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7 There are three learning objectives for this program. Please read through them before proceeding to the next slide. 7 of 42

8 This program will address important concepts related to safety for long-term care residents. These include: safety issues related to litigation, culture changes in long-term care facilities, and examples of safety issues. A case study of a lawsuit will also be discussed. 8 of 42

9 Senior managers of long-term care settings are the leaders who create the overall structure and interactive environment of the facility. They set the tone for the culture of the facility and lead by example, showing compassion for the residents. Senior managers must address safety issues within the long-term care setting so that staff is able to provide high-quality, compassionate care for residents. Some issues that will be addressed in this educational program that affect the overall safety of the facility include: staffing; risk management; and worker safety. Senior management personnel should be committed to improving the safety of their facility for both residents and employees. Senior managers and consumers are interested as to whether the physical environment of a long-term care facility can enhance the residents quality of life. Many senior managers may not be aware of how to create this change within their budgets constraints. State and federal government regulations list specific requirements that long-term care facilities need to follow. Making physical facility changes can be challenging for senior managers trying to meet both the needs of consumers and the standards of governing bodies. 9 of 42

10 A research study published in 2013 by Stevenson and colleagues reviewed more than 6,000 negligence claims brought against approximately 1,500 nursing homes. They looked for similarities between 9 quality measures and 3 litigation experience variables. The study concluded that there were no associations between nursing home litigation and quality care improvement. In fact, quality performance may have decreased slightly with litigation. At least once every 15 months, regulatory agencies inspect nursing homes for quality of the facility, resident care, and staffing. When a federal regulatory standard is found to be out of compliance, the facility is cited for a deficiency. The Centers for Medicare and Medicaid Services (or CMS) collect and maintain Certification and Survey Provider Enhanced Reporting (CASPER) data. CASPER is part of the Quality Improvement Evaluation System (QIES), which replaces OSCAR, an On-line Survey Certification and Reporting System. All US institutions report information to this survey process. Nursing homes in particular are required to participate if they certified to provide Medicare or Medicaid services or they will receive a 2% reduction in their annual payment. 10 of 42

11 Staffing is a safety issue that should be constantly monitored by senior managers. Michelle H. Halligan and colleagues investigated the safety culture of a long-term care setting by discussing staffing issues with employees. They performed a case study on a high-risk secured unit for residents who had cognitive impairment. The investigators reported that recruiting qualified, compassionate staff is necessary to develop a good working team. Once hired, the staff must be trained properly on the facility policies and equipment. Staffing ratios need to meet regulatory agency standards, but also should be appropriate for the level of individual care that residents require. Inappropriate staffing leads to employee fatigue, stress, and burn-out, in addition to the negative effect on the residents. Next, the senior manager needs to consider the importance of retention. If there are significant budget constraints that reduce the ability to afford appropriate staffing ratios, adequate training, or safety technology equipment, the long-term care facility is more likely to have higher staff turnover. Lower safety culture scores have previously been associated with low nursing staff levels. If direct care employees feel overwhelmed in their roles, they are not likely to remain at the facility for an extended period of time. Staff shortages and high workloads were considered to be major barriers to improving resident safety. 11 of 42

12 New standards of care in the safe handling of residents have been developed to replace manual lifting with the use of technological lifting equipment. On June 25, 2013, the American Nurses Association (or ANA) issued a news release announcing national standards on Safe Patient Handling and Mobility. The ANA s official position is that manual lifting of patients will and must be eliminated. The Occupational Safety and Health Administration (or OSHA) also requires the use of technology for lifting. This agency created Safe Patient Handling guidelines in response to the high musculoskeletal injury rates of healthcare employees. If your facility has not done so already, begin incorporating a Safe Patient Handling program. The resource section of this educational presentation provides a website link to the white paper that was released by The Facility Guidelines Institute in 2010 that provides a business case for establishing patient handling and movement assessments. 12 of 42

13 How do you determine the safety issues at your long-term care facility? Start by developing a risk management program. To begin this process, senior managers should have a risk management tool that can be used to collect information on incidents of adverse events and near misses. The Department of Health and Human Services provides an example of an incident data collection tool with an explanation of how these tools can assist in the prevention of future incidents. After data have been collected, review and analyze the reports and determine a safety plan to address the issues identified. However, the risk management program will not succeed unless all staff are encouraged to complete incident reports. The culture within the facility should focus on addressing safety issues in a positive manner instead of blaming an employee and punishing them. Involve middle managers and all staff to effect this change in culture throughout the facility. In the case study by Halligan and colleagues, the nurses who were interviewed explained that many incident reports were not done due to inadequate staffing and not enough time to complete extra forms. Therefore, many incidents did not get reported to management. Prevent this from happening at your facility. Make sure staffing is adequate, staff is less stressed, and the reporting environment is positively focused on receiving these reports. This process will enhance your facility s culture of safety. 13 of 42

14 The goal of culture change is to create an atmosphere that seems like a household, not an institution. This household should function as a cohesive family of residents who are able to make choices and function to the highest of their abilities. This begins with changing organizational patterns. Instead of an environment created for staff efficiency, it should be created for the comfort and desires of the residents. This change in philosophy takes into consideration each resident s values, beliefs, and wishes. This is a change from the institutional model to a more homelike environment that allows the residents more choices to improve their quality of life. Kapp s 2013 article about culture change explains that staff apprehension can be an obstacle in adopting the culture change model. In response to this, senior managers can involve staff in the change process. Engage them in providing ideas for culture change, develop ways to put the ideas into practice, and let them decorate the facility throughout the year in appropriate seasonal décor. By doing this, employees will be excited about the change. Their positive attitude will improve the quality of life for both the residents and the staff. 14 of 42

15 Providing individualized resident care includes allowing residents to have individualized schedules. Performing activities of daily living based on the resident s choice instead of the employee s schedule is a big change for many facilities. One example is to provide showers or baths for residents when they decide they want one, not during a prescheduled bathing time. Bathing should be a relaxing and enjoyable experience, not rushed or uncomfortable. Residents should have soft towels and relaxing music for their baths. Another example is respect for each individual resident s sleep/wake cycle. Residents can choose when they want to go to bed, and when they wake up in the morning. This way, residents do not feel rushed to comply with a staff schedule. Improved sleep patterns provide residents with more energy and desire to engage in activities. Recreational activities should be determined based on resident interests and available at the times they want to participate. Staff should remember that residents should be treated as well functioning adults and not patients in an institutional setting. 15 of 42

16 To continue the homelike atmosphere of the facility, create an entrance that is warm and inviting. Landscaping should include brightly colored flowers and a well-lit sign at the main entrance that can easily been seen during the day and night. Decorate the interior with colors and items that are appropriate for the season and holiday. The reception area should have adequate security with personnel, cameras, and a locked front door, but also be inviting for visitors. Consider installing a fish tank in the reception area for residents and visitors to gaze upon while waiting. Have a table with coffee and fresh-baked goods for visitors. Have a dedicated reception greeter to give a warm hello upon entry and assist visitors in locating residents and common areas. Corridors have wonderful decorating potential. Décor on the corridor walls should change regularly. This can be accomplished by using rotating framed artwork created by residents. Corridors should also have attractive signs for each unit with appealing names instead of numbers and letters. Corridors should be clear of all equipment and other items that can cause fall hazards. Good lighting and grab bars on both sides will help improve safety by reducing falls. 16 of 42

17 In 2011, new dining practice standards were created for nursing homes in the United States. This means that each resident should have their personal choice of foods, while considering their health issues, and a more enjoyable dining experience. An example of this change is offering a variety of foods in buffet-style, café-style, or family-style dining. Institute special themed dining nights featuring foods of other countries, such as Italy or Mexico. Dining changes can include adding different tablecloths and battery-powered lanterns to tables. Heavy-duty, moisture-proof vinyl tablecloths can easily be sanitized to enhance safety. These can be purchased in different colors and patterns to help make the dining room more festive and inviting. The use of battery-powered lighting adds a nice ambiance to the room and reduces the risk of fire hazard. Other dining changes include offering residents the choice of when they want to eat and who they want as tablemates. Try to keep noise levels low in dining areas so residents can engage in conversations. This can be accomplished by adding drapes, reducing background music, and covering tables. Consider adding social hours for residents. These added changes can improve the residents desire for dining, increase social interactions, and enhance their overall quality of life. 17 of 42

18 Michelle H. Halligan and colleagues published an article in 2013 about the safety culture in long-term care settings. During their investigation, they discovered several major barriers that inhibited achieving goals for improving the safety culture. The first barrier is staff workloads that are too burdensome. Make sure that staffing is adequate for the level of care that is required for your facility s residents. The second barrier is caused by inadequate financial resources and tight budgets. Find creative ways to increase revenue and use that income to purchase safety equipment. To add extra income for the facility and also meet individual dining needs, small café-style dining can be available for residents on special evenings and the large dining room can be used to cater community events. This also increases facility exposure and is a good marketing tool. The third barrier was identified as a lack of staff incentives and rewards. Providing staff rewards for good safety behavior can help facility safety awareness improve. Institute a monthly point system for the staff where the employee with the highest point total receives a reward. 18 of 42

19 The staff that Halligan and colleagues interviewed stated that safety concerns are often overlooked by the facility s management team. Senior managers should verify that safety issues identified by the staff are addressed by middle managers. Halligan and colleagues identified another barrier as the lack of safety culture education for employees. It is important to continuously educate staff on safety as issues are identified. Poor feedback to staff about incident reports was another identified barrier. It is important that adverse event reports are completed by staff and analyzed by management. Share these findings with employees so that they can be involved with the safety improvement process and prevention strategies. The last barrier identified is low levels of communication between groups of staff. All levels of staff should work as a team. Provide team-building exercises for all employees to help improve communication. If senior managers address these identified barriers, their longterm care facility s safety culture will be enhanced. 19 of 42

20 Adverse event reporting is an important safety feature for long-term care settings. Senior managers should encourage staff to complete incident reports and ensure that they are analyzed. Adverse events and near miss reports should be reviewed by a designated person and/or committee on a regular basis.plans can be developed based on information from these reports that identify safety-related situations. Senior managers must educate staff on how to appropriately complete the reports and what types of situations are considered reportable incidents. Halligan and colleagues noted that employees stated they did not have enough time to complete the forms. This needs to be addressed and rectified to facilitate compliance with incident reporting. One way to enhance reporting of adverse events by staff is to change the atmosphere of the facility. Instead of a punitive blaming environment, the culture should be positive with open dialog among employees that encourages reporting incidents. Create a learning environment that enhances facility safety based on the types of reports received. Once the staff experiences this collaborative relationship with adverse event reporting, senior managers will acquire more data to analyze for enhancement of the facility s safety culture. 20 of 42

21 In 2012, a 72-year-old female nursing home resident in New York died due to employee negligence. The resident, who was placed into the nursing home on a temporary basis for rehabilitation, had a physician order to be hooked up to a ventilator at night. The licensed professional who was supposed to perform this task did not read the order and the resident was not connected to the ventilator. As a result, when the resident went to sleep she stopped breathing and died. Alarms sounded, but the licensed professional ignored them. A nurse s aide who was not assigned to care for her responded to the alarms and found that she was dead. The corporation and the top administrator attempted to cover up this situation. In addition, the owner of the nursing home diverted 60 million dollars in Medicaid funds to himself and some other employees. The owner was charged with fraud in a civil lawsuit by the New York Attorney General. In addition, seven employees were arrested due to this incident. 21 of 42

22 According to the American Association for Long Term Care Nursing, nearly 5 billion dollars are spent annually on avoidable hospitalizations of nursing home residents. These elderly residents are at significant risk for medical complications due to their age and medical conditions. This results in additional unforeseen costs and possible litigation. Nursing homes and assisted living facilities have some of the highest rates of unnecessary and avoidable injury and illness. According to the Bureau of Labor Statistics, nursing homes and assisted living employees have an average rate of 7.6 lost workdays due to injury and illness, as compared to private industry, which has an average rate of only of 42

23 Staff injuries lead to increased costs for worker s compensation claims, loss of work time, and less staff to care for residents. Beware of the domino effect that one mishap may have on the facility. If a resident is dropped during a transfer, they may suffer a severe injury. Resident injuries lead to higher medical bills, complications, illness or death, which may result in costs associated with litigation. According to Collins et al., Research has shown that safe resident lifting programs reduce resident-handling workers compensation injury rates by 61%, lost workday injury rates by 66%, restricted workdays by 38%, and the number of workers suffering from repeat injuries. Senior managers need to review incident report data and communicate with middle managers and direct care staff to determine which types of devices or mechanical lifts are needed in the facility. Once purchased, staff should be trained to use the newly acquired lifting equipment prior to first use. Training must be ongoing for new staff. Senior managers can provide employees with timely updates on the number of staff and resident injuries that have been prevented since introducing ergonomics into the facility. 23 of 42

24 The senior manager should supervise the development of an emergency operations plan for the long-term care facility. The Joint Commission provides long-term care facilities with standards for preparing and managing emergency situations. Various types of emergencies can cause resident care interruptions and affect the staff and facility. Some emergencies may include power outages, water and fuel shortages, flooding, or communication problems. The senior manager should ensure that emergency standards are incorporated in the facility s policies and procedures and that these policies are followed. This structure includes emergency preparations, responses, and identification of staff members responsible for the emergency response activities. Once the emergency situation has passed, the plan should address the recovery process for the facility. Once recovery has been completed, evaluate the plan and determine if any revisions are necessary based on the response to the emergency. Testing the components of the emergency operations plan can be completed by scheduling emergency drills. 24 of 42

25 What is your facility s plan to respond to fires and how well does your staff know this plan? The city of Colorado Springs requires a written fire safety and evacuation plan for all assisted living facilities and nursing homes. A cover page, written plan, site plan, and floor plans with evacuation routes must be included. The fire safety plan should explain how the facility will account for all employees and residents when an evacuation has occurred. The plans are submitted to the Fire Marshal, who reviews them and provides approval. The emergency plans should be reviewed and communicated in advance to the community s first responders. Employees must be trained on emergency preparedness so that they know what their duties are during an emergency situation, including emergency plans for residents with special needs. This training should occur during new hire orientation and then on a regular basis. It should include fire prevention, fire safety, evacuation, and emergency lockdown training. Residents also need to participate in training and practice drills for responding to an emergency and assisting in their own evacuation to the best of their ability. Any time there is an unwanted fire or a fire alarm is triggered, the fire department must be notified. When this occurs, the fire emergency response and evacuation plan will go into effect within the facility. 25 of 42

26 How well do your employees know how to respond when the facility s emergency plan is initiated? Do they practice emergency drills on a regular basis? The senior manager should ensure that these drills are conducted and that an appropriate staff response occurs. Types of drills that should be practiced regularly include fire safety drills, resident evacuation drills, and lockdown drills. Staff should be educated about their specific role in shelter-inplace plans, otherwise known as a lockdown. A lockdown is an emergency situation when residents within the facility need to be secured somewhere within the facility because there is a risk with evacuating outside the building. The city of Colorado Springs requires that assisted living facility emergency drills be conducted at least 6 times per year. All assisted living facility residents must participate in the drills and actually be evacuated to a selected safe meeting place outside the facility. Residents in nursing homes with special evacuation needs are not required to participate in these drills. Keep records of all drills. Notify your local fire department prior to drills if a fire alarm will be used to initiate it. 26 of 42

27 Have you created an agreement with an outside facility that can house all of your residents during an emergency situation? Arrangements for a safe location should be made by the senior managers ahead of time, so that during an emergency situation a location has already been set and will be prepared to handle the influx of residents. Do you have a plan to transport the evacuated residents to the outside safe location? Do you have a plant to transport residents with complicated transportation needs? A contract with a transportation company for emergency evacuation of the residents in your facility should be established. This is a national requirement that has been included on the Centers for Medicare & Medicaid Services checklist for emergency preparedness. The resource section of this educational program has a link to the Centers for Medicare & Medicaid Services national requirements for evacuation preparations. Network with other long-term care providers to find resources for these issues. 27 of 42

28 Extended power outages are another type of emergency situation that can occur in the longterm care setting. Senior managers should be aware of the state requirements for preparedness for this type of situation. For example, according to the Vermont government, when an extended power outage occurs in a long-term care setting, it is important that the facility immediately contact a contractor or the electric company to try to remedy the situation as quickly as possible. The power outage can adversely affect the indoor climate, which can lead to illness in residents. If the facility has a generator, an adequate number of days of fuel should be available. The amount will depend on the requirements of your facility s governing authorities. The senior manager should designate an employee to respond to power outage emergency situations and initiate use of the generator. Regular maintenance should be conducted to keep the facility s generator in proper working order. If the facility does not have a generator, then senior managers will need to oversee the evacuation of residents for transfer to a safe location as needed. For short-term power outages, the facility should keep a ready supply of extra blankets, mittens, and socks. 28 of 42

29 External and internal communication safety issues should be addressed by senior managers. External communication occurs with agencies or facilities outside the long-term care setting. Prior to the occurrence of an emergency situation, senior managers can establish a good working relationship with other nursing home administrators and local emergency service providers. This will help the management team to work cohesively with these agencies should an emergency occur. Senior managers can discuss emergency preparedness issues explore alternative methods for handling emergencies or finding resources. 29 of 42

30 Internal communication systems are needed for emergency situations. Staff members on the unit need the ability to communicate with other employees located elsewhere inside the facility. For this, senior managers may choose to use equipment such as walkie-talkies. Staff also needs to be able to communicate with emergency workers outside the building. The communication devices must be charged and checked on a regular basis. An employee should be designated to keep them in good working order to be used at any given moment. Do not depend on cell phone communication. 30 of 42

31 In conclusion, senior managers need to utilize their leadership skills to create an environment that merges the culture change movement with a culture of safety. Begin by getting staff and residents excited and involved with creation of a comfortable, homelike atmosphere. Enhance safety by regularly analyzing adverse event and near miss incidents. Encourage staff to complete incident reports by changing from a blame type of atmosphere to a learning environment. It is important that senior managers oversee the use of policies, procedures, and drills for emergency situations. These should align with local, state, and national requirements. Senior managers can begin collaborative relationships with the local emergency response services, a transportation service, a safe facility to utilize for evacuations, and other long-term care facilities. Reduce rates of resident and employee injuries by utilizing ergonomic strategies. Make sure that units are staffed adequately for resident and employee safety and reduced stress. All of these changes can help improve safety, reduce litigation, and improve relationships among residents and staff. As senior manager, you can lead the way for the vision of culture change and safety awareness to improve your long-term care facility. 31 of 42

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