So, the facility got a deficiency cited on this resident related to his falls. The deficiency puts the facility out of compliance with their Medicaid and Medicare agreement. The deficiency has to be lifted in a maximum of 180 days or your facility faces losing their Medicare/Medicaid provider agreement, in which case, you will not be able to accept or provide care for these residents at the facility and those living there would be transported elsewhere. There are fines and other remedies that are imposed along the way before 180 days is reached. That’s why it’s important the facility clear the citation as soon as possible.

It is irrelevant if he progressed from 2 to 1, that alone would not clear a deficiency. However, it would need to be reflected on his care plan, MDS, and ADL sheets. The important thing to remember is that an incident report itself is pretty much useless other than to communicate what happened. There should be a reasonable care plan falls intervention put into place immediately after each fall. This should have made it less likely for the resident to fall repeatedly. This is most likely where the citation is aimed. Many times if a resident is a repeat faller, it’s difficult for a facility to ensure appropriate interventions are put in place immediately; so, the resident has another fall without a new intervention – which in the State’s eyes – could have potentially been prevented.

It is common to inservice both direct care and therapy staff when trying to clear a care tag such as this. That doesn’t necessarily mean that you did anything wrong. The facility simply needs to prove that they have made reasonable effort to communicate this to the staff.

I hope this helps.

Thanks for your feedback and contribution, Mark.