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I Spy… Behavioral Symptoms

Imagine you are eating dinner in a restaurant. It is a small, quaint place with a warm, homey atmosphere. A man in the corner picks up his fork and begins to tap it loudly against the table. Several other diners turn to look at this unexpected noise. An older woman across the room points towards the noise and begins to shout, “Stop banging! Stop banging! Stop banging!” Then, two others in the dining area quietly get up and leave before receiving their food. Another man roughly pushes his table away from him; it collides with the table of the man still tapping the table with his fork, causing his table to bruise his arm. A lady to his right, responding to all of the commotion, yells, “I think the horses are getting out!”

While most would find this situation highly unusual in any restaurant, if the setting is shifted to a secure dementia unit dining room, it may seem like more of a normal dining experience. However, while the behaviors exhibited may be common in a dementia unit dining room, they still should not be considered normal. If a behavior would not be considered normal in another environment, it should not be considered normal in the nursing home. Unfortunately, when behaviors like those exhibited in the example become the norm or even an expected part of the environment, nurse assessment coordinators (NACs) may under-document the behavioral symptoms on the MDS.

Reviewing this scenario again, in the context of a dementia unit dining room, let’s identify the behaviors observed and how they should be documented according to the RAI User’s Manual.

The gentleman tapping his fork is Mr. George. The tapping of the fork would be documented as an Other behavioral symptom not directed toward others, since making this disruptive sound was not observed to be directed at others. The woman who started yelling “Stop banging!” is Mrs. Garcia. While this behavior was a reaction to Mr. George’s tapping, it is still a behavioral symptom. Mrs. Garcia would be documented as having a Verbal behavioral symptom directed toward others, since she clearly directed the verbal behavior toward the person making the noise.


Below are the excerpts from the RAI User’s Manual that pertain to these behaviors:

RAI User’s Manual, page E-4:

Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)  

Verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others)  

Other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds)  

Mr. Thompson and Ms. Jules left the dining area. This action, in and of itself, may not be a behavior, but it is important to further explore what happened next. Mr. Thompson went directly to his room and shut the door. Once the dining room had settled, staff went and asked Mr. Thompson if he was ready to eat and he returned to the dining area. Ms. Jules was found in another resident’s room, rummaging through the clothes drawer. She was easily redirected by staff and returned to the dining room to eat. While Mr. Thompson had no behaviors to document, Ms. Jules would be documented for wandering, since she wandered into another resident’s room, and for rummaging, which is an Other Behavioral Symptom Not Directed Toward Others.


Below is the excerpt from the RAI User’s Manual that pertains to wandering:

RAI User’s Manual, page E-18
Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to his or her physical or safety needs. The resident may have a purpose such as searching to find something, but he or she persists without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g., when a resident believes she must find her mother, who staff know is deceased).

Mr. Morris was the resident who pushed his table into Mr. George’s table. This would be documented as a Physical behavioral symptom directed towards others. While Mr. Morris did not directly push Mr. George, the action of purposefully pushing the table toward him caused the other table to hit Mr. George, which would fall in the physical behavioral symptoms category.

Mrs. Gray, who expressed concern for the horses, requires a little more investigation to understand the type of behavior she was displaying. When staff attempted to redirect Mrs. Gray, letting her know that the noise and commotion was in the dining room and not the horses, she insisted it was the horses. She became increasingly upset, hollering, “They are gonna tear down the whole fence if Roger doesn’t get out there now.” A staff member calmed Mrs. Gray by confirming she would get Roger, the resident’s late husband, to take care of the horses. Mrs. Gray responded well to this redirection. Since Mrs. Gray’s believed the noises came from the horses and she held this as true even with evidence to the contrary, this would be documented as a delusion.

Below is the excerpt from the RAI User’s Manual that pertains to hallucination and delusions:

RAI User’s Manual page E-1, Definitions  

Hallucination: The perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch.  

Delusions: A fixed, false belief not shared by others that the resident holds even in the face of evidence to the contrary.

The failure to properly identify and document behaviors directly affects the accuracy of the MDS assessment, which may lead to behaviors being inadequately represented on the care plan and failing to implement behavior-reducing interventions. Ongoing staff training that supports the recognition and documentation of all behaviors is key. As training, NACs can even use real-time observations and follow-up questions to ensure complete information and to practice working as a team. Ask direct care staff what behaviors were observed and how they would be documented. Using real-life situations can help staff understand and retain training concepts, and the results can also be used to identify the need for further education that will directly impact the NAC’s ability to do his or her job.

In addition to identifying the actual behaviors noted in this scenario, the impact of these behaviors on the resident and others must also be determined for proper MDS coding.

  • Mr. George’s Other behavioral symptom not directed toward others significantly impacted the environment. His behavior caused a disruption to the living environment, which impacted several other residents.
  • Mrs. Garcia’s verbal symptoms directed at others did not impact Mrs. Garcia but did disrupt the care of living environment.
  • Ms. Jules’ other behavioral symptoms did not impact her but did significantly intrude on the privacy of others.
  • Mr. Morris’ physical behavior did not impact him, but it did put others at significant risk for physical injury.
  • Mrs. Gray did not have a behavior that required follow-up on impact to self or others.

It is important to understand that the behaviors noted during the observation period must be captured on the MDS regardless of the reason why they occurred. Assessors completing section E should not solely rely on the documentation or their own observation. Interviewing direct care staff is vital to ensure the MDS represents most accurate picture of the resident and, ultimately, informs the care plan. Interviews with staff can be documented in the medical record to support what occurred during the observation period.

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