Long-Term Care Survey Alert

When it comes to privacy and dignity F tags, it's the little things that get a facility in trouble with surveyors. By the same token, simple strategies and documentation can keep these common citations at bay.

One of the most common reasons facilities get F tags during the survey is that staff become anxious and forget to knock on a resident's door, says Gene Larrabee, principal of Primus Care in Valparaiso, IN. Ditto for pulling those privacy curtains. And while most of these citations are at a C to E level, Larrabee has seen facilities get a G-level (actual harm) citation when surveyors see several residents uncovered or exposed with the doors to their rooms left open.

Thus, frequent mock surveys and a pep talk on survey days can help staff keep their cool even when surveyors are scrutinizing their every move.

Surveyors hand out F tags like hot cakes when they see residents whose bath towels or robes slip when they are transported through the hallways, observes Richard Butler, principal of Survey Management Services in Indianapolis.

That potential problem is easy to prevent, however, by using shower ponchos, which go over the resident's head and down to the floor, suggests Kathy Hurst, a consultant with Hurst Consulting Group in Chino Hills, CA. "If a facility cannot afford the ponchos as part of its linen costs, then staff should make sure to use two bath towels to cover the front and back so the resident's back side isn't left exposed," Hurst suggests.

Surveyors tend to focus on the more superficial privacy/dignity because these are easy to see and substantiate. But a facility might successfully avert an F tag if staff can show surveyors that an incident isn't a concern to the resident. "In such a case, bring the resident into the discussion with surveyors, if need be," Larrabee advises.

For example, Butler recalls how one surveyor became very upset that a staff person dressed a wound on a resident's back near the buttocks without pulling the curtain completely between the cubicles. "The door was closed but the resident's roommate was sitting in a chair across the room during the dressing change," Butler relates.

When the surveyor threatened to write up the facility, the staff asked the resident about it and he confirmed that he didn't care at all about the privacy issue. "And when staff asked the resident sitting across the room about the incident, the resident replied: 'Hey, I wish I could see that far.'"

Larrabee has seen one instance where a surveyor cited a facility because a staff person didn't knock on the door of a deaf resident's room. But staff were able to counter the surveyors' concerns by pointing out that they knew the resident couldn't hear the knocking information that the surveyors would have known if they'd readthe resident's care plan and chart.

Lesson learned: If a resident has a condition or quirk that might lead surveyors to conclude you're violating his privacy/dignity needs, document the anomaly in the care plan and medical record. Examples include the resident who asks to skip the bib-type covering at mealtime or the person who refuses to use continence products. In the latter instance, Hurst recommends that staff periodically reassess and document the resident's unwillingness to use the products even though staff have re-explained the impact of her decision on her skin condition and related privacy/dignity issues.

Tip: Take into account cultural differences when accommodating residents' unique preferences and privacy/dignity issues. Areas to assess include food preferences, recreational activities, family involvement and privacy issues with personal care, such as taboos about family members being present, etc., suggests nurse researcher Linda Ann Gerdner at the University of Minnesota.

"It's helpful to understand the cultural norms but also assess each person individually," she emphasizes.

Meal times are also fraught with opportunities for surveyors to hand out privacy and dignity tags. For example, some surveyors like to cite facilities when they see residents with food crumbs on their face or clothing after meals. Here again, if you have a rationale for your approach with a resident, be prepared to explain it to surveyors.

The Centers for Medicare & Medicaid Services is, for example, aware that some residents find it humiliating to have staff tie a bib or napkin on them at meal times, federal surveyor Stephanie Williams told DONs at a nursing conference in Nashville, TN.

And it may actually be more embarrassing for the resident to have someone automatically clean him up like a child or transport him all the way down the hall to do the same, Butler observes. A little training in how to handle such situations can help maintain residents' dignity and convince surveyors the facility is being sensitive to residents' feelings. "For example, the nurse or dietary aide might say, 'Mrs. Smith, you left a little egg on your lip. Do you want me to help you see where it is?,'" Butler suggests.

Take credit with surveyors for your training and other efforts to promote privacy and dignity. Do a little "show and tell" about how your facility is addressing the more substantive privacy and dignity issues, such as giving residents choices in their daily routine and other quality of life initiatives.

Tip: Even though most privacy and dignity tags are cited at a low level of scope and severity, no facility wants consumers to think it violates residents' rights in this way. Butler thus suggests facilities IDR citations if they have any kind of rationale for why they should not have been cited. That way the facility's rebuttal will be part of the public record (for the inside secrets to winning IDR, see the next issue of Long-Term Care Survey Alert).