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of VRE. Enterococcus is an organism that normally occurs in the colorectal tract. VRE infections have been associated with prior antibiotic use. C. difficile is a bacterial species of the genus clostridium, which are gram-positive, anaerobic, spore-forming rods (bacilli). The organism normally lives benignly in the colon in spore form. When antibiotic use eradicates normal intestinal flora, the organism may become active and produce a toxin that causes symptoms such as diarrhea, abdominal pain, and fever. More severe cases can lead to additional complications such as intestinal damage and severe fluid loss. Treatment options include stopping antibiotics and starting specific anticlostridial antibiotics, e.g., metronidazole or oral vancomycin. If a resident has diarrhea due to C. difficile, large numbers of C. difficile organisms will be released from the intestine into the environment and may be transferred to other individuals, causing additional infections. Contact precautions are instituted for residents with symptomatic C. difficile infection. Thorough hand washing with soap and water after caring for the resident reduces the risk of cross-transmission. Another control measure is to give the resident his or her own toilet facilities that will not be shared by other residents. The C. difficile can survive in the environment (e.g., on floors, bed rails or around toilet seats) in its spore form for up to 6 months. Rigorously cleaning the environment removes C. difficile spores, and can help prevent transmission of the organism. 106 Cleaning equipment used for residents with C. difficile with a 1:10 dilution of sodium hypochlorite (nine parts water to one part bleach) will also reduce the spread of the organism. Once mixed, the solution is effective for 24 hours. PREVENTING INFECTIONS RELATED TO THE USE OF SPECIFIC DEVICES Intravascular catheters are used widely to provide vascular access, and are increasingly seen in nursing homes. While providing such access, they may increase the risk for local and systemic infections and additional complications such as septic thrombophlebitis. Central venous catheters (CVCs) have also been associated with infectious complications. Other intravascular catheters such as dialysis catheters and implanted ports may be accessed multiple times per day, such as for hemodynamic measurements, or to obtain samples for laboratory analysis, thus increasing the risk of contamination and subsequent clinical infection. Limiting access to central venous catheters for only the primary purpose may help reduce the risk of infection. Consistent use of appropriate infection control measures when caring for residents with vascular access catheters reduces the risk for catheter-related infections. 107 Surveillance consistently includes all residents with vascular access, including those with venous access and implanted ports such as peripherally inserted central catheter lines, and midline access catheters. Activities to reduce infection risk includes surveillance such as observation of insertion sites, routine dressing changes, use of appropriate PPE and hand hygiene during the care and treatment of residents with venous catheters, and review of the resident for clinical evidence of infection. 107 It is important that practices reflect the most current CDC guidelines.
ENDNOTES 68 Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and the Healthcare Infection Control Practices Advisory Committee. (2007 June). 2007 Guideline for Isolation Precautions: Preventing transmission of infectious agents in healthcare settings. Pp. 71. Accessed December 10, 2008 from http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf 69 Centers for Disease Control and Prevention (CDC). (2002). Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002; 51 (No.RR-16). pp. 3. Accessed December 10, 2008 from http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf 70 Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and the Healthcare Infection Control Practices Advisory Committee. (2007 June). 2007 Guideline for Isolation Precautions: Preventing transmission of infectious agents in healthcare settings. Pp. 71. Accessed December 10, 2008 from http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf 71 Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and the Healthcare Infection Control Practices Advisory Committee. (2007 June). 2007 Guideline for Isolation Precautions: Preventing transmission of infectious agents in healthcare settings. Pp. 70. Accessed December 10, 2008 from http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf 72 Siegel, J.D., Rhinehart, E., Jackson, M., and Chiarello, L. (2006). Management of multidrugresistant organisms in healthcare settings, 2006. Pp. 5. Accessed December 8, 2008 from http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf 73 American Medical Directors Association (AMDA). (2006). Clinical practice guideline; managing common infections in the assisted living setting. Assisted Living Consult, Jan/Feb 2006: Pp.31 74 Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L., and the Healthcare Infection Control Practices Advisory Committee. (2007 June). 2007 Guideline for Isolation Precautions: Preventing transmission of infectious agents in healthcare settings. Pp. 66. Accessed December 10, 2008 from http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf 75 Nicolle, L.E., Strausbaugh, L.J., and Garibaldi, R.A. (1996, Jan.). Infections and antibiotic resistance in nursing homes. Clinical Microbiology Reviews. 9(1): 1-17 76 Richards, C. (2002). Infections in residents of long-term facilities. J AM Geriatr Soc 2002; 50. Pp.676. 77 Smith, P.W., Bennett, G., Bradley, S., Drinka, P., Lautenbach, E., Marx, J., Mody, L., Nicolle,
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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
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42 CFR §483.20(b)(1), Tag F272, Co
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DEFICIENCY CATEGORIZATION (Part IV,
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If immediate jeopardy has been rule
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Intent §483.25(j) The intent of th
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Is proper administration technique
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§483.25(k)(5) Standard: Tracheal S
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(v) In the presence of adverse cons
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physical actions such as: pacing, c
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o Support decisions about modifying
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individual with dementia, to improv
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Medication management is based in t
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Whether the signs, symptoms, or rel
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o Pain; o Chronic psychiatric illne
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Common Conditions/ Symptoms Example
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Identifying the essential informati
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necessarily indicate a need for dos
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Sometimes, the decision about wheth
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The continued use is in accordance
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J., & Bates, D.W. (2005). Incidence
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(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
Page 513 and 514: Documentation of actual disposition
Page 515 and 516: the pharmaceutical services. Fourth
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Page 519 and 520: The facility in collaboration with
Page 521 and 522: (2) The pharmacist must report any
Page 523 and 524: errors, or other irregularities, an
Page 525 and 526: NOTE: The surveyor‘s review of me
Page 527 and 528: o Seizure activity; o Spontaneous o
Page 529 and 530: Common Medication-Medication Intera
Page 531 and 532: The identification of any irregular
Page 533 and 534: aspects of pharmaceutical services.
Page 535 and 536: The pharmacist‘s MRR failed to id
Page 537 and 538: (3) Determines that drug records ar
Page 539 and 540: During a medication pass, medicatio
Page 541 and 542: This requirement has several aspect
Page 543 and 544: Determine whether the noncompliance
Page 545 and 546: §483.65 Infection Control The faci
Page 547 and 548: ―Contact precautions‖ are measu
Page 549 and 550: Critical aspects of the infection p
Page 551 and 552: Conducting data analysis to help de
Page 553 and 554: observations of staff practices and
Page 555 and 556: Complications from invasive diagnos
Page 557 and 558: Airborne transmission can occur by
Page 559 and 560: After removing gloves or aprons; an
Page 561 and 562: Depending on the situation, options
Page 563: tears or holes be replaced. It is r
Page 567 and 568: Guidelines for environmental infect
Page 570 and 571: INVESTIGATIVE PROTOCOL FOR INFECTIO
Page 572 and 573: Multiple use items (e.g., shower ch
Page 574 and 575: Interview the Designated Infection
Page 576 and 577: Utilize infection precautions to mi
Page 578 and 579: Properly implement transmission bas
Page 580 and 581: influenza in residents on another,
Page 582 and 583: §483.70(a)(6)(ii) The dispensers a
Page 584 and 585: Additional guidance is available in
Page 586 and 587: §483.70(d)(1)(i) Accommodate no mo
Page 588 and 589: Procedures: §483.70(d)(1)(iv) Ther
Page 590 and 591: Interpretive Guidelines: §483.70(d
Page 592 and 593: centralized nursing station, this c
Page 594 and 595: Are spaces adaptable for all intend
Page 596 and 597: defined as substandard quality of c
Page 598 and 599: (ii) Responsible for the management
Page 600 and 601: Probes: §483.75(e)(2 - 4) During a
Page 602 and 603: 1919(e)(2)(A) of the Act the facili
Page 604 and 605: Interpretive Guidelines: §483.75(f
Page 606 and 607: The medical director helps the faci
Page 608 and 609: MEDICAL DIRECTION The facility is r
Page 610 and 611: The medical director is responsible
Page 612 and 613: 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
Page 660 and 661:
RESIDENT REVIEW WORKSHEET (continue
Page 662:
RESIDENT REVIEW WORKSHEET (continue
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