CORRECTIVE AND PREVENTIVE ACTION

PLAN
Lisa-Ann Datu
Arizona State University
HCR 461: Corrective & Preventive Action Plans
Professor Paris LaBruzzo, MHA
April 30, 2023
 Topics
 Summary Statement

 Cost of Falls

 Non-Conformity Overview

 Corrective and Preventive Actions

Figure 1: (Compassus, 2023)

 Assessment
 Summary Statement
A complaint was received by our Quality Manager from family members of
one of our patients. A high-risk patient had fallen in their room while trying
to go to the bathroom. An investigation was carried out to find out what
happened. The patient and staff members were interviewed, and a Root
Cause Analysis was conducted to determine the root cause of the fall. This
CAPA has been created in response to this adverse event to ensure that we
have taken appropriate action to correct the non-conformities identified in
our investigation and to prevent future occurrences of any of our patients
experiencing a fall in our facilities. This CAPA also includes evaluation
methods to ensure that the CAPA is working as intended.
 Costs of Falls
Impact on Patients Impact on Facilities
 Physical Impacts: Further injuries  Increased costs
(CDC, 2020, The Joint Commission,  Possible Malpractice/Lawsuits
2015)
(Baker & Avarnitis, 2017)
 Death (CDC, 2020)
 Non-compliance with regulations
 Psychological Impacts: Fear of
falling/fear of being active (CDC
 Reputation
2020; Parasol Medical LLC, 2023) Figure 3: (CDC, 2020, Slide 10 of 80)

Figure 2: (CDC, 2020, Slide 6 of 80)

 Non-Conformity Overview
What is the Non-Conformity
Inadequate assessment of patient
contributed to fall risk.
Communication failures leading
to the fall risk.
What is the Requirement?
Care planning created for the patient
should have included protocol to
include assistance for the patient when
being transported around to prevent
falls. Assessment of the patient should
continue to account for any changes in
care like a change in medication or
functional status (Joint Commission,
2015).
White boards in patient rooms should
be adequately updated to communicate
information about the patient like
current staff on duty, alerts, tasks,
records, fall concerns, etc. (Joint
Commission, 2015).
Based on what evidence?
Known intrinsic risk factors of the patient:
History of falls, lower extremity weakness,
and medication (Pearson & Coburn, 2011).
Internal interviews conducted revealed that
known intrinsic risk factors were not noted
in the care planning report when the
patient was admitted to the facility. No
updates have been made as there are
changes to the patient’s health
functionality.
Internal interviews conducted revealed that
Staff did not update the board when there
were staffing changes so patient was not
able to contact the correct staff members
for help when they needed help to the
bathroom.
 Non-Conformity Overview (continued)
What is the Non-Conformity
Lack of adherence to protocols and
safety practices contributed to fall
risk.
Inadequate training of staff on
protocol and safety practices
contributed to the fall risk.
Staffing issues contribute to fall risk.
What is the Requirement?
Patient should have received assistance
from at least two staff members when
being transported to the bathroom.
Flooring surfaces should be in good
condition and clear of any trip hazards.
Staff is required to take mandatory safety
training to prevent adverse actions.
The facility is required to meet staffing
levels so that patients receive proper care
and are kept safe.
Based on what evidence?
Internal interviews conducted showed that the
patient experienced extrinsic risk factors at the
time of adverse event including poor lighting,
poor condition of flooring surfaces with trip
hazards (equipment cords not wrapped up),
and did not receive assistance from staff.
Although there are protocols that address plan
of care, communication and safety practices,
staff members are not properly trained to
know the importance of preventing falls. Low
staffing levels contribute to staff not being able
to receive proper training on safety.
Although the facility does try to make an effort
to fully schedule their staff, there can be
unexpected call-outs that can leave them short-
staff and not able to provide a high level of safe
care.
 Corrective and Preventive Action Plan
Improve adherence to protocols and safety practices contributed to fall risk.
• Do a peripheral sweep of the room before leaving to make sure that the ground has a clear pathway with no tripping hazards (i.e.
equipment cords).
• Spills should be adequately marked with proper signage until the spill has been cleaned up.
• Grab bars should be strategically placed around the room and in the bathroom.
• Light switches should be close to the patient so that they can easily turn on the light to see inside their room and not navigate in the
dark.
• Any patients marked as high-risk for falls should be assisted by staff when they are trying to move or walk.
• Uneven surfaces should be reported immediately to management.

Improve Communication to prevent fall risk.

• Patient whiteboards in their room must contain up-to-date information like current staff on duty, any alerts—like if the patient is high-
risk for falls, tasks like upcoming appointments for the patient, patient goals, emergency contacts, etc.
• Staff must also communicate with their patients on their own care, letting them know what they are able to do on their own and what
they need assistance with so that they are kept safe.

Perform appropriate assessment of patient’s Plan of Care to prevent fall risk.

• Staff must make sure that the patient’s Plan of Care is appropriately assessed when they are admitted to the facility.
• Staff must regularly access the patient so that if there are any changes with the patient’s health, the Plan of Care is properly updated to
address those changes. Examples of changes can be a change in medication or functional status (Joint Commission, 2015).
• Staff must ensure all documents in the patient’s file are adequately documented with proper notes and data, dated, and signed off on
by the treating provider.
Corrective and Preventive Action Plan (continued)

Hire more staff to improve staffing issues and prevent fall risk.

• The organization will increase staff by hiring per-diem (or on-call) employees who are able to come in to fill in for staff that are out
for illness, family matters, and miscellaneous time off:
• Maintaining adequate staffing levels will help the organization ensure that staff are able to communicate effectively because they
are not stretched thin caring for patients.
• Improved staffing allow better responses to our patients when they need help in a timely manner.
• Improved staffing will also allow our staff to regularly attend compliance training so they are current on any CAPA, safety
requirements, and federal and state laws

Training of staff on protocol and safety practices contributed to the fall risk.

• All staff are required to complete mandatory annual compliance training on fall prevention and patient safety.
• The organization is required to communicate and keep their staff up-to-date on any changes to policy regarding fall prevention and
patient safety.
• Compliance Hotline is once again shared to report any potential wrongdoing.
 Assessment of Effectiveness
 Communication of Corrective and Preventive
Action Plan
 Mandatory Training for Fall Prevention and
Patient Safety for all staff of Sun Devil HealthCare
Facility
 Annual Web-Based training class
 Monthly knowledge checks
 Monitoring and auditing

Figure 4: (Sara Marberry LLC, 2013)

 References
AHRQ. (2013). Preventing falls in hospitals. Agency for Healthcare Research and Quality. Retrieved April 16, 2023, from
https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/practices.html#3-6.

Arizona Falls Prevention Coalition on Facebook. (n.d.). Retrieved April 29, 2023, from
https://www.facebook.com/arizonafallspreventioncoalition/photos/a.1893684810945657/2782052582108871/?type=3

Baker, D., & Arvanitis, C. (2017, March 5). The Best approach to design effective corrective action plans. HCCA Compliance Institute.
https://assets.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/2017/105print2.pdf

CDC. (2020, September 16). STEADI: Empowering healthcare providers to reduce fall risk. https://www.cdc.gov/steadi/provider-training/index.html

Compassus. (2023). Reducing the risk of falls in older adults. Retrieved April 29, 2023, from
https://www.compassus.com/news_items/858-preventing-falls-in-older-adults/

The Joint Commission. (2015). Sentinel Event Alert 55 Preventing Falls and fall related injuries in health care facilities. Retrieved April 15, 2023, from
https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-eventalert-newsletters/sentinel-event-alert-55-preventing-falls-and-fall-relat
ed-injuries-in-health-carefacilities/
.

Pearson, K. & Coburn, A. (2011). Evidence based falls prevention in Critical Access Hospitals. Retrieved April 15, 2023, from
https://www.flexmonitoring.org/sites/flexmonitoring.umn.edu/files/media/policybrief24_fallsprevention.pdf.

Sara Marberry LLC. (2013, August 20). Falling short on falls prevention in hospitals. https://www.saramarberry.com/falls-prevention-in-hospitals/

Troklus, D. & Vacca, S. (2016). Compliance 101 (4th ed.). Health Care Compliance Association.
 Thank you!

Figure 5: (Arizona Falls Prevention Coalition on Facebook, n.d.)