When assessing a nursing home’s risk for errors on surveys, the Centers for Medicare and Medicaid Services (CMS) and state survey agencies are increasingly focused on patterns, system reliability and whether failures could reasonably recur at a facility.
This is according to former multi-state surveyor Linzie Bugg and registered nurse Amanda Odom, who said during a webinar hosted by the American College of Health Care Administrators (ACHCA) that most high-level deficiencies and immediate jeopardy (IJ) situations do not arise from a single failure but instead develop through missed opportunities and breakdowns in communication, handoffs, escalation and follow-through.
During surveys, reviewers reconstruct timelines to identify where intervention should have occurred but did not, with particular attention to how information is transferred and acted upon across disciplines, they said. And lack of alignment between documentation and actual practice, or inconsistent staff responses to basic process questions, is viewed as evidence of system failure.
Facility leaders should “pressure test” systems through rounding, observation, and asking staff to explain processes in real time to ensure consistency, Odom advised.
“Leaders should routinely pressure test communication pathways by asking staff to walk through real scenarios and real time. This is extremely important,” she said.
This also means moving beyond reactive correction and instead maintaining continuous awareness of operational risk using real data sources such as Certification and Survey Provider Enhanced (CASPER) reports.
“We’ve got to rely on our actual factual evidence like your CASPER data. You can use your CASPER data at the resident level and also at facility level [to ask], what is the acuity of your population, and most importantly, your operational pressures,” Odom said. “So strong organizations build a daily leadership alongside operational processes. Task completion alone is not enough.”
Moreover, a hallmark of a strong program that can withstand surveyor scrutiny is regularly pausing to assess whether safeguards are not too thin and whether there is not an over-reliance on staff memory but instead on dependable systems.
“If you are relying on individual staff memory, then your system is already failing before you have even identified it,” Odom said.
Staffing-to-census ratios, resident acuity and operational pressures should be central to these discussions to satisfy surveyors, who focus on these same vulnerabilities during reviews.
Red flag: Lack of follow-up on documentation
Misalignment between documentation and actual practice is a major red flag. When staff cannot consistently explain a process or when answers vary across shifts or disciplines, surveyors interpret this as evidence that systems are not standardized, Bugg and Odom said.
A useful approach is whether three different staff members would provide the same answer when asked about the same process, they said.
In sharing a real-life clinical example involving a resident with congestive heart failure (CHF) returning to the SNF following a hospital stay, Odom and Bugg illustrated how system failures develop. The resident returned from the hospital with orders to monitor his daily weight and respiratory status. When certified nursing assistant (CNA) staff observed shortness of breath and a three-pound weight gain within a few days, it was documented but no follow-ups were carried out through further assessment or physician intervention.
“This is where we begin building the timeline,” Bugg said. “We’re going to ask, ‘what did the staff know and what did they do with that information’? You have two clear clinical indicators here. So shortness of breath and rapid weight gain, both are red flags for fluid overload in the CHF patient. So the expectation is immediate assessment, escalation and physician notification.”
And since no follow-up occurred, the resident deteriorated and required rehospitalization.
“When surveyors review this, we’re not just going to look at the outcome, but we’re going to look at those missed opportunities and protocol for changing conditions,” Bugg said. “Did the nurse recognize the significance of the findings? Was there a process for escalation? How is leadership monitoring these situations? When those answers are unclear, it becomes a system failure.”
Given this, surveyors would view this not as a single missed step but as a breakdown in assessment, escalation, communication and care planning since the risk was foreseeable and not addressed, and the situation could rise to IJ depending on scope and severity, Bugg said.
“This can trigger multiple areas: failure to assess, to notify the physician, implement those interventions and potential failure in care planning,” she said.
System failure on medication management
A second real-life example Odom and Bugg shared involved the management of high-risk medications such as an anticoagulant.
In the scenario, the medication was documented as unavailable during an evening medication pass, but the nurse failed to escalate the situation. The nurse did not contact the pharmacy or provider, create a substitute plan or communicate the issue to the next shift. As a result, the resident missed multiple doses, creating a systemwide failure rather than an isolated omission.
It’s this kind of pattern of systemwide failure that surveyors are on the lookout for in episodes of missed medications, checking to see whether staff followed escalation practices and whether high-risk drugs were appropriately prioritized. Repeated failures across shifts suggest systemic breakdown and can lead to multiple citations, including those related to quality of care and medication administration, and may escalate to higher severity findings, Odom and Bugg noted.
Steps for better survey performance
A strong program should have certain features, especially when there is a change in a resident’s condition. In these cases, staff must understand exactly what steps to take, including assessment, notification and intervention. And, any delays or deviations from standard practice signal system weakness.
Interdisciplinary team (IDT) meetings should be treated as critical to risk management structures rather than routine reporting sessions, which they sometimes are at facilities.
Effective IDTs prioritize high-risk residents, reconcile differing clinical perspectives in real time, and assign clear ownership for follow-up actions, Odom said. Each identified risk should have a responsible person, a defined action and a timeline for completion. Without these elements, accountability breaks down and communication becomes fragmented, increasing regulatory risk, she said.
After all, surveyors assess reliability by looking across multiple residents, shifts and staff members to determine whether care delivery is consistent. If outcomes vary depending on who is working or when care is delivered, the system is considered unreliable. This variability is a key driver of citations and IJs because it demonstrates that safe care is not consistently provided.
If things go wrong, Odom and Bugg said to follow certain tried-and-true protocols.
“We call this our Rapid Response Framework when things go wrong, and we all know things go wrong,” Odom said. “At their core, reliable systems do five things consistently: [Staff] identify risk early, escalate, decisively, intervene appropriately, monitor deliberately and document actions and continue to document actions, not just observe. When a single one of these steps breaks down, your risk is automatically going to increase.”
Failure at any step increases risk for serious deficiencies, and surveyors are trained to evaluate exactly where this sequence breaks down, Odom noted.
