The greatest value of a mock survey is not the list of potential deficiencies at the end of the visit.
A mock survey can identify a potential deficiency. The greater value comes from understanding why the issue occurred and what will prevent it from happening again.
Too often, corrective action focuses only on the individual observation: replace the missing lid, update the care plan, reeducate the nurse, or complete another audit. Those steps may address the immediate concern, but they do not always correct the process that allowed the concern to develop.
During recent mock surveys, our team identified several examples that required a deeper look. In each case, the most effective recommendation went beyond correcting the finding and focused on the resident, the workflow, the equipment, or the oversight process behind it.
The examples that follow highlight how a thoughtful mock survey can uncover the deeper cause of a finding and lead to practical, sustainable process improvement.
Accident Prevention: Look for the Pattern Behind the Fall
Facilities are not expected to prevent every fall. They are expected to identify foreseeable risks, implement individualized interventions, and revise the plan when those interventions are not effective.
A recent mock survey provided an important reminder that meaningful root cause analysis requires the team to understand the resident, not simply the circumstances immediately surrounding the fall.
From the Field
Our team identified that a resident had experienced multiple falls during the early-morning hours in or near the bathroom. Each incident had been reviewed individually, and additional fall interventions had been added, but the falls continued.
When our consultant looked more closely at the timing of the falls and the resident’s personal history, staff shared that she had been someone who worked on a farm and had routinely started her day around 4:00 a.m. for most of her adult life. She was not simply waking unexpectedly or attempting to toilet without assistance. She was following a lifelong routine and trying to get ready for her day.
We recommended revising the plan of care so night-shift staff could assist the resident with toileting and her early-morning routine before she attempted to get ready for the day independently. Following implementation of the revised approach, the resident’s falls decreased.
The lesson: The most effective intervention may not be another standard fall precaution. Person-centered root cause analysis looks at who the resident is, what the resident is trying to accomplish, and how staff can support that routine more safely.
Infection Prevention: Make the Correct Process Easier to Follow
Infection prevention findings are often identified through direct observation. Policies may be appropriate and staff may understand the requirements, but the workflow does not always make it easy to consistently follow the correct procedure.
One recent observation demonstrated why leaders should look beyond staff education and consider whether supplies, equipment, and workflow support compliance.
From the Field
During an observed wound care procedure, our consultant noted that the nurse was visibly nervous but demonstrated that she understood the requirement to establish a clean surface with a barrier before beginning treatment.
However, while attempting to carry all the necessary supplies into the resident’s room, she placed several items on the resident’s bed rather than on the prepared clean surface. The nurse knew the appropriate procedure but was trying to manage multiple supplies at once while maintaining the clean field.
We recommended using disposable trays for wound care setup. Staff could gather and carry supplies into the room on the tray, which could also provide a clean barrier during the procedure. This would eliminate the need to “juggle” supplies and make it easier to consistently maintain appropriate infection control practices.
The lesson: When staff understand the expectations but struggle with implementation, the facility should evaluate whether the workflow supports the required practice. A simple operational change may be more effective than repeating the same education.
Person-Centered Care Planning: Capture What Staff Know
The care plan should provide staff with the information needed to deliver consistent, individualized care. However, valuable resident-specific knowledge is sometimes shared verbally among experienced staff without being incorporated into the formal plan of care.
This creates risk when a new employee, agency staff member, or team member from another shift does not have access to the same information.
From the Field
During interviews, staff were able to clearly describe to our consultant the individualized strategies they used to prevent or reduce a resident’s behaviors.
They knew the resident’s triggers, which approaches should be avoided, how to redirect the resident, and which interventions were most effective when behaviors occurred. However, the non-pharmacological interventions described by staff were not included in the resident’s care plan.
We recommended updating the care plan to include the resident’s known triggers, preferred approaches, successful redirection techniques, and other individualized interventions. We also recommended reviewing the care-planning process to ensure that effective strategies identified by direct-care staff are communicated to the interdisciplinary team and incorporated into the formal plan of care.
The lesson: Staff knowledge is valuable, but effective interventions should not depend on which employee happens to be working. Successful strategies must be captured in the care plan so they can be implemented consistently.
Kitchen Sanitation: Consider Whether the Equipment Supports Compliance
Some kitchen findings may initially appear to be simple staff-performance issues. A closer review may show that the equipment itself makes consistent compliance difficult.
A recent kitchen observation demonstrated why repeated reminders are unlikely to produce sustained improvement when outdated equipment continues to work against the expected process.
From the Field
During a mock survey, our consultant observed trash receptacles throughout the food preparation and cooking areas without lids or with lids that did not fully cover the containers.
The kitchen was using older 39-gallon trash cans with removable lids. Some lids had been set aside during food preparation, while others were missing altogether.
Although staff could be reminded to replace the lids after each use, loose lids could easily become separated from the cans or remain off during busy meal preparation periods.
We recommended evaluating the size and location of the receptacles and replacing the older cans with appropriately sized commercial receptacles equipped with attached, self-closing, swing-style, or foot-operated lids. This would prevent lids from being misplaced and make it easier for staff to keep the receptacles covered throughout the day.
The lesson: When equipment makes the correct practice difficult to maintain, replacing or redesigning the equipment may provide a more sustainable correction than repeated staff reminders.
Psychotropic Medication Review: Ensure Newly Initiated Medications Receive Timely Follow-Up
Hospital discharge orders should be implemented as prescribed. However, when a resident returns with a newly initiated psychotropic medication, the facility should also ensure that the clinical indication, target symptoms, monitoring expectations, and continued need are clearly understood and incorporated into the resident’s ongoing plan of care.
The concern is not that hospital-ordered medications should routinely be changed or discontinued. The concern arises when a newly initiated medication continues without a clear supporting indication, appropriate monitoring, or timely evaluation of changes in the resident’s condition.
From the Field
Our team identified a resident who had returned from the hospital with a new low-dose antipsychotic medication. The facility record did not contain a supporting diagnosis or clear documentation of the clinical indication or target symptoms.
Four weeks later, the resident remained on the medication. During that period, staff documented decreased participation in activities and therapy, along with reduced meal intake. However, the changes in the resident’s condition had not prompted a review of the newly initiated medication or whether it remained clinically appropriate.
The medication was eventually identified during the consultant pharmacist’s monthly review. The pharmacist recommended that the practitioner evaluate its continued need. Another two weeks passed before the recommendation was addressed and an order was received to discontinue the medication.
We recommended strengthening the medication reconciliation and psychotropic medication review processes. Newly initiated antipsychotics should be flagged for timely interdisciplinary review to verify the diagnosis or clinical indication, target symptoms, monitoring plan, potential adverse consequences, and continued need. We also recommended establishing expectations for prompt follow-up on consultant pharmacist recommendations.
The lesson: Newly initiated psychotropic medications require timely clinical review and monitoring. The goal is not to override hospital orders, but to ensure the medication remains appropriate and that changes in the resident’s condition are recognized and evaluated.
QAPI: Identifying the Problem Is Only the Beginning
A facility may correctly identify an issue, discuss it through QAPI, and develop an appropriate monitoring plan. The process still fails if the planned audits are not completed, results are not reviewed, or leadership does not verify that improvement has occurred.
A recent mock survey illustrated the difference between placing an issue on the QAPI agenda and actually achieving sustained correction.
From the Field
Residents had raised concerns about meal timing and food temperatures. The facility appropriately brought the issue to QAPI and developed a plan to monitor meal delivery times and tray temperatures.
However, our team found that the planned audits and leadership oversight had not been consistently completed. The facility could not demonstrate that it had evaluated whether its corrective actions resolved the residents’ concerns.
During the mock survey, our tray test identified continued problems with food temperatures and meal delivery timing.
The continued concerns could also have implications related to food quality, meal service, and the facility’s response to resident grievances. However, the broader system issue was the failure to implement and follow through on the corrective action already established through QAPI.
We recommended reestablishing routine tray testing across different units, meals, days of the week, and points along the meal-delivery process. Responsibility for completing and reviewing the audits should be clearly assigned, results should be reported back to QAPI, and identified concerns should require documented follow-up. Monitoring should continue until the facility can demonstrate sustained improvement.
The lesson: Bringing a concern to QAPI does not, by itself, correct the problem. The plan must be implemented, results must be evaluated, and monitoring must continue until the facility can demonstrate that improvement has been sustained.
Moving Beyond the Individual Finding
These examples involve different regulatory areas, but they share a common theme. Correcting the individual observation is not the same as correcting the process that allowed it to occur.
Each mock survey finding should prompt leaders to ask:
- What happened?
- Why did the existing process allow it to happen?
- Could the same issue affect other residents or departments?
- Does the current workflow support the expected practice?
- Who is responsible for implementing and monitoring the correction?
- How will the facility verify that improvement has been sustained?
The greatest value of a mock survey is not the list of potential deficiencies at the end of the visit. It is the opportunity to identify system weaknesses, test whether corrective actions are working, and make practical improvements before those weaknesses contribute to resident harm or are identified during a regulatory survey.
Polaris Group conducts hundreds of mock surveys each year across skilled nursing facilities nationwide. That experience gives our consultants a broad view of recurring risk areas, evolving survey concerns, and practical process improvements that can help facilities strengthen care and reduce regulatory risk.
Our support does not have to end with the mock survey. In addition to identifying potential deficiencies, our clinical consultants can help facility and organizational leaders implement recommendations, strengthen high-risk systems, monitor corrective actions, and address ongoing clinical and regulatory priorities.
Whether your organization needs a comprehensive mock survey, focused follow-up assistance, or ongoing clinical consulting support, Polaris Group can provide the experience and practical guidance needed to move from identifying risk to achieving lasting improvement. Contact us today to learn more.
