Long-Term Care Survey Alert

It's about attitude and taking action to protect residents.

Developing a culture of staff responsibility and accountability can reduce the odds of serious negative events. Experts suggest these approaches to keep staff on their toes and focused on the ultimate goal -- residents' wellbeing and safety.

1. Stop the buck before it turns into an F tag. Require staff to follow through with what they started -- or clearly designate someone else to do so in their absence. For example, "if a nurse receives a physician order, such as one for INR monitoring [for a resident on Coumadin], then that nurse should make sure the order has been carried out," says Diana Waugh, RN, BSN, principal of Waugh Consulting in Waterville, OH.

Nursing staff should also be on the lookout for omissions downstream and correct them before they cause a major problem. For example, suppose the lab doesn't act on a faxed order for INR monitoring. "The nurse giving the Coumadin should catch the fact that there are no lab results and follow-up on that," Waugh adds.

2. Encourage staff to speak up. Encouraging staff to "speak up" is a culture issue that starts at the top with the administrator and the director of nursing, supervisors, etc., says Darlene Greenhill, a consultant in Atlanta.

Waugh agrees, noting that fear of sharing observations about potential safety issues can pave the way for resident harm.

Example: A staff person at one nursing facility put poinsettias on the dining room tables to provide a decorative touch for Valentine's Day, Waugh relays. No one said anything about the staff person's well-intentioned gesture at the time. But when questioned later, some staff admitted they had heard that poinsettias could be toxic, if eaten, Waugh says. You need a culture where people speak up and assist their teammates while focusing on resident safety and well-being, she emphasizes.

Tip: Assign residents the same CNAs, and encourage CNAs to speak up about what they think will and won't work in helping a resident avoid falls. Data show that residents who have the same caregiver do better and are safer, says Joy Morrow, RN, PhD, senior clinical consultant with Hansen, Hunter, and Company PC in Beaverton, OR.

3. Don't be afraid to weed out the bad apples. Sometimes "the fix" for persistent problems in the facility ultimately includes letting people go, says Kathy Hurst, RN, JD, director of healthcare operations for TSW Management Group in Anaheim, CA, which owns and manages nursing facilities in the state.

"You'd be very surprised at what happens when you remove the bad apples," she says. "Morale and productivity can improve. Staff actually knows who the crummy workers are -- and they know before the managers do."

Address this fear: Hurst notes that nursing facilities sometimes fear letting people go because of the specter of a disgruntled employee testifying against them at some point.

That's why TSW Management asks people to sign an elder abuse release when they leave, saying they didn't see any reportable elder abuse, if that's the case.

"That way when they are in a deposition and claim otherwise, we at least have that form to discredit their testimony," Hurst reports.