Guest Editorial

Why the Nursing Director Is Key to Survival


It’s pretty much universally accepted in nursing homes these days that resident care systems are the foundations for high-quality care. Effective systems describe the facility’s outcomes expectations for a particular care issue and prescribe organizational and staff behaviors designed to achieve those outcomes. What nursing home would be without solid systems that focus on, for example, fall prevention, appropriate use of restraints, or prevention and treatment of pressure ulcers? These systems are in place in nursing homes today because they provide the best chance for high-quality care for residents and the best opportunity for success for the facilities.

And what Director of Nursing Services (DNS, also known in many facilities as the DON) wouldn’t be fully engaged in ongoing monitoring of the outcomes of the care, the direct evidence of the effectiveness of those systems? DNSs can be found routinely poring over weekly pressure ulcer reports, daily fall incidents, and restraint committee minutes, problem solving and guiding staff-and altering care systems-when necessary to achieve better resident outcomes. Often, administrators, too, keep a close eye on outcomes related to resident care systems in full recognition that the ultimate accountability lies with them.

It’s time to apply those same principles and processes to the critical facility activities that underlie reimbursement, resident care, and quality monitoring by surveyors and consumers-the activities that surround the MDS process. Oftentimes, responsibility as well as accountability for the entire MDS process is handed off to a nurse, although significant operational issues that contribute to success or failure are out of the control of that nurse.

Communication is a major key to success here. The MDS team should rely on its own observations, to be sure, but equally important to MDS coding accuracy is information developed by other sources on all shifts and across all disciplines within the facility. How that information gets from the source to the MDS nurse generally is not under the control of the MDS nurse.

For example, what might seem to be a small nuance of decline in a resident’s ability to transfer to the bedside commode in the middle of the night potentially translates into an increase of more than $45 per day in reimbursement at the Rehab Ultra-High level-if the right people find out about it. Many facilities have tried implementing CNA flow sheets that mimic the complex Section G1 of the MDS in the hopes of capturing such data, but it’s difficult to find an MDS nurse who finds the documentation to be accurate or helpful. “Copycat charting” seems to be more the norm. Depression documentation is another example: A resident is admitted with a diagnosis of depression. Nursing staff identify two signs of depression to monitor, and those two signs are monitored throughout the stay. For the resident in the Clinically Complex category, when the resident exhibits a third indicator of depression, it is likely that nobody thinks to document it, because it isn’t on the resident’s monitoring sheet. The oversight potentially represents a reimbursement loss of $16.90 per day at Clinically Complex level C.

Even more significant than the reimbursement issues, of course, are the resident care issues. If the right people do not know about the functional decline that appeared in the middle of the night or the increase in indicators of depression, appropriate care planning and intervention are unlikely to occur. These symptoms could be the beginning of a downward spiral from which the residents might not be able to recover if intervention isn’t swift. Clearly, in these cases, these systems are not working.

This is where the authority, the creativity, and the critical thinking skills of the DNS can make a major impact. For example, if flow sheet documentation doesn’t work, it should not be the cornerstone of important resident care and reimbursement systems. One thing that does seem to work in most healthcare settings is word-of-mouth exchange of information. CNAs, charge nurses, and ancillary staff know their residents. What they don’t know is what information is critical to report for MDS purposes-such as that added indicator of depression that the activity assistant noticed one afternoon or the need for greater-than-usual assistance in transferring during the night. All facility staff must have a clear understanding of the kinds of information that must be reported. Once they know what to report, all they have to do is get the information to the designated person to take it from there. As an example of how that might work, for a decline in function, if it is reported to the charge nurse and entered into the 24-hour report log, the charge nurse would use that information as the starting point for thorough assessment to determine underlying causes and to develop appropriate interventions. The MDS nurse would use the information in making MDS coding decisions. The charge nurse’s assessment and the resulting care planning and follow-up would provide the documentation necessary to support the MDS.

Only the leadership of the DNS, working deliberately and in collaboration with the nursing and ancillary staffs, can make this kind of culture change happen. The same principle applies to other resident care issues that are crying out for systems change. One example is the need for processes built into daily life in the nursing home to get residents up on their feet and out of wheelchairs as much as possible to stave off functional decline. Another example is the need to change the way facilities monitor meal intakes and nutritional status to prevent weight loss before it shows up on the monthly weights. Individual nurses may try to make these kinds of changes happen, but they do not have the clout to get the attention and cooperation of their colleagues in the nursing and ancillary departments.

It’s time to stop struggling with resident care systems that don’t work-for resident care and reimbursement reasons, and because of the need to provide medical records that can withstand legal scrutiny. With systematic, collaborative efforts to identify the need for change and to develop and implement new processes that are backed by the full weight of the authority of the administrator and the DNS, resident care and reimbursement outcomes are very likely to improve. NH

Rena R. Shephard, MHA, RN, FACDONA, RAC-C, is the chair of the American Association of Nurse Assessment Coordinators (AANAC), and the president of RRS Healthcare Consulting Services, San Diego. To comment on this editorial, please send an e-mail to

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