The priority of the incident determines when it must be reported to the Commission.

There are exceptions where reporting externally is optional where an assault has been carried out by residents with a mental impairment.

• In this case the facility must have reasonable grounds for believing that the person who carried out the reportable assault is a resident with diagnosed mental impairment. The facility must form this view within the 24 hours after the allegation of the reportable assault or after starting to suspect on reasonable grounds that a reportable assault has occurred:
• In this case an internal report must be done and care plans for behaviour management reviewed and evaluated to prevent repeat of similar incident. The records of both the incident, management plans for prevention of the repeated incident must be kept in the Compulsory reporting files.