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Long-Term Care Survey Alert

Survey Management:

Ditch Tag-Along Tags For Pressure Ulcers

Published on Wed Jan 26, 2005 Print Friendly and PDF PDF

Prepare now for surveyors to do more 'root cause' analysis of wounds.

No one likes a tag-along - except maybe surveyors who hand out multiple citations for a pressure ulcer or other negative outcome.

Avoiding a fistful of F tags for a single deficiency may require nursing facilities to shadowbox a little faster than they have in the past.

Know the low-down: So-called "tag-along" tags have always been a problem where surveyors in some states automatically cite an administrative tag to accompany almost any substantive deficiency, as an example, observes attorney Joseph Bianculli in Arlington, VA.

And now the handwriting is on the wall for surveyors to look harder for underlying shortfalls that caused a pressure ulcer (F314). The new investigative protocol for pressure ulcers actually provides a list of related F tags for surveyors to consider in that regard.

In addition, the Centers for Medicare & Medicaid Services is measuring surveyors as part of an initiative on state performance standards, cautions Michael Kogut, an attorney in Boston. "So there's a lot of pressure on surveyors to look harder for related deficiencies when they cite a pressure ulcer or other deficient practice," Kogut says.

Beware multiple G's: "Facilities that get 'tag-along tags' for a single G-level deficiency for a pressure ulcer (for staffing, care planning, etc.) can end up with several G deficiencies," cautions John Lessner, an attorney with Ober/Kaler in Baltimore. "And that paints a picture a facility doesn't want to have painted," one that can pave the way for public relations and liability insurance problems - and lawsuits.

Thus, your best bet is to head off the core deficiency or any related  tags before and during the survey - or in negotiations with the state survey agency before the CMS 2567 is a done deal. Follow these proactive steps to stop tags in their tracks:

1. Identify all potential tag-along tags upfront. Review all the F tags and related regulatory requirements that surveyors might cite related to F314 for pressure ulcers. The revised F314 survey interpretive guidelines specifically identify these tags:

  •  F157, Notification of Changes
  •  F272, Comprehensive Assessments
  •  F279, Comprehensive Care Plans
  •  F280, Comprehensive Care Plan Revision
  •  F281, Services Provided Meet Professional Standards
  •  F309, Quality of Care
  •  F353, Sufficient Staff
  •  F385, Physician Supervision
  •  F501, Medical Director

    Don't box yourself in: The above list isn't exhaustive. "Surveyors could also cite deficiencies for weight loss, dehydration and/or abuse and neglect," as examples, cautions Nancy Augustine, RN, MSN, a consultant with LTCQ Inc. in Lexington, MA.

    Review CMS' directions for investigating the above list of F tags at     www.cms.hhs.gov/manuals/pm_trans/R4SOM.pdf 

    2. Audit your care planning and documentation on a regular basis. After you've identified all of the potential "tag-along" tags, audit your care planning and documentation to see if you're in compliance.

    Make sure the charts include all of the required risk assessments, including the nutritional piece, care planning and implementation - and how the staff have handled a non-healing wound," advises Kathy Hurst, RN, JD. Hurst is director of human resources and health care operations for Anaheim Hills, CA-based TSW Management Group, which manages a number of nursing facilities in that state.

    Tip: If a wound isn't healing after two to four weeks into a treatment regimen, notify the doctor for a potential change in plan of care - and document what transpired. "If the facility doesn't do that - bang, it's looking at tags for failing to notify the doctor and for failing to treat the pressure ulcer," cautions Augustine.

    3. Be prepared to defend your wound-care protocols. Surveyors can hand out F tags for failure to meet professional standards (F281) if you can't explain clinical rationales for your wound-care approaches. For example, TSW-managed facilities tailor treatment to a particular wound based on evidence-based practices or, in some cases, the prevailing community standard of practice, Hurst reports. 

    To get everyone on the same page with wound care, TSW has developed skin care guidelines that divide pressure ulcers into 17 types of wounds based on staging (stage 1 through IV), the presence of necrotic tissue and various levels of wound drainage, etc.

    The guidelines also list the treatments considered appropriate for each type of wound - and citations from the literature as evidence-based rationale to show surveyors.

    TSW gives clinicians latitude to select favored treatments known to produce comparable outcomes, says Hurst. The organization reviews wound products and outcomes on a regular basis to update the guidelines.

    4. Recognize and address systems issues. Use your mock survey and QA process to preempt a slew of G-level tags - or immediate jeopardy - by identifying whether a pressure ulcer was unavoidable, an isolated incident or the sign of a systems breakdown.

    "A facility doesn't always have a systemic issue with a pressure ulcer," counsels Augustine. "But sometimes the facility has extensive protocols for wound assessment and care and documentation tools that they fail to implement," she cautions.

    If a resident develops a pressure ulcer, start climbing the care plan ladder by looking at assessment, interventions, implementation, evaluation and any needed care plan revisions. For example, "if the facility didn't assess the resident's risks (incontinence, nutritional issues, mobility) and/or didn't address them timely, then the QA team should look at other residents" for similar shortfalls in care, Augustine advises.

    If consistent implementation of a solid care plan proves to be the problem, reassess your staffing plan and training.

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