How many deficiencies does your facility have?

Moogie · Feb 23, 2010

Thank you, Deb. I wish I had thought to look at surveys before even looking at jobs before dipping my toes into LTC. There are some issues like dignity and frequent falls that just raise red flags in my opinion.

CapeCodMermaid, RN · Feb 23, 2010

I've spent most of my career in LTC and am passionate about it. Often times there is NOTHING to be done about frequent falls. You can't restrict or restrain people without just cause and it's always about the risk vs. the benefit. Dignity on the other hand should go without saying. There is no excuse for not treating our residents in a dignified manner. PS...not only do DPH surveyors read this board, the BONs of the various states check it out too!

RNMLIS · Feb 24, 2010

My facility is rated 5 stars - what a joke - we prepared for 6 months for a yearly review so the focus of this facility for 1/2 year was on preparing for the state which included mock surveys, rewriting nursing notes...I think the error had to do with back up meds I am no longer there or in ltc

I was clueless when I landed in hell after 6 months on a tele floor....my experence in ltc further dashed and smashed many new nurse hopes dreams expectations.

If the facility I worked at was judged a 5 star - scary stuff. I enjoy geri care but ltc industry is out of control. I briefly worked at a not for profit ltc//sub acute much better but largly r/t the extra effort on PT, activities faciity layout...sadly nurses had even more patients and

I would be curious as to what a state evaluator has to say re:ltc

stelarRN · Feb 24, 2010

i'm not sure, but i heard that with our last state survey we had no deficiencies. we're having a mock survey tomorrow (joy). i hate these things.

debRN0417 · Feb 27, 2010

Most all of you are familiar with the survey process, or you should be. The first thing that happens is that the survey team does an initial tour. On this initial tour many observations are made regarding the condition of the residents, the environment, and staff/resident interactions. This is a very important time and can sometimes set the direction of the survey. That is why they are unannounced. We want to try to get a picture of what goes on in the facility every day because we know that things change after we get on site, in most places. There are facilities, though, that because they are doing the right things every day, that the survey process is just a validation of the good care they are providing. I am not saying that just because a facility "presents well" does not mean there are not problems. Odors in a facility are a definite red flag- not just those transient odors that are natural, but you know what I am talking about, especially if that is validated by a resident who is visibly soiled in a public area- which happens more than you'd like to think. The OM/QI's give the team a list of "potential residents' to include in the survey sample due to what thay have triggered, but his does not mean that these are the only resident's that are included. There are other factors that are considered, such as observations made on that initial tour, facility reported incidents, or complaints. There are several "tasks" that are completed that can also identify areas of concern, such as the med pass, resident interviews, group interview, and environmental rounds. Observations are made all the time- when walking, talking with staff, interviewing/observing. Record reviews are important and many deficiencies originate from charts/or lack of charting. Things that get attention are, as I said unkept residents- soiled with food, drool, or urine- look at nail care, shaving, hair...then how does the resident feel about the way they look, if they are not able to answer, it is what a prudent person would prefer? Then review of the record to correlate all these things- do they refuse care, is it documented, is it care planned, what alternatives have been tried..etc...etc... this applies to anything- first it's observation, then interviews, then correlation and further investigation.

Nurses notes that do not follow-up on what happens- A resident shows a decline in condition and there is no documentation as to an assessment or continuing assessment- maybe 6/5/09 at 11:00 am resident "A" complains of trouble breathing. The nurse takes vital signs and says "will continue to monitor". Then 6/5/09 8:00 p.m., resident "A" "Sent to ER for respiratory distress". And that is all...hummmmm... Or resident "b" falls out of bed or the chair and the notes say "no apparent injury". Then a little later, say maybe 5 or 6 hours, Resident "b" is having pain, or there is brusing, and the resident has a hip fracture. Where is the assessment after that fall? Range of motion, skin condition? No apparent injury is not an assessment. It all is one big circle- Observation, interview (if possible), assessment, documentation, care planning, reassessment,....these are critical not only for appropriate resident care, but also preventing deficient practice....this just skims the surface...

I could go on...but I hope you get the picture-

I have been places where the staff scatter and I cannot find a soul. Now if I can't find a soul, who is watching the residents and caring for them? I have been places where the staff have made me feel very welcome and are proud of the care they are giving. They "own" it, they are responsible and care about what they do. When I ask a question they are responsive and tell me what I need to know, or direct me to someone who can help me. The survey process is extremely stressful because it is hard to know that someone is observing.

There should be no bias. Personalities should not have anything to do with anything, however I cannot speak for the personality deficiencies of some people. Of course there are some administrative people who will try to blame their problems on a biased surveyor and there are surveyors who will dig and dig and dig because they are immature, for lack of a better word, because of a personality conflict- I don't know why- I don't get involved in all that drama.... I try to treat people the way I want to be treated.

We know that things are different when we are not there. We won't see things because people are on their best behavior.

I hear people talking about working in "hell holes" on this board. I say advocate for the residents- that is what we all are supposed to do. If someting is wrong- speak up- tell the administration in a non threatening way that things are not good and that changes need to be made for the sake of the residents and their quality of care and quality of life. If they don't listen, then there is always the option of calling a complaint into the state agency. Please, think about the residents. You can go home every day, but that is their home and they depend on us.

I hope I have answered some questions. I am NOT a consultant (my disclaimer). There is the State Operations Manual that lists all the regulations and the survey process and it is helpful if you are familiar with the regs. I will be gald to try to help explain things if I can, as a nurse with surveying and long term care experience.

SuesquatchRN, BSN, RN · Feb 27, 2010

Nurses notes that do not follow-up on what happens- A resident shows a decline in condition and there is no documentation as to an assessment or continuing assessment- maybe 6/5/09 at 11:00 am resident "A" complains of trouble breathing. The nurse takes vital signs and says "will continue to monitor". Then 6/5/09 8:00 p.m., resident "A" "Sent to ER for respiratory distress". And that is all...hummmmm...

I don't understand. They noted the problem, continued to monitor, and sent him out. What is missing to your surveyor's eye? Seriously, no snark, what should have been documented?

As to talking to everyone - we had one disgruntled aide cause us a lot of problems when asked about a problem resident, who is a problem because neither we nor any other facility is really equipped to deal with him adequately. Can we say, "lack of geri-psych units"?

debRN0417 · Feb 27, 2010

I don't understand. They noted the problem, continued to monitor, and sent him out. What is missing to your surveyor's eye? Seriously, no snark, what should have been documented?
As to talking to everyone - we had one disgruntled aide cause us a lot of problems when asked about a problem resident, who is a problem because neither we nor any other facility is really equipped to deal with him adequately. Can we say, "lack of geri-psych units"?[/QUOTe]
What happened between the time the complaints of the resident were noted and the time the resident was sent out? Where is the "continue to monitor part"? When you say "continue to monitor" there needs to be evidence of the monitoring.
Great problems ensue expecially if the resident succumbs and there is no evidence that the resident was "monitored".
We are certainly aware of the disgruntled employees. That is why the surveyor should be interviewing more than one person. There are also many unjust complaints called in be disgruntled employees. Any survyeor worth their salt can spot this a mile off, and investigate further. There has to be real evidence to back up what the person is complaining about.
Lack of geri-psych is a real problem, If you're doing everything you can, social service is involved, maybe APS, care plan, assessment, document, document, document, then it is what it is. There is always a degree of frustration when dealing with a resident who needs placement elsewhere.
Hope that helps explain a little better.

SuesquatchRN, BSN, RN · Feb 27, 2010

So I should expunge that phrase from my notes, methinks, if monitoring means hourly vitals.

Thanks.

debRN0417 · Feb 27, 2010

We need to choose our phrases judiciously- unless we are prepared to back them up if the occasion arises.

CapeCodMermaid, RN · Feb 27, 2010

I'm not a surveyor, although I'd like to be one when I grow up, but I do spend a considerable amount of time reviewing charts. If I read that the resident complained of difficulty breathing and a set of vitals was done but nothing else documented, I'd be asking the nurse what s/he did in the meantime. Was the doctor called? O2 started? Lung sounds? Did the nurse go back in a half hour or so to see if the patient was better? Surveyors aren't the only ones who expect things to be done correctly and documented correctly.

SuesquatchRN, BSN, RN · Feb 27, 2010

I'm not a surveyor, although I'd like to be one when I grow up, but I do spend a considerable amount of time reviewing charts. If I read that the resident complained of difficulty breathing and a set of vitals was done but nothing else documented, I'd be asking the nurse what s/he did in the meantime. Was the doctor called? O2 started? Lung sounds? Did the nurse go back in a half hour or so to see if the patient was better? Surveyors aren't the only ones who expect things to be done correctly and documented correctly.

I'm having trouble getting people to do anything correctly and it doesn't matter how incompetent someone is, there are absolutely no consequences. If you are a body with a pulse and a license your job is secure.

CapeCodMermaid, RN · Feb 27, 2010

It used to be like that at the facility I left yesterday. There is a union and somehow the thought was those people had jobs for life no matter how bad they were. We aren't making widgets, people. I've fired 3 people since I started. Is it annoying to have to dot every i and cross every t and show you followed the disciplinary procedure? Yep. Is it more than annoying to have to sit in arbitrations for hours until YOU feel like YOU'RE the guilty one? Yep. Is it worth it to make sure we have the best nurses possible taking care of our residents? You bet it is. Don't let the incompetent ones reign.