Review of F323 Related to Falls. Marilyn Hirsch Region V December 16, 2015

Transcription

1 Review of F323 Related to Falls Marilyn Hirsch Region V December 16, 2015

2 Objectives Describe Region V F323 Project Review F323 Regulation Review and discuss citations

3 History At our meeting two years ago, we discussed focusing on certain tags that were cited frequently to see if we could come up with ways to reduce that frequency In Region V, we finally had some time to organize such a project Two choices: F323 or F441 I decided to focus on F323 because I thought it was easier to figure out what the issues were for which F323 was most cited

4 Region V DSC Project Question: what is the distribution of reasons why surveyors cite F323? Random sample of F323 cites for each of the six States 10 recertification surveys and 10 complaint surveys with a cite at F323 were randomly selected (one State only had 8 F323 complaint cites) Volunteers from staff reviewed the sampled citations and classified them A sample of cases was re-reviewed to check for reliability

5 Region V DSC Project Results Distribution of Reasons for F323 Citation by Region V States All F323 Citations FY 2015 Reason for F323 cite Percentage Distribution Recertification Surveys (60) Complaint Surveys (58) Falls* 60% 72% Elopement 2% 9% Other 38% 19% *Any citation where falls is an issue, regardless of whether it is the only issue or there is more than one issue, is counted in the Falls category.

6 Region V DSC Project Results Distribution of Reasons for F323 Citation by Region V States Citations at Immediate Jeopardy and Actual Harm Level Reason for F323 cite FY 2015 Recertification Surveys (8) Percentage Distribution Complaint Surveys (23) Falls* 100% 65% Elopement 0% 9% Other 0% 26% *Any citation where falls is an issue, regardless of whether it is the only issue or there is more than one issue, is counted in the Falls category.

7 Regulation 42 CFR (h) Accidents Wording of the regulation: The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.

8 Intent 42 CFR (h)(1) and (2) Accidents and Supervision 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 hazards 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.

9 Definitions Resident Environment The physical surroundings to which the resident has access. Accident Any unexpected or unintentional incident that may result in injury or illness to a resident. Avoidable accident Accident occurring because of something the facility failed to do related to identification, evaluation, implementation and/or monitoring. Unavoidable accident Accident occurring despite facility efforts to identify, evaluate, implement, and monitor.

10 Definitions Hazards Elements of the resident environment that have the potential to cause injury or illness. Hazards over which the facility has control are hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness. Free of accident hazards as is possible refers to being free of accident hazards over which the facility has control.

11 Definitions Adequate supervision Refers to an intervention and means of mitigating the risk of an accident. Defined by the type and frequency of supervision based on individual s assessed needs and identified hazards in the resident environment. Assistive device Any item that is used by or in the care of a resident to promote, supplement or enhance the resident s function and/or safety. Examples are handrails, grab bars, transfer lifts, canes, and wheelchairs. F323 applies to assistive devices that create hazards; are not provided or do not meet the resident s needs; and/or are used without adequate supervision when required.

12 Definitions Risk Any external factor or characteristic of an individual resident that influences the likelihood of an accident. Fall The MDS defines a fall as unintentionally coming to rest on the ground, floor or other lower level, but not as the result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident loses his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence otherwise, when a resident is found on the floor, a fall is considered to have occurred. However, not every fall can be avoided and therefore, not every fall is a deficient practice.

13 Avoidance of Accidents Facilities should commit to safety and implement systems that address resident risk and environmental hazards to minimize the likelihood of accidents. Facilities with a commitment to safety: Acknowledge high-risk nature of its population and setting; Develop a reporting system that does not place blame; Involve all staff in identifying solutions to ensure a safe environment; Direct resources to address safety concerns; and Demonstrate a commitment to safety at all levels of the organization.

14 Facility Responsibility Facility has to balance protecting residents rights to make choices and its responsibility to comply with the regulations. Facility has responsibility to educate residents, family and staff regarding the significant risks associated with resident choices. Consent by resident or responsible party does not relieve facility of its responsibility to assure the health, safety and welfare of its residents. Regulations do not create the right of the resident or responsible party to demand that the facility use specific medical interventions or treatments that the facility deems inappropriate. The regulations hold the facility ultimately responsible for the residents care and safety.

15 Facility Responsibility Identification of Hazards and Risks is the process by which facility becomes aware of potential hazards and risks. All staff should be involved in observing and identifying potential hazards while taking into account individual resident characteristics so that such identification is unique to each resident. Sources that provide information about hazards and risks include quality assurance activities, environmental rounds, MDS data, medical history and physical exam and individual observation.

16 Facility Responsibility Evaluation and analysis is the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce potential for accidents Process should be interdisciplinary. Analysis may include the severity of the hazards, immediacy of risk and trends in what is happening when.

17 Facility Responsibility Implementation of interventions is the use of specific interventions to try to reduce a resident s risk from hazards Need to communicate interventions to all relevant staff. Assign responsibility for reducing risks. Provide training. Document interventions. Ensure the interventions are put into place, for example, training, repair equipment or revise policies and procedures.

18 Facility Responsibility Monitoring and modification of interventions Monitoring is the process of evaluating the effectiveness of interventions. Modification is the process of adjusting interventions to make them more effective.

19 Facility Responsibility Factors that contribute to falls Resident condition Environmental Hazards Personal fit and condition of assistive devices Staff practices Lighting

20 Facility Responsibility Proper actions following a fall include: Ascertaining if there were injuries and providing treatment as needed; Determining what may have caused or contributed to the fall; Addressing the factors for the fall; and Revising the resident s plan of care and/or facility practices to reduce the likelihood of another fall.

21 Survey Process The F323 guidance includes an Investigative Protocol to be used for: A sampled resident who is at risk for or who has a history of falls to determine if the facility provided care and services to prevent avoidable accidents, including adequate supervision, and to reduce the resident s risk to the extent possible; and Determining if there are facility practices in place to identify, evaluate and analyze hazards/risks; implement interventions to reduce or eliminate the hazards/risks, to the extent possible; and monitor the effectiveness of the interventions. If falls are triggered on a QIS survey, the Accidents Critical Element Pathway would be used to investigate them.

22 Compliance The facility is in compliance with this regulation if the facility has: Identified hazards and risks of an avoidable fall based on the facility s assessment of the resident environment and the resident; Evaluated/analyzed the hazards and risks; Implemented interventions to reduce the risks of a fall consistent with a resident s needs, goals, plan of care and current standards of practice; Provided assistive devices consistent with a resident s needs; Properly deployed and maintained resident specific equipment; Provided a safe environment; Assured equipment is used in accordance with manufacturer s recommendations and resident needs; Provided and maintained a secure environment to prevent negative outcomes; and Monitored the effectiveness of the interventions and modified them as necessary and appropriate.

23 Severity Determination Examples Related to Falls Severity Level 4: Immediate Jeopardy to Resident Health or Safety Examples of negative outcomes of falls at the IJ level: Loss of consciousness related to head injuries. Fracture or other injury that may require surgical intervention and results in significant decline in mental and/or physical functioning. Falls that result in or have the potential to result in serious injury, impairment, harm or death and for which the facility has no established measures or practices or ineffective measures or practices that would have prevented the fall or limited the injury.

24 Severity Determination Examples Related to Falls Severity Level 3: Actual Harm that is Not Immediate Jeopardy Examples of negative outcomes of falls at the actual harm level: Short-term disability. Pain that interferes with normal activities. Fracture or other injury that may require surgical intervention and does not result in significant decline in mental and/or physical functioning. Situation for which medical evaluation is necessary and treatment beyond first aid is required. Falls that result in actual harm and the facility has established measures or practices in place that limit the resident s potential to fall and limit the resident s injury and prevent the harm from rising to a level of immediate jeopardy.

25 Severity Determination Examples Related to Falls Severity Level 2: No Actual Harm with Potential for More than Minimal Harm that is Not Immediate Jeopardy Examples of negative outcomes or potential for negative outcomes at severity level 2: Bruising and minor skin abrasions. Pain that does not impair normal activities. Medical evaluation or consultation may or may not have been necessary and treatment such as first aid may have been required. Falls which result in no more than minimal harm because the facility had additional established measures or practices that limit the resident s potential to fall or limit the injury or potential for injury.

26 Severity Determination Examples Related to Falls Severity Level 1: No Actual Harm with Potential for Minimal Harm The failure of the facility to provide a safe environment and adequate supervision places residents at risk for more than minimal harm. Severity Level 1 does not apply for this regulatory requirement.

27 Next Steps Divide into groups Review F323 citations Provider groups will review the citation as written to determine if they agree with the citation, if the findings support the citation, what the facility failed to do, what Severity/Scope level it should have been cited at and whether additional investigation should have been done and if so, what. Regulatory groups will discuss what the plan of correction should look like. Each citation is being reviewed by a provider group and a regulatory group. Report out Discuss where to go from here