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assists in monitoring responses to interventions. Monitoring residents who experience unplanned weight loss, including reweighing at least weekly until weight is stable or increasing and then routinely thereafter, helps clarify his/her responses to interventions. However in some residents, subsequent weight monitoring may not be clinically indicated (e.g., palliative care resident). Nutrition-related goals may need to be modified, depending on factors such as further clarification of underlying causes (e.g., when evidence suggests that unmodifiable factors may prevent improved or stabilized nutritional status) and responses to current interventions. In some cases, the current plan of care may need to be modified and new or additional interventions implemented. The facility explains any decisions to continue current interventions when the resident‘s nutritional status continues to decline. For example, because the goal of care for someone with a terminal, advanced, or irreversible condition has changed to palliation. ENDNOTES 1 Vella, C., & Kravitz, L. (2002). Sarcopenia: The mystery of muscle loss. IDEA Personal Trainer, 13(4), 30-35 2 3 4 5 Thomas, D.R. (2002). Distinguishing starvation from cachexia. Clinics of Geriatric Medicine, 18(4), 883-892. VanItallie, T.B. (2003). Frailty in the elderly: Contributions of sarcopenia and visceral protein depletion. Metabolism, 52(10), Supplement 2 (October), 22-26. Morley, J.E., & Thomas, D. R. (Eds). (2007) Geriatric Nutrition. Boca Raton: CRC Press Bouras, E.P., Lange, S.M., & Scolapio, J.S. (2001). Rational approach to patients with unintentional weight loss. Mayo Clinic Proceedings, 76(9), 923-929. 6 Kieselhorst, K.J., Skates, J., & Pritchett, E. (2005). American Dietetic Association: Standards of practice in nutrition care and updated standards of professional performance. Journal of the American Dietetic Association, 105(4), 641-645. 7 Lacey, K. & Pritchett, E. (2003). Nutrition care process and model: ADA adopts road map to quality care and outcomes management. Journal of the American Dietetic Association, 103(8), 1061-1072. 8 Walker, G. (Ed.) (2005). Pocket Guide for Nutrition Assessment. Chicago, IL: Consulting Dietitians in Healthcare Facilities. 9 Thomas D.R., Tariq, S.H., Makhdomm S., Haddad R., & Moinuddin A. (2003). Physician misdiagnosis of dehydration in older adults. Journal of the American Medical Directors Association, 4(5), 251–254. 10 Wilson, M.G., Thomas, D.R., Rubenstein, L.Z., Chibnall, J.T., Anderson, S., Baxi, A., Diebold, M., & Morley, J.E. (2005). Appetite assessment: Simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents. American Journal of Clinical Nutrition, 82(5), 1074-1081.
11 Chouinard, J. (2000). Dysphagia in Alzheimer‘s disease: A review. Journal of Nutrition, Health and Aging, 4(4), 214-217. 12 Pronsky ZM, Crowe JP, Young VSL, Elbe D, Epstein S. Food-medication interactions, 14th Edition. Food Medications Interactions 2006. 13 Sullivan, D.H. (2001). What do the serum proteins tell us about our elderly patients? Journal of Gerontology Series A: Biological Sciences and Medical Sciences, 56(2), M71-M74. 14 15 16 17 Covinsky, K.E., Covinsky, M.H., Palmer, R.M., & Sehgal, A.R. (2002). Serum albumin concentration and clinical assessments of nutritional status in hospitalized older people: Different sides of different coins? Journal of the American Geriatrics Society, 50(4) 631- 637 American Dietetic Association. (2005). Position of the American Dietetic Association: Liberalization of the diet prescription improves quality of life for older adults in long-term care. Journal of the American Dietetic Association, 105, 1955- 1965. Mathus-Vliegen, E.M. (2004). Old age, malnutrition, and pressure sores: An ill-fated alliance. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 59(4), M355-M360. Alzheimer‘s Association. (2006). Eating, Retrieved July 27, 2006 from http://www.alz.org/living_with_Alzheimers_eating.asp 18 Groher, M.E. & McKaig, T.N. (1995). Dysphagia and dietary levels in skilled nursing facilities. Journal of the American Geriatric Society, 43(5), 528-532. 19 20 21 Kikawada, M., Iwamoto, T., & Takasaki, M. (2005). Aspiration and infection in the elderly. Drugs Aging, 22(2), 115-130. Loeb, M.B., Becker, M., Eady, A., & Walker-Dilks, C. (2003). Interventions to prevent aspiration pneumonia in older adults: A systematic review. Journal of the American Geriatrics Society, 51(7), 1018-1022. Feinberg, M.J., Knebl, J., & Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over 3 years. Dysphagia, 11(2), 104-109. 22 Mamun, K., & Lim, J. (2005). Role of nasogastric tube in preventing aspiration pneumonia in patients with dysphagia. Singapore Medical Journal, 46(11), 627-631. 23 24 Pronsky ZM, Crowe JP, Young VSL, Elbe D, Epstein S. Food-medication Interactions, 14th Edition. Food Medications Interactions 2006. Thomas, D.R. (2006). Guidelines for the use of orexigenic drugs in long-term care. Nutrition in Clinical Practice, 21(1), 82-87.
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CMS Manual System Pub. 100-07 State
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State Operations Manual Appendix PP
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§483.25(n) Influenza and Pneumococ
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(including eligibility, coverage, c
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___________________________________
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Procedures §483.10(a)(3) and (4) D
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―Advance directive‖ means a wri
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§483.10(b)(5) -- The facility must
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Provide written information concern
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___________________________________
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§483.10(c)(3) Deposit of Funds (i)
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Were limits placed on amounts that
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___________________________________
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(B) Dietary services as required at
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medical service that is recognized
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satisfactorily resolved by discussi
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(i) Transfer to another health care
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Interpretive Guidelines §483.10(g)
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(ii) Any representative of the Stat
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___________________________________
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efore the resident may exercise tha
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§483.12(a) Transfer, and Discharge
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§483.10(o), Tag F177, addresses th
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Look for changes in source of payme
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How to notify the ombudsman (name,
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___________________________________
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Interpretive Guidelines §483.12(d)
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Interpretive Guidelines §483.12(d)
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―Convenience‖ is defined as any
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order reflecting the presence of a
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consistently implemented. Determine
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monitored separation from other Res
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to prevent occurrences, monitoring
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injurious behaviors, residents with
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A certified nurse aide found guilty
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o Day-to-day use of plastic cutlery
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for the resident‘s safety. For ex
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If a facility changes its policy to
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___________________________________
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Staff should strive to reasonably a
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egarding medical information. The f
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The report stated that, ―Resident
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If not contraindicated, modifying t
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o Visual interaction and to compens
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For residents from diverse ethnic o
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Encouraging volunteer-type work tha
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12 Christenson, M.A. (1996). Enviro
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selected this activity. The Nationa
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Interview the social services staff
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Identifies how the facility will pr
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o Determine if the facility has acc
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(ii) Has 2 years of experience in a
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Once the team has completed its inv
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___________________________________
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transportation services that are no
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F252 (Rev. 66, Issued: 10-01-10, Ef
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Although this Tag can be used for i
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___________________________________
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___________________________________
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Intent §483.20 To provide the faci
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(vii) Psychosocial well-being ―Ps
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___________________________________
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Resident‘s decision making change
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___________________________________
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(i) Admission assessment. (ii) Annu
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Completing an assessment that is no
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Interpretive Guidelines §483.20(h)
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Submitting correction(s) to informa
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If the resident has refused treatme
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. Do the dietitian and speech thera
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Are physicians‘ orders carried ou
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What types of pre-discharge prepara
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If the resident‘s PAS report indi
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Briefly review the assessment, care
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and knowledge of the resident, shou
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Determine whether the facility had
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NOTE: Guidance regarding pressure u
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The resident has the right to refus
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others being hypersensitivity, idio
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Examples of clinical resources avai
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indicators which may represent pain
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• Impact of pain on quality of li
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National Center for Complementary a
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3 National Center for Complementary
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The objective of this protocol is t
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How effective the interventions hav
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Nurse Interview. Interview a nurse
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Communicated with the health care p
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qualified persons with input from t
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of pain. First, the team must rule
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The resident experienced daily or l
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Extensive Assistance - While reside
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Procedures: §483.25(a)(1)(ii) Dete
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Identify if resident triggers CAAs
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USE OF SPEECH, LANGUAGE, OR OTHER F
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___________________________________
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Probes: §483.25(b) Identify if res
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―Debridement‖- Debridement is t
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OVERVIEW A pressure ulcer can occur
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procedures, during prolonged ambula
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Assessment of a resident‘s skin c
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Both urine and feces contain substa
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use of lifting devices for repositi
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in accord with resident‘s overall
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Whether pain, if present, is being
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Some clinicians utilize validated i
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generally impairs wound healing, se
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15 Fuhrer M., Garber S., Rintola D.
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of Localized Chronic Wound Infectio
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Previously unidentified open areas;
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complications including reassessmen
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If not, the development of the pres
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o Determine if the care plan was pe
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Examples of possible avoidable nega
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(Rev. 66, Issued: 10-01-10, Effecti
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later stages of dementia, diabetes,
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the resident‘s concerns and offer
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Functional and cognitive capabiliti
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toileting and response to specific
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cognitive deficit—provided that t
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the epidermis (comparable to a deep
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adequate. Based on the resident‘s
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Follow-Up of UTIs rectal temperatur
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9 Maki, D.G. & Tambyah, P.A. (2001)
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Whether the resident is on a schedu
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catheter/continence services. Reque
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Defines the catheter, tubing and ba
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If the attending physician is unava
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Assess, prevent (to the extent poss
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perform relevant activities of dail
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Requires immediate correction, as t
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The failures of the facility to pro
Page 265 and 266: Identify if resident triggers CAAs
Page 267 and 268: Probes: §483.25(f)(1) For sampled
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Page 271 and 272: Using universal precautions and cle
Page 273 and 274: Monitor the effectiveness of the
Page 275 and 276: Directs resources to address safety
Page 277 and 278: Monitoring is the process of evalua
Page 279 and 280: those (e.g., disease, environment)
Page 281 and 282: Addressing the factors for the fall
Page 283 and 284: 155°F 148°F 140°F 133°F 127°F
Page 285 and 286: NOTE: The Safe Medical Devices Act
Page 287 and 288: ENDNOTES 1 Centers for Medicare & M
Page 289 and 290: Use To evaluate whether the facilit
Page 291 and 292: 2. Interview The adequacy of the su
Page 293 and 294: Changes in condition such as the ab
Page 295 and 296: Noncompliance for F323 After comple
Page 297 and 298: Once the survey team has completed
Page 299 and 300: Unsafe wandering and/or elopement t
Page 301 and 302: Severity Level 1 Considerations: No
Page 303 and 304: ―Qualified dietitian‖ refers to
Page 305 and 306: Current standards of practice recom
Page 307 and 308: dry mouth, and diseases of the orop
Page 309 and 310: Based on analysis of relevant infor
Page 311 and 312: For many residents (including overw
Page 313 and 314: In deciding whether and how to inte
Page 315: End-of-Life Resident choices and cl
Page 319 and 320: Objectives Use INVESTIGATIVE PROTOC
Page 321 and 322: Nutrition interventions, such as sn
Page 323 and 324: Whether the facility identified res
Page 325 and 326: Review of Facility Practices Relate
Page 327 and 328: 42 CFR §483.20(b)(1), Tag F272, Co
Page 329 and 330: DEFICIENCY CATEGORIZATION (Part IV,
Page 331 and 332: If immediate jeopardy has been rule
Page 333 and 334: Intent §483.25(j) The intent of th
Page 335 and 336: Is proper administration technique
Page 337 and 338: §483.25(k)(5) Standard: Tracheal S
Page 339 and 340: (v) In the presence of adverse cons
Page 341 and 342: physical actions such as: pacing, c
Page 343 and 344: o Support decisions about modifying
Page 345 and 346: individual with dementia, to improv
Page 347 and 348: Medication management is based in t
Page 349 and 350: Whether the signs, symptoms, or rel
Page 351 and 352: o Pain; o Chronic psychiatric illne
Page 353 and 354: Common Conditions/ Symptoms Example
Page 355 and 356: Identifying the essential informati
Page 357 and 358: necessarily indicate a need for dos
Page 359 and 360: Sometimes, the decision about wheth
Page 361 and 362: The continued use is in accordance
Page 363 and 364: J., & Bates, D.W. (2005). Incidence
Page 365 and 366: (NSAIDs) Medication Issues and Conc
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Antibiotics Medication Issues and C
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Medication Issues and Concerns prim
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Medication Issues and Concerns Mono
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chlorpropamide glyburide Antifungal
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Medication Issues and Concerns MAO
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Medication Issues and Concerns days
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Medication Issues and Concerns Medi
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uspirone Medication Issues and Conc
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Medication Issues and Concerns amio
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Medication Issues and Concerns Angi
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Nitrates, e.g., Medication Issues a
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Medication Issues and Concerns Anti
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Medication Issues and Concerns esom
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Medication Issues and Concerns laxa
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Medication Issues and Concerns Resp
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Medication Issues and Concerns hygi
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Medication Issues and Concerns All
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iperiden trihexyphenidyl olanzapine
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NOTE: This review is not intended t
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If during the review, you identify
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How he/she approaches the MRR proce
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o Failure to monitor a medication c
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42 CFR 483.20(b), F272, Comprehensi
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Complications (such as diarrhea wit
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NOTE: If Severity Level 3 (actual h
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―Resident Condition‖ -- The res
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Medication Errors Due to Failure to
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Medications Administered with Enter
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if the facility uses the ―recap
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technique requires a comparison of
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eaction to the vaccine than would h
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o Persons who are 50 years of age o
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Sampling: To determine if education
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Processes to address issues that ar
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The facility failed to document tha
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Requires immediate correction as th
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(ii) other nursing personnel. §483
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(3) The State finds that, for any p
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(A) Has only patients whose physici
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For SNFs and SNF/NFs which may be w
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Assessing special nutritional needs
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Probes: §483.35(c)(1) Are resident
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___________________________________
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Interpretive Guidelines: §483.35(f
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―Food Preparation‖ refers to th
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for growth of harmful pathogens. Ba
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Source of Primary Agents of Primary
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Food Receiving and Storage When foo
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specified below will either kill da
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may consist of a combination of foo
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at the manifold, which is the area
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INVESTIGATIVE PROTOCOL SANITARY CON
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2. Interview Observe that foods are
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cooling, and ensure that PHF/TCS fo
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2. Degree of harm (actual or potent
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Severity Level 1 Considerations: No
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Intent: §483.35(h) The intent of t
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Whether they are assisting assigned
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and drink. If concerns are identifi
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Compliance with 42 CFR 483.35(h), F
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eligibility to eat and drink with a
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Examples of the facility‘s non-co
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delegating and supervising follow-u
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Probes: §483.40(b) Do services ord
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For what reasons are residents sent
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(2) Obtain the required services fr
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Probes: §483.45(a)(1)(2) 1. For ph
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a care plan must be developed, foll
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Are residents missing teeth and may
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Definitions are provided to clarify
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The National Coordinating Council f
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Establish procedures that address m
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How the receipt of medications from
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Documentation of actual disposition
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the pharmaceutical services. Fourth
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The facility‘s failure to involve
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The facility in collaboration with
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(2) The pharmacist must report any
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errors, or other irregularities, an
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NOTE: The surveyor‘s review of me
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o Seizure activity; o Spontaneous o
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Common Medication-Medication Intera
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The identification of any irregular
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aspects of pharmaceutical services.
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The pharmacist‘s MRR failed to id
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(3) Determines that drug records ar
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During a medication pass, medicatio
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This requirement has several aspect
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Determine whether the noncompliance
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§483.65 Infection Control The faci
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―Contact precautions‖ are measu
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Critical aspects of the infection p
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Conducting data analysis to help de
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observations of staff practices and
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Complications from invasive diagnos
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Airborne transmission can occur by
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After removing gloves or aprons; an
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Depending on the situation, options
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tears or holes be replaced. It is r
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ENDNOTES 68 Siegel, J.D., Rhinehart
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Guidelines for environmental infect
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INVESTIGATIVE PROTOCOL FOR INFECTIO
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Multiple use items (e.g., shower ch
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Interview the Designated Infection
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Utilize infection precautions to mi
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Properly implement transmission bas
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influenza in residents on another,
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§483.70(a)(6)(ii) The dispensers a
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Additional guidance is available in
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§483.70(d)(1)(i) Accommodate no mo
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Procedures: §483.70(d)(1)(iv) Ther
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Interpretive Guidelines: §483.70(d
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centralized nursing station, this c
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Are spaces adaptable for all intend
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defined as substandard quality of c
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(ii) Responsible for the management
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Probes: §483.75(e)(2 - 4) During a
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1919(e)(2)(A) of the Act the facili
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Interpretive Guidelines: §483.75(f
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The medical director helps the faci
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MEDICAL DIRECTION The facility is r
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The medical director is responsible
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REFERENCES 1 Pattee JJ, Otteson OJ.
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support with ventilators, intraveno
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The medical director provides input
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V. DEFICIENCY CATEGORIZATION (Part
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NOTE: If immediate jeopardy has bee
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Intent: §483.75(j)(1) The intent o
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Probes: §483.75(j)(1)(i) - (iv) Ar
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An inability to order radiological
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There is a written policy, at the h
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If there is a problem with confiden
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(i) Residents will be transferred f
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Preventing deviation from care proc
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Meetings of the QAA committee must
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INVESTIGATIVE PROTOCOL QUALITY ASSE
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The assigned surveyor should interv
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2. Degree of harm (actual or potent
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The facility‘s QAA committee meet
Page 646 and 647:
R04SOM 11/12/2004 Guidance to Surve
Page 648 and 649:
e. Special Care Fl19____ Receiving
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Form CMS-672 (10/10) ReSIDent CenSu
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Form CMS-672 (10/10) ReSIDent CenSu
Page 654 and 655:
DEPARTMENT OF HEALTH AND HUMAN SERV
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22. Psychoactive Medications: If th
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16. Weight Change/Nutrition/Swallow
Page 660 and 661:
RESIDENT REVIEW WORKSHEET (continue
Page 662:
RESIDENT REVIEW WORKSHEET (continue
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