02/17/2022

Survey Tip of the Week: Falls with Major Injury

Accidents and hazards, F-tag 689, was the third-highest citation for complaint survey citations in 2021 in Ohio. It was the fourth-highest cited F-tag for annual surveys in Ohio in 2019. Falls with major injury is an area commonly cited in F-tag 689. Common reasons for the citations include care plan interventions not in place or not carried out at the time of the fall such as not using a Hoyer lift or two-person transfer. The opportunity to impact this measure is to reduce the number of falls through root cause analysis. Mitigating the risk of citations for falls should include evaluating falls to determine if they were avoidable or unavoidable. CMS defines the avoidable and unavoidable criteria in Appendix PP of the State Operations Manual:

“Unavoidable Accident” means that an accident occurred despite sufficient and comprehensive facility systems designed and implemented to: 

• Identify environmental hazards and individual resident risk of an accident, including the need for supervision; and 
• Evaluate/analyze the hazards and risks and eliminate them, if possible and, if not possible, reduce them as much as possible; 
• Implement interventions, including adequate supervision, consistent with the resident’s needs, goals, care plan, and current professional standards of practice in order to eliminate or reduce the risk of an accident; and 
• Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current professional standards of practice.

“Avoidable Accident” means that an accident occurred because the facility failed to: 

• Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or 
• Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; and/or 
• Implement interventions, including adequate supervision and assistive devices, consistent with a resident’s needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and/or 
• Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice.

LeadingAge Ohio encourages facilities to utilize the LTC survey pathways to monitor for compliance. The survey pathways can be found on the CMS Nursing Home webpage, under the download section, and within the zip file called LTC Survey Pathways.

For more information about the citations occurring in Ohio, please join us on the monthly STAT: Survey Tips and Tactics call. Register now for the March 9 call at 10:00am.

Ohio annual surveys restarted in January, so LeadingAge Ohio is sharing tips to assist members during the survey process. Send questions you’d like addressed in future Tips of the Week to Stephanie DeWees at sdewees@leadingageohio.org.