We encounter risk every day. Risk is present in the most innocuous actions, like crossing the street, walking into the supermarket, and even eating dinner. And as nursing home operators and providers well know, caring for the elderly is far from innocuous — it’s risky business.
What operators and providers may not realize is how many sources of risk they grapple with on a daily basis.
Risk in a nursing home comes from almost too many sources to name: residents and families, federal and state regulators, vendors, payers, insurance companies, referral sources, partner relationships, plaintiff attorneys, the media. And, though an operator may not like to admit it, some of the risk comes from their staff.
Whatever the source of risk, a poor resident outcome may result in a lawsuit, an allegation of criminal actions, or investigations by any number of higher-ups: state attorneys general, Medicaid fraud control, the Department of Justice, or the Office of Inspector General.
There are 10 things that you can do tomorrow to mitigate risk, beyond the fatherly advice of “be careful.” Let’s review them together.
1. Expect things to happen, and get ahead of them. Aristotle said that quality is not an act, but a habit. Providing a safe environment and safe care is non-negotiable. Start by thinking about your nursing home in terms of its true overall safety. Notice that I didn’t include the phrase “in your survey window.” I didn’t focus on Monday through Friday. I didn’t mention the day shift. Most bad things don’t happen when the lights are shining bright, and staff are striding through the hallways. Over 24 hours a day, 365 days a year, though, there will be times that are riskier than others. So constantly ask yourself: How safe is your facility at its least safe point? Better yet, look at past incidents to determine the riskiest times to be a resident in your building. By expecting things to happen, you will gain insight into how to mitigate them.
2. Sail into problems. Every complaint is a gift, and often a second chance. Be curious when something occurs; don’t neglect the details. Many of us are very skilled at doing root cause analysis — here’s where those skills pay off! Solve the problem at the lowest possible level, meaning at its very core. When a staff member, family member, or resident reports a problem, it should be celebrated.
3. Call with good news. Often, family members only hear from us when we have bad news. That’s unfortunate, because we do many great things with our residents that families are not aware of. Reaching out to share a resident’s accomplishments, even if they seem small, creates a positive record with the family. They’ll trust you more, and when a problem arises, they’ll be more likely to turn to you to solve it versus someone else.
4. Make data your superpower. Start by looking at your facility assessment. How does it inform your budget, staffing and training? What do your Five-Star rating and social media presence tell the community (and potential staff) about your facility and its care? Your public data is manipulated to serve various agendas, but we never talk about how this data can be your superpower and help you tell the best possible story.
5. Read charts. I can feel your grimace, but bear with me! Does the medical record tell a consistent and coherent story about the resident? Do a gap analysis. Are the strengths and weaknesses that were identified on the MDS reflected in the resident’s care plan? Is there documentation to support that the care plan was implemented? Is there documentation about the results of that care? If you are missing documentation, your system is likely asking too much of its caregivers. Honestly, I have never seen a record without missing documentation. But I have seen countless examples of duplicated documentation, and of policies and procedures that exceed state and federal requirements.
6. Put your money where their mouths are. Families (and residents) have always been concerned about food and nutrition over everything else. Therefore, properly investing in food and mealtimes, and in the staff required to support residents’ nutrition, is essential. Easier said than done — but think of the problems you avoid by doing so. Pay careful attention during end of life. We know that forced hydration and nutrition are not only undignified, but cause pain for the dying resident. Family may mistakenly feel that you are “starving” a loved one by not giving them food and water at the end of life. Bring them along on this process and share the evidence that supports this care.
7. Don’t rotate staff. We are in a relationship business. Rotating staff compromises our efforts to build trust, safety, and efficiency. Think about primary care nurse assistant teams. Even with our staffing shortage, maintaining staff should be the goal. It’s the right thing for the residents, it’s the right thing for staff, and it increases safety and efficiency. Even with contract staff, work diligently to ensure the same staff are being sent from the agency. Insist upon it.
8. Put yourself on hold. Look at what your facility’s marketing materials say. Are you overpromising and underdelivering? It is essential that you accurately represent your facility on your website, in social media, and in your marketing collaterals. Call your facility and listen to the outgoing hold message. What does it say, and is it accurate?
9. Stop admissions. If you cannot deliver appropriate care for the residents you currently have, you must stop admissions until you can. Individually, that might mean pausing admissions for certain types of residents where staff competencies don’t exist. Be brave. You may also need to conduct a facility-wide stop, where you carefully assess whether your staffing is adequate to address the acuities in your current resident population.
10. Learn how to apologize. Be impeccable with your word. If you say that you’re going to do something in response to a negative event, you must deliver. Try not to take things personally, but always do your best. Check back with residents and families to see if they are satisfied with how the negative event was handled. This will help you prevent further mistakes.
You can mitigate risk and future losses, but just like crossing the street, nursing home operations will never be free from risk. These 10 actions, however, will reduce a significant volume of risk coming from your nursing home and provide important benefits.
Steven Littlehale is a gerontological clinical nurse specialist and chief innovation officer at Zimmet Healthcare Services Group.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
