State Calculations

CapeCodMermaid, RN · May 6, 2011

They use new math.

When they do a med pass to calculate error rate, it wouldn't be feasible for them to watch every nurse give every medication so they use chances for mistakes divided by actual mistakes. It's not fair, but it is what it is.

marthyellen · May 6, 2011

It may depend under which tag the error was written. If it is f332, then it would be medication error rate calculation and the surveyor can choose whatever sample size he chooses, unfortunately. If it is written under f 333 it can be one mistake can be a deficiency.

I am not sure how he can put flowsheets as medication errors. Did he watch med pass?

According to CMS:

http://www.cms.gov/CFCsAndCoPs/Downloads/som107ap_pp_guidelines_ltcf.pdf

Do not rely solely on a paper review to determine medication errors. Detection of blank

spaces on a medication administration record does not constitute the detection of actual

medication errors. Paper review only identifies possible errors in most cases. In some

cases paper review can help identify actual errors but research has shown that the

procedure is time consuming for the number of actual errors detected.

txdon · May 7, 2011

It was tag F306. The surveyor didn't "watch" med pass. He requested particular residents diabetic flowsheets and discovered errors on 3 out of the six flowsheets. I'm confused because he rated the error rate at 50% but didn't count every opportunity on the sheet for medication error. Each flowsheet has roughly 90 medication opportunities. He didn't count the total number of insulins administered. If he would have counted all the medications administered on the sheet the total error rate would have been less that 1%.

debRN0417 · May 7, 2011

There's two kinds of medication errors- observed and unobserved. The calculation for medication errors is :

Significant error + non-significant error/doses given+ doses ordered but not given X 100 .

Anything equaling 5% or greater is a medication error deficiency.

Unobserved medication errors are different. The above formula is for an observed medication pass. I will have to do a little more research on this because I have not seen this before. There is no F306--did you mean F309?

txdon · May 7, 2011

Yes, it is F309. The original tag was based on documentation only. This was the revisit to clear and he did the same thing again, but this time took a smaller sample of flowsheets to look at. Thanks in advance for your help.

txdon · May 7, 2011

Where can I go to find the specific tag references? I looked on the CMS website and couldn't find them. Also, if we got a tag for 441 - infection control (uncovered linen cart) does this open my facility up to all infection control issues. If so, I need direction on what state surveyors might be looking at. I know handwashing, glove use, soiled linen disposal practices,etc. Is there anything else I need to be aware of. The infection policy book is very vague and does not specify what surveyors monitor regarding infection control.

marthyellen · May 7, 2011

F 309 is not a medication error, it is quality of care. There is no percentage rate. The surveyor only has to see a pattern to write it. He saying at least half the documentation he looked had errors so there is a pattern.

https://www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf

This link gives you an overview of the tags.

As for F441 -- it can be written for a variety of reasons, which is why it is one of the most common tags written. I have heard it being written for a nurse who ate her lunch at the station and did not wash her hands afterward. Also a nurse who licked her fingers while turning the pages of the med book while passing meds. (same building different surveys). Good luck on infection control. It really depends on the surveyors in you area.

txdon · May 8, 2011

Thanks for clarifying that. So in otherwards, the quality of care tag just has to show an error since it's not under the medication tag regulation? I was hoping by showing the complete picture of flowsheets they would clear this tag. What do you think?

debRN0417 · May 9, 2011

Thanks for clarifying that. So in otherwards, the quality of care tag just has to show an error since it's not under the medication tag regulation? I was hoping by showing the complete picture of flowsheets they would clear this tag. What do you think?[/QUO
Being under 309 makes it difficult. That means they cited you for most likely not following the physicians orders. If it was a tag for a revisit and you were recited on the 309, then on your second revisit the 309 will be an issue again....however, if the team finds anything else that would be a 309 Quality of Care, even if it is not the same thing, it causes you to be recited again. It does not have to be the same issue to get you in trouble, just the same area. That goes for any citation.
Infection control is also a tough one for any facility to get and have to be looked at again on a revisit. It could be anything that could fall nunder that area...handwashing, linens, passing meal trays, residents on isolation, anything that could be an infection control issue.
Whatever you have documented as your plan of correction must be adhered to. You must have the credible evidence that you have done what you said you are going to do as far as fixing it. If you know they are loooking at those diabetic sheets, my advice to you would be daily monitoring until you can clear. You might get lucky, though and if it is found again, the team could cite it under 281 for Professional Standards of Practice and free you from the 309. Although it would be a deficiency, it would not be a repeat deficiency.
Did your facility receive a "G" deficiency what caused the revisit? If not, then I"m wondering why you would have one. I mean, the surveyors can come at any time, but usually do not do a revisit unless there is a "G" level deficiency, or the facility gets a complaint before the AOC date (the date you say you are going to be in compliance). It is always wise for facilities to set their AOC date as soon as possible and not wait the 45 days, if they possibly can to prevent such an issue.
So just to get my head clear on this, you had a standard survey, and got a revisit due to a "G" or why? Then you had a revisit which picked up this flowsheet issue. This was your first revisit, and you are awaiting a second?

txdon · May 9, 2011

Thanks for trying to help me understand this. This tag was generated by a complaint, it was not due to a regular survey. The complaint visit revealed holes in MARS and TARS which was tagged differently. The surveyor also found multiple discrepancies with the diabetic flowsheets. MD's were not called, wrong dosages were given, etc. It was a G tag. When he came back for the revisit he took 6 flowsheets and found 3 with problems, so we were recited. Our window has closed but they can't do the survey until we are cleared. We have submitted ALL of our diabetic flowsheets to show compliance on all but 2 others, but I am thinking that since we weren't cited on medication error tag it won't matter. The quality of care tag just has to show an error not that the error is less than 5%. Also, if a facility is recited what happens to medicare reimbursement? Thanks again for helping me understand this.

CapeCodMermaid, RN · May 9, 2011

Not to muddy the water, but...did the surveyor show there was actual harm done to a resident? I had a complaint survey last year...long story short, a resident had a low blood sugar on an out trip but suffered no harm. Surveyor said she'd give me a G tag unless the doc. could say that despite all of our efforts, the woman's blood sugars were brittle. I was all set to argue no harm but she backed off once the doc told her all the ins and outs. How can you get a G tag if there is no harm?