Long-Term Care Survey Alert

6 ways to stave off F323 and related tags

With revised survey guidance for F323 tag now in effect, you need to get a step ahead of surveyors--and fast. These proactive interventions will go a long way toward keeping your residents and survey record out of harm's way.

1. Do risk assessments at admission or even before to flag residents at risk for falls and elopement. Falls and elopement will be a major focus under F323, which subsumes the old F324 tag for supervision. And while "it takes time to do a fall assessment, you have to come up with a fall prevention plan for frail elderly people admitted from the hospital," says David Mehr, MD, with the University of Missouri-Columbia. "Keep in mind that ambulatory people who are losing functioning are the ones who fall and have serious injuries."

Ask this pivotal question: Has the person fallen in a previous setting or displayed wandering behaviors?

A history of falls is a "strong predictor" whether someone will fall again, warned Jacqueline Vance, RN, in a presentation on falls at the most recent American Association of Homes & Services for the Aging annual conference. So if the person had a fall within the last 90 days, you definitely want to put that on his problem list and initial plan of care, advised Vance, director of clinical affairs for the American Medical Directors Association.

People with dementia who previously displayed wandering behaviors are at the highest risk for elopement within the first 24 to 48 hours after admission, in the experience of nurse attorney Barbara Miltenberger with Husch & Eppenberger in Kansas City, MO. 

Another major red flag: A person with dementia who is observed fidgeting with her WanderGuard bracelet, door alarms or windows. "Those people have a mindset where they are determined to get out of the facility. And, unfortunately, they usually do," says Miltenberger.

2. Provide extra supervision for high-risk residents for a few days after admission. For example, place residents at high risk for falls near the nursing station, says Mehr.

Smart idea: Facilities in which LTC Systems consults have turned sterile isolation rooms into cheerful admission rooms to keep long-term stay residents for a couple of days after admission to figure out exactly what they need and then place them appropriately, says Lynda Mathis, RN, lead consultant for the firm in Conway, AR. "Medicare patients go on units with higher staffing" at admission.

3. Compare your risk assessment to the resident's care plan and documentation of interventions. Surveyors "will throw care plans in your face, saying you identified the risk and care planned to address it but didn't follow through--therefore, you neglected to provide required services," warns Nancy Shellhorse, JD, in Austin, TX. As a result, the facility can end up with not only F323 citations but also abuse and neglect tags, she says.

4. Keep systems simple to get to the heart of what caused and can prevent an incident. A facility can  "be its own worst enemy" by creating too many systems and layers to investigate an accident, such as a fall, counsels Nancy Augustine, RN, MSN, a consultant with LTCQ Inc. in Lexington, MA. Instead, just ask one simple question, she suggests: "What do we need to know and do in order to prevent [the same problem] from happening again?" For example, staff should ask residents with even significant dementia simple questions in a kindly tone about how they fell, advises Augustine. To not do that "is a huge mistake."

Example: One resident with cognitive impairment was able to let staff know that a loose toilet seat riser screwed onto the toilet caused her to fall, relays Augustine.

Sidestep this common trap: Sometimes facilities implement a bunch of interventions after a resident falls, observes Edythe Cassel Walters, MBA, RN, NHA, a consultant in Harrisburg, PA. But if they haven't really figured out the causes of the fall, "they have made more work for themselves than needed. And if the person continues to fall, they don't know which of the interventions" helped.

5. Don't skip or skimp on any step in the post-investigation process. Facilities are supposed to investigate an incident to find the root cause, make recommendations, implement them--and then evaluate whether the changes are working, reminds Augustine. Yet facilities don't always follow through with that post-event process like they should, she cautions. "If surveyors look at the post-investigation process, they will have a field day in many facilities."

6. Develop systematic ways to trend accidents and injuries. To be able to comply with F323, "facilities will have to collect data" and look at trends to identify their hazards, says attorney Chris Puri, with the law firm of Boult Cummings Conners & Berry in Nashville, TN. "That's part of what the revisions appear to be getting at."

Good questions: As part of your trending, look at whether patients who fall are cared for by a certain caregiver, suggested Vance in her AAHSA presentation. Maybe the facility didn't catch that a physician is inappropriately treating his patients with Demerol or Darvocet or something that is leading to the falls, relayed Vance. Or a nurse aide may be using improper lift techniques and patients are falling as a result, she noted.

Critical tip: Implement primary CNA assignments to promote accountability and reduce risk of falls, elopements and other negative outcomes, suggests Augustine. If you don't use that staffing model, it's almost impossible to detect which CNAs are providing poor care in a large building, she adds. Also, "the CNAs who really know a resident can also tell you whether certain fall interventions will work for that individual."

Editor's note: Read "What Wasn't I Thinking? Identify, Fix Common Safety Hazards" in the next Long-Term Care Survey Alert.