Abuse & Neglect, Reporting, Investigative Protocols, Accidents & Supervision, Online Reporting System and the Roster Sample Matrix, and the CMS 672 and 802 By Rebecca L. Hall, M.Ed. Long Term Care Educator Survey Process Update 2010 November 30, 2010 GAO Report, November 2009 GAO addressed the factors underlying understatement of serious care issues Recommendations to CMS CMS survey methodology and guidance Workforce shortages Training Supervisory review External pressures Nursing Home Deficiency Citations for Abuse Research by Nicholas Castle, Journal of Applied Gerontology published on August 4, 2010 Hypotheses: It is likely that several internal, organizational, and external factors will be associated with deficiency citations for abuse. 1
Nursing Home Deficiency Citations for Abuse Factors of interest Staffing levels Quality Medicaid resident occupancy Medicaid reimbursement rates Hypothesis 1: Low nursing home staffing will be associated with deficiency citations for abuse The association identified between staffing and quality 59 studies concluded that approximately 40% of the quality indicators examined had an association with nursing home staffing levels Staffing levels appear to influence many aspects of care in nursing homes, including processes of care and resident outcomes Hypothesis 2: Poor nursing home quality will be associated with deficiency citations for abuse It could be that nursing homes that provide generally poor quality of care are also likely l to be involved in the prevention of resident abuse 2
Medicaid Factors Nursing homes with high Medicaid occupancy will be associated with deficiency citations for abuse Nursing homes with low Medicaid reimbursement rates will be associated with deficiency citations for abuse Medicaid Factors Nursing homes with both high Medicaid occupancy and low Medicaid reimbursement rates The financial difficulties associated with Medicaid reimbursement can influence the operation of nursing homes Staff turnover Quality of care Abuse/Neglect in the News Sept. 18, 2010. Gov. Steve Beshear, Kentucky, ordered state officials to immediately implement 20 improvements to the way reports of abuse and neglect at Kentucky nursing homes are investigated. Better process of notifying local law enforcement about allegations More required training 3
Beshear Takes Action on Nursing Homes More intensive, coordinated investigations 107 citations at level 4 citations of abuse and/or death issued over a 3- year period were examined Of the 107 cases, only 7 were prosecuted as crimes Citations under review involved: 18 deaths 30 hospitalizations 5brokenones ones 2 amputations 13 residents were injured as a result of lapses by staff members Results The Governor asked that the effectiveness of the coordination of efforts among state agencies and local prosecutors and law enforcement be reviewed Prosecutors stated that coroners are usually not called in cases of suspected abuse and neglect. Coroners should be notified and autopsies performed 4
Results Law enforcement officers needed more training to investigate the allegations Law enforcement asked to get reports of abuse and neglect more quickly and Needed cameras and video equipment to preserve evidence. Providers requested to improved staffing and turnover of nursing home inspectors Recommendations Improve notification to local agencies of suspected adult abuse and neglect Establish regional specialized Adult Protective Service teams Allow better information sharing Involve coroners offices Increase training of long-term care investigators in the Office of Inspector General Recommendations Explore buying cameras and video recorders to document evidence Revitalize an Elder Abuse Committee Amend licensing regulations to require inservice training on abuse and neglect for all long-term care facility staff Provide training for law enforcement officials and prosecutors on elder abuse and neglect issues 5
Recommendations Publish statements of deficiencies issues by the Office of Inspector General in an easy-to-use format for the public Family Awarded $42.75 Million in Nursing Home Case Posted on November 19, 2010 Family sued a Madisonville, Ky. nursing home, saying the home s neglect led to the man s death according to court documents Resident was 92. The attorney stated that he became lethally dehydrated despite having a feeding tube. Kentucky Case Family alleged that nursing home staff members neglected the resident causing him to suffer sever dehydration, malnutrition, bedsores, infections and ultimately death Facility is vigorously challenging the decision 6
What are Bloggers Saying about Abuse? Bed sores: An Uncontrollable Killer 45,000 hospital admissions had pressure ulcers as the primary diagnosis 1 in 25 hospitalizations related to pressure sores resulted in death during the admission Dirty Needles may be Cause of Hepatitis B Outbreak in Nursing Home in North Carolina Outbreak stems from 5 medical technicians reusing diabetes pens when checking blood sugar levels Blogs Terminated employee for allegedly stuffing a sock in the mouth of a resident crying for help Terminated employee for prior criminal record. Witnessed pulling resident's hair Tennessee resident admitted to hospital from nursing home. Severe hemorrhaging, broken ribs and pressure sores Fractured femur Blogs Demented sense of humor amongst nursing home workers in California Staff covered dementia patients at the facility with lubricant from head to toe, making them slippery for staff on the next shift to handle Class action lawsuit brought against California corporation for systematic under-staffing at 22 nursing homes Understaffing contributes to incidents of abuse and neglect 7
Blogs 5 nursing home patients were seriously injured in portable heater mishaps in Minnesota nursing homes Alzheimer resident with first and second degree burns found on a radiator Resident wiggled her leg out of bed and into contact with the electric heat register foot severely blistered Resident had severe burns to fingers Blogs Illinois nursing home. Resident with history of agitation, irritability and combativeness abused by CNA Resident s finger was swollen and bruised Resident stated that 2 female CNA harassed her by holding her down, twisting and wiggling her finger, telling her they were stronger than she was Blogs Same resident at the Illinois nursing home Resident scratched nurse. Nurse wrapped the resident's hand with a washcloth and told her not to fight Care plan stated that the resident is resistive to care and had specific interventions (approach resident in gentle manner, explain what you are going to do, re-approach later and/or differently if resistant) CNA slapped resident s hands because the resident pinched her 8
Blogs Nursing home administration did not investigate this allegation of abuse until 4 days after the incident 100 year old resident admitted with history of falls, weakness, impaired balance and mobility (unsteady gate) Requires 2 person assist during toilet and transfer Nursing staff left resident sitting on toilet Resident fell and hit her head resulting in a head contusion and cut. Transferred to ER. Died 4 days later Blogs In Chicago, a quarter of the city s 119 nursing homes have suffered from rape allegations since July, 2007 Of the 86 cases investigated, only 1 arrest has been made In January, 2010, authorities made arrests at two Chicago nursing homes for residents with outstanding arrest warrants Governor Pat Quinn s Nursing Home Safety Task Force issued a final report proposing to reduce the number of psychiatric patient and convicted felons housed in nursing homes Blogs South Carolina Creates New Department to Investigate Suspicious Nursing Home Deaths 725 complaints of suspicious deaths were reported to the unit 12 deaths were related to accidents 231 death cases remain open 9
Blog At a New York nursing home, CNA became irritated after resident repeatedly used a call light for assistance CNA tied resident in wheelchair with a sheet and placed her in a darkened room Blog Two Kentucky Nursing Homes cited after employees improperly used cellular phones to take photos of residents At another facility, an investigation revealed staff took cell phone photos of residents and sent them to other workers with sexually explicit text messages Blog North Carolina Nursing Home cited for the following conditions: Failure to provide pain medications Sexual assaults committed on MR residents by other residents Fire ant bites on residents UTIs from a fecal crusted towel to wash urinary catheter Lack of RN coverage Resident in power wheelchair tipped over in transport van 10
Recent Studies One study 44% of nursing home residents have suffered some form of abuse 48% reported having been treated or handled roughly 38% reported having witnessed the abuse of others Recent Studies About 30% of long term care staff have witnessed some form of physical abuse of a patient in the previous year 81% have seen some form of verbal abuse One-third of nursing homes have been cited for violations that had the potential to lead to abuse 10% were cited for actual physical abuse 85% of nursing home staff blame staffing shortages Regulatory Guidance for Abuse and Neglect 11
F223 483.13(b) Abuse The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Intent: 483.13(b) Abuse Each resident has the right to be free from: Abuse Corporal punishment and Involuntary seclusion Intent (continued) Residents must not be subjected to abuse by anyone, including, but not limited to: Facility staff Other residents Consultants Volunteers Staff of other agencies serving residents Family members Legal guardians Friends 12
Definition of Abuse ABUSE is the willful infliction of injury, unreasonable confinement, intimidation, i id i or punishment with resulting physical harm, pain, or mental anguish. Different Types of Abuse Physical Abuse Sexual Abuse Verbal Abuse Mental Abuse Involuntary Seclusion Physical Abuse Hitting Slapping Pinching Kicking Controlling behavior through corporal punishment 13
Sexual Abuse Sexual harassment Sexual coercionc o Sexual assault Verbal Abuse Use of: Oral Written or Gestured language that willfully includes disparaging and derogatory terms to residents or their families within hearing distance, regardless of age, ability to comprehend, or disability Examples of verbal abuse Threats of harm Saying things to frighten residents Telling a resident that he/she will never see his/her family again 14
Mental Abuse Humiliation Harassment Threats of punishment Threats of deprivation Involuntary seclusion Separation of a resident from other residents or from her/his room Confinement to her/his room (with or without roommates) against the resident s will or the will or the resident s legal representative Involuntary seclusion Emergency or short term monitored separation from other residents is not involuntary seclusion May be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident s needs. 15
F 224 483.13(c) Each resident has the right to be free from mistreatment, neglect and misappropriation of property. Neglect means failure to provide goods and services necessary to avoid: Physical harm Mental anguish Mental illness Misappropriation of resident property Means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident s belongings or money without the resident s consent. How Do Surveyors Survey Abuse and Neglect? It begins with Task 2 Entrance Conference/Onsite Preparatory Activities The team leader will request the following: Facility policies and procedures to prohibit and investigate allegations of abuse and the name of a person the Administrator designates to answer questions about what the facility does to prevent abuse. 16
Sub-Task 5G Abuse Prohibition Review- Investigative Protocol General Objective To determine if the facility has developed and operationalized policies and procedures that prohibit abuse, neglect, involuntary seclusion and misappropriation of property for all residents. The review includes components of the facility s policies and procedures as contained in Guidance to Surveyors at 42 CFR 483.13 (c), F226. ABUSE PROHIBITION REVIEW These include policies and procedures for the following: Screening for potential hires Training of employees (both for new employees, and ongoing training for all employees) Prevention policies and procedures Identification of possible incidents or allegations which need investigation Investigation of incidents and allegations Protection of residents during investigations Reporting of incidents, investigations, and facility response to the results of their investigations ABUSE PROHIBITION REVIEW General Procedures and Use: Surveyors will utilize the Abuse Prohibition Investigative Protocol to complete this task. This protocol is used on every standard survey and every complaint investigation in which violations of 483.13(b), Abuse are substantiated 17
ABUSE PROHIBITION REVIEW PROCEDURES Surveyors will obtain and review the facility s abuse prohibition policies and procedures to determine that they include key components as outlined in F226. It is not necessary for these items to be collected in one document or manual. ABUSE PROHIBITION PROCEDURES (continued) Key components that must be included in abuse prohibition policies and procedures: Screening Training Prevention Identification Investigation Protection Reporting/response ABUSE PROHIBITION REVIEW PROCEDURES Surveyors will interview the individual(s) identified by the facility as responsible for coordinating the policies and procedures to evaluate how each component of the policies and procedures is operationalized, if not obvious from the policies. How do you monitor the staff providing and/or supervising the delivery of resident care and services to assure that care service is provided as needed to assure that neglect of care does not occur? 18
ADDITIONAL QUESTIONS: How do you determine which injuries of unknown origin should be investigated as alleged occurrences of abuse? How are you ensuring that residents, families, and staff feel free to communicate concerns without fear of reprisal? ABUSE PROHIBITION REVIEW PROCEDURES Surveyors will request written evidence of how the facility has handled alleged violations. They will select 2-3 alleged violations (if the facility has this many) since the previous standard survey or the previous time this review has been done by the State. ABUSE PROHIBITION REVIEW PROCEDURES Surveyors will determine if the facility implemented adequate procedures: For reporting and investigating For protection ti of the resident during the investigation For the provision of corrective action NOTE: the reporting requirements at 483.13(c) specify both a report of the alleged violation and a report of the results of the investigation to the State survey agency 19
ABUSE PROHIBITION REVIEW PROCEDURES Surveyors will determine if the facility reevaluated and revised applicable procedures as necessary Surveyors will interview several residents and families regarding their awareness of to whom and how to report allegations, incidents and/or complaints. This information can be obtained through formal resident, group and family interviews. ABUSE PROHIBITION REVIEW PROCEDURES Surveyors will interview at least five (5) direct care staff, representing all three shifts, including activity staff and nursing assistants, to determine the following: If staff are trained in and knowledgeable about how to appropriately intervene in situations involving residents who have aggressive or catastrophic reactions. Catastrophic Reactions Catastrophic reactions are extraordinary reactions of residents to ordinary stimuli such as an attempt to provide care. One definition to in current literature e is: catastrophic reactions are defined as reactions or mood changes of the resident in response to what may seem to be minimal stimuli (e.g..: bathing, dressing, having to go to the bathroom, a question asked of the person) that can be characterized by weeping, blushing, anger, agitation, or stubbornness. 20
ABUSE PROHIBITION REVIEW PROCEDURES If staff are knowledgeable regarding what, when and to whom to report according to the facility policies Surveyors will interview at least three (3) front line supervisors of staff who interact with residents (Nursing, Dietary, Housekeeping, Activities, Social Services). They will determine how they monitor the provision of care/services, the staff/resident interactions, deployment of staff to meet the residents needs, and the potential for staff burnout which could lead to resident abuse. ABUSE PROHIBITION REVIEW PROCEDURES Surveyors will obtain a list of all employees hired within the previous four months. From the list, 5 will be selected. The surveyor will ask the facility to provide written evidence that the facility conducted pre-screening based on the regulatory requirements at 42 CFR 483.13(c). Follow your policies and procedures about screening employees. Routinely check the nurse aide registry. Recommendations During resident council meetings, discuss abuse and neglect Make sure residents know how to report Consider having family meetings about abuse and neglect Consider sending family members information about abuse and neglect and how to report 21
CMS Problem-Solving Cycle Periodic review and revision of all abuse and neglect policies and procedures Monitoring activities Analysis of all incidents Satisfaction surveys Review of incident reports Review of reported abuse for trends Suggestions That May Minimize Frustration Know residents rights Know caretaker rights and responsibilities Seek support from an employer such as through an Employee Assistance Program (EPA) Seek support and education from local professional and service organizations Know your limits or breaking point Restraints - F221 F222 Abuse/Neglect - F223 F224 F226 F225 Federal Tags 22
Report of Abuse, Neglect, Misappropriation of Property, and Injury of Unknown Origin New Policy and Form Effective January 16, 2005 What to Report to the State Agency When to Report Where to Report How to Report OBJECTIVES: 1. Purpose of the Abuse, Neglect, Misappropriation of Resident Property, and Injury of Unknown n Origin Report 2. How to Use the Report 3. Expectations of the State Agency Regarding Use of the Report OVERVIEW OF THE REPORT The Report Was Sent to All Nursing Homes and Became Effective January 16, 2005. The Report Was Developed to Assist You in Your Decisions For: When to Report Where to Report How to Report and What to Report to the State Agency. 23
WHAT TO REPORT: The facility must ensure that all alleged violations involving: Abuse Neglect Mistreatment Misappropriation of resident property and Injuries of unknown source Are reported immediately (as soon as possible but not to exceed 24 hours) to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). WHAT TO REPORT Alleged violations that would constitute violations of criminal statutes, such as: Murders Rapes and Assaults Must also be reported to the appropriate local law enforcement agency. What Are Injuries of Unknown Source? Injuries of unknown source: An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. 24
When are facilities required to report potential incidents of resident on resident abuse? If the perpetrating resident is known to the facility to be cognitively i intact, the facility must report the resident to resident incident to the state agency. Resident on resident abuse If the perpetrating resident has some degree of cognitive impairment or If the cognitive status of the perpetrating resident is not known or is uncertain, the facility must: Take steps to determine whether the act was willful. Investigate! Resident s medical record Interview resident Interview staff Resident on Resident Abuse At the conclusion of the investigation, determine if the resident had willful intent. Regardless of cognitive status, if the resident remembers the incident and expressed an intention to injure or harm the other resident, the act was a willful one and should be reported. Even if the perpetrating resident was delusional. 25
Resident on Resident Abuse If the facility determines that the act was not willful and the resident due to cognitive status did not intend to injure or harm the resident, then treat it as an accident. It would not have to be reported Maintain an investigative file to support your determination Resident on Resident Abuse In either case, investigate! Take steps to prevent further similar incidents Maintain the investigation Conclusions Documentation of preventive steps on file Produce all documents when requested during a survey WHEN TO REPORT All alleged violations involving abuse, mistreatment, misappropriation of resident property, and injuries of unknown source are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). 26
WHEN TO REPORT The results of all investigations must be reported to the administrator or his/her designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident. And if the alleged violation is verified, appropriate corrective action must be taken. WHEN TO REPORT Within 5 working days of the incident, send a copy of the ENTIRE investigative file to the Division of Health Care Facilities Complaint Unit Failure to send the entire investigative file may increase the likelihood of an onsite visit WHERE TO REPORT Alabama Department of Public Health Division of Health Care Facilities 201 Monroe Street, t Suite 600 Montgomery, Alabama 36104 ATTN: COMPLAINT UNIT 27
HOW TO REPORT Eldercare Hotline 1-800-356-9596 (answering machine after hours) Eldercare fax line (334) 206-5161 Fax should be plainly marked ATTN: Complaint Unit Email: complaintunit@adph.state.al.us WHAT DOES THE ENTIRE INVESTIGATIVE FILE MEAN? Information You Have Related to an Investigation Such As Date/Time incident occurred Name of Resident(s) Involved in the Incident Names of Staff Involved in the Incident Accused Person(s) Name(s) Address, Telephone Number, Social Security Number of the Accused. INVESTIGATIVE FILE INFORMATION CONTINUED Name(s), Telephone Number(s) and Address(s) of Witnesses Documentation of Interviews With the Accused and Witness Details of the incidentid Seriousness of the injury How the injury occurred Documentation of Any Injuries or Assessments Completed Outcome of the Investigation What Corrective Actions Were Taken As a Result of the Investigation Immediate correction? 28
INVESTIGATIVE FILE CON T The State Agency May Also Request Additional Information Related to the Case at a Later Date Such As: Information From Personnel Files Any Other Information That Is Necessary in Making a Determination of Compliance. Was the incident reported to law enforcement? Reporting Requirements All Incidents (whether reportable to the State or not), including injuries of unknown origin, must be thoroughly investigated within 5 working days to determine the cause of the injury/incident Reporting Requirements The outcome of the investigation must also determine whether h or not the incident was abusive or neglectful in nature 29
Reporting Requirements All investigations must be documented in a written report, and contained within the facility, and be made available upon request to the Division of Health Care Facilities. Reporting Requirements If there is reasonable cause to believe or suspect that an injury has been neglectfully ll or abusively inflicted upon a resident, the facility is required to report it Examples of Non-Reportable Incidents or Occurrences: Witnessed falls where you do not suspect abuse or neglect. Unwitnessed falls where you do not suspect abuse or neglect. Falls requiring medical intervention such as an x-ray where you do not suspect abuse or neglect. 30
Investigative Protocols Protocols Mandated For Every Survey: Abuse (Appendix P & F223 226) Quality Assurance (F520) Unnecessary Medication Medication Regimen Review (F329, F428) Immunizations (F334) Activities (F248) Infection Control (F441) Protocols That Are Resident-Specific Use When Triggers Are Present Pressure Ulcer (F314) Urinary Incontinence (F315) Accidents & Supervision (F323) Unintended Weight Loss (Appendix P & F325) Hydration (Appendix P & F327) Dining And Food Service (Appendix P & F363 369) Protocols That Are To Be Used Only When Triggered Nursing Services, Sufficient Staffing (Appendix P & F353) Medical Director (F501) Paid Feeding Assistants (F373) Investigative Protocols Format: Objective Use Procedures Observations Interviews Record review Investigative Protocols Determination of Compliance Synopsis of regulation Criteria for compliance Criteria for non-compliance Potential tags for additional investigation Deficiency categorization Examples of severity levels Guidance on harm 31
Accidents and Supervision F 323 483.25(h) Regulatory Language Accidents and Supervision F323 F324 and F323 collapsed into F323 The facility must ensure that: The resident environment remains as free of accident hazards as is possible; and Each resident receives adequate supervision and assistance devices to prevent accidents. Intent Ensure the resident environment remains as free of accident hazards as possible. Ensure each resident receives adequate supervision and assistance devices to prevent accidents In other words the facility must provide an environment that is free from hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. 32
Methods to Meet Intent Identifying hazards and risks; Evaluating and analyzing hazards and risks; Implementing interventions to reduce hazards and risks; and Monitoring for effectiveness and modifying interventions as indicated. Definition: Accident Unexpected or unintentional incident May result in injury or illness Not an adverse outcome directly related to treatment or care that is provided in accordance with current standards of practice, i.e., drug side effects or reaction Definition: Avoidable Accident Facility failed to: Identify environmental hazard and resident risk including the need for supervision Evaluate/analyze hazard and risk Implement interventions consistent with resident needs, goals, plan of care, and current standards of practice Monitor and modify interventions as needed 33
Definition: Unavoidable Accident Accident occurred despite facility s efforts to: Identify environmental hazard and resident risk including the need for supervision Evaluate/analyze hazard and risk Implement interventions consistent with resident needs, goals, plan of care, and current standards of practice Monitor and modify interventions as needed Definition: Assistance/Assistive Device Any device used by or in care of a resident to promote, supplement, or enhance the resident s s function and/or safety. Assistive Device and Assistance Device used interchangeably Examples: handrails, grab bars, transfer lifts, canes, wheelchairs, etc. Definition: Environment/Resident Environment Environment refers to the resident environment. Environment and Resident environment are used synonymous in the Guidance Resident environment includes the physical surroundings to which the resident has access (e.g., room, unit, common use areas, and facility grounds, etc.). 34
Definition: Hazards Hazards refer to elements of the resident environment that have the potential to cause injury or illness. Hazards over which h the facility has control are those 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. Definition: Risk Risk refers to any external factor or characteristic of an individual id resident that influences the likelihood of an accident. Definition: Supervision/Adequate Supervision Facilities are obligated to provide adequate supervision to prevent accidents. Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident s assessed needs and identified hazards in the resident environment. 35
Overview: Commitment to Safety A facility with a commitment to safety: Identifies risk and acknowledges the high-risk nature of its activities Develops a reporting system that t does not place blame on the staff member for reporting risks Involves all staff in the identification of solutions Utilizes and directs resources to address safety concerns Commitment to safety demonstrated at all levels of organization A Systems Approach Monitor and Modify Identify Implement Evaluate A Systems Approach Identification of Hazards and Risks Sources for identifying hazards may include: Quality assurance activities Environmental rounds MDS/CAAs data Medical history and physical exam Individual observation 36
A Systems Approach Evaluation and Analysis The facility examines data gathered through identification of hazards and risks and applies it to the development of interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of this process all staff must be involved A Systems Approach Implementation of Interventions The process includes: Communicating the interventions to all relevant staff; Assigning responsibility; Providing training as needed; Implementing and documenting interventions; and Ensuring that interventions are implemented. Example What measures are implemented when there is a spill? Cones? Supervising the area until the spill is cleaned up? A Systems Approach Monitoring and Modification Monitoring and modification processes include: Ensuring that interventions are implemented correctly and consistently; Evaluating the effectiveness of interventions; Modifying or replacing interventions as needed; and Evaluating the effectiveness of new interventions. 37
Supervision Supervision is an intervention and a means of mitigating accident risk. Adequacy is defined by the type and frequency of supervision. Adequate supervision may vary from resident to resident and from time to time for the same resident. CMS mentions that the use of tools, i.e., personal alarms, can help to monitor a resident s activities, but does not eliminate the need for staff vigilance and are not be utilized in lieu of supervision. Supervision Resident-to-Resident Altercations Facilities need to take reasonable precautions to prevent resident-to-resident altercations. Certain situations or conditions may increase potential for resident-to-resident to altercations: History of aggressive behavior striking out, verbal outbursts Negative interactions with other resident(s) Disruptive or annoying behavior constant verbalization, making negative remarks, restlessness, repetitive behaviors, taking items belonging to others, going in others rooms, inappropriate dressing Supervision Resident-to-Resident Altercations An incident involving a resident who willfully inflicts injury upon another resident should be reviewed as abuse under the guidance for 42 C.F.R. 483.13(b) at F223. Willful means that the individual intended the action itself that he/she knew or should have known could cause physical harm, pain, or mental anguish. Even though a resident may have a cognitive impairment, he/she could still commit a willful act. However, there are instances when a resident s willful intent cannot be determined. In those cases, a resident-to-resident altercation should be reviewed under this tag, F323. 38
Resident Risks and Environmental Hazards This section provides information regarding the most common, but not all, potential hazards. The physical plant, devices, and equipment described may not be hazards in and of themselves. It is the interaction between these potential hazards and the vulnerable resident that may lead to an accident. Resident Risks & Environmental Hazards: Resident Vulnerabilities Falls are defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force. An episode where a resident loses his/his balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Resident Risks & Environmental Hazards: Resident Vulnerabilities Proper action following a fall includes: Ascertaining if there were injuries and providing treatment as necessary; Determining what may have caused or contributed to the fall; Addressing the contributing factors for the fall; and Revising the resident s plan of care and/or facility practices to reduce the likelihood of another fall. In other words, evaluation of the causal factors leading to a resident fall is necessary to provide consistent interventions to help prevent future occurrences. 39
Resident Risks & Environmental Hazards Resident Vulnerabilities Unsafe Wandering: wandering is locomotion with no apparent destination and is most often associated with dementia. Unsafe wandering occurs when the resident enters an area that is physically hazardous. Elopement occurs when a resident who needs supervision leaves a safe area without supervision. CMS stresses that alarms should not be used in lieu of staff supervision Resident Risks & Environmental Hazards: Resident Vulnerabilities Facility policies that define mechanisms and procedures can help to mitigate the risk of a resident leaving a safe area without staff supervision. The resident should have interventions in their comprehensive plan of care to address the potential for elopement. A facility s disaster and emergency preparedness plan should include a plan to locate a missing resident. Resident Risks & Environmental Hazards: Physical Plant Hazards Chemicals and Toxics Water Temperature Electrical Safety Lighting 40
Physical Plant Hazards: Chemicals & Toxics Potentially hazardous materials include: Chemicals used by facility staff in the course of their duties; Drugs & therapeutic agents; and Plants and other natural materials found indoors or outdoors Facilities are required to have the Material Safety Data Sheet (MSDS). Poison control centers are also a source of information for potential hazards. Physical Plant Hazards: Water Temperature Water may reach temperatures in hand sinks, showers, and tubs that can scald a resident. In Alabama regulations regarding the specific maximum water temperature that is allowed is 110 degrees F. Physical Plant Hazards: Electrical Safety The use of electrical space heaters are prohibited in resident care areas. The wires on electric blankets should not be tucked in or squeezed. A resident should not go to sleep with electric blankets or heating pads turned on. The use of Ground Fault Circuit Interruption s (GFCI) may be required near water sources. 41
Physical Plant Hazards: Lighting There is variability in vision, thus no single level of illumination is recommended. Creating transitional zones between light and dark spaces helps to improve sight recovery. Providing extra visual cues that clearly define needed items can help to enable safe performance of tasks. Providing supplemental light near beds for patients may assist in safe mobility at night. Assistive Devices/Equipment Hazards: Assistive Devices for Mobility Mobility devices include canes, walkers, and wheelchairs. There are 3 reasons why a resident may be at risk of an accident: Resident condition Personal fit and device condition Staff practices Assistive Devices/Equipment Hazards: Assistive Devices for Transfer Transfer devices include portable total body lifts, sit-to-stand devices, and transfer belts. Factors that place a resident at risk include: Staff availability Resident abilities Staff training 42
Assistive Devices/Equipment Hazards: Devices Associated with Entrapment Risks Bed rails and bed accessories can pose increased risk to resident safety. Entrapment may occur when a resident slips between the mattress, regular or airfilled, and the bed rail. Improper sizing of mattresses and bent bed rails increase the risk of resident entrapment. Assistive Devices/Equipment Hazards: Devices Associated with Entrapment Risks NOTE: 42 C.F.R. 483.13(a), F221, applies to the use of physical restraints. 42 C.F.R. 483.25(h)(2), F323 applies to assistive devices that create hazards a (e.g., devices that are defective; not used properly or according to manufacturer s specifications; disabled or removed; not provided or do not meet the resident s needs (poor fit or not adapted); and/or used without adequate supervision when required). Investigative Protocol Accidents & Supervision 43
Investigative Protocol: Use Use this protocol: For a sampled resident who is at risk to determine if the facility provided care and services, including assistive devices as necessary, to prevent avoidable accidents and to reduce the resident s risk; For a sampled resident who is at risk for accidents or who creates a risk to others, to determine if the facility has provided adequate supervision; and For identified hazards, to determine if there are facility practices in place to analyze hazards; implement interventions to reduce the hazards; and monitor the effectiveness of the interventions. Investigative Protocol: Procedures Observe the environment for the presence of potential/actual hazards: Accessibility of chemicals; Conditions in the environment; Staff response to alarms and verbal calls for help; Assistive devices that are defective; and Staff response to potential and actual hazards. Investigative Protocol: Procedures Interview the resident and his/her family to identify: If the resident was aware of his/her risk of an accident; If the resident was aware of hazards for other residents; If the resident reported a hazard to staff; and How and when staff responded to a hazard once it was identified. 44
Investigative Protocol: Procedures Interview staff to determine: If they were aware of planned interventions to reduce a resident s risk; If they reported potential resident risks; If they took action to correct an immediate hazard; and If they received training regarding facility procedures to remove or reduce hazards. Investigative Protocol: Procedures Record Review: Assessment & Evaluation Determine if the facility assessment is consistent with the record and reflects the resident s: Risk of unsafe wandering and elopement Hearing, visual, and sensory impairments Diagnoses of Alzheimer s and other dementias Medication use History of falls Investigative Protocol: Procedures Record Review: Plan of Care If the resident has had an accident, review the record to determine if it was: The result of an order not being followed; and/or A care need not being addressed; and/or A plan of care not being implemented. 45
Investigative Protocol: Procedures Review facility practices. Determine if the facility: Identified potential hazards and risks; Evaluated information gathered to identify the causes of the risks; Implemented interventions; and Monitored implementation of interventions. Determination of Compliance 42 CFR 483.25(h) (1) and (2), F323 For the resident who has had an accident, the facility is in compliance with this requirement if staff have: Identified hazards; Evaluated the hazards; Implemented interventions; Provided assistive devices; and Provided a secure environment. Determination of Compliance 42 CFR 483.25(h) (2), F323 For the resident who has had an accident, the facility is in compliance with this requirement if staff have: Identified hazards; Evaluated the hazards; Implemented adequate supervision; and Monitored the effectiveness of the supervision and modified the interventions as necessary. 46
Determination of Compliance 42 CFR 483.25(h) (1) F323 The facility is in compliance with this requirement if the staff have: Maintained the general resident environment and equipment; Received training i and periodic monitoring i regarding use of resident-specific equipment; Provided a safe environment during general housekeeping activities; and Operated equipment in accordance with manufacturer s recommendations and resident need. Determination of Compliance Noncompliance For F323 Noncompliance may include, but is not limited to, failure to: Provide each resident with an environment that is safe; Provide adequate supervision; Address hazards; Provide assistive devices; and Assess and develop interventions. Deficiency Categorization Severity Level 4 Considerations Examples of Level 4 might include: Esophageal damage due to ingestion of corrosive substances; Loss of consciousness related to head injuries; 3rd degree burn, or a 2nd degree burn covering a large surface area; Fracture or other injury that may require surgical intervention and results in significant decline in mental and/or physical functioning; Electric shock due to use of unsafe or improperly maintained equipment; 47
Deficiency Categorization Severity Level 4 Considerations Entrapment of body parts, such as limbs, head, neck, or chest that cause injury or death as a result of defective or improperly latched side rails or spaces within side rails, between ee split rails, between rails and the mattress, between side rails and the bed frame, or spaces between side rails and the head or foot board of the bed; Entrapment of body parts, such as limbs, head, neck, or chest that causes or has the potential to cause serious injury, harm, impairment or death as a result of any manual method, physical or mechanical device, material, or equipment; Deficiency Categorization Severity Level 4 Considerations Unsafe wandering and/or elopement that resulted in or had the potential to result in serious injury, impairment, harm or death (e.g., resident leaves facility or locked unit unnoticed and sustained or had potential to sustain serious injury, impairment, harm or death), and the facility had no established measure(s) or practice(s), or ineffective measure(s) or practice(s), that would have prevented or limited the resident s exposure to hazards. Deficiency Categorization Severity Level 3 Considerations Examples of Level 3 might include: Short-term disability; Pain that interfered with normal activities; 2nd degree burn; Fracture or other injury that may require surgical intervention and does not result in significant decline in mental and/or physical functioning; Medical evaluation was necessary, and treatment beyond first aid (e.g., sutures) was required; 48
Deficiency Categorization Severity Level 3 Considerations Fall(s) that resulted in actual harm (e.g., shortterm disability; pain that interfered 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; or medical evaluation was necessary, and treatment beyond first aid (e.g., sutures) was required) and the facility had established measure(s) or practice(s) in place that limited the resident s potential to fall and limited the resident s injury and prevented the harm from rising to a level of immediate jeopardy; or Deficiency Categorization Severity Level 3 Considerations Unsafe wandering and/or elopement that resulted in actual harm and the facility had established measure(s) or practice(s) in place that limited the resident s exposure to hazards and prevented the harm from rising to a level of immediate jeopardy. Deficiency Categorization Severity Level 3 Considerations NOTE: Unsafe wandering or elopement that resulted in actual harm and the facility had no established measure(s) or practice(s), or ineffective measure(s) or practice(s) that would have prevented or limited the resident s exposure to hazards should be cited at Level 4, Immediate Jeopardy. 49
Deficiency Categorization Severity Level 2 Considerations Examples of Level 2 Severity might include: Bruising, minor skin abrasions, and rashes; Pain that does not impair normal activities; 1st degree burn; Medical evaluation or consultation may or may not have been necessary, and treatment such as first aid may have been required; Deficiency Categorization Severity Level 2 Considerations Fall(s) which resulted in no more than minimal harm (e.g., bruising or minor skin abrasions; pain that does not impair normal activities; or medical evaluation or consultation may or may not have been necessary, and/or treatment such as first aid may have been required) because the facility had additional established measure(s) or practice(s) that limited the resident s potential to fall or limited the injury or potential for injury; or Deficiency Categorization Severity Level 2 Considerations Unsafe wandering and/or elopement, which resulted in no more than minimal harm because the facility had additional established measure(s) or practice(s) that limited the resident ss exposure to hazards. For example, a resident with Alzheimer s disease left the locked unit and was quickly found unharmed on another unit, and the building was considered a safe environment, as there was no way for the resident to leave the building. 50
Alabama Department of Public Health Online Incident Reporting System Online Incident Reporting System Log In: Facility ID and Facility PIN You have reached the Online Incident Reporting System for Nursing Homes From this screen you can make an incident id report to the Alabama Department of Public Health for your facility Every facility must submit an initial online report within 24 hours for all types of event and incidents that require reporting The file may be sent through the mail (postmarked by the 5 th working day) or hand delivered (by the 5 th working day) Step 2 Enter contact information NEXT Select incident type single or series Do not make two reports Include in one narrative of one report a description of both types of abuse that occurred 51
Step 2 Select Incident Type Select Category Sexual abuse Physical abuse Verbal abuse Mental abuse Neglect Misappropriation of Resident Property Suspicious Injury or Injuries of an Unknown Source Fire Next> Step 3 Enter Incident Detail Name(s) of residents involved Is the name of the perpetrator(s) or alleged perpetrator(s) known? Date and time of incident id or alleged incident id Narrative summary of incident Was the resident injured? Describe the injuries to the resident(s) Was the incident reported to law enforcement? Action(s) taken by the facility in response to the incident: Next> Step 4 Review and Submit Report Review your responses for accuracy Click on the Back button to go back and make any corrections to your report Respond to statement I have reviewed all responses and they are true and correct to the best of my knowledge. After you have verified the accuracy, click on the Submit button 52
Additional Information You may also access: Suggestions for conducting a complete and thorough five-day investigation of abuse incidents Each series of questions covers an aspect of the investigations that should be considered by the facility Roster Sample Matrix CMS-802 for Facilities This form is used by the facility to list all current residents (including bedholds) and to note pertinent care categories. The facility may use MDS data to provide a worksheet of the form, but must amend item responses as necessary to represent current resident status on day 1 of survey Changes to the CMS Form 802 Falls/Fractures is now a separate field from Abrasions/Bruises Behavioral Symptoms is now a separate field from Depression Resident Characteristics have been renumbered 53
New 802 Changes for Providers Renumbering of the resident characteristic fields MDS 3.0 coding or manual coding instructions Some providers have previously automated the 802 and all of the filed were filled in based on the MDS 2.0 Some fields are not reflected in the MDS 3.0 such as Fecal Impaction and the form now contains instructions for the provider to code the information manually Facilities must complete the 802 with the information you have in the clinical record regardless of the availability of MDS information New 802 Changes for Surveyors References to QM/QIs removed Resident Characteristic fields renumbered CMS 802 This form should be completed by the facility by the end of the initial tour or to provide this information in some other format (computer generated list) The facility may make modifications for accuracy or add additional information within 24 hours 54
CMS 802 for Surveyors This is a tool for selecting the resident sample and may be used for recording information from the tour It reflects the survey team s concerns Resident Census & Conditions of Residents (CMS 672) Revisions to 672 instructions MDS 3.0 coding replaces MDS 2.0 coding references Manual coding for some fields Some providers have previously automated the 672 and all of the fields were filled in based on the MDS 2.0 instrument Some fields are not reflected in the MDS 3.0 such as the item on Bedfast Residents. Code this manually Complete the 672 with the information in your clinical records regardless of the availability of MDS information The End Rebecca L. Hall rhall4@elmore.rr.com (334) 462-2672 (334) 567-0800 55