| Treating Trees as Medicine in a World of Lockdowns | <p><img src="/Topics/Guest-Columns/PublishingImages/2021/Masonic-Campus-Photos-90.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:300px;height:194px;" />March 2020 is a time that no one will soon forget. The fundamental way people lived their lives changed overnight, as all across the world people collectively went into lockdown to prevent the spread of COVID-19. As people were urged to stay home, particular caution and care were afforded to those who were deemed especially susceptible to the virus: the immunocompromised, frontline workers, and, of course, the elderly. <br></p><p>Health care facilities reacted swiftly to lockdown and secure their campuses in a conscious effort to protect their vulnerable populations. Nursing homes and assisted living communities have had a challenging time during the pandemic, as these facilities rely on a consistent flow of volunteers and family members visiting the residents.</p><p>Suddenly the residents found themselves cut off from the rest of the world, and these facilities had to find ways to help them adapt. They had to work to find new ways to keep their residents’ minds engaged and uplifted throughout the lockdown. </p><p>Masonic Homes Kentucky’s Louisville Campus turned to an unexpected outlet of healing and comfort during this time: Trees.</p><h3 class="ms-rteElement-H3B">About Masonic Homes’ 82-Acre Arboretum</h3><p><span><img src="/Topics/Guest-Columns/PublishingImages/2021/Masonic-Campus-Photos-311.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:150px;height:225px;" /></span>Trees and the green spaces the trees create play a massive role in the landscape for Masonic Homes Kentucky. In particular, the Louisville Campus was designed in 1927 by renowned landscape architectural firm, The Olmsted Brothers.</p><p>It was established by the sons of the landscape architect Frederick Law Olmsted who is best known for his work in designing the grounds of New York City’s Central Park, the U.S. Capitol in Washington, D.C., and the Biltmore Estate in North Carolina. </p><p>“Masonic has taken great care and consideration to preserve elements of the original design and to replicate it whenever possible,” says J Scott Judy, chief executive officer, Masonic Homes Kentucky.</p><p>“One of the many beauties of Kentucky is the changing of its seasons. Masonic’s parklike setting offers four miles of paved walking paths that intertwine the historic and the contemporary community buildings.”</p><p>The Masonic Homes Kentucky community hires certified professional grounds staff who are responsible for all of its three campuses, each with its own unique landscape. These professionals understand trees and green landscapes as an investment in the well-being of the residents and staff of the communities. </p><p>In addition, the Louisville Campus will soon add walking paths that will line the campus to help encourage employees and residents alike to spend more time outside.</p><h3 class="ms-rteElement-H3B">Recognized By Arbor Day</h3><p>Masonic Home Louisville is recognized as a Tree Campus Healthcare facility to highlight its dedication to trees and nature. Tree Campus Healthcare is a program of the Arbor Day Foundation, the world’s largest membership nonprofit dedicated to planting trees.</p><p><img src="/Topics/Guest-Columns/PublishingImages/2021/Masonic-Campus-Photos-99.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:199px;height:299px;" />Launched in 2019, Tree Campus Healthcare is one of the newest recognition programs from the Arbor Day Foundation that aims to recognize any health care facility purposefully using trees and green spaces to promote good health and well-being for its employees and occupants.</p><p>For Masonic Home Louisville, its designation as a Tree Campus Healthcare facility serves as an opportunity to remind its leadership to continue investing in these types of greening projects and as a general reminder for everyone of the close relationship nature can have for the care and healing of residents. <br></p><h3 class="ms-rteElement-H3B">The Healing Benefits of Trees</h3><p>Trees can help more than just the environment; they help with human health. Research shows that patient recovery improves when there is interaction and incorporation of green spaces, gardens, and parks. Natural areas help patients reduce stress, help restore physical health, and shorten the overall recovery process, according to R.S. Ulrich, reporting in Science magazine. <br></p><p>Spending time outside in hospital gardens is highly beneficial for the patient and additionally, hospital window views of natural scenes have been shown to reduce post-operative hospital stays. Having trees on a health care campus is a natural partnership. </p><p>“Outdoors is a respite for so many residents during the pandemic,” says Judy. “The vast grounds offered residents a safe sanctuary to enjoy fresh air, exercise, and beautiful scenery while allowing social distancing.”</p><p>To curb the risk of exposure during the pandemic, the facility decided to close its campus to all nonessential visitors. However, Masonic Home Louisville took a creative approach to share the beauty of its facility campus. It created a virtual landscape tour, which highlighted unique trees and interesting landscaping. The trees and green spaces served an essential purpose for the residents and staff: They provided hope during the lockdown.</p><p><img src="/Topics/Guest-Columns/PublishingImages/2021/Masonic-Campus-Photos-July-2019-68.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:288px;height:197px;" />It is evident that trees are a priority for the Louisville Campus, but the community ultimately prides itself on its commitment to caring for its residents. Masonic Home Louisville is not only a Tree Campus Healthcare facility, but it is also part of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).</p><p>The facility enjoys being a member of the association because of the relationships cultivated and the resources provided. AHCA/NCAL’s values encouraged Masonic Homes Kentucky to rise above and beyond the regular standard of care for its residents, even if it means extra care routinely given to maintaining and cultivating the landscaping and greenery of the grounds. <br></p><p>Little did Masonic Home Lousiville know that this dedication and love of nature would provide a safe space, six feet apart.</p><h3 class="ms-rteElement-H3B">Make Trees a Priority </h3><p><img src="/Topics/Guest-Columns/PublishingImages/2021/Village_Adams-Hall.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:277px;height:190px;" />More
trees mean more benefits for everyone. Trees take care of the air,
water, and wildlife everywhere they exist. Trees are considered the
lungs of the earth because they take in carbon dioxide and release fresh
oxygen. Trees help reduce urban runoff and the amount of sediment,
pollutants, and organic matter that reach streams.</p><p>Planting trees
is also a great way to encourage local biodiversity in urban
communities. The list of good things trees accomplish can go on and on,
but the message is the same: Trees deserve to be a higher priority on
everyone’s list.</p><p>To learn more about the Arbor Day Foundation’s Tree Campus Healthcare program, go to <a href="https://www.arborday.org/programs/tree-campus-healthcare/" target="_blank">arborday.org/programs/tree-campus-healthcare/</a>. </p><p><img src="/Topics/Guest-Columns/PublishingImages/2021/LoganDonahoo.jpg" class="ms-rtePosition-2" alt="Logan Donahoo" style="margin:5px;width:140px;height:140px;" />As program manager, Logan Donahoo leads the Tree Campus “family” of recognition programs at the Arbor Day Foundation, which includes Tree Campus Healthcare. In her role, she focuses on growing participation in each program, creation of resources for program participants, and cultivation of relationships with collaborating organizations and networks. Donahoo can be reached at <a href="mailto:ldonahoo@arborday.org" target="_blank">ldonahoo@arborday.org</a>.</p><p><br></p> | 2021-11-30T05:00:00Z | <img alt="" src="/Topics/Guest-Columns/PublishingImages/2021/700_3576.jpg" style="BORDER:0px solid;" /> | COVID-19;Caregiving | March 2020 is a time that no one will soon forget. The fundamental way people lived their lives changed overnight. |
| Common PDPM Missteps and How to Avoid Them | <p><img src="/Monthly-Issue/2021/October/PublishingImages/JenniferLaBay.jpg" alt="Jennifer LaBay" class="ms-rtePosition-1" style="margin:5px;width:145px;height:186px;" />In October 2019, the Patient-Driven Payment Model (PDPM) became the new payment methodology for Medicare Part A residents in skilled nursing facilities (SNFs). Although PDPM has been in effect for two years, the public health emergency may have temporarily shifted priorities for some facilities.<br></p><p>This temporary shift, combined with PDPM’s relative newness and recent staff turnover, may have significantly affected Medicare revenue over the past 18 months.<br></p><p>Here are three common missteps that may be impacting a facility’s Medicare reimbursement.<br><br><em>1. Managing the Assessment Reference Date (ARD)</em><br>The Medicare 5-Day assessment has an ARD range of Days 1-8 of the SNF Part A-covered stay. Nurse assessment coordinators (NACs) who insist on using Day 8 as the ARD for all 5-Day assessments may not capture all the services or conditions that impact Medicare revenue.<br></p><p>Since payment is no longer based on therapy minutes, facilities may benefit from finessing their ARDs to ensure documentation is in place to capture key services and diagnoses. The ARD for the 5-Day assessment must be set on a Minimum Data Set (MDS) form or in the MDS software no later than 11:59 p.m. on Day 8 of the Medicare stay. Once that time and date passes, the ARD cannot be changed, but until that point, it can be adjusted.<br></p><p>Ideally, on Day 8, the NAC should be completing a full chart review, including preadmission records, to determine the care and services that were provided. Using the calculation worksheets in chapter 6 of the “Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual,” the NAC can determine the optimal ARD to capture the care and services, which will result in the best PDPM case-mix groups (CMGs).<br></p><p>Choosing Day 8 as the ARD instead of Day 2 could make a difference of hundreds of dollars per day, depending on what services were delivered and diagnoses assigned during the observation period.<br></p><p>Some examples of missed opportunities related to improper ARD selection include:<br></p><ul><li>Not capturing cognitive impairment under the Speech-Language Pathology (SLP) component can occur when the Brief Interview for Mental Status (BIMS) is not conducted during the look-back period. If BIMS was completed on Day 1 of the stay and the ARD selected is Day 8, the BIMS is outside of the range for inclusion on the MDS.</li></ul><p>Per RAI manual instructions, page C-2, “Item C0100 must be coded 1, Yes, and the standard ‘no information’ code (a dash ‘-’) entered in the resident interview items. Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted but was not done.”<br></p><p>Preferably, the BIMS should be completed on the day of or the day before the ARD. Staff must be aware of all services that have been provided each day so that an ARD can be selected for a timely completion of the interview.<br></p><ul><li>Not capturing IV fluids or parenteral feeding from the hospital will impact the Nursing component of PDPM. Calculation for the Special Care High CMG comes from a 7-day look-back for both while a resident and while not a resident. If these services were received in the hospital, it may be beneficial to choose an earlier ARD to capture the IV or parenteral feeding.<br></li></ul><p><em>2. Assigning Primary Diagnosis Codes</em><br>Part of PDPM accuracy is ensuring the appropriate primary diagnosis is selected in section I0020B of the MDS. Some common diagnoses that have historically been used as a primary reason for admission to a SNF that, per the Centers for Medicare and Medicaid Services, will not map to a billable clinical category include weakness, failure to thrive, falls, and altered mental status. All of these calculate as return to provider (RTP) diagnoses in the PDPM ICD-10-CM mapping tool.<br></p><p>RTP diagnoses do not reflect care and services that would meet the skilled coverage criteria outlined in chapter 8 of the “Medicare Benefit Policy Manual” and will not generate a CMG. This may lead to payment at the default rate or, worse, provider liability. When this occurs, facilities need to dig deeper and query the physician or non-physician providers (NPP) about the cause of these conditions. <br></p><p>The better clinicians understand the nature of the problem, the better resident care will be, and the more accurate the payment category. It is important for the SNF team to discuss as a group before and after admission to ensure the medical record and MDS reflect the true reason for all skilled care. If there is no underlying cause found, the resident may not meet Medicare skilled coverage criteria. <br><br><em>3. Assigning Additional Diagnosis Codes</em><br>In addition to the Primary Diagnosis at I0020B, which affects the Physical Therapy (PT), Occupational Therapy (OT), and SLP components, the additional diagnoses in section I of the MDS may impact the SLP, Nursing, and Non-Therapy Ancillary (NTA) components as well. Unlike I0020B, diagnoses coded in sections I0100 – I8000 do not have to follow the clinical category map with the RTP restriction.<br></p><p>However, facilities do still need to use the ICD-10-CM map. SLP and NTA comorbidities captured in I8000 must be cross-referenced with the corresponding tabs in the ICD-10-CM mapping tool to determine if the criteria have been met for capturing the comorbidity in the PDPM CMG.<br></p><p>Another requirement for capturing the diagnosis in section I of the MDS is that the diagnosis must be documented in the medical record by the physician or NPP within 60 days of the ARD and must be active in the 7-day look-back period (excluding UTI, which must be active in the last 30 days).<br></p><p>If the medical record suggests a historical diagnosis, but there is not proper documentation from the provider during the look-back period, it is beneficial to use a later ARD to allow time for the provider to include this documentation in the medical record. <br></p><p>Some common PDPM missteps related to ICD-10-CM coding include:<br></p><ul><li>Assigning a primary diagnosis that affects only one discipline instead of the overall skilled needs of the resident. For example, PT, OT, and nursing are treating removal (explantation) of hip joint, which maps to Orthopedic Surgery, while nursing is treating complication of infected hip joint, which maps to Acute Infections. Because most of the skilled care is provided to treat the explantation of the hip, that should be captured as the primary diagnosis.</li><li>Not capturing a diagnosis such as septicemia that is active at the beginning of the Medicare stay. An earlier ARD could allow capture of an active diagnosis from the hospital.</li><li>Not querying the physician or NPP for diagnosis clarification when the diagnosis is only listed in past medical history. For example, a history of cerebrovascular accident (CVA) with no residual deficits identified may miss clinically present sequelae (neurologic deficits).</li><li>Not capturing section I diagnoses correctly. Some NTA comorbidity points are assigned by section I0100 - I7900 checkboxes and others by I8000 ICD-10-CM codes. For example, coding Diabetes Type 2, E11.9, in I8000, will not accrue NTA points. MDS item I2900 for diabetes must be checked.</li></ul><p>NACs must diligently apply all the rules of PDPM, MDS, and ICD-10-CM coding. Understanding the “RAI User’s Manual” instructions and ICD-10-CM coding guidelines is essential to PDPM accuracy and success. <br><br><em><a href="mailto:jlabay@AAPACN.org" target="_blank">Jennifer LaBay,</a> RN, RAC-MT, RAC-MTA, CRC, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). </em><br></p> | 2021-10-01T04:00:00Z | <img alt="" src="/Monthly-Issue/2021/October/PublishingImages/1021_mgmt.jpg" style="BORDER:0px solid;" /> | Management | Nurse assessment coordinators must assign each patient’s assessment reference date to capture key diagnoses that impact Medicare revenue. |
| High-intensity Resistance Training in Post-Acute Care Produces Better Outcomes | <p></p><p>Results of a study by researchers from the University of Colorado Anschutz Medical Campus show that high-intensity rehabilitation training for older patients in skilled nursing facilities can safely and effectively accelerate improvements in their function, enabling them to return home sooner. The study was published in <em>Physical Therapy</em>, October 2020.<br></p><p>Skilled nursing facilities provide medical and rehabilitation services to individuals post-hospitalization to help facilitate the transition to home or the next level of care. However, research has shown the trajectory of functional recovery following hospitalization and skilled nursing stay care is generally poor, with fewer than 25 percent of patients returning to pre-hospitalization levels of function. </p><h2>How the Study Worked</h2><p>“Our study identified an impactful opportunity to improve the way we care for patients in skilled nursing facilities,” said lead author Allison Gustavson, PT, DPT, PhD, at the CU Anschutz Medical Campus. “Our findings demonstrate that high-intensity resistance training is safe, effective, and preferable in caring for medically complex older adults in skilled nursing facilities.”<br></p><p>The study split 103 participants into two nonrandomized independent groups—usual care and high-intensity care—within a single skilled nursing facility. For both groups, physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge.</p><h2>Results of the Study</h2><p>For the high-intensity training group, the physical therapists used the i-STRONGER program (Intensive Therapeutic Rehabilitation for Older Skilled Nursing Home Residents).<br></p><p>The patients participating in the high-intensity program benefited by increasing their functional independence, as evidenced by a significant and clinically meaningful increase in their walking speed from evaluation to discharge by 0.13 meters/second more than the usual care group. This is a critical outcome for this patient population, as improvements in walking speed greater than 0.1 meters/second are associated with reduced mortality.<br></p><p>Also, the patients’ stay at the skilled nursing facility was reduced by 3.5 days.</p><h2>Implications for Future Rehab Approaches</h2><p>Based on their findings, the researchers advocate the need to increase the intensity of rehabilitation provided to patients with medically complex conditions to promote greater value and patient experience within post-acute care. <br></p><p>“Our study shows that the quality of rehabilitation compared to the quantity drives better outcomes,” said Principal Investigator Jennifer Stevens-Lapsley, MPT, PhD, FAPTA. “These findings provide a timely solution to address rehabilitation value in the context of recent post-acute care changes by policymakers who are looking to raise the bar on the quality and efficiency of post-acute care services,” she said.<br></p><p>“We are eager to support the transition to this safer and more effective high-intensity care approach,” said Stevens-Lapsley, a professor and director of the Rehabilitation Science PhD Program at the CU Anschutz Medical Campus.<br></p><p>“We are encouraged by the results that accelerated the improvement in patient function, created positive patient and clinician experience, and resulted in less time needed for care in the skilled nursing facility,” she said.<br></p><p><img src="/Topics/Special-Features/PublishingImages/2021/1021/LaurenHinrichs.jpg" alt="Lauren Hinrichs" class="ms-rtePosition-1" style="margin:5px;width:170px;height:216px;" />The University of Colorado has partnered with the American Health Care Association to offer a CEU-credited High-intensity Resistance training program. For those interested in learning more about the research or training or for implementation support, contact Lauren Hinrichs or visit <a href="http://www.movement4everyone.org/" target="_blank">www.movement4everyone.org</a> for more information. <br><br><em>Lauren Hinrichs, PT, DPT, OCS, board-certified in orthopedics, is a Rehabilitation Science PhD student with the Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine. She can be reached at </em><a href="mailto:lauren.hinrichs@CUAnschutz.edu" target="_blank"><em>lauren.hinrichs@CUAnschutz.edu</em></a><em>.</em><br></p> | 2021-10-01T04:00:00Z | <img alt="" src="/Topics/Special-Features/PublishingImages/2021/1021/SF_intensity.jpg" style="BORDER:0px solid;" /> | Clinical;Diet | Researchers advocate the need to increase the intensity of rehabilitation provided to post-acute patients to promote greater value and patient satisfaction. |
| 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. |