Long-Term Care Survey Alert

If your facility is waking up residents to give TID meds, take a look at that practice.

Nursing home providers or surveyors who think the current survey process is much to do about rules -- and too little about quality of life -- might be heartened by a Rhode Island pilot initiative.

The pilot focused on individualizing residents' waking times, eating and bathing, as well as providing consistent staff assignments, reports David Gifford, MD, former director of the Rhode Island Department of Health, which initiated the pilot.

Surveyors discussed these areas with nursing facility during the survey's initial tour and interview, Gifford relays. If the staff said they were accommodating residents' preferences, surveyors took a look to see if that appeared to be the case. "If surveyors saw everyone waking up at the same time or blood draws or med pass at 5 a.m., they knew there was no way the facility was meeting individual resident needs," he notes.

"If the facility said it had consistent assignments, the surveyors would talk to CNAs to find out what they knew about the residents," Gifford adds. "If they didn't know much or anything, the surveyors knew they didn't have consistent assignments."

If this sounds like a "gotch ya" technique, it wasn't. Surveyors weren't making the observations to cite facilities, says Gifford. Rather, the approach generated a dialogue between the surveyors, director of nursing, and unit managers about what the regulations really involve, he explains.

2 examples: Some staff believed that "a resident can't go more than 12 hours without eating in the nursing home, which a resident would do if they ate dinner at 6 and slept in until 8 or so and didn't want breakfast until 9 or 10," Gifford says. "The way the regulatory requirement is worded, however, the person has to be offered food or have the ability to access it every x number of hours. Lots of people living at home go 12 hours without eating between the evening meal and a late breakfast, including elders."

Med pass was another example. "If the physician writes a medication order that says every eight hours, that's one thing, but if it's written TID -- and it's not a medicine that's critical to be given every eight hours -- then you don't have to wake people up to give it," Gifford points out.

"In the pilot initiative, surveyors looked at their own practices and how their expectations contributed to more rigid schedules, such as medications being given at designated times rather than based on the residents' routines," reports Barbara Frank, a culture-change consultant in Providence, R.I., who provided surveyor training for the initiative. "One surveyor said she used to think it was good to see all the residents up and dressed early in the morning but realizes now that not all residents may want to be up at that time."

Nursing facilities showed improvement on a number of resident-centered practices during the pilot. "Some of the changes appeared to happen relatively quickly and with relatively little capital investment" on nursing homes' part, says David Stevenson, PhD, associate professor of health policy at Harvard Medical School, who served as an evaluator in the pilot study. "These included letting people eat when they want and to choose when and how they want to bathe. The changes didn't necessarily require a wholesale transformation" to accomplish, he tells Eli.

At the pilot's outset, 44.9 percent of facilities always allowed residents to choose how they bathe before the pilot -- 61.2 percent did so at its conclusion. (To review the positive impact on other areas of personalized care, see the article on the pilot initiative at www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/Dec/1463_Stevenson_impact_regulatory_intervention_nursing_home_Rhode_Island_ib.pdf.)

"The most interesting thing that came out of the project," says Gifford, "is how surveyors became jazzed about it and excited about their jobs. Many were feeling demoralized because they were having to fight homes on strict issues like the temp wasn't this or there's no documentation about that." While those are important issues, they aren't focused on the resident, he points out.

In the pilot initiative, the Rhode Island Quality Improvement Organization assisted facilities with their person-centered practices, which is something surveyors aren't allowed to do -- "they aren't available to provide technical assistance," adds Gifford. "So the QIO was a nice complement to the survey approach."

A "take home message," from the study, adds Stevenson, "is that the regulatory process can be a positive force for change. This isn't a lesson for facilities as much as for policymakers."