Resident Assessment Required by Federal Law
Nursing Home Must Make Comprehensive Assessment of Residents Needs
Pursuant to 42 CFR § 483.20, the facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessments of each resident’s functional capacity.
(a) Admission orders. At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care.
(b) Comprehensive assessments—(1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS.
Resident Assessment Must Include Key Issues of Resident Risks and Needs
The assessment must include at least the following:
(i) Identification and demographic information.
(ii) Customary routine.
(iii) Cognitive patterns.
(vi) Mood and behavior patterns.
(vii) Psychosocial well-being.
(viii) Physical functioning and structural problems.
(x) Disease diagnoses and health conditions.
(xi) Dental and nutritional status.
(xii) Skin condition.
(xiii) Activity pursuit.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.
The failure of facilities to evaluate the risks and needs of residents leads to many types of elder abuse and neglect including falls, pressure sores, medication errors, sexual assault and others.
Unlike many other types of injury claims, there are standards and regulations, both state and federal for most care provided in a nursing home, which apply to all facilities which accept Medicare and Medicaid residents. Pursuant to Minnesota Rule 4658.0015 a nursing home must “operate and provide services in compliance with all applicable federal, state, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in a nursing home.”
Most cases are a result of some combination of short staffing, poor training, lack of medical supplies and equipment and a failure to follow care plans and to regularly assess residents especially when there has been a change of condition, including medical conditions and accidents/incidents. The failure to respond to changes in condition in a timely manner leads to many serious injuries such as amputations and often times death. Injuries and death due to the lack of proper supervision and assessment are truly preventable and the type of situations that could be improved with a movement towards holding facilities accountable.
Please contact elder abuse and neglect Attorney Kenneth LaBore with any questions you may have at 612-743-9048.