Long-Term Care Survey Alert

Published on Mon Apr 21, 2008 PDF

This framework will help citation-proof your facility.

Everyone's talking about the benefits of culture change in nursing homes, but can the person-centered approach create survey troubles?

"The answer is yes and no," says consultant Diana Waugh, RN, BSN, in Waterville, OH. To prevent citations, you have to know what the regs require -- "and you can't do culture change willy nilly," she stresses.

The regulatory reality: Nursing facilities striving to provide person-centered care can't expect culture change to be a "get out of F tags free" card for avoidable negative clinical outcomes, according to medical director Matthew Wayne, CMD, in Cleveland. He notes that you can't, for example, shrug off the fact that a resident who chooses to sleep in late and skip breakfast is losing weight as a result. Telling surveyors in such a situation, "Well, that's the resident's choice and part of culture change" will likely net the facility a citation, cautions Wayne.

Instead: Comply with the regs and accommodate residents' choices -- and when the two conflict, show how you've gone through a process to accommodate both goals.

"The regulations hold the expectation that the facility will assess residents at admission to identify their clinical issues, risk factors, problems, etc.," Wayne points out.

After using the assessment to identify problems and significant risks, the facility creates the plan of care, keeping in mind that "in a culture change environment, staff incorporates resident choice in the care plan," Wayne says.

Example: Pressure ulcer-related odor control may be the most important concern for a resident with a pressure ulcer, noted a speaker at a recent Webinar on pressure ulcers sponsored by Advancing Excellence (see the front page story for details).

As the next steps in the care planning process, the staff implements the interventions and evaluates the plan's effectiveness in preventing or addressing falls, pressure ulcers, weight loss and other problems.

Staff should also make sure the plan optimizes the resident's quality of life.

The staff then identifies any negative outcomes and collaborates with the resident or her designee to modify the plan of care accordingly.

The facility also has to document how it's gone through the above steps. "When a facility is faithful to those steps, it can move ahead in a culture-change environment," Wayne tells Eli.

Suppose a resident prefers to wear an incontinence brief at night because she wants to sleep through the night without staff waking her up to go to the toilet or to turn and reposition her. Staff accommodates her wishes but notes that the woman is developing skin maceration in the perineal area. In such a case, staff could discuss with the resident the risks and benefits of her choice to sleep undisturbed through the night and offer alternatives -- "for example, perhaps using a different brief or barrier protection or getting her up just once at night to toilet," Wayne counsels. "Then when surveyors question what's going on, you can show that you understand the issue, care planned it, documented the resident's understanding of the issue and offered alternatives."

Real-life scenario: Waugh encountered one scenario where a resident with quadriplegia had become very depressed. His mother bought him a wheelchair but he wouldn't get in it. But when staff taught him how to play a computer game where he could win tokens, he began sitting in the wheelchair in order to work and play on the computer, Waugh relays. Subsequently, he gained weight and began to enjoy himself more.

Unfortunately, the resident spent so much time in the wheelchair that he developed skin breakdown on his buttocks that "was at risk for not healing" or getting worse, she says.

Staff tried various interventions to relieve the pressure. The resident, however, told the surveyor that he didn't care about the skin breakdown -- he was pleased with the quality of his life sitting up in the wheelchair.

Once the surveyor heard from the resident, she decided against citing the facility at F314, Waugh says.

Playing it safe: In this type of situation, document how the team addressed the issue with the resident and describe the alternatives offered, Wayne suggests.

For example, perhaps the resident would agree to spend time in bed on his side using a laptop computer to play the game. Continue to show you're working with the resident to find a "win-win" approach to the clinical issue.

Using the above approach to accommodate residents' care choices doesn't guarantee a surveyor isn't going to cite a facility, Wayne says. But applying the basic principles should give your facility "a good leg to stand on in challenging a citation."