This week’s Ftag of the Week on the CMSCG Blog is F676 Activities of Daily Living (ADLs)/ Maintain Abilities, which is part of the Quality of Life regulatory group. F676 spells out the facility’s responsibility for the provision of care and services to ensure that a resident’s activities of daily living do not diminish unless there is evidence that the resident’s clinical condition changed so that the diminishment was unavoidable.
As a reminder, ADLs include:
- Hygiene (bathing/ grooming/ oral care/ dressing)
- Mobility (transfer/ ambulation)
- Elimination (toileting)
- Dining (eating)
- Communication (speech/ language/ other functional communication systems)
Appendix PP of the State Operations Manual (SOM) directs the reader to F677 ADL Care Provided for Dependent Residents for Interpretive Guidance. We will look at F677 ADL Care in a future CMSCG Blog post, but for now, here are some of the ways that F676 has been cited on survey:
- Hygiene: A resident who required extensive bathing assistance was scheduled to receive seven showers in a specific month, but the bathing record report showed that the resident was only showered twice (S/S: D)
- Mobility: A cognitively impaired resident had a decline in ambulation over a 9-month period, resulting in the resident not being able to walk. A review of the Quarterly MDS assessment and physician’s notes did not address or provide a clinical rationale as to why the resident was no longer able to ambulate (S/S: G)
- Elimination: A resident who was assessed as requiring supervision with one person assistance for toileting and mobility told a surveyor on interview that it was difficult to get any assistance because staff did not answer his call light timely to assist him with toileting needs and emptying his urinal (S/S: D)
- Dining: A resident who was coded as requiring extensive assistance with eating was observed trying to feed himself after dropping his napkin on top of the food on his plate. The resident continued to attempt to scoop the food up and bring the empty fork to his mouth six different times before a nurse came to provide him with his morning meds. The staff member did not remove the napkin or assist the resident. The surveyor continued to observe the resident and documented that he was able to consume approximately 5% of his meal before giving up, even while staff members assisted other residents at the table (S/S: D)
- Communication:Two residents whose second language was English were not provided with a functional system to meet their communication needs. One resident had interventions in place that staff should speak English slowly to the resident and to stand where the resident could see the staff’s face and mouth. On interview, staff stated that these would not be effective in helping a non-native English speaker to communicate better. The second resident had a communication board in his room with only Spanish phrases and no English equivalents. On interview, the resident said he was not familiar with this because it was the first time he had seen it. A staff member interviewed reviewed the information on the board and stated that without the English translation, she had no idea what was being said (S/S: E)
As you can see from these citations, it is very easy for a surveyor to visually observe a resident and then follow up with documentation review and interviews with both the resident and staff and identify a negative outcome, such as the example of the resident losing the ability to ambulate. What an unacceptable outcome for that resident.
How do observations such as these occur during a survey? Unfortunately, many of them occur because responsible staff are not routinely monitoring that the developed plan of care is consistently being carried out or, if it is being carried out, documentation does not validate that care and services were provided. It is not uncommon for a survey to highlight the need for a facility to review its systems related to a cited F-tag. Remember it is our responsibility to provide the necessary care and services for a resident to maintain or improve their ability to carry out activities of daily living. If they do diminish, a surveyor should be able to review the medical record, interview staff and identify that any loss was unavoidable and not reflective of an inadequate system or poor compliance with carrying out the plan of care.