Q: A resident recently had a serious fall when the care plan was not followed. What steps do you recommend when preparing for an anticipated Complaint Survey?

A: I am sorry to hear about the serious event that occurred. You are wise to be prepared for a surveyor visit. If you have not already done so, hold an ad hoc QAPI meeting to discuss this event.  In the minutes,  review and document: 

  • What immediate interventions were initiated for the identified resident
  • What immediate actions were taken to identify all residents potentially affected
  • What continued and immediate interventions were implemented for the affected residents and those potentially affected in the future
  • Any system changes made or modified
  • Systemic education that was completed to enhance staff knowledge
  • If applicable: Education completed through the immediate resident council
  • Continued Quality Assurance audits initiated to ensure enhanced system compliance
  • The root cause of the event

I recommend you immediately assign 10 charts to nurse leaders, including yourself, the ADON, MDS nurse and other nurse leaders in your facility to review care plans and ensure they are current and appropriate.

Education should be completed for all direct care staff with the goal of having 90% educated in 24 hours.  They need to be able to show their understanding of education by filling out a questionnaire or verbally repeating what they learned.  Any staff members you cannot reach need to receive education prior to their next shift.

If you have everything corrected prior to the survey, you just might get issued an F-tag at a past non-compliance level.  That is what I will hope for you as it is the best outcome (except for no F-tag at all.)

Please send your resident care-related questions to Nancy Tuders at [email protected].

From the September 2024 Issue of McKnight's Long-Term Care News