Behavioral health can be one of the most complex aspects of long term care. Thoughtful and personalized care planning is key to both proactive preventative strategies and an effective response to challenging behaviors.  This week’s blog breaks down the critical components of a successful behavioral health care plan…

Overview of Behaviors

Section E of the MDS identifies the following types of behaviors:

      • Physical behavioral symptoms directed towards others (g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually)
      • Verbal behavioral symptoms directed toward others (g., threatening others, screaming at others, cursing at others)
      • Other behavioral symptoms not directed toward others (g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds)
      • Rejection of Care (g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident’s goals for health and well-being.
      • Wandering – 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).

Potential Causes of Behaviors include:

      • Mental Illness – Schizophrenia, Bipolar Disorder, Anxiety, Depression, OCD, etc.
      • Dementia – Mental and/or Physical Needs not being met
      • Personality Differences
      • Bullying Tendencies
      • Desire for Control
      • Physical causes, such as pain, hunger, constipation, urinary retention, fatigue, insomnia, poor sleep
      • Psychological causes, such as: anxiety, fear, depression, frustration, boredom
      • Environmental causes, such as: caregiver approaches, institutional routines, misinterpretation of events/setting, over/under stimulation, changes from normal routine
      • Delirium, secondary to medical issues such as: medication side effects, infections, metabolic/electrolyte disturbances, dehydration

Behavioral Health Care Plan Development

There is no ‘one-size-fits-all’ solution for addressing behaviors. Each resident’s plan of care for challenging behaviors must be uniquely developed for them based on the RAI process.  Applying information from Section F of the MDS (Preferences for Customary Routine and Activities) may provide helpful guidance for understanding each resident’s preferences in order to proactively prevent problems.

Chapter 4 of the RAI Manual states, “The care plan is driven not only by identified resident issues and/or conditions but also by a resident’s unique characteristics, strengths, and needs. A care plan that is based on a thorough clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents.”  For example, considerations for pain management, communication/social interaction, and finding comfort when tired or stressed can guide effective intervention planning on the person-centered behavioral care plan.

Prior to developing a plan of care, a thorough assessment must be completed consisting of the MDS, supplemental assessments (e.g., fall risk, elopement risk, BRADEN, etc.), gathering a life history, review of the clinical record (H&P, progress notes, active diagnoses, etc.), resident and/or resident representative input (preferences, goals and desired outcomes) and staff interviews. Based on all of the assessment data, the triggered CAA’s can be completed to identify possible issues and/or conditions that the resident may have. After completing the care plan decisions for triggered CAA’s, the IDT and other key staff members should review and revised the current care plan as indicated.

The basic care plan consists of 3 parts

      1. Focus
      2. Goal(s)
      3. Interventions

Care Plan Focus/Problem

Identify the behavior(s). Be specific. Clearly characterize and document behavior(s) or symptom(s), including frequency, severity, triggers, and consequences.  Include diagnoses/conditions that impact the behavior. Identify risks that may result from the behavior(s).

Most MDS/Care Plan software programs have basic startup care plans that the IDT members build off of, such as: “Resident is at risk for wandering”. Asking this question alone is not sufficient. Determine the following: Where does the resident wander? When does the resident wander? Why does the resident wander? What are the risks associated with this behavior?

Example of a Person-Centered Care focus: “Ruby wanders up and down the hallways most afternoons and occasionally pushes on exit doors. She has sundowning due to dementia and believes that her children should be arriving home from school. She gets worried and anxious when she cannot find them. She is at risk for exiting resident care areas unsupervised.”


Care Plan Goals

Goals should be SMART:

S – Specific

M – Measurable

A – Achievable

R – Realistic

T- Time-bound


Example of a generic goal: “Resident will not exit the facility unsupervised.”

Example of a Person-Centered Care Goal: “Ruby will participate in small group afternoon activities for 15-minute intervals as a diversion from exit seeking behavior when searching for her children through next review.”

Focus’ can have more than 1 goal, but each goal should be person centered.


Care Plan Interventions

Interventions, like the focus and goal, should be person-centered to align with the resident’s preferences and goals, and address the resident’s medical, physical, mental and psychosocial needs. Interventions should also follow facility policy as applicable. When interventions are found to be ineffective and/or the resident has a change in condition, revisions should be made.

Examples of generic interventions for a wander risk resident may include:

      1. Administer medication as ordered.
      2. Redirect when exit seeking.
      3. Monitor location every (Specify: 15/30/60) minutes.
      4. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes.
      5. WANDER ALERT: Device # Model

Example of  Person-Centered Care Interventions:

      1. Attempt to keep Ruby involved in afternoon small group activities from 2:30 until supper. She usually responds well to reminiscing about sewing and quilting, looking at and discussing magazines about flower gardens, holding her purse brings comfort. She also enjoys afternoon snack related activities.
      2. Ruby is frequently comforted when staff gently reminds her that “the children are riding the bus to their Grandma’s house today and will be home in time for supper.”
      3. If Ruby chooses not to stay in the activity room during the afternoon, attempt to keep her away from the front lobby between 3:30-4:00 to prevent her from seeing the city school bus goes by. She will become anxious when her children do not get off the bus.
      4. Ruby wears a Wander Alert bracelet on her left ankle – verify placement Q shift and prn. Replace Q 30 days (refer to TAR for schedule).
      5. If Ruby exhibits exit seeking behavior, such as pushing on exit doors, then implement ‘Increased Monitoring Protocol’ X 72hours as per Wander Risk policy.
      6. If Ruby begins to show signs of anxiety, provide reassurance in a calm, soothing manner. Do not attempt to reorientate.

Care Plan Implementation

Even the best written care plan serves no purpose if it isn’t actively followed.  All appropriate staff members should have easy access to the resident care plans. The facility should have a process in place to ensure that changes/updates to the resident care plans are communicated to the staff members involved.   The clinical record should contain documentation reflecting implementation of the resident specific interventions. Documentation may appear on the resident’s MAR/TAR, paper or electronic flow sheets, progress notes or an assessment/evaluation form.

Using the example of Ruby’s wandering behavior care plan, documentation in the clinical record might include:

      • Behavior monitoring which includes interventions and their outcomes if a behavior is observed;
      • Flow sheet for Increased Monitoring (when applicable);
      • Documentation on the TAR verifying placement of Alert Bracelet Q shift;
      • Documentation of activity participation.

Care Plan Revisions

The resident’s care plan must be reviewed after each assessment and revised based on changing goals, preferences and needs of the resident and in response to current interventions.  Care plan revisions should be completed timely to ensure it is person-centered to meet resident’s preferences and goals, and address the resident’s medical, physical, mental and psychosocial needs. Ongoing revisions need to be effectively communicated to appropriate staff members.

Contact Proactive LTC Consulting for an expert review of care planning practices with specific guidance and feedback for behavioral health, repeated falls and other challenging care areas.   Check out these on-demand webinars related to behavioral health care:

For further reading on recognizing and documenting behavioral symptoms, check out the AAPACN article “I Spy…Behavioral Symptoms” (McGill, J., 2021 Nov. 2)





Angie Hamer, RN, RAC-CT
Clinical Consultant

Learn more about the rest of the Proactive team.