Our facility received F 279, F 280, F314, F323, F 278 and F 356. Centered around care plan, revising care plans (especially falls), development of pressure ulcer with low risk, accidents and supervision for not completing a root cause analysis on ALL falls and posting of nurse staffing.
Spent a lot of time on the floor, watched wound care and reviewed 10 medical charts with a census of 96. Reviewed mixture of Medicaid and Medicare. Requested multiple policies (staffing posting, restraint, pressure ulcers, catheters, indwelling catheters, care of UTIs, antipsychotics, gradual dose reduction of antipsychotics, non-pharm interventions of antipsychotics and fall prevention.
Requested immediately:
Facility data sheet, resident roster, list of catheters (insertion and diagnosis), restraints (dates initiated), log of pressure sores, UTIs for past 6 months and accident/incidents since Jan 2015.
It was as stressful as an annual survey. Was interesting because they were not well versed on the MDS, e.g. tried to tell us that the when the NAC signs the MDS she is responsible for accuracy of all sections of the MDS. Pulled references to show they were wrong.
From Judy: They got a G in F323, for a fall with injury. Facility did not update/review the care plan after each fall so could not prove they reviewed and revisied care plan to prevent further injury from falls."
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