of F314 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
The harm level
How severely F314 is cited
16.7% 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
G116.7%
H—
I—
No harm, potential for more than minimal
D466.7%
E116.7%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F314 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F314 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 29, 2017
Based on observation, interview and record review the facility did not ensure that a resident who enters the facility without a pressure injury (PI) does not develop a PI for 3 of 6 residents (R1, R2, and R3). The facility failed to put interventions in place to prevent PI development, and the facility failed to complete the weekly Braden skin assessments per standards of practice.
R1 was admitted to the facility without a PI and was identified to be at moderate risk for PI development. R1's physician was not updated when R1 developed an avoidable stage 3 PI on the left buttock that evolved into an infected stage 4 PI to the sacrum. …
Based on interview and document review, the facility failed to ensure that ordered treatments and repositioning were provided to 1 of 3 residents, R1, to prevent and treat pressure ulcers. The facility also failed to accurately document the severity of R1's wounds and provide additional treatments.
A Medication Administration Record [REDACTED]. There is no documentation that staff applied the paste in August, September, or October.
A MAR indicated [REDACTED]. There is no documentation that staff applied the ointment in August, September, or October.
A MAR indicated [REDACTED]. …
E · No harm, potential for more than minimal, patternAugust 30, 2018
Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) received the necessary treatment and services consistent with the facility policy and her care plan to promote healing of her pressure ulcers (damage to the skin or underlying tissue related to prolonged pressure on the skin) when:
1. Licensed Nurses (LN) did not conduct weekly wound assessments (measurements and evaluation of current treatment) as per the facility policy.
2. Resident 1's fluid intake and output and weights were not consistently monitored.
3. …
C · No harm, potential for minimal, widespreadFebruary 25, 2016
Based on observations from 2/23/16 thru 2/25/16, interviews to nursing staff and record review (RR), it was determined that the facility failed to include in their revision of protocols nationally recognized guidelines that serves as the authoritative voice to improve resident outcomes this practice had the potential to affect for 5 out of 5 residents (R) in the sample selection (RR #1, through # 5) and 4 out of 4 residents in the random sample selection (RR #1, through #4).
Findings include:
1. A mechanism to ensure that the facility promote the use of clinical practice guideline best practices care during the management of residents who had pressure ulcers was not promoted accordingly with the following findings identified during survey procedures on 2/23/16 through 2/25/16:
a. …
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