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What You Need To Know About Resident Condition–Related Care Tags

By Jessica Kunkler, MA - April 18, 2018

With nearly 1,500 citations since the launch of the new survey process on November 28, 2017, resident condition–related tags are popping up in facilities in every region. These are the top five tags to look out for:

1.       Quality-of-care tags are diverse, with deficiencies related to many elements of care. These include pressure ulcers, accidents, pain, positioning, toileting, and nutrition.

Tag # 0684

Quality of Care

331 Tags

 

76% of all F-Tag 684 (Quality of Care) citations are at a scope of D.

D

251

E

55

G

21

H

1

J

2

K

1

 

 

 

·         F-Tag 684, Quality of Care, Scope of D: Based on observation, interview, and record review, it was determined that the facility failed to a.) apply skin protectant on a resident during incontinence care for the prevention of skin irritation and breakdown, and b.) ensure the appropriate fluid was given with medication pass in accordance with a physician order.

·         F-Tag 684, Quality of Care, Scope of D: Based on observation, interview, and document review the facility failed to provide appropriate wheelchair positioning for 1 of 1 resident (R15) reviewed for positioning. In addition, the facility failed to ensure [MEDICAL CONDITION] (swelling) management program was followed for 1 of 1 resident (R182) who had bilateral lower extremity [MEDICAL CONDITION] with presence of blood clot in left lower extremity.

·         F-Tag 684, Quality of Care, Scope of D: Based on interview and record review the facility did not ensure 1 of 35 sampled residents (R120) received the necessary care and services to maintain normal bowel habits and prevent constipation. R120 was placed on pain medication due to increased pain. The facility did not recognize and did not implement modalities to prevent R120 from developing constipation. Additionally, there was no care plan developed to direct staff on how to manage R120's constipation. R120 consequently self-limited pain medications and food intake in attempt to remedy the constipation.

·         F-Tag 684, Quality of Care, Scope of H: Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 5 residents reviewed for indwelling urinary catheters. (Resident #s 1 and 2) 1. Resident #1 had an indwelling urinary catheter with the incorrect bulb size inserted, causing bleeding from his penis. Resident #1 was admitted to the hospital with [REDACTED]. Resident #1's gross hematuria (blood in the urine that can be seen with the naked eye) was thought to be secondary to indwelling urinary catheter trauma. He received 2 units of blood due to acute blood loss per urethra. 2. The facility did not properly insert Resident #2's indwelling urinary catheter, resulting in bleeding due to traumatic urethral injury. This failure could place 12 residents with indwelling urinary catheters at risk of pain, injury, and infection.

·         F-Tag 684, Quality of Care, Scope of J: Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure that after becoming aware of Resident #1's burns, nursing assessed his/her burns, took appropriate actions to provide care and treatment for [REDACTED]. #1 to the hospital for evaluation and treatment of [REDACTED]. Resident #1 spilled hot coffee onto his/her left and right thigh, resulting in full thickness (third-degree) [MEDICAL CONDITION] and partial thickness (second-degree) burns. Resident #1 was transferred to the hospital approximately 16 hours after the Facility became aware of his/her burns, where he/she was admitted to the ICU (Intensive Care Unit) Burn Unit with superimposed cellulitis (serious bacterial infection of the skin), required IV (Intravenous) antibiotics and surgical management of his/her [MEDICAL CONDITION], excisional debridement and skin grafting.

·         F-Tag 684, Quality of Care, Scope of K: Based on record review and interview, the facility failed to ensure necessary care and services were provided after a fall with injury, as evidenced by failure to ensure new onset hip pain with range of motion was evaluated to rule out a serious fall-related injury; failure to ensure the severity of pain and limitations in range of motion were thoroughly assessed by nursing as ordered for 72 hours following a fall; failure to ensure nursing staff communicated to Physical Therapy staff that the resident had sustained a fall so that therapy staff would take the necessary precautions to prevent potential exacerbation of any existing injury; failure to ensure Therapy staff immediately stopped therapy and communicated the resident's complaints of pain with range of motion to licensed nursing staff; failure to ensure the physician was immediately provided with complete radiology results, which resulted in a delay in treatment for [REDACTED] (#5) of 7 (Residents #1 through #7) case mix residents who were at risk for falls. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #5, who experienced a fall that resulted in fractures and did not receive treatment for [REDACTED]. The failed practices also had the potential to cause more than minimal harm to 26 residents who had falls in the past 60 days, as documented on a list provided by the Director of Nursing (DON) on 12/15/17. The facility was informed of the Immediate Jeopardy condition on 12/14/17 at 4:45 p.m.

 

2.       Pressure ulcer tags are happening, and happening a lot. Many pressure ulcer deficiencies are related to failures to prevent and treat ulcers, which extends to weekly assessment, positioning, infection control, and optimal nutrition.

Tag # 0686

Treatment/Services to Prevent/Heal Pressure Ulcers

246 Tags

 

70% of all F-Tag 686 (Treatment/Services to Prevent/Heal Pressure Ulcers) citations are at a scope of D.

 

D

171

E

26

G

44

H

1

J

1

K

3

 

·         F-Tag 686, Treatment/Services to Prevent/Heal Pressure Ulcers, Scope of D: Based on observation, interview and record review conducted during the Standard Survey completed on 12/22/17, the facility did not ensure that a resident with pressure ulcers receives the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing. Two (Residents #4 and #5) of three residents reviewed for pressure ulcers lacked documented weekly assessments by a qualified person. In addition, the lack of maintaining proper infection control practices during treatment applications and treatments were not completed as ordered by the Physician (#4).

·         F-Tag 686, Treatment/Services to Prevent/Heal Pressure Ulcers, Scope of D: Based on clinical record reviews, review of facility documentation, and interviews for one of three sampled residents (Resident #167) who was at risk for skin breakdown, the facility failed to implement interventions when the resident exhibited a behavior of rubbing both heels on the mattress while in bed.

·         F-Tag 686, Treatment/Services to Prevent/Heal Pressure Ulcers, Scope of D: Based on observation, interview and record review, the facility failed to provide pressure ulcer care per health care provider order and standards of clinical practice and failed to ensure the application of infection control principles during wound care for one (#701) of two Residents reviewed for wound care, of a total sample of three, resulting in inappropriate wound care technique, application of an un-ordered [MEDICATION NAME] ointment to a pressure ulcer, and the potential for wound worsening, delaying wound healing, infection, and overall deterioration in health status . . .

·         F-Tag 686, Treatment/Services to Prevent/Heal Pressure Ulcers, Scope of D: Based on observation, interview, and record review, the facility did not provide appropriate care and treatment for 1 of 4 sampled residents (R35) who were at risk for pressure injuries. R35 was at risk for pressure injuries to her heels. R35 was observed in bed and her feet were not elevated, in accordance with her care plan.

·         F-Tag 686, Treatment/Services to Prevent/Heal Pressure Ulcers, Scope of H: Based on observation, record review and interview; the facility staff failed to identify pressure ulcers and failed to implement assessed interventions to prevent development of pressure ulcers for 4 (Resident 3, 36, 51 and 160) of 4 sampled residents. The facility staff identified a census of 66. Findings are: A. Record review of Resident 51's Minimal Data Set (MDS: a federally mandated comprehensive assessment tool used for care planning) signed as completed on 12-06-2017 revealed the facility staff assessed the following about Resident 51: Brief Interview for Mental Status (BIMS) was a 14. According to the MDS Manual a score of 13 to 15 indicates a person is cognitively intact. Required supervision with eating. Required extensive assistance with 2 or more persons assisting with bed mobility, transfers, dressing, toilet use and personal hygiene. Always incontinent of bowel and bladder. Identified Resident 51 at risk for the development of pressure ulcers. Record review of Resident 51's Braden Scale (tool used for predicting pressure sore risk) dated 12-06-2017 revealed Resident 51 scored a High Risk rating. Record review of Resident 51's Comprehensive Care Plan (CCP) dated 11-24-2017 revealed Resident 51 had the [DIAGNOSES REDACTED]. Further review of Resident 51's CCP updated on 12-06-2017 revealed Resident 51 had returned from the hospital with an open wound to the sacrum and Prevalon boots (type of pressure relieving foot wear) in place to both feet. According to Resident 51's CCP, the Prevalon boots were worn at all times. Observation on 12-20-2017 at 2:49 PM revealed Resident 51 was in bed, in a back laying position and did not have the Prevalon boots on. Observation on 12-21-2017 at 11:00 AM revealed Resident 51 was in bed, in a back laying position and did not have the Prevalon boots on. Observation on 12-21-2017 11:22 AM revealed Resident 51 was in bed, in a back laying position and did not have the Prevalon boots on. Observation on 12-21-2017 at 1:10 PM revealed Resident 51 was in bed, in a back laying position and did not have the Prevalon boots on. Further observation on 12-21-2017 at 1:10 PM revealed Resident 51's Family member was in the room with Resident 51. Resident 51's Family member stated see (gender) doesn't have (gender) boots on and with a pointing movement indicated the Prevalon boots were placed in a chair in Resident 51's room. Resident 51's family member confirmed the Prevalon boots were to be on Resident 51. Observation on 12-21-2017 2:00 PM with Licensed Practical Nurse (LPN) B of Resident 51's heels revealed Resident 51 had an approximately 5 centimeters (cm) roundish fluid looking blister to the left heel. On 12-21-2017 at 2:00 PM an interview was conducted with LPN B. During the interview, LPN B confirmed Resident 51 did not have the Prevalon boots on (gender) feet. LPN B further reported not being aware Resident 51 had a wound to the left heel. Record review of Resident 51's record revealed there was no evidence Resident 51 had a pressure area to the left heel. Further review of Resident 51's medical record revealed there was no evidence the facility had completed daily monitoring of Resident 51's feet. Record review of a Skin Pressure Ulcer Weekly (SPUW) sheet dated 12-21-2017 with a time of 2:50 PM revealed the area to Resident 51's left heel was measured as 2.9 cm by 2.5 cm and staged as a Suspected Deep Tissue Injury (SDTI). The description of the left heel SDTI was identified as black/brown, eschar (dead tissue). According to Woundeducators.com, a SDTI is A deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise.

·         F-Tag 686, Treatment/Services to Prevent/Heal Pressure Ulcers, Scope of K: Based on observation, clinical record review, staff and resident interviews, the facility failed to provide appropriate wound care services for 6 of 6 residents with pressure sores placing residents as immediate jeopardy to their health and safety. (Residents #4, #6, #8, #9, #11, and #13) The facility failed to provide timely wound assessments for 6 of 6 residents, the facility failed to provide treatments as prescribed for Residents #4, #6, #8, failed to update and follow the planned Care Plans for Residents # 6, #8, #11, #13, failed to notify the primary care physician for Residents #4, #11 and failed to identify a pressure sore for Resident #4, #11. The facility census was 39 residents.

 

3.       Surveyors have an eye on toileting plans. As with care plans, toileting plans are only useful if followed. Many lower-scope deficiencies address a failure to follow resident plans, whereas higher-scope tags often involve a lack of necessary interventions.

Tag # 0690

Bowel/Bladder Incontinence, Catheter, UTI

209 Tags

 

79% of all F-Tag 690 (Bowel/Bladder Incontinence, Catheter, UTI) citations are at a scope of D.

D

165

E

36

G

7

H

1

 

·         F-Tag 690, Bowel/Bladder Incontinence, Catheter, UTI, Scope of D: Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for bladder/bowel incontinence, the facility did not provide services in accordance with the resident's written plan of care. Specifically, Resident #6 was not toileted per the plan of care.

·         F-Tag 690, Bowel/Bladder Incontinence, Catheter, UTI, Scope of D: Based on observation, interview and document review, the facility failed to assist 1 of 1 resident (R45) to the bathroom, in accordance with scheduled toileting plan.

·         F-Tag 690, Bowel/Bladder Incontinence, Catheter, UTI, Scope of D: Based on medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to keep the drainage bag off the floor for 1 of 5 (Resident #75) sampled residents reviewed for indwelling urinary catheters.

·         F-Tag 690, Bowel/Bladder Incontinence, Catheter, UTI, Scope of G: Based on observation, interview, and record review, the facility failed to adequately assess a Foley catheter for 1 (#11) resident, who had not received adequate perineal care, and who was found to have a urinary tract infection, of 17 sampled residents.

·         F-Tag 690, Bowel/Bladder Incontinence, Catheter, UTI, Scope of H: Based on record reviews and interviews, the facility failed to comprehensively assess and implement individualized interventions to restore bladder function. Actual Harm occurred when the facility failed to administer physician ordered medication to Resident #259 to treat an overactive bladder and her urinary incontinence declined to frequently incontinent. Actual Harm occurred when the facility failed to implement interventions to restore bladder function for Resident #5 and urinary continence declined from always continent to incontinent. Actual harm occurred when Resident #48 who was identified on quarterly assessment to be frequently continent of bladder experienced a decline and became always incontinent of bladder without appropriate assessments/reassessments to determine the cause of the decline and the type of incontinence. The facility failed to implement any training programs or interventions to attempt to prevent further declines and/or improve his bladder function. Actual harm occurred when Resident #55 who was occasionally incontinent of bladder declined to frequently incontinent of bladder without assessment of the type of incontinence or interventions to prevent the decline. This affected four residents (Resident #5, #48, #55 and #259) of five residents reviewed for urinary incontinence. The facility identified 15 residents occasionally or frequently incontinent of urine.

 

 

4.       Weight loss and hydration, and appropriate interventions, are on the radar. Reasons for deficiencies range from failure to provide prescribed nutrition and hydration, to failure to notify dietitian of weight loss, to failure to inappropriately monitor and intervene for weight loss.

Tag # 0692

Nutrition/Hydration Status Maintenance

147 Tags

 

76% of all F-Tag 692 (Nutrition/Hydration Status Maintenance) citations are at a scope of D.

B

1

D

112

E

18

G

14

H

1

J

1

 

·         F-Tag 692, Nutrition/Hydration Status Maintenance, Scope of D: Based on record review and interview the facility failed to ensure Resident #65 received recommended nutritional supplements to address identified weight loss sustained by the resident.

·         F-Tag 692, Nutrition/Hydration Status Maintenance, Scope of D: Based on record review, observation, interview, and policy review, the facility failed to ensure the dietitian was notified of one resident's weight loss. This affected one (#45) of two residents reviewed for weight loss. The facility identified three residents with unplanned weight loss.

·         F-Tag 692, Nutrition/Hydration Status Maintenance, Scope of D: Based on medical record review, observation and staff interview, the facility failed to properly provide fluids to residents who were severely cognitively impaired.

·         F-Tag 692, Nutrition/Hydration Status Maintenance, Scope of D: Based on observation, record reviews, and staff interviews, the facility did not ensure that a resident maintained acceptable parameters of nutritional status. Specifically, the facility did not effectively monitor a resident at risk for weight loss and weight fluctuations. The facility did not identify the resident's poor intake, and 24 lb weight loss. The failure to identify the weight loss resulted in the resident's plan of care not being reviewed and revised in a timely manner. As a result there were no interventions put in place to prevent a further decline in the resident's weight.

·         F-Tag 692, Nutrition/Hydration Status Maintenance, Scope of G: Based on observation, interview, and record review, the facility failed to identify, assess and intervene when four of six residents (#23, 32, 27 and 21) reviewed for nutrition experienced weight loss. This resulted in actual harm to Resident #23, who experienced severe weight loss of 45 pounds (23% of her body weight), in approximately three months.

·         F-Tag 692, Nutrition/Hydration Status Maintenance, Scope of H: Based on observation, interview, and record review, the facility failed to ensure the resident maintained acceptable nutritional status, such as usual body weight or desirable body weight, unless the resident clinical condition demonstrated this was not possible, for one (Resident #5) of 13 residents reviewed for nutritional status. The facility did not develop and implement interventions to address Resident #5's unplanned significant weight gain. Resident #5 gained a total 42 pounds in six months since her admission to the facility, which caused the resident to be upset by her physical appearance. This failure placed the  resident, who was prescribed [MEDICATION NAME] for depression and also had a [DIAGNOSES REDACTED]  for not having their needs identified and/or met.

 

5.       Appropriate oxygen delivery as prescribed is non-negotiable. Deficiencies related to Respiratory/Tracheostomy Care and Suctioning are frequently related to failure to administer oxygen as prescribed.

Tag # 0695

Respiratory/Tracheostomy Care and Suctioning

127 Tags

 

77% of all F-Tag 695 (Respiratory/Tracheostomy Care and Suctioning) citations are at a scope of D.

D

98

E

27

G

1

J

1

 

 

·         F-Tag 695, Respiratory/Tracheostomy Care and Suctioning, Scope of D: Based on observation, interview and record review, it was determined that the facility failed to provide the necessary respiratory care and services for 2 of 35 residents (Resident #9 and #86) reviewed.

·         F-Tag 695, Respiratory/Tracheostomy Care and Suctioning, Scope of D: Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that oxygen was administered according to physician's orders [REDACTED].

·         F-Tag 695, Respiratory/Tracheostomy Care and Suctioning, Scope of D: Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident received oxygen as ordered, for one (1) of three (3) residents observed with oxygen, Resident #10.

·         F-Tag 695, Respiratory/Tracheostomy Care and Suctioning, Scope of G: Based on observation, record review and interview, the facility failed to ensure a portable oxygen tank had oxygen in it for 1 (R #289) of 1 (R 289) residents reviewed for respiratory care. This deficient practice has the potential to affect residents with [MEDICAL CONDITIONS], shortness of breath and dependence on supplemental oxygen by not supplying enough oxygen in order to prevent [MEDICAL CONDITION] (decreased oxygen to the body).

Conclusion

Be sure that staff know that it only takes a seemingly small lapse in care, and for only one resident, to prompt a citation; more than that, for some deficiencies, failure to deliver care as prescribed to one or two residents can result in an actual harm or jeopardy situation. As a rule, the more residents involved in the failure to deliver the proper care, the higher the scope of the citation, which may be isolated, pattern, or widespread.

A key to success: Pay lots of attention to staff members’ awareness of what is in each resident’s care plan. Include nurse aides in care plan meetings and institute consistent staffing. The more your care team knows about each resident’s care plan, the more likely it is that staff will have the knowledge to implement the plan, preventing risks for residents and avoiding resident condition–related tags.

Tag #

Name of Tag

# of Tags

0684

Quality of Care

331

0686

Treatment/Services to Prevent/Heal Pressure Ulcers

246

0690

Bowel/Bladder Incontinence, Catheter, UTI

209

0692

Nutrition/Hydration Status Maintenance

147

0695

Respiratory/Tracheostomy Care and Suctioning

127

0679

Activities Meet Interest/Needs of Each Resident

102

0697

Pain Management

90

0698

Dialysis

72

0693

Tube Feeding Management/Restore Eating Skills

66

0700

Bedrails

43

0685

Treatment/Devices to Maintain Hearing/Vision

39

0694

Parenteral/IV Fluids

15

0687

Foot Care

6

0691

Colostomy, Urostomy, or Ileostomy Care

4

 


 


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