Long-Term Care Survey Alert

Foresight and fast action can save you from the unforeseen.

You can't always prevent a worst case scenario from happening while surveyors are on the premises. But whether you get an IJ or actual-harm citation depends, in part, on your survey management prowess at each step of the process.

A case in point: Surveyors targeted a resident who was a frequent faller, relays Roberta Reed, MSN, RN, a former surveyor currently working for a nursing facility chain in Ohio. "The surveyors were sitting in the man's room when he fell and broke his hip," she relays. "The surveyors couldn't get to him fast enough to prevent the fall."

Smart move: The staff came in the room and asked surveyors to provide suggestions on how to keep the resident from falling. For example, restraints weren't an answer. "The family had not wanted the person in restraints," adds Reed. "And when the facility had tried restraints, the resident was able to get out of them and often fell in the process."

After the fall, surveyors combed through the resident's chart and care plans to find some area of deficiency, Reed relays. "The chart included the 15 months of MDSs and care plans which showed that every time the resident had fallen, the staff documented it," she says. The facility had "involved physical therapy [in the fall reduction plan] and had a running list of interventions and risk assessments and re-assessments."

Staff had also kept detailed notes about how they contacted the resident's family each time he fell and discussed what the team planned to try next.

Guess what? The facility didn't get cited.

Key points: Make sure the interdisciplinary team documentation conveys the decision-making that went into the care planning process, including evaluation, suggests former surveyor Kurt Haas, currently a consultant in Amanda, OH. "You want to convey why the team chose an intervention as best for a particular resident--even though that intervention isn't perfect."

Also know which residents surveyors will likely target during the survey, which will include frequent fallers and those who try to elope. Use your QI/QM reports before the survey to make sure your documentation is in line for residents who flag on various ones, emphasizes Nathan Lake, RN, an MDS expert in Seattle.

Respond Quickly, Appropriately

The way staff responds to a resident in  jeopardy can also head off an F tag--even if the worst occurs.

Worst-case scenario: "A resident fell down the stairs and was killed during a survey," relays attorney Joseph Bianculli who is in private practice in Arlington, VA. "But the facility didn't get cited because the resident was not at risk of wandering--and staff responded immediately to the door alarm," he says.

On the other hand, if staff doesn't make a full press effort to prevent a second incident involving the same resident during the survey--all bets are off.

A real-life cautionary tale: In another case involving an inner city facility built on a hill, surveyors observed staff catching a resident who had one leg over a fence that served as a "barrier to a 30-foot drop off," relays Reed. The man was a known wanderer but his family didn't want him to wear a Wander- Guard, which "staff had documented," she says.

The next day, the resident again made it to the fence and tried to climb over it. And this time, the surveyors called immediate jeopardy. "The facility was probably already looking at an F tag for the first elopement attempt, given the resident was at high risk" for that type of behavior, says Reed. "The surveyors also looked at the MDS which had identified the [elopement] risks." The staff hadn't really addressed the identified risks effectively, she adds.

But the second incident cinched an IJ citation because the staff didn't take proper action to prevent the resident's repeat performance. "The facility hadn't done anything but provided one-on-one supervision for an eight-hour shift, which surveyors considered to be insufficient," says Reed.

Don't Placate But Explain Your Care Plan

An incident at Waterman Village in 2001 where a nurse didn't respond to a non-nurse surveyor's satisfaction to a resident sitting in the hall "choking" as he drank his morning coffee may have started the immediate jeopardy ball rolling for the facility.

Here's what happened: The resident had refused thickened coffee and typically coughed and sputtered some as he drank it. That's why the nurses always positioned the man in the hall to keep an eye on him as he enjoyed his morning coffee. "The resident had refused thickened coffee," says Dale Lind, executive director for the facility in Mt. Dora, FL. The physician knew the staff was giving the resident thin coffee. In addition, the interdisciplinary team "had met with the resident's family members, who agreed in writing that the resident should have his thin coffee, which made him happy," reports Lind. But when the surveyor who became alarmed over the man's so-called "choking" dug into the chart, she found "a small discrepancy" where the physician had not changed the order for thickened liquids, Lind reports. And the survey team cited IJ.

Difficult lesson learned: Lind says the facility administrators have speculated that if the nurse had responded differently to the surveyor by saying "I can see you are concerned but here's the situation," the surveyor might not have investigated the situation further. And the nursing facility might have sidestepped a heap of trouble.

The facility prevailed at appeal, Lind reports, but it cost $70,000 in legal fees to do so.