March Survey Review
28 Reviews
9.9 average numbers of deficiencies up from 9.2 in February
277 total tags!
There was 1 zero deficiency survey. Congratulations go to Parkview
Care Center in Osborne.
2 Non-compliant re-visits resulting in 16 tags, including 1 G level
tag
11 surveys resulted in 17 State deficiencies cited in addition to
Federal deficiencies
4 G+ level tags
2-F314
NE: SS=G: Failed to ensure residents with PUs received necessary care & services to promote healing of & prevent new PUs
from developing
SC: SS=G: Failed to provide consistent accurate placement of pressure relieving boots & timely repositioning services to a
dependent resident to prevent development of an avoidable PU
2-F323
NE: SS=J: Failed to provide adequate supervision to prevent res with dementia from leaving facility without staff knowledge &
walking on 2 lane street without sidewalks on cold windy evening which put res in immediate jeopardy & failed to place timely
interventions in place for res with falls; failed to ensure door alarms functioned properly
SC: SS=G: Failed to thoroughly investigate all falls & implement appropriate fall interventions to prevent accidents for multiple
residents; failed to ensure res environment remained free of accident hazards by failure to properly secure chemicals
Regional Demographics Reported:
 Western Region averaged 9.8 deficiencies with 4 surveys
reported
 Southeast Region averaged 9.4 deficiencies with 5 surveys
reported
 South Central Region averaged 13.2 deficiencies with 5 surveys
reported
 Northeast Region averaged 9.3 deficiencies with 6 surveys
reported
 North Central averaged 8.6 deficiencies with 8 surveys reported
Ownership Status Reported

Non-profits averaged 8.7 deficiencies per survey
 For-Profits averaged 10.6 deficiencies per survey
68%
19/28
F323 Free of Accident Hazards/Supervision/Devices
54%
15/28
F441 Infection Control
46%
13/28
F280 Right to Participate in Planning Care-Revise Care Plan
F329 Unnecessary Drugs
F371 Food Procure, Store/Prepare/Serve-Sanitary
39%
11/28
F253 Housekeeping & Maintenance Services
F309 Provide Care/Services for Highest Well-Being
36%
10/28
F431 Drug Records, Label/Store Drugs & Biologicals
32%
9/28
F279 Develop Comprehensive Care Plans
F314 Treatment/Svcs to Prevent/Heal Pressure Ulcers
F428 Drug Regimen Review
29%
8/28
F241 Dignity & Respect of Individuality
F312 ADL Care Provided for Dependent Residents
25%
7/28
F225 Investigate/Report Allegations/Individuals
F272 Comprehensive Assessments
21%
6/28
F242 Self-Determination-Right to Make Choices
F520 QAA Committee-Members/Meet Quarterly/Plans
18%
5/28
F281 Professional Standards of Services
F315 No catheter, Prevent UTI, Restore Bladder
F425 Pharmaceutical Svc-Accurate Procedures
14%
4/28
F353 Sufficient 24-hr Nursing Staff Per Care Plans
F465 Safe/Functional/Sanitary/Comfortable Environment
S1174 Door Monitoring System
11%
3/28
F160 Conveyance of Personal Funds Upon Death
F164 Personal Privacy/Confidentiality of Records
F166 Grievance Resolution
F250 Provision of Medically Related Social Services
F278 Assessment Accuracy/Coordination/Certified
F463 Resident Call System
7%
2/28
F157 Notify of changes (Injury/Decline/Room, etc)
F159 Facility Management of Personal Funds
F170 Right to Privacy-Send/Receive Unopened Mail
F273 Comprehensive Assessment 14 days after Admit
F274 Comprehensive Assess After Significant Change
F322 Naso-Gastric Tube Feeding
F325 Nutrition
F332 Medication Errors
F363 Menus and Nutritional Adequacy
F464 Dining and Resident Activities
S1166 Nursing Facility Support System
S1172 Nursing Facility Support System
S1354 Heating, Ventilation & AC
S1364 Electrical Requirements
4%
1/28
F156 Notice of Rights, Rules, Services, Charges
F167 Right to Survey Results-Readily Accessible
F174 Telephone
F202 Documentation for Tranfer/Discharge of Resident
F203 Notice Requirements Before Transfer/Discharge
F204 Preparation for Safe/Orderly Transfer/Discharge
F221 Physical Restraints
F226 Develop/Implement Abuse/Neglect, Etc. Policies
F244 Family Groups
F248 Activities Meet Interests/Needs of Each Res
F252 Environment
F256 Adequate Lighting
F258 Maintenance of Comfortable Sound Levels
F275 Comprehensive Assessment After Significant Change
F318 Range in Motion
F327 Hydration
F334 Influenza & Pneumococcal Immunization
F362 Standard Sufficient Staff
F364 Nutritive Value/Appear, Palatable/Prefer Temp
F366 Substitutes of Similar Nutritive Value
F368 Frequency of Meals
F411 Dental Services
F412 Routine/Emergency Dental Services in NFS
F467 Adequate Outside Ventilation
F514 Res Records-Complete/Accurate/Accessible
S600 Dietary Services
S856 Site Development
S1116 Bathing Room
S1173 Nursing Facility Support System
S1176 Door Monitoring System
March Reflections
This month has bad news and good news. The bad news is that we rose to 9.9 tags/survey
from 9.2 last month! But there is good news mixed into the findings...only 4 G+ tags which is
down from 10 last month. All providers can do is review processes, in-service and train your
staff then continue to monitor your processes for sustaining improvement. There is a survey
consistency taskforce meeting on April 16th so if you have issues you or your staff would like
raised, please give me a call or send me an email. Below is the 2014 YTD numbers for your
review.
The number one tag in March was F323, Accident Hazards in 76% of the surveys resulting in 2
G+ tags, one a J related to an elopement. KHCA is hosting a webinar on Fall Prevention on May
13 from 10:30-11:30am during which “best practices” will be discussed. Call the KHCA office to
sign up or just go to the website and register for the webinar. The most frequent findings for
F323 include: failure to implement effective interventions which results in injuries; accessible
chemicals; excessive water temps; failure to implement care planned interventions; side rail
gaps; failure to complete thorough investigations to reveal root causes for falls and elder
experiences fall with injury(ies); burns from hot liquids; elopement & failure to develop timely
and effective interventions. This is probably the right spot to address a couple new findings that
have come up recently about side rails and restraints...side rail gaps need to be included in the
side rail assessment to document the gaps have been assessed. Also, if mechanical low air loss
mattresses are used, use great caution because of the gap created when the air mattress is
compressed along the edge. If an air mattress is used as a pressure relieving measure the side
rails need thorough assessment to ensure safety in the gaps. Also raised this month is the fact
that perimeter mattresses may be considered a restraint and requires assessment if used as a
safety intervention. If you have questions about those assessments, please give me a call.
LICA-MedMan subscribers can find an amended nursing assessment in the Policy Library which
includes a Side Rail Assessment including gap measurements and a new Restraint Assessment
also in the Policy Library.
Sixty percent of the surveys resulted in F441, Infection Control. The most frequent findings
include: inappropriate cleaning procedures in the rooms, especially isolation rooms (PLEASE
make sure the housekeeping staff know and understand the manufacturer’s recommendations for
wet times for the sanitization products used); failure to appropriately clean and store oxygen
equipment including nebulizer masks; failure to clean glucometer according to manufacturer
recommendations before and after each individual elder use and failure to use gloves during
procedure; inappropriate dressing changes including providing a clean barrier and changing glove
and hand hygiene between contaminated process and clean process; failure to track and trend
infections including specific inclusions on the tracking and trending of: specific location of
infections, effectiveness of antibiotics, culture results, nosocomial status, trends, analysis of logs
including specific infection data and culture result review, (the key to tracking and trending is the
analysis of the results); inappropriate peri-care including hand hygiene and changing gloves and
failure to cover laundry during transport.
F280, Care Plan Revisions; F329, Unnecessary Medications; and F371, Kitchen Sanitation were
tagged in 52% of the March re-surveys. The key to F280 is the ability of nursing staff to revise
the care plan in “real time”. The upcoming KHCA Spring Quality Conference includes a session
on appropriate care planning, so hope to see many of you there. But having the care plan
thorough and individualized is only the first step, the staff MUST know what is in the care plan
and implement the planned interventions. I had a question this month from a pharmacist related
to careplanning Black Box Warnings. I clarified the question with Audrey Sunderraj who
confirmed no changes have been made to the requirement. All Black Box Warnings must be
included on the care plan so all staff have the information for monitoring. A reference to the
MAR is not sufficient even if the BBW is included on the MAR.
The key to F329 is monitoring efficacy and side effects of drugs. Targeted behavior monitoring
for each individual drug for each individual targeted behavior is the requirement. Staff must also
monitor blood sugar levels as ordered and report to the ordering physician if outside parameters
and hold/administer meds as ordered. The same goes for cardiovascular meds such as antihypertensives and cardiac rhythm drugs. Also included in monitoring are bowel management
meds and following established protocols.
There is no further information I can give you about F371. Your facility must have processes in
place to monitor for compliance. It does appear that the initial kitchen inspection and that first
meal observations are the keys to success with F371. If things look good at the start, it will
result in a more positive outcome. Do a walk-through in the kitchen and dining rooms OFTEN
and include this issue in your QAPI. Complete checklists then base your in-service and training
on the results of your checklists.
I hope you find this information helpful to your facility and especially your elders. Have a happy
Spring! And don’t forget to let me know your concerns you would like presented at the Survey
Consistency Taskforce next week.
Linda Farrar, RN/BSN/LNHA
linda@licamedman.com
785-383-3826