| Putting the Care Back in Care Planning | <p>F-tag 656, failure to develop and implement a comprehensive care plan, has been on the top 10 deficiencies list for years. Although this is not a new regulatory requirement, facility staff still struggle to achieve compliance with care planning during annual and complaint surveys. <br></p><p>Negative and siloed views such as, “No one looks at the care plan anyway” or “Only the nurse assessment coordinator is allowed to update the care plan,” serve only to further distance the care plan from its actual intent. While some may mistakenly view it as useless paper compliance, care plans should be viewed as a valuable tool for all staff.<br></p><p>The overall intent of the care plan is to articulate an approach to meet the resident’s goals and preferences and address medical, physical, mental, and psychosocial needs. However, care plans often look instead like lists of general interventions for nonspecific problems, which cannot actually drive resident care.<br></p><p>Refocusing the development and use of the care plan as a valuable tool for the interdisciplinary team (IDT) may help to provide more resident-centered care, improve outcomes, and reduce the risk of receiving an F656 citation during survey.</p><h2>Redefine the Care Plan as an Invaluable IDT Tool </h2><p>The guidance provided in the “State Operations Manual (SOM)” for §483.21(b) requires that “facility staff must work with the resident and his/her representative, if applicable, to understand and meet the resident’s preferences, choices, and goals during their stay at the facility.” However, the regulation allows the facility to determine how this process will be completed and to delegate to appropriate staff members.<br></p><p>The guidance continues that, “the facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life.”<br></p><p>While this regulation is well-known to most facility staff and is used to develop the comprehensive care plan, the final product often falls short of becoming an ongoing IDT tool to drive the care and services that the resident receives daily. The focus must be on developing the care plan to meet the needs and preferences of the resident, which will meet the regulatory requirements. However, if the focus is on checking a box for regulation, the team will miss critical elements or interventions. <br></p><p>If a physician asks, “What are we doing for Mr. Jones’ chronic obstructive pulmonary disease [COPD]?” The answer, from medication to diet, should be articulated in the care plan, providing the full holistic approach from the IDT. If Mrs. Johnson’s daughter asks what the facility is doing to prevent her mother from falling, all current interventions, from activities to rehabilitation, should be present in the care plan. <br></p><p>Using the care plan as a collaborative tool among all departments helps align the care and services the resident receives to assist them toward their goals. However, to achieve this, facilities must establish clear expectations regarding the level of detail and enforce and monitor timely updating.<br></p><p>If the team shifts its focus from meeting the minimums of regulatory requirements to instead elevate the purpose of the care plan, they can accomplish both by more effectively driving the care and services for the resident.</p><h2>Self-Identify Problems with Care Planning </h2><p>Care plans can come in various shapes and sizes; they may be handwritten on paper, completed electronically and printed, or maintained in electronic medical records (EMRs). Although EMRs have many benefits, they can also leave some gaps. Often, EMR users add interventions by simply checking an electronic box, which can lead to generic care plans that are not resident-centered.<br></p><p>Ready-to-go interventions often require individualization once added to the care plan. Failing to individualize results in confusing and incomplete care plans. <br></p><p>While direct care staff should frequently be accessing and updating the care plans, clinical leaders should also monitor for compliance and the quality of these updates. If a resident’s care or interventions have changed, did the team member responsible for the change update the appropriate care plan? Have resolved interventions been appropriately archived? Are the care plans easy to read for non-medical individuals? <br></p><p>Each time clinical leaders identify an incomplete or generalized intervention, or failure to timely update, they also identify a potential survey tag. While the process of monitoring and identifying these problems may be labor-intensive initially, as the facility’s culture adopts the care plan as a tool, the task becomes easier. </p><h2>Remove the Siloes </h2><p>Often, staff develop multidisciplinary care plans and believe they are creating interdisciplinary care plans. The key difference is that multidisciplinary care plans focus on the discipline, not the resident. One way to move toward a successful interdisciplinary care plan is to focus on the resident and their actual or potential needs. <br></p><p>For example, often the dietary department is responsible for completing section K of the Minimum Data Set, Swallowing and Nutritional Status. If a resident is coded as having a therapeutic diet, such as a diabetic diet, it will trigger the nutritional status care area assessment (CAA). This may result in the dietary manager or dietitian creating a care plan by focusing on the triggering reason. <br></p><p>The problem statement may read, “Mr. Jones receives a therapeutic diabetic diet due to having a diagnosis of diabetes.” This type of siloed care planning does not allow for an interdisciplinary approach because it does not focus on the resident’s needs. The resident’s need is not for a therapeutic diet, but rather, the management of his diabetes; the therapeutic diet is just one intervention the IDT provides the resident.<br></p><p>When the team shifts the focus to the resident’s needs and the resident’s goal is established with the team, the care plan becomes the IDT’s holistic approach to addressing these needs. As the road map to care, it is used to measure progress toward goals and ensure the resident’s preferences are being met.<br></p><p>The SOM, §483.21(b), states, “Care planning drives the type of care and services that a resident receives. If care planning is not complete, or is inadequate, the consequences may negatively impact the resident’s quality of life, as well as the quality of care and services received.” </p><h2>Include the Resident</h2><p>Among the tools available to surveyors are the Long-Term Care (LTC) Critical Element Pathways (CEPs). While there are over 40 tools, there is not one specifically for care planning. However, there are numerous pathways, from activities to behavior, and emotional status to nutrition.<br></p><p>All ask the same question: Did the facility develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs and includes the resident’s goals, desired outcomes, and preferences? <br>If this was not achieved, the facility will receive a F656 citation.<br></p><p>It is not enough to address what the IDT is doing for the resident’s needs—the resident must play an active part in developing the goals, expressing to staff what his or her desired outcome is, and the staff must understand his or her preferences for care. And just like updating the care plan when changes occur, the resident’s goals and preferences must be frequently reviewed with the resident to ensure it continues to reflect those goals and preferences. <br><br><em>Jessie McGill, RN, RAC-MT, RAC-MTA, is a curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at <a href="mailto:jmcgill@AAPACN.org" target="_blank">jmcgill@AAPACN.org</a>.</em></p> | 2021-09-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/September/PublishingImages/0921_cgiving.jpg" style="BORDER:0px solid;" /> | Caregiving | The overall intent of the care plan is to articulate an approach to meet the resident’s goals and preferences and address medical, physical, mental, and psychosocial needs. |
| Develop Nurses’ Clinical Skills to Enhance Care | <p><img src="/Monthly-Issue/2021/August/PublishingImages/0821_cgvng.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:100px;height:100px;" />Perhaps now more than ever, nurses must utilize strong clinical assessment skills so that they can detect even the subtlest of changes and provide care that meets the needs of such a vulnerable population. <a href="https://pagepro.mydigitalpublication.com/publication/?m=63330&i=716028&p=24&ver=html5">Read more.</a></p> | 2021-08-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/August/PublishingImages/0821_cgvng.jpg" style="BORDER:0px solid;" /> | Caregiving | Over the past several years, the acuity and medical complexity of residents receiving care in skilled nursing facilities (SNFs) has increased significantly. For many SNFs, the medical complexity of the population has only intensified with the COVID-19 pandemic. |
| Managing Behavior Without Drugs: It’s a Team Effort | <p>For myriad reasons, post-acute facilities are compelled to limit the use of antipsychotics and other sedating medications to the lowest possible levels. But this comes at a time when the population of residents with serious psychiatric illness in skilled nursing facilities continues to rise. <a href="https://pagepro.mydigitalpublication.com/publication/?m=63330&i=716028&p=28&ver=html5" target="_blank">Read more.</a></p> | 2021-08-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/August/PublishingImages/0821_mgmt.jpg" style="BORDER:0px solid;" /> | Management | For myriad reasons, post-acute facilities are compelled to limit the use of antipsychotics and other sedating medications to the lowest possible levels. But this comes at a time when the population of residents with serious psychiatric illness in skilled nursing facilities continues to rise. |
| Walking the Tightrope Between Risk and Autonomy | <p>In the morning stand-up meeting, the charge nurse reports that Mrs. Jones (pseudonym) was upset that she was not offered cake when most of the other residents had been given some. Mrs. Jones has diabetes, her blood sugar is not well controlled, and her physician has ordered a diabetic diet. The staff offer her alternatives, but they note she is getting more upset and has started to decline going to meals and activities. She has told her nurse assistant that “it’s not worth living this way.”<br></p><p>It is the quintessential challenge for health care providers in long term care: balancing the rights of each resident to make decisions and the multiple risks that may co-exist in supporting those choices. Balancing these sometimes conflicting responsibilities often feels like walking a tightrope without a net, but just as with performers, it gets better with practice. </p><h2>Resident Rights and Duty of Care</h2><p><a href="http://cms.gov/" target="_blank">The Centers for Medicare and Medicaid Services</a> website contains a document for residents titled, “Your Rights and Protections as a Nursing Home Resident,” and within the first paragraph it talks about residents’ rights to be informed and to make their own decisions. The bottom line is that people do not give away their civil rights on taking up residence in a long term care community.<br></p><p>All health care professionals have the duty of care, to avoid behaviors that could reasonably and foreseeably cause harm. So, on this surface is where the conflict occurs, between the resident right to self-determination and the professional and organizational responsibility to minimize potential for harm.</p><h2>Informed Decision</h2><p>Several important caveats to consider are capacity and risk. Does the resident have the capacity to understand the risks and make an informed choice? The key factor here is that capacity is a legal term and not something that is determined solely by the staff. Only when an advanced directive or power of attorney has been triggered would the staff look to another individual for decision making.<br></p><p>The second important issue is that the resident has been made aware of the risks and benefits of different options. Additionally, the options cannot be putting other residents at risk.</p><h2>Defining Risk</h2><p>Geriatrician G. Allen Power, MD, has described risk as “the chance that something occurs that is different than is expected.” Health care professionals tend to focus on the negative risk, concentrating on the bad things that could happen. However, there are positive risks as well, that something better than expected may happen.<br></p><p>It is also important to keep in mind that risks are not only physical, but they can also be psychological and social. Health care professionals have been taught to focus primarily on the physical risk. This is what gave rise to the era of “physical restraints” since they were thought to increase physical safety (they were wrong), and there was little to no attention to the psychological and social implications of their use.<br></p><p>In their own lives, health care professionals take physical risks every day; they eat, walk, take a shower. Yet rarely do they think of these things as risky because they do not expect to choke, trip on the stairs, or slip in the shower. People value doing those activities, so the tradeoff of a small potential negative event is outweighed by the positive effect gained in doing it. No one has led a risk-free life.<br></p><p>Like everyone else, older adults must balance freedom of choice against safety/risk: It is the balance between what is important to them and what is important for them. <br></p><p>Health care has historically been paternalistic by making decisions for people, presuming to be acting “in their best interest” of safety over autonomy, deciding what is important for the resident or the organization providing the care. What health care has often failed to recognize is that there is dignity in risk; making choices is integral to experiencing life.<br></p><p>With advancing resident rights, health care practitioners are realizing that learning what is important to the resident, and having open communication to make informed decisions, can support a solution that is both important to the resident and more likely to be the best for them as an individual. It means being flexible in addressing individual resident challenges and recognizing that one-size-fits-all rules and regulations are what depersonalize care delivery. Just like risk is not the same to each person, the response of an organization and staff must have nuance as well.<br></p><p>Thus, the challenge arises not when the resident makes a choice, it is when he or she makes a choice that the health care professionals or the community do not agree with. This is not to say the health care professional should not make recommendations based on training and expertise, but the resident’s values and life experiences must be elicited and understood first, since all decisions must be viewed through their lens. <br></p><p>Risk should be reviewed for potential physical, psychological, and social impact. Beyond these it must address both the potential benefits and negative implications of taking one action versus another, including taking no action at all.</p><p style="text-align:center;"><img src="/Monthly-Issue/2021/July/PublishingImages/mgmt_RiskTaking.jpg" alt="Risk Taking" class="ms-rtePosition-4 ms-rteImage-1" style="margin:5px;width:375px;height:369px;" /><br></p><p>A realistic view of both the likelihood and potential severity of any consequences needs to be mutually established and understood to the best of the team’s ability. Additionally, decisions should be evaluated through a lens of proportionality; that is, are the suggested interventions or even the need for interventions at a level commensurate with the issue at hand? Like the physical restraint example listed earlier, restricting all mobility because some mobility is unsafe was not a proportional response. </p><h2>Documenting Risk Discussions</h2><p>Like most areas of long term care, documenting the decision-making process and resident involvement is critical. A written record of the assessment of options, potential positive and negative implications, and recommendations from professionals involved is required to show informed decision making.<br></p><p>Clear documenting should reflect that the resident is aware of the potential positive and negative outcomes as could reasonably be known to the group. Keep in mind, this could be a negotiation where each side may need to readjust their options to find a decision that can support the resident and be accommodated by the home. Managed risk contracts may be an option to show this process as an addendum to a care plan.</p><h2>Ongoing Review and Learning</h2><p>The plan of care should be reviewed on a regular basis to see if the decision still meets the resident’s needs, values, and preferences. These ongoing reviews will also help the resident to see if their decisions are having the desired outcome or if additional interventions may be needed to support or alter their decision. <br></p><p>Staff should also use reflection on the process, the decisions, and a review of what is working and not working as they adapt to a more person-centered approach. It may be uncomfortable to accept when their professional judgment was considered but the resident chose a different direction. However, seeing the person, their values and preferences, and how those contributed to the resident making a different choice can reframe the care delivery process, so the resident is truly at the center of the health care team.<br></p><p>It is also important for everyone to recognize that these decisions are not written in stone, just on the care plan. They can and should be edited as more information is revealed via resident and staff experience.<br></p><p>A trial “failure” should be a learning experience, where in this situation with these variables something did not have the outcome expected. Proper implementation, documentation, and ongoing review and support to minimize potential risk within the resident’s life choices are the keys to balancing risk and autonomy while providing person-centered care.<br></p><p>For Mrs. Jones, a restrictive diet is more likely to help her physically by keeping her blood sugar more tightly regulated, but her lack of engagement and socialization with meals and activities is impacting her psychologically and socially. Further dialogue is clearly needed to determine reasonable options for monitoring food selection and the risks to her health, while staff need to better understand her life and health care priorities.<span></span></p><p><span><em><img src="/PublishingImages/Headshots/CathyHainesCiolek.png" class="ms-rtePosition-1" alt="" style="margin:5px;" /></em></span>Based on this real-life example, it was mutually agreed that Mrs. Jones’ care plan was updated to keep the diabetic diet for meals, but have it relaxed for a “regular” snack in activities with her friends. With this she completed a larger portion of her meals, and there was not a significant change in her blood sugar regulation with the new plan. <em><br></em></p><p><em>Cathy Haines Ciolek, PT, DPT, FAPTA, is president of Living Well With Dementia®, providing education and consulting to improve well-being and create positive expectations for aging adults. She can be reached at <a href="mailto:cciolek@livingwellwithdementiallc.com" target="_blank">cciolek@livingwellwithdementiallc.com</a> or 302-753-9725.</em></p> | 2021-07-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/July/PublishingImages/0721_mgmt.jpg" style="BORDER:0px solid;" /> | Management | It is the quintessential challenge for health care providers in long term care: balancing the rights of each resident to make decisions and the multiple risks that may co-exist in supporting those choices. |
| Hitting Reset on Pressure Injury Prevention | <p>The complexities of the COVID-19 public health emergency required skilled nursing facility (SNF) operations to change dramatically and often to save the lives of the most vulnerable population. Through heroic efforts, SNFs transformed clinical systems of care, sometimes in less than a day, to win the war against the pandemic.<br></p><p>While operations and resources shifted to battle COVID-19, unintended consequences emerged—one being greater incidence of pressure injuries. Now that the pandemic is at a turning point, facilities can start to refocus and improve this trend. This article suggests ways to reorient efforts toward preventing and managing pressure injuries. </p><h2>Maximize Role of Wound Nurse </h2><p>Imagine if the infection preventionist’s sole responsibility were to treat residents who have an infection. This suggestion seems odd because it ignores the scope and breadth of what must be done to control and prevent infections for all residents. Yet when considering the wound nurse’s role, this person’s time is often consumed by completing daily dressing changes, at least five days a week, and the weekly comprehensive wound assessments.<br></p><p>While dressing changes and weekly wound assessments are critical tasks, there is a missed opportunity to utilize the wound nurse’s expertise and talents to champion skin integrity for all residents. Therefore, to refocus on pressure injury prevention, reset the wound nurse’s role. </p><h2>Identify, Adjust Care Plan</h2><p>The wound nurse can contribute to the goal of preventing pressure injuries in significant ways. One of the most imperative is by developing and implementing care delivery processes that consistently yield outcomes that support skin integrity.<br></p><p>For example, introducing and overseeing a process that consistently identifies residents’ risk for skin breakdown is vital to address these risks. <br></p><p>While most SNFs require the Braden risk assessment to be completed at regular intervals, the Braden is a tool to capture the risks; it is not the process. A nurse must first accurately assess the resident and then select the responses on the Braden that best correspond to their assessment.<br></p><p>This task may seem straightforward, but an audit of the Braden risk assessments could reveal variation in how the nurses assess and thus complete them. If so, the wound nurse can work with the nurses to improve their assessment skills to ensure the initial risk information can be relied upon.<br></p><p>Next, the wound nurse can ensure that information from the Braden is being utilized to develop an individualized care plan that comprehensively addresses the resident’s risk. Then, the wound nurse can support the implementation of care-planned interventions at the bedside by working with caregivers, offering just-in-time training, and being available to answer questions.<br></p><p>Lastly, the wound nurse can confirm that the interventions are effective at maintaining skin integrity or adjust the care plan accordingly. </p><h2>A Data-driven Approach </h2><p>Data should drive the determination of whether there is a problem and, if so, where to focus resources to improve processes. If these decisions regarding pressure injury prevention and management have been based solely on the count of pressure injuries, consider a reset that improves how the data are interpreted or give more context for decision making. <br></p><p>A change in the count of pressure injuries doesn’t necessarily mean something is good or bad. Rather, it’s an indicator to prompt questions and translate the data into usable information. The instability of the pressure injury count makes it difficult to glean meaning from the measure.<br></p><p>Using count data collected from week to week presents clinical leaders random ups and downs of trying to manage a number without considering why they are managing it. Starting with the right measurement of pressure injuries—one that correlates with the goals and acceptable threshold for performance—is the first step to using data in a meaningful way. </p><h2>Calculate Injuries Monthly</h2><p>A more stable and telling indicator of performance is to calculate the pressure injury rate each month, using occupied bed days. For example, if two facilities have 10 pressure injuries, but one facility has four times the census of the other, the count of 10 ignores that the facility with the higher census may be more successful at managing pressure injuries.<br></p><p>To calculate the pressure injury rate, follow these steps:<br></p><ol><li>Count the number of pressure injuries during the month.</li><li>Determine the number of occupied bed days for the month. Use the same point in time each month so the calculation is consistent. The business office can provide these data.</li><li>Divide the number of acquired pressure injuries by the number of occupied bed days.</li><li>Multiply the results in step 3 by 1,000. This will yield the pressure injury rate per 1,000 occupied bed days, providing a stable rate that can be compared each month.</li></ol><p></p><h2>Establish Goals</h2><p>This measurement can be used to establish an acceptable threshold (the minimum acceptable level of performance) and a goal (the level of performance that is desired). Sustainable improvement can take significant time to achieve, so consider achievability and the reality of the facility’s situation when setting goals and thresholds for pressure injury prevention and management.<br></p><p>To establish goals and thresholds:<br></p><ol><li>Examine pressure injury performance trends over time. This provides a realistic perspective of performance so that a facility avoids overreacting if a measure falls outside an acceptable range.</li><li>Use a baseline. A baseline uses existing data to provide a starting point. If the performance trends indicate the average pressure injury rate is 10 percent, this is the baseline to consider how much improvement is realistic and to evaluate improvements or declines in performance over time. </li><li>Benchmark performance. A benchmark serves as the standard to measure the facility’s performance against. State and national pressure injury quality measure data are sources to benchmark against. </li></ol><p></p><p>Changes in the monthly pressure injury rate prompt leaders to ask questions and narrow down which processes are problematic. The following questions will help leaders uncover the details needed to identify the issues and respond accordingly: <br></p><p><em>What is the rate of admitted vs. acquired pressure injuries?</em><br></p><p>If the admitted rate is higher than acquired, shift focus to treatment processes. If the rate of acquired is higher, shift to prevention processes. <br></p><p><em>What are the healing rates for the stages?</em><br></p><p>If it takes prolonged periods to heal pressure injuries, especially stages 1 and 2, focus on treatment processes. <br></p><p><em>At what stage do we usually identify pressure injuries? Do we identify them early at stage 1, or are they caught at stages 2 and 3 instead?</em><br></p><p>If identification occurs in the later stages, focus on monitoring, identification, assessment, and reporting processes. </p><p><em>Is occurrence of acquired pressure injuries on multiple residents, or is there one resident with multiple pressure injuries that increases the rate dramatically?</em><br></p><p>If pressure injuries are on multiple residents, focus on prevention processes. If pressure injuries are mostly related to one resident, focus on this resident’s care plan. <em><br></em></p><p><em>What is the most common location (for example, behind ears) for acquired pressure injuries?</em><br></p><p>Relate the location to prevention processes (for example, protect skin behind ears for all residents that use oxygen). <br><br><span><em><img src="/Monthly-Issue/2021/July/PublishingImages/AlexisRoam.jpg" alt="Alexis Roam, MSN" class="ms-rtePosition-1" style="margin:5px;width:124px;height:157px;" /></em></span>SNFs have learned to be agile and adapt quickly. With this capacity for change, hitting reset is an opportunity to look toward the future to enhance operations and achieve even greater performance. <br><br><em>Alexis Roam, MSN, RN-BC, DNS-CT, QCP, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at <a href="mailto:aroam@aapacn.org">aroam@aapacn.org</a>.</em><br></p> | 2021-07-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/July/PublishingImages/0721_cgiving.jpg" style="BORDER:0px solid;" /> | Pressure Ulcers | While operations and resources shifted to battle COVID-19, unintended consequences emerged—one being greater incidence of pressure injuries. |
| CNAs and Vaccination: An Issue of Trust | <p>Although COVID-19 vaccination rates for certified nurse assistants (CNAs) have increased significantly since the beginning of the year, many CNAs remain unvaccinated, for a variety of reasons.<br></p><p>As someone who worked for many years as a CNA and who now heads the largest professional association for CNAs, I believe that doctors who serve as medical directors for nursing homes hold the key to persuading those CNAs who are persuadable to get vaccinated and protect residents, their co-workers, their loved ones, and themselves.<br></p><p>Why do I say that? Because trust is a huge issue for CNAs, and they are more likely to trust the medical directors at their facilities to give them accurate, honest information about the vaccines than just about anyone else.</p><h2>Medical Directors are Local Experts</h2><p>According to a <a href="https://www.ahrq.gov/nursing-home/materials/prevention/vaccine-trust.html" target="_blank">new guide</a> from the federal government for building CNAs’ confidence in the COVID-19 vaccines, CNAs who are most resistant to getting vaccinated also tend to trust their employers the least. Among those they trust most: local medical experts. This is critical, because CNAs get a lot of their information—and misinformation—on social media, especially Facebook.<br></p><p>Not only do CNAs view their medical directors as their local medical experts, but many also see them as their personal physicians. This is especially common in rural areas that are short on doctors.<br></p><p>CNAs typically have good working relationships with their facility medical directors, who respect their hands-on experience and expertise, as well as their compassion for the residents they care for. This respect is greatly appreciated by CNAs, who are among the lowest-paid workers in health care and who often feel underappreciated. In addition, medical directors aren’t nursing home employees, and CNAs see them not only as credible but also as more independent than other nursing home leaders.</p><h2>COVID Ups the Stakes</h2><p>CNAs have a tough time, and COVID-19 has made it tougher. Even before the pandemic, they worked long hours, often at multiple jobs. But this past year has been hell for them. Many have been sick themselves; they’ve also lost residents they cared for and co-workers as well. Their jobs have been incredibly stressful and demanding, even as the demands on them at home have increased.<br></p><p>There are many reasons why CNAs aren’t getting vaccinated. Some have taken a “wait and see” attitude, while others harbor fears and concerns that they feel haven’t been addressed. Some would like to get vaccinated, but they can’t afford to take unpaid time off from work, especially if they get sick from side effects, or they don’t have transportation or child care.<br></p><p>And remember: CNAs have been on the front lines of battling this virus and watching it unfold for over a year. Either they’ve gotten it and survived, or they haven’t gotten it at all.  The way they see it, they don’t need the vaccine. If they’ve gotten this far without it, why would they need it now?</p><h2>Meeting Early, Lingering Concerns</h2><p>I myself was wary of getting vaccinated at first. I thought those first vaccines came out too fast. They couldn’t be safe. But then my organization did a <a href="https://www.youtube.com/watch?v=QJhk71PLRBk" target="_blank">vaccine education webinar</a> with AMDA, which represents medical directors serving long term care facilities and whose panelists were not only credible but open and respectful. They answered all my questions, so I came out in support of the vaccine and made my declaration to our members.<br></p><p>That’s who CNAs need to hear from: trusted medical experts at their facilities who will listen to their concerns about the vaccines and address them fully and respectfully. Very few administrators have time to do that—and I know, because I used to be a nursing home administrator, too.<br></p><p>I believe that the best way to persuade CNAs is to appeal to their desire to do good and protect others, especially their residents and co-workers. But they need to be heard out, and some of them may need logistical help as well.<br></p><p>Medical directors can play a strong role here. They can do one-on-ones with CNAs, either in person or virtually. They can speak at staff meetings or give webinars. They can be the go-to contact person at the facility for workers who have questions about the vaccines and respond via email or phone or in person.<br></p><p>To fully protect nursing home residents and workers against COVID-19, we need to vaccinate more CNAs. Medical directors of America, we trust you to answer our questions. When can we talk?<br></p><p><em><strong>Lori Porter </strong>is co-founder and chief executive officer of the National Association of Health Care Assistants (NAHCA). She can be reached at</em> <a href="mailto:lporter@nahcacna.org" target="_blank">lporter@nahcacna.org</a>. <br></p> | 2021-06-29T04:00:00Z | <img alt="" src="/Topics/Guest-Columns/PublishingImages/LoriPorter.jpg" style="BORDER:0px solid;" /> | COVID-19;Workforce | Although COVID-19 vaccination rates for certified nurse assistants (CNAs) have increased significantly since the beginning of the year, many CNAs remain unvaccinated, for a variety of reasons. |
| Conducting Thorough Investigations | <p><img src="/Monthly-Issue/2021/June/PublishingImages/DeniseWinzeler.jpg" alt="Denise Winzeler" class="ms-rtePosition-1" style="margin:5px;width:120px;height:156px;" />When a resident at facility A sustained a bruise of unknown origin on his right forearm, the director of nursing services (DNS) completed what she felt was a thorough investigation of the injury. However, during a subsequent facility visit, surveyors did not find evidence the DNS adequately investigated the incident and cited the facility for inadequate investigation.<br></p><p>Does this scenario sound familiar? Inadequately investigating an incident can trigger repercussions, including citations for noncompliance, inadvertently supporting plaintiffs’ legal claims, and, above all, negative effects on the resident’s well-being.<br></p><p>Thoroughly investigating all allegations and incidents is vital to gain facts, prevent recurrence, and maintain resident safety. Facility leaders should implement these tips to ensure their investigations are detailed and thorough.</p><h2>Organization is Key </h2><p>Merriam-Webster defines investigation as a “study by close examination and systematic inquiry.” To inquire systematically and examine all factors thoroughly, organization is key. Facility leaders must plan and prioritize, recognizing that some parts of an investigation will require more time than others.<br></p><p>Often, facility leaders conduct multiple investigations simultaneously, because they know that all allegations and incidents should be reviewed or investigated, not just those confirmed or involving a crime.<br></p><p>An organized approach enables the thorough review necessary for regulatory requirements, even when conducting multiple investigations. The 4-step process below can help facility leadership remain organized so they can conduct thorough investigations.<br></p><h3>Step 1: Determine the purpose for the investigation. </h3><p>The first step of the process is determining the purpose(s) of the investigation and answering, “Why is an investigation being conducted?” Articulating purpose helps guide the investigator to avenues the investigative process should explore. <br></p><p>For example, a bruise of unknown origin investigation may include the following purposes:<br></p><ul><li>To determine why the bruise occurred</li><li>To determine if abuse occurred</li><li>If abuse occurred, to identify the perpetrator for disciplinary action</li><li>To identify other residents who may be similarly affected </li><li>To learn why a bruise of unknown origin was not promptly reported per facility policy.</li></ul><p></p><h3>Step 2: Develop a plan for the investigation.</h3><p>First and foremost, facility leadership must ensure the residents involved or affected are safe. Next, facility leaders should develop an investigation plan by asking:<br></p><ul><li>Were all required entities notified, such as the department of health, local authorities, boards, etc.? </li><li>Who will lead this investigation?</li><li>Will anyone else be needed to assist? </li><li>What evidence should be reviewed? </li><li>Who should be interviewed? </li><li>Who will conduct the interviews? </li><li>Are staff involved, and does that involvement require temporary suspension pending the investigation’s findings? </li></ul><p></p><h3>Step 3: Review tangible evidence and conduct interviews.</h3><p>Relevant tangible evidence may include in-house documents, like medical records, billing statements, staffing records, personnel files, schedules, or policies and procedures.<br>Other documents might come from outside sources, such as hospital or emergency medical service records or police reports. Evidence like camera footage, incident reports, or digital call- light printouts may also be needed to help the investigator determine what happened and the root cause(s).<br></p><p>Tangible evidence to review for a bruise of unknown origin may include:<br></p><ul><li>Resident A’s medical record, including diagnosis, recent diagnostics, nurses’ notes, </li><li>and medication and treatment sheets</li><li>Assessment and observations of </li><li>Resident A</li><li>Incident report</li><li>Visitor log</li><li>Staffing assignments and staff schedule</li><li>Equipment used to aid the resident to ensure it is in working order and does not need repairs</li><li>Assessments and medical records of residents in similar situations, often referred to as “like residents,” to determine if other residents also have similar injuries.</li></ul><p></p><h2>Conduct Interviews</h2><p>Although it may not always be possible, try having two interviewers in each interview, one to ask the questions and another to write the statement or note-take.<br></p><p>It is best practice to have at least one interviewer present for all interviews. This is important for two reasons. First is consistency, so that all interviewees are asked the questions the same way. Second is the need to assess witness credibility, especially if it is one person’s word against another. It may be necessary to interview some people multiple times, especially if there are contradictions. <br></p><p>Before the start of the interview process, the interviewer should have standard questions to ask the interviewees, such as “Have you worked on A wing in the last month?” or “Have you ever cared for Resident A?” After easing into those questions, the interviewer can probe the situation in more detail.<br></p><p>Any residents involved in the incident should be interviewed unless they are semi-comatose or comatose. An investigator might erroneously not interview residents with impaired cognition, believing the impairment prevents the resident from giving any pertinent information. <br></p><p>Generally, this is mistaken. When interviewing residents, the interviewer is trying to determine if the resident perceives they have experienced harm, as well as details that help establish timelines and may identify root causes. Those with cognitive impairment can still contribute their perspective.<br></p><p>The interviewer may wish to consult with corporate staff or legal counsel before interviewing family members and visitors to receive any special instructions on how to conduct the interviews—such as who should conduct it or if the interview should occur with family members separately or as a group. <br></p><p>Each interview should yield a written statement. For people who are interviewed multiple times, prepare a separate statement for each interview and clearly mark each with the date and time. If there are contradictions in the statements, documenting this way will help to show discrepancies.<br></p><h2>Interview More People</h2><p>A common mistake investigators make is not interviewing enough people. Leadership must ensure the interview process is exhaustive and includes all who may be involved, including those who may have witnessed or been affected by the incident. For example, in the bruise of unknown origin scenario, leadership may wish to interview:<br></p><ul><li>Resident A</li><li>Resident A’s roommate</li><li>Like residents</li><li>Staff and volunteers with access to Resident A who worked during the two-week period when the bruise is believed to have occurred</li><li>Visitors who had access to Resident A in the same time period.</li></ul><p></p><h3>Step 4: Conclude and follow up.</h3><p>After reviewing the evidence collected and conducting interviews, the investigator conducts a root-cause analysis. Once the investigator makes a reasonable determination of cause, the facility must follow up to close the investigation. <br></p><p>Follow-up may include completing mandatory reports, such as the facility-reported incident (FRI) sent to the department of health, education needs, disciplinary actions, or policy and process changes.<br></p><p>The nursing home administrator or designee may wish to again consult corporate staff or legal counsel before conversations with family members, especially if the information being relayed is negative. Facility leaders should also inform the medical director of the investigation’s outcome. Then, update the medical record and provide any reimbursement, as necessary, in cases of theft or misappropriation.<br><br>Conducting a thorough investigation ensures no details are missed and that the voices of all involved in the allegation or incident are heard. It also mitigates risk of survey issues, litigation, and recurring safety issues. Facility leaders should prioritize thorough investigations and reassess processes now to avoid the possible repercussions of inaction or inadequacy.  <br><br><strong>Denise Winzeler, BSN, RN, LNHA, DNS-CT, QCP,</strong> <em>is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at <a href="mailto:dwinzeler@aapacn.org" target="_blank">dwinzeler@aapacn.org</a>.<br></em></p><p><em><br></em></p><p style="text-align:center;"><em><a href="http://aapacn.org/" target="_blank"><img src="/SiteCollectionImages/logos/AAPACN.jpg" alt="AAPACN " style="margin:5px;width:235px;height:71px;" /></a><br></em></p><p><em><br></em></p><p><em>References<br></em></p><ul><li><em><a href="https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0018/259011/what_is_a_patient_safety_incident.pdf" target="_blank">Clinical Commission (Australia). (2014). Clinical excellence commission open disclosure handbook: What is a patient safety incident? </a></em></li><li><em><a href="https://www.merriam-webster.com/dictionary/investigate" target="_blank">Merriam-Webster. Merriam-Webster.com dictionary. Retrieved March 23, 2021.</a><br></em></li><li><em><a href="https://www.compliance.com/resources/26-tips-experts-conducting-witness-interviews/" target="_blank">Strategic Management Services LLC. (2015, January). 26 Tips from experts on conducting witness interviews. Compliance.com. </a></em></li></ul> | 2021-06-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/June/PublishingImages/0621_Caregiving.jpg" style="BORDER:0px solid;" /> | Caregiving;Legal | Merriam-Webster defines investigation as a “study by close examination and systematic inquiry.” To inquire systematically and examine all factors thoroughly, organization is key. |
| COVID Highlights Importance of Leadership | <p></p>The COVID-19 pandemic seems to be settling down at the time of writing this article, but no one knows what the future may hold as far as variants, future surges, duration of vaccine immunity, and many other unknowns go. What is known is that COVID-19 has been absolutely devastating in post-acute and long term care centers, first and foremost to residents and their families, but also to staff.<br><div><br></div><div>Providers have also learned some lessons from the pandemic about leadership (and lack thereof) on many levels, about infection prevention and control, and about the courage and dedication their frontline workers have demonstrated.</div><br>It is impossible to express how grateful providers are to their nurse assistants, nurses, and all of the other heroes who have placed themselves and their families at personal risk day after day. <br><div><br></div><div>Probably every reader can appreciate the magnitude of the pandemic’s swath through long term care settings in the United States and worldwide. Even as health care professionals edge back toward normalcy, there will be profound and enduring changes to the way they do things. The full gravity of this pandemic will not be understood and appreciated for years to come. </div><h2>What the Pandemic Revealed</h2>The pandemic has clearly shed light on some of the shortcomings of the current paradigms in long term care. Providers have learned the vital importance of emergency preparedness, robust infection prevention and control measures, and the need for ample personal protective equipment (PPE).<br><div><br></div><div>There have been many calls for an overhaul of the long term care industry and increasing scrutiny on issues of equity, staffing, workforce, and infection prevention and control. </div><br>One lesson some nursing centers and corporations have learned is that medical leadership from the facility medical director can be of immense value. While there has been a federal mandate since 1975 for every nursing center to have a medical director, and while the duties of the medical director have been defined since the Omnibus Budget Reconciliation Act of 1987 (implementation of resident care policies and coordination of medical care in the facility—a tall order), there is huge variability in the extent to which medical directors actually fulfill their duties. <br><h2>The Plus Side</h2>Some nursing centers employ medical directors who demonstrate clear dedication, engagement, knowledge of geriatric medicine and infectious disease principles, and awareness of the complex regulatory framework in which they operate. <br><div><br></div><div>These medical directors for the most part have stepped up throughout the pandemic, helping residents, families, staff, and the administration navigate the difficult, confusing, often frankly contradictory guidance on PPE, cohorting, testing, vaccination, and visitation from a variety of agencies and public health authorities. </div><br>These leaders have helped create and roll out mitigation plans and other policies and procedures to protect their residents and staff and have helped ensure that goal-concordant medical treatments have been provided whenever possible—including attention to comfort and dignity with appropriate advance care planning.<br><h2>Different Approaches, Results</h2>Many medical directors have been in direct contact with survey teams and representatives of local and state public health departments. Many of these dedicated medical directors have also devoted their time and passion to helping educate staff about vaccination, and these efforts have been evidenced in an increased vaccine uptake among staff. <br><div><br></div><div>Conversely, there are medical directors who appear to have little interest in performing their federally mandated duties of implementing resident care policies and coordinating the medical care in their nursing centers. <br></div><div><br></div><div>There have been many tragic consequences of lapses on the part of these medical directors, perhaps none as infamous as what occurred at one nursing center in the northeast, where staff were directed to let symptomatic presumed COVID-positive residents eat in a common dining room with asymptomatic, COVID-negative residents.</div><div><br></div><div>But a common thread in facilities where strike teams from Doctors Without Borders had to come in and assist was that the medical directors of these facilities were largely missing in action.</div><h2>Tightening Ship</h2>Historically, some nursing centers and corporations have sought to retain medical directors who can drive census, such as doctors affiliated with hospitalist groups, Accountable Care Organizations, or other entities. There’s nothing wrong with having a medical director who will refer patients to a nursing center, but that medical director needs to also have some basic competencies, and many do not.<br><div><br></div><div>Other nursing centers have chosen to retain medical directors who have little knowledge or interest in geriatrics or long term care (sometimes retired surgeons or pediatricians) and who will essentially not “make waves” and just sign whatever paperwork they are handed. </div><div><br></div><div>This is no longer going to be acceptable, and this would be a good time to plan ahead to avoid future problems.</div><div><br></div><div>The sheer devastation related to COVID-19 in nursing centers has brought attention to the role of the medical director, and federal authorities are among those taking notice. It is reasonable to expect now that routine surveys are getting underway that there may be more of a focus on the role of the medical director in the Infection Prevention and Control Program and Quality Assurance/Performance Improvement (QAPI), and nursing centers should prepare for this.</div><h2>Value of Certification</h2>So, how does a nursing center find a qualified, competent medical director? One simple strategy is to make certification (available through the <a href="http://www.abplm.org/" target="_blank" title="www.abplm.org">American Board of Post-Acute and Long term Care Medicine</a>,) a requirement for the position, either as a condition of initial hire or as an expectation within a set time frame.<br><div><br></div><div>The Certified Medical Director (CMD) certification requires about 40 hours of continuing medical education specific to the nursing care setting, including more than 20 core areas that encompass clinical, regulatory, bioethical, and other topics.</div><div><br></div><div>California has legislation pending (AB 749) that will require all licensed skilled nursing facilities to engage a medical director who has a CMD certificate within five years, and a handful of other states have similar requirements for minimal credentialing or knowledge.</div><div><br></div><div>Short of the actual certification, nursing centers can also contractually require their medical directors to be members of medical societies like AMDA – The Society for Post-Acute and Long Term Care Medicine and maintain a minimum number of annual educational hours from such organizations that focus on geriatrics and long term care.</div><div><br></div><div>Some facilities also engage an associate medical director (or director of post-acute or a variety of other titles) to assist with quality initiatives, and this can be helpful.</div><div><br></div><div>Considering the high acuity of the case mix these days in most nursing centers, and especially in light of hard lessons learned from the pandemic, this would be an excellent time for all nursing centers to assess their current medical director’s level of dedication, engagement, knowledge base, and accessibility—and if lacking, strongly consider remediation or replacement. </div><div><br></div><div>Nursing centers pay reasonable stipends for these duties and deserve to have qualified, competent medical directors. Their residents, families, and staff deserve nothing less. </div><br><strong>Karl Steinberg, MD, CMD, HMDC, </strong><em>is president of AMDA – The Society for Post-Acute and Long Term Care Medicine. He has been a nursing home and hospice medical director in the San Diego area since 1995 and is chief medical officer for Mariner Health Central and Beecan Health. </em><br> | 2021-06-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/June/PublishingImages/0621_meddirector.jpg" style="BORDER:0px solid;" /> | Management | The COVID-19 pandemic seems to be settling down at the time of writing this article, but no one knows what the future may hold as far as variants, future surges, duration of vaccine immunity, and many other unknowns go. |
| Creating a Behavior Enhancement Program | <p>As more states move increasingly toward the deinstitutionalization of patients from the long-term acute psychiatric setting, post-acute care communities find themselves struggling with the multiple challenges of appropriately managing this population. <br></p><p>This is especially true for those residents who are younger, many of whom have substance use issues, don’t qualify for Medicare, and who are more cognitively intact. This is compounded in some states by less than adequate Medicaid reimbursement for necessary mental health professionals, often resulting in less than adequate services.</p><h2>Other Impediments</h2><p>Poor communication from staff to the mental health team regarding specific targeted behaviors requiring interventions, or poor internal communication to staff regarding the mental health team’s recommendations, presents additional barriers.<br></p><p>With lack of continuity of care and minimal mental health training to the line staff, the interdisciplinary team often finds itself constantly dealing reactively with the fallout from the same repetitive undesirable behavioral patterns rather than proactively identifying and addressing root causes to improve them.<br></p><p>This results in multiple negative outcomes to residents, families, staff, and the long term care community as a whole. Repetitive transfers to a short-term acute psychiatric setting are of no benefit to anyone, especially the affected resident. The other long term care residents and their family members will likely voice concerns regarding the impact of certain resident behaviors. Staff will become vocal, feeling a sense of frustration and lack of support on how to manage these residents. <br></p><p>Fortunately, through commitment and dedication from ownership and the entire facility team, this cycle can be broken. </p><h2>Behavior Enhancement Plan</h2><p>So what are the key ingredients to a successful Behavior Enhancement Program and how does a community implement one?<br></p><p>The best starting point is to establish an interdisciplinary committee consisting of key managers and line staff from all departments, as well as the facility’s mental health professionals and medical director so all team members have input into developing the critical policies and parameters of the program.<br></p><p>It will be vital that this committee remain in place and meet weekly to discuss all program criteria, including policies, assigned staff, staff training monitoring, and specific residents’ behavioral progress. It is highly recommended that a dedicated, secured unit be established for the program for optimum opportunity for success. <br></p><p>The ultimate mission of the Behavior Enhancement Program would be to provide a structured environment that invites resident participation, promotes dignity and respect, and encourages positive behaviors, leading to successful residents “graduating” from the program and being transferred off-unit where they can engage socially in acceptable, meaningful interactions throughout the facility</p><h2>Establishing Standards</h2><p>The interdisciplinary committee will want to establish unit/program admission criteria to include residents with a mental health diagnosis and at least one challenging behavior, as well as a BIMS (Brief Interview for Mental Status) score high enough for the resident to appropriately participate in the program. <br></p><p>Once the admission criteria are developed, the team can then work together to identify residents they feel meet them and who may benefit from the program. Involving residents and their family members throughout the process is a critical factor for success.</p><h2>Staff and Training</h2><p>The team’s next challenge will be to identify line staff who exhibit the right qualities and have the desire to work with this population. As with any specialty program, it is important that only the primary and back-up staff designated and trained to work on this unit are assigned to work there, which will require good communication to the staffing coordinator and off-shift nursing supervisors as well. <br></p><p>The next step is to outline program training requirements to include overall program philosophy and policies, definitions of the basic mental health disorders, and to ensure each team member on all shifts is aware of each resident’s specific targeted behaviors, triggers to those behaviors once identified, and interventions to proactively minimize those triggers from occurring. <br></p><p>This is where a strong relationship between the facility’s mental health team and line staff is extremely beneficial. The clinical team will also be focusing on developing policies regarding critical assessments such as the Trauma Assessment Tool or Functional Assessment Observation Form they may want to implement in order to best document resident behaviors, the interventions implemented, and their rates of success.</p><h2>Recreation Program Options</h2><p>No Behavior Enhancement Program will be successful without a structured, individualized recreation program ideally seven days a week between the hours of 9 a.m. and 8 p.m. Managing residents’ behaviors by providing nursing staff with additional support especially on the 3 p.m. to 11 p.m. and weekend shifts is completely necessary. Various groups can be fused into the recreation calendar. <br></p><p>While psychotherapy groups are highly effective, the benefit of other groups involving team members should not be underestimated. For example, does one of the certified nurse assistants have a musical background and would like to lead a weekly music group for the residents?<br></p><p>Additionally, incorporating residents’ life skills to better engage them can have significant positive effects on behavior reduction. Perhaps one of the residents has a background in maintenance. Assigning the resident basic beneficial maintenance tasks such as identifying stained ceiling tiles and loose handrails and even offering them participation in the facility’s Safety Committee can help reinstate the resident’s sense of self-worth and esteem.<br></p><p>Finally, it is highly recommended that the facility establish behavior session and recreation attendance goals for the residents, offering reasonable rewards of the resident’s choice upon successfully achieving one of these goals, including increasing off-unit privileges per program policy.<br></p><p>Other program considerations may include use of Behavior Contracts, Smoking Program overview, and Alcoholics Anonymous or similar substance abuse support as necessary.</p><h2>Many Benefits</h2><p>There are many post-acute care communities that have placed effort and focus on developing structured, person-centered specialty dementia units/programs for residents with cognitive impairments, and the same can be accomplished for higher-functioning residents who are cognitively intact but with psychiatric diagnoses and behavior challenges as well. <br></p><p>A holistic, well-structured Behavior Enhancement Program will have positive ripple effects on many levels. Significant reduction in behavior transfers can be expected through proactive versus reactive behavior management methods. A decrease in psychotropic medications is also highly likely for a number of participating residents. Other benefits include enhanced collaboration between mental health professionals and the facility team, reduction in staff stress, and diminished resident- and family-related complaints. Increased revenue potential through the patient-driven payment model may be achieved by capturing depression or other related mental health diagnoses, or increased Part A census potential by admitting residents into the program who also have other skilled service needs.<br></p><p>But, most importantly, the greatest benefit is to the residents who realize more positive behavior outcomes, self-worth, and an improved sense of quality of life through participation in a Behavior Enhancement Program. <br><br><strong><img src="/Monthly-Issue/2021/May/PublishingImages/cgiving_RonDenti.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:116px;height:150px;" />Ron Denti, LNHA,</strong> is a nursing home administrator with more than 30 years of experience who has developed the DIAMONDS<sup>©</sup> Behavior Enhancement Program geared toward residents in the post-acute care setting. For more information, go to <a href="http://www.behaviormanagementltc.com/" target="_blank">www.behaviormanagementltc.com</a>.</p> | 2021-05-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/May/PublishingImages/0521-cgiving.jpg" style="BORDER:0px solid;" /> | Clinical | As more states move increasingly toward the deinstitutionalization of patients from the long-term acute psychiatric setting, post-acute care communities find themselves struggling with the multiple challenges of appropriately managing this population. |
| How to Improve Administrator and DNS Relationships | <p><img src="/Monthly-Issue/2021/April/PublishingImages/AmyStewart.jpg" alt="Amy Stewart" class="ms-rtePosition-1" style="margin:5px;width:157px;height:200px;" />The relationship between the administrator and director of nursing services (DNS) has never been more important. Pandemic stress, coupled with increased regulatory scrutiny, has further strained what was already fraught; often, these stressors lead to turnover in one or both positions. <br></p><p>This critical relationship, often compared to a marriage, drives many aspects of care delivery. It affects facility culture because staff want to work on a cohesive team. It eases certification or complaint surveys by providing support. It generates financial benefits when these two collaborate on budget and census goals. And it improves the environment for residents and staff alike when communication between the two is transparent and truthful. <br></p><p>Achieving these results takes focus on the DNS-administrator relationship itself. When time and skill are invested in cultivating the relationship, it can withstand adversity, but if neglected, there can be far-reaching consequences. </p><h3>Improvement on Both Sides</h3><p>Consider this scenario: Joe, who recently started as the administrator, just told Nancy, the long-time DNS, she will need to cut her nursing budget this month. Nancy immediately became defensive, assuming he was saying she must make staffing changes. But, while Joe said she had to lower expenses, he hadn’t said to cut staff. In fact, Joe had wanted to review options with Nancy, but she jumped to conclusions. <br></p><p>Clearly, this does not create a cohesive team. If Nancy had listened carefully before responding, she would have known Joe wasn’t referring specifically to staffing. If Joe had built trust and established clear expectations, or communicated his wish to weigh options together, he could have avoided Nancy’s overreaction.<br></p><p>This scenario is far too common. When such conflicts occur frequently, they create irreparable damage. Below are five ways to improve the DNS-administrator relationship, regardless of tenure in each role.<br></p><h3 class="ms-rteElement-H3B">1. Teamwork Makes the Dream Work</h3><p>A solid foundation is necessary for a long-lasting, trusting relationship. Commit to working together as a team. Although each role has different responsibilities, the two must work together to meet patient outcomes and budgetary goals. <br></p><p>Yet teamwork goes both ways. Connect daily to discuss challenges, successes, and expectations. Start meetings by sharing what was done well before exploring what needs attention. Use reflective listening to understand what the other is saying before responding.<br></p><p>This takes practice. It is easy to let emotions take over, but reflection on the words used is more productive than reaction. Take time to learn each other’s strengths and weaknesses; use those strengths to improve care delivery and the work environment. A foundation of commitment and collaboration between the administrator and DNS will also reinforce teamwork within other departments and their staff. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>When Liz joined a small facility as the new DNS, tensions were high: The facility had recent survey issues, and census was low. Renee, the administrator, met with Liz daily. Renee discussed expectations and reviewed budget and census goals while Liz shared clinical improvements and concerns. By working to understand one another, Liz and Renee built trust and respected each others’ roles. </p><h3 class="ms-rteElement-H3B">2. Healthy Communication Every Time</h3><p>Learn each other’s preferred communication style and use it when possible. Some people prefer face-to-face communication, while others are perfectly happy with email. Whatever the style, remember that words are very powerful, so choose them wisely. Communicate frequently and honestly. Don’t hide issues to keep the conversations “nice and polite.”<br></p><p>Prioritizing communication requires a safe space to discuss tough situations that inevitably arise. Candid conversations are often necessary to improve care. Being truthful and having respect for each other avoids a negative work environment and supports the other’s efforts. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>When Mrs. Smith’s daughter arrived angry and demanded to speak to the administrator about care delivery concerns, Jen, the administrator, was already aware of the situation. She explained measures that had been initiated to improve care, and Mrs. Smith’s daughter felt reassured about how it was being handled. This confrontation could have gone differently if the DNS and administrator didn’t communicate regularly and transparently. </p><h3 class="ms-rteElement-H3B">3. Conflict Resolution that Works</h3><p>It is unrealistic to think that two people will always agree. Be prepared with a plan to overcome conflicts that will arise. It is best to disagree behind closed doors and work together toward resolution. Brainstorm options and discuss them until an agreement is reached. Sometimes, there isn’t a resolution; when that occurs, agree to disagree and move on.<br></p><p>Because the administrator and DNS are the two top leaders in a facility, staff watch the relationship closely. If staff observe disagreements, they may feel compelled to take sides. Don’t let conflict interfere with the facility’s mission and goals. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>Brenda, the administrator, and Amy, the DNS, discussed changing the uniform policy. Brenda wants nurses to wear one color uniform and nurse assistants another so patients know if the person entering the room is a nurse or assistant. Amy doesn’t agree.<br></p><p>Unhappy staff later question Amy about the change. Although Amy doesn’t like it, she explains the rationale fairly. Staff don’t need to know she disagreed, because it won’t change the policy, but could harm the work environment.</p><h3 class="ms-rteElement-H3B">4. Support Each Other</h3><p>There will be days when the stress level is so high that each person cannot be their normal self. Long term care has many stressful challenges, such as surveys, staffing, census, and regulatory change. When stakes are high, be a support system. Recognize when stressors are taking a toll.<br>Many of these challenges are unique to long term care, and no one can understand like the administrator or DNS. When things get tough, lean on each other. Occasionally, share a small token of gratitude to show you value one another. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>Already stressed about staffing, DNS Mike has just been told the survey team has arrived. Soon after, a surveyor asks Mike about an incident, and the conversation goes poorly. Administrator Tom recognizes that Mike’s stress level is increasing and checks on him, bringing a favorite coffee, moral support, and a sympathetic ear. This leaves Mike feeling heard, valued, and appreciated. </p><h3 class="ms-rteElement-H3B">5. Be Goal-Getters </h3><p>It’s easy to set goals, but the DNS and administrator must collaborate to achieve them. Being goal-getters requires a cohesive team. Offer to help one another with individual and mutual goals. When goals are not aligned, attainment becomes more difficult, and both parties become frustrated. However, when the two work together, goals are more easily achieved. And don’t forget to recognize and celebrate successes. </p><h3 class="ms-rteElement-H3B">• Case in Point</h3><p>Kathy, the DNS, proposes an annual goal of being deficiency-free with no complaint surveys. Bob, the administrator, recognizes that this is an ambitious goal and asks Kathy if she might want to consider a more realistic goal, such as fewer complaint surveys and two fewer deficiencies than last year. <br></p><p>Bob shares his census and budget goals and discusses how Kathy could help meet them. He asks her to include goals that increase the staff’s ability to care for medically complex patients, to help meet budget and census goals.<br></p><p>Cohesiveness in the administrator-DNS relationship has many benefits for a facility. Studies have shown that tenure of the two roles is associated with less staff turnover and lower survey deficiencies. It also enables better patient outcomes, as expectations, goals, and communication remain central to the working relationship. When both parties work together to provide the best care in a transparent manner, they can improve this critical relationship. </p><p><br><em>Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, RAC-MTA, is vice president of education and certification strategy at the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at <a href="mailto:astewart@aapacn.org" target="_blank">astewart@aapacn.org</a> <br></em></p><p style="text-align:center;"><a href="http://www.aapacn.org/" target="_blank"><img src="/Monthly-Issue/2021/April/PublishingImages/AAPACN.jpg" class="ms-rtePosition-3" alt="" style="margin:5px;width:200px;height:58px;" /></a> </p><p><em></em></p> | 2021-04-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/April/PublishingImages/0421-mgmt.jpg" style="BORDER:0px solid;" /> | Management;Workforce | The relationship between the administrator and director of nursing services has never been more important. |