Many of the risks seen in Memory Care are the same risks that arise in skilled nursing and assisted living. However, there are unique legal risks inherent in the provision of memory care services that leadership should not ignore. While this article is not an exhaustive list of those risks, some of the often-overlooked enhanced risks are identified below.
By: Karen Davila
Memory Care in the CCC
The existence of a Memory Care Unit allows residents to remain in the CCC longer, but the risks of caring for those individuals increases substantially. Memory Care services are generally provided in a secure (“closed”) unit with staff with specialized trained to understand the unique needs of residents with dementia. Risks are different from those elsewhere in the CCC in part due to (a) the geographic and physical isolation (restricted ingress/egress) that are common for Memory Care Units; and (b) the unique capabilities and vulnerabilities of residents, rendering them unable to comply with safety guidance and participate meaningfully in analysis of any adverse event. Because of this, leadership should recognize and attempt to mitigate risks associated with falls, elopements, aggressive/disruptive behaviors, infectious disease, adequacy of staff training, and 24/7 staff supervision, among others. Additional thoughts and considerations on each of these are discussed below.
A core resident safety objective in any CCC is to minimize the risk of falls. Leadership and staff are familiar with the importance of mitigating this risk and many interventions are deployed. However, residents with dementia may have difficulty complying with the interventions (e.g., call buttons/lights, handrails, bedrails) intended to protect them. Memory Care staff should be vigilant and conduct regular rounds with residents to assure resident safety around the clock.
Adequate security and supervision must be provided in Memory Care to prevent residents from eloping. Each potential resident should be assessed for elopement risk and the Memory Care Unit should admit only those residents it is able to safely serve. Staff should be trained to identify the signs of wandering or elopement. Physical security must include locking doors, windows, gates, and other physical barriers. The Memory Care Unit also should have appropriate and monitored surveillance equipment as well as alarms on doors, beds, and wheelchairs. And the Memory Care Unit should have a protocol to immediately respond to and manage any elopement event, including reporting to appropriate authorities when a resident cannot be located immediately.
Harmful resident behaviors are more common in Memory Care where residents can be confused and frustrated over any changes to their schedules and activities. Harm to self, other residents, staff, and visitors is common in the Memory Care setting. Identifying the risk of harmful behavior and then taking steps to prevent harm is critical in any Memory Care setting. Memory Care providers must:
- Screen all incoming residents.
- Train staff to deal with any violent propensities.
Memory Care providers must make sure that existing residents and new residents can co-exist safely. Failure to remove and/or isolate violate residents can lead to violence, including sexual assaults and rape, for which the Memory Care provider can be held liable.
Exposure to infections is a major concern of any health care provider. With the onslaught of COVID-19, CCCs have made significant strides to mitigate risks of spread of infectious disease. However, in a Memory Care Unit, some residents may not be compliant with infection control measures. Absent significant vigilance, wandering residents who are unable or unwilling to comply with those measures can expose others to any infectious disease they may be carrying. In an investigation at one CCC recently, a single Memory Care resident infected at least 10 other residents and became known as “Madame Butterfly”, flitting around socially from one room to the next, unhindered by staff or leadership.
Adequacy of Specialized Training for Staff
Staff who are properly trained to manage Memory Care residents will know how to redirect and manage risky behaviors. “Floating” staff from a skilled nursing or assisted living level is possible, but only with significant preparation and specialized training. Training staff to identify and deescalate the situation when triggers are present mitigates these risks.
Leadership/Supervision of Staff 24/7
Since Memory Care is a 24/7 operation, leadership should provide adequate supervision on all shifts. One of the things that has been observed in Memory Care is that leadership rounds less frequently because of its geographic isolation and limited access. Less visibility leads to less accountability of staff, increasing risks for the CCC. Only by conducting periodic rounds across all shifts can leadership identify areas of risk and implement steps to mitigate those risks.
Administration in any CCC that offers Memory Care should understand the special needs of the residents, implement adequate physical safety and security, and properly train and supervise the staff providing care. Leadership must assure that there is adequate oversight on all shifts and that the individuals leading these units are physically present to identify and mitigate the inherent risks. Leadership should consider conducting a comprehensive risk assessment and implementation of a plan responsive to any risks identified through that assessment.