Long-Term Care Survey Alert

Careful: Some of these occur when facilities are trying hard to do the right thing.

Bad things can happen to good facilities, and an immediate jeopardy citation is certainly one of them.

And while a nursing facility can't completely control its survey destiny, it can anticipate and take steps to prevent scenarios known to trigger IJ.

A cautionary tale: One nursing facility with a great reputation in the community and that "from every lens you can use" was doing well, ended up with IJ during a survey, reported consultant Eleanor Alvarez in a presentation at the fall 2007 American Homes & Services for the Aging annual conference. As she relayed, the survey was going on and "we were almost excited about it" because the facility was going into year four deficiency free. Then the head surveyor came walking in with a stern face and said, "We have to talk ... As of this moment, I'm invoking immediate jeopardy."

The initial reaction: "What do you mean? We're doing good work here," said Alvarez.

The problem: The director of nursing (DON) in the "zest and zeal to be best" had decided the facility was going to go restraint fee and led that charge, Alvarez explained. Yet the facility hadn't laid the proper foundation for making this major change. It also hadn't provided staff training on an appropriate falls program. So when residents began to fall and suffer injuries, the appropriate assessment process didn't occur, she cautioned.

Lesson learned: When making dramatic and good changes, look carefully at your outcomes and make sure you're interpreting the data in the right way and responding to it.

Facilities can also prevent IJ by paying extra attention to areas fraught with the potential for serious harm to residents. For example, Alvarez noted there's an "incredible focus on lab work" right now. One facility didn't follow-up on the lab's failure to respond to a faxed order for lab testing to monitor a resident on the blood thinner, Coumadin. The lab work wasn't done so the resident was at tremendous risk for negative outcomes, she noted.

Proactive strategy: Implement "tickler" systems to ensure things get done. You can develop simple systems to track lab work, for example, says Diana Waugh, BSN, RN, a consultant in Waterville, OH. When she was a DON, her facility simply put the lab work on a calendar and crossed it off when staff got the lab results. "That was before facilities had PCs in use. Now you could use a computer program to kick out all the labs that haven't been reported or to keep a running agenda of things to be completed," she says.

Immediately Investigate, Address Unexpected Negative Outcomes

A single negative event, such as an accident or fall, an abuse situation or elopement, as examples, can pave the way for IJ, Alvarez noted. "Many IJ situations ... are based on an example of one resident" where something went terribly wrong, she said. Or sometimes an unhappy family member, staff person or media situation can get the survey snowball rolling.

Proactive strategy: Leadership needs to be in touch with the care being provided, as well as staff, residents and families, Alvarez counseled. She recommended the administrator routinely select randomly a list of five family members to call and compare notes on how things are going for their residents.

How proactively a facility manages an accident or negative event can sometimes help stave off an IJ citation. Attorney Paula Sanders with Post & Schell in Harrisburg, PA, knows of a facility that had an accident involving a resident that was a reportable incident to the state survey agency. A root-cause analysis of the incident showed that the problem had the potential to be viewed as widespread because it involved an unexpected flaw in a piece of standard equipment used in the facility. "So the facility treated the situation as immediate jeopardy and immediately came up with a correction plan to fix it before sending the report of the incident to the state agency," Sanders tells Eli. And the facility didn't get cited for IJ.

Other potential trouble areas that can land a facility with IJ, according to Alvarez:

• Inability to meet the acuity or behavioral needs of unique populations. For example, Alvarez reported seeing behavior units that mix people with dementia with younger residents who have behavior problems, including substance abuse issues. And that combination is "just asking for trouble ...," she cautioned.

• Staffing and training shortfalls. Conduct competency training for nurses during orientation, Alvarez advised. And if the facility uses temporary agency staff, it has to make sure the staff is totally oriented.

Editor's note: For inside legal tips on what a facility should do when cited with IJ, read the next Long-Term Care Survey Alert.