A:The three aspects of the emergency preparedness plan most important for the nursing department are: staffing, supplies/resources and communications. Let’s consider each in depth.

During an emergency, staff may be personally impacted and therefore unable to report to work. A recent Office of Inspector General study found that 77% of facilities reporting challenges with preparedness activities rated having adequate staff available in an emergency as most problematic. The DNS will need a plan to ensure adequate staff are available to meet residents’ care needs. Have a list of staff who live near the facility who can come help in an emergency. Also, include in the plan a place to offer rest periods for staff unable to leave the facility. 

During an emergency, the facility can lose access to resources and supplies. Loss of power, water or heat may involve backup resources,such as generators, or require patient transfers. The DNS should ensure the facility will have adequate resources, even in a disaster.

Stocking up on supplies is another important aspect. The facility will need backup inventory for water, food and medical supplies, and weather-related events like snow storms or hurricanes can delay deliveries for days or weeks. 

Facilities also need to inform family members and staff how the facility is handling an emergency. In advance, develop a communication plan and assign someone to oversee it. Test the plan before a real emergency occurs.

Facilities in areas at high risk for natural disasters may need to review plans more than once a year. Community outbreaks  also can constitute emergencies, so monitor risk. As that risk increases, review plans before they must be implemented. 

A: This fall and winter, facility staff may face outbreaks of several respiratory illnesses, including influenza, respiratory syncytial virus (RSV) and COVID-19. 

Nurse leaders, with the help of the infection preventionist, should start by re-educating all staff on hand washing and hand hygiene. To ensure compliance, have a plan for auditing hand hygiene. Keep “Clean Hands Count” posters from the Centers for Disease Control and Prevention posted prominently and remind staff frequently of hand hygiene’s importance. 

Educating residents and staff about cough etiquette also will help decrease the spread of respiratory illnesses.

Also teach staff signs and symptoms of influenza, RSV and COVID-19 so they can report them. When individuals present with respiratory illness symptoms, follow standard and droplet precautions to limit the spread. Maintain precautions for seven days after the onset of illness or 24 hours after the resolution of a fever, whichever is longer. Allow staff to stay home when sick. 

The facility also can prepare by stocking up on personal protective equipment  and reviewing proper donning and doffing with staff. An ample supply can help contain outbreaks — if used correctly. 

Lastly, educate and offer vaccines. Influenza, RSV and COVID all have vaccines available. Ensure that the facility has them on hand and is offering them to eligible individuals to help prevent the spread of illness. Make sure nursing staff understand proper vaccine storage to maintain the efficacy of the vaccine. 

Having a plan in place to identify and respond timely to respiratory illnesses will assist in mitigating the scale of the outbreak and can help ensure the safety of residents and staff.

A:The Centers for Medicare & Medicaid Services form CMS-20058, QAPI and QAA Pathway, which surveyors use, is a great way to structure staff QAPI education so it includes all necessary components. 

Staff must be engaged in the QAPI efforts and understand what QAPI efforts the facility is working on and why. Nurse leaders could post this information in the break room or provide it during staff meetings, being sure to identify a contact for questions on quality improvement efforts. 

Once staff understand what QAPI is and how the facility is implementing it, there are many ways to increase participation. First, highlight avenues to raise concerns  about processes or policies. Often, staff see potential issues before problems occur, but they must feel safe to share those issues.

Emphasize that all ideas and concerns are welcome so that facilities can make changes before problems occur. Consider designating a place where staff can submit comments and concerns about quality issues if they are uncomfortable coming directly to leadership. 

During the QAPI process, solicit staff feedback regarding changes that affect them. Staff can provide valuable input by helping test, sustain and reflect on changes. Since staff are closest to the work, they can advise on whether changes in practice work. Staff also can help monitor data trends. For example, the restorative nurse may be able to identify in real time any changes in activities of daily living so the facility can introduce interventions to mitigate further declines. 

Staff participation is a key component of a successful QAPI program. Look for ways to involve staff members at every step of the process. 

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com.

A: Providing a reconciled medication list to subsequent providers or the resident/caregiver improves care coordination and decreases adverse events. Beginning with fiscal year 2024 (Oct. 1, 2023), the MDS-collected current reconciled medication list will inform the SNF QRP Transfer of Health Information quality measures. 

When preparing for this change, first consider who will provide the list at the time of discharge. Educate these individuals on how to deliver and document this information. The MDS offers several options for route of delivery, including electronic health record, health information exchange, paper-based, text or email.

It can be verbal, in writing, or both, but the person providing the reconciled medication list must know how to deliver it. If the information is going to the subsequent provider, clarify the provider’s preferences for receipt. If the information is going to residents or caregivers, consider how they learn best. Health literacy may affect routes of transmission. When communicating, use language that the resident or caregiver understands. 

Some residents may not be on any medications, prescribed or over-the-counter. If so, document this in the medical record and code the MDS as yes, the current medication list was provided. If the facility does not give a current reconciled medication list, the discharging nurse should document the reason.

In summary, it is critical that you review your current process, revise policies, educate on new processes, and document delivery of current reconciled medications upon discharge. 

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com.

A: Fraud is deception intended to result in financial or personal gain. It includes false representations, false statements or concealing information. The Office of Inspector General maintains a website and hotline where the public can submit complaints and report suspected fraud. 

The RAI User’s Manual offers definitive guidance. To seek payment, conditions must be coded accurately — which includes meeting all criteria from the instructions. If circumstances do not satisfy all criteria, do not code them.

For example, if a resident does not satisfy all four criteria for isolation, knowingly coding isolation to achieve a higher case-mix classification would constitute fraud. Alternatively, asking a physician for an unsupported diagnosis to exclude the resident from a quality measure could also be fraud. Both scenarios involve presenting false representations for gain. 

The MDS attestations require individuals coding the MDS to sign. The RAI manual states, “Legally, it is an attestation of accuracy with the primary responsibility for its accuracy with the person selecting the MDS item response.” It warns those signing that “the information you entered on the MDS, to the best of your knowledge, most accurately reflects the resident’s status. Penalties may be applied for submitting false information.” 

Human error occurs and coding discrepancies do happen. When an MDS inaccuracy emerges, follow the RAI User’s Manual instructions. It requires modification of that MDS within 14 days of discovery. Concealing errors to avoid repayment would be another form of fraud.

Whether an intentional falsehood or a concealed mistake that goes uncorrected, presenting false information for gain constitutes fraud. 

Amy Stewart, MSN, RN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, is vice president of education and certification strategy for AAPACN. Send her your nursing questions at ltcnews@mcknights.com.

A: Social isolation is a self-reported social determinant of health item coming to the Minimum Data Set this October. Section D responses range from “never” to “always,” with options if the resident is unwilling or unable to respond. 

Social isolation refers to lack of social contact with others. One-fourth of adults over 65 are socially isolated, according to NASEM. Loneliness is the feeling of being alone, regardless of social contact. 

The Centers for Disease Control and Prevention warns that social isolation and loneliness increase serious health risks, including risk of premature death. They also increase healthcare utilization. Chemical restraint, fall incidence, incontinence and feeding tubes increase residents’ risk for social isolation. 

When residents self-disclose social isolation, develop a care plan to mitigate or eliminate associated risks. Care planning for social isolation requires in-depth analysis of a resident’s experience, contributing factors and associated risks. Consider residents’ social networks, individual relationships’ strength and psychosocial functioning. 

Care planning should cover both a stay and after discharge. For residents lonely in the facility, invite them to activities they enjoy. If preferred activities aren’t available, try to incorporate them. For example, residents accustomed to a daily walk may enjoy a restorative walking program. When discharge planning, emphasize interventions such as visits from family, friends, clergy, or community groups.  

Because social isolation has such a significant impact on health risks, addressing it effectively positions residents for wellness both during and after their stays in a facility.

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com.

A: When transitioning care, the first step is ensuring the next provider can adequately care for the patient. Make sure any home health partner can see the patient soon after discharge, preferably within 24 to 48 hours. 

Home health agencies also must have enough information and resources to meet the patient’s needs. You’ll need to verify equipment, medications, treatments and follow-up appointments. 

Durable medical equipment. Ensure equipment is ordered and has been or will be delivered. This includes items like wheelchairs or beds, but it may also include medical devices for treatment. 

Medications. Upon discharge, ensure  home health receives the medication reconciliation. Additionally, ensure patients can get their medications, noting any finance or transportation issues. Address this prior to discharge and express any concerns to the agency. 

Treatments. Ensure supplies have been ordered and delivered. Wound supplies, nebulizer supplies, CPAP/BiPAP supplies, blood glucose monitoring supplies and more may be necessary in the home. 

Follow-up appointments. When possible, schedule and alert home health to any follow-up appointments. Making the appointments for the patient improves chance of attendance. Ensure the patient has transportation or arrange it. 

Finally, call the patient and/or caregiver within 48 hours to ensure home health has seen them. Confirm the patient has received all the above items and answer follow-up questions. Easing the transition can assure needed care continues even after the patient leaves your facility.  

A: Facility-wide assessments determine the resources necessary to care for residents competently. Yet information from the facility assessment also can help improve resident care and outcomes. 

For this question, let’s focus on one required item: resident-level information, such as diseases, conditions, physical and cognitive disabilities, and overall acuity. This one item can inform multiple decisions regarding facility resources.

Budget-use — Facility assessments might prompt adjustments for resources such as the number and type of staff, equipment and staff education costs. For example, if the assessment shows a high volume of wounds, a facility might invest in a certified wound nurse, who could educate on wound care and treatments. 

Education — Apply resident diagnosis information to competency-based educational offerings for all staff. For example, if 60% of residents have a diagnosis of depression, provide staff education on depression. Similarly, review facility-acquired infections and have the infection preventionist develop education on preventing these types of infections.

QAPI — Compare the facility assessment to that of previous years. Look for trends that may merit a performance improvement plan. Decreasing infections, wounds, falls, weight loss and behaviors all improve resident outcomes. 

Annually reviewing the facility assessment can yield information that helps facility leaders tailor care delivery. Using that information as a planning tool to assist with budgeting, education and QAPI efforts provides an opportunity to care not only competently, but in a way that also improves resident outcomes.

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com. 

A: The interrupted stay policy applies when a resident on a Medicare Part A stay discharges from a SNF and resumes skilled care in the same SNF for a Part A-covered stay during the
interruption window.

That window is the three-day period starting with the first day of the Part A discharge and including the two following calendar days. If a resident on a Part A stay discharges from Part A, the resident must resume Part A services by 11:59 p.m. of the third consecutive non-covered day to constitute an
interrupted stay.

If the resident remains in the facility after Part A services end and skilled services resume before 11:59 p.m. on the third non-covered day, it is an interrupted stay. Since there was no physical discharge, no new assessments are required.  However, if the Part A stay ends due to physical discharge and the resident returns for skilled services before 11:59 p.m. on the third non-covered day, OBRA discharge and entry tracking records are required. A PPS discharge assessment is not. In either instance, the nurse assessment coordinator and team should consider an optional Interim Payment Assessment. 

If the resident returns for skilled services after the third day, it is not an interrupted stay; OBRA and PPS discharge assessments are required. Upon return, an entry tracking record and a new 5-Day PPS assessment are required. Subsequent OBRA assessments depend on the type of discharge. If a return is anticipated, the assessment schedule continues where it ended. If a return is not anticipated, a new OBRA Admission assessment is required; it can combine with the 5-Day PPS assessment. 

Q: Recently, there has been an increase in the number of staff who like to cause drama and gossip. I can’t afford to lose workers. What can I do?

A: Managers are often concerned that if they intervene to stop gossip and drama, employees will quit. But when managers avoid confrontation, trust in the manager erodes. Further, productivity decreases, and staff become anxious and unhappy in a hostile work environment. Caring employees quit and the instigators of incivility remain only to repeat the behaviors.

The first step to stop the cycle is to develop relationships with staff and demonstrate acceptable behavior. Modeling professional behavior sets the example for others to follow but also sets accountability standards. Managers must never engage in gossip or drama themselves. If they do, they lose all credibility.

When gossip or drama occurs, take swift action. Meet with responsible staff individually. Determine why they are acting out. Gossip is often driven by emotions, a lack of problem-solving ability and limited conflict resolution skills. Knowing underlying reasons for uncivil behavior, a manager can help an employee formulate a professional response.

It’s also important to explain that the employee’s behavior negatively impacts residents and co-workers, and it undermines the organization’s mission. Make it clear that this type of behavior will not be tolerated. If the employee needs help to address a problem, they should seek help from management.

If an individual causing drama refuses to change, the manager must follow the organization’s policy to terminate. By addressing the issue, managers gain trust and respect and provide a pleasant, fun work environment.

Amy Stewart, MSN, RN, RAC-MT, RAC-MTA, DNS-MT, QCP-MT, is vice president of education for AAPACN. Send her your nursing-related questions at ltcnews@mcknights.com.