Download Resident Care

NURSING HOME ADMINISTRATOR LICENSURE
EXAM REVIEW COURSE
◘ MODULE 2
National Exam
Resident Care
 Speed Reader
Examination 1
Examination 2
Examination 3
Stan Mucinic, LNHA
Resident Care
Copyright © 2005-2012 by Stan Mucinic. All rights reserved.
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Legal Notices
Students enrolled in the “National Nursing Home Administrator Licensing Course” are
purchasing the professional knowledge of the instructor to assist the student to prepare for the
national licensure exam administered by the National Association of Boards of Examiners
(NAB).
This is a 5-week intensive independent study program designed to provide students a unique
personalized and structured learning environment where progress is monitored by the
instructor through email to help students maintain focus and complete scheduled assignments
timely.
THE INSTRUCTOR MAKES NO EXPRESS OR IMPLIED WARRANTY OR
REPRESENTATION OF ANY KIND THAT COMPLETION OF THIS OR ANY LICENSURE
PREPARATION COURSE OFFERED BY INSTRUCTOR WILL GUARANTEE A PASSING
SCORE ON ANY LICENSING EXAM.
An individual’s ultimate success in passing the licensure exam is dependent on an individual’s
professional experience, academic preparation, and the time and energy the individual can
commit to exam study and preparation. A student’s work schedule or other commitments may
require more time to prepare for an exam than allotted. The student is solely responsible for
licensing exam registration/testing and retesting fees.
HOW TO USE THE STUDY GUIDES
Step 1 – VERY IMPORTANT - The personalized test organizer that comes with the program is the key
to your success and sets this program apart from any other. It is critical you follow the instructions and
score each exam, and file the completed exams into your binder. Try to keep to the schedule and email
your test results to the instructor to stay focused.
Step 2. - Speed Reader – Read the speed reader for each module once or twice before taking the
module exam(s). Read the speed reader over and over again until you familiarize yourself with its
contents. THE MORE TIMES YOU LOOK IT THE MORE LIKELY YOU ARE TO REMEMBER IT.
Step 3 – Exam Packet - The exam packet contains questions designed to measure your comprehension
and retention of the material you read. Take each exam over and over again until you score 100%.
Make sure you score each exam and record the results in your organizer or you will not be able to gauge
your progress.
The exam questions are cross referenced to the speed reader to allow you to
quickly find and review material you missed on the exam as follows:
Page Number
2/1.8(13)
Section number
Thus, the specific material would be found on page 2 of the speed reader, section 1.8,
subparagraph 13.
Contact Information
Email Stan Mucinic at [email protected] with any questions and after you score each practice
exam
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Resident Care
Section
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Resident Care
Subject
Inform Residents of Rights
Medicare and Medicaid Benefits
Financial Affairs
Resident Personal Property
Resident Funds
Trust Fund Surety Bond
Resident Records
Informed Consent
Equal Access to Care
Grievances
Resident Council/Groups
Drugs and Biologicals
Pharmacy Services
Consultant Pharmacist
Right to Inspect Survey Results
Privacy
Access to Residents
Miscellaneous Rights
Married Couples to Share Room
Discharge/Transfer
Bed hold Policy
Resident Competency
Advanced Directives
Surrogates and Proxies
Limitations on Surrogate Powers
Quality of Resident Care
Physician Services
Right to Medicare and Medicaid
Required Notices to Residents and Physician
Resident Billing Rights
Right to Privacy
Review Survey Results
Right to Work for facility
Physical and Chemical Restraints
Abuse
Quality of Life
Activities Program
Social Services Program
Physical Environment
Resident Assessment
Comprehensive Care Plan
Admission to Facility
Therapeutic Diet
Medication Error Rate
Nursing Services
Dietary Services
Food Hygiene
Specialized Rehabilitation Services
Restorative Rehabilitation
Dental Services
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Copyright © 2005-2012 by Stan Mucinic. All rights reserved.
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Table of Contents (Continued)
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Resident Care
Skilled Nursing Facility Defined
Personal Clinical Records
Required Notice of Discharge
Objections to Advanced Directives
Medical Terminology
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Resident Care
 SECTION 1 - INFORM RESIDENTS OF RIGHTS
 1.1 - INFORM RESIDENTS OF RIGHTS
1. Must inform residents of rights both orally and in writing in a language they understand at or upon
admission, discharge, and upon request
2. Must provide written information to residents of their rights and obligations under facility rules and policies
3. Most provide residents 14 days advance notice of changes in state and federal laws, facility rules and the
resident contract
4. Notice of rights and any amendments must be acknowledged in writing by the resident
5. Must provide an interpreter if needed
6. Must provide written translations of the notice of rights in the language must commonly spoken in the facility
7. May provide a resident an oral summary and written copy of he resident rights if a resident fully understands
the information provided
8. Must provide residents notice of all available services and costs prior to or upon admission
9. Must inform residents of all covered and non-covered services under Medicare and Medicaid
10. Must have large print copies of the resident’s rights
11. A facility must not charge residents for copies of their rights provided to them
 SECTION 2 - MEDICARE AND MEDICAID BENEFITS
 2.1 - MEDICARE AND MEDICAID BENEFITS
1.
2.
3.
4.
5.
Must advise residents of Medicaid benefits in writing upon admission or when they become eligible
Must advise residents of items and services included and not included in the state plan
Must advise residents of which items the resident may be charged for
Must inform residents of changes in charges as they occur (within 14 days)
Cannot charge for services included the Medicare and Medicaid plan – for example:
a) Nursing services
b) Dietary services
c) Activities program
d) Razors
e) Dentures adhesive and cleanser
f) Depends diapers
g) Notions and novelties
6. Items and services that may be charged to residents
a)
b)
c)
d)
e)
f)
g)
h)
Telephone and television
Personal clothing
Gifts
Reading material
Privately hired nurses and aides
Specially prepared foods
Social events and entertainment outside scope of activities program
A private room (unless required for infection control)
 SECTION 3 - FINANCIAL AFFAIRS
 3.1 - FINANCIAL AFFAIRS
1. A facility can never act as a representative or guardian or exercise the rights of a resident at any time
2. A resident has the right to manage their own personal affairs as long as they desire and are competent to
do so
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3. A facility may not condition admission on a waiver of the resident’s right to manage their own funds or
require the resident to authorize the facility to manage their funds
 SECTION 4 - RESIDENT PERSONAL PROPERTY

4.1 - RESIDENT PERSONAL PROPERTY
1. Residents have the right to keep and use personal possessions
2. Residents should be encouraged to bring in their own clothes, familiar furnishings and possessions to create
a homelike atmosphere
3. A facility may impose some limitations on personal belongings in view of space limitations and the fire safety
code
4. The facility should encourage residents to bring in familiar furnishings and possessions to create a homelike
atmosphere
 SECTION 5 - RESIDENT FUNDS
 5.1 – HANDLING TRUST FUNDS
1. A Medicare beneficiary who requires services not covered by Medicare can be required to deposit money to
cover those expenses
2. Must refund the funds of a deceased resident within 30 days of death
3. The resident and the facility must have a written agreement for facility to hold resident’s funds
4. Must provide the resident a report at least quarterly on the status of their funds held in trust
5. A resident may request a facility to temporarily hold funds in a safe place without a trust agreement
6. A facility must have written procedures regarding the handling of resident funds
7. A facility cannot commingle facility funds with resident funds (mix resident funds with facility funds)
8. A Facility may not use resident property without their express consent
9. A facility must manage resident funds if the resident requests the facility to do so
10. A facility must establish and maintain a system that assures a full and complete accounting of resident funds
 5.2 – INTEREST BEARING ACCOUNT
1. Medicaid Resident Funds
a) The facility must deposit funds into a non-interest bearing account (totaling less than $50)
b) Must deposit funds into an interest bearing account (in excess of $50)
2. Medicare Resident Funds (in excess of $100)
a)
Must deposit funds into an interest bearing account if funds total more than $100
 5.3 - HANDLING TRUST FUNDS
1. Must have sufficient petty cash on hand to meet resident requests for small cash amounts on a daily basis
2. Requests for $50 or less should be honored within 3 days
3. Cannot pass on banking charges to resident for costs to maintain a trust account
 5.4 - QUARTERLY STATEMENTS
1. A statement and accounting of resident trust funds should be provided to residents quarterly (within 30 days
after the end of each quarter)
2. Residents should be given a receipt of all transactions
3. Proper bookkeeping procedures include an individual ledger card or ledger sheet for each resident
4. A Facility is required to notify Medicaid residents when their resident accounts reach $200 less then the SSI
resource limit for one person
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 5.5 - FINAL ACCOUNTING UPON DEATH
1.
Refund all funds and provide a final accounting to a resident’s estate or the probate court within 30
days of death
 5.6 - ALLOWABLE DEDUCTION FROM TRUST FUNDS
1. Can deduct unpaid Medicare deductibles and co-payments from a resident trust fund
2. Can deduct for any services not covered by Medicare and Medicaid
3. Cannot deduct for any charges for services not requested by the resident
 SECTION 6 - TRUST FUND SURETY BONDS
 6.1 - TRUST FUND SURETY BONDS
1.
2.
3.
4.
Must purchase a surety bond if facility holds any resident funds
The resident and the sate are named co-beneficiary of the surety bond
The facility pays the premiums for the surety bond
The facility cannot self insure for resident losses
 SECTION 7 - RESIDENT RECORDS
 7.1 – MANDATORY RESPONSE TIMES
1.
2.
3.
4.
5.
6.
Must provide residents access to their records within 24 hours of either oral or written request
Must provide photocopies of records within 2 working days
The facility may charge a reasonable photocopy charge and clerical costs to copy records
Cannot charge for time to locate records or type form letters or envelopes
Residents are entitled to inspect their own financial records/contract, including resident trust account
Residents can withhold consent to allow family members to access their records
 7.2 - CONSENT TO RELEASE RECORDS
1. Resident does not have right to refuse the release of personal and medical information when:
a) Transferred to another facility
b) When required by law (subpoena)
Note: the resident has the right to refuse state ombudsman to review their personal and medical
information
 SECTION 8 - INFORMED CONSENT
 8.1 - INFORMED CONSENT
1.
2.
3.
4.
A resident has the right to information on medical care insurance coverage
A resident has the right to full information about their total health status (functional, nutritional, cognitive rehab)
A resident has the right to be informed in a language they understand, free of jargon, etc
A resident has the right to refuse treatment – the facility must do the following
a)
b)
c)
d)
e)
f)
5.
6.
Staff must determine exactly what the resident is refusing and why
Must advise the resident of the consequences of refusal of treatment and any alternatives
The physician should be notified
Must document the refusal in the patient chart and describe the action taken
Must provide all other treatment not refused
Cannot provide any treatment that was not consented to
A resident has the right to refuse a shower or bath
A resident has the right to participate in experimental research which includes:
a)
b)
The right to refuse to participate
To be advised of the nature of the experiment
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c)
d)
e)
The possible consequences of participation
The right at any point to withdraw from the research project
The facility must document their participation in the plan of care
7.
A person adjudged incompetent by a court or has cognitive impairments must be consulted on personal preferences
to the extent practicable
8. Residents and family should be encouraged to participate in resident care plans
9. The facility must balance a resident’s rights and also their health care needs and offer alternatives to comply with
resident preferences to the extent practicable
10. Care provided to a resident to maintain or restore health, improve functional levels or relieve symptoms is called
“palliative care”
11. The development and testing of clinical treatments such as an investigational drug or therapy is called “experimental
research”
 SECTION 9 - EQUAL ACCESS TO CARE
 9.1 - EQUAL ACCESS TO CARE
1. Resident’s have the right to equal choice and to participate in care planning and medical treatment
2. Resident have the right to be informed in advance of resident obligations and limitations of available services
and choice under facility rules
3. Resident’s must be encouraged to participate in their care and planning, and daily activities, despite any
cognition or sensory deficit, to the extent they are capable of understanding and can participate
4. A facility must establish and maintain identical policies and practices regarding transfer, discharge and the
provision of services under the state plan for all residents, regardless of payment source
 SECTION 10 – GRIEVANCES
 10.1 – GRIEVANCES – A RESIDENT HAS THE RIGHT TO:
1, Voice grievances without reprisal
1. Voice grievance and complaints orally and in writing
2. Acknowledgement from the facility of receipt of a grievance
3. Be kept informed of the progress of a grievance or complaint
4. A prompt resolution of grievances
5. Organize resident groups
6. Distribute information to other residents
7. Associate with other residents and family members
8. Contact state survey agencies and state ombudsman
9. Document resident grievances and efforts to resolve them
10. Voice grievances of the behavior and conduct of other residents
11. Surveyors want to see incident or grievance reports
 SECTION 11 - RESIDENT COUNCILS
 11.1 – REQUIREMENTS
1.
2.
3.
4.
A resident has the right to organize and participate in resident groups in facility
Resident family members have right to meet with families of other residents
A facility must provide private space for a resident council
Staff and visitors may attend resident groups at the group’s invitation
 11.2 - RESPONSE TO RESIDENT COUNCIL CONCERNS
1. The facility must listen to views of the resident group/council
2. The facility must act upon grievances and recommendations of residents (must respond to suggestions and
complaints but not required to implement them)
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3. The facility must designate staff person to assist resident council and respond to written requests that result
from group meetings
4. The facility does not need to implement all recommendations from the resident council but must review and
respond to them
 SECTION 12 - DRUGS AND BIOLOGICALS
 12.1 – SELF ADMINISTER DRUGS
1. Residents have the right to self administer drugs
2. The interdisciplinary team must determine if resident is competent and safe to self administer
3. The interdisciplinary must determine who will store and document administration of the drugs by the
resident
4. Errors made by residents who self administer drugs are not calculated in the facility medication error rate
5. Self administration must be noted in the resident’s care plan
 12.2 - LABELING DRUGS AND BIOLOGICALS
1.
2.
3.
4.
All drugs and biologicals must be labeled in accord with accepted professional principles
The critical element of the label is the name of the drug and the strength
The label must identify the resident what the drug was intended for
Must have the manufacturer’s expiration date on the label
 12.3 - STORAGE OF DRUGS AND BIOLOGICALS
1. All drugs and biologicals must be stored in locked compartments and under proper temperature controls
2. Must only permit authorized personnel to have keys to locked drug compartments
3. Schedule II controlled drugs must be stored in a permanently affixed drawer and have separate locks from
the main compartment door
4. Schedule I drugs are illegal drugs and are not allowed in the facility
5. Legend drugs are prescription drugs
 SECTION 13 - PHARMACY SERVICES
 13.1 – PHARMACY SERVICES
1.
2.
3.
4.
The facility must provide routine and emergency drugs and biologicals
The facility must provide pharmacy services under contract if no in-house pharmacy
Unlicensed personnel may administer drugs under supervision of licensed nurse
The facility must administer drugs to residents during set times (facility policy specifies this)
 13.2 - PHARMACY PROCEDURES
1.
The facility must have procedures to accurately order, receive and dispense drugs
 SECTION 14 - CONSULTANT PHARMACIST
 14.1 – CONSULTANT PHARMACIST
1.
2.
3.
4.
5.
The facility must have a consultant pharmacist to review resident drug regimens monthly and Identify
over use or inappropriate use of medications
Must establish receipt and disposition of all drugs
Must review each resident drug regimen each month
Each resident’s drug regimen must be free from unnecessary drugs
Anti-psychotic drugs are not to be used unless there is a diagnosed medical condition and documented
in the medical record
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6.
Residents must be progressively weaned from anti-psychotic drugs to the extent practicable with the
goal to eliminate use entirely
7. The consultant pharmacist is responsible to determine whether drug records are in order and all
controlled drugs are accounted for, maintained and periodically reconciled
8. The Medication Administration Record (MAR) is proof of receipt/disposition of a controlled drug
9. Must reconcile drug records quarterly (identify any missing drugs or drug shortages – theft)
10. Each resident’s drug regimen must be reviewed monthly
11. Federal rules do not prohibit shortages of controlled drugs if all drugs are accounted for
12. The consultant pharmacist must report any irregularities to the DON and the attending physician
 14.2 - MISSING CONTROLLED DRUGS
1.
2.
3.
The consultant pharmacist must notify the DON if any controlled drugs are missing
The facility must utilize proof of use sheets until the source of the loss is identified
When the drug records are again reconciled, the facility may revert to periodic reconciliation
 14.3 –CONSULTANT PHARMACIST REPORTS
1.
2.
3.
The consultant pharmacist is encouraged but not required to share the results of the drug regimen
review with the medical director
Both the DON and attending physician must act upon the reports submitted by the consultant phamacist
The DON and the attending physician do not have to agree with the consultant pharmacist reports, but
they are required to provide a rationale for their acceptance or rejection of the reports
 SECTION 15 - RIGHT TO INSPECT RECENT SURVEY
 15.1 - RIGHT TO INSPECT RECENT SURVEYS
1. The facility must post the facility’s recent survey results in publicly accessible area
 SECTION 16 - PRIVACY IN COMMUNICATION AND VISITATION
 16.1 - PRIVACY IN COMMUNICATION AND VISITATION
1. Residents have the right to send and receive unopened mail
2. Residents have the right of access to stationary, pens and postage at the resident’s expense
3. Ingoing mail must be forwarded to resident within 24 hours from delivery by the Post Office and outgoing mail
delivered to the post office within 24 hours of mailing by the resident
 SECTION 17 - ACCESS TO RESIDENTS
 17.1 - ACCESS TO RESIDENTS
1. Federal and state government officials, law enforcement, and ombudsman have right to access to any resident
at any reasonable time
2. The ombudsman can access patient clinical records only with the patient’s consent
3. The facility must provide resident access to telephone (cordless phone or phone jack in room)
4. The facility must provide to the family, legal guardians, health and legal professionals, community and religious
groups and client advocate agencies access to and privacy when visiting a resident
5. The facility must post contact info for state survey and licensure offices, the state ombudsman, and the
Medicaid fraud control unit in public places in facility
6. The facility must post a statement that the resident may file a complaint with the state concerning resident
abuse, neglect and misappropriation of resident property
7. The facility must post the requirements and procedures to establish eligibility for Medicaid, including the right to
request assessment of a couple’s non-exempt resources at the time of institutionalization
8. Immediate family and other relatives are not subject to visiting hour limitations
9. The facility may change location or place reasonable restrictions on visits to protect privacy of the resident and
Others
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10. The facility may only provide the state ombudsman access to a resident’s clinical records if the resident
consents
11. Allowing a resident to use a phone in staff offices or the nurses station is not acceptable
12. The facility may provide a resident cordless phone and allow them to call from a location of their choosing
13. The facility must place a phone at a height accessible to wheelchair bound residents
14.
 SECTION 18 - MISCELLANEOUS RIGHTS
 18.1 - MISCELLANEOUS RIGHTS – RESIDENTS HAVE THE RIGHT TO:
1.
2.
3.
4.
5.
6.
A dignified existence
Self determination
Right to work in the facility – they just need to request it
Communicate with individuals inside and outside a facility
Smoke under staff supervision only in designated smoking areas
A Medicare beneficiary who requires services that are not covered by Medicare can be required to deposit money
to cover those expenses
 SECTION 19 - MARRIED COUPLES TO SHARE ROOM
 19.1 - MARRIED COUPLES TO SHARE ROOM
1. Married couples have a right to share a room if they both consent
2. The couple must both have the same pay source (i.e., if the beds in the room are Medicare only or Medicaid only
certified, they must have the corresponding payor source or pay private pay. The couple must reside in a bedroom
with beds that are Medicare or Medicaid certified if that is their payor source.
 SECTION 20 - INVOLUNTARY TRANSFER/DISCHARGE
 20.1 – TERMS DEFINED
1. Transfer - Moving a resident within a facility or to another facility or institution
2. Discharge - Moving a resident to a non institutional setting when the releasing institution ceases to be responsible
 20.2 - REASONS FOR TRANSFER OR DISCHARGE
1.
2.
3.
4.
5.
6.
The resident’s needs cannot be met by the facility
The resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility
The safety of other individuals in the facility are endangered by the resident’s continued presence in the facility
The resident’s failure to pay patient bills (30 day notice required)
The facility is closing
The facility nay not transfer a patient because of a change of payor source
 20.3 -SUBSTANTIATION OF TRANSFER
1. The facility must document and explain the reasons for a transfer and the specific legal authority
2. Medical Transfer – must be signed by a physician and documented in the care plan
3. Non medical transfer – the administrator must sign the discharge (non payment)
 20.4 - ADVANCE NOTICE PRIOR TO DISCHARGE OR TRANSFER (3O DAY NOTICE)
1. The facility must provide residents and family 30 days written notice in advance of intended discharge or transfer
2. The facility must explain the reasons and provide contact info for the state ombudsman
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 20.5 - EMERGENCY DISCHARGE NOTICE (WITHOUT 30-DAYS NOTICE)
1.
2.
3.
4.
5.
The resident is a danger to the safety and health of others (Baker Act)
The resident’s health improved to allow an immediate discharge (short term patients)
Urgent medical needs necessitate immediate transfer to a hospital with little notice to family or attending physician
The resident has resided in the facility for less than 14 days (Notice not required)
The facility must advise Medicaid patients of Medicaid bed-hold policy and readmission policies upon transfer to
the hospital
 20.6 - DISCHARGE ORIENTATION
1. Upon discharge, the facility must provide sufficient orientation and prep to ensure a safe and orderly discharge
from the facility
 SECTION 21 - BEDHOLD POLICY
 21.1 - RESIDENT RETURN TO FACILITY
1. A facility must provide the bed-hold notice in advance (upon admission) and at the time of transfer in writing
2. The purpose for a bedhold is to pay a facility to hold an empty bed for a resident who wants to return to the
facility and be assured they will have a bed. It is really only requested when a facility is nearly full and cannot
guarantee that a bed will be available when a resident is ready to return.
3. In the event of an emergency transfer, the facility must provide a notice of transfer to the resident and family
members within 24 hours of transfer
4. The required bed-hold notice may be provided to the resident and family members in an emergency transfer,
by sending the written notice with the papers sent to the hospital with the resident
5. For private pay residents, the facility must hold a bed for 30 days if requested and they can be required to
pay the bed hold amount in advance
6. Medicaid is the only payor that pays to hold a bed for hospitalization or therapeutic leave and the number of
days varies from state to state. Usually the facility must be at a certain occupancy level (i.e. 95% full for
example) to be eligible for payment. If you have lots of beds available few people will pay the extra cost.
7. Medicare does not pay to hold a bed for Medicare residents hospitalized during SNF stay
 21.2 - RE-ADMISSION WHEN BED-HOLD PERIOD EXCEEDED
1. A facility must establish written policies for readmission of Medicaid residents who exceed the bed-hold
period
2. Medicaid patients who exceed the bed-hold period must be re-admitted on the first availability of a bed in a
semi private room
3. Medicaid patients must be re-admitted if they still require the services provided by the facility and are eligible
for Medicaid
4. Medicare does not pay for a bedhold
5. Non Medicaid patients who exceed the bedhold period do not have to be re-admitted – the facility has
discretion
6. The facility must refund a bedhold deposit if a bed is not held as promised
 21.3 - TRANSFER OF MEDICAID PATIENT ONCE RE-ADMITTED
1. The facility can transfer or discharge a Medicaid patient once re-admitted if it can prove the resident has
unpaid bills and has provided required notice of discharge (30 days)
2. The facility must provide the resident the required notice of discharge
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 SECTION 22 - RESIDENT COMPETENCY
1.
A guardian will be appointed by the court for a resident judged incompetent by the court and granted the
authority to make health care decisions and any other powers the court deems appropriate
 SECTION 23 - ADVANCED DIRECTIVES
1.
2.
3.
4.
5.
6.
7.
8.
An advanced directive is defined as a written instruction relating to the provision of health care when an
individual is incapacitated
Must orally and in writing inform residents of their right to make decisions concerning medical care and to
formulate medical directives
Cannot condition the provision of care on whether the resident executes an advanced directive
Must note in the facility contract whether the resident has executed an advanced directive
May not force a resident to make an advanced directive on a facility form
Must have policies and procedures to implement advanced directives
Must advise residents of their right to refuse medical treatment
Must arrange transfer to another facility if they cannot meet a resident’s needs (Facility pays transport costs)
 SECTION 24 - SURROGATES AND PROXIES
 24.1 - SURROGATES AND PROXIES
1. The facility has a legal obligation to promote resident rights
2. Residents have a legal right to delegate decision making authority to a representative or surrogate in accordance
with state law
3. A facility must respect informal delegations of decision making arrangements between the resident and family
4. The facility must verify the authority of a representative, guardian or other individual to make decisions for a
resident
5. Individuals with a power of attorney have the authority to make financial decisions, but not health care decisions
6. A Durable Power of Attorney gives an individual the power to make financial decisions and also health care
decisions to the extent delegated by the resident
 SECTION 25 - LIMITATIONS ON SURROGATE POWERS
 25.1 - LIMITATIONS ON SURROGATE POWERS
1. A delegation of decision making to a surrogate does not relieve the facility from its duty to protect the interests of
the resident from a decision by a surrogate to insist on treatment that is neither medically nor legally appropriate
nor permissible.
2. Irrespective of any delegation of decision making, the facility must still inform the resident of their care and solicit
their consent and to participate to the extent practicable
 SECTION 26 - QUALITY OF RESIDENT CARE
 26.1 - QUALITY OF RESIDENT CARE
1. A facility must provide both efficient and cost effective care
2. A facility must allow the resident to attain the highest practicable physical, mental, and psychosocial wellbeing
3. A facility must meet state and federal minimum requirements
 SECTION 27 - PHYSICIAN SERVICES
 27.1 – RIGHT TO CHOOSE PERSONAL ATTENDING PHYSICIAN
1. The facility must arrange for physician services 24 hours a day
2. Residents have a right to choose their own physician
3. A facility must provide contact info and assist residents in locating a physician
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4. A facility does not have to allow a physician chosen by a resident to serve as attending physician if they fail to
meet facility credentialing requirements or state and federal and regulatory requirements
5. A physician must personally sign an order admitting an individual to a skilled nursing facility
6. Each resident in the facility must remain under the care of a physician
7. A physician must supervise the medical care of each resident
8. In the event the attending physician is unavailable to supervise the care of a resident, then another
physician must supervise the resident’s care
 27.2 - PHYSICIAN VISITS
1. The physician must review the resident’s total plan of care, including medications and treatment at each
required visit
2. The physician must write, sign and date progress notes at each visit
3. The physician must sign and date orders at each visit
4. A physician does need to re-sign facsimile orders transmitted to the facility
5. Facsimile orders may be transmitted to the facility by a physician under the following conditions
a. The physician must retain the signed original order
b. The facility should copy a fax order since they fade overtime
c. The faxed order can be discarded once the photocopy is made
 27.3 - REQUIRED PHYSICIAN SCHEDULE
1.
2.
3.
4.
Residents must be seen once every 30 days for the first 90 days
Then once every 60 days from day 91 forward
A visit is timely if it occurs not later than 10 days after the visit was required.
After the initial visit, the physician can alternate visits with a physician’s assistant, nurse practitioner to see
patients
5. A physician may use a nurse practitioner, physician assistant or clinical nurse practitioner to visit the resident
In place of the physician every other required patient visit
6. A physician may provide an alternate visitation schedule if he can justify the reason and document the clinical
record
7. A physician may not delegate a task that he is required to perform by law
 SECTION 28 - RIGHT TO MEDICARE AND MEDICAID INFORMATION
 28.1 – BENEFIT INFORMATION
1.
2.
3.
A facility may use written materials from the state Medicaid agency and the federal government
A facility can fulfill their requirement to orally advise residents of the their rights and benefits to
Medicare and Medicaid by giving them the phone number to contact the local social security
and Medicaid office
The physician must orally provide detailed information about Medicare and Medicaid eligibility
rules
4. The physician must provide residents information on how to get refunds for
previous payments under Medicaid and Medicare
 28.2 - COERCING WAIVER OF MEDICARE AND MEDICAID BENEFITS
1.
2.
3.
4.
A facility cannot require potential residents to orally or in writing promise they will not apply for Medicare or Medicaid
benefits or sign a mandatory arbitration agreement
A facility cannot require residents to waive their rights to Medicaid or Medicare benefits
A facility cannot require residents to sign an admissions contract waiving their right to or promising not to apply for
Medicare or Medicaid benefits
A facility cannot require resident to commit to pay private pay rate for a set period of time as a condition to applying for
Medicare/Medicaid benefits
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 28.3 - GIFTS, DONATIONS OR MONEY FROM POTENTIAL MEDICAID RESIDENT
1. A facility may not accept gifts or money as a condition to admit, expedite the admission of
or allow a Medicaid resident to stay in a facility
2. A facility can accept gifts and donations from charitable, religious or philanthropic organizations or a person
unrelated to a Medicaid applicant, provided it is not related to admission or continued stay of a Medicaid resident
3. A facility may charge a Medicaid resident for services and items that they requested and
received and are not covered under the State plan
4. The state is not required to provide services additional to those provided in the state plan
 SECTION 29 - REQUIRED NOTICE TO RESIDENT AND PHYSICIAN
 29.1 - NOTICE TO RESIDENT, FAMILY AND PHYSICIAN
1. Must notify the resident, family and attending physician when:
a.
b.
c.
d.
An accident occurs which results in injury or has the potential for requiring a physician’s attention
A significant change in the resident’s physical, mental or psychosocial status
A need to significantly alter treatment
In the event the resident dies, the attending physician must be notified immediately
 29.2 -WHEN ATTENDING PHYSICIAN NEED NOT BE CALLED:
1. Must notify the resident and family (BUT NOT PHYSICIAN) when:
a. A facility updates the resident contact information
b. To keep family updated of resident’s health status
c. Should not contact family members or specific family members if the resident
directly instructs the facility not to
d. When changing a room or roommate
e. Notification of change in state or federal regulations
 SECTION 30 - RESIDENT BILLING RIGHTS
 30.1 – REQUIREMENTS
1.
2.
3.
4.
5.
Cannot charge a resident for services not requested by the resident
Cannot require a resident to request any item or service as a condition of admission or continued stay
Must advise residents of the charge in advance of any service or item requested by the resident
Cannot deduct funds from the resident trust fund for items or services not requested by the resident
Can bill residents for services and items requested and not included in Medicare and Medicaid
reimbursement plan (telephone, television, food from the outside, activities outside facility, etc)
 30.2 - BILLING THIRD PARTY
1. Cannot require family member or third party to obligate themselves to guarantee payment of resident
charges, out of their own funds, as a condition of admission or continued stay in the facility
2. The facility may require an individual with access to resident funds or income to sign a contract to provide the
facility payment from the resident’s income or resources
3. The facility must advise residents in advance when changes occur in bills
4. The facility can charge residents any amount they want for non-covered services provided notice and
disclosure is provided and charges are clearly disclosed
 SECTION 31 - RIGHT TO PRIVACY
 31.1 – REQUIREMENTS
1. A resident has a right to privacy and confidentiality in the handling of their bodies and their personal information
Must provide privacy when resident meets with visitors in facility or talks on phone
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2. The facility does not have to provide a resident a private room
3. The facility must not open resident mail
 31.2 - PRIVACY IN RECEIVING CARE
1.
2.
3.
4.
5.
The facility must provide residents full visual privacy when examining and treating residents
Nurses should not administer drugs to residents in the hallway
Residents must be provided privacy when toileting, showering, and other personal hygiene activities
The facility must provide residents full visual and auditory privacy
Staff must knock before entering a resident’s room
 31.3 - CONSENSUAL RELATIONS
1. Residents have right to be private with whomever they want to be with
2. Consenting adult residents have the right to engage in consensual sexual relations
3. If they do not share a room, then the facility must provide them private space
4. If facility cannot accommodate based on conscientious grounds, must advise residents of their right to transfer to
another facility if their needs cannot be met
 SECTION 32 - REVIEW SURVEYS/INSPECTIONS
 32.1 - REVIEW SURVEYS/INSPECTIONS
1.
2.
3.
4.
5.
Must provide residents access to the most recent survey and plan of correction
Must display the most recent survey results in a public area accessible to residents and visitors
Must post a notice of the availability of the most recent survey
Must not charge a fee to inspect the survey results
Must not alter the survey report in any way
 SECTION 33 - RIGHT TO WORK IN FACILITY
 33.1 - RIGHT TO WORK IN FACILITY
1. Residents have the right to perform work for the facility if he or she chooses
2. The facility must document the need or desire to work in the plan of care
3. The facility must document the nature of services to be provided and whether to be paid or voluntary
 SECTION 34 - PHYSICAL AND CHEMICAL RESTRAINTS
 34.1 – REQUIREMENTS
1. Residents have a right to be free from any chemical or physical restraints imposed for discipline or
convenience
2. Restraints may only be used for medical symptoms that warrant use of restraints
3. Medical symptoms that warrant restraints must be reflected in the comprehensive assessment and care plan
4. “Discipline” is action taken by a facility to punish or penalize a resident
5. “Restraint” - A manual or physical method or mechanical device, material or equipment attached or adjacent to
a resident’s body that restricts movement
6. “Convenience” Any action taken by the facility to control resident behavior to reduce staff effort and not in best
interest of the resident is called “convenience”
7. “Chemical Restraint” - A pharmacological drug used to discipline or for convenience and not required to treat
medical symptoms
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 34.2 - EXAMPLES OF PHYSICAL RESTRAINTS
1. Tucking in a sheet so tight that a bed bound residents cannot move
2. Placing residents in a chair to prevent rising
3. Placing residents in a wheel chair placed close to wall to prevent rising
 SECTION 35 - ABUSE
 35.1 – DEFINITIONS
“Abuse” – a willful infliction of injury, unreasonable confinement, intimidation pr punishment resulting in
physical harm or pain or mental anguish
“Verbal Abuse” - Oral, written or gestured language that threatens residents or their families
“Sexual abuse” - Sexual harassment, sexual coercion or sexual assault
“Physical Abuse” Hitting, slapping, punching and kicking
“Mental Abuse” - Humiliation, harassment, threats of punishment or deprivation
“Involuntary Seclusion” - Separating a resident from other residents or confinement to room against their will
1.
2.
3.
4.
5.
6.
 35.2 - PREVENTING MISTREATMENT OF RESIDENTS
1. The facility must prevent mistreatment and neglect and misappropriation of personal property
2. The facility must identify residents who present a threat to other residents
3. The facility must develop intervention strategies and monitor for changes that may trigger abusive behavior
between residents
4. The facility must report alleged violations, investigate allegations and report the results to
appropriate authorities
5. The facility must check the state nurse registry prior to hiring
6. The facility must do a criminal background check or investigate past histories of all employees considered for
hiring
 35.3 - ALLEGATION OF ABUSE OF A RESIDENT BY AN EMPLOYEE
1. Any abuse allegations must be immediately reported to the administrator and to other
officials according to state law
2. The facility must have evidence that all allegations are thoroughly investigated and steps were taken to
prevent further potential abuse while the investigation was in progress.
3. The results of the investigation must be reported to the administrator and state officials within 5 days of the
incident
 SECTION 36 - RESIDENT QUALITY OF LIFE
 36.1 – REQUIREMENTS
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
The facility must provide services per the comprehensive assessment and care plan
The facility must prevent to the extent practicable decline in ADL’s
The facility must will not be cited if a resident declines due to the resident’s clinical condition
Residents have a right to participate in activities both inside and outside of facility
Residents have a right to make choices about their own life
The facility must provide residents a humanizing and individualized environment
The facility must allow resident to dress in their own clothes
Residents should be groomed to feel attractive
Should not use bibs - use napkins instead
Should not use plastic cutlery and paper plates
Discourage aides and staff from yelling/talking while feeding residents
Must knock on doors before entering
Must ask permission to change television or radio channels
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n) Must address residents by name and look at them when talking with them
o) The facility can inspect all electrical appliances brought into the facility by residents
p) Residents have right to eat at any hour of the day they want
 36.2 - ACCOMMODATING RESIDENT NEEDS
1. Must help resident attain and maintain independent functioning, dignity and well being to the extent possible
in accord with resident preferences, assessment and care plan
2. The facility must accommodate resident activities and schedule bathing and eating times per resident
preferences
3. Residents must be notified in advance of planned room change or roommate change
4. Lack of access to hearing aid care, dental care, podiatric care can have negative impact on
resident well-being
 SECTION 37 - ACTIVITIES PROGRAM – REQUIREMENTS
 37.1 – OBJECTIVES
1.
2.
3.
4.
The activities plan for resident should meet the objectives of the comprehensive assessment
The activities program should stimulate resident’s cognitive, physical and psychosocial and emotional needs
A facility must post a calendar of planned activities throughout the facility
A facility must have sufficient staff to meet resident needs
 37.2 - PROGRAM DIRECTOR QUALIFICATIONS
1. The activities program director must have either:
a. Completed a state approved training course or
b. Be a qualified occupational therapist or occupational therapy assistant or
c. Be a qualified therapeutic specialist or activities professional.
 SECTION 38 - SOCIAL SERVICES PROGRAM
 38.1 – OBJECTIVES
1. The facility must attain or maintain the highest practicable physical, mental, and psychosocial well being of each
resident
2. The facility must assist residents in maintaining contact with family
3. The facility must Inform residents about their health status and health choices
4. The facility must obtain referrals and arranges services from outside entities
5. A facility with more than 120 beds is required to have a full time social worker
 38.2 - QUALIFICATIONS OF A SOCIAL WORKER
1. A qualified social workers must have a:
a) a) Have a bachelor’s degree in social work or human services (sociology, special education and
b)
rehabilitation counseling) and
c) b) One year of supervised social work experience in health care setting
 SECTION 39 - PHYSICAL ENVIRONMENT
 39.1 - PHYSICAL ENVIRONMENT
1. The facility must provide residents a safe, clean, comfortable and homelike environment
2. The facility must allow a resident to use their belongings
3. The administrator is responsible for the resident’s environment
4. The facility must keep sound levels down and maintain comfortable temperature levels
5. The environment consists of the following
a) Therapy rooms
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b) Hallways
c) Activity areas
 SECTION 40 - RESIDENT ASSESSMENT
 40.1 - RESIDENT ASSESSMENT
1.
The resident comprehensive assessment (MDS) is done with the resident Assessment Instrument (RAI) that is comprised of
the minimum data set (MDS) and utilization guidelines (which includes the RAPS (resident assessment protocols)
The minimum data set (MDS) describes the resident’s capability to perform daily life functions and significant impairments in
functional capacity.
The Comprehensive assessment must be completed within 14 days of admission
The Comprehensive assessment must be reviewed every 3 months to ensure the continued accuracy of the instrument
The resident must be re-assessed prior to the next scheduled review or annual assessment if the resident experiences a
significant change in physical and mental condition
The comprehensive assessment must be done every 12 months or since the last assessment if there was a significant
change in status
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
The comprehensive assessment is not required if the resident will be discharged within 14 days or less.
A registered nurse must certify the accuracy and completion of the resident assessment
Each person who completes a section must complete and sign each portion of the resident assessment they completed
The registered nurse coordinates assessments done by the various health professionals involved
It is a crime to knowingly certify information that is not true on a comprehensive assessment
The initial comprehensive assessment must be transmitted to the state within 7 days of completion of the assessment.
After transmission of the initial assessment, the facility must transmitted comprehensive assessment for all residents to
the state every 30 days.
 SECTION 41 - COMPREHENSIVE CARE PLAN
 41.1 - COMPREHENSIVE CARE PLAN
1.
2.
The comprehensive care plan must be developed within 7 days of the assessment.
The care plan is completed by an interdisciplinary team which must consist of all of the following:
a)
b)
c)
3.
4.
5.
6.
7.
A registered nurse
Attending physician
Appropriate staff in required disciplines
The care plan must have measurable objectives and timetables to meet a resident’s medical, nursing and mental and
psychosocial needs
The care plan must describe the services to be furnished to attain the resident’s highest, practicable, physical, mental and
psychosocial well being
The care plan must identify any other services required and being withheld due to the resident’s refusal of treatment
The care plan addresses the needs, strengths and preferences identified in the comprehensive assessment
The services provided to residents must be provided in accordance with the resident’s plan of care
 SECTION 42 - ADMISSION TO FACILITY
 42.1 - ADMISSION TO FACILITY
1.
2.
The order to admit a resident to the facility must be signed by a physician
The admission order should include the following:
a)
b)
c)
3.
4.
Dietary needs
Medication needs
Routine care instructions
Any individuals seeking admission to a skilled nursing facility must be screened by the DON to determine if the individual’s
needs can be meet by a facility
The assessment that is done to determine the level of services required for an individual with mental retardation (MR) and
mental impairment (MI) is called a PAS (pre-admission screening)
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 SECTION 43 - THERAPEUTIC DIET
 43.1 - THERAPEUTIC DIET
1. Significant weight loss of 5% within 1 month is significant
2. Significant weight loss = 7.5% within 3 months
3. Severe weight loss is greater than 10% within 6 months
 SECTION 44 - MEDICATION ERROR RATE
 44.1 - MEDICATION ERROR RATE
1. The allowable medication error rate in a facility is 5%
 SECTION 45 - NURSING SERVICES

45.1 – NURSING SERVICES
1.
2.
3.
4.
A facility must designate a licensed nurse to serve as a charge nurse on each tour of duty
A facility must have a registered nurse on duty 8 hours a day, seven days a week
A facility must designate a registered nurse as the director of nursing on a full time basis
The director of nursing can serve as the charge nurse in a facility with 60 or fewer residents
 SECTION 46 - DIETARY SERVICES
 46.1 - DIETARY STAFF
1.
2.
3.
4.
5.
The facility must employ a registered dietician on a full time, part time or consultant basis
A food services director must be employed if a dietician is not employed full-time
Food services director must have scheduled consultations with a registered dietician
The facility must provide a balanced, palatable meal that meets nutritional and special dietary needs
The facility must have sufficient dietary personnel to competently carry out the functions of dietary services to prepare
nutritious meals at the proper temperature and at appropriate times
6. The registered dietician must be registered with the American Dietetic Association
 46.2 - MENUS
1. Menus must be prepared every 4 weeks and in advance
2. Menus must be followed
3. Menus must be retained for 4 weeks
 46.3 - FOOD PREPARATION
1. Food must be prepared by methods that conserve nutritive value, flavor and appearance
2. The facility must serve food that is attractive, palatable and at room temperature
3. Food must be prepared in a form that meets individual needs
 46.4 - FOOD SUBSTITUTES
1. Residents have a right to refuse to eat a meal
2. The facility must offer a substitute of similar nutritive value and in form satisfactory to the resident
3. Therapeutic diets must be prescribed by an attending physician
 46.5 - DEFINITIONS
1. “Palatability” – Pertains to flavor and taste of food
2. “Food attractiveness”- Pertains to appearance of food when served to residents
3. The following affect the nutritive, flavor and appearance of food
a.
b.
Addition of baking soda
Holding on steam table
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c.
Cooking food in large volume of water
4. “Therapeutic diet” - a diet ordered by a physician as part of a treatment for a disease
5. “Mechanically altered diet” When the texture of food is altered
 46.6 – TIMING OF MEALS
1.
2.
3.
4.
5.
6.
Each resident must be served 3 meals each day
No more than 14 hours may pass between a substantial evening meal and breakfast
The facility must offer residents a nourishing snack in the evening
16 hours may pass between the evening meal and breakfast if a nourishing snack is served
A facility must provide residents with special eating equipment and utensils for residents who need them
Residents have the right to eat at any hour of the day and facility must have food available to feed them
 SECTION 47 - FOOD HYGIENE
 47.1 – FOOD PREPARATION AND STORAGE
1.
2.
3.
4.
5.
6.
7.
8.
9.
must procure food from approved sources
must store, prepare and distribute food under sanitary conditions
Proper food handling prevents spread of food-borne illness and contamination
Salmonella or botulinum are examples of toxigenic organisms
Salmonella comes from poultry
E-Coli comes from beef
Foods of plant origin can become hazardous if skin or peel is breached
The most common contributing factor for food-borne illness is improper holding temperature
Potentially hazardous foods deal with raw beef, poultry, fish and eggs
 47.2 – FOOD TEMPERATURES
1. Cold foods should be kept at 41F and below
2. Hot foods must be kept at 135F and above
3. The freezer temperature should be set at 0 F
 47.3 – FOOD STORAGE
1. Raw meats should be stored on the bottom shelf in the refrigerator
2. Vegetables and fruits should stored in the refrigerator above the meats
3. Food should be stored 6 inches off the floor
 47.4 – SINKS / DISHWASHING
1. A three compartment sink has a wash, rinse, sanitize compartments
1st compartment hot detergent water, 2nd contains clean water. 3rd contains sanitizer
2. A dishwasher that uses hot water wash and rinse cycles must have a
Initial wash cycle at 140 F, rinse cycle 160 F and final rinse cycle of 180 F
3. A low temperature dishwasher uses hot water at 120 F and bleach at 25 ppm of bleach
4. Hazardous foods focus on meat, eggs and poultry
 47.5 - GARBAGE REFUSE
1. Keep refuse containers in good shape (no leaks)
2. Keep dumpsters and compacter with lids covered
3. Keep garbage storage areas clean and odor free
 SECTION 48 – SPECIALIZED REHABILITATIVE SERVICES

48.1 - SPECIALIZED REHABILITATIVE SERVICES
1. Physical therapy – works with weight bearing muscles in lower body
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2. Speech language therapy – trains residents to speak and swallow
3. Occupational therapy – works with upper body and retrains residents in ADL’s, trains residents to use adaptive eating
utensils
4. Specialized rehabilitative therapy must be provided under the written order of a physician
 SECTION 49 - RESTORATIVE REHABILITATION
 49.1 - RESTORATIVE REHABILITATION
1. Restorative care is provided by the nursing department and involves low intensity physical exercise to maintain
physical functioning
 SECTION 50 - DENTAL SERVICES
 50.1 - DENTAL SERVICES
1.
2.
3.
4.
5.
Must assist residents in obtaining routine and 24 hour emergency dental care
Must provide or obtain from an outside source, routine and emergency dental services
Must assist residents in making appointments and arranging for transportation
Not required to pay for the expense for resident dental care – just assist residents to get needed services
The facility is required to pay for emergency dental care for Medicaid residents if they cannot afford such care and it is
medically necessary (infected tooth, etc)
 SECTION 51 - SKILLED NURSING FACILITY TERMS
 51.1 – SKILLED NURSING FACILITY TERMS
1. Under new federal rules, the nursing home is referred to as a Skilled Nursing Facility or a nursing facility
 SECTION 52 – PERSONAL CLINICAL RECORDS
 52.1 – PERSONAL CLINICAL RECORDS
1. Personal or clinical records include all of the following:
a)
b)
c)
d)
Medical history
Social history
Trust Fund account
Financial records
 SECTION 53 – REQUIRED NOTICE OF DISCHARGE
 53.1 – REQUIRED NOTICE OF DISCHARGE
1. A written notice of transfer or discharge must contain the following
a)
b)
c)
d)
The reason for transfer or discharge
The effective date of discharge
The location to be transferred or discharged
A statement that the notice can be appealed
2. A notice of discharge must include the name and address for all of the following:
a) The State long term care ombudsman
b) The agency for the protection of mentally ill individuals
c) The Agency for Health Care Administration
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 SECTION 54 – CONSCIENTIOUS OBJECTIONS/ADVANCED DIRECTIVES

54.1 – CONSCIENTIOUS OBJECTIONS TO IMPLEMENTING ADVANCED DIRECTIIVES
1. A facility cannot be forced to implement an advanced directive that violates its ethical, religious or
moral beliefs, provided it does all of the following
a) The facility must advise residents upon admission of its policies and procedures regarding conscientious
beliefs concerning advanced directives and limits to carrying out them out (withholding life prolonging
measures)
b) The facility must have a community education effort that explains the resident’s right to formulate advanced
directives
c) The facility must transfer the resident to a facility willing to provide treatment within 7 days
d) If a facility fails to transfer resident to willing provider within the required time period, the facility must provide
the requested treatment regardless of moral or ethical beliefs.
 SECTION 55.1 – MEDICAL TERMINOLOGY
Term
Definition
Abrasion
A scraping of the outer layer of the skin
Alzheimer’s
A progressive and incurable disease where the brain tissue and
structures are progressively destroyed
Analgesics
Used to treat pain – Tylenol or painkillers
Anemia
A decrease in the number of red blood cells
Aneurysm
A condition where the artery ruptures and causes uncontrolled bleeding
and hypotension where blood pressure falls to dangerously low levels
Anorexia
A loss of appetite where an individual literally starves themselves to
death because they perceive themselves as being overweight
Antacid
A chemical agent used to neutralize acid in the stomach that can cause
uncomfortable burning, gas and lead to ulceration of the lining of the
stomach (Tums)
Anti Anxiety
A chemical agent that acts in the brain to reduce anxiety (Ativan)
Anti Coagulants
A chemical agent that keeps cells in the blood from coagulating or
clumping together.
Anti Depressants
A chemical agent which uses serotonin reuptake inhibitors to improve
mood and lessen depression
Anti Inflammatory
Reduces inflammation
Anti psychotics
Used to treat symptoms of psychosis - Must have a documented and
valid rationale for using an anti psychotic medication
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Anti Virals
A medication used to inhibit the growth of viruses
Anti-Hypertensive
Medications designed to reduce the force of the heart muscle
contractions and lower blood pressure
Aphasia
Difficulty in finding or forming words - especially after a stroke
Aricept
A medication that slows the progression of Alzheimer’s and memory
loss
Aging
Aging is a highly individualized process that is different for each
individual
Arthritis
An inflammation of the joints
Aspiration
A condition where fluids go down the air passageway instead of the
esophagus
Asthma
A condition where the bronchial tubes constrict and the individual has
trouble breathing
Arteriosclerosis
A narrowing or blockage in arteries caused by plaque or cholesterol
Atherosclerosis
A hardening of the artery walls that weakens the artery and may rupture
if pressure of blood flowing through artery is very high (Hypertension)
Ativan
anti anxiety medication commonly prescribed in nursing homes
Bacteremia
Bacterial infection of the blood
BID
Twice a day
Bi-polar
A condition where a person moves between mania and depression
Blood Pressure
Normal range is 140/80
Blood Spills
Blood spills must be completely cleaned and sanitized
Bradycardia
A slow heart beat
Bronchitis
A condition where the lungs produce a lot of sputum or mucus
Bronchodilators
A medication that opens or dilates the bronchial tubes in the lungs
Bruise
A break in the skin that allows blood to seep into surrounding tissue
CABG
Coronary Artery Bypass Graft (arteries are taken from arms and legs
and used to replaced damaged arteries in the heart
CAD
Means "coronary artery disease"
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Calcium
A critical mineral for muscle contraction and blood flow
Cancer
A condition where cells grow at an uncontrollable rate and destroy
healthy cells in the body
Canula
A plastic tube that insert into the nostrils to supply oxygen to the lungs.
Carbohydrates
Carbohydrates such as starches and sugar are used by the body as
energy or fuel
Cardiac Recovery Therapy
Therapy designed to help an individual to recover from a heart attack
Cardiologist
A physician who specializes in the diseases of the heart
Cardiovascular system
The heart (cardio) pumps blood through a system of arteries and veins
which supplies oxygenated blood to the major organs and cells in the
body
CAT Scan
A scan of the brain
Cataracts
A condition where a thin layer of tissue develops over the pupil of the
eye and obstructs clear vision
Catheter
A catheter is a tube inserted directly into the bladder and it drains urine
directly into a collection bag. An indwelling catheter is changed every
30 days.
C-Diff
A common bacterial infection of the intestinal tract that causes serious
and unrelenting diarrhea for weeks at a time. Requires powerful
antibiotics to resolve the infection.
Cerebral Vascular System
A system of arteries and veins that supplies oxygen to the brain. A clot
in this system results in a stroke
Cerebrovascular Accident
A stroke or blockage of the flow of blood in the brain.
CHF
Means congested heart failure where fluid builds up in the heart and lungs because
of weakened heart valves
CMS
Means the Centers for Medicare and Medicaid services which administers all
Medicare and Medicaid contracts
Colace
Used to soften stools to produce a bowel movement
Colitis
Inflammation of the colon
Contusion
See Bruise
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Colostomy bag
A colostomy bag rests on top of the stomach and is attached to the stomach wall
COPD
Means "Chronic Obstructive Pulmonary Disease"
Coumadin
A commonly used blood thinner
CPM
Means "continuous passive motion machine" which used after a patient has had
knee replacement. The leg is placed on the machine and it automatically exercises
the leg and the new joint for hours on end.
CVA
See "Cerebrovascular accident"
Decongestants
A chemical that breaks up mucus in the lungs
Decubitus Sores
A decubitis (De-Cue-be-tus) sore is an opening in the upper and deeper layer of the
skin. Caused by lack of oxygen to skin tissue cells or friction or sheering by bones
rubbing against the skin. Stage 1 (red or inflamed patch of skin Stage 2 - a blister
of open sore Stage 3 - The skin is open and tissue loss extends to the upper layers
of the skin Stage 4 is tissue loss down to the muscle and down to the bone.
Delusions
An unshakeable belief that is not based in reality that their thoughts are being
controlled by others or to harm the individual in some way
Dentition
Refers to the teeth. Missing or broken teeth or teeth decay can make it difficult to
chew and swallow properly and may result in malnutrition
DHHS
Department of Health and Human Services
Diabetes Mellitus
A disease where the pancreas is not able to control insulin levels in the blood. There
are 2 types of diabetes - 1) is juvenile diabetes where you are born with the inability
to produce insulin and need to control glucose with daily insulin injections and type 2
is adult onset and can be treated with diet and tablets
Discharge Summary
The discharge summary can be the final progress note in the resident chart
Digestion
The process where the body extracts nutrients from food - digestion starts in the
mouth where is chewed and saliva starts dissolving the food
Disclosure of Ownership
Must notify the state when there is a change in personnel affecting the DON,
Administrator, governing body and corporate officers
Diuretics
A medication or agent that draws fluid from the body
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Drug Dose Reduction
A facility is required to have a process to continually review resident drug usage and
ensure individuals are taking the lowest effective dose possible
Drug Holiday
Skipping a medication 1 or 2 days a week
DX
Means diagnosis
Dysphasia
Trouble swallowing - especially after a stoke
Drug Administration Routes
1) Orally or by mouth 2) Sublingually (under the tongue) 3) IM - Intramuscular
injection 4) IV Intravenous injection and 5) rectal insertion.
Drug Label
Drug label must contain 1) name of resident, 2 name of drug, 3 mode of
administration 4 Dose amount 5) how often to administer drug and 6) expiration
date (Do not need physician name or manufacturer name)
Drug interaction
The effect of 2 or more drugs working at the same time
E-coli
A food borne illness found in beef
EEG
Electro Encephlo Graph measures electrical activity in the brain
EKG
Electro Cardio Graph measures electrical activity in the heart muscle
Embolism
Means a clot that travels from another part of the body
Emphysema
A respiratory disease where the lung tissue loses elasticity and cannot fully inflate
and deflate, causing breathlessness and decreased oxygenation to the body
Encephalitis
Swelling in the brain
End Stage renal failure
The final stage of renal failure where there is no urine production at all
Expectorants
A chemical agent used to encourage the lungs to expel mucus
Fecal Impaction
A serious condition where fecal matter in the intestines becomes extremely hard and
cannot pass through the rectum and builds up toxins in the body
Feeding assistants
feeding assistants or volunteers must be supervised by an LPN or RN
Formal Dispute Resolution
A process involving requesting a formal administrative hearing before an
administrative judge to appeal a citation
Gastro intestinal tract
Gastro = stomach Intestinal = Intestines digestive tract
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Gastronomy Tube
Means a Gastronomy tube or a tube inserted directly through the stomach wall and
into the stomach to pump liquefied food formula into the stomach
GERD
Gastroesophogeal reflux disease - acids in the stomach back up into the esophagus
and burn the fragile lining of the esophagus.
Gerontology
The study of aging
Glaucoma
A condition where pressure builds up in the eyes as fluids in the eye that normally
drain build up in the eye, pressing on the optic nerve, causing extreme pain and can
lead to blindness
G-Tube
Means a gastronomy tube or a tube inserted directly through the stomach wall and
into the stomach to pump liquefied food formula into the stomach
Hallucinations
A hallucination is the perception of the existence of a an external stimuli in the
environment that does not actually exist. Hallucinations are auditory, visual, touch
and smell.
Haldol
A powerful antipsychotic medication
HCFA
Means the Health Care Financing Administration which is responsible to set the rates
for Medicare reimbursements while the CMS administers Medicare and Medicaid
contracts
Hematoma
A collection of blood outside the blood vessels of an organ or soft tissue
Hemiplegia
Means paralysis of one side of the body
Heparin
This is an anti-coagulant - keeps cells from sticking together and forming a clot
Hepatitis
Inflammation of the liver
Holistic Care
Treating a person in their entirety as in their whole. For instance, a patient with high
blood pressure would not only be given an anti-hypertensive drug but also prescribed
stress management and relaxation, meditation, yoga, exercise and a healthy diet
Hormones
Hormones are chemical messengers in the blood and are used to send messages
between cells
HS
Dispense at night time
HTN
Means Hypertension (requires a low salt diet and exercise)
IM
Means intramuscular - injecting into the muscle
Hyperbaric Treatment
A procedure where a patient is place is a glass chamber filled with 100% oxygen to speed the
healing of wounds. Very expensive ($1K-2K per treatment)
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Incontinence
Unable to control bowel and bladder. 1) Stress incontinence is where you cough or laugh and
release urine, 2) urge incontinence is where you do not feel the urge to urinate and urinate
without warning and cannot get to the bathroom on time, 3) functional incontinence is failing to
get to the bathroom on time due to dementia or a physical problem, and 4) overflow
incontinence is where you do not completely empty the bladder and constant dribble of urine
Indwelling Catheter
A catheter that is left in the bladder for an extended period of time
Informal Dispute Resolution
This a process where a facility can informally write a letter or request a meeting with state
surveyor to review a citation and try to get it reduced or rescinded without going to a formal
administrative hearing
Insulin
Insulin is a hormone that controls glucose in the blood stream that is required by the cells for
energy to function. There are 3 types of insulin - 1) regular insulin, 2) Humalog insulin and 3)
Novalog insulin
IV
An intravenous injection where a substance is injected directly into the veins
Joints
The point where two pones join in the body
Kidney Stones
Kidney stones are actually calcium crystals that form into a solid mass that will
continue to expand and can damage or destroy the kidney
Laxatives
A medication or agent used to promote a bowel movement
Left Side Brain
Controls Right of Brain
Levin Tube
A levin tube is the same as a naso gastric tube
Librium
A medication is that used to treat individuals who are actively undergoing alcohol
withdrawal
Low Fat Diet
A diet intended to reduce cholesterol in the blood stream and to reduces blockage
and plaque build up in the arteries (arteriosclerosis)
Low Salt Diet
A diet that restricts salt which can increase blood pressure
Macular Degeneration
A loss of vision in the central field of vision and the individual can see left of center
and right of center but not the central point of what they are looking at.
MDS
MDS is the comprehensive assessment. 2. Must complete the comprehensive
assessment within 14 days of admission (5 days for Medicaid resident). 3. The
MDS is transmitted by modem or computer to the state. 4. Most keep most recent
MDS in active chart but keep 15 months on hand- since last survey 5. MDS is a
federal requirement under OBRA 1987
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Medical Records
Belong to the Facility
Medication Errors
Allowable medication error rate is 5%. A medication error is where a med is
administered to the wrong patient, in the wrong dosage, wrong route of
administration, wrong time, and wrong medication,
Medicare Part A
Pays for inpatient services while in a hospital or nursing home
Medicare Part B
Pays for doctors visits, outpatient physical therapy and lab tests when an individual
lives at home
Medicare Part D
Pays for prescription drugs
Medication Stop Order
The physician must be notified before a medication with a stop order is refilled. This
order limits the amount of refills allowed for a medication
Metabolism
The process the body uses to process or manufacture the substances necessary to
maintain life. For example, the body will either burn energy store energy if not
needed and you will either lose weight or gain weight
Metastasis
A condition where cancer cells move from one part of the body to other parts of the
body
Milieu Therapy
Therapy that uses the environment
MRI
Magnetic resonance imaging - uses magnetic waves to get a picture of the body
MRSA
A bacterial infection that is highly resistant to anti-biotics
Musculoskeletal System
The system of bones, joints and connecting muscles and tendons
Music Therapy
Using music as therapy
Myocardial Infarction
An infarct is a heart attack
Namenda
A medication effective in slowing the process of memory loss
Nasogastric Tube
A tube that is inserted through the nose and down the esophagus to feed an
individual who cannot swallow foods
Nebulizer
A machine that pumps a mist that contains a decongestant into the lungs to break
up the mucus and improve breathing
Nephritis
Inflammation of the kidneys
Nephrologist
A physician who specializes in kidney disorders
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Neurologist
A physician who specializes in disorders of the brain and nervous system
NG Tube
Means a naso gastric tube - see "naso gastric tube"
NIOSH
Means the National Institute of Occupational Safety and Health which provides
research to OSHA
Nosocomial
Means an infection that develops while an individual is a patient in that institution (
acquired in-house as opposed to came with it from the hospital or from home)
Nurse Practice Control Act
Nurses are licensed under state nurse practice control acts that define their
professional and ethical responsibilities in nursing activites
Nursing Hours
determined by the states - approved by federal government – must post hours in
lobby
Nutrients
Provides energy to body's cells
OIG
Office of Inspector General - investigates Medicare and Medicaid fraud
Oncologist
A physician who specializes in diagnosing and treating cancer
ORIF
Means "Open Reduction Internal Fixation" - a common procedure to replace a hip
or knee joint
Osteoarthritis
Arthritis of the joints
Otologist
A hearing specialist
Oxygen concentrator
A machine that can synthesize oxygen up to 5 liters
Palliative care
Palliative care is providing a person care that alleviates pain and maintain highest
functioning and comfort. When used in hospice care, a terminally ill patient would
not be provided aggressive treatment like radiation or chemotherapy to treat a
terminal illness, they would be provided other care and treatment.
Paraplegia
Paralyzed from the waist down
Parkinson’s
A progressive disease characterized by shuffling gait, slurred speech and tremors.
Person Centered Care
Focuses on resident's total quality of life
Physiatrist
A physician who specializes in the musculo-skeletal system and works closely with
physical therapy. Do not confuse with psychiatrist
Physical Restrains
check restraints every 30 minutes, release every 2 hours for 1 hr
Physician Desk Reference
A reference book that lists all medications, purpose and size effects
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PO
Physician order
Plegia
Means paralysis
Pneumonia
A build of fluid in lungs
Poly Pharmacy
Taking several drugs at the same time (7.2 or more drugs)
Potassium
A mineral essential in maintaining electrolytes in our body
Pressure Sores
See "Decubitis Sores"
PRN
Means dispense when requested. Patient must request treatment or medication
Prophylactic
A treatment used to prevent development of disease (i.e., a vaccine)
Prostatitis
An inflammation of the prostate gland
Psychiatrist
A physician who specializes in mental disorders and psychiatric illness
Psychologist
A health care professional who provides clinical counseling to individuals
QD
Dispense every day
QH
Dispense every hour
QOD
Dispense every other day
QOH
Dispense every other hour
Quadriplegia
Paralyzed from the neck down
RAI
Resident assessment instrument - comprised of the MDS, RAPs or resident
assessment protocols and guidelines for using the MDS and RAPs
Reality Orientation
A therapy that uses clocks, calendars and current events to help individuals to
orient to time
Red Blood Cells
Blood cells that carry oxygen to the body
Regular Insulin
See" insulin"
Registered dietician
The registered dietician responsible to document resident food preferences, track
weight gain and loss, assess nutritional needs and to review resident dietary
status at least weekly.
Renal failure
A condition where the kidneys do not function properly
Renal System
Pertains to the kidneys
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Respite Care
This type of benefit is designed to provide a caretaker a brief respite or vacation
from caring for an individual who requires 24 hour care at home. Medicare,
insurance and the VA will pay to care for an individual for up to 2 weeks under
respite care.
Rheumatoid Arthritis
A form of arthritis where the immune system attacks the joints and causes
deformation, inflammation and pain
Right side of Brain
Controls Left side of body
RX
Means a prescription
Salmonella
Food borne illness found in chicken. Imagine a 6 foot yellow chicken with a name
tag that says "SAL"
Scabies
A condition caused by an insect like a tick that burrows beneath the skin and lays
eggs which causes severe irritation and itching. Highly contagious and once
discovered all affected individuals and their immediate bedding, clothing and room
must be thoroughly cleaned and the individuals treated with a powerful medication
that kills the ticks.
Septicemia
An infection of the blood
Sepsis
See “Septicemia”
Seroquel
An anti psychotic medication commonly prescribed for nursing home residents to
treat agitation.
Shingles
A condition caused by the same virus that causes chicken pox. The virus infects
the nerves in the lower back and can cause itching and pain when in an active
infectious state
Significant change
A significant change in an individual's physical, mental and psycho-social well
being – must process in 14 days – mild pneumonia is not a significant change
SOB
Shortness of Breath
Sodium
A mineral essential in regulating fluid in the body
Social Worker
Cannot provide psychiatric therapy
Sphygmomanometer
Sphygmomanometer or blood pressure meter is a device used to measure blood
pressure, comprising an inflatable cuff to restrict blood flow, and a mercury or
mechanical manometer to measure the pressure.
Spirometer
A graduated tube you blow into that measures the force of the air expelled by the
lungs
Stat
Means immediately
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Significant change
A significant change must be processed within 14 days
Stool Softeners
Colace loosens hard stools or fecal matter in the intestines that can be become
very hard in people who are dehydrated and can lead to fecal impaction
Stroke
A blockage of blood flow in the brain results in lack of oxygen and damage to brain
cells
Stroke Therapy
Therapy used with an individual who suffered a stroke Anti-coagulants would be
main treatment for stroke to prevent further clots and damage to the brain
Syncope
A condition where an individual feels lightheaded upon suddenly standing and can
result in unconsciousness
TIA
A trans ischemic Attack – a small clot in the brain that temporally block blood flow
in the brain but is dislodged before major damage to the brain cells
TID
Three times a day
Tintinitis
A disorder where there is a ringing in the ears
TO
Telephone order - an order that is phoned into a facility by a physician that must be
signed on the next visit
.
A fast heart beat
Tachycardia
Tardive Dyskinesia
A syndrome where an individual constantly smacks their lips and is unable to
control facial expressions
Tort
Civil wrong or negligence
Tracheotomy
Means the removal of the tracheal tube
Trans Ischemic Attack
See "TIA"
Tuberculosis
A disease where bacteria damages the lungs
TX
Means treatment
Tylenol
An analgesic that reduces pain
Ulcer
A condition where the lining of a the stomach has been damaged
Validation Therapy
Therapy used with patient with severe dementia where the therapist places their hands
on their face and communicates with the individual by looking into their eyes and
mirroring the facial gestures and sounds they make
Vasodilators
A medication that opens up or dilates the arteries and veins and increases blood flow
Weight loss
Main reason for weight loss is poor dentition (broken teeth, cavities)
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White Blood Cells
These blood cells are critical to your immune system since they can detect and destroy
invading cells
Zoloft
An anti-depressant/anti psychotic medication
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Study Notes
Page
Exam #
Comment/Problem
Done
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
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