CMS Manual System - Louisiana Department of Health and Hospitals

Interpretive Guidelines §483.10(b)(3)
―Total health status‖ includes functional status, medical care, nursing care, nutritional
status, rehabilitation and restorative potential, activities potential, cognitive status, oral
health status, psychosocial status, and sensory and physical impairments. Information on
health status must be presented in language that the resident can understand. This
includes minimizing use of technical jargon in communicating with the resident, having
the ability to communicate in a foreign language and the use of sign language or other
aids, as necessary. (See §483.10(d)(3), F175, for the right of the resident to plan care and
treatment.)
Procedures §483.10(b)(3)
Look, particularly during observations and record reviews, for on-going efforts on the
part of facility staff to keep residents informed. Look for evidence that information is
communicated in a manner that is understandable to residents and communicated at times
it could be most useful to residents, such as when they are expressing concerns, or raising
questions, as well as on an on-going basis.
§483.10(d)(2) – The resident has the right to be fully informed in advance about care
and treatment and of any changes in that care or treatment that may affect the
resident’s well-being;
Interpretive Guidelines §483.10(d)(2)
―Informed in advance‖ means that the resident receives information necessary to make a
health care decision, including information about his/her medical condition and changes
in medical condition, about the benefits and reasonable risks of the treatment, and about
reasonable available alternatives.
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F155
§483.10(b)(4) -- The resident has the right to refuse treatment, to refuse to
participate in experimental research, and to formulate an advance directive as
specified in paragraph (8) of this section; and
Interpretive Guidelines §483.10(b)(4)
―Treatment‖ is defined as care provided for purposes of maintaining/restoring health,
improving functional level, or relieving symptoms.
―Experimental research‖ is defined as development and testing of clinical treatments,
such as an investigational drug or therapy, that involve treatment and/or control groups.
For example, a clinical trial of an investigational drug would be experimental research.