Download ddfdfde - Care Providers of Minnesota

Nursing Home Survey
Findings
Fall Region Forums - 2014
Doug Beardsley
VP Member Services
Care Providers of Minnesota
Many similar trends, but a few new ones
• Increased Problem Areas:
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•
•
•
Infection Control
Dialysis
Antipsychotic Medications
Physician Responses to Pharmaceutical
Recommendations
• Drug Storage
Many similar trends, but a few new ones
• Decreased Problem Areas:
•
•
•
•
Pressure Ulcers
Incontinence
Reporting of Suspected Abuse
Policies regarding reporting of suspected abuse
Many similar trends, but a few new ones
• Oddities:
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•
•
•
Posting of Staff Hours
Dialysis focus
Expired Nurses licenses
Failure to act/respond to issues in the Resident Council
Minutes
• Providing notice of new roommate
• Call lights not within reach
11.0
10.0
9.0
Average Number of Deficiencies per Survey
MN = 6.2
National = 5.7
CMS Region V = 6.1
8.0
7.0
6.0
5.0
1st
2nd
3rd
4th
1st
2nd
3rd
4th
1st
2nd
3rd
4th
1st
2nd
3rd
4th
1st
2nd
3rd
4th
1st
2nd
3rd
4th
1st
2nd
Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter
2008 2008 2008 2008 2009 2009 2009 2009 2010 2010 2010 2010 2011 2011 2011 2011 2012 2012 2012 2012 2013 2013 2013 2013 2014 2014
Average # of Deficiencies MN
Average # of Deficiencies U.S.
Average # of Deficiencies CMS Region V
40%+
30%-40%
Qualified Staff
Infection
20%-30%
Highest Practicable Level
Storage of Drugs
Unnecessary Drugs
Control
Accidents & Supervision
Care Plans
Kitchen Issues
Monthly Med Review
Current Nursing Home survey deficiencies
issued in 40% or more of surveys
F441: Infection Control
•Infection control program
•Staff infection control breaches
•Resource – QIS Infection Control List
Current Nursing Home survey deficiencies
issued in 30% - 40% of surveys
F282: Qualified Staff
F329: Unnecessary Drugs
F371: Kitchen Issues
Current Nursing Home survey deficiencies
issued in 30% - 40% of surveys
F282: Qualified Staff
•Staff not performing their job consistent
with the directives of the Care Plan or
facility policies and procedures.
Current Nursing Home survey deficiencies
issued in 30% - 40% of surveys
F329: Unnecessary Drug
•Antipsychotics remain the major focus
•Also sleep medications, antidepressants, & prn
•Resource – QIS Unnecessary Meds Pathway
Current Nursing Home survey deficiencies
issued in 30% - 40% of surveys
F371: Kitchen Stuff
• Cleanliness and upkeep of the kitchen
• Infection control (hand washing/gloving)
• Proper cooling of food for storage
• Steam table food temps during meal
• Dishwasher temperatures
• Resources – Food Cooling Poster and Training Sheet
QIS Kitchen/Food Service Observation Form
Current Nursing Home survey deficiencies
issued in 20% - 30% of surveys
F309: Highest Practicable Level
F431: Storage of Drugs
F323: Accidents & Supervision
F279: Care Plans
F428: Monthly Med Review
Current Nursing Home survey deficiencies
issued in 20% - 30% of surveys
F309: Highest Practicable Level
• Pain
• Dialysis
• Hospice
• Positioning
• Etc.
• Resources – QIS Resident Interview
QIS Dialysis Critical Elements form
Current Nursing Home survey deficiencies
issued in 20% - 30% of surveys
F431: Storage of Drugs
•Expired Meds
•Multi-Use Vials not dated when opened
•Temperatures
•Unsecured meds
Current Nursing Home survey deficiencies
issued in 20% - 30% of surveys
F323: Accidents &
Supervision
•Falls
•Alarms
•Siderails
Current Nursing Home survey deficiencies
issued in 20% - 30% of surveys
F279: Care Plans
•Ineffective or nonexistent approaches to
identified or observed patient care needs or
issues
•Dialysis
Current Nursing Home survey deficiencies
issued in 20% - 30% of surveys
F428: Monthly Med
Review
•Consultant Pharmacist missed something
•Physician failed to act on Consultant
Pharmacists recommendations
Take-Aways:
• Look at the examples provided
• Audit your nursing home to determine if you have
similar deficient practices
• Make changes, and re-audit!