Long-Term Care Survey Alert

Published on Fri May 05, 2006 PDF

Here's what surveyors will target starting June 1.

The new Psychosocial Outcome Severity Guide gives surveyors a road map for citing G-level or even IJ when your facility causes or fails to address a resident's psychosocial distress.

Starting June 1, surveyors   will look for several situations involving negative psychosocial outcomes related to a deficient practice, according to Centers for Medicare & Medicaid Services' Karen Schoeneman, MPA, in a recent CMS surveyor training session and Webcast on the Psychosocial Outcome Severity Guide. These include:

1. The resident who "coherently communicates" how he responded to a deficient practice. The person may report something humiliated him or he's bored and unengaged by activities, as examples. The interviewer needs to probe further to see if the resident's psychosocial response has resulted in changes in mood or behaviors such as crying constantly or expressing a desire to die or not leaving the room any more, according to Schoeneman.

"Some individuals lose so much self-esteem through humiliation  that they become depressed," warned CMS regional office survey official Alfreda Walker, MSN, RN, in the recent CMS Webcast.

Watch out for dehumanizing interactions: Examples of dehumanizing communications include instances where a resident says "I to don't like the food," and the staff says but "that's what you have to eat--come on you like that," cautioned Webcast presenter Judah Ronch, PhD, a national dementia expert.

Another example: The resident says, "I have to go to the bathroom," and the nurse says "I just took you to the bathroom." These are examples, he said, of not treating the person as a human being with feelings, self-respect and pride. The staff person is communicating that what you need really doesn't matter to me, noted Ronch.

2. The resident unable to communicate verbally but shows a nonverbal outcome to the deficient practice. For example, if surveyors see staff forcing a resident to be showered against her will and the resident is trying to push them away and crying and screaming--this is abuse," warned Schoeneman.

Expect Surveyors to Use the "Reasonable Person" Concept

Watch out: Surveyors can bump up the severity level of a deficiency if the resident has a "markedly incongruous response" or is unable to comprehend the significance of what most people would find a demeaning practice.

Thus, when assessing psychosocial implications of a deficient practice, the Webcast encourages surveyors to ask themselves how most people would respond to a deficient practice, explained Schoeneman.

For example, a resident may state she doesn't mind a humiliating experience because "that's just how things are here."

Example: A resident tells surveyors that when she asks to go to the bathroom at night, the staff tell her to just go in the bed and they will clean it up tomorrow. The resident says this happens often and appears resigned to the situation because she's been "institutionalized" to expect deficient care.

A resident may be comatose or  demented to the point that he can't understand the "psychosocial significance" of being pushed to the shower with "private parts showing," as another example.

Address Adjustment, Pre-Existing Psychosocial Problems

Surveyors will also be on the lookout for a facility's failure to address a resident's depression, anxiety, apathy, anger and/or behavioral symptoms that persist or worsen.

For example, people entering a nursing home will show emotional responses to what may be one of the most traumatic experiences in their lives, noted Ronch.

The problem exists when the facility fails to deal with the resident's pre-existing psychosocial issues, he said.

Thus, surveyors will look at whether the facility addresses a problem that the person "came in the door with."

Don't do this: If a resident complains or cries about feeling anxious, the staff shouldn't tell her "there's nothing to worry about." Instead, get to the root of the anxiety, which is often pain, particularly in people with cognitive impairment, Ronch said. New anxiety could mean a person is having a new physical health problem or a recurring one. "Some medical conditions will manifest with anxiety," and the physician should make that evaluation, Ronch advised.