Challenging the Citation and not the Citer

Nursing home surveys are frequently anxiety provoking for the staff. Not many individuals welcome others coming into their facility with the intent to play close scrutiny to the environment. This is quite similar to individuals experiencing someone who comes into their home and walks around, looking for things to find, such as a real estate agent, a perspective home buyer, or a nosy neighbor.  In both cases it infringes upon our normal comfort zone that leads to a level of anxiety that is not normally found in the daily milieu. 

However, this type of oversight, regardless of it being anxiety-provoking, it is a natural part of nursing home administration and the regulatory environment that exists in long-term care. Furthermore, all administrators will eventually encounter a situation, where they feel that certain citations are not justified. In this case what should the administrator and their staff do?

The survey environment can be a very emotional situation. Staff or often at ease, on edge and frequently feel like they are walking on glass. In other words, it leads to a tension-filled environment during the survey. This tension is accentuated when citations are given and magnified even further when certain citations are provided, which are felt to be unjustified. Moreover, often administrators feel that there are only two alternatives to deal with this situation: swallow your pride, take the citation or in other words, do nothing, or get into a contentious challenge with the surveyor(s). 

The former is chosen due to the mindset of thinking that if a challenge is mounted, the surveyor will cite even more and with a greater vengeance. The latter is chosen on the basis of frustration, pride and provincialism, with the attitude of “who are these people to come into my building, take it over, and tell me what to do and what is wrong.” This is no new revelation and all administrators and administrative staff have felt both of these feelings at one time or another. 

However, in reality, most citations that are given out are justified. Additionally, most good administrators know this and if they have been doing their job well, have been closely in touch with their facility and their quality indicator reports, and understand the survey process, will not be surprised by the citations that are received by the facility. Furthermore, most surveyors are not vindictive, but are usually doing their job in an appropriate manner. This being stated as human beings, mistakes can be made, by administrators, staff, as well as surveyors. Therefore there are times when citations are given out that may not be appropriate and need to be addressed. 

In the first scenario above, it was stated that many administrators would just let the citation go unchallenged, no matter how inappropriate they may view it as being. A major problem with this “let sleeping dogs lie” approach is that if the administrator feels that a particular citation is unjustified, most of the other administrative staff will also view it as unjustified. If the administrator fails to challenge an unjustified citation, the staff will view the administrator, who is the leader of the facility, as a person who feels helpless, powerless, as well as being a person who is unable or unwilling to address an issue that they feel strongly about and that needs to be remedied. This does not fit well with the leadership role. 

Conversely, in the second situation, when and administrator addresses the situation due to their pride, frustration, and provincialism, they will often come to lose sight of the problem. Their anger and frustration with the citation escalates into a contentious interaction with a surveyor(s), leading to a situation that will accentuate ill will and bad feelings between the administrator, their staff, and the survey team. The hubris of the administrator now leads them to feel that they are being a true leader by getting into the face of the surveyor and confronting them on the perceived inappropriate citation. The “I am not going to let them push me around” thinking is self-serving, failing to take the good of the facility into consideration, and fails to target the problem at hand.

So where does this leave us?  The administrator as the leader has to avoid moving to either extreme. First, it is appropriate for an administrator to address issues that they feel are not valid. Second, to address the issue they have to do it factually. Finally, the demeanor of the administrator should address the issue cogently and in a professional manner. No person likes to admit to errors in judgment. Keeping this in mind, addressing the perceived error has to be done in a manner that will avoid what is psychologically called “reactance,” where individuals attempt to protect their sense of self from threats against it, and therefore react outwardly toward individuals that threaten their sense of self. Therefore, when a perceived inappropriate citation is challenged, it should be done so between the team leader and administrator, in private, to protect the threats against a person’s self that can be augmented when challenges are done in public.                             

When a survey is done, after the exit is completed, there is usually a period of time in which the administrator can challenge an inappropriate citation in what is often referred to as a level one informal dispute resolution. Although surveyors will frequently want to leave the facility and get back to the office, it is quite appropriate to advance your level one informal dispute resolution privilege and speak to the team leader in private about any concerns you may have regarding a citation. Doing so in private, in a respectful and professional manner, will usually quell the likelihood for reactance. 

There is a school of thought that one should never speak to surveyors by themselves and they should always have someone else present. However, in this situation, it is probably best for the administrator and the team leader to meet in a dyadic, one-to-one private meeting. Again, this helps to protect each person’s sense of self, and it limits the probability for reactance to happen. Furthermore, phrasing the problem in a language that does not attribute blame or incompetence, placing the surveyor on the defensive, is very important to eliminate reactance. This is very important for establishing a rapport in which further evidence could be provided to the survey team to assist in addressing perceived inappropriate citations. In most cases the survey team will allow you to submit information the following day to demonstrate compliance.

However, if you have failed to build rapport, develop a level of professional trust, as well as nurture their need for respect rather than vilification, you have lost your case before you could even provide substantive supporting material.           

It is important to recognize that surveyors can and do make mistakes. Even though most citations are justified, there are situations when particular citations should be challenged. The administrator as the leader of the facility needs to understand the need to challenge a citation that they may view as an egregious error in judgment. If such a citation does exist, it is quite appropriate to mount a challenge. However, as this article has discussed, there is a way to do this and the means for challenging a citation is often more important than the end that one seeks. If the correct means is not implemented, the end that one seeks will never come to fruition. Please feel free to comment on this subject matter.