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Regulations Update

Federal Regulation – F323 Accidents and Supervision

This regulation ranks #2 in the top ten of 42 deficiencies cited in South Dakota long-term care facilities in 2009.

Marci Pederson, RN, BSN, Nurse Educator/Consultant

F323 states, “The facility must ensure that – The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.”

“Intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes:

  • Identifying hazard(s) and risk(s)
  • Evaluating and analyzing hazard(s) and risk(s)
  • Implementing interventions to reduce hazard(s) and risk(s)
  • Monitoring for effectiveness and modifying interventions when necessary.”

The Guidance to Surveyors includes definitions for following terms:

  • Accident
  • Avoidable Accident
  • Unavoidable Accident
  • Assistance Device or Assistive Device
  • Environment
  • Fall
  • Hazards
  • Resident Environment
  • Risk
  • Supervision/Adequate Supervision

This regulation presents a big challenge to nursing home facilities because of the vulnerability of the residents. The priority goal should be to prevent avoidable accidents from happening. It is ideal for a team to do a safety check because each one of us sees our environment in our own unique way and therefore together the team will accomplish more.

We all are able to recognize accident hazards when we are fully present in the moment. Sometimes we are so busy focusing on getting our assigned tasks done without observing what is going on around us that we miss recognizing a safety concern. For example, my 92 year old aunt lives in her own home. She is still a busy lady – does her own cleaning, yard work, and laundry. Her Formica countertop in the kitchen had a piece which had been loose for quite some time. She was used to it being there. Everyday she sat at her kitchen table in the same chair which was right next to the loose Formica. Nothing happened until one day she got up from her chair and caught her elbow on the loose Formica. She had difficulty stopping the bleeding due to the blood thinning pill she takes so she went to the clinic and was the proud recipient of 18 stitches. She was so accustomed to the loose Formica she did not think of it as a hazard until her accident.

Where do we find accident hazards in nursing homes?

  • Bathrooms
  • Handrails
  • Biohazard materials
  • Cleaning chemicals – need to be stored so they are not accessible to the residents.
  • Equipment such as wheelchairs, mechanical lifts, and walkers
  • Floors – broken linoleum and wet floors
  • Water temperatures – over 125°F

In a perfect world we can prevent all accidents, both avoidable and unavoidable. We do not, however, live in a perfect world. So what do we do when a fall occurs with an injury? There are suggestions in the Guidance for Surveyors regarding what types of assessments to do. Many of you have a system in place so your staff knows what to do in the event of a fall. The RAI system is an excellent system but it is also not perfect. That is why I encourage facilities to do a review of the Quality Indicators on a regular basis to determine which indicators are real problems and which ones are not. Recently I was reviewing a resident’s medical record based on the facility’s Quality Indicators. She was one of a number of residents who triggered for hypnotic use. She had not triggered for falls when the data was put into the system, but her medical record showed she had fallen two times in February. In reviewing what had been done after she had fallen, I found a medication review had not been done to determine if her hypnotic usage played a part in causing her to fall. Her drug regimen review revealed the pharmacist reported there were no drug irregularities to address for this resident. This led me to ask if the pharmacist had access to all medical record information available to determine there were no drug irregularities for this resident. Further investigation revealed there was a gap between when nurses’ notes were documented regarding the falls and when they were placed in the medical record. This may have been a factor in the pharmacist’s determination. The other piece to this picture was the drug manufacturer’s recommendation -- this hypnotic should be administered for short time periods of ten nights or less.

In conclusion, the two messages I would like you to take from this update are:

  • Prevention can be achieved through an active Safety Team.
  • Always remember to do a Medication Review after a resident’s fall.

Contact me at  for all of your Regulatory Compliance and Survey Preparation needs.

Do the math! The facility bottom line improves when resident care continually improves.

As a former health facilities senior surveyor, Marci worked at the Department of Health Office of Licensure and Certification for eight years. Marci provides Survey Preparedness Consulting designed to create a culture of constant survey preparedness by helping staff understand regulatory requirements, not just comply with them.

Read more Regulations Updates.  The Avera Solutions’ Blog contains writings from Marci and other Avera Education & Staffing Solutions staff and consultants.


Marci Pederson, RN, BSN

Marci Pederson, RN, BSN

As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.

Have a question for Marci? A topic idea for her next column? Need more information on having a mock survey at your facility? Send her an email at