Tag Cited: F (h)(1) & (2) Accidents and Supervision Issue Cited: Interventions to Minimize Falls/Accidents

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1 Click here to view this document in Microsoft Word Plan of Correction / Allegation of Compliance Tag Cited: F (h)(1) & (2) Accidents and Supervision Issue Cited: Interventions to Minimize Falls/Accidents Preparation and/or execution of this plan do not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility s credible allegation of compliance. 1. Immediate action(s) taken for the resident(s) found to have been affected include: The Director of Nursing Services and the Resident Assessment Instrument Coordinator met with the nursing and care staff on. Safety and fall risk assessments were completed for Resident # and Resident #. Appropriate revisions were made to the care plans to reflect all current safety interventions. The revised assessments and care plans were reviewed with staff involved in the care of each resident. 2. Identification of other residents having the potential to be affected was accomplished by: The nursing management team reviewed the MDS Assessments for all residents who have been identified as h aving a p otential risk for falls. Fall and safety risk assessments are complete and interventions currently in place are appropriate. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: All Licensed Nursing staff will be inserviced on the facility policy for Accidents and Supervision. All resident falls/accidents will be reviewed daily by the nursing management team to ensure appropriate implementation of safety interventions including updating the plan of care. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The nursing management team will review each incident report upon occurrence to ensure appropriate interventions are implemented and updated plan of care is complete. The Director of Nursing Services (DNS), or designee, will complete random weekly chart audits for six (6) consecutive weeks and review all fall incident reports to ensure that appropriate interventions have been put in place to reduce the risk of resident falls/accidents and that care plans have been updated to reflect these interventions. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee. Audit results will be shared with the Resident/Family Group Council for comment and suggestions. Corrective action completion date:.

2 Plan of Correction/Allegation of Compliance Accidents and Supervision F-323- Accidents and Supervision Date Implemented: Date Reviewed/Revised: Reviewed/Revised By: Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) 2. Evaluating and analyzing hazard(s) and risk(s) 3. Implementing interventions to reduce hazard(s) and risk(s) 4. Monitoring for effectiveness and modifying interventions when necessary Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks-the process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident. c. Various sources provide information about hazards and risks in the resident environment. d. These sources may include, but are not limited to: i. quality assurance activities ii. environmental rounds iii. MDS/CAA data iv. medical history v. physical exam vi. individual observation e. This information is to be documented and communicated across all disciplines. 2. Evaluation and Analysis-the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process. a. Analysis may include, for example, considering the severity of hazards, the immediacy of risk, and trends such as time of day, location, etc. b. Both the facility-centered and resident-directed approaches include evaluating hazard and accident risk data, analyzing potential causes for each hazard and accident risk, and identifying or developing interventions based on the severity of the hazards and immediacy of risk. c. Evaluations also look at trends such as time of day, location, etc.

3 Plan of Correction / Allegation of Compliance 3. Implementation of Interventions-using specific interventions to try to reduce a resident s risks from hazards in the environment. The process includes: a. Communicating the interventions to all relevant staff b. Assigning responsibility c. Providing training as needed d. Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) e. Ensuring that the interventions are put into action. f. Interventions are based on the results of the evaluation and analysis of information about hazards and risks and are consistent with relevant standards, including evidence-based practice. g. Development of interim safety measures may be necessary if interventions cannot immediately be implemented fully. h. Facility-based interventions may include, but are not limited to: i. educating staff ii. repairing the device/equipment iii. developing or revising policies and procedures i. Resident-directed approaches may include: i. implementing specific interventions as part of the plan of care ii. iii. supervising staff and residents, etc. facility records document the implementation of these interventions 4. Monitoring and Modification-Monitoring is the process of evaluating the effectiveness of interventions. Modification is the process of adjusting interventions as needed to make them more effective in addressing hazards and risks. Monitoring and modification processes include: a. Ensuring that interventions are implemented correctly and consistently b. Evaluating the effectiveness of interventions c. Modifying or replacing interventions as needed d. Evaluating the effectiveness of new interventions

4 Plan of Correction/Allegation of Compliance F-323- Accidents and Supervision Audit Form Accidents and Supervision Interventions to Minimize Falls/Accidents Purpose: To ensure timely an appropriate implementation of interventions to minimize falls/accidents. Record observations below. Provide corrective action if needed. Date: Reviewed By: Medical Record Reviewed Date of Fall or Accident Intervention Implemented Care Plan Updated Corrective Action Comments Yes No Yes No Yes No

5 Plan of Correction / Allegation of Compliance Accidents and Supervision In-Service Training Guide F-323 Quality of Care Review Regulation(s): (h) Accidents The facility must ensure that- (1) The resident environment remains as free from accident hazards as possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. Review Intent of Regulation: The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: Identifying hazard(s) and risk(s); Evaluating and analyzing hazard(s) and risk(s); Implementing interventions to reduce hazard(s) and risk(s); and Monitoring for effectiveness and modifying interventions when necessary. Definitions Provided to Clarify Terms Related to Providing Supervision and Other Interventions to Prevent Accidents: Accident refers to any unexpected or unintentional incident, which may result in injury or illness to a resident. This does not include adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current standards of practice (e.g., drug side effects or reaction). A review for the continued necessity of the dose Attempts or consideration of the possibility of, tapering a medication; and A documented clinical rationale for the benefit or, or necessity for, the dose or for the use of multiple medications from the same pharmacological class. Avoidable Accident means that an accident occurred because the facility failed to: Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and or Evaluate/analyze the hazards and risks; and/or Implement interventions, including adequate supervision consistent with a resident s needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice. Unavoidable Accident means that an accident occurred despite the facility efforts to: Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and or Evaluate/analyze the hazards and risks; and/or Implement interventions, including adequate supervision consistent with a resident s needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; and/or Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice.

6 Plan of Correction/Allegation of Compliance Facility Policy and Practice Review: F-323- Accidents and Supervision Facility s Accidents and Supervision Plan of Correction. Facility s Accidents and Supervision Policy. Facility s Accidents and Supervision/Interventions to Minimize Falls/Accidents Audit Form. Record of Training Complete Record of In-service Training and Attendance Form. Be sure all participants sign-in.

7 Plan of Correction / Allegation of Compliance Accidents and Supervision Interventions to Minimize Falls/Accidents Record of In-Service Training and Attendance Form The following personnel attended the Accidents and Supervision-Interventions to Minimize Falls/Accidents in-service training program conducted on. Printed Name Signature License Number (as applicable) Time Started: Instructor (Printed Name) Instructor (Signature) Time Ended: Use additional sheets as necessary.

8 Plan of Correction/Allegation of Compliance F-323- Accidents and Supervision (For use in determining compliance with F (h)(1)&(2) Interventions to Minimize Accidents/Falls Confidential Data: Risk Management/QA Committee Work Document Purpose: To determine if interventions are implemented appropriately following a fall or accident. Instructions: Randomly select medical records and review to ensure interventions are implanted and care plans are updated following a fall or accident to ensure staff is following the facility policy for Accidents and Supervision. Provide completed report to the Risk Management/QA Committee. Use additional copies of this form as necessary. Date: Reviewed By: Job Position/Title: Medical Record Reviewed Observations Care Intervention Plan Implemented Updated Corrective Action Y N* Y N* Y N ** Comments 0 EXAMPLE: SMITH, Marvin * If NO, provide explanation in Comment