When bad things happen to good providers.

Wendy L. Bonifazi, RN, is a contributing writer to Contemporary Long Term Care.

EVEN IF YOU'VE HAD YEARS OF ZERO-DEFICIENCY SURVEYS, you are not immune from heightened stringency and the specter of financial penalties. And whether you're used to mediocre or near-perfect results, a bad survey can have a devastating effect on both your internal and external publics. What can you do when your carefully built reputation--not to mention facility morale--is suddenly at risk?

Madrid Home, a restraint-free, 175-bed skilled, residential, and nursing facility in Madrid, Iowa, has enjoyed a good reputation for nearly a century. in three of the past five years, Madrid thanked employees for deficiency-free surveys with blue jean days, pizza parties, and chocolates.

One of those parties took place after a survey last June. But two days before Christmas, someone complained about Madrid's patient supervision. A month later, the Department of Inspections and Appeals returned to review a sample of 14 residents.

Thirteen were acceptable. The fourteenth was another matter. Diagnosed with cancer, Alzheimer's, and osteoporosis, he was ambulatory but unsteady and fell several times. One night, while attempting to toilet himself, he fell. Surveyors attributed his broken hip to the fall.

The negative outcome triggered a citation for lack of supervision, a $2,000 fine, and conditional status for Madrid's license (carrying an automatic administration citation). Madrid also faced a potential retroactive $300-a-day fine if the resurvey found any fault--including bruises or skin tears--under the broad supervision tag.

Madrid is appealing. "We don't even think the findings constitute a deficiency," says President Bill Thayer, a licensed administrator. Staff, notes Thayer, had made repeated efforts and tried several techniques to discourage the resident from self-transfers and to prevent falls. And the hip may have broken earlier, or even caused the fall, as osteoporotic bones can shatter with dismaying ease. Madrid also disputes surveyors recommendation that the Low Stimulation Unit adopt sound alarms, concerned that they agitate residents with dementia.

While waiting for his appeal to be heard, Thayer moved fast to boost his staff's sagging morale, following three basic principles: be open, support staff, and find opportunities for improvement. "The best thing is disclosure, quick and honest," he says.

"Survey is an emotional rollercoaster," he adds. "You can feel the pall come over people--not just direct caregivers. Every employee takes any deficiency as a mark against their name."

The DON was present when Thayer learned about the penalties and took responsibility for spreading word to employees, who were understandably upset. Thayer wanted to refocus staff on work--but not too quickly. "Employees need three or four days to adjust to this kind of news," he says. "Until then, they're not ready to hear redirection."

Managers also need time to evaluate reports and strategies, says management consultant Maryanne Peabody, RN, vice-president of Boston-based Stybel, Peabody and Associates. "Go to department heads to determine which are substantive or problem practices and which are surveyor perception, misinterpretations, or paper compliance," says Peabody, who previously supervised professional care in more than 20 facilities. "Admit real deficiencies and admit you can do better. Write out corrective steps and have department heads meet with their staff."

Six days after learning of the results, when paychecks were distributed, Thayer gave employees a letter arming them with facts and answers to questions they'd be asked. It summarized the situation, reminded them of confidentiality and safety basics, and cautioned them to avoid injuries. "All of us can improve, and I asked employees to do that," says Thayer. He included a message for outsiders, emphasizing Madrid's restraint-free philosophy and previously unblemished reputation while expressing regrets for any injuries suffered by residents.

Employees, Thayer notes, can be overwhelmed by negative surveys, particularly long ones. "When it seems everything's wrong and nothing's right, focus on the three or four most important things to satisfy customers," he advises. "Focusing on units they can understand gets them over frustration and starts the healing."

Peabody agrees. "Focus on what's solvable, resolvable, and valid," she says. Many problems can be addressed even before survey by practice audits, mandatory committee review for all incidents and accidents, and a good QA program, but sometimes there is no solution. If you think a deficiency isn't substantive or appropriate, Peabody advises, say so, but tell staff it can be used to improve practices nonetheless. "Then ask employees to come up with alternatives and do their best."

Staff involved in incidents merit special attention. Although you can't stop the grapevine, Thayer discourages coworkers' antagonism and shields employees' identities. Privately and individually, he meets with each employee involved to discuss deficient practices and let them know he wants to keep them, if they're good people. (Employees guilty of serious offenses, such as abuse, would be terminated.) He uses incidents--such as administering two asthma inhalants too closely together--as facility-wide opportunities to improve practices.

Staff who are concerned about their licenses also may need special support and information. Madrid's DON worked closely with one apprehensive RN who had experienced negative surveys elsewhere; she remains on the job.

Employees aren't the only people who need explanations. Immediately after getting the resurvey results, Thayer notified his medical director, board of directors, and resident council. He brought Madrid's state legislators in to visit so they would see Madrid's philosophy--and how its level of care compared to other facilities that generated complaints. He alerted trade associations, the Iowa Board of Examiners for Nursing Homes, and churches connected to Madrid. "If they're going to read it in the paper, tell them first," he says. The responses, he says, were positive. Several former residents even offered their support.

"If [residents] feel safe, cared for and respected, they'll disregard a poor survey," says Peabody. However, she acknowledges, "They'll feel as badly as staff about a negative report." When incidents will go public, administrators and other facility spokesmen should tell residents and families what happened, why, and what they're doing about it. Express regrets, says Peabody, but acknowledge that some risks are unavoidable. For major crises, she suggests administrators supplement announcements at resident or family council meetings with mail, special meetings, breakfasts, and unit visits.

It's also best to take the initiative with local media. Rather than taking an ostrich approach, Thayer informed area reporters and editors personally. I told them, 'When we get good news, you do a good job, so when we get bad news, we want to tell you,' "he says. He believes newspapers treated Madrid fairly; their front-page coverage included his explanation of the incident and the facility's record and history.

Specialists in public relations can help craft messages and media strategies, and polish the spokesman's soundbites, especially if the facility must deal with radio and TV.

Madrid was found in substantial compliance during a recent resurvey. Meanwhile, Thayer has used the experience as a lesson in setting his own agenda rather than simply reacting to HCFA's. "Giving more attention to negatives than positives is inherent in the [survey] process," he says. "We're rethinking that."