The safety of residents is a top priority for a skilled nursing facility (SNF). But how does one promote safety in such a dynamic environment? Three critical steps the director of nursing services (DNS) and other facility leaders can take are: cultivate trust and transparency with staff, residents, and families; conduct thorough investigations of allegations and incidents; and develop a systematic approach to interpreting incident data and implementing process changes to mitigate or prevent future occurrences.
Below are concrete suggestions DNSs and other facility leaders can apply to improve resident safety in their facilities.
Trust and Transparency
Facility leaders strive to provide residents with the highest quality of care possible, including providing a safe, homelike environment. A culture of safety is essential to creating this homelike environment in the facility. Staff must understand leadership’s beliefs regarding safety and know what is expected of them. Trust and transparency are key to ensuring staff follow the facility policy and protocols for timely notification. Facilities need staff to share their knowledge of events with leadership. Trust and transparency ensure staff feel supported to report all errors, suspicions, and incidents. Conversely, in environments that lack trust and transparency, staff instead often feel they should keep secrets to avoid punishment and reprisal. When staff feel they work in an organization without secrets or reprisals, they are more connected to and invested in outcomes, and more likely to report issues. To cultivate trust and transparency in a facility, leadership should:
- Build relationships – Relationship building creates safety, understanding, appreciation, and reliability. Nurture relationships with staff, residents, and families.
- Be honest – When leaders withhold information, it erodes trust. If the leader does not have the answer or is waiting on further data, it’s important to share that. Candor shows respect for staff, understanding of their concerns, and acknowledgement of their need for information.
- Promote a positive environment – Staff need an environment that does not tolerate uncivil interactions, unproductive gossip, or negative behaviors. There should be no question that these behaviors will not be tolerated.
- Be composed – Leaders who have self-control, poise, and patience minimize workplace anxiety. Leaders can acknowledge there is a problem while still remaining calm (University of Florida, n.d.).
- Communicate – Promptly addressing issues with staff is critical. Give as much information as possible without divulging confidences or laying blame. Ensure staff know what the steps are to correct a situation and communicate often on where leadership is in the process of mitigation. Reiterate the facility’s stand on transparency and the need for leadership to be apprised of issues whether big or small.
Once staff, residents, and family members are comfortable coming to leadership with issues, it’s important to conduct a thorough investigation of information brought to your attention. Doing so ensures that no details are missed and that the voices of all involved in the allegation or incident are heard. Demonstrating that the facility thoroughly investigates issues shows that resident safety is a top priority and that concerns will not be taken lightly.
Facility leadership may wish to use the following process to assist them in conducting a thorough investigation.
1. Determine the purpose for the investigation
First, determine the purpose of the investigation and answer the question, “Why is an investigation being conducted?” Knowing the purpose will help to guide the investigator down the avenues that should be explored during the investigative process.
2. Develop a plan for the investigation
Planning the investigation is a must. First and foremost, facility leadership needs to ensure that the resident(s) involved are safe as well as any other resident who may have been affected. Next, facility leaders should organize the plan by asking:
- Were all of the required entities notified, such as the department of health, local authorities, boards, etc.?
- Who will lead this investigation?
- Will there be anyone else needed to assist with the investigation?
- What evidence needs to be reviewed?
- Who needs to be interviewed?
- Who will conduct the interviews?
- Are staff involved?
3. Review Tangible Evidence and Conduct Interviews
- Reviewing tangible evidence
Any available evidence that can assist the investigator in determining what happened and the root cause should be reviewed. This evidence may include in-house documents such as medical records, billing statements, staffing records, personnel files, schedules, or policies and procedures. Other documents might come from outside sources, like the hospital, EMS records, or even police reports. Other evidence, such as camera footage, incident reports, or digital call light printouts, may also shed light on the issue.
- Conducting interviews
Although it may not always be possible, try having two interviewers in each interview— one to ask the questions and the second to write the statement or take notes. Prior to the start of the interview process, the interviewer should have some standard questions to ask the interviewees. Additional questions can be raised, if the answers to the initial questions require follow-up or further exploration.
The resident(s) involved in the incident in question should be interviewed unless they are semi-comatose/comatose. An investigator might make the mistake of not interviewing residents with impaired cognition because he or she believes that due to the impairment, the resident is unable to give any pertinent information. This is often not the case. When conducting interviewing residents, the investigator is trying to determine if the resident perceives they have experienced harm, as well as details that help establish a timeline and may also help identify the root cause(s).
The interviewer may wish to have a discussion with corporate staff or the facility’s attorney prior to interviewing family members and visitors to receive any special instructions on how to conduct the interviews (Strategic Management Services, 2015).
Each interview conducted needs to generate a written statement documenting the conversation. For those persons interviewed more than once, have a separate statement for each interview with each statement’s date and time clearly marked to keep them organized. If there are contradictions in the statements, documenting this way will be helpful to show those discrepancies. More detailed information regarding the review of documentation and the interview process can be found in the newGuide to Enhanced Resident Safety: Part 1, Incident Management developed by the American Association of Post-Acute Care Nursing (AAPACN).
4. Conclusion and Follow-up
It is at this point that the investigator reviews all the data that was collected. Utilize all resources available to conduct a root cause analysis and make a reasonable determination. Once a determination is made, the facility should complete any follow-up to close the investigation. Follow-up may include completion of mandatory reports such as the facility reported incident (FRI) sent to the department of health, education needs, disciplinary actions, or policy changes. The nursing home administrator or designee may wish to have another discussion with corporate staff or legal counsel prior to any conversation with family members for advice on how to have the conversation, especially if the information to be relayed is not positive. Inform the medical director of the outcome of the investigation as well. Update the medical record as necessary and provide any reimbursement as necessary in cases such as theft or misappropriation.
Having strong incidence surveillance in a facility ensures that issues affecting resident safety are reviewed over time to see if a correction to a process is needed. To achieve a comprehensive incidence surveillance program, facility leaders should:
- Identify and log incidents – Once an incident occurs, the facts and circumstances surrounding the incident should be logged in chronological order and should, at the very least, include the following information: name of resident, date of occurrence, time of occurrence, place of occurrence, type of incident, and if an injury occurred.
- Monitoring incidence – The time frame for monitoring depends on the facility policy and the expectations set forth by the QAA Committee. The facility’s QAPI plan may also outline parameters for monitoring frequency. For example, the director of maintenance may monitor a log related to water temperatures weekly, while the DNS may monitor the fall incidence log monthly.
- Analyzing and synthesizing incidence data – Facility leaders should analyze the incidence data to identify any patterns, trends, or shifts. For example, analysis might reveal that most falls occur at shift change or that the incidence of pressure injuries acquired on a certain wing is higher than on other wings. Synthesizing the data is the act of understanding what the patterns, trends, or shifts mean as well as identifying gaps in processes so that appropriate corrective action can be taken. An example might be that a procedure is lacking an important step.
- Initiate Improvement – Correcting breakdowns or gaps in processes mitigates the risk of future incidents. Initiating improvement may take the form of a corrective action plan, or a full-scale Performance Improvement Plan (PIP) may be chartered depending on the severity of the issue and the nature of the root causes.
- Evaluation – Once improvements have been implemented, an evaluation should be completed to determine if the improvements are working or if new actions are needed. Evaluation must not be overlooked, as it is essential to know if the improvements prevented or at least mitigated further incidents from occurring. Once the improvement’s results are known, the QAA committee and designated leaders will continue the cycle by conducting ongoing monitoring.
AAPACN’s new Guide to Enhanced Resident Safety: Part 2, a QAPI Approach to Incidence Surveillance has more details on how to develop a systematic approach to interpreting data collected from multiple incidents and, using the information, implementing changes in processes designed to mitigate or prevent future occurrences, thus making the facility a safer place for residents.
AAPACN’s new Guide to Enhanced Resident Safety: Incident Management and Guide to Enhanced Resident Safety: A QAPI Approach to Incidence Surveillance can help facility leadership to make improvements and sustainable change in their incident management and surveillance processes. They will be available soon on the AAPACN website.
Quick Tips on How to Use the New Resident Safety Guides:
- Print out the many tools to assist with incident management and incidence surveillance.
- The resources in both guides are interactive and designed to be used again and again.
- The table of contents is very detailed and interactive. Click on each section title to navigate quickly and go directly to the page for the needed information.
- A detailed Excel® spreadsheet is included which generates graphs to assist with outcome surveillance tracking and trending.
University of Florida. (n.d.). Maximize your leadership potential: Build Trust. http://training.hr.ufl.edu/resources/LeadershipToolkit/job_aids/CreatingaCultureofTransparency.pdf
Strategic Management Services, LLC. (2015, January). 26 Tips from experts on conducting witness interviews. Compliance.com. https://www.compliance.com/resources/26-tips-experts-conducting-witness-interviews/