The Lessons of the “Million Dollar Baby” Doll

Director/star Clint Eastwood claimed that at his age and career stature, he was more interested in telling a story than in making money. But, as it turned out, he made lots of money with this movie. Sometimes, you go looking for one thing and find another.

Speaking of which, consider all the time and energy nursing home administrators (NHAs) spend looking, in this case, for lost items. Lost items are a serious issue. Some lost items (clothing, personal belongings) serve more as a nuisance, and their recovery is primarily a matter of customer satisfaction. Other lost items (dentures, hearing aids, etc.), though, generate a more significant sense of urgency because they have material value, are costly to replace, and have significant potential survey/compliance issues. Here’s where “looking for one thing and finding another” comes in-and the tale of the “Million Dollar Baby” doll.

Consider the following scenarios: Resident A reports a lost personal clothing item-a nightgown. Let’s look at the Four Rs: replacement cost-$15; regulatory exposure-minimal at best; relations (public) impact-minimal and manageable; and response-the NHA replaces the item at cost and makes no attempts at root-cause analysis of the initial loss. In other words, the response is close to zero.

Resident B reports the loss of her hearing aid: replacement cost-$800 minimum; regulatory exposure-high “quality of life” vulnerability (F313); relations (public) impact-high (family will tell everyone); and response-the NHA stops everything, skips lunch, and personally embarks on a facility-wide tour to find the hearing aid. It is found and returned. Crisis averted!

Resident A now loses a “Raggedy Ann” doll: replacement cost-a minimal $8; regulatory exposure-none (or so it would appear); relations (public) impact-minimal; and response-the NHA quickly offers to replace the Raggedy Ann doll at cost and, once again, makes no attempts at root-cause analysis of the loss. In other words, the response is minimal at best.

But wait! Unbeknownst to the NHA, Resident A becomes depressed over the loss of her Raggedy Ann doll (she has had it since she was a little girl; the resident is 88, the doll, 85). She won’t accept the replacement; although she is hard of hearing and partially blind, she recognizes the smell and feel of her old doll. The new one, to her, is just a stuffed toy. The old one is all of her childhood memories in a nice, neat (well, maybe not so neat), fluffy little package with a bow on it (two in fact-one in the doll’s hair and one on the back of her dress). Resident A stops eating and becomes withdrawn and immobile. Now at risk for developing a decubitus ulcer, she represents potentially significant survey issues, potentially significant treatment costs, and painful legal and administrative costs (Is this, in fact, a “Million Dollar Baby” doll?). The soon-to-arrive Statement of Deficiencies, form CMS-2567L, will not mention the Raggedy Ann doll, but it will spell out numerous violations of F-tags for “quality of life” (F310, F314, and F320) and may hint at “actual harm,” along with a threat to “deny payments for new admissions” and a notification that “CMS must terminate your provider agreement” if you fail to achieve substantial compliance. Throw in lost revenue of 15 fewer admissions per month at their average daily rate over a three- to six-month period during the “informal dispute resolution” process, in addition to development and implementation of a Plan of Correction, the associated legal and consulting fees, increased insurance premiums, potential settlements or legal judgments, etc., and a million dollars starts to sound like a bargain for Raggedy Ann.

Admittedly, this scenario is hypothetical and extreme-but also entirely possible and insidiously beneath the surface for the NHA who tends to respond in an informal, relaxed manner to lost items. This well-meaning but complacent NHA has missed the cause-and-effect relationship of the lost doll and Resident A’s potential declining clinical picture and its many and varied dire consequences.

But (unlike Million Dollar Baby), let’s have a happy ending, shall we? Resident B loses that darned hearing aid again and, in the process of stopping everything, skipping lunch, and touring the entire facility to find it, the administrator stumbles over Raggedy Ann! (Sometimes, you go looking for one thing and find another.) The hearing aid turns up an hour later, and all is well.

Moral of the story: Don’t rely on the administrator’s luck. Take resident losses seriously and think through all the possible consequences. Don’t end up looking for an easy solution and finding problems you never expected.

• F310 º483.25(a)(1)(iv) Activities of Daily Living-Eating: A resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to eat.

• F313 º483.25(b) Vision and Hearing: To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities….

• F314 º483.25(c)(1) Pressure Sores:A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable.

• F320 º483.25(f)(2) Mental and Psychosocial Functioning: A resident whose assessment did not reveal a mental or psychological adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident’s clinical condition demonstrates that such a pattern is unavoidable.