of F309 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F309 is cited
12.5% 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
G112.5%
H—
I—
No harm, potential for more than minimal
D450.0%
E337.5%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F309 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F309 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.
K · Immediate jeopardy, patternNovember 21, 2017
Based on interview and record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being in accordance with the physician orders [REDACTED].#21) whose care was reviewed for Code Status in that:
LVN C, LVN E and RN D failed to assess Resident # 21's after change in condition declined, no vital signs were taken, and Cardiopulmonary Resuscitation (CPR) was not initiated for Resident #21 who was unresponsive, pulseless and a full code status contributing to Resident #21's death.
This failure resulted in identification of an IJ (Immediate Jeopardy) on [DATE]. …
Based on interview and record review, the facility failed to follow its policy and follow a residents' plan of care for one of three sampled residents (Resident 1). Resident 1 sustained two (2) falls that resulted in a transfer to the general acute care hospital (GACH) on 6/20/17.
As a result, Resident 1 sustained injuries requiring a transfer to the GACH and diagnosed with [REDACTED].
Findings:
A review of Resident 1's Admission Record (face sheet) indicated Resident 1 was admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 1's [DIAGNOSES REDACTED]. …
E · No harm, potential for more than minimal, patternAugust 30, 2018
Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the plan of care, and in accordance with professional standards for pain assessment and management for one of three sampled residents (Resident 1).
The failure to properly assess Resident 1's pain resulted in a delay in identifying a fracture to her left hip.
Findings:
A review of the facility's Pain Assessment and Management policy, revised 3/2015, indicated the purpose of the policy was to identify pain, develop interventions, and to address the underlying cause of the pain. …
B · No harm, potential for minimal, patternNovember 2, 2017
Based upon observation, interview and record review the facility failed to ensure that medications were passed within regulatory requirements. This failure has the potential to affect 61 residents residing on the 1st floor.
Findings include;
The (10/24/17) daily schedule includes one Nurse assigned to the 1st floor on AM, PM and Night shift.
On 10/24/17 at 12:34pm, E13 (Registered Nurse) affirmed that one (1) Nurse is assigned to 55 (1st floor) residents on today's date.
On 10/30/17 at 9:48am, surveyor noted E14 (Licensed Practical Nurse) sitting idly at the Nurse's station. E14 stated that he is assigned to 29 (1st floor) residents on today's date. …
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