In Part 3 of our CMSCG “Ftag of the Week” blog series for F742 we will finish reviewing the Investigative Protocol outlined in SOM Appendix PP for this regulation and provide some citation examples to help you better understand how issues can be identified during a survey. On CMSCG mock surveys, we often find during medical record review for residents with mental/ psychosocial concerns that there just isn’t good evidence of assessment and care planning, so we’ll dig deep into this section.
Record Review
Surveyors are guided to:
- Identify if the resident triggers for CAAs for activities, mood state, psychosocial well-being and/or psychotropic drug use
- Review the resident’s care plan . . .
. . . not the way that many facilities “review” the care plan by adjusting the goal dates, but really review the plan of care for things like:
- If the resident’s preferences and customary routines have been assessed and incorporated into the plan of care
- Interventions to address the assessed problem
- How the resident expresses/ indicated distress related to the assessed problem
- The types of activities and programs that have been implemented for this resident to help him/her reach and maintain his/her highest level of mental/psychosocial functioning
- Presence of “measurable” language which allows the effective of the care plan to be assessed
- If data is being collected and used to evaluate the effectiveness of the care plan – i.e., routine behavior notes, response to interventions, etc.
Let’s look at another survey citation which reflects a circumstance that everyone has had to deal with – wandering residents and their impact on others.
F742 S/S: D – Recertification Survey Citation
A cognitively intact resident diagnosed with PTSD due to a past life experience was interviewed by a surveyor and she told the surveyor that residents wandering into her room scared her and she was afraid they would come into her room at night. She further stated that she had asked the facility to do something to assist with this issue, but they only put up a paper “stop” sign on her door. This did not prevent residents from wandering into her room. On interview, the DNS stated that they had used mesh stop signs in the past and would revisit using the mesh stop signs but they also needed to try to come up with other ways to address the resident’s fear of wandering residents.
The resident did not want a room change because she wanted to be by the Nurses’ Station and her roommate did not like the door closed, so while the facility had attempted some options, the surveyors found their efforts to be insufficient. The facility was cited for failure to readdress the resident’s PTSD for fear of residents entering her room when stop signs did not prevent residents from entering the room.
How do you address wandering residents and the safety of others in your facility? Have you looked specifically at the potential for negative psychosocial outcomes in addition to the focus on preventing physical altercations? Don’t forget – behavioral health concerns can be cited under several F-tags, so while F742 specifically addressed residents who display or have a diagnosis of a mental disorder/ psychosocial adjustment difficulty or history of trauma/PTSD, there’s other areas where surveyors can identify deficient practices.
Here’s a challenge – go back and look at some of your residents who have mental or psychosocial concerns. Do their care plans address the areas surveyors are guided to review in the medical record? Are they addressed in an individualized manner – or did your staff fall into the trap of clicking through the generic care plan library after inserting a generic goal and multiple interventions that look the same for every resident in the building?
While some of you are probably reading this and thinking, “guilty” and others are rolling their eyes and thinking, “not in this facility,” there’s a likelihood that some of your residents who would really benefit from the IDT spending some time thinking about the best way to care for these residents who don’t have care plans that reflect the actual plan.
F742 S/S: G (Actual Harm) – Recertification Survey Citation
A surveyor observed a resident crying and interviewed her. The resident stated he/she is depressed and feels lonely and has flashbacks from PTSD that upset him/her. The resident had been trying to get an appointment with a therapist but there were wait lists and he/she was unaware that there were mental health services available in the facility – none had been offered to him/her.
During review of the resident’s record, there was an indication in the care plan that the resident had reported past trauma, but there were no associated goals or interventions in the care plan. Documentation from various assessments indicated that the resident had PTSD, depression, anxiety and a history of multiple suicide attempts. A psych eval was requested – and not completed. The resident’s care plan for depression lacked a plan or treatment interventions despite multiple progress notes indicating the resident felt very depressed. Further, the resident was documented as stating that he/she had thoughts of no longer wanting to live, but there was no follow-up until the surveyor brought it to the attention of the Social Worker – a month after the statements were made. The NP was made aware, and the facility planned to send the resident to the hospital to evaluate his/her symptoms.
You can obviously understand how this would end up as a harm-level citation, and in some instances, the outcome could have been even more negative.
Surveyors are also instructed to determine if the resident’s record provides evidence that the care planned interventions are effective in decreasing the resident’s expressions/ indications of distress. How do those charts you reviewed look now? Do you see the same behaviors – and behavior notes – over and over again which show that the generic interventions aren’t working? Further, the Interpretive Guidance states the following guidance:
“If the data collected indicate that expressions or indications of distress are unchanged in frequency or severity over two or more assessment periods, is the plan reassessed and intervention approaches revised to support the resident in attaining the highest practicable mental and psychosocial well-being?”
State Operations Manual Appendix PP – Interpretive Guidance for F742
When interventions aren’t effective for clinical concerns, such as a pressure injury or swallowing difficulty, the resident is re-assessed, the care plan is reviewed, revised and individualized to ensure the necessary care and services are provided to meet that resident’s assessed need. The question that needs to be answered is why the expectation isn’t the same for residents who have psychosocial or other concerns. Why is it that if a resident, who has a diagnosis of PTSD, for example, isn’t assessed and care-planned for in the same way as other residents? It may be that there is a knowledge gap with staff responsible for these residents’ needs, or staff are rushing through the process. Both are problematic for the residents – and your survey results.
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