code blog: tales of a nurse

Lynn, RN, writes:

I am an RN living and working in a rural area. I am DON (Director of Nursing) of a mid-sized (80-ish) nursing facility; I have been in this position here for 6 years. I have been turned in to the Nursing Board by the state that I live in and would like to tell my story.

Every 9-15 months we have what is called an Annual Survey done by the State. The US Government (CMS) is actually charged with doing this survey, but they contract with the State for the State to do it. Therefore, on 5% of the State surveys, the feds come in to survey the surveyors. This is what happened to us. This is called a FOSS (Federal Oversight) survey, and it isn't pretty. State surveyors' jobs are on the line, they are being surveyed while they inspect us. The problem is, in order to impress the feds, they become even more picky and punitive than usual, and that is a more extreme stance than you can imagine. I understand the survey process and the need for it, but things do get out of hand, and it is not unusual for surveyors to exaggerate or fabricate errors on our part to create deficiencies to cite.

It was even worse this time, even with the feds there watching. I knew the system was corrupt, but I had no idea that the worst behavior of the surveyors were supported by the feds. Just a quick example--in the kitchen they were measuring the temperature of the food to be served. Our kitchen manager had a thermometer, and the surveyors had a thermometer. Well, the temps displayed differently on the different thermometers, so the surveyor immediately said to the kitchen manager that her thermometer was wrong. She challenged this, saying "how do we know OURS is wrong and not yours?" So the surveyor told her to check hers in ice water "and it should read 0 degrees," which of course is wrong. The kitchen manager checked hers in ice water, it registered 32 degrees and she showed this to the surveyor, who said, "Oh, of course, that is correct."

Then two weeks later when we received our deficiencies in the mail, that temperature was recorded as incorrect and we still got the deficiency. I won't bore you, but there were over a dozen instances like that during this survey, some written as deficiencies. Anyway, to the real story. We had a resident in our facility who had been admitted about 9 weeks before the surveyors came. In the first two weeks of his stay with us, he kept insisting he had to leave, and kept trying to leave. This is not unusual in long term care, the man had dementia and did not understand who we were, where he was, or what was happening to him. Actually he was much better off than some residents in this situation--his wife had already been at our facility for two years (also dementia, plus a couple of bad strokes brought her to us) and he had 2 grown children, both retired, living nearby with plenty of motivation to spend time with their ailing parents, and who visited frequently.

But still, his transition to the facility was a problem. Twice he left the building, staff in tow, and went down the street. We got him back, once in a staffer's vehicle and once by calling in the daughter who helped talk him into coming back. Eventually we got a handle on this behavior and he quit trying to leave. He only got off the premises twice, but during the first month he was with us he probably got out the door a hundred times. We have an alarm system on the door which is the only reason he never actually got away from us completely. Staff MOVE when they hear that alarm, find him just walking out the door and bring him back. So the problem was that we allowed a resident to leave the facility (elope, they call it) without adequate controls to keep him in the facility. The thing is, it is standard practice, at least in this area, to let them go outside and walk with them, let them get tired then bring them back. The deficiencies as written by the State say that we are located on 4 busy streets, which is not true. We are actually located on 3 dead-end streets and one other street that runs from the main street of town and dead-ends at our facility (3 blocks) so is technically also a dead-end street.

Anyway, what I am interested in, is if anyone out there has had similar experiences and knows how the Board responds to such incidents and allegations. I have been an RN since 1976 and actually have another career in the works as small business owner, but surely had no plans for giving up my nursing license. This is an incredibly emotional issue for me, it is terrifying to have your license/career threatened in this way. And let me say that this family is so supportive of us--they met with the State surveyor for almost an hour while they were here, and the surveyor tried really hard to get them to say awful things about us, and they defended us totally. Each of the 2 grown children has written letters of support and the letters state how attentive we have been to the resident's needs and special behavior problems, and I will be including this letter in my response to the Board. I am writing my response to the Board, which is due NOW and I am not sure how to frame it. It sure is hard not to be defensive. I would welcome comments from those in long term care who deal with this stuff daily and understand the problems and needs of our special old people.