SNF Should Have Considered Staffing Increase after Spike in Falls, DAB Says

October 4, 2019 | Aging Services Risk Management


Although a skilled nursing facility (SNF) assessed residents and implemented and monitored interventions in response to a spike in falls, the SNF's failure to consider adjusting staffing, after those interventions failed to address the problem, represented a failure to comply with federal regulations, the US. Department of Health and Human Services' Departmental Appeals Board (DAB) has held. In so ruling, it affirmed an administrative law judge (ALJ) decision upholding deficiency citations and penalties issued by the Centers for Medicare and Medicaid Services (CMS).

In summer 2013, the SNF's quality assurance committee and management adjusted staff work and activity schedules in the Alzheimer's care unit to better ensure residents' needs were being met. Beginning later in 2013 and continuing through early 2014, however, the falls rate in the Alzheimer's care unit increased significantly, from 8 in November 2013, to 19 in December 2013, to 33 in January 2014. The spike was due mainly to an increase in falls among five residents, who fell a collective 43 times over several months. Most of these falls occurred from December 2013 through March 2014. All five residents were ambulatory and were assessed as being at high risk for falls. The SNF conducted assessments and implemented interventions in response to the...

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