Page 50 - The Deep Seated Issue of Choice

THE DEEP SEATED ISSUE OF CHOICE
WHAT MAKES NEW IDEAS DIFFICULT?
Their elaboration on Maxim 10 is particularly relevant:
“Even federal nursing home regulations contain contradictions, a situation that is inevitable because some sections call for resident choice and individualization, whereas others establish protocols for safety. State rules multiply the contradictions. When advocates for culture change have sought federal interpretation of state rules that seem to restrict residents, regulators have rendered decisions that those states were within their rights in making more precise safety rules than were federally required – even though these rules interfered with resident choice. Some states do specify how facilities must seek and honor resident consent and preferences, but most apply regulatory fine points only to safety concerns.” (Kane and Cutler, 2007)
How can states limit residents’ constitutional rights to self-determination? Obviously this is a policy question beyond the scope of this paper, and beyond the knowledge of this writer, but one that clearly needs immediate resolution if resident rights are to be universally honored.
Even within a specific state, variability from one team to another, and from one team member to another on the same team, present a barrier of inconsistent support and challenges for culture change. Lindsey shares his thoughts, identifying survey variability as the biggest barrier to moving forward:
While we didn’t really encounter any significant barriers in moving to households, I believe that was because we had (survey) people locally who ‘got it.’ The problem with our current system is that so much is left to the interpretation of the local field office, surveyor, housing inspector or fire code enforcement officer. We were fortunate in all of these respects, but we have heard from many others that they have not been as successful. When we received our occupancy survey, one of the surveyors had a real issue with plates being stacked in the cabinets of the kitchen...she felt that this could be a safety issue (‘What if a resident pulled a whole stack of dishes down on themselves?’) Fortunately, her supervisor literally slapped her on the shoulder and said, ‘Come on...do you really think that will happen?’ That exchange set the tone for the rest of the survey...but if it had gone the other way, we could realistically be storing all of the dishes and other supplies in another room, where the residents would not have access to them. It is those kinds of decisions, based on the judgment and interpretation of a local surveyor, that can make all the difference in the environment that is created for elders. Multiply that by all of the life safety issues (open kitchens) and fire code enforcement decisions that are made and you can end up with situations where something may be perfectly acceptable in our area but rejected in some other part of the state or country. (Lindsey, 2009)
Three other facilities who chose not to be identified in this paper share their stories:
Our latest change has been to work closely with the DOH to set up a program where nursing personnel can cook or prepare simple items for the residents on the unit. A food safety specialist with the DOH visited our facility and read our newly developed policies and gave us a variance to be able to provide this service. There is a regulation which states those involved in direct care (CNAs and nurses) could not prepare food. After training with a certified food safety instructor, we have begun a breakfast program on one unit.
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