By Steve Moran
Over the last year or so, there have been a number of news stories about horrible things happening in senior living communities that often ended with the death of a resident. In each one of these cases, there was a lawsuit, and that lawsuit was settled before trial.
We as an industry and the public are left pondering what really happened. I get why these things settle, but the downside is that, except perhaps inside the organization where the fail happens, there are lessons we could learn from these stories as an industry. Lessons that could make us better and save lives.
I don’t blame the companies for keeping everything under wraps. Talking about it publicly could lead to further legal action, and bad publicity that would hurt the company, which in turn would be damaging to residents and family members.
And yet, what if we could learn from them?
In my 20s I was a flight instructor, and I feared one thing more than any other, and that was running into another airplane. The risk is really tiny, but not zero. Flight instruction is particularly dangerous because you are making lots of direction and altitude changes. You and the student need to be watching out the window for traffic all of the time, and at the same time, you need to be instructing and watching the student.
I never had a midair collision, but I did have three or four times where I looked out the window to see an airplane that was uncomfortably close.
In senior living, we have way more close encounters than any one wants to talk about, because they are so scary. Some have suggested the Washington Post inflated their numbers in their recent articles about senior living. My guess is that they are undercounted by a long shot.
In the aviation world, there exists something called the Aviation Safety Reporting Program. It is a nonpunitive system for anonymously reporting violations and safety concerns without risk of civil penalty or loss of a license or certificate.
There are a number of conditions attached to the system so that it cannot be abused to avoid culpability for a major incident.
The other thing the FAA does is an extensive review of every single accident, and part of what comes out of that accident report are recommendations designed to make it less likely that the same thing will happen again.
We Would Be So Much Better If …
- We had a system that would allow us to report bad things that are happening before they cause actual harm or loss of life.
- We had a way to dissect those horrible cases where bad things did happen and develop real learning lessons that would make those things less likely to ever happen again.
Looking at the Washington Post story about the woman who go locked out, here are some questions that would be worth asking:
- How did she leave without being noticed?
- Was the fact that she left the building a problem or an exercise of her personal freedom?
- Why did no one notice her trying to get in for hours and hours and hours?
- What could have been done to make sure that when a resident gets locked out they can get back in?
- Is there technology that could have prevented this from happening?
- What are the consequences of removing cameras as described in the story?
- Was the number of staff really inadequate, or did the staff simply not do their job?
- Did management know there was a problem with the team members?
- What could management have done to motivate the staff to do what they should have done (assuming this was the problem)?
- Was there a hiring problem?
- Was there a training problem?
- Was there a staffing pattern problem? (For instance, flight crews are mixed all the time, because airlines know that when the same crew flies together over and over again, complacency becomes an issue.)
- What role did the family play that might have contributed to the problem?
- Were the financial pressures that caused problems? (For instance, was she not in memory care because of cost?)
- If the community could have a do-over, what would they do, or what should they have done to make sure this would not happen?
How much better off the industry would be, residents would be, team members would be, if we were to take a proactive approach to these disasters.
It is simply not good enough for us to say, “Well, it does not happen that often.” That approach will keep occupancy low and cause people to distrust us.