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F689 Accident Survey Citations: What’s Behind These Immediate Jeopardies?

F-tag 689 (Free of Accident Hazards/Supervision/Devices) was the No. 1 tag cited at the immediate jeopardy (IJ) level in 2023—and remains at the top halfway into 2024, according to QCOR data accessed on June 30, 2024. In many ways, F689 is a catch-all tag, says Angie Szumlinski, LNHA, RN, GERO-BC, RAC-CT, BS, director of risk management for the liability insurer HealthCap at Chelsea Rhone LLC in Ann Arbor, MI. “Surveyors can use this citation for almost any type of unexpected or unintentional incident that the facility could have avoided and that may cause resident harm.”

The following statement of intent and definitions excerpted from the F689 guidance to surveyors in Appendix PP of the State Operations Manual bear this out:

Intent (483.25(d))  

The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:  
  • Identifying hazard(s) and risk(s);

  • Evaluating and analyzing hazard(s) and risk(s);

  • Implementing interventions to reduce hazard(s) and risk(s); and

  • Monitoring for effectiveness and modifying interventions when necessary.  


Definitions (483.25(d))  
Definitions are provided to clarify terms related to providing supervision and other interventions to prevent accidents.  

“Accident” refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. This does not include other types of harm, such as adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current professional standards of practice (e.g., drug side effects or reaction).  

“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 and 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.  


“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 and 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, plan of care, and current professional standards of practice in order to eliminate the risk, if possible, and, if not, 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.

Three common avoidable accident scenarios that are often particularly risky for nursing homes are as follows, according to Szumlinski:

  • Elopements;
  • Burns from hot liquids; and
  • Choking.

In the F689 guidance, the Centers for Medicare & Medicaid Services (CMS) focuses on the need for nursing homes to use an interdisciplinary systems approach to prevent avoidable accidents, says Szumlinski. “The key question is: What is your system for identifying hazards and risks; evaluating those concerns; implementing interventions, including resident-specific interventions; and monitoring intervention effectiveness?”

Note: For details on how to implement each step of a systems approach, see the section “A Systems Approach” in the F689 guidance in Appendix PP.

Szumlinski offers the following insights into common systems issues that can impact the three high-risk areas that she identified:

Elopements

“An elopement can be catastrophic. Unfortunately, most of the time it doesn’t end well,” says Szumlinski. “In that scenario, it is easy for the survey team to find fault with staff or with the way that the systems are working in the building.”

However, some elopement citations at the IJ level are essentially “low-hanging fruit,” says Szumlinski. “For example, a resident with dementia leaves the memory care unit—but not the building. Depending on the state, the nursing home may be required to report the resident walking out the door of the memory care unit as an elopement. Then, the survey team issues an IJ-level citation due to a reasonable expectation that this resident could suffer serious injury, harm, impairment, or death. So, there is a lot of nuance as to what could trigger an IJ citation.”

Often, though, the problem boils down to the nursing home either not following its own elopement policy and procedure or not following standards of practice, says Szumlinski. “Systems issues that may impact whether you have an elopement include: Was the resident assessed for elopement risk? Have they attempted to leave before? What is the plan for each resident individually, and then what is your environmental plan so that you know that your alarms are working on a regular basis? For example, are staff trained to go to every exit when an alarm goes off to be sure that that resident is not outside? Do you have lights that come on outside if a resident leaves at night? And, do you do a full headcount in the building post-elopement?”

Note: Search the term “elopement” at the HealthCap Resource and Education Center to find a sample admissions elopement assessment policy, elopement policy and procedure, elopement response guidelines, and an elopement and wander management toolkit, as well as an elopement webinar with continuing education credit. For details on how IJ is applied, review the Immediate Jeopardy Template in CMS’s Survey Resources folder.

Additional resources include the AAPACN articles “Elopement Program Success Hinges on Staff Education and Training” and “Elopement Risk Management: Learn How to Increase Resident Safety and Reduce Facility Risk,” as well as the AAPACN Emergency Drills: Code and Elopement Toolkit.

Burns

“Burns from hot liquids are a huge IJ risk,” says Szumlinski. This includes two key types of burns:

* The consumption of hot liquids. “The interdisciplinary team should conduct a hot liquids assessment for at-risk residents to be sure that they are safe to drink hot liquids independently, suggests Szumlinski. “These assessments are not commonly done, but you don’t want to wait until a resident gets burned—and it does happen.”

Szumlinski offers the example of a resident with Parkinson’s disease who enjoys drinking coffee. “If you give this resident a hot cup of coffee, there is a high risk that they may spill that coffee. You don’t want to serve them lukewarm coffee that they won’t like, but you want them to be safe,” she notes. “Having occupational therapy evaluate that resident to determine if there is a safer way for them to consume hot liquids so that they can enjoy their coffee is a useful step toward honoring that resident’s choice while mitigating their risk.”

The F689 guidance addresses how to navigate the potential conflicts that may arise when resident choice and resident safety are at odds:

Resident Vulnerabilities  
The responsibility to respect a resident’s choices is balanced by considering the resident’s right to direct the care they receive with the potential impact of these choices on their well-being, other residents, and on the facility’s obligation to protect residents from harm. The facility has a responsibility to educate a resident, family, and staff regarding significant risks related to a resident’s choices. When a resident’s choice poses some risk, staff should work with the resident to understand reasons for the choice, and discuss options for the facility to honor the choice. For example, a resident may express a desire to use a cane instead of a walker or wheelchair in order to maintain dignity and self-esteem. This preference should be discussed to review potential positive and negative consequences of possible courses of action (including potential negative consequences that may result from preventing the choice) and to find ways to develop a care plan in which staff honor the choice while mitigating risks. For resources on care planning to mitigate risk, see A Process for Care Planning Resident Choice.  

Verbal consent or signed consent/waiver forms do not eliminate a facility’s responsibility to protect a resident from an avoidable accident, nor does it relieve the provider of its responsibility to assure the health, safety, and welfare of its residents. While federal regulations affirm the resident’s right to participate in care planning and to refuse treatment, the regulations do not create the right for a resident or representative to demand the facility use specific medical interventions or treatments that the facility deems inappropriate. The regulations hold the facility ultimately accountable for the resident’s care and safety.

Another issue with the consumption of hot liquids is cutting corners on systems, such as checking point-of service temperatures, says Szumlinski. “For example, if you have a dining program where staff sometimes bring out a big crockpot of soup and ladle it into bowls at the table, that presentation can be a positive quality-of-life experience for your residents. However, do staff know how long that crockpot was unplugged? Are they checking the point-of-service temperature to determine if the soup is in the safe temperature range before they ladle it out?”

* Environmental water sources. “Burns can come from water that is too hot in the shower room, in resident bathrooms, and in community bathrooms,” says Szumlinski. “Environmental staff should check all hot water temperatures on a routine basis. When, for example, you have an independent elderly resident who wants to shower on their own with the curtain closed, it doesn’t actually take much heat to burn their fragile skin.”

Note: Search the term “hot liquids” at the HealthCap Resource and Education Center to find a sample hot liquids risk screen, hot liquids policy and procedure, and hot liquids handling protocol.

Choking

“Many nursing homes allow residents to choose—as a resident right—whether they eat in the dining room or in their room,” says Szumlinski. “However, consider what may happen if you have 10 residents dining in their rooms and only one staff member monitoring the hallway. If a resident begins choking on something during their meal, what are the chances that your staff member will get to that resident in time? A choking resident is much more likely to reach for their throat than to reach for a call light. So, choking is another really high-risk concern.”

At a minimum, residents shouldn’t eat breakfast in bed, says Szumlinski. “While that’s usually considered a luxury, eating in bed is not the safest way of dining for a resident who is compromised enough to need to live in a nursing home. And, choking is not the only risk involved with eating in bed. It also makes it easier for residents to spill hot liquids like tea or coffee and burn themselves.”

The first step to mitigate choking risks is to educate the residents and their families at admission about why dining in the room isn’t encouraged, says Szumlinski. “Your team should be explaining the benefits of participating in the dining program. For example, you might say, ‘We have fine dining, and we put music on. It’s a really social environment where you visit with the other residents.’ Many facilities have separate private dining rooms for short-stay vs. long-stay residents to ensure that all residents are comfortable eating together, and if you haven’t taken that step, it’s definitely worth considering to encourage participation in the dining program.”

Another concern that leads to choking is not ensuring that residents are on the right diet texture, says Szumlinski. “Sometimes, a resident has not been assessed for choking risk, so staff serve them the wrong diet. Or, a resident who has impulsive behaviors is not monitored appropriately during the meal. So even though they were served the right diet texture, they reach over and take another resident’s food—that they then choke on.”

Training on the Heimlich maneuver should be mandatory for all staff who work with residents, suggests Szumlinski. “Waiters at fine dining restaurants receive this training, so a layperson can do the Heimlich maneuver. Ensuring that your inservice calendars include Heimlich maneuver training, as well as putting up educational posters in the kitchen area to re-enforce that training, is a good idea.”

Note: Search the term “choking” at the HealthCap Resource and Education Center to find a sample choking/Heimlich maneuver policy and procedure.

A key step toward resident safety: Empower staff

“Again, elopements, burns from hot liquids, and choking are far from the only ways to get F689 citations at the IJ level,” stresses Szumlinski. “It’s any type of avoidable incident that could cause significant resident harm. For example, a fall with fracture may be cited even though not all fall risks are avoidable if the facility doesn’t have documented evidence of a well-implemented system with individualized interventions.”

One core preventive step that nurse leaders can take to reduce the chances of an IJ-level citation under F689 is to empower staff to deal with equipment issues, suggests Szumlinski. “For example, locks not working on equipment is a common problem. When that happens, staff often say something like, ‘Yes, it’s broken. I just put my foot behind the wheel so that it doesn’t move.’”

However, locks are on equipment for a reason, points out Szumlinski. “So if a lock isn’t working or there is some other equipment hazard, staff should be empowered to know that they need to take that piece of equipment out of service, tag it as unsafe to use, put it aside in a locked room somewhere, and immediately alert maintenance.”

Staff also should be empowered to address resident-specific equipment hazards as they are identified, suggests Szumlinski. “For example, a resident falls out of bed at midnight. The resident isn’t hurt, and staff put them back in the same bed that they fell out of because they don’t have access to a low bed—and they don’t know if they are allowed to put the resident’s mattress on the floor. At 3 a.m., the resident falls out of bed again and breaks their hip.”

In this scenario, staff either need to be empowered to put the resident’s mattress on the floor for the rest of the night or to call management to make a decision about how to reduce the resident’s risk in the middle of the night, says Szumlinski. “Staff have to be educated and empowered to do the right thing and take action to mitigate this resident’s risk of harm from another fall.”

Note: To learn more about how surveyors assess F689, see the Accidents Critical Element Pathway (form CMS-20127) in CMS’s Survey Resources folder. In addition, CMS offers a free training, Quality in Focus Resources for Addressing LTC Free of Accident Citations, to help providers recognize potential citations and develop a plan of correction. Finally, providers can use the AHRQ Surveys on Patient Safety Culture (SOPS) Nursing Home Survey to assess their safety culture and incorporate the results into their Quality Assurance and Performance Improvement (QAPI) program.

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