Revised CMS Guidance to Nursing Home Surveyors: Accident Hazards and Supervision

Effective August 6, 2007, the Centers for Medicare and Medicaid Services ("CMS") revised its interpretive guidance for surveyors on accident hazards and appropriate supervision, expanding Tag F323 to include guidance formerly provided in Tag F324 and clarifying what nursing homes must do to demonstrate compliance. The new Tag F323 describes how facilities must ensure that the resident environment remains as free from accident hazards as possible and that residents are provided with adequate supervision and assistance devices to prevent accidents, as required by 42 C.F.R. § 483.25(h)(1) and (2). The revised guidance also describes how facilities are required to implement interventions to reduce accident hazards and risks and monitor the effectiveness of those interventions, modifying them as necessary.

The revised guidance states that facilities can effectively avoid accidents by committing to resident safety and implementing systems that address resident risk and environmental hazards. Further, the revised guidance explains that a facility with a commitment to safety does the following: (i) acknowledges the high-risk nature of its population and setting; (ii) develops a reporting system that does not blame the staff member-reporting risks and hazards; (iii) involves all staff in helping identify solutions to ensure a safe-resident environment; (iv) directs resources to address safety concerns; and (v) demonstrates a commitment to safety at all levels of the organization.

When surveyors check to see if a facility is compliant with revised Tag F323, they will determine the following:

• whether the facility has identified hazards in the resident environment and residents' risks for an avoidable accident posed by those hazards;
• whether a resident accident was avoidable or unavoidable;
• whether the facility provides an environment that is free as possible of hazards over which the facility has control and minimizes the potential for harm; and
• whether the facility provides adequate supervision and assistive devices to prevent avoidable accidents.

Surveyors will look for specific environmental hazards, such as accessibility of chemicals, toxins, medications, sharp utensils/tools and cigarette lighters/smoking materials. They also will examine environmental conditions, such as unstable or slippery floor surfaces, loose hand rails, excessive water temperatures, electrical hazards, insufficient or excessive light arrangement of living spaces, obstacles in corridors, unsupervised access into or out of the facility, defective or nonfunctioning beds or malfunctioning wheelchair brakes.

In addition, surveyors will decide whether staff responses to residents' verbal calls for help and alarms are appropriate. They also will determine whether assistive devices and equipment are defective, not used properly or according to manufacturer's specifications, disabled or removed, or are used without adequate supervision. Finally, surveyors will observe staff response to potential and actual hazards (e.g., cleaning up spilled liquids in a resident area).

The guidance indicates that surveyors should cite noncompliance with F323 when facilities fail to:

• provide each resident an environment that is as free as possible from hazards over which the facility has control, such as assuring safe storage of toxic chemicals and medications as well as safe use of equipment and electrical appliances;
• provide adequate supervision for a resident who has exhibited unsafe wandering or has a risk of, or a history of, elopement;
• identify and correct hazards, such as nonfunctional alarms or call systems, disabled locks, fire doors that have been propped open, irregular walking surfaces, inadequate lighting or unsafe water temperature;
• supervise and monitor a resident who smokes and whose comprehensive assessment and plan of care indicates a need for supervision;
• provide assistive devices and/or appropriate training for the use of assistive devices, based upon the resident's assessed needs;
• monitor for defective or disabled equipment, such as pumps, ventilators or other equipment, or the improper use of assistive devices;
• assess, develop interventions and/or revise the plan of care for a resident who has experienced falls or who is at risk for falls; and
• assess, develop interventions and/or revise the plan of care for a resident who has exhibited or has a risk for unsafe wandering or elopement.

For more information or individualized consultation regarding nursing home regulatory compliance and survey matters, please do not hesitate to contact a member of the Health Care Department at Reinhart Boerner Van Deuren s.c.