Long-Term Care Survey Alert

Find out how surveyors might cite 3 common scenarios.

Here are the answers to last month's "You Be the Surveyor" quiz on how Centers for Medicare & Medicaid Services' panel members said they'd recommend citing the following scenarios. The panel members shared their recommendations in a recent CMS Webcast training surveyors on the new Psychosocial Outcome Severity Guide. The Webcast also included some therapeutic alternatives to the scenarios described below.

Scenario No. 1: A resident becomes combative during a shower. A resident tells the CNAs she doesn't want a shower, but they insist on taking her to the shower anyway. The resident continues to verbally resist the CNAs' efforts to bathe her and at one point says she doesn't like the CNAs looking at "her tail." Finally, the resident bites one of the CNAs. Even so, the CNAs continue to bathe the resident until the resident's shower chair tips over backwards in the shower, resulting in what looks like a serious fall.

Analysis: The CMS panel members noted the resident resists the shower verbally and then physically tries to protect herself from unwanted intrusion. Then there's the "horrible" accident where the resident's chair tips backwards. We don't know how severely hurt the resident was from the accident. But even if the accident had not happened, the psychosocial outcome is severe, said the CMS panel.

Level of severity: Level 4 or immediate jeopardy cited at F223 (abuse) due to the resident's sustained and intense crying or combative behavior.

Alternative: Caregivers honor the resident's refusal to take a shower and suggest that they just do a little washing up, a suggestion to which the resident agrees. Once in the shower, the staff keep the resident covered. One nursing assistant asks the resident about her church--a subject that engages the resident. The staff asks the resident's permission toward the end to remove her gown so they can rinse her quickly.

Tip: Some facilities are giving their communal shower rooms a spa-type décor and ambiance with towel warmers, music, aromatherapy and shampoo massages, relates Rebecca Yackel, NHA, a nursing home administrator in Land-o-Lakes, FL.

Scenario No. 2: A resident has persistent adjustment issues after admission to the facility. During the survey, the resident repeatedly bangs on the locked door to the unit, tearfully saying she wants to go home. She also says "this is no life for me" and says she's someone who is "full of energy" and wants to get out out and do things. The facility hasn't addressed the resident's adjustment issues.

Analysis: The mere presence of a certain affect does not equate to a deficient practice unless the facility doesn't respond to the underlying psychosocial issue so that it persists or worsens. In this case, the resident's persistent depressed mood, social withdrawal, hopelessness and tearfulness and verbal and psychomotor agitation are persistent and rise to the level of compromise or actual harm (G-level or Level 3).

Alternative: A staff person who knows the resident and has been to her home approaches her as she bangs on the door. The staff person offers her hand to the resident who accepts it in a trusting way. They walk together to the facility garden to look at the flowers. The activities person knows the resident enjoyed having a garden at home and uses this information to engage her in a conversation about gardening.

Scenario No. 3: Surveyors see residents with dementia sitting around with nothing to do on every day of the survey. The residents aren't actively complaining about being bored. The survey team has sampled many residents, finding that many either have no care plan for activities or the care plan hasn't been implemented. Surveyors could not interview the residents in question because of the residents' dementia.

Analysis: Since the residents can't communicate, surveyors have to use the "reasonable person" concept to gauge how most people would respond to being dependent and "left all day every day" without stimulation or activity.

The scenario would warrant a Level 2 deficiency.

Alternatives: The Webcast includes a clip of an activities staff person involving a group of residents sitting around a table in an informal discussion and singing a familiar song. The message: Activities don't have to be fancy to create a sense of engagement and belonging.