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Teach staff to walk in surveyors' shoes: all staff need to be aware of regulatory guidelines regarding abuse. (Feature Article).

In his song "Standing on the Corner," Dean Martin sings, "Brother, you can't go to jail for what you're thinking." But beware: If you work in a long-term care facility in California, you just might wind up behind bars for doing what you thought was correct.

Without question, dealing with violent behavior in facilities with patients who have psychiatric conditions is a daily routine for many staffs. An administrator in California was criminally convicted for deciding not to report an altercation between a staff member and a resident with a history of violence. Irrespective of the facts of the case, an executive was punished because -- based on the guidelines available -- a decision was made by the administrator to do what was thought to be best for everyone involved. However, the authorities' interpretation did not agree with the administrator's interpretation.

Interpretation is a person's perception of something, and a guideline is a suggested path to follow; interpretations and guidelines can be both ambiguous and indefinite. If 5 administrators and 5 surveyors interpret the same guideline, it might result in 10 different interpretations --interpretation is a subjective process, which often leads to contradictory opinions. Additionally, when the growing number of surveyors in Southern California who speak English as a second language is factored into the equation, the margin of error for misinterpreting English-language guidelines grows alarmingly.

The fact that the nursing home industry, or any industry, is regulated by "interpretive guidelines" is a fundamental flaw in itself. The convicted administrator interpreted guidelines one way, state authorities interpreted them another, and the courts interpreted them yet a third way. As long as there are interpretive guidelines, there will be as many differing interpretations as there are nursing home providers, surveyors, and courts.

Traditionally, only upper management has been responsible for learning interpretive guidelines. However, when it comes to the emotional issue of abuse, all staff must be taught regulatory guidelines, so they can gain a better understanding of the regulatory process and help to minimize procedural errors that maylead to complaints alleging mistreatment and abuse.

Those who must followthe procedural guidelines should be taught directly from the source. Teach staff OBRA Regulations, Interpretive Guidelines, 483.13(b) through 483.13(c)(l)(ii) and (iii), arid 483.75(e), which are outlined in the Facility Guide to OBRA Regulations, Interpretive Guidelines and the LTC Survey Process manual (Heaton Publications, [800] 221-2469; Use the manual to design an abuse prevention program that focuses on teaching federal regulations, guidelines, and surveyor protocol for abuse investigations.

Create an Abuse Prevention Program

First, it is imperative that each administrator helps his staff to understand the vagaries of working under interpretive guidelines. It is important to build staff's confidence that they indeed can perform in a manner that will be acceptable to the interpreting surveyors. It is equally vital that they trust that the administrators know that despite the staffs very best performances, there is always the possibility that the surveyors' perception of an incident might differ from their own. Poor-quality care or abuse should never be tolerated, but when surveyors fault a staff member who is guilty of neither, it is important that the targeted person knows that administrators recognize his or her disappointment or apprehension, as well as his or her prudent and appropriate incident-specific behavior.

Policies and procedures outlining the facility's approach to preventing abuse are a critical component of any abuse prevention program. When surveyors enter a facility on an abuse complaint or during a survey, the guidelines instruct them to review facility policies and procedures to ensure they contain seven required components:

* Does the facility screen employees? [483.13(c)]

* Does the facility train employees regarding abuse? [483.75(e)]

* Are abuse prevention policies and procedures in place? [483.13(b)]

* How does the facility identify possible abusive incidents? [483.13(c) (2)]

* How does the facility investigate incidents and allegations of abuse? [483.13 (c)(3)J

* How does the facility protect residents during investigations? [483.13(c)(3)]

* How does the facility report incidents and investigations, as well as respond to the results of investigations? [483.13(c)(1)(iii), 483.13(c)(2), and 483.13(c)(4)]

Interpretive guidelines also require that the policies and procedures clearly define how the facility operationally integrates the seven components. For example, if the policies and procedures state that the facility must train staff in abuse prevention, the surveyors will request to see documentation and in-service records that reveal proper training was conducted and that the staff knows the following [Training: 483.75(e)]:

* interventions to deal with aggressive and/or catastrophic reactions

* how to report alleged abuse without fear of reprisal

* how to recognize signs of burnout, frustration, and stress that may lead to abuse

* definitions for abuse, neglect, and misappropriation of resident property

Prepare Staff to Answer Surveyors' Questions

Teaching staff the interpretive guidelines will prepare them to correctly respond to surveyors' questions. A better understanding of the guidelines can best prepare the staff to respond in the most effective manner during a survey. For instance, all staff must know the name of the facility's abuse prevention coordinator. Surveyors will also ask, "What do you do if you see a resident being abused?" The incorrect staff response most commonly heard is, "Report it." Staff should say, "Stop it, then report it."

Another question from the guidelines is, "What do you do when a resident has a catastrophic reaction?" The guidelines define a catastrophic reaction as an extreme, sudden reaction or change in mood in response to minor stimuli (e.g., bathing, dressing, staff asking a question, etc.). Catastrophic reactions include agitation, crying, screaming, and even blushing. Be sure to include interventions that deal with such behaviors in abuse prevention training in order to increase the staffs probabilities for giving appropriate answers to surveyors' questions.

Maintain Your Abuse Prevention Program

In addition to teaching interpretive guidelines to staff, administrators should frequently audit their abuse prevention program to ensure guidelines are being followed. Continuous updating of policies and procedures to match regulatory mandates is essential. The audit must include reviews of the past three investigations to ensure interpretive guidelines were followed correctly. It's also important to routinely test staffs knowledge of abuse guidelines. For example, the administrator can ask five direct-care staff and three front-line supervisors the same questions surveyors are required to ask from the Abuse Prohibition Review (Task 5G, interpretive guidelines manual). Through this audit process, the administrator will discover the weaknesses or strengths in the training program and can make adjustments to better comply with the federal guidelines.

The Best Abuse Prevention!

Most experts say "quality care" is the answer to abuse prevention. Easy to say! But quality care is just another concept open to interpretation. Close interpretation gaps by teaching staff from the guidelines, so they learn the overall expectations and standards of federal regulations.

By implementing a consistent abuse prevention program that teaches regulatory guidelines and surveyor protocol, a facility can reduce its exposure to procedural errors that lead to complaints alleging mistreatment or abuse. The more staff knows about interpretive guidelines for preventing abuse, the less surveyors will have to interpret during an abuse prohibition review. Ultimately, the best benefit from an effective abuse prevention program is better care for the residents. For those who are committed to the well-being of the frail elderly, giving quality care should be what makes the world of long-term care go round: No doubt Dean Martin would have insisted, "That's amore." And by anyone's interpretation, that's just something there's too little of.

Jime Todd is a nursing home administrator and turnaround consultant based in Claremont, California. For further information, phone (909) 624-7324. To comment on this article, please send e-mail to todd0203@
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Author:Todd, Jaime
Publication:Nursing Homes
Geographic Code:1USA
Date:Feb 1, 2003
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