How soon is soon enough?
Bill Vaughan, RN
Providing quality care and avoiding survey issues involves not only doing certain things but doing them in a timely manner. While regulations are prescriptive when it comes to the timing of some requirements (i.e., care plan development, MDS transmission, etc.), the implementation of other interventions is less defined. This ambiguity lends itself to professional disagreements between providers and surveyors with both groups often equally passionate regarding their positions.
Take for example the words “immediate” and “immediately”, terms that appear 253 times in the State Operation Manual, Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Nurses are required to immediately inform the physician when there is a significant change in a resident's condition, facilities must provide the ombudsman immediate access to residents, Medicaid residents who wish to return to the facility after hospitalization must be readmitted immediately to the first available semi-private bed and there is even an admonition to crack eggs immediately before cooking. Immediately is actually defined under F 225 in the context of how soon alleged incidents of abuse, neglect, etc. must be reported to the administrator and state agency:
“…“Immediately” means as soon as possible, but ought not exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement…”
Obviously this definition is not applicable to many clinical situations, for example, the initiation of CPR. It's unlikely that surveyors would view the provision of any emergency procedure as timely if it's begun 24 hours after the event. Another source, Merriam-Webster, defines immediately as “without interval of time”. Taken literally, this definition suggests that certain regulatory requirements must be initiated instantaneously.
I have spent hundreds of hours discussing cases with surveyors trying to determine how soon is soon enough. The reality is that regulations are written broadly to address certain important public health goals while allowing providers the flexibility to determine which practices best achieve those goals. Scrutiny of those practices is inevitable, so what is the key to compliance? Simply put, it's always having an evidenced-based rationale for the care you provide and consistently basing your actions on the needs of each resident. Starting CPR promptly (assuming there is no DNR) is a no brainer, but the timing of other clinical interventions isn't always so obvious.
Take for example the case of an elderly female in a nursing facility who falls and fractures her hip at 11 pm. A surveyor reviews this resident's record and notes that she was not transferred to the hospital until 8 am the next morning, thus delaying definitive treatment for the fracture. The surveyor prepares to cite a significant deficiency regarding a delay in treatment until she reads a note in the medical record documenting the rationale for the apparent delay. The resident's physician, who was on staff at the hospital, knew that had she gone to the ER at 11 pm her surgery would not have been performed until the next morning when the orthopedic surgeon was available. So instead of spending the night on a gurney in a busy ER the resident was keep in her own bed, her leg was immobilized and her pain was addressed. The risks and benefits of delaying her transfer were discussed with the resident and her daughter, and both agreed with the plan. What appeared, on first blush, to be a serious deficiency was actually an exceptional example of resident-centered, compassionate care.
Determining the timing of interventions through a thoughtful risk/benefit analysis, based on the needs of residents, will surely promote better clinical and survey outcomes.William Vaughan, RN, is the vice president of education and clinical affairs at Remedi SeniorCare and was previously a surveyor.