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Survey Survival

November 1, 2007
by RETA A. UNDERWOOD, ADC
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Danger zone: An accident waiting to happen

Long-term care facilities are not strangers to regulation 483.25(h) Accidents as it historically represents and continues to make the Centers for Medicaid & Medicare Services' (CMS) worst dressed list of top ten most frequently cited deficiencies year after year. In addition, F-tag 323 often achieves a top five ranking in most cited actual harm with immediate jeopardy violations. So, it was not a surprise that CMS chose to make revisions and that the revisions were vast.

The revisions include additional regulatory language, intent, definitions, an overview, system approach guidelines, example scenarios that include resident smoking and resident-to-resident altercation, investigative protocol, and determination of compliance directives.

Add-on regulatory language. The facility must ensure that (1) the resident environment remains as free from accident hazards as is possible and that (2) each resident receives adequate supervision and assistance devices to prevent accidents.

Survey survival considerations. Legal argument and debate can be made as to what is an accident hazard in an LTC environment as well as whether it was possible to keep a specific LTC environment free of an accident hazard or that a specific resident received “adequate” supervision or assistance devices to prevent accidents. I do not believe in giving a potential accident deficiency unless an exhaustive effort was conducted to prove the facility had good intentions, keeping the individual resident and facility's uniqueness in mind. For example, the facility may have built-in preventions such as nonskid flooring, safe wandering paths, and so on, but the individual resident's daily routines and habits (such as afternoon wandering) may provide a direct link as to why an accident occurred. Keeping these factors in mind will assist in proving the facility tried to ensure a hazard-free environment.

Intent. There are four functions of the intent language:

  • Identifying hazard(s) and risk(s)

  • Evaluating and analyzing hazard(s) and risk(s)

  • Implementing interventions to reduce hazard(s) and risk(s)

  • Monitoring for effectiveness and modifying interventions when necessary.

Good news can be found in the F323 document's wording “over which the facility has control.” It provides wiggle room when designing a systems policy and procedures.

Four Focal Points for Policy and Procedure Development

  1. The facility must show how it is ensuring an environment free from accident hazards.

  2. Methods of providing supervision in an effort to prevent accidents.

  3. Identify and implement thorough assessment for those residents who need assistive devices to prevent avoidable accidents.

  4. A quality assurance program that identifies, evaluates, analyzes, and assists in the reduction of hazards and risks that proves to be effective and allows for modification as needed.

The Regulatory Overview

The facility's commitment to safety along with other remarkable interpretive language is found in the regulatory overview portion of F323. It hints towards staff education expectations where accidents and safety are concerned, along with the facility's ultimate responsibility for accountability and its role in risk identification and accident prevention.

A Successful Accident Avoidance System

When designing a long-term care system where the probability of serious or immediate danger may be present, acknowledgment of these risks is paramount. This includes facility and staff limitations. Traditionally a comprehensive long-term care system contains the following items:

  • standards of care

  • policy and procedures

  • forms, tools, and equipment

  • financial allocation of necessary funds

  • outlined and assigned staff accountabilities and responsibilities

  • education and training modules that include competency assurance

  • quality assurance mechanism

Today's rewrite of F323 Accidents requires items to be added to the accident avoidance systems found in long-term care. Include Life Safety Code items on the hazards of resident smoking as well as the inclusion of the definition of “willful” found in F-223 Abuse regarding resident-to-resident altercations to provide necessary substance to one's own unique facility system needs. Matters needing enhanced consideration can include specialized units, multilevel structures, environmental age, and décor. However, each facility is unique in its design, décor, resident population, and so on, therefore, only an independent nonbiased facility analysis can pinpoint specific additional accident system needs.

Resident Accident Risk Assessment

Occasionally, it's advisable to add a new piece of paper to assist in a comprehensive resident assessment–an accident risk assessment may be one of them. Of the thousands of medical record reviews I've conducted through the years routine assessments identifying resident risks and vulnerabilities has been virtually nonexistent. Consequently, many identifiable and potentially preventable accidents have occurred and resulted in a noncompliance situation for facilities and injury to their charges. This is an opportunity to improve. To do so, the assessment must take place and include dictated regulatory topics and items (see pages 240-247 of the SOM, Risk and Environmental Hazard).

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