Newsletter

Volume 1, No 5

Long-Term Healthcare Compliance
 

Deficiencies in compliance regulations result in "bad surveys", or even worse
may lead to litigation because of those deficiencies.  Many times the Director of Nursing
or the Administrator are inexperienced and do not know or understand the regulations,
both State and Federal which will cause substandard care or immediate jeopardy. 
Facilities that have Administrators or Directors of Nursing that do not go out on
 the floor to make rounds and do not address the concerns of the residents, staff
and families are at high risk for litigation.

Carolyn Frazier BSN, RN, Nursing Home Administrator in Pasadena, Texas

Prevention of Building Deficiencies

Survey Posting.     "The last 12 months which must also include the last
Standard Annual Survey must be kept in a place that is accessible 24 hours a day,
7 days a week.  The survey must be kept in a place where anyone wishing to see
it does not need to ask an employee for assistance."  The survey report should be placed
in a notebook or binder, put on a table in the front lobby, or in a plastic bin outside
the Administrator's door or even in the entry way where it can be easily found.  The location
should then be posted on a bulletin board where it can be found easily.

Temperature Logs.     "All refrigerators must have a temperature log which is
kept daily.  Usually it is the night shift that logs the date, temperature, initial, and
last name of person documenting the temperature.  The D.O.N. or Administrator
should spot check to be sure there are no holes."

Glucometer Checks.     "The night shift should also be responsible for glucometic
checks on every glucometer in the facility.  The glucometer log should have the
normal range and control number for the tests strip as well as the expiration date"
(this will not change until a new bottle of test strips is opened.)  If the glucometer
 reads "low" the nurse must document what she did to correct the deficiency
reading i.e. changed the battery, new test strip, etc.  The D.O.N. and Administrator
should do spot checks to be sure that the glucometer checks are being done
 and that there are no holes in the logs.

Shower/Whirlpool Cultures.     "Whirlpools and showers should be cultured
 every month and the results kept in the infection control book.  Before the whirlpool or
shower is cultured, nursing should ask the housekeeping supervisor to clean the
shower EXTRA well with disinfectant."

 A copy of the manufacturer's instructions on cleaning and disinfecting the whirlpool is posted in the Whirlpool Room.  There should be in-services with the Nursing Staff to be sure that the CNA and License Staff know how to disinfect and clean the whirlpool.

Fire Drills.     "This is a frequent F-tag because the facility fails to have the required
fire drills in a timely manner.  There should be one fire drill on each shift each quarter."
The dates on the fire extinguishers have to be correct.  The fire extinguisher inspector
 has to date and sign the tags on the extinguishers.

In-Services.     "There is a list of in-services that are required yearly.  The facility
should check their  in-services to be sure these have been done.  All employees
must have an in-service record.  For Bloodborne pathogens in-servicing, the
qualifications of the presenter must be kept in writing with the material presented."

Patient Assessments

There are a number of assessments that must be done on all residents in the facility
on admission, and re-evaluated at least quarterly when the MDS (Minimum Data Set)
 and Care Plans are done.  These assessments have to be done and kept current
on each resident.  The assessments must match the MDS and the results of the assessments are care
planned. Each assessment has many components.  CNA and
licensed staff must have proper orientation and in-services on these assessments.  A
short summary of each assessment is listed below.


Mandatory Assessments :
 

1.  Bowel and Bladder Assessment:  The largest portion of residents will fit into a
pad and brief program which must be documented on the Assessment form.  A Care Plan
must be done on each resident regardless of which category the resident falls into.  Each resident must be re-evaluated quarterly with their quarterly MDS and C.P.  Also if there
is a change of condition with the resident, there must be a re-assessment done.  This change of condition would also include if a resident that was in the continent category suddenly became incontinent.  It is extremely important that all residents' Bowel
Movements be documented correctly.  The nurse should make this documentation
instead of an aide or CMA.  Under the new HCFA guidelines that went into effect
9/1/99, a fecal impaction is considered a "sentinel event" (An unexpected incident,
related to system or process deficiencies, which leads to death or major and enduring
loss of function for a recipient of health care services) which will cause a deficiency.

2.  Skin Assessment:  Skin assessments must be done on all residents.  The Braden
Scale is highly authoritative.  For all residents that fall into the category for "At Risk" for Pressure Sores or with Actual Pressure Sores, a care plan must be initiated.  If a resident has more than one site, each site must be Care Planned separately.  Each resident with a risk for pressure sores or actual pressure sores must be on some type of pressure relief mattress.  The facility should not use foam rubber or egg crate because these are not incontinent proof and will cause odor; and if these are washed, they are no longer fire retardant.  The
resident must also be placed on a pressure relief device when up in a
wheel chair.  Certain labs have to be done for each resident with pressure sores or
at risk for pressure sores to be sure that their dietary intake is adequate to promote healing/prevent breakdown.   If the labs are not current, the physician is to
be notified for lab orders.

The U.S. Department of Health and Human Services publishes a purple book called
Clinical Practice Guideline, which is a resource book for surveyors and attorneys.
 State Surveyors were more interested in anything above a Stage II in the old survey process.  With the new survey process the surveyors will be also looking at
Stage I through Stage IV pressures.

3.  Restraint Assessment:  Restraints are a high liability issue.  Specific  rules
and regulations apply.  A restraint consent form must be signed by the
responsible party.  Restraints include physical and chemical.  Physical restraints
have to be untied at least every 2 hours and the patient repositioned.  Patients also
have to be offered something to drink and a chance to go to the bathroom.  If  the patient
resident is incontinent, he/she should be checked and changed.)

4.  Fall Assessment: must be done on all residents in the facility.  These should be
done on Admission as well as quarterly or on change of condition, just like all other
assessments.  If a resident has a fall, another fall assessment must be initiated to see if there has been a change in the resident's condition (even if a fall assessment
was completed the day before.)

A resident that is determined via the assessment to be "at risk" for falls must be
care planned with appropriate approaches.  If a resident does fall and the fall is
unwitnessed, you must assume the resident hit their head.  Therefore, all unwitnessed
falls will have Neuro vital signs done every 2 hours and documented on a Neuro Vital Sign Sheet x 72 hours.  If the resident tells you they did not hit their head, and the nurse
believes the resident, the MDS must be consulted to see if the resident's long term
memory and short term memory are intact.  Frequently the resident states they did not hit their head and the nurse believes the resident; however, the MDS states that the
resident is or has periods of confusion).  Also, the resident may have hit their head but cannot remember.  Therefore, the Neuro Vital Signs should be obtained to cover
the staff and facility.

5.  Antipsychotic Assessment:  must be completed on all residents
receiving antipsychotic drugs.  If a resident is on an antipsychotic drug, then the
 resident MUST have a Behavior Monitoring Sheet to document the resident's
behavior that requires the use of antipsychotic drugs.  These Behavior Sheets must be documented on each shift each day.   In addition, an AIMS Test must be done
on all residents receiving antipsychotic drugs to document the resident does
not have or has not had any adverse reactions to the drugs.  All residents on antipsychotic drugs must have an appropriate diagnosis.  Organic Brain Syndrome and Alzheimer's
are not appropriate diagnoses.  All residents on antipsychotics must have a signed
consent form by the responsible  person and be Care Planned.  Patients on
antipsychotics are high risk for falls.

6.  Anti-Depressant Assessment:  Staff should be careful of residents on
anti-depressant drugs, as they may have weight loss and an increased risk for falls.

7.  Smoking Assessment:  Indicates residents who are at risk for burning or injuring themselves if left to smoke alone.

C.Q.I. (Continued Quality Improvement) and Risk Management

"All Long Term Care Facilities must have an active CQI and Risk Management program in  place.  This means that any Risk Management (potential negative outcomes) must be
 taken through the CQI process, and the individual departments within the facility must communicate with each other to prevent negative outcomes.

Malpractice claims have significantly increased with extremely large settlements
 being awarded due to professional negligence.  This negligence could include
(but not limited to) breach of Standards of Care or duty, any careless act which has
caused injury and measurable harm.

Nurses may be liable for failure to follow physician's orders, following physician's orders without questions when the nurse knew or should have known that the orders were inconsistent with current standards of practice, failure to take correct telephone orders or verbal orders, failure to report to MD significant changes in patient's condition, medication administration that is in violation of the Nursing Practice Act, state or federal laws or facility policies, patient injuries which could have been preventable (falls elopement, pressure sores, etc.), or failure to establish policies and procedures.  Although very few nurses are named in malpractice law suits, more and more frequently attorneys are naming
nurses hoping that the nurses may become plaintiff's witnesses if the suit against
them is dropped.

Liability is established when the injury was caused by the careless act of another. 
 Negligence is defined as the failure of a person to exercise the proper degree
of care required by the circumstances.

Incident reports, concern forms, patient satisfaction surveys and safety reports
are all tools that the facility should use to identify potential Risk Management concerns.

Effective methods used to control potential risks include staff education, the
 CQI process at the staff level, frequent review and revision of policies and
procedures, monitoring of quality of care and quality indicators, intervention
and follow up by the management team on all concerns and grievances."

CQI meetings must include the Medical Director, department heads and the
Administrator.  Some facilities have Nurse's Aides and Licensed Staff attend the
meetings.  Others outline the meeting and report at a staff meeting what will be done
to correct the concerns, as the State may ask the CNA staff how they got the information
from the CQI meeting.  The main concern is that all staff be involved in the
CQI process.  Not matter what the concerns are, administrative staff cannot
correct them alone.  Support of the staff must be included.
 The staff must understand the "why" of the concern, and the
 "how" the issue will be resolved.  The staff must "take ownership" of the
building and "buy into" the corrections to be successful.

The Guidelines to Surveyors in the State Operating Manuals state that if the
facility makes a "good faith attempt to identify and correct, quality deficiencies
will not be used as a basis for sanctions." f-521 (4).  By identifying the above concerns,
 writing action plans, taking the concerns and their plan for correction before the CQI Committee, the facility can usually avoid being cited for anything the facility
has identified.  But, the facility must follow their plan exactly or it can be cited.

"The Long Term Care Survey Manual published by the American Health Care
Association is a guideline to surveyors.  This manual tells the surveyors exactly what 
 they can look for, and gives probes for how the deficiencies are to be written."
The manual not only gives the regulations but also gives the interpretive guidelines
 that the surveyors must use, and the intent of the regulation.  "This manual really
should be the Director of Nurses and the Administrator's 'Bible'.  If a Director of Nurses
or Administrator are to be successful, they must know the regulations as well as the
State Surveyors."
 

Source:  Frazier, Carolyn Casey (2000).  The Guide To Compliance In Long Term
Care.  Millennium Health Care Publishers in Huffman, Texas.

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An increasing number of nursing home litigations have been filed as a result
of the growing nursing home population and laws regulating their care.
 Understanding the litigation process and developing an awareness of the issues
 examined by attorneys and experts for both the plaintiff and defense are important for
staff  working in long-term care. Knowing the standards of care can prepare nurses
and staff to anticipate and successfully defend their positions.

Peterson, Ann M. (2002).  Geriatric Nursing, Volume 23, abstract from pages 37-42.


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Nursing Home Inspections

State governments oversee the licensing of nursing homes.  In addition, states have a contract with the Centers for Medicare and Medicaid (CMS) to monitor those nursing homes that want to be eligible to provide care to Medicare and Medicaid beneficiaries.  Congress established minimum requirements for nursing homes that want to provide services under Medicare and Medicaid.  These requirements are broadly outlined in the Social Security Act (the Act).  The Act also entrusts the Secretary of Health and Human Services (DHHS) with the responsibility of monitoring and enforcing these requirements.  CMS, a DHHS Agency, is
also charged with the responsibility of working out the details of the law and how it
will be implemented, which it does by writing regulations and manuals.

CMS contracts with each state to conduct onsite inspections that determine whether its nursing homes meet the minimum Medicare and Medicaid quality and performance
 standards.  Typically, the part of State government that takes care of this duty is the
Health Department or Department of Human Services.  The State conducts inspections
of each nursing home that participates in Medicare and/or Medicaid on average about
once a year.  If the nursing home is performing poorly, the State inspectors may go
 in more frequently.  The State also investigates complaints about nursing home care.

During the nursing home inspection, the State looks at many aspects of quality.
The inspection team observes resident care processes, staff/resident interaction, and environment.  Using an established protocol, the team interviews a sample of residents
and family members about their life within the nursing home, and interview
caregivers and administrative staff.  The team reviews clinical records.

The inspection team consists of trained inspectors, including at least one registered
nurse.  This team evaluates whether the nursing home meets individual resident needs. 
In addition, fire safety specialists evaluate whether a nursing home meets standards
 for safe construction.  When an inspection team finds that a home does not meet
a specific regulation, it issues a deficiency citation.

The regulations cover a wide range of aspects of resident life, from specifying
 standards for the safe storage and preparation of food to protecting residents from
physical or mental abuse or inadequate care practices.  There are over 150 regulatory standards that nursing homes must meet at all times.  Many are related.

Depending on the nature of the problem, CMS can take action against the nursing home. 
The law permits CMS to take a variety of actions; for example, CMS may fine the nursing home, deny payment to the nursing home, assign a temporary manager, or install a
State monitor.  CMS considers the extent of harm caused by the failure to meet
requirements when it takes an enforcement action.  If the nursing home does not
 correct its problems, CMS terminates its agreement with the nursing home.
 As a result, the nursing home is no longer certified to provide care to Medicare
 and Medicaid beneficiaries.  Any beneficiaries residing in the home at the time of the termination are transferred to certified facilities.

Source: http://www.medicare.gov/Nursing/AboutInspections.asp Updated July 25,2005.
 

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