Skip to Main Content

Regulations Update

Marci Pederson, RN, BSN, Nurse Educator/Consultant

Federal Regulation F323

"Facility is Free of Accident Hazards"

South Dakota long-term care facilities had 17 deficiencies cited for F323 in 2010. It ranks number 9 in the top twenty deficiencies for long-term care facilities in South Dakota.

The regulation F323 states,

"§483.25(h) Accidents

The facility must ensure that--


Each resident receives adequate supervision and assistance devices to prevent accidents."


The intent of this requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The process incudes the following steps:

  • Identifying hazard(s) and risks(s);
  • Evaluating and analyzing hazard(s) and risks(s);
  • Implementing interventions to reduce hazard(s) and risk(s); and
  • Monitoring for effectiveness and modifying interventions when necessary.

This process is comparable to the nursing process, quality improvement process, scientific process and/or problem-solving process. When our facilities have a process such as this in place, we have a system that will help us promote the safety and well-being for our residents/patients. What happens though when our facilities have such a system in place, but we see an increase in accidents and injuries for the residents/patients? Of the many potential reasons, I would like to explore two:

  1. Not all accidents are avoidable. The frailty of some residents increases their vulnerability to hazards in the resident environment and can result in life threatening injuries. Sometimes even with everything in place for a safe environment and every one of the staff doing everything they can to participate in the process, a resident may still fall.
  2. Have you ever fallen, cut yourself, bruised yourself from bumping a piece of furniture, etc.? I believe we all have to say yes to this. But if we were to replay the events that occured prior to our accidents, we would be surprised at what we find. We would find our accidents are usually not random in nature. Many times accidents occur to us because we are simply burned out.

Jesse Lynn Hanley, MD, co-author of Tired of Being Tired, has identified five levels of burn out.

  • DRIVEN  We're working continually in a non-stop blur of accomplishment. We feel like we can go on forever, but we can't!
  • DRAGGING  We're using sugar and caffeine to fight the fatigue we are feeling from doing too much. We may even try over-the-counter sleep aids to 'sleep faster'.
  • LOSING IT  We're clearly tired, visibly plump (or alarmingly thin) and frequently grumpy. At night we lie awake with thoughts racing, longing for sleep. Sometimes at work we begin to feel guilty because we raise our voice at co-workers or even residents/patients, something we do not normally do.
  • HITTING THE WALL  We are suffering with aches and pains, gaining (or losing) weight, lose our temper, forget our computer passwords or cry easily.
  • BURNED OUT  By now we may have a serious illness, such as heart disease, auto-immune disorder or have been in a serious car accident. As Hanley writes, "If you do not die during this stage, there is no place to go but up."

Do any of these levels of burn out sound familiar? This is one of the reasons accidents occur even when a facility has a wonderful system in place. A facility is only as safe as its workers are well. Will regulations such as "ensure healthcare workers manage stress" or "prevent burn out" be helpful? This is not likely. How we treat our bodies is always a personal choice, and sadly most of us have to go through a time of suffering before we see the light and begin to participate in our healing process. If we are ready to begin, authors such as Hanley recommend five principles to follow that can help prevent burn out.

  • BECOME A GRAZER  Eat more, but eat healthier. Choose to eat all different colors of vegetables and fruits and drink lots of water. Eat whole foods with fiber and opt for lean protein sources such as fish, beans and nuts. By making these changes, you'll discover you are calmer and can begin to let go and relax.
  • SLEEP AS IF OUR LIVES DEPEND ON IT Some people feel superior when they work around the clock. This is like proudly pouring salt in a wound. Sleep makes us smarter, better-looking and more creative. It adds years and enhances the quality of our lives. Even if it means making material sacrifices, we need to make it a priority to get enough sleep. If we are at the point of burn out, we need eight to ten hours of sleep a night plus three 15 to 30 minute naps or retreats. If we are not at the burn out level but we want to prevent the worst, we need eight hours of sleep a night with one period of quiet relaxation (even if its in the restroom stall) for 10 to 15 minutes.
  • EXERCISE FOR FUN Regardless of what stage we might be in, we need to ask if we are having fun when we are exercising. In burn out, we need to listen to our body and excercise less. If we are "dragging", we should limit hard exercises for one hour three times a week or one to three sessions of moderate activity like light yoga or strolls in the park. If we are "losing it", we need to do three gentle hours of exercise a week. If we are "hitting the wall", gentle stretches or other gentle exercise for 30 minutes is needed. If we are burned out, we should roll over in bed occasionally until we are stronger. If we are to the point of burn out, we should be consulting with our primary care physician.
  • UNPLUG HEATERS, PLUG IN COOLERS  First, list the people we interact with, environments we inhabit and usual activities. Next, we need to imagine each item separately and notice how our bodies react. We may notice jaw clenching, tightening shoulder muscles, stomach churning or even smiles or ease in breathing. We live in the real world and so we cannot eliminate all of the heaters in our lives, but we can unplug them every few hours by taking a few deep breaths in and out, by looking outside, drinking water or visualizing a situation when we felt gratitude.
  • PRACTICE PEACE Let's face it, we live in a world that is sometimes chaotic. Things can go wrong and we have to solve problems. We can choose to work through these challenges in panic or peace. This is easier said than done, but it is possible with practice. We need to choose to make time for prayer or meditation, focusing on our breath or taking five minutes a day to tell ourselves "I am alright in this moment". Doing this increases peace in our mind and body. We will be amazed at the subtle changes in us after we practice peace for awhile.

How does a whole facility prevent burn out and emphasize health, peace and balance in the health care team? A step at a time, with leaders who 'walk the talk' and by remembering we each make our individual choices about our health and the effect it can have on ourselves, residents/patients, co-workers and family members. Perhaps our facilities might offer wellness programs that address healthy food choices, adequate sleep practices, exercise, how we choose to react to our environment and the practice of peace in a creative method which will draw optimum participation.

If your facility would like to improve regulatory compliance and quality of care, contact Avera Education & Staffing Solutions at (605) 668-8475.


As a former health facilities senior surveyor, Marci worked at the Department of Health Office of Licensure and Certification for eight years. Marci provides Survey Preparedness Consulting designed to create a culture of constant survey preparedness by helping staff understand regulatory requirements, not just comply with them.

Do the math! The facility bottom line improves when resident care continually improves.

Read more Regulations Updates. The Avera Solutions’ Blog contains writings from Marci and other Avera Education & Staffing Solutions staff and consultants.

Marci Pederson, RN, BSN

Marci Pederson, RN, BSN

As a former health facilities senior surveyor, Marci served a variety of health care facilities. Her experience includes nursing education, medical/surgical nursing, psychiatric nursing, infection control, utilization review and quality assurance.