Task 5: Information Gathering

5300.3 - Task 5: Information Gathering (Rev. 18, Issued: 03-17-06; Effective/Implementation Dates: 03-17-06) The order and manner in which information is gathered depends on the type of complaint that is being investigated. Conduct comprehensive, focused, and/or closed record reviews as appropriate for the type of complaint. Generally, it is not necessary to review records and information from more than one year ago. However, the SA is not precluded from doing so if concerns identified during the investigation indicate it is necessary in order to determine current compliance. It is very important to remember that the determination of whether the complaint happened is not enough. The surveyor needs to determine noncompliant facility practices related to the complaint situation and which, if any, requirements are not met by the facility. Perform information gathering in order of priorities, i.e., obtain the most critical information first. Based on this critical information about the incident, determine what other information to obtain in the investigation. Observations, record review and interviews can be done in any order necessary. As information is obtained, use what has been learned to determine what needs to be clarified or verified as the investigation continues. Observe the physical environment, situations, procedures, patterns of care, delivery of services to residents, and interactions related to the complaint. Also, if necessary, observe other residents with the same care need. After determining what occurred, i.e., what happened to the resident and the outcome, investigate what facility practice(s) or procedures affected the occurrence of the incident. EXAMPLE It was verified through the investigation that a resident developed a pressure sore/ulcer which progressed to a Stage IV, became infected and resulted in the resident requiring hospitalization for aggressive antibiotic therapy. Observe as appropriate: dressing changes, especially to any other residents with Stage III or IV pressure sores; infection control techniques such as hand washing, linen handling, and care of residents with infections; care given to prevent development of pressure sores (e.g., turning and repositioning, use of specialized bedding when appropriate, treatments done when ordered, keeping residents dry, and provision of adequate nutritional support for wound healing). Record Review: If a specific resident is involved, focus on the condition of the resident before and after the incident. If there are care issues, determine whether the appropriate assessments, care planning, implementation of care, and evaluations of the outcome of care have been done as specified by the regulatory requirements. EXAMPLE For a complaint of verbal and physical abuse, review the record to determine the resident’s mood and demeanor before and after the alleged abuse. Determine if there are any other reasons for the change in the resident’s demeanor and behavior. Determine whether an assessment has been done to determine the reason for the change in mood and behavior. Does the record document any unexplained bruises and/or complaints of pain, and whether they occurred in relation to the alleged incident? Interviews: Interview the person who made the complaint. If the complainant is not at the facility at the time of the survey, he/she should be interviewed by telephone, if possible. Also, interview the person the complaint is about. Then, interview any other witnesses or staff involved. In order to maintain the confidentiality of witnesses, change the order of interviews if necessary. It may not always be desirable to interview the person who made the complaint first, as that may identify the person as the complainant to the facility. Interview residents with similar care needs at their convenience. As interviews proceed, prepare outlines needed for other identified witnesses and revise outlines as new information is obtained. During information gathering to investigate a complaint about the care and services provided to residents in a nursing home, findings of past noncompliance may be identified. Before considering a citation of past noncompliance with a specific regulatory tag, surveyors must determine if current compliance with the specific regulatory tag exists. Similar to verifying correction of current noncompliance on a revisit, surveyors should use a variety of methods to determine whether correction of the past noncompliance occurred and continues. This may include, but is not limited to, the following: • Interviews with facility staff, such as the administrator, nursing staff, social services staff, medical director, quality assessment and assurance committee members, and/or other facility staff, as indicated, to determine what procedures, systems, structures, and processes have been changed. • Reviewing through observation, interview and record review, how the facility identified and implemented interventions to address the noncompliance. Examples of interventions may include, but are not limited to: o The facility’s review, revision, or development of policies and/or procedures to address the areas of concerns; o The provision and use of new equipment, as necessary; o The provision of staff training required to assure ongoing compliance for the implementation and use of new and/or revised policies, procedures, and/or equipment, especially with new and/or temporary staff; o The provision of additional staffing, changes in assignments or deployment of staff, as needed; and o The provision of a monitoring mechanism to assure that the changes made are being supervised, evaluated, and reinforced by responsible facility staff. • Evaluating whether the facility has a functioning quality assessment and assurance committee whose responsibilities include the identification of quality issues; providing timely response to ascertain the cause; implementing corrective action; implementing monitoring mechanisms in place to assure continued correction and revision of approaches, as necessary, to eliminate the potential risk of occurrence to other residents and to assure continued compliance. A citation of past noncompliance must meet all of the criteria described in Task 6 below.