​There is nothing like a little Zone Program Integrity or Recovery Audit Contractor audit to bring out the flaws in a nursing home team. When the medical record charts of a nurse, physical therapist, and occupational therapist don’t agree, the fingers start pointing and the blame starts flying.
Consider the following example from an actual Additional Documentation Request audit:
Physical Therapist: Patient was seen today for gait training, and lower extremities strengthening exercises. Patient reports moderate right knee pain and swelling in the right knee and foot. Patient performed therapy exercises in sitting position on left lower extremity with 3 repetitions of hip flex, and knee extensions. Patient ambulated 80’ x 2 with four-wheeled walker, standby assist. Patient tolerated treatment with minimal difficulty despite being confused and agitated.
Occupational Therapist: Patient participated in therapy activity while standing with contact guard assist and non-weight bearing on right lower extremity. Patient participated in bilateral upper extremity range-of-motion stretches while sitting in wheel chair. Completed 12 repetitions. Patient appeared to become preoccupied about the size of her thighs and that her knee was swollen, then stated, “They gave me something in the water, and now when I wear my pants they are not on right.” Therapist redirected patient and educated patient on elevating leg and to massage leg to assist with swelling. Patient verbalized understanding and demonstrated proper use of her leg rests on wheel chair to elevate her right lower extremity. Patient went from sitting to standing five times, with contact guard assist and verbal cues for safety.
Nurse: Resident moved out of bed to wheelchair; self-propelled in wheelchair ad lib about the room. Resident is in front of the mirror, rolling her hair in curlers quite skillfully at shift end. Patient denies pain or discomfort when asked. Vitals: 98.2, 74, 18, 146/85. All meds and therapy as per doc orders (adapted from Brandt, Chiles, Kelly, & McCauslin, 2011).
The physical therapist ambulated the resident 80 feet with standby assist. The occupational therapist indicated the resident was non-weight bearing and needed contact guard assist. The nurse saw the resident self-propel around the unit without assistance. This Medicare claim was denied!

Teamwork Vital

The lack of cohesive goals is one casualty of poor coordination of care for a Medicare beneficiary. When team members are not cognizant of the Medicare plan and don’t work together to achieve it, the result is poor care outcomes and payment issues.
Besides leading to denial of payment for conflicting charting, poor teamwork also takes a big toll on Medicare minimum data set (MDS) scheduling. Missed assessments, resulting in default payments or provider liability, frequently occur when just one team member tracks the Medicare MDS schedule. When there is strained coordination and limited cross-checking between the nursing and therapy departments’ MDS schedules, assessments can easily get missed.
Not only do therapists collide with nurses, but the MDS nurses can have conflict with clinical staff nurses. It is not unusual for a clinical nurse on a care unit to dread seeing the MDS nurse who is looking for information. In fact, some nurses feel territorial about their ability to assess pain.
The resident assessment instrument (RAI) process was intended to be interdisciplinary but often becomes territorial, as many team members have difficulty collaborating to complete the MDS, Care Area Assessment, and care plan.
Turf wars occur in nursing homes when team members do not communicate and work together cohesively. The resulting conflict between staff members and even entire departments in a nursing home can have a devastating effect on residents, the facility’s revenue, survey outcomes, and staff.

Separate Person From Problem

In a perfect world, charting doesn’t contradict itself, assessments aren’t missed, and all staff work together effectively to care for residents so that they can attain and maintain their highest practicable physical, mental, and psychosocial well-being.
How can facilities foster healthy teamwork? According to Ben Dattner, PhD, “Almost every team develops some kind of habits in terms of how the team goes about doing its work, and/or in terms of norms of interaction.”
If teams take time to step back and look at how they function, they might be able to identify patterns of dysfunction or even ruts that they are in. “Some habits or norms, like ‘truth speaks to power’ or ‘we separate the person from the problem,’ can be very helpful,” Dattner says. “Other habits or norms, like ‘senior members of the team speak first even if they don’t understand the issues that well’ or ‘we shoot the messenger’ can be very harmful.”
Unhealthy patterns of communication and teamwork need to be identified and rooted out.
To improve teamwork on the Medicare program in nursing homes, consider meeting frequently to discuss residents’ progress toward goals—and be detailed. For example, don’t just say, “Resident on skilled rehab.” Spell out exactly what modalities are being utilized for which deficits and the goals they are designed to impact.

Specify Topics To Address

Specify the nursing actions that should occur to support the rehabilitation plan. Discuss ways to mesh the individualized interventions of each discipline so that all tasks are synchronized and the entire team understands the whole picture of the resident’s needs. Identify key topics that disciplines should address in their notes to demonstrate a joint effort. Remember to involve the resident in team discussions where appropriate.
During the meetings, the nursing and therapy departments should each bring their MDS schedules and cross-check them with each other. Compare each others’ notes regarding if and when the next Change of Therapy assessment might be due. Review minutes and resulting resource utilization groups together to avoid errors.
Healthy teamwork can exist, but it takes effort, motivation, openness, and mutual dedication. A team approach provides the foundation for overcoming turf wars. It combines the efforts of the varied disciplines into a unified focus.
Healthy teamwork results in treatment plans and supporting documentation that present a clear picture of resident progress and ultimately results in facility success.
Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.