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Creating a Culture of Safety
Joy Schultz, LNHA, ALMC
Risk Management Consultant
Evolucent
Objectives
• Identify what risks we face in ALF communities
• Identify the risk areas we can change
• Identify risk areas we may not be able to change
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The Culture of Safety
• Direct Care Workers generally rate the Culture of
Safety lower than members of the management
team
• Assessing your home’s Culture of Safety is the first
step to improvement
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Risks We Face
• Continuing challenges with recruitment and
retention of qualified staff
• Time constraints for staff education related to
workload and staffing challenges
• Meeting the needs of a diverse population – baby
boomers, mental health, dementia, clinical acuity,
aging in place
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Easy?
• No!
• We understand these challenges
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Staffing
Acuity
Elopement Risk
Behaviors
Higher service level/needs
Etc.
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Today
We are going to focus on diversity/changing needs in
our resident population and some of the
environmental challenges we face
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Things You Can and Cannot
Change
• You will always have challenges
• Some you can change
• Others you can’t
• Let’s talk about it
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Environmental Factors
Things We CAN Change
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Medical Waste
• Is there a contract for disposal of medical waste?
• Are you still mixing kitty litter for medication
disposal?
• Do all departments have current MSDS information
readily available?
• Remember, if residents are able to do their own
personal laundry, etc. there are chemical risks
• Where are sharps disposed of and is it a secure
location? What about those residents selfadministering insulin?
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Call Light System
• Is it audible?
• Who is answering call lights?
• Are pendants used and if so are they voluntary?
• The down side to call lights is that people have to
remember to use them!
• Cognitive awareness can wax and wane throughout
the day
• Are you assessing residents on different shifts on
their ability to request assistance or only on day
shift?
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Doors
• Are all doors alarmed? Including courtyard doors?
• Are staff able to disengage the alarms?
• What are your safeguards for alarm
maintenance/checking?
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Stairwells
• Are stairwells alarmed?
• Are staff able to disengage the alarms?
• Do alarms sound repeatedly throughout the day?
• What response to alarms do you observe by your
staff?
• The good news is few residents prefer to use the
elevator
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Alarms
• Are all alarms wired into the electrical system?
• Does the facility have a generator for power
failure?
• If not, is there a protocol for monitoring for
elopement during electrical failure?
• Remember, even in a high functioning population
there are times when cognitive decline is subtle
and may go unnoticed until an event happens;
avoid the event!
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Wanderguard/Electronic
Departure Alert System
• Is there a Wanderguard system?
• Is there written criteria for determining
appropriateness for each resident?
• How do you identify who would benefit from a
bracelet?
• How do you determine when to discontinue the
device?
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Wanderguard/Electronic
Departure Alert System
• Higher functioning residents will resist any type of
device that limits their activity
• Choose wisely, understanding the needs of the
higher functioning residents; bracelets are easily
removed with a pair of scissors (happens)!
• Review your policy and procedure
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Water Temps
• Water temperatures in resident care areas <120 degrees
• Documentation supports that resident care areas are
evaluated on a scheduled basis
• Shower rooms with mixer valves too?
• Do your higher functioning residents shower
independently?
• What about meal service? Is there a hot coffee pot
available for residents to self-serve (or serve others)?
• Are you performing a hot liquid assessment on all residents
on a scheduled basis?
• What is your system for monitoring the temperatures of hot
liquids?
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Electrical
• No frayed cords, etc.
• Maintenance evaluates any new equipment
brought in by family
• Exit signs illuminate
• No extension cords/power strips in use
• Cords for fans, oxygen concentrators, etc. are not a
hazard
• This will shock you but families “sneak” things in,
seriously!
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Shower Rooms
• Non-skid flooring
• Good lighting
• Grab bars placed per manufacturer guidelines and
per Community Member’s needs
• Shower chairs; these are not intended to be used
as transport chairs and locks on wheels often do
not “hold”
• Consider installing built in seats in shower areas
• Avoid an institutional feel in these areas; spa
settings are much more attractive
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Evacuation
• Floor plan posted throughout the community
• “You are here” is identified on each floor plan
• Staff aware of postings
• Alert and oriented residents aware
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Life Safety
• Fire drills are held quarterly or per life safety code
requirements
• Documentation available
• Fire extinguishers checked monthly
• Manual alarm system checked monthly
• Automatic alarm systems and panel working and
checked
• Sprinkler systems are checked by certified vendor
annually
• Enclosed, built in closets are sprinkled
• Smoke detectors in each resident room (not required if
fully sprinkled)
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Life Safety
• Fire doors not blocked or propped
• Kitchen hood system and automatic fuel shut off
inspected at least annually/as required by licensure
• Smoke and heat detectors inspected by a certified
professional at least annually/as required by licensure
• Generators tested per manufacturer guidelines and/or
licensing requirements and findings are documented
• Emergency power outlets identifiable
• Employees aware of main shut off valves
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Don’t Forget Outside – Thinking
about Falls & Accidents
• Paved areas are free of cracks, shifting
• Change of grade is identified with paint/signage
• Parking areas do not limit visibility
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Don’t Forget Outside – Thinking
about Falls & Accidents
• Courtyard walkways are clear of trip hazards, cracks
and lifting
• Foliage/trees are maintained and free of hazards
(i.e. hanging limbs, etc.)
• Seating areas are available outdoors for residents
and visitors who may become fatigued
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Don’t Forget Outside – Thinking
about Falls & Accidents
• Walkways free of snow/ice
• Policy and procedure in place to address inclement
weather and snow removal
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Things That ARE Changing
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What About the Changing
Demographics?
• How are you engaging the community to encourage
census building?
• Are you meeting the needs of a diverse population?
• Is your acuity similar to a mini nursing home?
• HOW do you mitigate the risks?
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Pre-Admission/Admission Process
Are you:
• Setting realistic expectations?
• Performing community visits/assessments?
• Assessing for risk upon admission?
• Discussing arbitration upon admission?
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Limitations
• Do residents understand and agree to the
community “rules”
• Are you a non-smoking campus? Is this explained
during the referral process?
• Are you accommodating electric
wheelchairs/scooters and familiar with the FHA and
ADA requirements?
• What about pets? Do you only allow certain ones
or none at all?
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The Physical Plant Layout
• Good lighting
• Clear, wide corridors
• Accessible showers and color contrasted toilets
• Accent colors to distinguish light switches
• Flooring to improve traction and tread ability
• Stable furniture – no modifications outside of
manufacturer’s guidelines
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The Workflow Environment Assigning Care Workers by
Acuity/Abilities
• Using evaluation tools to determine “level of care”
and providing services based on findings
• Training care workers routinely and systematically
on best standards of care
• Responding to changes in acuity/ability in “real
time”
• Evaluating work flow and adapting the environment
if needed i.e. supply rooms, equipment
accessibility, communication devices, etc.
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Things We CAN Change
How we can improve and adapt our Culture of Safety
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The New ALF Resident
When we talk about meeting the needs of the baby
boomer we should consider
• Wi-Fi availability
• Activities besides bingo
• Residents may like duck for dinner versus baked chicken
occasionally
• Happy hour is always a hit
• Spa services
• Ala carte room service for meals
• Menu/restaurant service in dining rooms
• Refrigerators/microwaves in rooms
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Electronic/Social Media/Baby
Boomers/
Oh My!
• Are your rooms equipped to accommodate several
pieces of electronic media? (i.e., outlets, etc.)?
• Is there a central computer area where residents
can congregate?
• Are meals served per resident preference or are
you still serving breakfast at 7:00?
• Do you still have a “get up list” for midnights?
• What about conjugal visits?
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Community Visits Before
Admission
• It is highly recommended that an on-site visit be
performed prior to accepting a new
resident/tenant
• Evaluating the client in their personal environment
will provide a more accurate assessment
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Community Visits Before
Admission
Look for signs of anti-social behaviors:
• Hoarding – is their environment filled with stacks of
personal belongings?
• Are medications stored haphazardly?
• Is a pet well cared for and the house odor free?
• Are there burns in clothing, furniture?
• Does client refuse to use assist devices as
recommended (i.e., walkers, canes)
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Resident Handbook
• Provide a resident handbook to new residents and
discuss during move in
• The community handbook should include:
• Behaviors – expected social standards
• Smoking – if smoke free, make no exceptions
• Visitation – if shared room
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Resident Handbook
The handbook should clearly outline the
community’s responsibilities for discharge/eviction if
the Community Member cannot fulfill criteria for
living in the community
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Pets
• We all love our pets but….
• What are your community policies on live in pets?
• If you allow residents to bring pets from home be
very careful with the “rules” on type of animal, size,
etc. to avoid any discriminatory practices
• Service animals are pretty much a must, not
recommended that you prohibit these (FHA, ADA)
• When in doubt consult legal counsel
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Pets
• Consider safety of other residents and guests
• Require veterinarian clearance including all state
required vaccines
• Be sure the resident handbook includes rules for
pet owners
• This can be done in a separate document if needed
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Pets
The rules need to include:
• Feeding responsibilities
• Walking responsibilities
• Leash rules
• Managing the “poop squad”
• Discharge if incontinent in community
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Self Administration of
Medications
• This is a great concept, few communities manage
the process well
• Some facilities perform an assessment to
determine if a resident is capable of self
administration but rarely complete the process
• What is your process?
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Plan and Succeed
• Upon admission explain the process of determining
self administration abilities
• Explain that this may change over time, similar to
being safe to drive a car
• The admission agreement should clearly describe
how the process works and when a resident may
not be able to self administer medications
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Assess and Assess Again!
• Use a validated assessment tool be used to
determine a resident’s ability to self-administer
medications
• So you assess on admission, that’s great, when do
you re-assess?
• Residents are not static, there are changes that
occur daily, sometimes hourly
• How are you identifying these changes early to
avoid medication errors/negative outcomes
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Medication Storage
• Residents may self administer medications however
safety is important
• Not only are we responsible to oversee that the
resident is taking their medications as ordered but we
are responsible for ensuring the medications are stored
securely
• There are many attractive medication lock boxes that
hang on the wall and look like mirrors, pictures, etc.
• There are also locks that can be installed on nightstand
drawers
• What is your process?
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Medication Storage
• The responsibility for ensuring medications are not
outdated, are taken timely and accurately is still ours
• Establish a process for checking expiration dates, etc.
• Consider counting the number of medications in each
container and auditing weekly x 4 weeks to determine
if the medications are being used per orders
• Some facilities have the resident sign off on an MAR
stored in their medication storage box
• This needs to be explained to the resident upon
admission and included in your policy
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The Environment and Sleep
Hygiene
• The number of accidents related to poor quality
sleep is substantial
• Increases risk of morbidity and mortality
• Exposure to natural light
• Exercise classes – vigorous earlier in day
• Relaxing exercise closer to bed time – i.e. yoga,
stretching
• Quiet/low noise times with lower lights during
hours of sleep
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Think About Your Life
How would you want to live?
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References
• Adelman, Rebecca (NCAL Risk Management Work Group). Litigation in Assisted Living – Case Studies for
Risk Management. www.AHCA/NCAL.org October, 2013.
• Castle, Nicholas G.; Wagner, Laura M.; Sonon, Kristen; Ferguson-Rome, Jamie C. Measuring Administrators'
and Direct Care Workers' Perceptions of the Safety Culture in Assisted Living Facilities. The Joint
Commission Journal on Quality and Patient Safety, Volume 38, Number 8, August 2012, pp. 375-385(11)
• Developing Risk-Management Protocols – Assisted Living; Long-term Living; November, 2005
• Epworth Sleepiness Scale. www.stanford.edu/~dement/epworth.html
• Grunewald, W. How Baby Boomers are Changing Retirement Living; The Washingtonian. March 13, 2014
• Sanders, D. Addressing Sleep Challenges. Aging Well; V.5, No. 3, p. 22; May/June 2012.
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