15 Most Frequently Cited Deficiencies Comparative Standard Complaint Life Safety.

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Transcript of 15 Most Frequently Cited Deficiencies Comparative Standard Complaint Life Safety.

15 Most Frequently Cited Deficiencies

Comparative Standard ComplaintLife Safety

Tennessee

Nursing Home Complaint Surveys

MOST FREQUENTLY CITED DEFICIENCIES

Comparative

Tag # Fiscal Year 2009 - Date Tennessee % Surveys

TN'09 TN'08 Nation'09

F0323 FACILITY IS FREE OF ACCIDENT HAZARDS 3.80% 6.30% 4.70%

F0281 SERVICES PROVIDED MEET PROFESSIONAL STANDARDS 3.20% 3.30% 2.60%

F0157 INFORM OF ACCIDENTS/SIG CHANGES/TRANSFER/ETC 1.40% 2.50% 2.50%

F0225 NOT EMPLOY PERSONS GUILTY OF ABUSE 1.40% 0.90% 2.40%

F0514 CLINICAL RECORDS MEET PROFESSIONAL STANDARDS 1.20% 2.50% 1.80%

F0272 COMPREHENSIVE ASSESSMENTS 1.20% 2.00% 0.80%

F0309 PROVIDE NECESS CARE FOR HIGHEST PRAC WELL BEING 1.20% 3.80% 3.40%

F0279 DEVELOP COMPREHENSIVE CARE PLANS 0.60% 1.00% 1.30%

F0502 FACIL PROVIDES/OBTAINS LAB SERVICES 0.60%  

F0250 MEDICALLY RELATED SOCIAL SERVICES 0.60%  

F0226 POLICIES, PROCEDURES PROHIBIT ABUSE, NEGLECT 0.60% 1.70% 1.30%

F0322 PROPER CARE & SERVICES FOR RES W/ NG TUBE 0.60%  

F0315 RES NOT CATHETERIZED UNLESS UNAVOIDABLE 0.60%  

F0333 RESIDENTS FREE FROM SIGNIFICANT MED ERRORS 0.60%  

F0312 ADL CARE PROVIDED FOR DEPENDENT RESIDENTS 0.30%  

Tennessee

Nursing Home Standard Health Surveys

MOST FREQUENTLY CITED DEFICIENCIES

Comparative % Surveys

Tag # Fiscal Year 2009 - Date Tennessee TN ’09 TN ’08 Nation’09

F0323 FACILITY IS FREE OF ACCIDENT HAZARDS 30.00% 38.50% 36.20%

F0371 STORE/PREPARE/DISTRIB FOOD UNDER SANITARY CONDS 28.50% 23.00% 34.60%

F0431 PROPER LABELING OF DRUGS & BIOLOGICALS 23.10% 17.50% 15.60%

F0444 WASH HANDS WHEN INDICATED 23.10% 24.60% 12.70%

F0332 MEDICATION ERROR RATES OF 5% OR MORE 22.30%  

F0441 FACILITY ESTABLISHES INFECTION CONTROL PROG 18.50% 20.20% 18.40%

F0281 SERVICES PROVIDED MEET PROFESSIONAL STANDARDS 18.50% 26.20% 26.40%

F0280 DEVELOPMENT/PREP/REVIEW OF COMP CARE PLAN 17.70%  

F0315 RES NOT CATHETERIZED UNLESS UNAVOIDABLE 16.90% 18.70% 18.00%

F0514 CLINICAL RECORDS MEET PROFESSIONAL STANDARDS 16.20% 13.90% 17.20%

F0309 PROVIDE NECESS CARE FOR HIGHEST PRAC WELL BEING 14.60% 26.60% 25.40%

F0221

RIGHT TO BE FREE FROM PHYSICAL RESTRAINTS NOT REQ'D FOR TREATMENT 14.60%

F0322 PROPER CARE & SERVICES FOR RES W/ NG TUBE 13.10%

F0164 PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS 12.30%

F0328 PROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS 12.30%

Tennessee

Nursing Home Life Safety Code Surveys

MOST FREQUENTLY CITED DEFICIENCIES

Comparative % Surveys

Tag # Fiscal Year 2009 - Date Tennessee TN ‘09 Region ‘09 Nation ‘09

K0147 ELECTRICAL WIRING AND EQUIPMENT 40.00% 22.10% 27.20%

K0062 SPRINKLER SYSTEM MAINTENANCE 33.60% 15.70% 28.50%

K0067 VENTILATING EQUIPMENT 22.40% 8.10% 12.20%

K0029 HAZARDOUS AREAS - SEPARATION 21.60% 19.90% 27.00%

K0025 SMOKE PARTITION CONSTRUCTION 21.60%   19.80%

K0018 CORRIDOR DOORS 20.80% 16.10% 27.80%

K0052 TESTING OF FIRE ALARM 20.80% 10.20% 13.70%

K0050 FIRE DRILLS 18.40% 7.70% 17.50%

K0038 EXIT ACCESS 16.80% 11.00% 19.90%

K0064 PORTABLE FIRE EXTINGUISHERS 16.00%  

K0130 OTHER 14.40% 7.30%

K0069 COOKING EQUIPMENT 11.20% 10.10% 11.50%

K0056 AUTOMATIC SPRINKLER SYSTEM 10.40% 12.70% 14.70%

K0054 SMOKE DETECTOR MAINTENANCE 8.80%  

K0066 SMOKING REGULATIONS 8.80%  

Regulation for Admission Agreements

42 CFR 489.22(d)(2)

The facility is in violation of its provider agreement – if they charge an individual for failure to remain an inpatient for any agreed-upon length of time or for failure to give advance notice of departure from the provider’s facility.

Registered Nurse Surveyors

http://state.tn.us/dohr/JobSearch/Employment.html

Click on Current OpeningsGo to page 3 Click on Public Health Nurse Consultant 1debbie.thrasher@tn.govvincent.davis@tn.gov