Survey Lessons: I didn’t know I was supposed to report it

Often times we wonder what information we should report to the nurse at the end of shift…most of us are very good with sharing the medical and nursing info. But what about the other things?

The following is an example of how our lack of sharing/reporting can have such an adverse effect on our residents. This is from an actual state survey of a nursing home in Colorado.

Interviewable sample resident #1, a 70-year-old woman, was admitted to the facility on 2/6/07 with diagnoses including (per face sheet) rehabilitation, cerebral arterial occlusion with infarction, dysphagia, late effect hemiplegia, hypertension, diabetes mellitus 2, esophageal reflux, generalized pain, depressive disorder, hypothyroidism, hypercholesterolemia and convulsions.

Review of the most current Minimum Data Set (MDS) dated 6/20/07 revealed the resident was assessed with modified independence with cognitive and decision-making skills. She had short-term memory problems, but her long-term memory was intact.

Surveyors read the charts more than we do.

On 8/27/07 at 10:45 a.m. the resident was observed sitting in her room in a large reclining wheelchair, crying and sobbing loudly. The surveyor asked her why she was upset, and the resident stated her brother had passed away the previous week on Thursday (7/23/07) and the funeral was today (8/27/07). The resident stated she was unable to go because her family was unable to find a van large enough to accommodate her wheelchair to transport her to the funeral. The resident stated the funeral was at 2:00 p.m. “today.”

On 8/27/07 at 10:50 a.m. the unit manager was interviewed and asked about the death of the resident’s brother. The unit manager stated she was sure the resident’s brother had not died recently or last week, and that the resident often “gets confused.”

On 8/27/07 at 10:52 a.m. the Social Service Director (SSD) was asked if the resident’s brother had died the week previous. The SSD answered, “No,” and added the resident “often gets confused.”

Can we see where this is going?

Later it was confirmed the resident’s brother had died the week before, on Thursday, 8/23/07. The SSD stated she didn’t know because she just got her “this morning” (Monday). When told the death occurred last week on Thursday, the SSD stated she was working in the facility at that time.

Review of the resident’s record on 8/27/07 revealed there were no social service notes documenting the death of the resident’s brother.

At 10:55 a.m. one of two certified nurse aides (CNAs) who were present during the discussion stated the resident’s sister had told her last week (on Thursday, the day he died), that the resident’s brother had died. The CNA stated, “I didn’t know I was supposed to report it to anyone.”

Oh boy.

Always, ALWAYS report these types of things to the nurse. Even for those residents who are confused and who repeat the same stories every single day. When we report these things, we hand over the issue to those above. Many times our residents’ confusion is an excuse for not taking their words seriously; both aides and nurses tend to disregard resident complaints and stories. In this case the family of the resident also told staff of the death. Perhaps everyone thought someone had reported this? In the end, the resident suffered because she could have and should have been able to attend her sisters funeral. The facility let the ball drop on this.

Lesson: Report EVERYTHING. Even the non medical, non nursing stuff. If you have access to your facilitie’s social worker/case manager, report these things to this person as well as to the nurse. And keep the ball rolling if need be! You are the resident’s advocate.