Across the Commonwealth, non-compliance related to resident falls in nursing facilities continues to be a concern. The Division of Health Care in the last quarter, July through September, identified deficient practice at F323 Accidents related to resident falls fifteen times. Of these deficiencies, three deficiencies were at a severity of actual harm and two were immediate jeopardy.

Historically, fall related deficiencies have been specific to facilities not ensuring care plan interventions were implemented and/or effective. The facilities had not ensured a thorough investigation was conducted to identify causal factors of the fall/incident. The facilities did not initiate their process/system to re-evaluate interventions, or develop and implement more effective interventions in order to prevent the recurrence of the fall. Additionally, those facilities with residents having repeated fall occurrence, through evidence of the survey(s), had not conducted a root cause analysis of the multiple falls i.e. track/trend data, review of investigations, interview of staff providing care, resident assessment and care plan implementation, review of the effectiveness of existing interventions, implementation of new interventions and follow-up to ensure new interventions were effective etc. Certified surveyors follow the federal regulation probes and investigative protocol validating whether an accident was avoidable through observation, interview and record review in order to determine compliance/non-compliance.

Below are copied portions of the Centers of Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP, F323 as it relates to falls. Please refer to the full regulation, interpretive guideline and investigative protocol as it relates to Accidents.

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