Nursing Home Surveys: “It’s Just Fundamentals”

    Several federal regulations and quality improvement instruments govern the type and quality of care provided in long-term care facilities, one of the most heavily regulated of all healthcare settings. A recent discussion with a state surveyor shed some interesting light on the entire long-term care survey process.

Even though (at press time) the final revised document has not been released, angst-laden anticipation is rife among nursing homes regarding the Centers for Medicare and Medicaid Services’ (CMS) revised Guidance to Surveyors for Pressure Ulcers (F314) and Urinary Incontinence and Catheters (F315). The most recent draft of these documents merely reflected current evidence — or consensus-based best wound care practice.

    When asked about wound care in particular, the first statement by the surveyor was, “It is simply nursing fundamentals.” The CMS and state governments hire surveyors to inspect (survey) long-term care facilities. Surveyors do not write specifically to the Guidance document, but rather evaluate whether a facility is adhering to OBRA (Omnibus Budget Reconciliation Act) regulations, using the Guidance documents for just that — guidance — for more specific explanations of OBRA regulations and best practice. Failure to comply with these regulations can mean fines and sanctions, up to and including the loss of the facility’s license.

    “I show the OBRA regulations to providers and that’s what I measure them against,” the surveyor said. “I’m not out to get people. I try to be collaborative, objective, and fair. I don’t get paid any more if I write 10 citations or none.” To put it simply, healthcare organizations must be familiar with OBRA guidelines in order to provide quality care, pass surveys, and avoid citations.

    The surveyor went on to explain that licensed personnel could address many situations if they just had the right information and training, especially when it comes to wound care. Other non-specialized peers rather than wound care experts are frequently the source of on-the-job wound care education. Subsequently, a facility’s wound care often does not adhere to best practice standards — “Nurses are woefully lacking in fundamentals when it comes to wounds,” the surveyor says. Nurses have an individual professional responsibility to seek state-of-the-art wound care training, to know their skill limits, and to know when to contact the physician and/or a Wound Ostomy Continence Nurse. It is crucial that nursing homes accept the fact that staff education is a critical and sound investment in the organization and the welfare of its residents.

    Often, the frequency of dressing changes is inappropriate for the patient’s wound. Many wounds do not require b.i.d. or t.i.d. dressing changes, yet nurses are reluctant to challenge the physician writing the orders. “Too frequent dressing changes on inappropriate wounds waste time and resources,” the surveyor says. Another area in which nurses must start challenging prescribing physicians relates to dressing selection. If the dressing is inappropriate to the characteristics of the wound (size, exudate, depth, debridement, and the like), nurses should proactively address the issue with the physician and suggest a more appropriate dressing.

    Another vulnerable area is the use of air-fluidized overlay mattresses. Air overlay mattresses often are misused because of inadequate inservicing by the manufacturer, high staff turnover, or operator error. Worse, when asked by the surveyor, the staff often are unable to produce the manufacturer’s instructions and guidelines on the proper use and operation of the device. This surveyor evaluated a 120-lb, at-risk resident on an air-fluidized overlay mattress that had been set for a 400-lb patient. “She may as well have been placed on a bed of rocks,” the surveyor remarked.

    Yet another, long-standing area of weakness for surveys and malpractice litigation relates to documentation. Documentation of wound care can be too scanty, absent, inconsistent, too complicated, redundant, or is located in too many different locations in the resident’s medical record. Documentation during an initial assessment is also critical. For example: A resident’s family files a complaint that the patient developed a pressure ulcer during a skilled nursing facility stay. “I’ll check the initial assessment,” says the surveyor, “and if it’s done properly, I know the pressure damage probably did not occur in the nursing home, but began during hospitalization.” In addition to a review of medical records, surveyors examine and observe other patients with wounds and interview residents, staff, and families to confirm or deny what does or does not happen, looking for trends and patterns.

    “Today, nurses are task-saturated and have a lot to carry,” the surveyor notes. However, regardless of whether continuing education credits are required in a state, nurses and their employers have a professional responsibility to remain current on state-of-the art wound care. Provider organizations also must realize that it all comes down to basic fundamentals — if the staff is not armed with that kind of knowledge, the facility (as well as its residents) is at risk. It is time to change business as usual and bring changes in wound care research and technology to the bedside of nursing home residents. The science of wound care has moved forward. Providers must ask themselves if they and their staff have moved forward with it.