F-Tags

Terri Kolenich's picture
compliant pressure ulcer documentation

by Terri Kolenich, RN, CWCA, AAPWCA

It has been a long week. The CMS state survey team entered your facility Sunday afternoon at 2pm. Thursday is finally here and the state survey exit meeting is only minutes away. Your heart is heavy and your mind is occupied with thoughts of an in-house acquired stage IV pressure ulcer. The surveyor observed your dressing change and reviewed every bit of documentation pertaining to this stage IV pressure ulcer. The burning in your gut has completely convinced your brain that your facility will receive the dreaded F-Tag 314 because of this in-house acquired pressure ulcer.

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Cheryl Carver's picture
medical documentation

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

In my role as a consultant and educator, I thought it would be interesting to acquire a handful of perspectives from wound care providers who work in the long-term care arena, and explore their responses.

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Cheryl Carver's picture
safety net

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

Substandard documentation tops the list of mistakes for long-term care facilities. It involves "all hands in the chart" so to speak. This encompasses all disciplines, from the nursing assistant to the physician. Discrepancies and gaps in documentation put your facility at risk of litigation. Impeccable documentation is essential in defending any case. Your facility must have a "safety net" in place. This "safety net" consists of educating staff about the importance of timely and detailed documentation not only for the facility, but for their license. Often times, clinicians are not aware of the legal repercussions of their actions. Surveyors will also consider other related Federal Tags (F-Tags) during investigations for compliance.

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Cheryl Carver's picture

by Cheryl Carver, LPN, WCC, CWCA, FACCWS, DAPWCA, CLTC

As a traveling wound care educator for physicians, I am observing many changes within the state survey process for long-term care. Wound care physicians working in long-term care are feeling the same anxiety that facility leaders and staff members are, as the time nears the window for an annual state survey.