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Medication Issues and Concerns safety; and E. Not due to psychological stressors (e.g., loneliness, taunting, abuse), or anxiety or fear stemming from misunderstanding related to his or her cognitive impairment (e.g., the mistaken belief that this is not where he/she lives or inability to find his or her clothes or glasses) that can be expected to improve or resolve as the situation is addressed After initiating or increasing the dose of an antipsychotic medication, the behavioral symptoms must be reevaluated periodically to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose Exception: When antipsychotic medications are used for behavioral disturbances related to Tourette‘s disorder, or for non-psychiatric indications such as movement disorders associated with Huntington‘s disease, hiccups, nausea and vomiting associated with cancer or cancer chemotherapy, or adjunctive therapy at end of life. Inadequate Indications Dosage In many situations, antipsychotic medications are not indicated. They should not be used if the only indication is one or more of the following: 1) wandering; 2) poor self-care; 3) restlessness; 4) impaired memory; 5) mild anxiety; 6) insomnia; 7) unsociability; 8) inattention or indifference to surroundings; 9) fidgeting; 10) nervousness; 11) uncooperativeness; or 12) verbal expressions or behavior that are not due to the conditions listed under ―Indications‖ and do not represent a danger to the resident or others. Doses for acute indications (for example, delirium) may differ from those used for long-term treatment, but should be the lowest possible to achieve the desired therapeutic effects Daily Dose Thresholds for Antipsychotic
Medication Issues and Concerns Medications Used to Manage Behavioral Symptoms Related to Dementing Illnesses Generic Medication Dosage First Generation chlorpromazine 75 mg fluphenazine 4 mg haloperidol 2 mg loxapine 10 mg molindone 10 mg perphenazine 8 mg pimozide * prochloroperazine * thioridazine 75 mg thiothixene 7 mg trifluoperazine 8 mg Second Generation aripiprazole 10 mg clozapine 50 mg olanzapine 7.5 mg quetiapine 150 mg risperidone 2 mg ziprasidone * * Not customarily used for the treatment of behavioral symptoms References: Katz, I.R. (2004). Optimizing atypical antipsychotic treatment strategies in the elderly. Journal of the American Geriatrics Society, 52, pp. 272-277. Schneider, L.S. (2005). Risk of death with atypical antipsychotic drug treatment for dementia. Metaanalysis of randomized placebo controlled trials. Journal of the American Medical Association, 294, pp. 1934-1943. Saltz, B.L., Woerner, M.G., Robinson, D.G., & Kane, J.M. (2000). Side effects of antipsychotic drugs: Avoiding and minimizing their impact in elderly patients. Postgraduate Medicine, 107, pp. 169- 178. Duration If used to manage behavior, stabilize mood, or treat a psychiatric disorder, refer to Section V –
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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
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Identify if resident triggers CAAs
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Probes: §483.25(f)(1) For sampled
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___________________________________
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Using universal precautions and cle
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Monitor the effectiveness of the
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Directs resources to address safety
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Monitoring is the process of evalua
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those (e.g., disease, environment)
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Addressing the factors for the fall
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155°F 148°F 140°F 133°F 127°F
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NOTE: The Safe Medical Devices Act
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ENDNOTES 1 Centers for Medicare & M
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Use To evaluate whether the facilit
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2. Interview The adequacy of the su
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Changes in condition such as the ab
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Noncompliance for F323 After comple
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Once the survey team has completed
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Unsafe wandering and/or elopement t
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Severity Level 1 Considerations: No
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―Qualified dietitian‖ refers to
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Current standards of practice recom
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dry mouth, and diseases of the orop
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Based on analysis of relevant infor
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For many residents (including overw
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In deciding whether and how to inte
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End-of-Life Resident choices and cl
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11 Chouinard, J. (2000). Dysphagia
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Objectives Use INVESTIGATIVE PROTOC
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Nutrition interventions, such as sn
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Whether the facility identified res
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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
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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
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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
Page 367 and 368: Antibiotics Medication Issues and C
Page 369 and 370: Medication Issues and Concerns prim
Page 371 and 372: Medication Issues and Concerns Mono
Page 373 and 374: chlorpropamide glyburide Antifungal
Page 375 and 376: Medication Issues and Concerns MAO
Page 377: Medication Issues and Concerns days
Page 381 and 382: uspirone Medication Issues and Conc
Page 383 and 384: Medication Issues and Concerns amio
Page 385 and 386: Medication Issues and Concerns Angi
Page 387 and 388: Nitrates, e.g., Medication Issues a
Page 389 and 390: Medication Issues and Concerns Anti
Page 391 and 392: Medication Issues and Concerns esom
Page 393 and 394: Medication Issues and Concerns laxa
Page 395 and 396: Medication Issues and Concerns Resp
Page 397 and 398: Medication Issues and Concerns hygi
Page 399 and 400: Medication Issues and Concerns All
Page 401 and 402: iperiden trihexyphenidyl olanzapine
Page 403 and 404: NOTE: This review is not intended t
Page 405 and 406: If during the review, you identify
Page 407 and 408: How he/she approaches the MRR proce
Page 409 and 410: o Failure to monitor a medication c
Page 411 and 412: 42 CFR 483.20(b), F272, Comprehensi
Page 413 and 414: Complications (such as diarrhea wit
Page 415 and 416: NOTE: If Severity Level 3 (actual h
Page 417 and 418: ―Resident Condition‖ -- The res
Page 419 and 420: Medication Errors Due to Failure to
Page 421 and 422: Medications Administered with Enter
Page 423 and 424: if the facility uses the ―recap
Page 425 and 426: technique requires a comparison of
Page 427 and 428: 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
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R04SOM 11/12/2004 Guidance to Surve
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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
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DEPARTMENT OF HEALTH AND HUMAN SERV
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22. Psychoactive Medications: If th
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16. Weight Change/Nutrition/Swallow
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RESIDENT REVIEW WORKSHEET (continue
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RESIDENT REVIEW WORKSHEET (continue
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