If you think this sounds like a very general category, you’re right! This tag can be used to cite many different types of deficient practices. One way to focus your attention would be to ask yourself: “What would any prudent nurse or therapist do in this situation?”
The surveyors can use this tag to cite failure to follow policies and procedures, insufficient or lack of drug regimen review, inappropriate delegation of tasks, failure to track/trend complaints, and poor or incomplete physical assessments. These are just a few of the ways in which this tag has been cited for our company in 2013. Each of these can, and often are, cited in other tags as well.
The surveyor will look for evidence of poor infection control, poor wound care procedures, and not following physician orders. If the patient is hospitalized, the surveyor will look at clinical documentation to see if we failed to notice signs of an impending problem. The surveyor will also compare the care observed during home visits and the clinical documentation to state practice acts as well as policies, procedures and physician orders.
Article submitted by: Lori Velko, Director of Compliance