of F278 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F278 is cited
0.0% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J—
K—
L—
Actual harm
G—
H—
I—
No harm, potential for more than minimal
D571.4%
E228.6%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F278 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F278 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedNovember 19, 2017
Based on record reviews and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) of a resident for use of side rails as a potential restraint. The resident (Resident #1) got his head stuck in the side rail of his bed and his head had to be released from inside the side rail by fire rescue personnel for 1 of 4 sampled residents who had side rails on their beds.
Immediate Jeopardy began on 10/24/17 when on the admission MDS side rails were not coded as a restraint for Resident #1. Immediate Jeopardy was removed on 11/18/17 when the facility provided and implemented a Credible Allegation of Compliance. …
Based on staff interviews and record review, the facility failed to accurately code section M (skin conditions) of the Minimum Data Set (MDS) assessment to reflect a deep tissue injury (DTI) on the resident's heel which resulted in lack of treatment and progression in the size of the wound for 1 of 3 residents reviewed for Pressure Ulcers (Resident #65).
Findings included:
Record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].
The Care Plan last updated on 12/6/2016 was reviewed. The Care Plan revealed a problem of a risk for Pressure Ulcers related to impaired mobility with a goal of no new areas of skin breakdown through the next review. …
D · No harm, potential for more than minimal, isolatedAugust 31, 2018
Based on interview and record review, the facility failed to ensure that Resident 1's assessment was accurate when the Resident Mood Interview section was incorrect and incomplete. This had the potential for Resident 1's care needs to not be met.
Findings:
Resident 1 was admitted to the facility on [DATE] from an assisted living facility, with [DIAGNOSES REDACTED].
On 3/2/17, the facility's minimum data set (MDS, an assessment tool), dated 11/21/16, was reviewed and showed that he was understood and was able to understand others, was cognitively intact (able to clearly think, remember and make decisions for himself). Section D for Moods included the question Should Resident Mood Interview be Conducted? - Attempt to conduct interview with all residents. …
B · No harm, potential for minimal, patternNovember 21, 2017
Based on surveyor review of the clinical record and interview with the facility staff, it was determined that the facility staff failed to ensure accurate MDS (Minimum Data Set) documentation for residents. This finding was evident in 2 of 18 (#2, #3) residents identified during the complaint survey. The findings include:
The Minimum Data Set (MDS) is a mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive and accurate assessment of each resident's functional capacity and health status to assist nursing home staff in identifying health problems. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames.
1. …
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