As we outlined in Part 1, many of the most serious accident‑related citations trace back to fundamental system failures—breakdowns in supervision, inconsistent implementation of care‑planned interventions, and environmental hazards that should have been identified and addressed. We also revisited the broad regulatory expectations under F689, which make it clear that accident prevention is not a task but an ongoing operational responsibility. With that foundation established, Part 2 turns to the heart of the issue: the importance of a systems approach to accident prevention.
More Terms to Understand
In Part I of this series, we reviewed some key definitions from Appendix PP of the State Operations Manual (SOM). Here’s a few more terms that we need to review before we jump in:
“Risk” refers to any facility characteristic, individual resident characteristic or external factor which influences the likelihood of an accident occurring.
“Hazards” are parts of the resident environment which have the potential to cause injury or illness.
“Hazards over which the facility has control” refer to hazards which the facility has the ability to influence the risk for an accident.
“Free of accident hazards as is possible” refers to the being free of accident hazards over which the facility has control.
Considerations for a Systems Approach to Accident Prevention
The Interpretive Guidance in Appendix PP outlines several core processes that should anchor a facility’s accident prevention program. A system-based approach requires facilities to think beyond isolated tasks and ensure that accident prevention is embedded in day‑to‑day operations. There are many areas which should be included.
How the facility proactively identifies environmental risks and/or a resident’s risk for an avoidable accident
All staff need to understand their responsibility for identification and communication of potential environmental hazards. To the extent possible, they should consider each resident’s needs and abilities. Staff don’t need to “know” a resident to touch a handrail and see that it’s loose or close a door that was inappropriately propped open for staff convenience and recognize the potential danger for a resident associated with such observations. Some staff may have roles which require them to keep the facility free of certain hazards, such as wet floors or hot water temperatures out of the acceptable range. Other staff who have more knowledge related to a specific resident can make further determinations about potential risk factors for a resident, such as determining his/her elopement or fall risk.
It’s an on-going team effort to keep a facility as free of accident hazards as possible. It’s also important that continuous evaluation occurs to attempt to prevent accidents from occurring. It’s not helpful (or compliant with regulatory expectations) to only identify a hazard after a resident has a burn or it’s been identified that a resident consumed some of the cleaning supplies that staff left accessible. Those are hazards which the facility has control over, and the Centers for Medicare & Medicaid Services (CMS) expect that facilities have a system in place to prevent accidents from occurring, to the extent possible.
The process used to identify potential hazards—including inadequate supervision, which continues to be one of the most frequently cited root causes of accidents
“Supervision/Adequate Supervision” – is both an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident’s assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident.
What systematic method the facility uses to evaluate risks and hazards
A comprehensive approach to accident prevention includes systematically analyzing available data to identify specific risks and hazards so individualized interventions can be implemented for risk reduction. It’s not enough to just add an intervention and hope for the best. Staff are responsible for ensuring that interventions are consistently monitored to ensure interventions are working and appropriate – then revise them when the interventions are no longer effective. When it comes to accident prevention, waiting for a quarterly or other scheduled review to look at a resident’s plan of care to update interventions is never sufficient. Interventions for high-risk areas, whether it’s unsafe smoking, non-compliance with requesting assistance before attempting to transfer or ensuring a cognitively impaired resident who wanders does not access unsafe, unmonitored areas of the facility (or worse) should be continuously monitored and revised.
Don’t forget, individualized, resident‑centered interventions are expected to be evident during observations to ensure residents receive the supervision and assistive devices needed to reduce accident risk and address environmental hazards. The facility’s “prevention” system also needs to address how each resident’s need for supervision is evaluated and addressed.
“Assistive Device” – A device which is any time that is used by a resident, or is used in the care of a resident, to promote, supplement or enhance the resident’s safety or function. Examples include mechanical devices or equipment such as walkers, wheelchairs or transfer equipment, as well as fixtures, such as handrails or grab bars.
Nodding your head that all of these are in place in your facility? Then why don’t your numbers for falls and other events make sense or decrease in number? It may be time to re-evaluate your accident prevention system more critically. We hear way too often, “we have tried everything and nothing works.” This simply is not acceptable when developing or reviewing a plan of care to address accident risk. Take a look at a few care plans in your own facility. It’s likely that you will identify where revisions can be made to the care plan or to a facility system or more often, where staff has failed to follow an established preventative system. Sometimes it is as simple as ensuring that staff are making rounds or toileting residents as outlined in the care plan.
