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7 There are two learning objectives for this program. Please read through the learning objectives before proceeding to the next slide. 7 of 37

8 This program will address important concepts related to safety for long-term care facilities and residents. This includes: patient safety related to litigation; culture changes in long-term care facilities; and interventions to improve long-term care resident safety. At the end of the program, a case study will be discussed 8 of 37

9 As the middle manager of a long-term care facility, it is important to stay focused on the goal of keeping the residents safe and free from injury. The National Advisory Council for Healthcare Research and Quality emphasized the importance of providing high-quality, evidence-based care. When negligence occurs, the patients who are harmed are not well served through the medical liability system. David G. Stevenson and his colleagues investigated if and how litigation affects health care quality in nursing home settings. This study reviewed information about the relationship between costs of litigation for negligence and quality of care. Surprisingly, they found that there is little or only minimal effect on quality of care with litigation. In fact, it is a mildly damaging relationship between the two. 9 of 37

10 John C. West explains the four elements that are required to prove medical negligence. They are: 1-existence of a duty between the provider and the patient to act within the applicable standard of care 2-a breach in the standard of care 3-an injury resulting from the breach 4-damages as a result of the injury All four elements are needed for a negligence cause of action. If any element is missing there is no negligent action. As a middle manager, it is important to ensure that direct care staff provides residents at long-term care facilities with high-quality care. This includes following standards of care, which are developed by regulatory agencies and professional organizations. When developing and updating facility policies, the middle manager should incorporate the most current standards available and should construct the policies based on current evidence that supports best practice. Supervision of direct care staff includes making sure that the facility s policies and procedures are being followed. Staff education needs to be constant and ongoing to make sure they staff members are aware of any new or updated policies and procedures. 10 of 37

11 Culture change is a movement that shifts the focus of care onto the desires and choices of the long-term care resident. This change in philosophy takes into consideration each resident s values, beliefs, and wishes. This is a change from the previous institutional model to a more homelike environment. The residents gain greater control over decisions in their daily lives. Allowing the residents more choices helps to improve quality of life for both residents and staff. Kapp s 2013 article about culture change explains that staff apprehension can be an obstacle for facilities in adopting the culture change model. Many staff may like the institutional type of long-term care setting because it is based on staff scheduling and control. The culture change causes alterations in this traditional structure. Some staff will not be comfortable with these changes. However, closer relationships between residents and staff have been noted as a result of this change in culture. Middle managers can empower direct care providers to take-on the role of change champion in the long-term care facility to help make the transition successful. 11 of 37

12 In 2013, Michelle H. Halligan and colleagues investigated the safety culture at long-term care settings. Findings of this study included identification of barriers that prevent improving a culture of safety in long-term care facilities. The article describes 7 barriers, starting with staff members who have workloads that cause them to feel overburdened. The second barrier is related to inadequate resources, which are the result of decreased funding. Poorly utilized staff incentives and rewards for employees who exhibit good safety behaviors contribute to the third barrier. The fourth and fifth barriers relate to safety concerns that are overlooked by the facility s management team and the lack of safety culture education. Inadequate communication between staff members and the management team s missed opportunities to provide feedback to staff about incident reports are the causes for the last two barriers in this list. 12 of 37

13 The Joint Commission standards for long-term care facilities represent state-of-the-art practices for long-term care. The 2014 National Patient Safety Goals that were developed by the Joint Commission include the importance of identifying residents correctly, the safe use of medicines, preventing infection, preventing resident falls, and preventing pressure ulcers. The Joint Commission stresses the importance of managing risks of the long-term care environment. This is performed by developing written plans that address the safety of the building, equipment, and people who work or reside within the facility. Aspects of the facility that need to be addressed in these written plans include: safety and security; hazardous materials and waste; fire safety; medical equipment; and utilities. 13 of 37

14 Poor adherence to evidence-based guidelines for long-term care staff is problematic. In one example, a study published in 2009 about the compliance of nursing staff to use evidencebased pain management practices showed a significant gap in how nursing home staff assessed and managed a resident s pain. Often staff was noncompliant with the established guidelines for pain management best practices, illustrated by their failure to assess the pain of the residents and neglect in evaluating the treatment plans. The focus of the middle manager should be to bridge this gap so that the best practice guidelines can be translated and put into practice within the long-term care setting. One way to increase staff compliance is to determine the reasons that guidelines are not being followed. Survey staff and investigate routine practice in the facility to determine obstacles to following policies. Determine whether noncompliance is due to a system failure of the facility or individual staff performance issues. 14 of 37

15 Emergency Management standards of the Joint Commission provide long-term care facilities with the criteria 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. These emergency standards will help guide middle managers to establish the structure on which to base emergency policies and procedures for the facility. This structure includes emergency preparations, responses, and identification of staff members responsible for implementing the emergency response activities. Once the emergency has passed, the plan addresses the recovery process for the facility. Once recovery has been completed, evaluate the plan and determine if any changes should be made based on the response to the emergency. This process of checking the components within the Emergency Operations Plan can also be completed by testing the plan in emergency drills. 15 of 37

16 For many years, residents and health care workers have suffered injuries as a result of lifting or moving residents manually. On June 25, 2013, the American Nurses Association (ANA) issued a news release announcing the National Standards on Safe Patient Handling and Mobility. The official position of the ANA is that manual lifting of patients should be eliminated. The foundation of these standards is to improve the culture of safety within various healthcare environments, which include long-term care settings. A group of interdisciplinary healthcare professionals worked together to develop these standards. This group included nurses, physical therapists, occupational therapists, safety experts, ergonomic experts, and risk managers. 16 of 37

17 According to the U.S. Bureau of Labor Statistics in 2011, nursing assistants and nurses have some of the highest numbers of lost workdays due to musculoskeletal injuries in the country. In a survey conducted by the ANA, it was reported that within a 12-month period more than 1 in 10 nurses were injured 3 or more times while on duty at work. Disability compensation, medical bills, and possible litigation-related costs that result from employee injuries increase employer costs. The Safe Patient Handling and Mobility Standards can help improve workplace injury statistics in the future and mitigate the unnecessary painful and costly injuries occurring in the workplace. Some of the principles these standards are based on include establishing a culture of safety; creating a sustainable safe patient handling program; incorporating ergonomic design principles; and developing a technology plan. 17 of 37

18 The last of the 8 principles of Safe Patient Handling and Mobility include: educating and training direct care staff; assessing patients to develop individualized care plans; providing employees with reasonable accommodations to return to work after having an injury; and implementing an evaluation system. Middle managers in long-term care facilities need to incorporate these principles into their workplace settings. This will help to reduce the amount of resident injuries that occur from staff performing manual lifting, moving, and repositioning. It will also help with reducing worker injury and loss of work from musculoskeletal injuries. 18 of 37

19 On OSHA s Safe Patient Handling website, it explains that health care facilities need to rely on technology for lifting, moving, and repositioning patients instead of having staff members perform these duties manually. Areas within long-term care settings that are considered high risk for injury include bathing areas. To help get cooperation from residents regarding the use of lifting equipment, it is best to have staff explain the planned lifting procedure and equipment prior to use. Explaining how this equipment works will help increase their safety and comfort with the move, and their sense of dignity will be increased. Incorporating a Safe Patient Handling program can also help offset costs of injuries within the long-term care facility. Musculoskeletal injuries lead to increased costs due to medical bills, disability compensation, and lawsuits. OSHA found that as many as 20% of nurses who leave direct patient care positions do so because of risks associated with the work. 19 of 37

20 Hourly rounding has been found to be a good strategy to help prevent falls. Daryl Dyck and colleagues trialed this program in a long-term care facility in This program consisted of routine screening with a standardized fall risk tool for all newly admitted residents within 48 hours of admission. Clinical practice guidelines for residents at high risk for falls were established. Algorithms were developed to determine fall distribution and use of fallprevention equipment. Mandatory staff education about falls and fall prevention was provided. The nursing staff identified residents at high risk for falls and placed a logo on their bed. Residents at high risk for falls were assessed for fall risk behaviors on an hourly schedule. Dyck and colleagues determined that the essential components that were needed to attain program success included: allowing sufficient time for preparation, requesting assistance from other facilities with experience in using the program, encouraging multidisciplinary collaboration, finding a creative approach to implement the program, and having staff fully engaged throughout the process. An early result was found to be a reduction in fall rates on the nursing unit trialed. 20 of 37

21 Middle managers need to develop an emergency operations plan. Once that is developed, middle managers will need to prepare in case an emergency situation occurs. Identify hazards that can cause an emergency, such as fires, floods, bioterrorism, hurricanes, pandemic illnesses, security issues, and tornados. Review the plan with local emergency management services in the facility s community. In collaboration with these services conduct exercises and drills on a regular basis with the staff. Determine where residents would be taken in case of an evacuation. Collaborate with a shelter to devise a plan for evacuation of the long-term care residents to the shelter. Decide what mode of transportation will be needed for the evacuation and create a plan with a transportation company to provide this service. Shelter-in-Place refers to a situation in which residents remain at the facility during an emergency. All middle managers in the facility should develop a plan for a facility emergency regarding maintenance (secure facility), dietary (emergency food storage), pharmacy (medication storage), vendors (supplies, transportation), and security (residents and facility). The facility managers should communicate the facility s emergency plan to an ombudsman so they will know where residents will be sheltered. 21 of 37

22 The Centers for Medicaid and Medicare Services (CMS) proposed emergency preparedness requirements in December Included in this proposal is information about the importance of facilities being able to provide subsistence to the staff and residents. The facility and suppliers need to have a plan in place that includes the quantities the facility will need to cover all staff and resident needs. Eventually the CMS guidelines will address this and how long the supplies should last. Most states have requirements for assisted living facilities that mandate non-perishable food and drinking water supplies for emergency situations. For example, the state of Georgia requires that the food supply must be available at all times in sealed containers and kept specifically for use in emergency situations. A three-day supply for the usual number of residents who live at the facility is included in Georgia s emergency regulations for assisted living facilities. It is also the middle manager s duty to make sure that any food supplies and emergency equipment have not expired past the date of safe use. Middle managers should coordinate with others in the facility to make sure that all emergency preparedness supplies, maintenance, and staff are ready when an emergency strikes. 22 of 37

23 The Joint Commission reviews safety and security issues during the accreditation process. The security issues that are included in the accreditation process address the facility s environment, resident information and data, secured area access, product recalls, and smoking. It is important for middle managers to make sure that these security topics are included in their facility s safety policies and procedures. 23 of 37

24 Extreme climate temperatures can greatly affect the health of older adults in a relatively short timeframe. Their underlying medical conditions can cause reduced responses to regulating body temperatures. Middle managers should be aware of any state or local requirements regarding climate control that must be met for their specific type of long-term care facility. An example of this is the assisted living facilities in the state of Georgia, which are required to maintain climate control for residents at above 62 F during the night or below 85 F during the day. If inside temperatures rise above 80 F, cooling devices are required. In addition, recommendations have been developed regarding climate control. The National Institute on Aging recommends that thermostats for elderly individuals in independent settings be set at 68 F to 70 F to avoid hypothermia. Blankets or afghans can be used over the legs or shoulders to help keep residents warm. Use of socks on feet and mittens on hands can assist in maintaining body heat indoors. In emergencies when climate cannot be controlled, the facility must provide measures such as heaters, fans, and extra blankets to help keep the residents body temperature at an adequate level. Middle managers should take immediate action to call for service and try to rectify any climate situations that occur. 24 of 37

25 In an article written by Timothy E.J. Folk and Rafael Haciski, Esquire in November 2013, they explained that there was a shift in plaintiff lawsuits from a focus on medical doctors and hospitals to long-term care facilities. This shift occurred due to tort reform and improved risk management interventions by physicians and hospitals. There is also an increase in long-term care related litigation due to an aging U.S. population. Many states have uncapped punitive damages, for example, Pennsylvania, whose elder population is over 15%. An example of a lawsuit relating to negligence in care from understaffing is the case of Scampone v. Highland Park Care Center. This was a case where the Pennsylvania Supreme Court held that a nursing home may be held directly liable under a theory of corporate negligence. This case changed how the Pennsylvania corporate liability doctrine is applied. 25 of 37

26 Madeline Scampone died of a heart attack at age 94. She was a resident at a nursing home in Allegheny County, Pennsylvania. Her family sued the nursing home, and an article on the case noted, It was alleged that as a result of neglect, primarily due to understaffing, the resident developed multiple urinary tract infections, dehydration, malnutrition and bed sores. It was further alleged that these conditions were substantial factors in causing cardiac arrest and death. Initially, the jury awarded the plaintiff $193,500 for compensatory damages. Both parties appealed the verdict to the Pennsylvania Supreme Court. According to the court, staffing decisions directly and detrimentally affected Ms. Scampone s care. They determined that the facility s understaffing ultimately led to her death. As a result, the nursing home was found directly liable for her death due to corporate negligence. Middle managers need to be cognizant of their staffing ratios. Check your facility s state regulations regarding staffing requirements. Also review national staffing guideline recommendations to determine whether or not your facility is being staffed appropriately to help meet the safety needs of the residents. 26 of 37

27 As we saw with the Scampone case previous lawsuit example, staffing is a vital issue for resident safety in long-term care settings. In addition, having quality staff that is adequately trained is another issue regarding resident safety and litigation risk. Folk & Haciski explain that the best way to prevent litigation is by making sure all of the staff at long-term care facilities is properly trained. This includes providing mandatory staff education on safetyrelated topics. Middle managers should make sure that areas of highest lawsuit potential are addressed with the staff in an educational format. These topics include: safe handling of residents, adequate supervision of residents who are immobile, warning signs of resident physical and sexual abuse, proper identification of a resident s level of care, following each resident s individualized care plan, and coordinating care between the medical director, personal physician, and nursing staff. 27 of 37

28 This program provided an overview for middle managers about prevalent safety issues that occur in long-term care facilities. Additional resources are provided on the next two slides that can assist the middle manager with developing policies and procedures to help prevent or adequately manage safety and emergency situations. Review state regulations and national guidelines for resident safety issues. Develop policies and procedures for your facility based on best-practice standards. Supervise evidence-based care for residents. Maintain adequate staffing for your facility, including the number of staff, types of staff, and quality of staff. Provide adequate training and equipment for employees to be able to perform their jobs in a safe manner. For adequate safe handling of residents, middle managers should eliminate manual lifting. This may include purchasing lift equipment for the facility and training staff on its use. Having an adequate Emergency Operations Plan prepared with regular practice sessions for staff is another way to improve safety in longterm care settings. Have a pro-active outlook toward avoidance of lawsuits. Safety prevention is the best way to avoid litigation. Utilize the strategies and resources provided in this educational program to help initiate, improve, or review your facility s program of safety. 28 of 37

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