Avoiding the "immediate-jeopardy" crunch - nursing home regulations and avoiding immediate jeopardy findings in inspections

Nursing Homes, Nov-Dec, 1998 by Beth A. Klitch

The nursing home industry has faced increased enforcement activity in recent weeks as a result of congressional hearings and Clinton administration initiatives to identify poor-quality nursing homes. Not only are surveyors citing higher numbers of deficiencies and cross-referencing a single fact pattern to multiple tag numbers, but the scope and severity assigned to these deficiencies is significantly higher, too. Especially worrisome is the dramatic jump in the number of immediate-jeopardy findings in recent surveys.

In one Midwest state, from September 1-23, 1998, surveyors cited 34 facilities for deficiencies at level J, K or L, resulting in a determination of not just substandard quality of care, but also immediate jeopardy to resident health or safety. Nearly three-fourths of those facilities found to have provided care that jeopardized the health and safety of residents were cited under regulation F324. Several important sections of this regulation are highlighted below:

F324 483.25(h)(2) ACCIDENTS

(h) The facility must ensure that -

(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

Intent: [section]483.25(h)(2)

The intent of this provision is that the facility identifies each resident at risk for accidents and/or falls, and adequately plans care and implements procedures to prevent accidents.

An accident is an unexpected, unintended event that can cause a resident bodily injury. It does not include adverse outcomes associated as a direct consequence of treatment or care, (e.g., drug side effects or reactions).

Procedures: [section]483.25(h)(2)

If a resident(s) selected for a comprehensive or focused review has had an accident, review the facility's investigation of that accident and their response to prevent the accident from recurring.

Identify if the resident triggers RAPs for falls, cognitive loss/dementia, physical restraints, and psychotropic drug use.

If the survey team identifies a number of or pattern of accidents, in Phase II sampling, review the quality assurance activities of the facility to determine the facility's response to accidents.

Probes: [section]483.25(h)(2)

Are there a number of accidents or injuries of a specific type or on any specific shift? (e.g., falls, skin injuries)?

Are residents who smoke properly supervised and monitored?

If the survey team identifies residents repeatedly involved in accidents or sampled residents who have had an accident:

1. Is the resident assessed for being at risk for falls?

2. What care-planning and implementation is the facility doing to prevent accidents and falls for those residents identified at risk?

3. How did the facility fit, and monitor, the use of that resident's assistance devices?

4. How were drugs that may cause postural hypotension, dizziness, or visual changes monitored?

Generally, the types of incidents that were cited under the F324 requirement included:

* Falls from beds, wheelchairs, toilets and during ambulation

* Elopement and wandering incidents

* Bathing/showering incidents, including slips, falls and scaldings

* Smoking incidents, including burns and fires

* Body entrapments in beds, side rails

* Body entrapments in chair restraints

While we don't have enough space to fully discuss each type of incident, let's focus on falls as a primary source of risk for resident injuries and facility deficiencies. In many instances, facilities were cited for failure to implement a house-wide falls-management protocol that identified residents at risk for falls, that added new interventions to treat residents who had already experienced a fall, and that tracked the numbers and types of falls throughout the facility. Below you will find an abbreviated falls management protocol that can be easily adapted to work in any facility.