Clearly when you speak to the Director of Nursing, Charge Nurse, therapist, etc. regarding non-compliance with Culture Change, it will be a dialogue between the two of you. True, the other department head or staff member may listen politely and attentively to your Culture Change request, and then agree with, “Yes. I realize that needs to be done, and the aides will try tomorrow to do that.” However, if there have been repeated areas of non-compliance, the DON, Charge Nurse, or CNA may respond, “Esther, Myrtle, and Eva were not transported to the Sing-A-Long because we were busy and short.” The “long form” of the “busy and short” reply is, “We were busy with other residents and due to call-offs. Thus we are working short-staffed with fewer staff members than what are needed.”

Reimbursement’s Role in the “Busy and Short” Dilemma
The problem with thinking of a response to the “busy and short” reply is that it in many facilities what was said to you is true. CNAs are busy. It’s no secret that due to the low reimbursement rate from state and federal governments, in some areas CNAs can make more money working at McDonalds than they can working in your facility. Possibly for this reason, the turnover rate in your facility may be high. Call-off rates are also high because the low pay rate can attract staff that only use the CNA job as a stopping-off point to make a few dollars to move on to the next job at which they can make a few more dollars.

But don’t get me wrong, of course it goes without saying that the vast majority of CNAs are dedicated, love working with the elderly, and treat their residents as a member of their own family. Most go the extra mile and come in when others would have called off. But the small percentage that fall into the margins of caring are a large enough percentage to create a hardship when they either call off or do not pull their weight at work. Agree?

So the problem with the “busy and short” reply to your request for transporting or doing activities is that it is not a hollow excuse, but it is a statement or indictment of an ongoing problem in long-term care, due to lack of adequate government reimbursement. So perhaps the old saying, “you get what you pay for” might be applied here in some cases. Of course, it goes without saying your facility may be the exception. You have adequately paid CNAs, with low turnover and low call-offs. So therefore, you might substitute the “busy and short” reply with another you may get for noncompliance regarding not transporting and not doing activities with residents.

List three other reasons, besides “busy and short,” you have gotten when you bring to the attention of a staff member that there is an area of noncompliance with Culture Change regarding transporting, scheduling, or activity involvement. You may find one of the responses you write below is actually a variation of “busy and short.”
1.

However, “busy and short” or one of the above can be said to you every time you point out non-compliance regarding CMS Culture Change guidelines regarding scheduling, transporting, and staff doing activities with residents. So how do you reply to gain compliance? How do you cope with this pivotal area regarding gaining department head and staff support?

Here’s a script you might consider. Of course, you will need to alter the wording to fit not only the way you talk, but the history of your relationship with this department head or staff member. Notice I refer to this as a “script” because I am suggesting you actually write out a script for your response to the reasons above and practice reading and saying the script before you actually deliver it. You have a history of interaction with this staff member, and in order to break out of your old “communication dance” you might find it beneficial to plan your words and rehearse them.
The situation: As indicated in the preceding Section 3 you have sent emails and posted lists regarding what you want to have done, for example:
1. Transporting residents;
2. Having a shower or medication schedule changed to facilitate activity involvement;
3. Placed activities in residents’ rooms for staff to provide residents with.
To take the example from section 3 to the next level, for the last three weeks you have sent the sample email provided in section 3 to the appropriate staff members. However, no residents are transported to your Tuesday Sing-A-Long, and when you have approached your DON or other appropriate staff member, they have replied, “Gee, I’m sorry, I know I received a copy of your email sent to the charge nurses. I have talked to each of them about the fact that transporting is a part of the CNA’s job. However, on Tuesday we had two call-offs and Harold fell and needed to be taken to the hospital.” Do you recognize this as being the “busy and short” reply?

Script #1: The long version explaining Activities CMS requirements…
Using the broken record technique, empathetically you state, “Yes, I realize CNAs are busy and were working short that day. It’s awful Harold fell. I hope he’s okay. And here’s my concern. Residents have not been transported for the last three weeks. I have concern for the facility’s compliance with CMS guidelines regarding Culture Change. As you know from Care Plan Conference, I have a Care Plan for these residents indicating group activity attendance. Because of that, I have an Attendance Record that needs to be completed, which indicates whether the resident attended the activity or not, along with progress notes reflecting the quality of the resident’s participation in the activity. If surveyors cross reference my Care Plan for one of these residents, for example Estelle; see she has a goal indicating group activity attendance; however the attendance record does not indicate her attendance, as well as the progress note, I have a concern that the facility will receive a deficiency. I spoke with Mr. Jones the administrator and he was quite clear with me that he wanted a good survey next time. In order for my department to comply, I need to have Estelle transported to the 2:00 Sing-along on Tuesday. I did… Is there a better way to encourage CNA’s to transport?”

Let’s break down the components of my script so that you can create your own in your words, appropriate to your relationship with this particular staff member during this particular meeting.

“Yes, I realize CNAs are busy and were working short that day. It’s awful Harold fell. I hope he’s okay. And here’s my concern. Residents have not been transported for the last three weeks.”
Write a statement showing agreement and empathy:

“I have concern for the facility’s compliance with CMS guidelines regarding Culture Change.”
Write a statement referencing CMS requirements:

“As you know from Care Plan Conference, I have a Care Plan for these residents indicating group activity attendance.”
Write a statement reminding the staff member that Activities has a Care Plan for this resident:

“Because of that, I have an Attendance Record that needs to be completed, which indicates whether the resident attended the activity or not, along with progress notes reflecting the quality of the resident’s participation in the activity.”
Write a statement explaining the Activity Care Plans, Attendance Records, and Progress Notes system:

“If surveyors cross reference my Care Plan for one of these residents, for example Estelle; see she has a goal indicating group activity attendance; however the attendance record does not indicate her attendance, as well as the progress note, I have a concern that the facility will receive a deficiency.”
Write a statement indicating your concern regarding a CMS deficiency:

“I spoke with Mr. Jones the administrator and he was quite clear with me that he wanted a good survey next time.”
Write a statement referencing your Administrator’s support:

“In order for my department to comply, I need to have Estelle transported to the 2:00 Sing-along on Tuesday. I did … Is there a better way to encourage CNA’s to transport?”
Write a specific statement indicating what you need to have happen using residents’ names, activity time, etc. Insert one of the examples you wrote in Section 1 of this Manual:

Use your common sense. Be polite, courteous, professional, but most of all sensitive to the fact that, like you, this staff member is busy and may not have time to hear your whole script. Don’t burn a bridge of support by ignoring the verbal and nonverbal cues to let you know the script may need to be delivered in two or three meetings.

Script #2: The next week: Be Short and Be Specific
After you have provided the long version, and transporting scheduling or activity involvement compliance is not what you would like, here’s a second script. Once again, schedule a meeting at a time convenient for, for example, your DON. Gauge the amount of cordial chit-chat appropriate, if any, depending on how businesslike or how busy he or she is.

“Last week we talked about Estelle and 6 other residents being transported to the 2:00 Tuesday Sing-a-Long. I noticed Estelle was transported but the 6 others were not. So I was unable to indicate their attendance on my Attendance Record. I have a Care Plan Goal that states group attendance. I have concern about the facility receiving a deficiency if this pattern continues. I sent emails to each charge nurse, posted a list at the nurse’s station, as well as gave a hard copy of the list to the charge nurse to give to the CNAs. Is there a better way to encourage CNA’s to transport?

Let’s break down the components of my script so that you can create your own in your words, appropriate to your relationship with this particular staff member during this particular meeting.

“Last week we talked about Estelle and 6 other residents being transported to the 2:00 Tuesday Sing-a-Long. I noticed Estelle was transported but the 6 others were not.” Be sure you have a written list in your hand. Don’t rely on your memory.
Write a statement specifically listing residents involved in the area of noncompliance:

“So I was unable to indicate their attendance on my Attendance Record. I have a Care Plan Goal that states group attendance for each of these residents.”
Write a statement indicating the connection between non-involvement, Attendance Record, and Care Plan:

“I have concern about the facility receiving a CMS deficiency if this pattern continues.”
Write a statement referencing potential CMS deficiency, should you deem appropriate:

“I sent emails to each charge nurse, posted a list at the nurse’s station, as well as gave a hard copy of the list to the charge nurse to give to the CNAs.”
Write a statement briefly outlining the steps you have taken to make staff aware of your request:

“Is there a better way to encourage CNA’s to transport?”
Write a statement involving your DON in problem-solving with you and suggesting a better approach:

Once again, use your common sense. Be polite, courteous, professional, but most of all sensitive to the fact that, like you, this staff member is busy and may not have time to hear your whole script. Don’t burn a bridge of support by ignoring his or her verbal and nonverbal cues that let you know the script may need to be delivered in two or three meetings. Your main goal and purpose is to build a supportive alliance so that he or she becomes invested in a solution.

Script #3: Next week: Repeat Above and Pin Point Problem
“I did the plan we discussed last week by doing… to remind the charge nurse about transporting residents. However, I noticed Estelle is still the only resident being transported to Sing-a-Long at 2:00 on Tuesday. Since I did …, is there a better way to encourage CNA’s to transport? Where do you think the break down in the system is?”

Let’s break down the components of my script so that you can create your own in your words appropriate to your relationship with this particular staff member during this particular meeting.

“I did the plan we discussed last week by doing… (brief details of your actions) to remind the charge nurse about transporting residents.”
Write a statement that explains briefly how you followed through with any suggestions made by the DON in your last meeting:

“However, I noticed Estelle is still the only resident being transported to Sing-a-Long at 2:00 on Tuesday.”
Write a statement listing residents not transported:

“Since I did… is there a better way to encourage CNA’s to transport? Where do you think the break down in the system is?”
Write a statement involving your DON in problem-solving with you and suggesting a better approach:

Keep in mind that this is a generic example and the time frame between each meeting may not be a week. I am providing you with an example of the least amount of support. Of course, delete or add scripts as needed.

Script #4: Next week: Escalate
“I did the plan we discussed last week by doing… to remind the charge nurse about transporting residents. However, I noticed Estelle is still the only resident being transported to Sing-a-Long to the 2:00 Tuesday Sing. Mr. Jones, the administrator, probably needs to be aware of the transporting situation, since the lack of consistency between my Care Plan goal, Attendance Record, and Progress notes may be noted by CMS surveyors.” Obviously, you weigh and measure very carefully at what point you want to escalate your request by indicating you will be informing someone above them in the formal structure of your facility.

Let’s break down the components of my script so that you can create your own in your words appropriate to your relationship with this particular staff member during this particular meeting.

“I did the plan we discussed last week by doing… to remind the charge nurse about transporting residents. However, I noticed Estelle is still the only resident being transported to Sing-a-Long to the 2:00 Tuesday Sing.”
Write a statement that explains briefly how you followed through with any suggestions made by the DON in your last meeting:

“Mr. Jones, the administrator, probably needs to be aware of the transporting situation, since the lack of consistency between my Care Plan goal, Attendance Record, and Progress notes may be noted by CMS surveyors.”
Write a statement indicating your plan to talk to someone about the situation above them in the formal structure of your facility:

Script #5: Each discussion gets shorter
“Gosh four residents were transported to the Sing-A-Long on Tuesday, but 2 were not. I noticed both residents were on B Wing, and Sara was the CAN, who is new. Does she know that transporting is part of her job?”

“Gosh four residents were transported to the Sing-A-Long on Tuesday, but 2 were not.”
Write a statement regarding current status:

“I noticed both residents were on B Wing, and Sara was the CNA who is new. Does she know that transporting is part of her job?”
Write a statement suggesting a specific solution:

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