Trascrizione completa di Accountability, Prevention, And The True Cost Of Missed Falls

has been very transparent about their interest in quality of care issues. 00:03:02.479 --> 00:03:14.319 And that has only increased over the last several years as they monitor what's going on with long-term care and continue to give recommendations to CMS. 00:03:14.960 --> 00:03:36.240 And when they did this look at claims-based data and compared it to what was being reported in MDSs and found such a disparity, it certainly raised concern on the part of OIG and resulted in these recommendations that are in the report that you just referenced to CMS. 00:03:36.639 --> 00:04:02.800 And then CMS, in their response, certainly agreed that this was of significant concern and noted that they are now using claims data both from Medicare and Medicaid across the continuum of care to validate that the falls with major injury data in the MDS, MDSs that are submitted is accurate. 00:04:03.039 --> 00:04:18.240 And I think that it will be a certainly guidance to surveyors, if not a more aggressive approach in the future with regard to any disparities that they see in the in the comparison of these two data sources. 00:04:19.439 --> 00:04:23.040 So at the facility level, are we doing audits? 00:04:23.360 --> 00:04:27.360 Are we looking at how we are coding? 00:04:27.519 --> 00:04:29.680 Obviously, that's the that's important. 00:04:29.839 --> 00:04:33.040 But before that, what is our fall prevention program? 00:04:33.199 --> 00:04:39.759 What's our systems level review of compliance to prevent falls from the get-go? 00:04:39.920 --> 00:04:44.959 So I want you to talk a little bit more about fall prevention and some best practices that you've seen. 00:04:45.439 --> 00:04:57.120 Well, and and I think that when you think about the leading factors that result in falls with major injury, it's the same leading factors that lead into falls in the first place. 00:04:57.279 --> 00:05:04.639 And unfortunately, in some cases, you know, a fall results in a fracture or significant laceration, et cetera. 00:05:04.879 --> 00:05:11.839 You know, residents' cognitive status, of course, comes to mind as a first step, really safety awareness here. 00:05:12.319 --> 00:05:23.439 If a resident may have, you know, dementia that has resulted in memory loss, but safety awareness may have been retained in the short run. 00:05:23.920 --> 00:05:32.160 And on the other hand, however, there may be residents who do well on a BIMS but have really poor safety awareness. 00:05:32.319 --> 00:05:34.399 And then history of falls, of course. 00:05:34.560 --> 00:05:41.839 So the more frequently you fall, you know, just statistically speaking, the more likely you are to have an injury. 00:05:42.079 --> 00:05:54.000 And so when we have a resident with a history of falls, the real issue here is how effective are our fall interventions. 00:05:54.240 --> 00:05:57.600 Are those interventions individualized for the resident? 00:05:57.839 --> 00:06:05.360 Are we doing a root cause analysis at the time of the

fall to really drill down to see why did the resident fall? 00:06:06.079 --> 00:06:10.560 They didn't fall because they have dementia or because they have Parkinson's disease. 00:06:10.720 --> 00:06:14.480 They fell because they were trying to do something. 00:06:14.959 --> 00:06:34.399 And so, really, you know, interviewing the resident, understanding what their motivation was for perhaps trying to get up out of the wheelchair or get out of bed really gives us insight into what kind of intervention to put in place to prevent future falls. 00:06:34.800 --> 00:06:42.399 So what I hear you saying is putting that fall prevention program in place, a comprehensive fall prevention program. 00:06:42.879 --> 00:06:46.240 So tell me a little bit more about some of the elements of that program. 00:06:46.639 --> 00:06:47.040 Absolutely. 00:06:47.120 --> 00:06:58.560 And so having a falls program within the organization that is structured and replicable has to be sort of a foundation for a successful facility. 00:06:58.879 --> 00:07:20.800 Starting really pre-admission, you know, is there a fall risk assessment that is completed by the interdisciplinary team prior to the resident ever arriving at the facility, recognizing what's really happening with them, what are their diagnoses, why are they in the hospital, have they already had a fall? 00:07:21.040 --> 00:07:30.720 And then implementing interventions prior to the resident ever coming to the building really gets you set off at the right on the right foot. 00:07:31.040 --> 00:07:41.920 And then following that with any significant changes as they occur and continuing to use standardized tools to identify fall risk. 00:07:42.240 --> 00:07:57.600 But while standardized tools are great, they don't make up for truly knowing our residents and truly knowing what the motivating factors are for that individual resident as we get to know them in the facility. 00:07:57.839 --> 00:08:04.079 And then continuing on with our quarterly assessments or any time that there is a significant change. 00:08:05.120 --> 00:08:17.759 So what you're saying is you've conducted a risk assessment of a resident, you've put a plan in place that you believe is going to help prevent falls, and you reassess and reevaluate. 00:08:18.000 --> 00:08:24.319 But let's say, despite all your efforts, the resident continues to have fall experiences. 00:08:24.560 --> 00:08:25.920 What do you do then? 00:08:26.160 --> 00:08:28.000 Take me down that path. 00:08:28.959 --> 00:08:49.519 And and so if I if I kind of walk through a process, I would say that the root cause analysis that's done by the team at the time of the fall is the key step in terms of obviously if no one, if a resident hasn't had any falls, then you're doing a good job, right? 00:08:49.679 --> 00:09:12.559 But it if we have a fall, to pull together an interdisciplinary team that includes the CNA that's caring for the resident, the nurse that is responsible for the care of the resident, any of the nurse leadership that is available, the director of therapy to take a look at the fall circumstance and talk to the resident at the time of the fall. 00:09:12.799 --> 00:09:15.759 Often these are called post-fall huddles. 00:09:16.399 --> 00:09:27.679 And using a standardized tool to always capture the same information during that little gaggle up to see what you know what really happened during this fall is a key. 00:09:27.919 --> 00:09:39.039 And then identifying an immediate intervention that will address whatever the circumstance was, and including that on the care plan, of course, very, very important. 00:09:39.919 --> 00:10:00.000 Then next step being whenever the interdisciplinary team has their next meeting, whether that's at the end of the day or the beginning of the next day, that a more in-depth root cause analysis is reviewed and identifying what were the factors that were involved in this fall. 00:10:00.960 --> 00:10:06.480 During that process, reviewing the entire care plan related to falls. 00:10:06.559 --> 00:10:10.159 So let's say that this is a resident that's been with us for three years. 00:10:10.320 --> 00:10:13.120 And during that three years, they've had multiple falls. 00:10:13.279 --> 00:10:24.559 Not only looking at this fall, but looking for commonalities across the most recent falls that the person has had, often will identify additional information that one fall might not. 00:10:24.799 --> 00:10:31.120 And then upgate updating the care plan again truly with an intro an individualized intervention. 00:10:31.279 --> 00:10:54.080 So for example, if a resident was attempting to get out of bed into the wheelchair, and they tell you that they were, you know, they wanted to get up and their feet slid out from under them, we wouldn't put in an intervention that related to bathroom safety, right? 00:10:54.159 --> 00:11:00.639 We we have to drill down to what really happened and identify an intervention that relates to that specific issue. 00:11:01.200 --> 00:11:09.120 Often we also see that in care plans if a resident has been with us for a long time and if they have fallen multiple times. 00:11:10.240 --> 00:11:13.759 Our fall prevention care plan might be pages long. 00:11:14.480 --> 00:11:29.759 And so if that's the case and you're the direct care provider for that resident, it's difficult to sift through all of the interventions that are listed on the care plan to identify truly what you should be doing in the care of the resident to keep them safe. 00:11:30.000 --> 00:11:49.840 And so winnowing your care plan to interventions that are truly individualized and proven to be effective, and don't say, you know, sort of generic items that we do for all of our residents really results in a much more effective care plan. 00:11:50.320 --> 00:11:58.080 So would you say getting this information to direct care staff, the team, so they know what it is we need to do? 00:11:58.720 --> 00:11:59.840 Absolutely.

00:12:00.799 --> 00:12:20.320 And and you know, when when we are together as an IDT and we are discussing and we've come up with a great new intervention and we're super excited about it, and we put it in the care plan, if we then all walk away and nothing else is done, how does the direct care provider know what it is that they're supposed to do that's new and different? 00:12:20.480 --> 00:12:37.759 And so a method for communication real time that might be a you know post-morning clinical meeting, you know, gaggle up with the direct care staff on the unit where the fall occurred, in which we talk about Mrs. 00:12:37.840 --> 00:12:43.440 Jones had a fall, this was the circumstance, and here's the intervention we would like to put in place. 00:12:43.600 --> 00:12:55.279 And then that that communication goes shift to shift on the go forward so that it's communicated directly, not just via the care plan, but also in a in a you know face-to-face way. 00:12:56.240 --> 00:13:10.240 So, you know, you talked a little bit about huddles or uh manners by which the staff come together and talk about here's our plan, here's how we're going to keep this resident from falling, certainly from having a major fall. 00:13:11.039 --> 00:13:26.799 And we know that it's important for the interdisciplinary team to talk, keep each other updated, any changes that is occurring with the resident, any early changes that could lead to their falls, certainly a major fall. 00:13:26.960 --> 00:13:28.399 So talk a little bit about that. 00:13:28.480 --> 00:13:32.480 So we want to we want to avoid falls, we do not want any further incidents. 00:13:32.720 --> 00:13:34.480 So talk a little bit about that. 00:13:37.120 --> 00:13:52.320 And and to your point there, you know, then three or four days later, most facilities have something that they would call resident review, incident review, something like that, and in which once a week they review residents that have had major changes. 00:13:52.559 --> 00:14:18.080 And so another recommendation then would be for any resident that's fallen in the last seven days since your last resident review meeting to go back and look at the intervention that was put in place after the most recent fall, and then discuss whether that intervention has been effective in the last few days and pulling in the direct care staff who directly treat care for the resident, the CNAs, and saying, What do you think? 00:14:18.240 --> 00:14:19.120 Is this working? 00:14:19.440 --> 00:14:21.679 Was this intervention effective? 00:14:21.919 --> 00:14:23.360 Should we try something else? 00:14:23.600 --> 00:14:27.679 And then, of course, documenting that discussion, right, would be an important piece. 00:14:28.399 --> 00:14:32.080 Of course, being a therapist, I have to throw in the therapy screen. 00:14:32.320 --> 00:14:40.000 So most facilities that I have worked with over the years that have really effective fall prevention programs. 00:14:40.320 --> 00:14:50.960

Their therapy team is highly engaged in all things fall prevention, both with regard to actual therapy treatment, resident equipment, positioning, et cetera. 00:14:51.279 --> 00:15:02.000 And that therapy screening process after a fall will take a look at whether there has been a change in independence with regard to mobility. 00:15:02.240 --> 00:15:16.879 And if so, then therapy, you know, seeks evaluate and treat orders and initiates treatment to try to address any change in mobility and move that person back up to their level of prior functioning. 00:15:17.200 --> 00:15:37.679 You know, if I if I would think about facilities that I have worked with over the years that have really struggled with high fall rates, an approach we used as monitors very frequently was something of a gap analysis in which we looked at the falls program of the facility. 00:15:38.000 --> 00:15:43.360 And typically every facility across the country would have a fall prevention program. 00:15:43.840 --> 00:15:56.159 And then we would say, okay, you know, there's 12 steps in this program, and then assess whether the individual facility was effectively using all of those steps. 00:15:56.320 --> 00:16:07.519 And if a gap was identified, then we would work with the facility to identify what the roadblocks are to implementing that missed step. 00:16:08.080 --> 00:16:11.600 And often we would see significant improvements involved. 00:16:12.000 --> 00:16:21.519 In my experience as a monitor, I have worked with organizations to conduct gap analysis exercises to look at resident falls. 00:16:22.320 --> 00:16:26.960 And looking at that is what you're doing is you're getting the policy and procedure out. 00:16:27.200 --> 00:16:31.440 That once you once you review that, are there any gaps in what we were supposed to do? 00:16:31.600 --> 00:16:32.480 What did we not do? 00:16:32.639 --> 00:16:34.320 That's identifying the gap. 00:16:34.480 --> 00:16:35.679 And from there you go. 00:16:35.919 --> 00:16:37.919 I had some great experiences doing that. 00:16:38.000 --> 00:16:43.360 And one thing I want to emphasize here is it's really important to get key stakeholders involved. 00:16:43.600 --> 00:16:59.679 Make sure that folks who know the residents and know what's going on with the residents on a day-to-day basis, all shifts, weekends, et cetera, that they are brought to the table to provide feedback on what their view is as to contributing factors for falls. 00:16:59.840 --> 00:17:01.519 So it's real important, key stakeholders. 00:17:01.840 --> 00:17:08.240 Well, you nicely outlined some of the steps that go into root cause analysis, gap analysis. 00:17:08.480 --> 00:17:09.279 What else are you doing? 00:17:09.440 --> 00:17:10.720 Can you tell us a little bit more? 00:17:11.200 --> 00:17:22.559 Some work that I'm doing right now in my company relates to really residents who have the unfortunate circumstance of having repeated falls over and over again. 00:17:23.039 --> 00:17:37.680 And so we're doing some work with regard to more of a deep dive analysis across falls in the same resident, looking at things like, you know, what are the diagnoses that this resident has? 00:17:38.400 --> 00:17:49.279 What are if we look at the circumstance or the events occurred in the in the last, you know, let's say five falls, what are the commonalities? 00:17:49.599 --> 00:17:54.480 Time of day, location, you know, what is the resident saying? 00:17:55.119 --> 00:17:56.960 And then looking at the BIMs. 00:17:57.359 --> 00:18:02.319 Is the resident able to remember these safety instructions that we give them? 00:18:02.559 --> 00:18:05.200 If not, what else do we need to be doing? 00:18:05.519 --> 00:18:20.880 Looking at the most recent therapy documentation and identifying the mobility status at the time of discharge, comparing that to the mobility status that we're seeing now, and asking for therapy referrals, if indeed we're seeing a decline. 00:18:21.599 --> 00:18:34.400 Reviewing care plan interventions to ensure that the interventions that are listed in the care plan are current, are effective, and are in place. 00:18:35.359 --> 00:18:43.359 So if the facility has a customer service rounding process, you know, we call it concierge rounds. 00:18:43.759 --> 00:18:46.079 Sometimes they're called guardian angel rounds. 00:18:47.279 --> 00:18:57.440 Is that concierge or guardian angel taking a look at safety every time they go into that resident room to see if the plant care planned interventions are in place? 00:18:58.559 --> 00:19:01.759 Next up, what medications is the resident on? 00:19:02.000 --> 00:19:13.519 Are they on a number of medications that are known to have potential side effects of dizziness, faintness, you know, uh vertigo, et cetera? 00:19:13.759 --> 00:19:22.480 Is there an opportunity for gradual dose reductions on psychoactive meds, which often result in issues with falls? 00:19:23.519 --> 00:19:37.200 Looking at provider notes and provider orders, not just of the direct care, sorry, the medical director or physician caring for the resident, but any consultations, perhaps psych notes, et cetera. 00:19:37.440 --> 00:19:51.599 And then based on that, what are we seeing as the commonalities across all of these pieces of data that may give us insight into what else might we be able to do to prevent future falls with the same resident? 00:19:53.359 --> 00:19:55.279 And this is certainly a time commitment. 00:19:55.359 --> 00:20:04.720 I mean, you're you're bringing folks together to start talking about what we can do to prevent falls, certainly major falls. 00:20:05.119 --> 00:20:08.720 It is a commitment, but it's well worth it because we're going to protect the resident. 00:20:11.359 --> 00:20:16.000 So we've talked about fall, fall prevention, uh avoiding major injuries. 00:20:16.160 --> 00:20:29.519 I want to go back again to the OIG, the CMS initiative to really examine more closely MDS accuracy and uh and Medicaid

Medicare claims. 00:20:29.680 --> 00:20:32.960 So come back to that and talk a little bit more about that. 00:20:33.680 --> 00:20:34.319 Certainly. 00:20:34.480 --> 00:20:58.319 And and you know, when you take a look at OIG guidance for long-term care in terms of internal audit and the kinds of things that we should be monitoring, one of the key elements is MBS accuracy, whether that is either for Medicare residents, but also truly for your Medicaid residents and your managed care residents as well. 00:20:58.559 --> 00:21:27.200 And so developing a standardized tool that you can use to do that auditing and then reporting that, those results to your compliance committee, as well as if there are errors in your MDSs, that you are modifying the MDSs to correct the errors, which may result in decreased reimbursement or may result in increased reimbursement based upon the timing of your audits. 00:21:27.680 --> 00:21:47.839 But a newer factor that OIG has really been focused on recently has been accuracy of MDS data as it relates to those factors that are included in quality measures and any quality reporting that results in changes to reimbursement. 00:21:48.160 --> 00:21:59.759 And so things like accuracy of if a resident has had a major injury due to a fall, is that coded correctly on an MDS is a perfect example of something that might. 00:22:00.160 --> 00:22:07.759 Be on your audit tool to ensure that you are aware of the accuracy of your MDSs in an individual facility or across a company. 00:22:08.319 --> 00:22:16.160 So, Janine, we know that the oversight, the review that will be conducted will have some far-reaching implications. 00:22:16.400 --> 00:22:18.319 You want to talk a little bit about that? 00:22:19.440 --> 00:22:20.079 Absolutely. 00:22:20.319 --> 00:22:20.720 Absolutely. 00:22:20.960 --> 00:22:29.920 And you know, one other thought related to OIG's focus and ultimately CMS's focus relates to special focus facilities. 00:22:30.079 --> 00:22:52.960 And so, you know, the fall prevalence of falls being a new component of determination of which facilities will become special focus facilities across the country, it just adds even more emphasis on the importance of fall prevention and the importance of really understanding what the gaps are in your falls programs and how to better prevent falls. 00:22:53.440 --> 00:23:08.319 Well, I think we have really conducted a pretty comprehensive review of the discussion related to falls with major injury, the implications indicated by the OIG and the CMS and where things are going to go. 00:23:08.559 --> 00:23:15.759 It's been great having you come in and share with me some of this information, and I hope to have you come back. 00:23:15.920 --> 00:23:22.400 There are a few more topics that I know you'll be able to help us develop and have some good discussion. 00:23:22.559 --> 00:23:24.079 Thank you again, Janine. 00:23:25.359 --> 00:23:26.720 I would love it, Dee. 00:23:28.000 --> 00:23:29.200 Thank you for listening. 00:23:29.440 --> 00:23:31.519 Your time is appreciated. 00:23:31.759 --> 00:23:38.640 We hope you enjoyed this episode of Vital Compliance Insights and found this to be informative. 00:23:39.359 --> 00:23:51.839 Please feel free to reach out to Verity Consulting at VerityTeam.com if you'd like further assistance with your healthcare compliance needs. 00:23:52.559 --> 00:23:55.200 Stay tuned for the next episode.