Wednesday, October 10, 2007

Vigilante Regulators...

Wow...Who wants to duck and run from long term care in Michigan today after yesterdays frightening "joint provider" training?

For those of you who are not fortunate enough to work in long term care, let me share with you that yesterday we (providers from all over Michigan) and our survey agency staff, affectionately called the "state" by providers sat thru the most vigilante/out to get you with a vengeance seminar/training that I have ever experienced. "The underlying theme I felt was that we, (providers) cause harm, have the potential to cause harm, and that we are going to be "caught" irregardless of what we do for our elders.. When I define caught, I am referring to the use of the surveyors new weapon against nursing facilities; the Immediate Jeopardy tag that strikes fear in the heart of every Nursing Home Owner, Administrator and staff care giver.... Read on for the highlights of yesterdays events.

The original purpose of these training seminars was to bring providers and the oversight agency from the State of Michigan together for training on best practices, new regulations and to create an environment that focused on collaborative visionary care thinking... Well the training continues but what originally was started as a collaborative "good will" event has quickly become a "here are the new rules and best practices as we see them; and by the way; tough about what you think is really important/priority for your elders"... Common sense and practical thinking about what elders really need and want be damned....

Maybe I am biased, maybe I am way off base, but when I sat and listened to the surveyors from the CMS regional office share "great stories" about facilities that have been closed, or suffered from an IJ tag with such relished enthusiasm I felt an illness in my stomach. Where is the elder in their enthusiasm? Where is the resident opinion and right in the citations that they quoted so joyously? As an advocate for elders I fear that our regulators are jumping to judgement without considering the resident point of view and their rights are being forgotten..

Let me share the story that made me the most ill and frightened for my elders..During a presentation about how an immediate jeopardy citation can be cited for the potential to cause harm, the CMS regulator spoke with great enthusiasm about a small facility in rural Wisconsin that had received four perfect, zero citation surveys during the past four years; only to get an IJ on the last day of survey for delivering a resident a birthday cupcake with a lit candle on it. The surveyor even described the scene, "the dining room was full of staff, families and residents; all there to celebrate this residents birthday and they were singing to her and it was her special day".

The problem? the resident had a nasal cannula in her nose with oxygen to it. NO she did not blow up, no fire, no injury no harm. Yet, they(the surveyors) ruin the excitement for this elder/staff and give them(the facility) an immediate jeopardy for the potential for a fire due to oxygen in her nose, and the small lit birthday candle....Could she have been hurt, possibly. Should they have known better, probably. Did the facility deserve to be fined, nearly closed, lose it's ability to admit residents, get placed on a "bad facility listing" and lose it's nurse aide training because of it? Not to mention the "label" and Internet label of poor performer; hardly.

As an Administrator this type of story is not only infuriating it is devastating. This facility has to be one of the best facilities you could encounter. Knowing the type of care/resident and staff interactions that must exist for a perfect survey to occur; I know that this facility has to have real person centered care relationships and outcomes in existence. I would bet this facility has great family, community, resident and staff support and enthusiasm. How do I know this? I use my own facility as a gauge and my peers who also have had the great fortune of a "perfect survey". To attain this you have to have reached beyond the regulations to create the remarkable person center nirvana that is the pinnacle of the elder care experience.
I can only imagine how crushed/damaged the dietary aide who delivered the cupcake would be. I think of my own enthusiastic, caring young people who work in my kitchen. I see them deliver the snacks in the hallway, in fact as I type this I am hearing them singing to one of my elders a rap song...there is laughter and a real relationship occurring spontaneously.

I think of the emotional damage to the elder. In our building, the elders are outspoken about their needs and wants. This is good! To me that says, "hey, I trust you to fix this, and I know it is o.k. to say what I think because I trust you, you will not harm me, you love me and want what is best for me when you care for me." They demand real relationships and the unconditional love that is given and received in a person centered care model.

I think about some of my elders and how devastated they would be if they knew that their special day and the love from the staff resulted in devastation for the very same caregivers who love and care for them. They would feel such guilt and be emotionally harmed by the knowledge that their event caused this. (No, my staff would not share, but trust me they would know, we exist as a community and family; that is why our great buildings remain great...)

So where was the elder in this citation? Yes, I agree we must protect our elders from actual harm. But to try and prevent every "possible harm outcome" is ludicrous. Every environment, every person has the ability to be a victim of potential harm. I think about when I fill up at a gas station, and see the person next to me smoking a cigarette or filling a gas can in the back of their pick up. I think about my own bad behavior of using my cell phone while driving. I think of the countless times I have spilled hot coffee on myself in my car; or while wearing ridiculously high heels I have tripped or stumbled.

I think of my parenting and how I raised my son. If you were to look at my environment when he was young, using this model of "potential for harm" you should have taken him from me early on...He broke his collar bone three times before he was 12 years old. I was present at only one of the fracturing events. Yet, he had actual harm from his own volition, and my apparent lack of keeping him from harm. Using the surveyor model, I should have been eliminated from the mother model.

Apparently, because "we" accept money to care for elders, "we" are now held to the light that we must eliminate every "potential for harm" that could exist for the person/elder we are being reimbursed to care for. Resident choice be damned; if your care is being funded by the government I am obligated to give you lukewarm coffee, and wrap you in bubble wrap...Your right to the dignity of making poor choices such as falling from trying to ambulate as long as possible,or smoking a cigarette with poor reflexes, or eating sugar while diabetic could get me an immediate jeopardy, and can no longer be tolerated if I am to exist as a provider of care.

I wonder how many great caregivers went home yesterday and pulled out the resume...This quest for culture change and person centered care is definitely not for the faint of heart.

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