Nurses who practice in long-term care facilities, along with those with aging parents — often one and the same — want information to help them care for patients and their aging parents. They need to know how quality is monitored and maintained and how inspections are conducted in nursing homes. Long-term care nurses need not fear the survey process. Staff, residents, families, and surveyors all have the same goal — providing quality of life and quality of care. A 2007 survey of consumer satisfaction in nursing home care focused on 22 individual survey items and the top 10 rankings based on correlational analyses between responses.1 The results showed that what mattered most to nursing home residents was —
- Care and concern of staff
- Competency of staff
- Quality of nursing care
- Quality of nursing assistant care
- Respectfulness of staff
- Safety of facility
- Responsiveness of management
- Adequate staff to meet needs
- Commitment to family updates
What mattered most to families of residents was —
- Care and concern of staff
- Competency of staff
- Quality of nursing staff
- Quality of nursing assistant staff
- Respectfulness of staff
- Adequate staff to meet needs
- Safety of facility
- Responsiveness of management
- Attention to resident grooming
In 1999, U.S. staff provided care for about 1.5 million residents in 16,500 nursing homes, which had an occupancy rate of about 83%.2 In 2006, there were 1.4 million residents in 15,900 nursing facilities.3 To ensure safety in these facilities, life-safety departments (depending upon the state) and local fire departments inspect them on a regular basis. To maintain state licensure and federal certification in most states, facilities participating in Medicare and Medicaid programs undergo inspection by surveyors operating under state regulatory agencies. Federal surveyors, working for the Centers for Medicare & Medicaid Services (CMS), use follow-up surveys to monitor state surveyors, randomly selecting 10% of the facilities and those with histories of problems, major citations, and zero deficiencies. The goal of both surveyors and staff is to ensure the quality of residents’ lives.
Before the passage of the Omnibus Budget Reconciliation Act in 1987, state surveyors spent much time reviewing policies and procedures.4 Now, in a detailed hands-on process, a team conducts inspections that concentrate on residents’ rights, quality of life, and quality of care.
Teams consist of RNs, social workers, and specialty surveyors (registered dietitians, pharmacists, and occasionally physicians). Specialty surveyors may be on-site only during that portion of the survey dealing with their area of expertise.5 To inspect an average, 120-bed facility, four or five inspectors work with a team coordinator. All surveyors are trained to perform the same tasks with the exception of skin checks and incontinence care checks. Only a nurse can perform these tasks. In the absence of a pharmacist, the nurse will also observe medication administration. The standard survey is the main inspection conducted yearly as mandated for renewal of federal certification. It is a resident-centered, outcome-oriented survey that relies on a case mix-stratified sample of residents to gather information about the facility’s compliance with participation requirements. The survey assesses a facility’s compliance with residents’ rights and quality of life, as well as the accuracy of residents’ comprehensive assessments and the adequacy of care plans based on these assessments. It also looks at the quality of care and services, measured by indicators of medical, nursing, and rehabilitative care and drug therapy; dietary and nutrition services; activities and social participation; sanitation and infection control; and effectiveness of the physical environment to empower residents, accommodate resident needs, and maintain their safety. In addition, inspectors conduct extended surveys if substandard quality of care is determined during a standard survey. They also conduct abbreviated standard surveys that focus on particular tasks after receiving complaints or after a change of ownership, management, or director of nursing. If, after an abbreviated standard survey or revisit, substandard quality of care is found and not previously identified, a partial extended survey is always conducted. To verify correction of deficiencies cited in a prior survey, a post-survey revisit or follow-up is conducted.5
Surveyors and their supervisors work out of a regional state government office. Several days before an annual standard survey, the team coordinator collects forms and reports needed for preselection of residents and for observations during the on-site inspection. One such information source, the Facility Quality Indicator Profile, is a facility-generated quarterly report of accidents, behavior/emotional patterns, clinical management, cognitive patterns, elimination/incontinence, infection control, nutrition/eating, physical functioning, psychotropic drug use, quality of life, and skin care.5 Another form, the Resident Level Quality Indicator Summary, lists residents who have experienced any of the treatments or events indicators listed on the Facility QI Profile. From the Summary, the team chooses or tags residents for evaluation during the survey. For example, if an unusual number of residents were checked under the QI “accidents,” surveyors would list this as a concern to be investigated. Still another form is the Facility Characteristics Report that includes gender, age, payment source, diagnoses, type of assessment, stability condition, and discharge potential of each resident.5
Team members also use the Statement of Deficiencies from the most recent survey to tag sample residents for observation during the survey. For instance, surveyors may have issued a deficiency citation related to Mrs. J., previously free of pressure ulcers, who had developed a stage-three decubitus and was not being turned every two hours as ordered.
In addition, before the on-site visit, the team collects information from other sources, such as the state ombudsman office; results of any complaint investigations; QI reports from the Standard Analytic Reporting System of the CMS National Resident Assessment Data Base; OSCAR (Health Care Financing Administration's Online Survey Certification and Reporting)5 reports, which detail the facility profile and compliance over the past four surveys; Preadmission Screening Annual Resident Reviews (PASSAR); information about waivers or variances; and any other relevant details from such sources as the media.5,6
The team coordinator then makes copies of pertinent forms and distributes them to team members to review at a team meeting. Members use the Roster/Sample Matrix, on which the facility lists all current residents and care categories of elimination, nutrition, physical function, and quality of life, to highlight concerns and to preselect residents for Phase I, the off-site portion of the survey.5 Surveyors use the Facility QI Profile to highlight residents with “sentinel health events,” such as recurring fecal impaction, dehydration, and pressure ulcers. They also assess the facility for anything over 85%, compared with others in the state. OSCAR reports are reviewed to determine a pattern of repeat deficiencies in requirements related to flagged QIs and to point out areas of large discrepancies.
On day one of the standard survey, the team arrives unannounced at Palm Manor (fictitious name). The team consists of Eileen, the RN team coordinator; two other RNs; a social worker; and a dietitian. While Eileen conducts the entrance conference with the administrator, other team members begin their initial tours to observe residents and the facility environment. Each takes a wing of the 120-bed, three-wing building, except for the dietitian, who goes directly to the kitchen.
At the entrance conference, Eileen explains the survey process to the administrator and asks for a nursing work schedule for the current time period; a list of admissions, transfers, and discharges; and evidence that the facility monitors accidents and other incidents. She asks that a notice announcing the survey be posted in an area easily observable by residents and visitors; the notice states surveyors will be able to meet with residents in private. She also requests that a Roster/Sample Matrix be completed by the end of the initial tour or that this information be provided via a computer-generated list. Eileen then gives the administrator copies of the Quality Indicator OSCAR reports that team members prepared off-site. She asks for an explanation of any discrepancies. Eileen also requests a list of key facility personnel, meal times, and copies of all menus, medication pass times, the current resident activity schedule, names of non-oral communicating residents, a list of residents who are capable of being interviewed, a copy of the facility’s admission contract(s) for all residents, any pertinent policies and procedures, CMS information, and regulation-relevant physical plant information.5
Meanwhile, surveyors are conducting initial tours to review the facility, all residents, and staff; evaluate the environment; confirm or invalidate preselected concerns; and add any new concerns discovered on-site. While talking with residents, surveyors focus on physical appearance, interaction between residents and staff, and the manner in which staff communicate with residents. Do staff members knock on doors before entering a room? Do they address residents by name or as “Granny”? Are they friendly, and do they smile? Surveyors also focus on residents’ emotional and behavioral conduct and on how special care needs are met. They look for skin tears, dehydration, edema, contractures, poor positioning, use of restraints, adverse effects of antipsychotic drugs, pressure sores, significant unintended weight loss, feeding tubes, ventilators, oxygen, IV therapy, and the appropriateness of scheduled activities.5
Surveyors ask staff to accompany them as personnel can answer their questions and provide introductions to residents and family. On B Wing, a surveyor has arrived at Mrs. J.’s room. The resident is asleep. “Does Mrs. J. still have a pressure ulcer?” the surveyor asks the accompanying RN, who says “yes” and shows the surveyor a turning schedule posted in an adjoining restroom. The last two times for turning are not initialed.
“When was Mrs. J.’s position last changed?” the surveyor asks. The RN studies the turning schedule and frowns. “I’ll have to ask the assigned nurse’s aide. It appears she has neglected to initial the turning schedule to indicate each time she changed her position,” she says.
The surveyor notes this on the Roster/Sample Matrix and also on the Surveyor Notes Worksheet as a concern to follow up later. Mrs. J. is on her right side, the surveyor observes. She’ll return in two hours and again in several hours to check on her. She has identified other concerns on the tour regarding all other preselected residents chosen during the off-site sample selection. For example, Mr. S. is tagged for incontinence. The surveyor asks the RN if Mr. S. is on a bowel and bladder training program.
Although the RN answers “yes,” the surveyor sees that Mr. S.’s trousers are urine-soaked. She makes another note on the surveyor’s Worksheet and Roster/Sample Matrix and will check to see if this resident is toileted according to the care plan.
Surveyors determine if all preselected residents are able to be interviewed. Facility staff are asked to identify residents who have no family, those newly admitted, those with special care needs, and those with possible quality-of-care and quality-of-life concerns. These residents will probably be selected for an on-site sample in-depth review.
What About the Kitchen and Dining Area?
In the dietary department, the dietitian surveyor is determining if the facility is storing, preparing, distributing, and serving food according to standards that prevent food-borne illness. The thermometer in the walk-in freezer registers the required temperature, but she sees uncovered dishes of pudding in the refrigerator. She highlights this on the Kitchen/Food Service Observation Worksheet. She asks to see recipes and then, looking at the menu, observes trays being prepared to determine if they are consistent with the menu. At the same time, she observes the tray line to check that meals are attractive, palatable, and nourishing to meet the needs of the residents, and that food is at the correct temperature with cold foods less than 45 F and hot foods above 140 F. She checks the availability of food in relation to the number of residents and if food is being held for more than 30 minutes before being served.5 “Do you have special utensils for handicapped residents?” she asks, to determine if residents are provided with services to maintain and improve eating skills.
In the dining room, she observes the noon and evening meal service, checking that residents have necessary dentures, eyeglasses, and hearing aids, and that they are positioned properly. She checks for timely arrival of food and watches the staff to determine if they encourage and assist residents as necessary. She also checks for adequate lighting and ventilation and for tables adjusted for wheelchair accommodation. Special attention is given to sampled residents identified with malnutrition, unintended weight loss, pressure ulcers, and hydration concerns, and if sampled residents consume adequate amounts of food as planned.5 To make certain that food requests are granted, she scans diet cards on trays. When she checks on special physician-ordered diets, she finds that a resident, ordered to receive a 1,500-calorie ADA diet, has a regular diet. She highlights this resident on the worksheet.
Time for Your Medication
After Eileen contacts the resident council president to announce the survey, she accompanies a facility LPN as she passes 1 p.m. medications using a cart containing unit doses. Eileen watches the LPN refer to the medication administration record (MAR) and obtain the corresponding unit dose from the cart. Eileen reconciles the name of the resident and the drug name, strength, and dosage on the label with the physician’s order as it appears on the MAR. She then records the administration on the Medication Pass Worksheet on which she has listed the sample residents preselected off-site. She makes a point of observing different routes of administration. If she finds no errors after reconciling the pass with the medical records of another 25 preselected residents, she will go to another wing of the facility and observe another med pass conducted by another facility nurse. Since she does find errors, she continues to observe another 20 opportunities for error. A special formula is used to calculate the number and type of errors.
Eileen finds three discrepancies. Levothyroxin sodium (Synthroid), ordered every other day, was given at 9 a.m. and is scheduled on the MAR to be administered every day at 9 a.m. Although furosemide (Lasix) 20 mg was ordered, the LPN gave furosemide 40 mg. In addition, the nurse instilled timolol maleate (Timoptic Solution), ordered 1 gtt OS, in both eyes.
At the nursing station, Eileen checks the medical records of the three residents. She reads that the physician had increased the furosemide to 40 mg. The other two discrepancies were found to be errors. On day three of the survey, Eileen will accompany an LPN on C Wing for a 9 a.m. medication pass. What she has found today causes Eileen to be concerned about quality of life and quality of care.
After reviewing three closed records, as determined by the Resident Sample Selection Table for a 120-bed facility, Eileen performs a review of residents receiving hospice care and a review of those receiving dialysis services.
At the end of the day, Eileen meets with the administrator and the director of nursing to discuss concerns from that day. The team starts a list of concerns to help them continue to determine potential deficiencies.
The Next Day
Sample Selection: The preselection of residents off-site is called the Phase 1 sample. The Phase 2 sample is selected on-site when the team has collected enough information to decide which concerns require further review. Regulations mandate a case-mix stratified sample of residents based on QIs and other on-site and off-site sources of information to assess compliance. This guarantees the sample will contain interviewable and non-interviewable residents, as well as residents from both heavy- and light-care categories.5 If infection control concerns are identified, policies and procedures on infection control practices are reviewed.
With information gathered from initial tours, the survey team meets to determine areas of concern for Phase 2 of the survey and select the remaining sample. These are added to the Phase 1 sample. Team members highlight each concern on a clean copy of the Sample Matrix worksheet and enter the selected residents’ names on the sheet. Selections are largely based on observation of special care needs; recent admissions; and residents most at-risk for neglect and abuse: those receiving hospice care, patients with end-stage renal disease, residents under age 55, residents who are non-oral, and those with mental illness.5
The RN who toured B Wing discusses her concern over lack of staff because Mrs. J. was not being repositioned, and Mr. S. was not receiving bowel and bladder training according to his program. Eileen reviews the staffing schedule. Other surveyors also discuss concerns and emphasize residents’ rights, quality of life, and quality of care. Eileen then assigns resident reviews and resident and family interviews to team members.
Resident reviews are integrated, holistic assessments that include assessment of drug therapies, including adverse drug reactions; quality of life as affected by room environment and daily interactions with staff; and pertinent care concerns identified for each sample resident by the survey team. The objective is to determine how residents’ outcomes and quality of life are related to the care provided. Has the care enabled residents to reach or maintain their highest level of physical, mental, and psychosocial well-being? Are residents assisted to have the best quality of life possible? Has the facility properly assessed its residents through the completion of the Resident Assessment Instrument?5
Because Palm Manor is a 120-bed facility, 24 resident reviews are mandated, as indicated on the Resident Sample Selection Table.5 Surveyors receive review assignments from Eileen that are chosen from the previously selected Phase 1 and Phase 2 samples.
Mrs. M. is highlighted as a recent admission with weight loss. After reviewing her medical record, the surveyor learns that she is an insulin-dependent diabetic who suffered a left-sided CVA before admission three weeks ago. Despite physical therapy ordered for range of motion exercises to her flaccid left hand and arm and walking exercises, she continues to drag her left foot and has made no progress with her upper extremity. Because of incontinence, she has an indwelling urinary catheter. When she is out of bed, restraints are in place, and she is depressed and has no appetite. She shares a room with a resident with aphasia.
When reviewing the assessment of care needs and care plan, the surveyor notes that the plan requires nursing staff to encourage eating, involvement with activities of daily living, and attendance at activities. A bowel and bladder training program is also part of the plan. The surveyor must now determine if staff has implemented the plan and evaluated Mrs. M.’s care.
She also notes areas where Mrs. M.’s care falls short in the Resident Room Review since rooming with a patient with aphasia limits her interactions. In the Daily Life Review, which involves staff responsiveness to care and interactions, choices, and activities, she notes that the staff does not encourage self-care. When assessing drug therapies, she determines no antidepressants or dietary supplements have been ordered. Under the care review assessment, an overall review of the resident’s assessment, she notes that no bladder-training program has been initiated, and the physician’s orders do not include physical restraints.
After surveyors complete reviews, they meet for discussion and documentation of findings. Later, Eileen meets with the administrator to review findings and concerns of the day.
In the conference room on day three, Eileen says, “First, let’s conduct quality assessments and assurance reviews.” This is accomplished using the previous day’s resident reviews. Team members assess residents’ quality of life and quality of rights from quality-of-life indicators. Also reviewed is abuse prohibition and investigation, if necessary.
Eileen then assigns surveyors to resident, family, and staff interviews. Interviews with family members of non-interviewable residents also take place. For example, a surveyor talks with the daughter of a resident with Alzheimer’s disease to determine if the daughter believes her mother is receiving individualized activities, care, and services. The surveyor asks what more the facility can do and learns the resident always enjoyed the outdoors and the beach; the surveyor will follow up with staff interviews to determine if they are aware of this information. She will also determine if they have suggestions to use this information to provide an improved quality of life for the resident.
Back in the conference room, Eileen asks surveyors if staff members treat residents with respect and regard for their privacy and observe residents’ rights, including self-determination and participation. All agree that staff interaction has a positive impact on the quality of residents’ lives. Next, they share information on quality-of-life indicators in such areas as activity choices, quality of food, and other key perceptions from interviews with five interviewable residents. The facility’s physical environment is discussed and assessed for residents’ quality of life, health, and safety.
Team members document any facility practice in question and its effect on a resident. They share concerns about conducting an extended survey.
Eileen attends a meeting of the resident council — a group of residents meeting monthly to discuss issues of concern about their life in the facility and perhaps make requests of the administrator — and explains the survey process. She encourages residents to discuss their life at Palm Manor and then asks questions such as —
Do you enjoy the activities?
Do you feel staff treat residents with respect?
Do you ever see insects or rodents?
Are the meats tender enough?
Are you aware of any resident abuse or neglect?
If anyone brings up concerns, Eileen asks for specifics. She asks if the administrator has responded to their complaints or requests. Residents say they’d like to play games other than bingo. Eileen adds this to her notes and then asks about other issues. She will follow up with the administrator to determine if he/she was aware of the complaints and if so what has already been done to remedy the problem.
After the meeting, Eileen and teammates share concerns and information from their interviews, including issues that specifically involve residents’ rights, quality of life, and quality of care. Next, they discuss deficiencies and specific areas of noncompliance with regulations. Other tasks such as general operations review, employee record review, medical record review, and abuse/neglect reports are started.
Problems Determined: This day, survey team members meet to review and analyze all information collected and to determine whether or not Palm Manor has failed to meet one or more of the regulatory requirements. The team members must review their worksheets to determine the scope and severity of the deficiencies and whether there are any negative outcomes due to failure to meet requirements related to quality care, resident rights, and quality of life. If there are, team members analyze these deficiencies to see if they result in actual or potential harm to residents. If immediate jeopardy is evident — a situation in which one or more unmet requirements caused or is likely to cause serious injury, harm, impairment, or death to a resident — the team coordinator must consult with a supervisor. If the supervisor concurs, the team leader informs the administrator that immediate jeopardy termination procedures are being invoked.5
Deficiencies Documented: Eileen documents deficiency decisions and the substance of evidence on the appropriate form (HCFA 2567). She proceeds from the first regulation, using surveyor interpretive guidelines and each potential area of deficiency. The surveyors and facility staff commonly refer to these as “F tags.” Team members affirm what they have identified and any supporting data they have gathered. The team cites deficiencies for medication administration errors; incorrect diet; care plans not carried out for residents to attain and maintain physical, mental, and psychosocial well-being; restraints applied without physician’s orders; environment not conducive to resident improvement; variety of activities not provided; and insufficient staffing.
Facility staff, a resident council officer, and several residents attend the exit conference. Eileen thanks the staff for their cooperation and describes the team’s deficiency findings, giving the number of the tag and the level of the deficiency. She then gives facility staff the opportunity to discuss and supply additional information that they believe pertinent to identified findings. In conclusion, she says that a report of the survey, listing deficiencies, will be mailed. The facility will be expected to respond with a plan of corrections.