In previous parts of our CMSCG Ftag of the Week series for F689 Accidents/Supervision, we reviewed key regulatory requirements and a laundry list of “little things” that can result in a negative outcome for a resident — and a facility. This week, we’re looking at situations where equipment or devices — when used incorrectly, inconsistently, or without proper maintenance — create significant accident hazards. These aren’t the “little things” anymore. These are the issues that can quickly escalate into serious injuries when systems or equipment aren’t functioning the way they should.
Broken, Poorly Maintained or Unsafe Equipment Hazards
Earlier in this Ftag series, we discussed the facility’s responsibility to identify potential hazards to avoid accidents. Equipment‑related concerns fall squarely into that category — and when something goes wrong, the condition of the equipment becomes a central part of the investigation. If a sling is torn, wheelchair brakes don’t hold, or any device isn’t functioning as intended, the issue quickly becomes bigger than the injury itself. (And let’s be honest: once faulty or poorly maintained equipment enters the picture, winning that IDR becomes significantly more challenging.) Some equipment failures you don’t want to see:
- Wheelchairs with missing footrests, brakes that don’t work, torn armrests, or anti-tippers that aren’t in place despite being in the plan of care
- Improperly functioning or fitting specialty mattresses – these can create a potential entrapment zone. If you’re using specialty mattresses that aren’t inflated to the correct level or functioning appropriately, a resident can easily end up with a negative outcome
- Bed rails – These are an IJ in the making . . . and have their own Ftag – F700 – so this is a key concern area.
- Call bell systems – whether the call bell doesn’t work, is out of reach, or is not connected to the call system, this is not a supervision failure that a facility wants to be hit with.
- Shower/Bathing Equipment – broken shower chairs are a key contributor to accidents and let’s not forget the importance of functioning shower chair seat belts.
Preventative maintenance is key – but so is your communication system for reporting identified concerns to the appropriate department for timely follow-up.
Device/Equipment Misuse or Improper Use
Even when equipment is available and functioning, how it’s used (or not used) can create significant accident hazards. This is where identified concerns really start to point to deeper systems failures. Staff not following the plan of care or not knowing the plan of care, staff not being aware of a resident’s current device needs, inconsistent practices by shift – these can all contribute to concerns with supervision, communication and training.
Here’s some common contributors to accidents:
- Residents’ assistive devices are not within reach, resulting in someone trying to unsafely self-transfer or reach unsafely. If an accident happens and this is a contributing factor, this will be viewed as a preventable hazard.
- Improper wheelchair positioning can lead to falls. If staff ignore red flags, such as a resident who is sliding forward, leaning too far to one side, or otherwise is poorly positioning, the lack of monitoring and follow-through can be problematic.
- Alarms that are ignored, not connected to the call system, or turned off. We are not proponents of bed alarms or chair alarms, but if your facility uses them, use them correctly and judiciously. Staff should never silence an alarm to complete another task first. If an alarm goes off but staff are not alerted to it or do not respond to it, then this is a systems failure. You have equipment in place, but the process for monitoring is broken.
Mechanical Lifts – One of the Most Common – and Serious – F689 Concerns
Mechanical lifts are intended to reduce injury risk, but when they’re used incorrectly or inconsistently, they become one of the highest risk devices in the building. Surveyors know this, which is why lift‑related accidents are among the most frequently cited F689 deficiencies nationwide.
When something goes wrong during a transfer, the investigation always comes back to the same core questions:
- Were staff following the plan of care?
- Was the equipment safe?
- Was it used correctly?
- Were staff trained and competent?
Common lift-related hazards include:
- Incorrect number of staff assisting – staff need to assist with the lift transfer, not merely be in the room.
- Staff who are not competent with the equipment – there’s training, and there’s competency. If staff are asked to demonstrate appropriate use, can they? If not, it’s a systems failure.
- Wrong sling size, type, etc.
- Lift not locked or stabilized prior to transfer
- Resident left unattended in the lift/sling
- Equipment not maintained or inspected routinely – who is checking the bolts that connect to the sling holder which have been carefully wrapped in moleskin to avoid resident injury?
Mechanical lift accidents are rarely viewed as isolated events. They almost always point to systemic failures — training gaps, poor communication, inadequate supervision, or a lack of an appropriate preventive maintenance schedule being followed. Take a look at the state of your slings – those torn seams and frayed/torn sling connectors can all spell disaster for a resident. Who is responsible for checking and replacing slings that are in poor repair? When a resident is injured during a lift transfer, the facility’s ability to defend itself is extremely limited.
Device-related hazards are not minor oversights that can be downplayed. They’re clear indicators to a surveyor as to whether a facility’s accident prevention system is functioning appropriately (and meeting regulatory expectations). When equipment is poorly maintained or misused, it significantly increases the risk to a resident. Oftentimes, these issues are not just reflective of individual staff errors – they’re evidence that staff haven’t been training appropriately, monitored/supervised sufficiently, or there’s a communication issue.
As we move into the next part of this series, we’ll shift from device‑related risks to the highest‑risk situations — the events that lead to the most serious injuries and the most severe F689 citations. These are the incidents that occur when multiple system failures converge, and the consequences can be life‑altering for residents and costly for facilities. If you don’t want to wait for the next post, take a look at the CMSCG “The State of IJs” series, which is packed with F689 Immediate Jeopardy examples and systems‑level issues that commonly lead to negative outcomes.
F689 citations often reveal deeper system failures. CMS Compliance Group’s survey readiness consultants can help you evaluate your processes, strengthen staff practices, and ensure your equipment‑related systems meet CMS expectations. Reach out to our team to discuss how we can support your facility before a negative outcome exposes the gaps.
