LeadingAge Minnesota
The Survey Review & Regulatory Analysis Committee examined four Ftags issued on surveys that were posted on June 3rd. Here are brief summaries of the deficient practices and recommendations on how to prevent them.
F279 (Use Assessment to Develop Care Plan)
Problem:Resident identified at risk of pressure ulcers had interventions (pressure-reducing cushions and mattress), but pressure ulcer still developed.
Recommendations:If resident is at moderate or high risk, use multiple interventions including repositioning, pericare twice daily and as needed, dietary consult. If the pressure ulcer develops, care plan should include treatments to prevent further decline.
Problems: Incomplete care plans (e.g., missing how much assistance is needed), “generic” care plans (e.g., not individualized), care plans not completed by 21st day, not match the MDS.
Recommendations:Have an identified person, such as an MDS nurse, responsible for ensuring the care plans are complete and accurate. This person should be responsible to report system issues to the DON/administrator for follow-up.
Problem: Lack of coordination between nursing home and hospice care plans.
Recommendation:Have an SNF representative and a hospice representative ensure the care plans are mutually understood and in agreement. Confirmation should be an ongoing process and should be verified at each care conference.
Problem:Psychotropic medications not noted in the care plan.
Recommendation:List all psychotropics in care plan as well as target behaviors, non-pharmacological interventions, and monitoring for side effects.
F282 (Services not Provided per Care Plan)
Problems: Resident at risk of falls. Care plan to have call light within reach at all times. Surveyors found call light hung on privacy curtain at end of bed.
Recommendation: Adopt a standard of practice that call lights are to clipped to the center of the bed (unless clipped to a seating place elsewhere in the room) so that they are visible at all times, and audit for compliance.
Problem: Care plan not followed for repositioning every 2 hours.
Recommendations: Have nursing staff complete repositioning audits—place a card under or near resident that says “return to nurse when found”, and have nurse verify it is within the 2 hours.
Problems: Care plan stated Wander Guard to be checked for functioning every shift. No documentation this was ever done.
Recommendations: Policy to reflect that functioning is checked weekly and placement is checked daily.
Problems: Inconsistencies between the TAR, care plan, resident care sheet, and physician/NP orders. Oral cares, repositioning, assistance with shaving were found to be care planned but not provided.
Recommendations:Review and audit to ensure that (1) orders are being accurately entered, (2) the care plan accurately reflects the orders, (3) any TAR or care sheet is consistent with the care plan, and (4) the care provided on the floor is in accordance with the care plan. Consider starting with the care plan and then working forward or backward.
F323 (Accident Hazards, Failure to Supervise)
Problem: Preventive maintenance not done—bed rails loose.
Recommendations: Check beds on regular schedule. Use CDs to measure side rail gaps.
Problem: Water temperatures too high.
Recommendations: Regular checks of water temps by maintenance. Document the checks.
Problem: Staff use a wheeled walker as a wheelchair for resident.
Recommendation: This is not safe. Review manufacturer’s instructions or have therapy staff train nursing staff on limitations of use of wheeled walkers.
Problem: Construction site not secured to prevent residents from going outside.
Recommendation: Make sure your contractors understand that it is their responsibility to ensure the safety of the construction site. Make sure your contract has an indemnification clause.
F329 (Unnecessary Drugs)
Problem: Resident with two similar drugs. Consulting pharmacist identified it, but physician did not accept the recommendation.
Recommendation: When physician doesn’t accept the recommendation, be sure to document that staff discussed the recommendation with the physician and the physician’s explanation.
Problem: Resident sleepy during the day and on three psychotropic drugs (antidepressant, antianxiety, antipsychotic) with no monitoring of target behaviors or adverse side effects.
Recommendation:Do not need to care plan for standard of practice, but target behaviors need to be charted, at least by exception. Side effects definitely need to be monitored and addressed as needed.
Problems: Labs draws not done—order for Hgb A1C every 3 months, not drawn for 6 months. Another resident had order for monthly orthostatic BPs to monitor Risperdal, but none done for 6 months.
Recommendation:DON or case manager set up a tickler file for residents’ medications related to lab draws, rather than relying on consulting pharmacist to catch it. Can set the MAR for the monthly BPs to trigger routinely, thus alerting the nurse.
Problems:Resident had orders to hold insulin if blood sugar below specific level; another resident had orders for 100 mg TSH, and thyroid lab work was at 0.04. The insulin wasn’t held when blood sugars went below 120, and no one contacted the physician about a medication change based on the thyroid lab results.
Recommendations: These follow-ups are a standard of nursing practice. Train and monitor staff for proper follow-through. You do not need a written protocol for lab value change follow-up.