INCREASING SAFETY, MANAGING RISK.
BEFORE CRIMINAL BACKGROUND CHECKS BECAME STANDARD INDUSTRY PRACTICE, A LONG TERM CARE administrator in Illinois paid $15 per inquiry for such checks on potential hires for the facility. Management ordered the inquiries halted for budgetary reasons. A few months later, facing holiday staff shortages around Christmastime, the administrator hired two new aides to help round out a skeletal staff.
"I did the registry checks, the reference checks, everything came in fine," recalls the administrator, who asked to remain anonymous in our reportage. "I came back in on Monday--Christmas was on Sunday--and got a report from [a resident's] family members that their mother had been sexually abused Christmas night."
A year later, in legal proceedings over the incident, the administrator was summoned to give a deposition about the center's hiring practices. In fact, it had been discovered that one of the aides hired did have a record of abuse. Because the administrator cited that he was not permitted to perform criminal background checks, a decision with which he disagreed, he became a key witness for the plaintiff. Management admitted liability and paid $1 million in damages awarded the plaintfiff.
That story comes as no surprise. You know the consequences. Fail to keep a resident safe and face a nightmare: staff reprimands, fines, liability--with no end of legal and compensatory costs, even potential regulatory shutdown. A single incident involving compromised safety among residents can tarnish an otherwise impeccable record of caregiving. And you must keep staff safe as well. Employee downtime from physical or psychological harm is bruising to morale and teamwork--and the bottom line.
Ensuring the well being of every resident and worker demands the convergence of several factors including effective design, maintenance, and vigilance. As a starting point, good planning can ease many potential perils--such as slippery surfaces, fire hazards, or inappropriate wandering by residents (see" 10 steps to safety," page 17). Detail-oriented maintenance programs can include periodic safety checks designed to pinpoint and alleviate additional dangers. And vigilance, instilled by solid safety awareness and promotion programs and specific training, becomes the 24/7 responsibility of every provider.
Rich Blackburn, president of Eldercare Risk Management in St. Charles, Ill., makes a business of evaluating safety concerns and potential risk in a range of long term care environments. At a basic level, suggests Blackburn, facilities should look at safety problems and care-issue problems as part of their quality-assurance programs. Safety committees become an integral, critical part of the mix, according to Blackburn. "Good basic quality assurance programs mean identifying problems and rectifying them at the time," he says.
SAFETY FIRST, BY COMMITTEE
Given the enormous care demands, staff shortages, and resulting time constraints placed on aides and administrators, how can you ensure that common sense prevails--that proper procedural reporting and diligent follow-up on safety concerns become the norm, not the exception? At a minimum, form a safety committee, or work with your existing safety committee to improve its function and direction. Sounds simple, right? But Blackburn claims that long term care safety committees are either nonexistent or operating only in keeping with the demands of quality-assurance programs, typically limiting committee work to reviewing staff safety issues.
A safety committee should meet monthly at a minimum--separate from quality assurance--to review both staff and resident safety, suggests Blackburn. Though the composition of safety committees may very among providers, Blackburn gives the nod to interdisciplinary players representing residents and departmental staff including aides, nurses, dietary employees, housekeepers, and laundry operators. Because communication and free flow of ideas are essential to committee success, overlook department heads, says Blackburn, and opt for staff-level representatives. "Administration doesn't need to be involved," he says. "Perhaps it's too intimidating"
Safety committees, according to Blackburn, should perform six critical duties, many ongoing:
* Review all accident and incident reports and recommend corrective action if appropriate;
* Define smoking regulations for staff and residents, particularly noting fire hazards;
* Identify unsafe work areas and work practices and suggest remedies or alternatives;
* Develop and implement with a workers' comprehensive insurance carrier an effective safety program;
* Similarly, develop and implement safety rules and regulations by departmental requirements;
* Follow up on staff violations of Occupational Safety and Health Administration (OSHA) guidelines and federal and state surveys, and outline corrective accident plans.
WATCHING, NOT WAITING
Having a safety committee in place cannot guarantee safety and cannot substitute for vigilance and awareness among staff members (see "Monitoring safety," below). "What I find surprising is what the committees are not doing," says Blackburn. In many long term care settings, the meetings become merely perfunctory, limited by time and interest--and ending up as not much more than mere lists of departmental occurrences. "They are basically complying with a safety regulation," says Blackburn. "But administrators should know better."
So the watchful eyes and open ears of staff become the keys to observing, reporting, and predicting behaviors or hazards that could compromise safety. (See "A systems approach to behavior management," May 2001 CLTC, page 12.) "It's ongoing, day-to-day, hands-on involvement that leads staff to go to a charge nurse and say, 'I noticed that Mildred just doesn't seem herself,' "explains Denise Brown, a former long term care professional who now publishes Caregiving Newsletter, directed to persons caring for their aging relatives. In fact, such observations by a CNA about "Mildred" and her apparent confusion or sluggishness, for example, may lead a charge nurse or director of nursing to assess Mildred's condition. Such communication may alert nursing staff to more serious problems such as dehydration or stroke and the potential for deterioration--falls, incontinence, accidents--as a result.
PROMOTING SAFETY SIMPLY
You can think safety in the simplest of circumstances, such as noticing that a heavily waxed floor creates blinding, disorienting glare and a slippery surface. (See "They all fall down," April 2001 CLTC, page 38.) And you can invest in precautionary measures including pressure-sensitive mattresses that help reduce the incidence of skin ulceration. Train your hands-on care staff that any type of skin change or redness should be reported since it may signal the onset of skin breakdown. "No matter how insignificant, report [problems such as] red spots or bruises," warns Blackburn.
Consider the 1998 death in a suburban Detroit assisted living facility where a resident suffocated between her bed and the aluminum rails intended to keep her safe. The rails were improperly installed, creating a hazardous situation gone unchecked. Train staff members to be aware, to know what care plans require. Blocking, padding, or correctly installed bedrails may have kept the Detroit resident safer and prevented death. "We know what the problems are," says Blackburn. "The only thing you can do is keep beating away at being aware of the care plan for each resident."
To develop such awareness means training, training, training. One of Blackburn's most recent strategies for improving staff training involves a strong orientation program and a skills checklist, plus five or more days working on the buddy system. A standard 90-day evaluation period creates the opportunity to help newer staff members strengthen apparent weaknesses, based on the skills checklist. "We've found that to be a really good tool," says Blackburn. "Instead of saying, 'You didn't show total proficiency,' you can say, 'We're going to spend a couple of days on that.'"
Critical to the success of such intense training is follow up on reported safety concerns by charge nurses or directors of nursing. "Put a back-up plan in place," advises Blackburn. "In some cases, we're sitting here training an unskilled, minimally educated person trying to turn them into a semi-professional requiring knowledge of basic anatomy and some physiology. We have to keep it simple. Most CNAS are able to be aware. What they lack is the need to tell somebody if anything different occurs or happens," claims Blackburn.
As a top-10 risk-awareness issue, falls by residents threaten their welfare and safety daily. Immobility and inactivity among the elderly have become the newfound enemy: greater physical activity may help maintain or improve mobility. Designing programs to increase strength, muscle tone, and coordination in residents may help lessen the risk of falling.
"When someone's unsteady on her feet, what do you do?," asks Brown. "You know that every fifth day that person is going to fall. You take that risk; you want a restraint-free environment. You may have an aide walking with her, and staff on the lookout." It's also a matter of effective programming, claims Brown. Finding "the right distraction" or stimulation may keep those unsteady residents calm and seated, less likely to attempt inappropriate walking.
Conversely, family members who push frail or infirm elderly toward physical activity that's too demanding may contribute to injury risks unknowingly. A form of denial, this push is something caregiving staff must be prepared for, says Brown. Have a plan of action which may include providing a geri chair at exercise sessions to help alleviate falls or offering gentle reminders to family members to increase their awareness of a loved one's limitations. For example, suggest they accompany their relative to an exercise or activity and assist them as needed.
BE AN OMBUDSMAN
To promote a safe environment, treat every concern as a legitimate one. "Any complaint--even from a resident with Alzheimer's--always has to be taken seriously," claims Brown, who suggests notifying family members immediately about any difficulties or issues affecting their loved ones' safety and health. "You never want to surprise a family member," she says. "And that can go a long way toward building a relationship."
Recognizing that some family complaints merely indicate a need for control or an attempt to cope with a trying situation or chronic illness, Brown says sometimes just listening is enough. What's critical, she says, is knowing what's just venting and what's justifiable cause for concern over safety. "The more you listen," she claims, "the less the complaints will come." And, she stresses, you might learn about something you've overlooked previously.
Listening to family members, residents, and other staff members can be an essential eye-opener. Notes Brown, "It's sometimes a hazard that staff has in keeping up with all of the charting, the paperwork. Sometimes we don't look at the big picture: Is our carpeting safe? Are our CNAs up to date? Are we so used to doing things a certain way that we need outside training?" (See "Safety at the threshold," page 19.)
By using quarterly care conferences effectively, the interdisciplinary team of caregivers and managers can take giant leaps toward awareness of safety and well being among residents and staff members. Again, it involves knowing what to watch for, what the risks are, and resolving incidents and accidents when they occur.
But safekeeping often boils down to effective action in the moment--in the nick of time. Says Brown, "You're always trying to think on your feet to offset a dangerous situation."
Rachel Long is a regular contributor to CLTC.
10 steps to safety
Can you name the top 10 issues affecting risk in long term care settings? We asked risk-management expert Rich Blackburn, who works with insurance carrier Lloyds of London on safety programs for commercial eldercare environments, to pinpoint the leading concerns.
1. Management. Taking safety seriously and instituting safe practices starts at the top.
2. Hiring practices. Resident and staff safety rely on employee integrity and trustworthiness.
3. Pressure sores and skin care. Even the tiniest abnormalities are worth reporting; such awareness can prevent further skin breakdown or health compromise.
4. Falls. Vigilance is key.
5. Medical records. Are charge nurses and directors of nursing hands-on?
6. Abuse and neglect. Watch for signs and take all reports seriously.
7. Elopement and wandering. Is your facility secure? Are you up to date on prevention practices and safeguards?
8. Practitioner credentialing. Current licensing and certificates of insurance should be mandatory for anyone practicing in your facilities. (Think beyond doctors and pharmacists to therapists, beauticians, and barbers.)
9. Quality assurance. What steps have you implemented toward top performance?
10. Overall safety. A team effort, this is everyone's business and in everyone's best interest. Let a staff-level safety committee take initiative, show leadership, and review every reported incident.
Do you have the right technology tools in your safety mix?
Good-bye restraints, hello wireless technologies. An array of sensors from by some counts, more than 17 manufacturers in the marketplace) can alert staff to fall-prone residents who are up and about. Welcome to the 21st century, where technology that notifies staff of resident movement or wandering-signaling potential trouble--is evolving constantly, from reactive to proactive. According to Megan Wysong, a product manager at Lincoln, Neb.-based Senior Technologies, this is because "there's been a lot of legislation to reduce the use of restraints in long term care."
"We can design a rocket ship--the technology's out there," says David Lange, business manager of Code Alert in Brookfield, Wisconsin, a manufacturer of security systems for health care applications. "How do we make it so staff can use it?" Lange recognizes the challenges of creating technologically enhanced safety systems for long term care--" making the application more robust, and still keeping it simple and cost effective."
Newer, more robust applications include proactive products that allow data transfer, plus related tracking and trending that help providers better formulate care plans. "A bed alarm is just a tool, a piece of the puzzle," says Lange. "The potential is managing cases by data compilation"-discerning behavioral and caregiving patterns that could affect health and safety.
Transmitters will now tell you that fall-prone residents are up, even that a resident has had an incontinent episode. If you don't want an alarm to sound when someone shifts out of bed, then a voice chip could activate, saying, "Please wait for the nurse." Wysong points Out, "The voice option is especially helpful if the resident doesn't speak English. The message can be recorded in the resident's native language, or by a favorite family member."
Who needs a bed monitor? Generally, notes Lange, residents with histories of falls, those on psychotropic medications (or medications that may affect eyesight or have uncertain interactions), and those residents whose incontinent episodes compromise their safety.
Of all the technical options for helping keep residents safe, Lange points to medical device regulations by the Food and Drug Administration that certify approved products and aim to discourage jury-rigged devices. "It's a preventive measure and a liability issue, 'Did you do everything you could to ensure safety?'"
Safety at the threshold
For all the safety issues you have to worry about, let's add one more: What potentially hazardous items are new residents bringing with them to your facility?
Consider a few cases, most involving individuals with a form of dementia. One woman lined her eyebrows with nail polish, Another woman pinned a brooch through her ear. Some drank perfume. Then think about a new resident bringing in a favorite old lamp with a frayed cord, a wobbly nightstand, and a dresser topped with chipped glass.
In your facility, a resident's personal effects suddenly become your liability. And while taking inventory of a new resident's belongings can help (and is, in fact, required by law for certain types of facilities), it's not failsafe. Once again, safekeeping for residents, guests, and staff requires not just constant vigilance, but understanding what may be hazardous.
"The list of what's hazardous may vary according to who that patient or resident is," according to Mary Jo Zeller, a licensed nursing home administrator who with Gloria Bersani founded Family Moving Solutions (based in Palatine, Ill.) to customize senior relocation. Zeller and Bersani, also a licensed nursing home administrator, understand specialized health needs--and related perils--when it comes to new residents.
From the toilet kit to the suitcase to the moving van, what to watch? Zeller and Bersani discussed a preliminary checklist:
* Personal care items. Nail clippers, make-up, and aftershave may be safe for many seniors, but for persons with impaired memory or eyesight, those same items may pose risks.
* Medical enhancements. Eyeglasses, hearing aids, and dentures must fit properly, with their prescriptions up-to-date to offer maximum health benefits. In one case, according to Bersani and Zeller, a woman who complained of not being able to eat preferred wearing her deceased husband's dentures, while her own remained tucked away. Because the woman was capable of maintaining personal oral hygiene, her weight loss cause was long undiagnosed.
* Jewelry. Pins and other items may be dangerous if used inappropriately. And security is always an issue.
* Prescription drugs. Residents may carry in outdated medication or drugs no longer appropriate for their current health status. And typically harmless over-the-counter remedies may interfere with current treatment plans.
* Foodstuffs. Outdated edibles pose a potential health threat, as do unlabeled items that could be confused for food. And, candy for a newly diagnosed diabetic is a potential health hazard.
* Clothing and footwear. Anything ill-fitting (too large or too small) is out, it may create a circulation or tripping hazard. Sturdy low-heeled shoes are sensible for everyone--and essential for anyone with a walker or cane. (And, Bersani and Zeller warn, some women insist on anchoring their knee-high nylon stockings with rubber bands--a circulatory "don't.")
* Photographs. Typically welcome and encouraged, photos can sometimes conjure volatile emotional episodes in dementia cases.
* Firearms and other weapons. Suggest, "Wouldn't your son/daughter appreciate this now?"
* Electronics. Bersani and Zeller discourage bringing in old radios, lamps, clocks, and microwave ovens that obviously need to be rewired. They could pose a significant fire hazard.
* Tschotkes. Beware falling objects: those lovely mementos need a remote place--not over the bed or on a shelf that could be easily bumped.
* Furniture. For safety's sake, no swivel chairs, please, or shaky old pieces (unless they are rejoined and reglued). Check glass tops for chips and cracks, check that chair cushions don't sag, suggest that glass-topped coffee tables (difficult to see) be left behind. Aim to help residents arrange furniture with clear pathways, and in a way that mimics their prior surroundings (bed facing same direction, nightstand on familiar side).
* Throw rugs. Zeller and Bersani suggest such slipping and tripping factors are unsafe indeed.
* Smart construction. They point to some new construction features that make for easier--and safer--living for seniors: lower cabinets in kitchens and bathrooms; light switches at lower levels; electrical outlets at higher levels; and good color contrast among depths and areas.
* Shared safety. In shared areas such as bathrooms, where toothbrushes and drinking glasses could be accidentally switched, look to label separate resident areas and personal items distinctly. Germspread could be potentially hazardous. And try dispensers for items such as bar soap, which could be mistaken for food or become a slippage hazard underfoot in tub or shower.
Take a stressful move, unfamiliar surroundings, and a new routine, and the mix can be disastrous. "Families want to help, but they don't know what's appropriate," says Zeller. "We started this business because if the moving day goes poorly, they'll say, 'I never should have come.' The more things you can have similar, the better off you are."
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|Publication:||Contemporary Long Term Care|
|Date:||Jun 1, 2001|
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