Long-Term Care Survey Alert

The right staff preparation can keep damaging quotes off the CMS 2567.

Imagine surveyors asking already nervous nursing home staff questions designed to nail down F tags. To avoid problems resulting from such conversations, make sure staff can spot and avoid falling in three common traps.

Top of the list: Agreeing when you really don't or don't know all the facts. For example, surveyors might ask a nurse aide: "Wouldn't you agree that it would have been much better if the facility had provided additional staff on the night Mrs. Jones fell?" says attorney Paula Sanders in Harrisburg, Pa. If the person responds to such a question by saying, "It's always better to have additional staff," that quote may end up on the statement of deficiencies to support insufficient staffing tied to a fall, Sanders cautions.

Even directors of nursing sometimes agree with surveyors that staff should have done something differently, and subsequently find those comments on the CMS 2567, observes Cheryl Boldt, RN, a consultant with Maun-Lemke in Omaha, Neb. Yet agreeing, for example, that more staff would have helped prevent a problem may not really have been the right answer, Boldt points out. When there's a problem, "the knee-jerk response" is often to say more staff or money would have helped when "in reality more staff and more money alone rarely solve any problem."

A better way: Staff should know they don't ever have to agree if they don't. And they should avoid the temptation of answering a question as it was asked, says Sanders. For example, when confronted with the leading question, "don't you agree it would have been better to have more staffing the night Mrs. Jones fell," staff could respond, if factual, "We were fully staffed on the night Mrs. Jones fell," she says.

Staff can also say they don't feel comfortable agreeing because they don't have all of the information about the specific issue, if that's the case, says Boldt. Then they should take the surveyor to someone who can provide more information.

Beware the Never/Ever Option

In one real-world situation, surveyors had concerns about a facility's evacuation procedures. "So they asked a CNA who worked part-time on the 11-7 shift if the facility ever conducted fire drills," relays attorney Jennifer Gimler Brady, with Potter Anderson & Corroon LLP in Wilmington, Del. The aide said No, which wasn't accurate. The facility hadn't conducted a drill the two nights per week that the CNA worked, but it had "ample documentation" showing it did regular fire drills, Brady says. Nonetheless, the aide's answer fueled surveyors concerns, she notes.

Solution: Teach staff to think, as they said on Dragnet, "Just the facts, mam," advises Boldt. Thus, when asked whether the facility ever conducted fire drills, the CNA working two nights a week should know to answer, "I am not aware of any fire drills we've had the two nights a week I'm here, but let me refer you to my manager to find out how many fire drills the facility has conducted."

Don't Fall for the Sympathy Card

In one case, a surveyor buddied up to a nurse aide during a survey and told her how much he admired her for working so hard, reports Brady. Then the surveyor asked the aide if she ever felt overwhelmed by taking care of so many residents. And the aide admitted that her job felt overwhelming at times and that she could really use some help. "Yet, the reality was that the facility not only met but often exceeded stringent staffing ratios," Brady adds.

Solution: Remind staff to be on guard the minute they start thinking of a surveyor as a confidant or friend. Also provide regular opportunities for staff to share their concerns about patient care and workload, etc. -- and do something to address legitimate issues. Other- wise, disgruntled staff may vent their concerns and feelings to surveyors all too willing to listen.

Training, Practice Strengthen Your Defense

Train CNAs to identify a confusing question or one requiring expertise beyond their scope of knowledge, advises Barbara Miltenberger, a nurse attorney with Husch Blackwell Sanders in Jefferson City, Mo. CNAs should also know that they can have the DON or another designated person present when they talk to surveyors, she adds.

Also, as part of survey preparation, do role playing where mock surveyors ask CNAs and other staff potentially difficult questions to get the staff used to how to respond, suggests Christine Twombly, RN, a consultant for Reingruber & Co. in St. Petersburg, Fla.