[KlareRN]

I work with several long term care facilities in northern Indiana as a consultant and am just wondering how other states are coping with their state surveys. Indiana has gotten to the point that very few facilities are able to clear a survey. Level G deficiencies are common. I know some buildings deserve them- but some of the facilities that are getting level G F-tags really do provide excellent care. The corporation I work for fortunately has excellent programs for restraints, psycotropics, falls, etc. but still cannot please the surveyors. They seem to be so out of touch with reality. Do the other states have surveyors that insist on finding something to cite? One facility got a level G tag for one resident that was unable to walk safely without assistance. He had a bed alarm, motion detector, and low bed in his room to try to keep him safe at noc. He tried to get up and when the alarms went off- staff ran to his room but was too late. He fell and broke his hip. Siderails were not an option- he tried to crawl through and over them. Our corporation does not allow vest restraints or roll-belts or any kind of "restraint" in bed because of the dangers. I agree with our no restraint in bed policy. But-what else could we have done? The surveyor said the facility should have done something for him- but was unable to give us any other recommendations. Any ideas or comments about long term care surveys?

"Those that can...do...And those that can't...survey!!!"

[jamistlc]

Originally posted by KlareRN
I work with several long term care facilities in northern Indiana as a consultant and am just wondering how other states are coping with their state surveys. The corporation I work for fortunately has excellent programs for restraints, psycotropics, falls, etc. but still cannot please the surveyors. They seem to be so out of touch with reality. One facility got a level G tag for one resident that was unable to walk safely without assistance. He had a bed alarm, motion detector, and low bed in his room to try to keep him safe at noc. He tried to get up and when the alarms went off- staff ran to his room but was too late. He fell and broke his hip. Siderails were not an option- he tried to crawl through and over them. Our corporation does not allow vest restraints or roll-belts or any kind of "restraint" in bed because of the dangers. I agree with our no restraint in bed policy. But-what else could we have done? The surveyor said the facility should have done something for him- but was unable to give us any other recommendations. Any ideas or comments about long term care surveys?

"Those that can...do...And those that can't...survey!!!"

Well how about a sitter for all who in this risk catergory
Not cost effective, right? Which is cheaper lossing the accrediation or paying for the sitter? Niether are real options but I bet that the surveyor would say they need a sitter, who'll pay for that? Also could ya get a Medical Director to sign off on that? No real ideas here! Sorry

[tex]

I have only lived through one survey last year. It was the most draining experience I went through. I learned alot. I also learned that when I heard the word from the surveyors "I have a concern" it meant a citation unless you can prove otherwise. I have posted alot of questions r/t the MDS/raps and care plan process on this site. I have worked very hard the last year + to do the best I can. But always a "concern" that I am over looking something. I would like to ask our owner to allow a consulant to come and review our raps and care plans. We were cited last year on care plans, we incorporated pressure ulcer and skin together and they didn't like it. In your experience should raps, be a nursing thesis? We type out our raps, sometimes, who am I kidding, most of the time, myself and an LPN, the ADON takes us one complete day to finish the raps alone. What is wrong with this picture. As I read in the RAI manuel, raps do not have to be exhaustive, but they are. We have a 122 bed facility. We also I think have a good restraint policy, we don't use them, watch our psychotropic meds, falls, wt policy etc. We were cited on Behavior, for an individual that wanders and can strike out, but when we addressed the problem the state stated not good enough, when we asked for their opinion, their mouths shut like clams...............................Tex

[KlareRN]

Tex-
I think we may have the biggest part of a "behavior management program" documented in a format the surveyors are OK with. (No citations for behaviors in either facility we have this up and running in). We use "CNA assignment sheets" that list each resident on the hall with "all" the information the aides need to care for those folks. (How many assist they need/ type of diet/positioning equipment/toileting program/shower days, etc.) On the back is each person on the hall that has behaviors. There is a column for behavior, trigger, and intervention. For each behavior- a trigger is identified and then interventions are listed. Example:Intrusive Wandering
Triggers: Hunger, Need to toilet, Boredom (be careful with this one- the surveyors don't think anyone should ever be bored). Then staff interventions are listed: Toilet, Offer food-drink, Offer puzzles or books, Talk about his farm...etc...
Each behavior-trigger-intervention has to be individualized to fit the resident and staff must carry their "brains" with them at all times so that they have the information on handling behaviors at their fingertips. If a surveyor questions "what would you do if this resident had this behavior?" all the aide (and nurse) have to do is pull out the sheet and read it to them ver batum. Nothing says it has to be memorized...just accessable!!! (And quotable!)
"Striking out" behaviors are difficult. Is it during assistance with ADLs? Intervention would be to reapproach later...Or is it when there is too much stimuli around the individual? "Remove from situation and take to a quiet place and offer reassurance" etc... Sometimes the striking out is just a characteristic of the disease process due to confusion/fear....(alzheimers/dementia).This is the same information you want to use for your interventions on the care plan. Then- EVERYTHING matches! Also- I will try to get some conclusive information about RAPS for you. I do not think they should be that detailed- but want to ask one of my corporate MDS Gurus so I don't mislead you. MDS is not my cup of tea and I have the utmost respect for those of you that have chosen to assume the responsibility for that kind of pressure.
If you have more questions or comments about behavior management that maybe I can help with- let me know. I'll get back with you on the RAPS question...
Happy Careplanning-
Klare

[Catsrule16]

"Those that can...do...And those that can't...survey!!!"

Sorry you feel this way. Some surveyors are still nurses in the real world just not in long term care. I am a surveyor and work part-time on every other weekend on an othropaedic floor which is a lot like working back in a nursing home. To keep one of my patients from trying to get out of bed with 10 lbs of bucks traction on, I had to sit at his bedside. Every time I left the room, I had to make a bargin with him to be back in a specific time frame. Had to take my charts in his room at least till his family showed up. He had a diagnosis of Dementia. When I did work in a long term care facility, many times I had company sitting at the desk with me to be supervised.

I feel your anguish with the cite of F324 Supervision to prevent accidents. I don't know the specifics leading up to the fall so I can't tell you what I would have done, so I'll ask a few specifics. What time of day did this happen? Was the resident in his room alone? Could this resident have been placed in an area of observation by other staff members during that time so the CNA's could finish giving care? Was there an activity going on at the time the resident could have attended?

I commend your corporation of having such a great program in place. Good Luck with future surveys.

[KlareRN]

Catsrule-
Thank you for your reply. The fall happened at 3AM. There were 2CNAs and 1LPN on the unit of 22 residents he lived on...staffing was actually "overstaffed" for a unit that size for 3rd shift. He had been sleeping all shift...not restless. It was an alzheimers unit and 3AM is bedcheck time...and sitting at bedside not an option because many of the residents on this unit were severely cognitively impaired-impossible to 2nd guess who might try to get up. Many were high risk for falls-not enough staff. Although this survey was over a year ago-it is still in litigation due to an IDR and our corporate attorney has gotten involved. I just think it is a shame that we have to spend all this time and energy defending the care we deliver instead of using this time and energy on patient care! Like I said- there are some horrible facilities out there...and we HAVE to have regulations....I just feel that the long term care surveys have gotten out of hand.

[bandaidexpert]

I have gone through 24 surveys in my career. I have been and MDS coordinator for 10 years. I have been deficiency free for the past 7 years. I am responsible for PPS/OBRA assessments in a 106 bed facility. I have learned over the years, to deal with a surveyor is to be confident and give them the right answers to their questions. The last thing a surveyor wants to hear is "I don't know". I am sure each state is different in the survey process, I decided along time ago to use the survey as a learning experience. I have been through some tough surveys. And I truly believe the reason I am deficiency free is because I don't let 'em see me sweat.

[tex]

Great responses. Just went to an inservice from our state today. The lady that was doing the "skimming" the entire RAI process knows it like no body else. But as I sat in the room with 60 other new MDS cord. And I probably had more experience 1 &1/2years I still learned, not from the speaker, just from sitting with cordindators that have had maybe 6 months experience. That is why I really like this site, I learn alot from you guys! And I appreciate it Tex

[tex]

An additional ?, do your facilities have more than just you doing the MDS? We have a S.W. that does not do MDS or raps or c/p, she has been there for 10 years, from my inservice today, the cognitive, mood, behavior, psychosocial and delirium is suppose to be done by the S.W., we have an LPN doing the nutrition, dehydration and tube feeds, and an activity director doing her part, but because our activity director is the only on in the building, she is so busy I end up doing her part. So MDS nurses, my ? I ask to all is how long does it take to do raps, for me, at least 4 to 6 hours on each resident, less if they are not cognitively impaired and no other emotional problems. Tex

[CoachCathy]

Going back to the fellow that falls, have you tried a low bed. It isn't comfortable for the staff, but it is a Godsend for those confused residents that still have quite a bit of mobility. I agree with bandaidexpert - don't let em see you sweat. The facility that I am working in was on the fast-track for poor-performing facility. They were so bad that admissions were frozen and they were paying serious fines. (they had gotten >50 deficiencies in one calendar year!) I started with them after the last *horrible* survey - doing QA of all things!! As you become more confident in the care that you are providing - and as your staff echoes that belief - the state will see the quality of care as well. We had state in our building nine times in 2001 - between the two annual surveys (fast track, remember) and the seven complaint surveys - we received only one deficiency for all. I think that if you take the approach with the surveyors that you are truly on the same side - ensuring quality care for the residents - that you'll find the surveys go much smoother. Going to Tex's concern - sometimes you reach a point where you realize that a resident may not be appropriately placed - especially with behavior concerns - that's when getting the ombudsman involved may be helpful. take care