G
5 G+ level tags
1-F314:
W: SS=G: Failed to provide necessary treatment & svcs to prevent pressure sores from developing for res who developed an avoidable unstageable pressure sore on heel
4-F323
SE: SS=G: Failed to provide interventions as planned to prevent accidents for res with hip fx; failed to ensure environment remained free of accident hazards in rehab room & day room
SC: SS=G: Failed to implement planned interventions for res resulting in fall in which res sustained multiple fractures; failed to safely store chemicals & meds to prevent accidents
NC: SS=G: Failed to provide appropriate supervision & assistive devices to prevent falls/accidents for multiple residents
NE: SS=G: Failed to provide supervision /or develop & implement adequate fall prevention interventions in a timely manner to prevent accidents for multiple residents including 1 with fall that resulted in mental status change & intracranial hemorrhage
(brain bleed) which required hospitalization and an unlocked closet on multiple days with hazardous chemicals
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71% 17/24
F323 Free of Accident Hazards/Supervision/Devices
63% 15/24
F371 Food Procure, Store/Prepare/Serve-Sanitary
58% 14/24
F329 Unnecessary Drugs
54% 13/24
F441 Infection Control
46% 11/24
F253 Housekeeping & Maintenance Services
F280 Right to Participate in Planning Care-Revise Care Plan
42% 10/24
F428 Drug Regimen Review
38% 9/24
F279 Develop Comprehensive Care Plans
29% 7/24
F241 Dignity & Respect of Individuality
F309 Provide Care/Services for Highest Well-Being
F314 Treatment/Svcs to Prevent/Heal Pressure Ulcers
F520 QAA Committee-Members/Meet Quarterly/Plans
25% 6/24
F312 ADL Care Provided for Dependent Residents
F315 No catheter, Prevent UTI, Restore Bladder
F325 Nutrition
F431 Drug Records, Label/Store Drugs & Biologicals
21% 5/24
F242 Self-Determination-Right to Make Choices
S600 Dietary Services
17% 4/24
F225 Investigate/Report Allegations/Individuals
F272 Comprehensive Assessments
F278 Assessment Accuracy/Coordination/Certified
F334 Influenza & Pneumococcal Immunization
F353 Sufficient 24-hr Nursing Staff Per Care Plans
F465 Safe/Functional/Sanitary/Comfortable Environment
13% 3/24
F157 Notify of changes (Injury/Decline/Room, etc)
F226 Develop/Implement Abuse/Neglect, Etc. Policies
F248 Activities Meet Interests/Needs of Each Res

8%
4%
F332 Medication Errors
2/24
F159 Facility Management of Personal Funds
F160 Conveyance of Personal Funds Upon Death
F166 Grievance Resolution
F281 Professional Standards of Services
F363 Menus and Nutritional Adequacy
F364 Nutritive Value/Appear, Palatable/Prefer Temp
F425 Pharmaceutical Svc-Accurate Procedures
F463 Resident Call System
S1116 Bathing Room
1/24
F156 Notice of Rights, Rules, Services, Charges
F170 Right to Privacy-Send/Receive Unopened Mail
F221 Physical Restraints
F244 Family Groups
F246 Reasonable Accommodation of Needs/Preferences
F247 Right to Notice Before Room/Roommate Change
F274 Comprehensive Assess After Significant Change
F318 Range in Motion
F319 Resident Adjustment Difficulty
F322 Naso-Gastric Tube Feeding
F327 Hydration
F354 Waiver-RN 8 hours 7 days/week, full time DON
F356 Posted Nurse Staffing Information
F372 Dispose Garbage & Refuse Properly
F456 Essential Equipment, Safe Operating Condition
F469 Maintains Effective Pest Control Program
F490 Administration
F514 Res Records-Complete/Accurate/Accessible
S1174 Door Monitoring System
S1354 Heating, Ventilation & AC
S3400 Dietary Areas

June Reflections
Good news...the average number of deficiencies decreased from 12.0 to 9.9...GREAT JOB,
FOLKS! There were 5 G level tags cited, one in each of the old regions. Another piece of good news is that there was only 1 G tag for pressure ulcers. That is a significant improvement for sure! It looks like many of you are putting improved processes in place to reduce pressure ulcer risk...not just the same old interventions that have been used in the past. Once again...GREAT
JOB! Let’s keep up the good work.
71% of the surveys reviewed resulted in F323, Accidents/Hazards and 4 of the 5 G tags occurred with F323, all of which involved falls with significant injuries. In 2013, F323 ranked 2 and 3 nd in Kansas rd nationally in being cited as a deficient practice, so that hasn’t changed much. So, let’s talk “best practice” to prevent falls. Would it surprise you that the vast majority of falls that were thoroughly investigated for causal factors were related to the elder needing to toilet? It is vital that each facility develops innovative interventions to improve continency for each elder as possible. Each elder should be assessed in detail on admission/readmission, quarterly and with any significant changes. Included in the assessment should be a 3 day voiding diary along with specific reasons for incontinency. Is the incontinency urgency, stress, functional, mixed, or something else? The assessment should address prostate problems, constipation, UTIs, medications, mental status, mobility limitations, frequency, type, circumstances and duration of the incontinency. From there, a nurse evaluates the results of the assessment and consults the physician, prompting consideration of effects of anticholinergic medications, the potential benefits of a toileting program and any other interventions possible.
Previously, a generic care plan was implemented such as “toileted upon arising, before and after meals and at bedtime” or “toilet every 2-3 hours”, but following an effective bowel/bladder assessment the toileting care plan can be individualized specifying the toileting schedule for that specific elder. Staff should investigate each case in which an elder does not have an individual plan to confirm that there is a valid reason for lack of a plan.
The next, and probably most challenging part of a good continence program is getting the program consistently implemented as planned. If your facility uses pagers, or other silent alert devices, the plan can be programmed into that system to alert staff. In ANY case, the plan should be specifically spelled out on the care plan and the direct care partners should be educated on the program and urged to follow the plan. Staff MUST understand why the program is important before they will follow the program. Then they must be held accountable to the program.
Reassessment is also vital. If, on the planned program, the elder is still incontinent multiple times during a 24 hour period, the plan needs to be changed and changed quickly...don’t wait until the next RAI cycle date.
Just in case you think this is all “hocus pocus”, here are some statistics about the relationship between falls and effective toileting programs. Research completed at a facility that developed a system to develop individualized toileting program shows that falls are highest in the elders’ rooms, usually occurring when the elder is on the way to or in the bathroom. Implementation of an individualized toileting schedule has markedly improved fall rates. The rate of falls fell from
8.345 falls per 1,000 elder days in 2003 to 6.1 per 1000 days in 2006 to 2.0 per 1000 elder days in (0.2%) in 2012. Now...that’s an effective QAPI program!

Other benefits can be obtained from implementing individualized toileting programs too...the same research shows that incontinence (F315) decreased from 76% of elders coded as occasional or frequently incontinent in 2004 to 31% coded as occasional or frequently incontinent in 2012 after full implementation of the individualized toileting program. Just consider how many elders that affected...and consider how much impact that had on a true quality of life for those elders that were successful! It would probably be safe to say that no one has being incontinent on their “bucket list”. Right? Other benefits realized from a comprehensive individualized toileting program includes a reduction in pressure ulcers from 12.4% in 2003 to 4.0% in 2012 and in 2013 the rate fell to less than 1%. (Just as a reminder, F314 Pressure Ulcers, has been a real problem for G tags in Kansas over the past several months.)
The real key to success in preventing falls is thoroughly investigating and effectively assessing each elder and each fall for each elder to determine the root cause and causal factors for the falls and implementing effective interventions.
As you all know by now, stakeholders will no longer receive copies of the 2567s as they are created. It is my earnest belief that the information received from those documents were used to assist providers to give better care to the elders served. I will continue to review reports that are accessible, and the only way for them to be accessible at this point in a timely manner is for you to send them to me for review as you get them. As always, the results will be used to develop trends to assist you in putting systems in place to meet the needs of the elders AND meet the expectations of the regulatory system. It takes numbers to develop trends, so please consider sending me or your association the results of your surveys. I don’t want you to think the surveys will be “secret”. The current plan is to notify the stakeholders of which facilities were surveyed each month and then at some point they will be posted on the KDADS website and the
CMS Nursing Home Compare website. The time delay will certainly delay timely reporting of findings to help you, which is why I believe it is important to continue to gather timely data. I will continue to analyze the data I receive. If you send me your 2567s, I will send you the findings and analysis. You may send your results to: lindaf670@gmail.com
or linda@licamedman.com
.
I hope you are all having a wonderful summer and everyone is afforded the time for some time off for refreshment, rejuvenation and relaxation.
Linda Farrar, RN/BSN/LNHA linda@licamedman.com
785-383-3826