Facilities can avoid a F689 citation with accident prevention, resident and environment supervision, and maintaining devices and equipment.
In 2022, F689 was the fourth most cited deficiency in standard surveys and the most frequently cited deficiency in complaint surveys. During the second quarter of 2023, F689 has been cited at an IJ level scope and severity in 27% of surveys and at a G level scope and severity in 53% of surveys nationwide.
To help your facility avoid a F689 citation, facilities need to focus on three key areas:
- accident prevention
- resident and environment supervision
- maintaining devices and equipment.
Strategies to prevent accidents
One of the primary ways to prevent accidents is to make sure your facility is adequately staffed. In understaffed environments, there are fewer staff and fewer eyes to make sure that all resident needs are addressed and minimize risk.
Staff training will also provide preparation for how preventive and responsive actions should occur for residents.
Smoking as a resident amenity carries its own set of surveillance and monitoring needs. Your facility might want to consider going smoke-free and devising a road map with an end date to implement this new policy.
Strategies to improve resident supervision and environmental safety
Preventing falls by more closely supervising residents and ensuring the environment has all resident needs in reach can reduce the frequency of falls. If your facility does not have a strong falls management program that is approved and monitored by your QAPI, connect with Polaris Group consultants who can help you develop an effective falls management program. Falls management programs should be customized to the needs of your residents, the layout of your building, and the environmental risks that challenge your teams.
55% of all complaints investigated involve some type of resident altercation. Adequate resident supervision plays a significant role in anticipating and identifying those residents who trigger behavior issues and de-escalating situations.
Be on the lookout for environmental hazards. Items such as propped open fire doors, disabled locks or latches, nonfunctioning alarms, torn carpet, cords, and access to toxic chemicals are all examples of environmental hazards that can lead to citation. In addition to preventing these hazards from occurring in the first place, be sure to educate staff on identifying, reporting, and remedying hazards.
Strategies to improve device and equipment maintenance
Regulations suggest there should be an auditing system in place to ensure any piece of equipment used by a resident is in safe and working order. Your facility needs to have a plan to inventory and check devices such as walkers, wheelchairs, motorized scooters, and mechanical lifts. Further, your maintenance team will need to document and keep records of water temperature and bed frame/mattress checks. Without this documentation, expect a citation from surveyors for lack of ensuring safety for all residents.
Mock surveys are an excellent way to identify your facility’s weakest links and put action steps into place to address deficiencies before citation. Taking issues to your monthly QAPI meetings also shows surveyors that you are aware of your challenges and want to develop measurable action steps to always ensure resident safety.
If you want assistance with identifying your facility’s opportunities for improvement, contact Polaris Group consultants for help. Our mock surveys will identify potential citations and our consultants will work with your teams to craft remediation plans and staff training to best prepare your facility.
