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The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia.A mixed-methods study was performed.During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica.Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χAntipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P .001), attempt gradual drug reduction (P.001), and provide adequate indications for psychotropics use (P.001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P.001) and provide nonpharmacologic interventions (P.001).This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

OBJECTIVES: The purpose of this study was to describe the incidence, pharmacologic management and impact of pain on function, agitation, and resistiveness to care among assisted living residents. DESIGN: This was a descriptive study. DATA SOURCES: Baseline data from 260 residents in the second cohort of the study, Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT). REVIEW/ANALYSIS METHODS: Descriptive analyses for the Pain Assessment in Advanced Dementia (PAINAD), Visual Descriptor Scale (VDS), and use of medication for pain management and hypothesis testing using linear regression analyses were performed. RESULTS: The majority of the sample was female (71%) and white (96%) with a mean age of 87 (SD=7). Fifty-two out of the 260 residents (20%) reported pain based on either the PAINAD or the VDS. Out of the total 260 residents, 75 (29%) received pain medication. Twenty-two out of the 52 individuals (42%) reporting pain were not getting pain medication. Controlling for age, gender and cognition, the PAINAD was significantly associated with agitation, function, and resistiveness to care and the VDS was only associated with function. CONCLUSIONS: The incidence of pain was low among participants based on the PAINAD or the VDS. Pain measured by the PAINAD was significantly associated with function, agitation and resistiveness to care. NURSING PRACTICE IMPLICATIONS: Pain assessments should include both objective and subjective measures and management of pain should be considered as it may help to optimize function and decrease behavioral symptoms among assisted living residents.

OBJECTIVES: The purpose of this study was to expand on prior work testing invariance on several depression measures in community based older adults and explore the psychometric properties and evidence of invariance between racial groups based on the Cornell Scale for Depression in Dementia DESIGN: This was a descriptive measurement study. SETTING AND PARTICIPANTS: This was a secondary data analysis using baseline data from two studies: Testing the Implementation of the Evidence Integration Triangle for Behavioral and Psychological Symptoms Associated with Dementia and the study Testing the Impact of Function and Behavior Focused Care for Nursing Home Residents with Dementia. Combined, 67 nursing homes participated from two states and 889 residents were recruited. The mean age of the participants was 86.58 (SD=10.31) and the majority was female (72%) and White (70%). METHODS: This was a descriptive study and a Rasch analysis was done to establish reliability based on internal consistency and evidence of Differential Item Functioning (DIF) across races. Validity was based on item fit and model testing with Structural Equation Modeling to compare models between White and Black participants. RESULTS: There was evidence of internal consistency (Alpha Coefficient of.98) and no significant evidence of DIF. The item related to suicide had a high logit and did not significantly load onto the measurement model for Blacks. There was not a good spread of the items across the concept of depression. The model had a better fit with the items when used with White versus Black participants. CONCLUSIONS AND IMPLICATIONS: The findings indicate that it would be helpful to add some additional items that reflect depressive symptoms among this population. Further the findings serve as a reminder that this measure may be biased toward identification of symptoms of depression among White versus Black residents.

Purpose The purpose of this study was to test the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for Behavioral and Psychological Symptoms Associated with Dementia (BPSD). Methods This study used baseline data from the first cohort of a larger randomized clinical trial testing the implementation of the Evidence of Integration Triangle for BPSD. Fourteen settings volunteered to participate, 8 from Maryland and 6 from Pennsylvania, and a total of 137 residents were recruited. In addition to completing the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD, assessments of depressive symptoms (Cornell Scale for Depression in Dementia), resistiveness to care (Resistiveness to Care Scale), and agitation (Cohen-Mansfield Agitation Inventory) were also completed on each participant. Reliability was tested based on evidence of internal consistency and inter-rater reliability. Construct validity was tested using a Rasch measurement model to determine item fit and hypothesis testing using bivariate correlations. Item mapping was also performed. Results The majority of the sample was female (69%), Caucasian (69%), non-Hispanic (98%), and not married (78%). The mean age of the sample was 82.01 years (standard deviation = 11.44). There was evidence of reliability based on internal consistency with a Cronbach alpha of 0.96 and inter-rater reliability with correlations between 2 evaluators of r = 0.93, P = .001. There was evidence of validity of the scale based on item fit as the infit statistics and outfit statistics were all within the acceptable range with the exception of the outfit statistic for the item focused on sexually inappropriate behaviors. Lastly, there was evidence of significant relationships between the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD and the Cornell Scale for Depression in Dementia (r = 0.38, P Conclusions There was sufficient evidence for the reliability and validity of the Care Plan Checklist for Evidence of Person-Centered Approaches for BPSD. Additional items should be considered to better differentiate those low on the Checklist for Evidence of Person-Centered Approaches for BPSD.

Background Nursing home (NH) residents with moderate-to-severe cognitive impairment experience mostly sedentary lifestyles. Aim Previous research has examined racial differences in physical activity (PA) levels in community-dwelling older adults but not in NH residents with cognitive impairment, and the current study aimed to examine these differences. Methods This was a secondary data analysis of baseline data from the Function and Behavior Focused Care Intervention (FBFC) study. The sample included 247 cognitively impaired residents from 12 NHs who wore an ActiGraph to measure PA. Results The residents' mean age was 82.6 (SD = 10.1) and had an average MMSE score of 7.8 (SD = 5.0). The sample (N = 247) was 41% African American and 59% White. African American and White residents engaged in only 50.6 and 46.2 min of light- and 1.5 and 1.1 min of moderate-level PA, respectively. Based on a multivariate analysis of covariance (MANCOVA), there was not a statistically significant difference between African American and White residents on combined dependent PA measures [F (8, 237) = 1.067, p = .387, Wilks' Λ = 0.962]. There was a trend that direct care providers subjectively reported that White residents engaged in more PA than their African American counterparts [F(8, 237) = 2.741, p = .09]. Conclusions These findings are not consistent with prior research. However, these findings indicate severely low levels of PA in NH residents, regardless of racial group. Future research should prioritize PA interventions that make accommodations for all NH residents, and especially consider their underlying physical comorbidities and cognitive function.

OBJECTIVE: The purpose of this study was to test the effectiveness of the Function and Behavior Focused Care for the Cognitively Impaired (FBFC-CI) intervention on function, physical activity and behavioral symptoms among nursing home residents with dementia, and to explore the adoption of the intervention at the facility level. DESIGN: This study was a clustered, randomized controlled trial with a repeated measures design that was implemented in 12 nursing homes randomized to either treatment (Function and Behavior Focused Care for the Cognitively Impaired Intervention (FBFC-CI) or educational control (Function and Behavior Focused Care Education (FBFC-ED). SETTING AND PARTICIPANTS: 12 nursing homes (6 treatment and 6 control) and 336 residents (173 treatment and 163 control) with moderate to severe cognitive impairment. MEASURES: Outcomes included functional ability (Barthel Index), physical activity (actigraphy and survey), behavioral symptoms (Resistiveness to Care Scale, Cohen Mansfield Agitation Inventory, Cornell Scale for Depression in Dementia) and psychotropic medication use. RESULTS: The participants 82.6 (SD=10.1) years of age, mostly female and were moderate to severely cognitively impaired (MMSE of 7.8, SD=5.1). There was a significantly greater increase in time spent in total activity (p=0.004), moderate activity (p=0.012) light activity (p=0.002), and a decrease in resistivenes to care (p=0.004) in the treatment versus control group at 4 months. There was no change in mood, agitation, and the use of psychotropic medications. There was some evidence of adoption of the intervention in treatment sites. CONCLUSIONS AND IMPLICATIONS: This study provides some support for the use of the FBFC-CI intervention to increase time spent in physical activity and decrease resistive behaviors during care commonly noted among nursing home residents with moderate to severe cognitive impairment.

Background Resistiveness to care is behavior that prevents or interferes with caregivers’ performing or assisting with activities of daily living and puts residents at risk for inappropriate use of antipsychotic drugs, other restraining interventions, social isolation, and physical abuse. The purpose of this study was to establish the psychometric properties of a previously developed Resistiveness to Care measure. Procedures This was a descriptive study using baseline data from an ongoing randomized controlled trial testing a Function and Behavior Focused Care (FBFC) intervention. Residents were eligible to participate if they were 55 years of age or older, had a Mini-Mental State Exam (MMSE) score of 15 or less, and were not enrolled in hospice or admitted for subacute care. Descriptive information included age, race, gender, cognitive status, and marital status. In addition to the Resistance to Care Scale, the Barthel Index, the Physical Activity Survey in Long Term Care (PAS-LTC), and the Cohen-Mansfield Agitation Inventory (CMAI) were completed. Psychometric testing was done using Rasch analysis and the Winsteps statistical program. Main findings The participants were moderate to severely cognitively impaired (MMSE of 7.23), functionally dependent (Barthel Index 47.31, SD 27.59), and engaged in only 134.17 (SD = 207.32) minutes of physical activity daily. Reliability was supported based on a Cronbach alpha of 0.84 and the DIF analysis, as there was no difference in function of the items between male and female participants. Validity was supported as all items fit the measurement model based on INFIT and OUTFIT statistics. Conclusions The findings support the reliability and validity of the Resistiveness to Care Scale for use with older adults with dementia in nursing home settings. Future work with the measure may benefit from the addition of items that are easier to endorse with regard to resistiveness to care (shutting eyes or spitting out food may be useful additions).

Pain has a significant effect on physical and psychological outcomes for older adults post orthopedic trauma. The purpose of this study was to describe the management of pain among older trauma patients and consider differences between those who received 3 or more dosages daily of opioids versus those who did not. This was a secondary data analysis using data from an intervention study testing the effect of Function Focused Care among older orthopedic trauma patients (FFC-AC). The FFC-AC study was done on trauma units in two acute care settings designated as Level I or II trauma centers from September 2014 to September 2015. All participants from the parent FFC-AC study were included. Data collection for the parent study was done within 24 hours of admission and within 24 hours of discharge and included demographics, medications, assessment of function, physical activity, mood, physical resilience, and whether the patient had pain and their pain intensity. Patient records included all 89 individuals from the parent study, 59 (66%) of whom were female and 82 (92%) were white. Records indicated that those who received more than three dosages per day of opioids had a shorter length of stay, were younger, had more intense pain, and were more resilient compared with those who received less than three dosages per day. This secondary data analysis provides support for the importance of considering pain and pain management among older adults post trauma.

Background The Robert Wood Johnson Foundation Nurse Faculty Scholars (RWJF NFS) program was developed to enhance the career trajectory of young nursing faculty and to train the next generation of nurse scholars. Although there are publications that describe the RWJF NFS, no evaluative reports have been published. The purpose of this study was to evaluate the first three cohorts (n = 42 scholars) of the RWJF NFS program. Methods A descriptive research design was used. Data were derived from quarterly and annual reports, and a questionnaire (seven open-ended questions) was administered via Survey Monkey Inc. (Palo Alto, CA, USA). Results During their tenure, scholars had on average six to seven articles published, were teaching/mentoring at the graduate level (93%), and holding leadership positions at their academic institutions (100%). Eleven scholars (26%) achieved fellowship in the American Academy of Nursing, one of the highest nursing honors. The average ratings on a Likert scale of 1 (not at all supportive) to 10 (extremely supportive) of whether or not RWJF had helped scholars achieve their goals in teaching, service, research, and leadership were 7.7, 8.0, 9.4, and 9.5, respectively. The majority of scholars reported a positive, supportive relationship with their primary nursing and research mentors; although, several scholars noted challenges in connecting for meetings or telephone calls with their national nursing mentors. Conclusions These initial results of the RWJF NFS program highlight the success of the program in meeting its overall goal—preparing the next generation of nursing academic scholars for leadership in the profession.

Approximately 25% of all nursing home residents take antipsychotics for behavioral disturbances, despite limited efficacy and warnings against their use. The purpose of this quality improvement project was to test the utility of an educational in-service to facilitate the appropriate use of antipsychotics for nursing home residents with dementia. A single group pre/post design targeting the reduction of antipsychotic medications in older adults was guided by Rogers' Diffusion of Innovations theory. Descriptive analyses were done to evaluate antipsychotic use and supporting documentation at baseline and 2 months following an educational intervention that focused on appropriate antipsychotic use, documentation requirements and non-pharmacologic interventions. The prescribing rate for antipsychotics showed a reduction from 20.3% to 15.4% and nursing documentation of non-pharmacological interventions increased from 16.7% to 75%. Assuring appropriate use of antipsychotics is currently mandated and is consistent with high quality, person centered care. This simple, yet individualized educational intervention and assessment can serve as a model for use in other long term care facilities.

Background Consistent with a care approach that optimizes the underlying ability of the patient/resident, the Omnibus Budget Reconciliation Act of 1987 mandated that residents attain and maintain their highest level of function. Restorative Care, which more recently has been referred to as Function Focused Care 4, is a philosophy of care that focuses on evaluating the older adult’s underlying capability with regard to function and physical activity and helping him or her optimize and maintain functional abilities and increase time spent in physical activity. The purpose of this review was to consider the work that has been done in testing function focused care and to provide guidance on the best ways in which to integrate this philosophy within any setting. Methods A systematic review of the available literature studying the impact of function focused care approaches was performed using MEDLINE and CINAHL search engines. The studies included were evaluated based on such things as design, specifically whether or not they were experimental designs (which included randomized trials or quasi experimental studies) or single group studies intended to pilot an intervention or for purposes of feasibility; randomization approaches; sample size/number of residents or patients included; descriptions of the intervention such as if there was a champion utilized (research supported or staff); or if motivation of older adults or caregivers was addressed. Results Out of 41 articles identified by CINAHL and 148 via MEDLINE, 20 articles met our inclusion and exclusion criteria. Overall the results provided support for the safety and efficacy of function focused care approaches. Continued research is particularly needed to consider best approaches for dissemination and implementation of function focused care and to test function focused care in acute care settings.

Job satisfaction among nursing assistants (NAs) is associated with NA retention, resident satisfaction, and residents' quality of care. The purpose of this study was to provide psychometric support for a measure of job satisfaction, the Job Attitude Scale (JAS), used with NAs that work in long-term care facilities. We performed a secondary data analysis and used traditional test theory and Rasch analysis to assess the reliability and validity of the JAS. The sample consisted of 508 NAs from 12 nursing homes and 96 NAs from 4 assisted living communities. We found evidence of reliability, validity, and generalizability when the measure was used in both settings and evidence that the JAS has the ability to assess variability in job satisfaction.

Objectives The purpose of this secondary data analysis was to evaluate the adverse events associated with a restorative care intervention (Res-Care) in nursing home (NH) residents. Design A randomized controlled repeated-measure design and generalized estimating equations were used to evaluate status at baseline and 4 and 12 months after initiation of the Res-Care Intervention. Setting Twelve NHs in Maryland. Participants A total of 487 residents; 256 in treatment sites and 231 in control sites, all long-stay NH residents ages 65 and older, with an MMSE of 11 or greater. Intervention The Res-Care Intervention was a 2-tiered self-efficacy–based intervention focused on motivating nursing assistants to actively engage residents in functional and physical activities. Measurements Baseline (2-month pre-intervention), 4-month, and 12-month records of adverse events, including falls, fall-related injuries, fractures, emergency room (ER) visits, hospital admissions, and death abstracted from NH records. Results There were significant baseline differences between treatment groups in resident race (more African Americans in control sites) and ER visits (more visits in treatment sites 2 months before intervention). Longitudinal models revealed significant differences in ER visits at 4 months and number of fallers at 12 months that were in the direction of a protective effect of treatment over time. Conclusion The Res-Care Intervention, which maximizes physical functioning, is safe to conduct in NH residents and does not result in increased risks of falling, injury, or other adverse events.

Objective The purpose of this study was to describe residents' self-efficacy and outcome expectations with regard to function and physical activity (PA); to measure functional performance and time in PA; to evaluate the fit between the resident and the environment; and to evaluate knowledge, beliefs, and care behaviors of nursing assistants (NAs) in 4 different assisted living (AL) communities. Design This was a descriptive study using baseline data from an ongoing intervention study, Testing the Impact of a Function Focused Care Intervention, Res-Care-AL. Setting Four assisted living communities in Maryland. Participants A total of 171 residents and 96 NAs consented, passed eligibility, and were included in this study. Measurements Descriptive data were obtained from NAs and residents. Resident data also included self-efficacy and outcome expectations associated with functional tasks and exercise, social support for exercise, and subjective and objective information about function and physical activity. NA data included self-efficacy and outcome expectations, knowledge, and performance of function-focused care. Results Residents were mostly female, white, and widowed; needed some assistance with activities of daily living; and engaged in very little PA based on subjective and objective reports. NAs were mostly female and black, had more than a decade of nursing experience, strong confidence but limited knowledge of function-focused care, and performed this care in 76% of observed care interactions. There were no site-specific differences among NAs with regard to beliefs, knowledge, or performance of function-focused care. There were site-specific differences in residents with regard to self-efficacy for functional ability; functional performance; social supports for exercise from experts; and from family, person-environment fit, and PA based on subjective surveys. There were no differences noted based on actigraphy. Conclusion Residents in AL communities engage in very limited amounts of PA and staff in these sites could benefit from ongoing education about how to increase PA among residents and help them adhere to current guidelines for PA so as to optimize overall health status.