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Teaching Notes: InvestigationTeaching Notesglances down at her watch during the segment. Shealso introduces herself with her name badgeobscured.Your Notes4. Show all of the segments with little comment becausethe analysis and critique of specific aspects will occuras skills are taught later in this chapter. Thesegments shown will be: Situation One (7:03 minutes/seconds): Intake(Segment Two with Mary reflecting back to Mrs.Woods the concerns Mary hears) Situation Two, (1:56): Observation, Mary’s WalkThrough Facility (use the version without captionsor the third observation segment with sound andvisuals on the captioned video) Situation Three, (1:56): Report Back to Resident Situation Four, (6:42): Resolution Meeting Situation Five, (4:18): Follow-up and MediationWith Residents5. After viewing all of the segments ask, “What did Marydo?” Write answers on a flip chart, capturing the bigpoints. Try to identify the actions listed on the flip chart thatcorrespond with the steps in the problem-solvingprocess: receive/identify a problem or concern;gather information,verify the problem,identify the underlying problem,analyze the situation,consider solutions,identify obstacles,choose an approach,act, andevaluate outcomes.B. Understanding Messages (30–60 minutes)California Long-Term Care Ombudsman Program8August 2007

Teaching Notes: InvestigationTeaching NotesYour NotesDistribute the handout, “What Does This Mean?” Askthe trainees to complete this handout as an individualexercise. Note: If any of the handout statements wereworked through by trainees using the curriculumresource material before this classroom session, usethe remaining statements or edit the handout and inserta different statement. You might want to keep thestatement and use the discussion to assess how welltrainees understood the pre-classroom material.Prepare headings on flip chart pages to facilitatediscussion.1. List potential meanings for each statement. Commenton the range of possible interpretations.2. Ask, “How would you go about determining what the‘real’ meaning is?” List the responses. Be alert toresponses that are solutions instead of steps todetermine what the meaning is. Separate these fromthe steps in learning what the problem is. Challengetrainees’ statement of assumptions about thesituation.3. Listen for statements about asking for a resident’spermission or other statements that reflectconfidentiality principles. If you do not hear commentsabout asking for resident’s permission to look into theproblem ask questions. How do you know if a resident wants you to act onthe stated problem? When and how would you get the resident’sapproval to look into the matter? How would you document permission to proceed? Distribute local LTCOP consent forms andexplain when and how to use these. Why is this step important?4. Ask a few follow-up probes. The amount of detail youcover will depend upon the available time. Some ofthese questions will be covered in more detail in alater section of this training. Suggested follow-upquestions are: You said you would talk with other people. WhoCalifornia Long-Term Care Ombudsman Program9August 2007

Teaching Notes: Investigation Teaching Noteswould this include?Why would you want to talk with each person?In what order would you talk with the individualslisted?What would you ask?How would you ask the questions?Are there other places you might go for supportinginformation?Would you make any observations? If so, what andwhy?Your Notes5. If you have time, ask questions that push trainees todraw upon their knowledge of the aging process,typical disease processes, and communication skills.Examples are: Would you approach this situation differently if theresident making this statement began mumblingsomething about aliens, then began talking abouther childhood? If so, how? What would you do if the resident became veryagitated when talking with you? How could you ask for more specific or personalinformation if this resident were very hard ofhearing?6. Lead the group in an analysis of their responses. Usethe responses listed on the flip chart to mark andlabel the big steps that correspond to the steps in theproblem-solving process and to the tools in aninvestigation. An example of what this might look likeis in Appendix A.Distribute the handout, “The Problem-SolvingProcess,” or refer trainees to the page containing thechart in the curriculum resource material. Concludeby pointing out that the problem-solving process is away to think through (analyze) a situation. This training is designed to help trainees refine theirskills and apply the LTCO values and ethics toresolving problems. Refer back to Mary and Mrs. Woods and recap thesimilarities in the approach Mary used and in theprocess the trainees just discussed relevant to thestatements. Key point7.California Long-Term Care Ombudsman Program10August 2007

Teaching Notes: InvestigationTeaching NotesYour Notes The problem-solving process LTCO use is verysimilar to the way each of us approaches trying todetermine what to do when confronted with aproblem: determine what is “missing, wrong, orneeds to be fixed,” consider options for resolving,and fix the problem.California Long-Term Care Ombudsman Program11August 2007

Teaching Notes: InvestigationTeaching NotesII. Investigation (45 minutes)Your NotesTransition into a focus on specific investigation tools byreminding trainees that they just identified the primarymethods of conducting an investigation: talking with people(interviewing), making observations while visiting in thefacility (observing), and looking at relevant printeddocuments including any laws or regulations (examiningofficial documents). Point back to the steps on the flip chartor to the problem-solving chart. Use examples from Maryand Mrs. Woods if needed.A. Purpose of a LTCO Investigation1. What is the purpose of any investigation? List responses. Briefly discuss responses, pointing out that aninvestigation is a process to gather the facts abouta situation.2. What is the purpose of a LTCO investigation? To gather enough information about whathappened to be able to resolve the situation to thesatisfaction of the resident or complainant. LTCO are impartial in investigation. In 2001 the American Bar Association approvedrecommendations, standards, and a reportrelated to Ombudsman practice. Thesedocuments recognize an Advocate Ombudsmanrole that is consistent with the LTCOresponsibilities in the OAA. Section 2 of the report, “Impartiality in ConductingInquiries and Investigations,” clarifies theOmbudsman’s impartial role in an investigationand how that role can change into an advocaterole. (pages 6–7, www.abanet.org) “Acting in an impartial manner, as a thresholdmatter, means that the Ombudsman is freefrom initial bias and conflicts of interest inconducting inquiries and investigations.” “Impartiality does not, however, preclude theOmbudsman from developing an interest inCalifornia Long-Term Care Ombudsman Program12August 2007

Teaching Notes: InvestigationTeaching Notessecuring the changes that are deemednecessary where the process demonstrates aneed for change nor from otherwise being anadvocate on behalf of a designatedconstituency. The Ombudsman therefore hasthe authority to become an advocate forchange where the results of the inquiry orinvestigation demonstrate the need for suchchange.”Your Notes There may be times when a LTCO cannot pursuewhat the resident wants. Can you think of any potential examples? List responses and briefly discuss. The listmight include situations such as the residentwants the LTCO to assist resident in engagingin an illegal activity. Or Develop a handout containing a few veryshort examples of situations where LTCO canand cannot pursue what the resident wants.Ask trainees to mark the situations where aLTCO can act on behalf of a resident. Thengive the correct answers and briefly discuss.This option will take more time than the firstbullet. Listen for ideas that might need to bechallenged or expanded. One example is thatwhat the resident wants is not required of thefacility, not supported in law or regulation.LTCO are to spend enough time to determinewhat the resident is really seeking. Manydesires that may not seem realistic can beaccomplished to some extent and can besupported by the Quality of Care or Quality ofLife provisions of the Nursing Home ReformLaw or perhaps under residents’ rightsprovisions for assisted living or board and careresidents.Point out any policies your LTCOP has regardingcomplaints that may not be pursued or when it isnot appropriate for a LTCO to pursue resolutionbased on the outcome of an investigation.California Long-Term Care Ombudsman Program13August 2007

Teaching Notes: InvestigationTeaching NotesB. Components of an InvestigationThere are three main methods used in an investigation.Your Notes1. Interviews Ask, “What is the difference between a casualconversation and an interview?” Solicit responses. An interview is a conversation with a purpose. Oneperson is seeking factual information.2. Observations Using all of your senses to gather informationpertinent to a complaint.3. Consulting Documents Looking at documents that might provide additionalinformation relevant to a complaint.C. Investigate to Identify the Underlying or Root Problem1. A LTCO investigates to determine what actuallyhappened in order to know what must be addressedto resolve the problem to the resident’s satisfaction.2. The purpose of a LTCO investigation differs from thepurpose of other types of investigations. Foradditional information about the similarities anddifferences between a LTCO investigation andinvestigations conducted by other programs, refer tothe chapter, “History and Role of the Long-Term CareOmbudsman Program,” and the PowerPointpresentation, “Unique Characteristics of the LongTerm Care Ombudsman Program.” Law enforcement, surveyors, adult protectiveservices, and others investigate to determine if astandard or law has been violated or if there is asufficient legal basis to act. The actions that followthese investigations are based on legal standardsor regulations. Ombudsman representatives investigate to gainenough information to resolve a problem on behalfof a resident.3. Sometimes the concern stated by the resident1 is notthe issue that must be addressed. To clarify the distinction between the statedCalifornia Long-Term Care Ombudsman Program14August 2007

Teaching Notes: InvestigationTeaching Notesproblem and the problem that must be addressedto resolve the concern, refer to the “What DoesThis Mean?” exercise. “My purse is missing” is a statement of a complaint.To know what must be done to resolve the problemand hopefully, to keep it from happening again, youneed more information. An investigation is neededto understand exactly what the resident is missingand to understand why it is missing. Understandingthe why’s reveal the underlying problem that mustbe resolved.Your Notes4. The amount of time and the thoroughness of a LTCOinvestigation can vary from one case to another. Ask,“What are some factors that might impact the amountof time spent on an investigation?” Quickly list responses and briefly elaborate on theones that are relevant. Factors to mention include: Ability of resident to remember and tell you abouta situation, Cooperation of facility staff and responsiveness inaddressing problems, Complexity of the issue, Amount of evidence needed to refer or to resolvethe issue, Number of individuals who need to be contacted, Whether complaint deals with the facility or ifother agencies or organizations have to becontacted. Let trainees know that you are going to look at eachof the primary tools for an investigation and howthey are used by LTCO. The amount of detail andthe time LTCO invest in an investigation will varyfrom case to case. Key points Determine what happened (facts) in order toresolve as the resident desires, LTCO may not be able to attain 100% residentsatisfaction but seek to come as close as possible.Teaching NotesIII. Interview (Total time: 2–25 hours. Sections A–D, 1.25–1.5California Long-Term Care Ombudsman Program15Your NotesAugust 2007

Teaching Notes: InvestigationTeaching Noteshours; Section E., 45 minutes–1 hour)Your NotesCarefully watch the available time while teaching thissection. The exercises can be expanded to make anumber of teaching points and to actively engage thetrainees. Stay focused on the essential teaching points toavoid spending too much time with detailed discussion inonly a few areas.Remember that one of the primary objectives during basictraining is to teach a process that reflects LTCOP valuesand process. While complex cases and details may bevery interesting to trainees, such cases may beoverwhelming or confusing to someone who is learning tofunction as a LTCO.Even individuals who come to training with interviewingand communication skills benefit from practicing theseskills as an Ombudsman. It can be surprisingly challengingto practice interviewing residents or other individualswithout using professional jargon or when the other personmay take awhile to focus and respond.A. Purpose of an Interview1. What is the purpose of an interview? To gather information related to a particular topic2. Use the type of information you are seeking to decidewho to interview.3. Prepare for an interview by planning. What information are you seeking? Who do you need to talk with? Why do you need to talk with that individual? How will you explain why you want to talk with aperson? What questions will you ask? How do you create an environment that is helpful toa conversation? In what order do you want to interview the differentindividuals?B. Setting the Stage for ConversationAsk “If you want someone to talk with you, what type ofCalifornia Long-Term Care Ombudsman Program16August 2007

Teaching Notes: InvestigationTeaching Notesdetails do you pay attention to in order to get theconversation flowing?”Your Notes1. Quickly list responses on a flip chart and highlight keyfactors important for LTCO. You might use a coloredmarker to reinforce key factors.Option: To vary the methodology, ask trainees tothink about a time when they needed to discuss asensitive topic with someone. Then ask them to takea sheet of paper and quickly list what they did to try tohelp the discussion go smoothly. After a couple ofminutes, ask for responses to be shared and list keyphrases, highlighting main factors.2. Look for factors like: Timing: find a time when the person can talkwithout watching the clock. Comfort: environment is comfortable so the personis at ease. Privacy: if the topic needs to be discussed in asetting where it will not be overheard Distractions: minimize distractions and interruptions Conversation flow: Begin with “small talk” orchatting about general topics before getting totopics that are more difficult to discuss. Establishcommon ground or a common interest or goal.3. If time permits, ask the group to give examples ofwhat these factors might look like in a SNF or in aRCFE. Do this with the entire group, write ideas onflip chart or ask trainees to list examples beside thefactors they wrote on their paper. A sample of thisexercise might look like the following. Timing Ö Avoid talking immediately before mealtime or a favorite TV show or staff shift change ifyou need to talk with a nurse or a certified nurseassistant (CNA). Comfort Ö Room temperature, LTCO proximity toresident or staff (invading personal space), seatingcomfort Privacy Ö Is anyone else present? If so, will thatmake a difference? Might have to change locationsto talk. Who will see this person talking with theLTCO? Who will know if this person talks with anOmbudsman?California Long-Term Care Ombudsman Program17August 2007

Teaching Notes: InvestigationTeaching Notes Distractions Ö The intercom system is on andannouncements are made or someone could listento conversation. Staff or other residents are comingor going. The TV is on or other background noise isloud. Medicines are being distributed.Your Notes4. Ask trainees how they might deal with the factorslisted above. The purpose is to provoke thinkingabout

Office of the State Long-Term Care Ombudsman Program . Suite 200 Sacramento, California 95834 Telephone: (916) 419-7510 www.aging.ca.gov stateomb@aging.ca.gov August 2007. Teaching Notes: Investigation California Long-Term Care Ombudsman Program August 2007 2 . examples in this chapter primarily focus on skilled nursing facilities (SNFs .