Long-Term Care Survey Alert

The devil is in the details - and so are most survey deficiencies. Oftentimes facilities end up with citations because CNAs get nervous during the survey and forget to do those little things that add up to a big deficiency in a surveyor's mind.

So it pays to review the list of "must do's" with frontline staff before the survey, especially in the following four areas of care where small omissions can tag your facility with a G-level deficiency.

1. Privacy measures. It never fails: CNAs pull those privacy curtains and drape patients during baths every day but survey day. Kathy Hurst, principal of Hurst Consulting Group in Chino Hills, CA, says she hardly gets through a survey without a deficiency (F164) for privacy and dignity because a CNA forgets to perform these basic privacy measures. "The facility can get a G-level privacy and dignity (actual harm) deficiency if the resident responds with visible distress like crying or complaining of embarrassment because she was physically exposed," she warns. "And while these deficiencies are usually D-level, you don't want people looking at your surveys and saying, 'They don't provide privacy and dignity at that facility.'"

2. Handwashingandcorrectuseofgloves. Facilities also get handed F tags for improper infection control procedures when a CNA forgets to wash her hands. "Reviewing basic infection control measures with CNAs is a must," says Doris Van Mullen, director of nursing for St. Thomas Hospital's subacute skilled nursing facility unit in Nashville,TN."ThesurveyorswillfollowtheCNAs around and watch them take a dietary tray in a room to see if they wash their hands."

If the CNA doesn't soap up before and after providing care, the facility would probably get F441 at a D-F level, depending on the scope of the problem. However, the facility could get a G- to I-level deficiency if the surveyors tie the lack of handwashing to an outbreak of infection in the facility, such as methicillin-resistant Staph or van-comycin-resistant enterococcus, Hurst warns.

CNAs also need to be reminded how and when to don gloves - and to take them off in between resident visits. "You don't want the CNAs running around the halls with gloves on their hands," says Hurst. "Staff should also be reminded how to handle the soiled linen."

3. Turning residents with pressure sores. "Failure to turn patients who have pressure sores that aren't healing or getting worse could result in a citation at F314 at a G level," Hurst cautions. "So CNAs should be reminded to turn these residents on schedule."

Since surveyors expect facility staff to be "all over residents with pressure sores," one sure-fire way to avoid a deficiency in this area is to assign an administrative person or even a charge nurse to turn the patients during the survey, Hurst notes.

4. Explaining and personalizing care. CNAs should be reminded to explain to residents the care they are performing - and why - even if the resident has severe dementia. "These verbalizations should reflect the personalized interventions recorded on the care plan," says Mary Knapp, senior director of ZA Consulting in Jenkintown, PA. "For example, if the CNA is getting Mrs. Smith up by the window for the morning, the CNA would say: 'I am putting you here by the window because I know you enjoy the morning light and you say it improves your mood for the day,'" she suggests. Staff should explain each step of the bath or personal care, especially to an unresponsive resident.

Failure to explain and personalize care would typically be cited at a D level at F241 (respect for resident dignity and individuality). An abuse tag (F223) could be in the offing, however, if the resident responds with fright or other behavioral symptoms to care provided without explanation or respect for his individual preferences and needs, which Hurst says she has seen happen to two facilities.

Staff should also be reminded repeatedly how to answer surveyors' questions in a way that doesn't invite trouble. The goal is to make sure surveyors get the answers they need so the facility doesn't get an unfair citation. But you don't want staff to provide unasked for details, which can appear as a deflective ploy, or sidetrack surveyors into areas where they would not have ventured otherwise.

"Staff should be told never to answer a question that they don't understand," or don't know the answer to, Hurst says. Instead, they should immediately get the charge nurse or someone who can address it. "At the same time, staff should avoid answering a question with more information than the surveyor has asked for, especially ifit'sasimple'yesorno'question,"sheemphasizes.