Long-Term Care Survey Alert

When does a nursing facility have enough  staffing, according to federal regulations? That’s a  trickier question than many facilities realize: OBRA  requires facilities only to have “sufficient   staffing” to  meet residents’ needs. But therein lies the potential F  tag (F353) any time surveyors cite your facility for a  quality of care problem, such as pressure ulcers.

Watch out if surveyors do tie a serious negative outcome to staffing shortfalls in your facility. In such a case, “surveyors are more likely to cite a deficiency at a G level or higher,” cautions Patricia Boyer, a nursing consultant with the Milwaukee office of BDO Seidman.

Your facility thus needs a plan to make sure it has enough staff, uses its staff wisely — and knows how to head off a staffing citation during the survey. Below, survey experts highlight eight key strategies that can help.

1. Develop a staffing system that you feel confident will meet residents’ needs. “Your best defense is to feel very comfortable explaining to surveyors how you staff to meet resident needs,” Boyer emphasizes.

Facilities have a number of options in that regard. “You can look at comparable facilities in your area and see how they are staffing,” suggests Kathy Hurst, principal, Hurst Consulting Group in  Chino Hills, CA. Hurst notes that in California, for example, which requires 3.2 hours of nursing time per patient day, she finds that one nursing assistant per eight patients is usually enough.

Your facility can also use an acuity-based tool, such as the resource utilization groups, to provide benchmarks for nurse staffing. While the RUGs grouper is probably the best tool available for  such purposes, it has its glitches. “A resident could group into a high RUG based on therapy needs” rather than nurse staffing requirements, cautions Hurst.

2. Use a risk management approach. In addition to benchmarking your staffing in some fashion, Hurst advises facilities to figure out when most of the resident injuries, falls and other incidents are  occurring. “If it’s times when you have a skeleton staff, that skeleton isn’t enough,” she notes.

3. Take steps to increase staffing efficiency and effectiveness. “Some facilities do fine with 2.9 hours of nursing care per resident/day while others will provide 4.5 hours and fee short staffed,”
notes Beth Klitch, president of Survey Solutions in Columbus, OH. “It doesn’t always have to do with acuity, either.”

Simple strategies can turn that scenario around. For example, that using two nursing assistant teams can be more efficient because the CNAs don’t have to wait five or 10 minutes each time they  need a two-person assist to move a resident, Klitch notes.  “Plus the extra help with lifting and moving is safer for residents and causes less work-related injuries.”

In addition, two-person teams can divvy up the work in terms of their individual strengths. “The collaborative approach may also reduce the risk of resident abuse,” Klitch adds.

Restorative nursing techniques can, over time, increase residents’ functional status and independence, relieving staff to focus care on other resident needs. A simple change in facility layout — such as closing unused rooms further down the hall — can also improve staffing efficiency.

4. Focus on critical interventions when staffing is short. A pressure ulcer can develop within hours, “so never allow short staffing to get in the way of turning and positioning residents for even a  single shift,” advises Donna Duss, a nursing consultant with Joanne Wilson’s Gerontological Nursing Ventures in Laurel, MD. “It’s a matter of prioritizing what staff do with their time,” she adds. “If you don’t have the nursing assistants to turn and reposition residents on a shift, get the licensed staff to assist with turning and positioning residents.”

Covering the bases is especially critical during surveys. “Surveyors will also be looking to see during the survey whether the staff omit care related to a quality of care problem, such as pressure ulcer or continence care,” Klitch cautions.

5. Make staffing issues part of your quality  improvement process. Your facility can preempt  surveyors by investigating negative resident outcomes  to see if they are related to staffing vs. a training need  or clinical issue. That way, if surveyors do hone in on  the fact that two patients developed stage 1 pressure  ulcers during a facility-wide staffing crisis, you can  show them you’re on top of the problem.

“In addition, any facility that has staffing challenges  should have a functioning retention and recruitment committee that is encouraging people to  ‘think out of the box’ in terms of attracting and 
keeping good nursing personnel,” Boyer suggests.

6. Advise staff never to tell anyone they  are “working short.” Such complaints can become  virtual mantras in some facilities. And it can be tempting for nursing staff to tell residents/families that the facility is down a caregiver or two so maybe they’ll understand when it takes a little longer to answer the call lights. Such disclosures by staff frighten some residents, however, Klitch warns. And anxious residents tend to act out more, not less, which ironically increases the need for staffing attention.

Worst of all, residents may hesitate to “bother” staff with requests for fluids or toileting. Over time, this can lead to dehydration and urinary tract infections, running your QIs right up the flagpole. “You’d be surprised at how many residents self-restrict liquids because they don’t want to bother busy caregivers to take them to the bathroom,” reports Stephanie Williams, a health quality review specialist and surveyor with the Centers for Medicare & Medicaid Services who spoke June 2 at the National Association of Directors of Nursing Administration in Long Term Care conference in Nashville, TN.

Surveyors may also try to get your staff to “admit” they are sometimes short staffed in order to validate that a staffing issue is behind pressure ulcers or other quality of care deficiencies, cautions Peter Mellette, an attorney with Crews & Hancock in Richmond, VA. In a state without a staffing mandate, surveyors may, in fact, need that confirmation to build a case against your facility, he notes.

7. Prevent “triggers” that connote staffing issues during the survey. Odors and unkempt residents will get surveyors scrambling for your staffing roster the moment they walk in the facility door.
“Other ‘trigger issues’ include unanswered call lights and residents not being up and dressed by mid-morning,” adds Mellette. Make sure water pitchers are filled and the dining room has adequate staff to help residents get positioned comfortably at the table and to eat, drink and enjoy their meals.

8. Be prepared to handle surveyor concerns with your staffing. Staffing rosters and “hours worked” documentation can provide the best evidence that your facility is at least meeting state staffing mandates. Boyer says she wouldn’t volunteer information up front about any staffing problems, however. “You keep the dialogue open throughout the survey process,” she advises. “So if
surveyors identify a negative outcome, then you explain what you are doing about that clinical issue.” If surveyors then say they believe the outcome is staffing related, make your best case for how your facility is staffing appropriately and addressing any staffing challenges through training and recruitment.