Facilites Must Assess For Changes in Condition Then Act
Change in Condition Attorney. One of the reasons people reside in nursing home, assisted living and memory care facilities is that in the event there is a change in their medical condition there is a qualified nursing professional available to assess them and get the care they require in a timely manner. Sometimes the change in condition is sudden with such as a cardiac event or stroke. Other times the change occurs over days or weeks as can be the case with some urinary tract infections and wound care neglect.
Nurses Must Notify Family and Doctor of Changes in Condition
Nursing homes are required to have trained registered nurses available to assess the resident on a regular basis and determine if there are any significant changes or new symptoms that need to be addressed. After the assessment the nursing team develops a care plan which is consistent with the resident’s needs and medical status. It is essential that the care plan is kept up to date reflecting the most current needs for each resident. The facility is required to staff based on the needs of the residents. The facility should have enough qualified well-trained staff to provide the cares listed on the care plan for each of the residents in the facility.
According to 43 CFR 483.20 (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. The assessment must include at least the following:
(i) Identification and demographic information.
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychosocial well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnoses and health conditions.
(xi) Dental and nutritional status.
(xii) Skin condition.
(xiii) Activity pursuit.
(xiv) Medications.
(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.
If there is change in the resident’s condition, it is required pursuant to 42 CFR § 483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident’s physician; and notify, consistent with his or her authority, the resident representative(s), when there is—
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident’s physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in § 483.15(c)(1)(ii).
Contact an Experienced Attorney to Discuss Your Case
If you have concerns about sudden changes in a residents condition, or other care issues in a nursing home or assisted living facility contact attorney Kenneth LaBore for a free consultation at 612-743-9048.
