Accidents / Quality of Care — Accident Prevention Program
A complete F-689 §483.25(d)(1)–(2) accident prevention and quality-of-care program policy plus survey-ready documentation tools for skilled nursing facilities. This template is built to be inserted verbatim into the facility's nursing P&P binder or adapted to site-specific language. It covers the hazard identification framework, individualized resident risk assessment, intervention selection, supervision protocols, incident reporting, post-incident review, and the surveyor-encounter workflow CMS uses during F-689 investigations.
F-689 is one of the highest-volume citations in the CMS scope-and-severity grid because it sits at the intersection of clinical risk, environmental safety, supervision, and quality-of-care delivery. The regulation at §483.25(d)(1) requires that the facility ensure that the resident environment remains as free of accident hazards as is possible, and §483.25(d)(2) requires that each resident receive adequate supervision and assistive devices to prevent accidents. The two halves of the regulation are independent citation triggers and surveyors citation both halves in the same 2567 when both paper trails break down. The most common patterns surveyors document are: an unwitnessed fall with no individualized fall-care-plan revision, a recurring faller with no supervision-protocol escalation, an elopement with wandering-risk screening not current, a burns/scalds incident tied to lack of individualized safety interventions, and an inadequate post-incident root cause analysis that doesn't identify a system gap. This template gives the DON, the unit nurse manager, the Staff Development Coordinator, and the interdisciplinary team a single shared workflow so that hazard surveillance, individualized assessment, intervention selection, and post-incident review all generate a defensible paper trail.
CMS guidance (State Operations Manual Appendix PP, F-689) treats a single fall with injury as a presumptive failure of the supervision requirement unless the care plan demonstrates individualized intervention selection matched to the resident's identified risks. Elopement of a resident with documented cognitive impairment and no individualized wandering-care-plan revision is treated as both a supervision failure and a quality-of-care failure. Burn, scald, choking, and ingestion-of-foreign-object incidents all fall under the same F-umbrella with similar expectations. The surveyor will trace each incident from the initial risk identification through individualized assessment through intervention selection through monitoring through post-incident review, and any gap in that chain is a citation trigger. This template closes that chain at each step.
This template is intended for use by the Director of Nursing (DON), the unit nurse manager, the Staff Development Coordinator, the attending physician for orders tied to supervision and assistive devices, the maintenance/environmental services lead for environmental hazard surveillance, and the interdisciplinary team for incident review. Facility leadership should review the program at least quarterly, with a documented review of all incidents, all intervention changes, and all care-plan revisions that result from incident review. The included surveyor-encounter sheet should be walked at minimum 30 days before any anticipated survey window.
Purpose
The purpose of this policy is to establish a single, defensible, surveyor-reviewable accident prevention and quality-of-care program under F-689 §483.25(d)(1)–(2). It defines hazard surveillance, individualized resident risk assessment, intervention selection, supervision protocols, incident reporting, post-incident review, and the documentation chain required to demonstrate that the facility both reduced accident hazards to the extent possible and provided adequate supervision and assistive devices to prevent accidents. The intent is to convert what is often a fragmented, incident-by-incident response into a coordinated program that survives the surveyor's full chart review from Day 1 through Day 3, and that continues to be defensible against any individual incident the surveyor pulls.
Policy
The facility shall maintain an accident prevention and quality-of-care program that meets the requirements of 42 CFR §483.25(d)(1)–(2). The resident environment shall be maintained as free of accident hazards as is possible through a documented environmental hazard surveillance program. Each resident shall receive adequate supervision and assistive devices to prevent accidents, matched to the resident's individualized risk profile. All incidents (falls, elopements, burns, scalds, choking, foreign-object ingestion, equipment-related injuries) shall be documented, reviewed by the DON and the interdisciplinary team, and addressed through care-plan revision where indicated. Documentation generated by this program shall be retained in the resident's medical record and shall be retrievable within surveyor timeframes.
Scope
This policy applies to all residents admitted to the facility for skilled nursing or long-term care, regardless of payer source. It applies to all clinical, environmental, and ancillary staff involved in hazard surveillance, risk assessment, supervision delivery, intervention selection, and incident response, including but not limited to: registered nurses, licensed practical nurses, certified nursing assistants, the attending physician, the DON, the Staff Development Coordinator, the unit nurse manager, the maintenance lead, the housekeeping lead, the activities staff, and any contracted therapy staff. The policy applies during routine operations, during transitions of care, during episodes of acute illness or acute change in condition, and during any period in which an incident has occurred or is reasonably foreseeable. It does not replace individualized clinical judgment by the attending physician or the DON.
Procedure
Environmental hazard surveillance
The maintenance lead shall conduct a documented environmental hazard surveillance walk of the entire facility at minimum monthly. Surveillance shall include: flooring condition, lighting, handrails, grab bars, bedside equipment placement, wheelchair and bed brake integrity, call-light reach and function, bathroom and shower safety equipment, common-area furniture stability, signage, evacuation-route obstructions, and any facility-identified hazards from prior incident review. Hazards identified shall be logged with the date, the location, the hazard description, the corrective action plan, the responsible party, and the target completion date. Open hazards shall be escalated to the DON and the administrator. The surveillance log and corrective action documentation shall be retained in the survey binder for the trailing 12 months.
Individualized risk assessment
Every resident shall receive a baseline accident-risk screening upon admission, completed by an RN within 24 hours of admission. Risk domains shall include: fall risk (using the facility's standardized fall-risk tool), elopement/wandering risk (for residents with cognitive impairment), skin breakdown risk (implicating equipment-related injuries), aspiration/choking risk (forward-referenced to F-693 and F-692), behavioral risk (implicating supervision needs), and equipment-specific risk (for residents with specialty beds, specialty chairs, or specialty restraints where clinically indicated). Each risk domain shall be reassessed at minimum quarterly, following any incident, following any significant change in condition, and following any care-plan revision that affects risk.
Intervention selection
Interventions to prevent accidents shall be selected, documented, and individualized to each resident's risk profile. Standard intervention categories include: environmental modifications (low bed, floor mats, bedside commode, removal of tripping hazards), supervision modifications (rounding frequency, observation level, toileting schedule, sitter when clinically indicated), assistive devices (gait belt, walker, wheelchair, specialty seating, hip protectors, geriatric chair with physician order when clinically indicated), and behavioral/cognitive interventions (wandering programs, redirection training, scheduled activities to reduce restlessness). Interventions shall be carried forward into the care plan with measurable targets, responsible parties, and review intervals. Fall-risk interventions shall be reviewed at minimum monthly by the unit nurse manager and the DON.
Supervision protocols
Adequate supervision shall be determined by an individualized assessment of the resident's risk profile, the resident's recent incident history, and the resident's current clinical condition. Supervision modifications shall be implemented when a change in any of these factors increases the resident's risk. Supervision levels shall be documented in the care plan and shall be communicated at every shift handoff. Sitter use, when clinically indicated, shall be ordered by the physician with documented clinical justification and shall be reviewed at minimum every shift. The DON shall review adequacy of supervision for residents with recurrent incidents at least monthly.
Incident reporting
All incidents (falls, elopements, burns, scalds, choking, foreign-object ingestion, equipment-related injuries, skin breakdown attributable to equipment) shall be documented in an incident report regardless of severity. The incident report shall include: date and time, location, witness(es), resident condition before and after, immediate intervention, physician notification, family notification (per facility protocol), supervisor notification, and the initial impression of contributing factors. The incident report shall be entered into the incident log and shall be linked to the resident's medical record entry. Incident report entries shall be factual and shall not contain speculative or blame-attributing language.
Post-incident review
The DON and the interdisciplinary team shall review every incident for root cause and appropriate care-plan revision. Post-incident review shall be documented within 72 hours for falls with injury and elopements, and within 7 calendar days for all other incidents. The review shall identify contributing factors (resident-related, environmental, supervision-related, equipment-related, communication-related), shall determine whether care-plan revision is indicated, and shall document the resulting intervention. Recurrent incident patterns (more than one fall with injury in a 30-day window, more than one elopement attempt in a 60-day window) shall trigger a documented interdisciplinary case conference with care-plan revision and a system-level review.
Documentation
Documentation generated by this program shall include: environmental hazard surveillance logs, individualized risk assessments on admission and at reassessment intervals, intervention documentation in the care plan, supervision-level documentation at every shift handoff, incident reports for every incident, post-incident review notes within facility-defined timelines, physician and family notification records, the care-plan revisions that result from incident review, and any system-level review documentation for recurrent incidents. Documentation shall identify the staff member completing the entry and the date and time of completion. Free-text clinical judgment is acceptable; however, the documentation shall clearly link risk identification to assessment to intervention to outcome so that the chain is reproducible from the chart alone.
Staff checklist
Charge nurse (RN/LPN) daily: verify that each resident's current supervision level is documented in the care plan; verify that all assistive devices are in place and in working condition; verify that environmental hazards identified in the daily inspection are addressed or escalated. CNA each shift: complete scheduled rounding per care-plan frequency; report any environmental hazard (wet floor, equipment blockage, lighting issue) immediately; report any change in resident condition that may affect supervision or intervention. Unit nurse manager weekly: review incident log for unit, review fall-risk interventions for residents with recurrent incidents, ensure incident reports and post-incident reviews are current and complete. DON monthly: review facility-wide incident patterns, review supervision adequacy for recurrent-incident residents, ensure environmental hazard surveillance log is current and actionable items are completed. Maintenance lead: complete monthly hazard surveillance walk with documented corrective action.
Surveyor-encounter sheet
When the surveyor requests F-689 documentation, the facility shall produce, in order: (1) the facility's accident prevention and quality-of-care program policy; (2) the environmental hazard surveillance log and corrective action documentation for the trailing 12 months; (3) the individualized risk assessments for each resident whose incident is being reviewed; (4) the care-plan revision history for that resident for the trailing 60 days; (5) the incident report and post-incident review for the specific incident under review, with documented contributing-factor analysis; (6) supervision-level documentation at every relevant shift handoff; (7) physician, family, and responsible-party notification records; (8) any system-level review documentation for recurrent incident patterns. The facility shall be ready to produce this documentation set within surveyor timeframes on Day 1 of survey, and shall maintain redundant retrievability through Day 3 and beyond.
Survey prep checklist
The DON and the unit nurse manager shall complete a 30-day pre-survey F-689 audit covering: environmental hazard surveillance log currency for the trailing 30 days (≥ 90% of monthly walks completed), individualized risk-assessment currency for each resident (≥ 95% current per protocol), care-plan revision currency for residents with incidents in the trailing 60 days, supervision-level documentation completeness for shift handoffs, incident-report completeness and post-incident review currency (≥ 90% within facility-defined timelines), and recurrent-incident case-conference documentation when triggered. Identified gaps shall be documented with corrective action and a target completion date, and corrective action documentation shall be retained in the survey binder.
References
Primary regulatory authority: 42 CFR §483.25(d)(1)–(2) — Quality of Care: Accidents and Supervision. CMS State Operations Manual, Appendix PP — Guidance to Surveyors for Long Term Care Facilities, F-689. The CMS Critical Element Pathway for Accidents (CEPI-Accidents) and for Elopement (CEPI-Elopement) are the surveyor protocols — review both pathways before survey week. AMDA and ASCP clinical practice guidelines on falls and fall-risk reduction in long-term care. Facility environmental safety and equipment-management policies. State-specific regulations governing supervision and incident reporting.