Long-Term Care Survey Alert

Follow this survival advice on a survey hot button issue.

Cardiopulmonary resuscitation is one area where you need to address everything that can go wrong, because surveyors will likely scrutinize every code you do or don't call.

With CPR, you "have to dot the I's and cross the T's," emphasizes Joseph Bianculli, an attorney in private practice in Arlington, VA. Here's what you need to do.

Address These IJ Triggers

The CPR-related triggers for immediate jeopardy citations involve lack of coordination among staff providing CPR, in the experience of nurse attorney Barbara Miltenberger, with Husch & Eppenberger in Jefferson City, MO. "The staff don't know if the person is DNR [do not resuscitate] and it takes too long to find out," she says. Or "they don't have the appropriate equipment in good working order." And if they do, sometimes they don't know how to operate it, she adds.

Miltenberger is also seeing cases where nursing home staff do not put a backboard under the resident when administering CPR, so the effort isn't effective.

Proactive strategies: Conduct CPR drills and assign someone to make sure the equipment is working correctly on a regular basis, suggests Miltenberger. "Staff should call 911 -- not the ambulance service," when a resident has an arrest, she says.

Get the medical director on board and document CPR inservices, advises Bianculli. Also check the crash carts: Attorney Jason Lundy says he sees "problems with crash carts all the time where the equipment doesn't work right, the cart isn't properly stocked -- or in the right location."

Fix your weakest link: And that's the "temp agency nurse trying to deal with a cardiac arrest at 1 a.m. in an unfamiliar building with the policy and procedures in huge binders on a shelf," says Lundy, with Foley & Lardner in Chicago. So "when agency people come in, reinforce the high points," including the CPR policy and location of the crash cart.

Document These 2 Areas

Bianculli handled one case where surveyors gave a facility an IJ tag for not resuscitating a newly admitted resident. The social worker knew the resident was DNR. "And the resident's daughter was at the bedside saying, "Don't resuscitate," he relates. The surveyor's rationale for citing IJ? The facility didn't yet have the countersigned DNR documentation. "Under state law, the physician had to sign and return the DNR along with the resident or his agent in order for it to be technically in effect and binding," says Bianculli.

While this particular case had some definite gray areas, facilities should make sure they document and strictly follow the requirements for DNR orders to the best of their ability -- that is, have the physician countersign the orders and periodically renew them. State law may spell out "periodic renewal" of DNR orders every 30 days, says Bianculli. Even if staff provides appropriate CPR, surveyors have been known to cite deficiencies because the staff failed to accurately document the code, adds Miltenberger.

The documentation should include the exact time that:

• the resident was found in cardiopulmonary arrest;

• staff started resuscitation efforts;

• called the physician;

• the first responders arrived.

"The nurse running the code should assign one person to mark the time, using one watch. Minutes are critical and can make the difference between an immediate jeopardy citation and regulatory compliance," says Miltenberger.

Case in point: Husch & Eppenberger helped a facility beat an IJ deficiency and civil monetary penalty on appeal in a case where the nurses had provided documentation or at least had an accurate recollection of the time sequence that coincided with the 911 call and first responders' arrival.

"The person the surveyor relied on [in citing the deficiency] had a totally different idea of the time sequence and it was off by a half hour," reports Miltenberger. "That person had never been involved in  a code situation and we believe  the person had a distorted sense  of time."