|The Snafu Scenario|
|BY RICHARD L.PECK, EDITOR|
| Snafu-that’s a term you don’t see very often these days. Years ago it was used fairly commonly-and accurately, judging from my U.S. Army experience, during which I heard it quite frequently. It means (in cleaned-up version), “Situation Normal: All Fouled Up.” I think snafu is an excellent concept to help explain why certain nursing facilities get into deep trouble with state surveyors and the legal system.|
The thought occurred to me as I was reading a recent e-mail from Editorial Advisory Board member Genevieve Gipson, director of the Career Nurse Assistants’ Programs in Norton, Ohio. Genevieve runs an online message board called The Trainers Connection, to which CNAs across the nation contribute. One recent notice was a lengthy incident report from a facility concerning the death of an elderly male resident from aspiration. In short, it describes a tragedy of errors.
|In a nutshell: The resident, who has Parkinson’s disease, is admitted to the facility following two falls at home. His five-day MDS discloses that he has swallowing problems, requires a mechanically altered diet and “does not use or have dentures.” Four days later he has a choking incident requiring suctioning and oxygen (and removal of his dentures), which he survives. A physician is called (no physician at any time visits the man personally), who instructs the staff to monitor the resident. Monitoring is not done. A speech therapy screening that same day recommends that a physician evaluate and treat the resident; this recommendation is not conveyed to the physician for three days. Meanwhile, the resident’s son takes him home for a holiday weekend and is able to feed him without incident. The son explains that the resident must be fed with small spoonfuls and small amounts of liquid at a time. Upon the resident’s return to the facility, however, he has another choking incident in the dining room, whereupon he is transferred to his bed three hallways away, laid down for suctioning and left lying there until a crash cart can be obtained. No maneuvers are performed to clear his airway; staff admits later they haven’t been trained for this. By the time the crash cart arrives, the resident has died (and the son learns of this via his answering machine).|
|This magazine has spent the past several months exploring various facets of risk management. It is clear that nursing facilities have special problems in maintaining adequate communication, training and documentation in caring for the seriously ill older people who reside in them. Society has not been helpful in financing or in offering moral support. Snafu is therefore not surprising in this setting. Nursing facilities must make special efforts to get their acts together, against all odds – and the better ones do. Their inspiring example needs to spread. NH|
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