Resident Care Policies and Procedures - With Links - Health ...

RESIDENT CARE POLICIES & PROCEDURES
SKILLED NURSING FACILITIES
VOLUME I
APRIL 1, 2008

Resident Care Policies and Procedures – Skilled Nursing Facility
Introduction
This manual is intended to be a resource that facilitates and supplements the development of
health care policies and procedures specific to the facility. It is intended for use in the health
care environment.
With regular changes in the regulations, business considerations, technology, and theory of
practice, a policies and procedures manual is a dynamic entity. As a result, this policies and
procedures manual was developed so that it can be revised as needed. In the table of contents,
it is indicated in italics where the facility should insert individualized policies or additional
information that is customized to specific facility or State requirements. The policies and
procedures may also reference other policy manuals. Policies and procedures with “HDGR”
are required by Health Dimensions Group and should not be altered.
When revisions are made to this manual, they should be logged onto the “Manual Revision,
Changes, and Updates” page, an approval signature provided, and dated.
At a minimum, the entire manual should be reviewed and updated on an annual basis and
approved by the facility’s Quality Council and medical director.
The majority of the policies relate directly to an OBRA/CMS F-Tag number.
At the top of each policy and procedures page, it notes: 1) the title of the policy and
procedure; 2) the origination date of the policy and procedure; 3) any revision dates; 4) any
corresponding Health Dimensions Group quality standard; and 5) any corresponding federal
(CMS) regulations “F-Tags.”
There is a separate manual dedicated to Protected Health Information (PHI) and the Health
Information Portability and Accountability Act (HIPAA).
The appendix contains a reference listing of many of the expert resources utilized in
developing this manual.
© Health Dimensions Group 2008 Introduction and Disclaimer
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Disclaimer
Health Dimensions Group, the author, and publisher cannot in any way
assume that the policies, procedures, and forms in this manual will be
used for the purposes intended; nor can they assure that this manual will
not be modified. Accordingly, Health Dimensions Group, the author, and
publisher do not assume any responsibility for their use. Health
Dimensions Group, the author, and publisher shall have neither liability
nor responsibility with respect to any losses or damages arising from the
information contained in this book or from the use of any electronic
media accompanying it.
Although Health Dimensions Group, the author, and publisher have
exhaustively researched all sources to ensure the accuracy and
completeness of the information contained in this book, we assume no
responsibility for errors, inaccuracies, omissions, or any other
inconsistency herein. Any slights against people or organizations are
unintentional. If legal, Medicare, medical, or other assistance is required,
the services of the appropriate government agency or competent
professional should be sought.
© Health Dimensions Group 2008 Introduction and Disclaimer
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Copyright
Copyright 2008 – Health Dimensions Group. All rights reserved.
This manual originated from the Long Term Care Policy & Procedure Manual, 5 th Edition
and the Medicare Part A Addendum to the Long Term Care Policy & Procedure Manual, 1 st
Edition. Both manuals are copyrighted 2008 by DPA Associates, Inc., Kansas City, Missouri.
All DPA Associates, Inc., rights are reserved. Limited permission is granted to Health
Dimensions Group to reproduce, store in or introduce into a retrieval system, and transmit in
any form or by any means now known or hereafter developed (electronic, mechanical,
photocopying, recording, or otherwise). This permission is granted to Health Dimensions
Group for corporate use and use in its managed or owned facilities. Permission for
commercial sale or distribution outside the limits specified is not granted. Modification,
additions, or revisions of this publication by Health Dimensions Group or its managed or
owned facilities does not, in any way, compromise or revoke the copyright to the material
originally contained within this publication.
Printed and bound in the United States of America.
Published by Health Dimensions Group
7101 Northland Circle, Suite 110
Minneapolis, MN 55428
Warning and Disclaimer
Although Health Dimensions Group, the author, and publisher have exhaustively researched
all sources to ensure the accuracy and completeness of the information contained in this
book, we assume no responsibility for errors, inaccuracies, omissions, or any other
inconsistency herein. Any slights against people or organizations are unintentional. If legal,
Medicare, medical, or other assistance is required, the services of the appropriate government
agency or competent professional should be sought.
Health Dimensions Group, the author, and publisher cannot in any way assume that the
policies, procedures, and forms in this book will be used for the purposes intended or that
they will not be modified. Accordingly, Health Dimensions Group, the author, and publisher
do not assume any responsibility for their use. Health Dimensions Group, the author, and
publisher shall have neither liability nor responsibility with respect to any loss or damages
arising from the information contained in this book or from the use of any electronic media
accompanying it.
© Health Dimensions Group 2008 Copyrights, Trademarks, and About the Authors
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Trademarks
All terms in this book that are known to be trademarks or service marks are appropriately
capitalized. Health Dimensions Group and DPA Associates, Inc., cannot attest to the
accuracy of this information. Use of any term in this book should not be viewed as affecting
the validity of any trademark or service mark.
About the Authors
Health Dimensions Group is one of the nation’s leading health care management and
consulting firms, serving the needs of hospitals, health systems, long-term care, and senior
health and housing providers across the nation. Health Dimensions Group is a privately
owned entity, serving a diverse group of clients for over 20 years.
Health Dimensions Group is committed to the core values of hospitality, stewardship,
integrity, respect, and humor. In addition to the significance and impact on the service we
provide, these core values represent permanence to those we serve.
Health Dimensions Group’s team of professionals provides tailored solutions that meet
today’s challenges, along with industry leadership that envisions tomorrow’s opportunities,
to meet the individual needs of each client. The Health Dimensions Group staff get to know
you and your organization, which allows us to develop solutions and respond to the unique
situations and specific challenges that your organization faces.
We believe that success in the changing health care environment requires innovation, as well
as knowledge and experience—a total solutions approach. As your total solutions partner, we
will work with you to help your organization adapt, reposition, and refine products and
services to meet the rapidly changing needs of your clients.
Diane Atchison is a registered nurse and an adult nurse practitioner. She is president of DPA
Associates, Inc.—a nurse consulting and education company. Ms. Atchison is a consultant in
long-term care, and she is experienced in long-term care operations management. She has
been an adult nurse practitioner in primary care and long-term care, a clinical nurse specialist
in rehabilitation, and a staff nurse. Ms. Atchison has taught in BSN programs at Rockhurst
College in Kansas City, MO; the University of Missouri - Kansas City; the University of
New Mexico, and; the University of Phoenix, Albuquerque, NM. Ms. Atchison has published
manuals on quality indicators, self care for amputees, restorative nursing and long-term care,
and Medicare policies and procedures. Ms. Atchison has also developed documentation
systems for RAPs and Medicare PPS. She has published articles on restorative nursing care.
Ms. Atchison consults with acute and long-term care facilities regarding survey deficiencies,
restorative care, Medicare, and Alzheimer’s issues. Ms. Atchison presents workshops and
seminars nationally on related long-term care topics.
Ms. Atchison has a BSN from Salve Regina University in Newport, RI, and a master's degree
in Primary Care from the University of Maryland - Baltimore. Ms. Atchison is a certified
adult nurse practitioner through the American Nurses Association.
© Health Dimensions Group 2008 Copyrights, Trademarks, and About the Authors
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Ted Atchinson is vice president of DPA Associates, Inc. He consults on long-term care
issues regarding operations, survey compliance, physical plant, and information technology.
He also provides project management and total quality management facilitation services. Mr.
Atchison manages the operations of DPA Associates, Inc. Mr. Atchinson is a licensed
nursing home administrator and holds a certificate of Nursing Home Administration from
Kansas City Kansas Community College. He has a bachelor’s of Electrical Engineering from
Oklahoma State University and a master’s of Electrical Engineering from the University of
Missouri, Columbia. Mr. Atchison serves the organizational committee of the Missouri
Culture Change Coalition and is active in the Kansas chapter of the Society for Advancement
of Gerontological Environments (SAGE). He has served as a member of the planning
committee for the Pioneer Network’s 2004 conference.
© Health Dimensions Group 2008 Copyrights, Trademarks, and About the Authors
Page 3 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Manual Revision, Changes, and Updates
Date Revised Policy/Procedure Revised Approval Signature/Title
© Health Dimensions Group 2008 Manual Revisions, Changes, and Updates
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Approvals by Quality Council and Medical Director
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
Signature Date Signature Date
© Health Dimensions Group 2008 Approvals by Quality Council and Medical Director
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Table of Contents
A
Abuse Prevention/Resident Treatment -HDGR with any State Specific Info to be added and
insert copy of facility form
Accidents/Falls - HDGR
Accommodation of Needs
Activities - add any additional facility information
Activities of Daily Living (ADL)
Adaptive Equipment - See Dining - Assistive Devices
Adjudicated Incompetent Residents
Administrator
Admission of a Resident - add any facility additional information and/or forms
Admission Orders
Admission Policy for Medicare Residents - HDGR
Admission Policy waiving Medicare/Medicaid Benefits - add any State specific information
Admission, Transfer and Discharges (General)
Advance Directives - add any facility and/or State specific information and insert copy of
facility form
Aggression - Resident - add any facility and/or State specific information
Allergic Reaction
Allergies - add any facility specific information and insert copy of facility forms
AM Care - See Morning Care
Anti-Coagulant Use (Coumadin/Warfarin) - HDGR including Education
Anti-Psychotics Medications - See Unnecessary Drugs - Anti - Psychotics
Aqua K Pad - See K Pad
Assessments (General)
B
Bandages
Bath in Bed
Bath in Shower
Bath in Tub
Bath in Whirlpool
Bed Changing While Occupied
Bed Changing While Unoccupied
Bed Cradle
© Health Dimensions Group 2008 Table of Contents
Page 1 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Bed Hold and Re-admission - add any facility and/or State specific information and insert
copy of facility form
Bed Making - Mitered Corners
Bedpan/Urinal Use and Storage
Bedside Commode - Chair Use
Bedside Commode - Cleaning
Behavior Monitoring - See Unnecessary Drug - Psychotropic Drugs
Blood Borne Pathogens -See Infection Control Manual
Blood Glucose Monitoring -See Glucometer Blood Sugar Testing
Body Mechanics
Bowel and Bladder Management - HDGR
C
Call Lights -See Resident Call System
Cardiopulmonary Resuscitation - add any facility and/or State specific information
Care Plans - Comprehensive - add any facility specific information and/or forms
Care Plans - Reviews/Conferences - add any facility specific information and any forms
Cast Care
Catheter - Drainage Bag Change (Closed System)
Catheter - External Condom/Texas Catheter
Catheter - Foley - See Foley Catheter
Catheter - Leg Bag Cleaning
Catheter - Management - See also Foley Catheter Care
Catheter - Suprapubic - See Suprapubic Catheter
Catheterization of a Resident including Intermittent catheter
Change of Condition Notification - See Notification to Physician/Family of change of
Condition
Clinical Record (General) - add any facility and/or State specific information
Colostomy Care
Colostomy Irrigation
Complaints/Grievances–Filing with the State - add facility and/or State specific information
and insert copy of facility form
Comprehensive Assessment MDS (General)
Compresses - Cold Moist
Computers and Software - add any facility and/or State specific information
Conformity with Federal - State - and Local Laws (General)
Corporate Compliance Program (General) - See Medicare Compliance Policy
CPR - See Cardiopulmonary Resuscitation
Cultures - Wound
© Health Dimensions Group 2008 Table of Contents
Page 2 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
D
Deep Breathing Exercises
Dental Services (General) - add any facility specific information
Denture Care - Oral Hygiene
Dietary Menu and Nutritional Adequacy (General)
Dietary Services (General)
Dietary Supplements - add any facility specific information
Dietician - Qualified (General)
Diets - Therapeutic - add any facility specific information
Dignity - Quality of Life (General)
Dining and Food Service - add any facility specific information
Dining - Assistive Devices - add any facility specific information
Director of Nurses
Disaster and Emergency Preparedness - add any facility and/or State specific information
Discharge Summary
Discharging a Resident
Disposal of Needles/Syringes
DNR - See Advance Directives - Cardiopulmonary Resuscitation
Dressing a Resident
Drug Regimen and Services Consultation - add any facility specific information
Drugs and Biological Storage - Labeling - SEE ALSO PHARMACY POLICIES
E
Ear - Instillation of Medications
Ear - Irrigation of
Elastic Anti-Embolic Hose (TED) Application
Electric Razors - cleaning
Elopement/Missing Resident - add any facility and/or State specific information
Emergency Physician Availability - See Physician Availability Emergency Care
Emergency Power - add any facility and/or State specific information
Enema - Disposable or Oil Retention
Enema - Tap Water
Enteral Feeding pumps - cleaning - add any facility specific information
Enteral/Parental Feedings -See Nasogastric/Gastrostomy Feeding
Environment - Cleaning of Equipment - add any facility specific information
Environment Physical (General) - See Physical Environment
Environment Quality of Life (General)
Equal Access to Quality Care (General)
Evening Care - add any additional facility specific information
© Health Dimensions Group 2008 Table of Contents
Page 3 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Examination of Survey Results - add any facility and/or State specific information
Exercise of Rights (General)
Eye - Compresses
Eye - Instillation of Medications
Eye - Irrigation
Eye - Prosthesis
F
Falls - See Accident/Falls
Family Council - See Resident/Family Council
Fecal Impaction Removal
Feeding Assistant - Paid
Feeding the Total Care Resident
Fire - See Disaster and Emergency Preparedness
Fire Watch - See Disaster and Emergency Preparedness
First Aid - Burns
First Aid - Choking
First Aid - Falls (General)
First Aid - Heimlich Maneuver
First Aid - Hemorrhage
First Aid - Insulin Reaction (General)
First Aid - Seizures
First Aid - Suicidal (General)
Fluid Restriction - See Also Hydration
Foley Catheter - Care - See Also Catheter Management
Foley Catheter - Emptying and Measuring
Foley Catheter - Insertion - See Also Catheterization of a Resident including Intermittent
Foley Catheter - Irrigation
Foley Catheter - Removing
Food - Sanitary Conditions (General)
Food - Substitutes - add any facility specific information
Foot Board - Bed
Foot Care
Free Choice (General)
G
Gait/Transfer Belt - add any facility specific information
Gastrostomy Feeding - See Nasogastric/Gastrostomy Feeding
Gloves - Non-Sterile
© Health Dimensions Group 2008 Table of Contents
Page 4 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Glucometer - Blood Sugar Testing - add any facility specific information
Grievances - See Complaints/Grievances
H
Hair Brush/Comb Care
Hair Care
Hand washing
Hearing Aid Care
Height - See Measuring Height
HIPAA - SEE HIPAA MANUAL
Hospice Care
Hydration - HDGR- See Also Fluid Restriction
Hypoglycemia - HDGR
I
Immunizations: Influenza - HDGR - add facility specific consent forms, educational
material, and Immunization Record
Immunizations: Pneumococal Vaccine - HDGR - add facility specific consent forms,
educational materials, and Immunization Record
Incompetent Residents -See Also Adjudicated Incompetent Resident
Individually Identifiable Information - See HIPAA section in Volume II of this manual
Infection Control (General) - See Also Infection Control Manual
Injection of Medication
In-Service Programs (General)
Insulin Administration
Insulin Storage
Intravenous Fluids (IV) (General) - See Pharmacy Manual
Irrigating Solutions
J
n/a
K
K Pad - Aqua
L
Labeling Resident Clothing and Personal Items - add any additional facility specific
information
Laboratory Results - Reporting - add any facility and/or State specific information
Laboratory Services
Leaving the Facility - Resident (LOA) - add any facility specific information and any forms
© Health Dimensions Group 2008 Table of Contents
Page 5 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Lift - Sit to Stand - add any additional facility specific information
Lift - Total Body/Maxi - add any additional facility specific information
Linens - Handling
Lost Clothing/Personal Items - add any additional facility specific information
M
Married Couples
Mattresses - Specialty
Meals - Frequency - add any additional facility specific information
Measuring Height - add any additional facility specific information
Measuring Weight - add any additional facility specific information
Medicaid Benefits - How to Apply
Medical Director and Responsibilities - add additional facility specific information
Medical Record - Inspection of (General) - See HIPAA section in Volume II of this manual
Medicare Compliance Triple Check/Pre-Billing Audit - HDGR
Medication - Administration from a Cart - See also Pharmacy Manual for additional
information
Medication Administration Record - See also Pharmacy Manual for additional information
Medications - Controlled - See also Pharmacy Manual for additional information
Medications - Crushing - add additional facility specific information
Medications - Discontinued for Deceased - or Discharged residents - See also Pharmacy
Manual for additional information
Medications - Errors - add additional facility specific information and insert copy of facility
form
Medications - Labeling - See also Pharmacy Manual for additional information
Medications - Ordering/Re-ordering/Receiving - See also Pharmacy Manual for additional
information
Medications - Sublingual
Minimum Data Set (MDS) Completion (General)
Mobility - Ambulation
Mobility - Assisted Transfers
Mobility - Rolling over in Bed
Mobility - Transfer from Bed to Stretcher
Mobility - Turning a Total Assist Resident
Morning Care - add any additional facility specific information
N
Nail Care
Narcotic Count -See Pharmacy Manual
Nasogastric/Gastrostomy Tube Administration of Medications
© Health Dimensions Group 2008 Table of Contents
Page 6 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Nasogastric/Gastrostomy Tube Feeding Bolus
Nasogastric/Gastrostomy Tube Feeding Pump
Nebulizer Therapy - add any additional facility specific information
Neurological Observations (Neuros) - add additional facility specific information and insert
copy of facility form
Notification to Physician/Family of Change in Condition - HDGR
Nurse Staffing Required Posting - insert copy of facility form
Nursing Administration and Staffing
Nursing Clinical Records (General)
Nursing Documentation (General) - add additional facility specific information
Nursing Rounds - add additional facility specific information
Nursing Services Quality of Resident Care (General)
Nutrition (General)
O
Ombudsman Program - add additional facility specific information
Oral Hygiene of Unconscious or Total Care Resident
Oxygen Administration
P
Pain Management - HDGR
Perineal Care
Personal Inventory - Residents Belongings - add additional facility specific information
Pet(s)
Pharmacy Services (General) - add additional facility specific information
Photography of a Resident - See HIPAA section in Volume II of this manual
Physical Environment - Dining and Activities (General)
Physical Environment - Emergency Water Supply add additional facility specific information
Physical Environment - Handrails (General)
Physical Environment - Life Safety (General)
Physical Environment - Outside Ventilation (General)
Physical Environment - Pest Control (General)
Physical Environment - Resident Room (General)
Physical Environment - Space - and Equipment (General)
Physical Restraints - See Restraint Free Care
Physician Availability - Emergency Care - add additional facility specific information
Physician Information - Resident Right
Physician’s Order - add additional facility specific information and insert copy of facility
form
Physician’s Order - Recording of - add additional facility specific information
© Health Dimensions Group 2008 Table of Contents
Page 7 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Physician’s Order Sheet - add additional facility specific information and insert copy of
facility form
Physician Services - Supervision/Visits/Frequency of Visits - add any facility and/or State
specific information
PM Care - See Evening Care
Positioning (General)
Post Mortem Care
Postural Drainage
Pre-Admission Screening for Mental Illness and Mental Retardation/PASSAR - add any
facility and/or State specific information
Pre-Admission Screening of Residents - HDGR
Pressure Ulcers/ Skin Integrity /Wound Management - HDGR - insert copy of facility forms
Privacy and Confidentiality
Private Duty Nursing - add additional facility specific information
Q
Quality Council/Assurance/Improvement - HDGR
Quality Council/Core Values - HDGR
R
Radiology /Diagnostic Services (General)
Range of Motion - add additional facility specific information and insert copy of facility form
Rectal (Digital) Examination
Refusal of Transfer
Rehabilitation Services Orders
Resident Call System - add additional facility specific information
Resident/Family Council - add additional facility specific information
Resident Funds - Protection of - add any facility and/or State specific information
Resident Health Status - Informed Choice
Resident Mail
Resident Rights - insert copy of facility form
Resident Rights - Access and Visitation - add additional facility specific information
Resident Rights - Accounting and Records - add additional facility specific information
Resident Rights - Assurance of Financial Security
Resident Rights - Conveyance Upon Death (General)
Resident Rights - Deposit of Funds (General)
Resident Rights - Limitations of Charges to Personal Funds
Resident Rights - Notices of Balances - add additional facility specific information
Resident Rights - Work
© Health Dimensions Group 2008 Table of Contents
Page 8 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Resident Rights and Services Included in Medicare/Medicaid - add additional facility
specific information
Resident Rights and Services Not Included in Medicare/Medicaid - add additional facility
specific information
Resident Trust Account - Availability Off-hours - add additional facility specific information
Restorative Program - add additional facility specific information
Restraint Free Care - HDGR
S
Safe Medical Device Act -See also Physical Environment
Self-Administration of Medications - add additional facility specific information and insert
copy of facility form
Shampooing the Bedridden Resident’s Hair
Shaving - Electric Razor
Shaving - Safety Razor
Shift to Shift Report - - add additional facility specific information
Side Rails - See Restraint Free Care
Skin Integrity - See Pressure Ulcers/Wound Management/Skin Integrity
Smoking - add additional facility specific information and insert copy of facility assessment
form
Social Services (General) - Revise if needed per State Requirements
Special Consent (General)
Special Needs (General)
Specimen Collection - Clean Urine Void Female
Specimen Collection - Clean Urine Void Male
Specimen Collection - Sputum
Spiritual Care - add additional facility specific information
Staff Qualifications (General)
Suctioning
Suppositories - Rectal
Suprapubic Catheter Care
T
TED Stockings - See Elastic Anti-Embolic Hose
Teeth - Flossing
Telephone - Resident Access - add additional facility specific information
Thickened Liquids - add additional facility specific information
Tracheotomy Care
Transferring a Resident to another Facility or to the Hospital - add additional facility specific
information
© Health Dimensions Group 2008 Table of Contents
Page 9 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Transferring a Resident within the Facility - add additional facility specific information
Treatment Record (General) - See also Pharmacy Manual for additional information
Triple Check/Pre-Billing Audit - See Medicare Compliance-Triple Check/Pre-billing Audit -
HDGR
Tuberculosis TB Management - See Infection Control Manual
U
Unnecessary Drugs - Antipsychotic Drugs - HDGR - insert copy of facility behavior
monitoring tools and any other forms
Unnecessary Drugs (General)
Urinals/Bedpans - Cleaning of - add additional facility specific information
Urinary Incontinence - See Bowel and Bladder Management
V
Vaginal Instillation/Irrigation
Vaginal Suppositories - Insertion of
Vision and Hearing (General)
Vital Signs - Measuring Pulse - Respirations - and Blood Pressure
Vital Signs - Temperature Measurement - add additional facility specific information
W
Water Pass - add additional facility specific information
Water Pitchers and Glasses - Cleaning - add additional facility specific information
Weight Loss - add additional facility specific information
Weight Measurement -See Measuring Weight
Wound Irrigation
Wound Management - See Pressure Ulcers/Wound Management/Skin Integrity
X
n/a
Y
n/a
Z
n/a
© Health Dimensions Group 2008 Table of Contents
Page 10 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
APPENDIX
F Tag Numbers
References
FORMS - Health Dimensions Group Required (HDGR) – Listing Only
Accidents - Falls-HDGR A Falls Risk Assessment Table
Accidents - Falls-HDGR B Falls Risk Post Fall Assessment
Admission Policy for Medicare Residents-HDGR A Physician's Certification and
Recertification
Admission Policy for Medicare Residents-HDGR B Medicare Secondary Payer Screen
Admission Policy for Medicare Residents HDGR C Assignment of Benefits
Anti-Coagulant Use (Coumadin, Warfarin) - HDGR PT-INR Flow Sheet
Bowel and Bladder Management-HDGR A Bowel and Bladder Functional Evaluation Tool
Bowel and Bladder Management-HDGR B Bowel and Bladder Treatment Plan
Bowel and Bladder Management-HDGR C Bowel and Bladder Quarterly Evaluation Review
Bowel and Bladder Management-HDGR D 3-Day Bowel and Bladder Tracking Tool
Medicare Compliance Triple Check Pre-Billing Audit-HDGR A Triple Check-Pre-Billing
Audit
Medicare Compliance Triple Check Pre-Billing Audit-HDGR B 53 RUG III PreScreening
Tool
Pain Management-HDGR A Pain Data Collection and Assessment
Pain Management-HDGR B Assessment in Advanced Dementia
Pain Management-HDGR C Assessment for Pain in Cognitively Impaired
Pre-Admission Screening of Resident-HDGR 53 RUG III Screening
Restraint Free Care-HDGR A Physical Restraints Assessment
Restraint Free Care-HDGR B Informed Education on Use of Physical Restraints
Restraint Free Care-HDGR C Physical Restraint Post Application Observation Tool
Restraint Free Care-HDGR D Restraint Reduction Tool
Restraint Free Care-HDGR E Half Side Rail Bed Bar Assessment
Unnecessary Drugs - Antipsychotic Drugs-HDGR Antipsychotic Medication Evaluation Tool
Quality Standards Key Codes
FP = Facility Procedures
RCS = Resident Care Services
HR = Human Resources
© Health Dimensions Group 2008 Table of Contents
Page 11 of 11

Resident Care Policies and Procedures – Skilled Nursing Facility
Table of Contents (Facility Specific)
A
B
C
D
E
© Health Dimensions Group 2008 Table of Contents (Facility Specific)
Page 1 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
F
G
H
I
J
© Health Dimensions Group 2008 Table of Contents (Facility Specific)
Page 2 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
K
L
M
N
O
P
© Health Dimensions Group 2008 Table of Contents (Facility Specific)
Page 3 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
Q
R
S
T
U
V
© Health Dimensions Group 2008 Table of Contents (Facility Specific)
Page 4 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
W
X
Y
Z
© Health Dimensions Group 2008 Table of Contents (Facility Specific)
Page 5 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Abuse Prevention/Resident Treatment - HDGR
F Tag
F223, F224, F225, F226
Quality Standard FP23, FP24
Origination Date April 1, 2008
Revision Date
POLICY
It is the policy of this facility to take appropriate steps to prevent the occurrence of:
• Abuse
• Neglect
• Misappropriation of resident property
It is also the policy of this facility to take appropriate steps to ensure that all alleged
violations of federal or state laws which involve mistreatment, neglect, abuse, injuries of
unknown source, and misappropriation of resident property (“alleged violations”) are
reported immediately to the administrator of the facility.
Such violations are also reported to state agencies in accordance with existing state law. The
facility investigates each such alleged violation thoroughly and reports the results of all
investigations to the administrator or his/her designee, as well as to state agencies as required
by state and federal law.
DEFINITIONS (Federal Misconduct)
• Misappropriation of resident property: The deliberate misplacement, exploitation, or
wrongful, temporary, or permanent use of a resident’s belongings or money without the
resident’s consent.
• Injury of unknown source: Any injury should be classified as an “injury of unknown
source” when both of the following conditions are met:
- The source of the injury was not observed by any person or the source of the injury
could not be explained by the resident; and
- The injury is suspicious because of the extent of the injury or the location of the
injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the
number of injuries observed at one particular point in time or the incidence of injuries
over time
• Neglect: Failure to provide goods and services necessary to avoid physical harm, mental
anguish, or mental illness.
• Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain, or mental anguish.
© Health Dimensions Group 2008 Abuse Prevention/Resident Treatment—HDGR
Page 1 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
- This includes the deprivation by an individual, including a caretaker, of goods or
services that are necessary to attain or maintain physical, mental, and psychosocial
well-being
- This presumes that instances of abuse of all residents, even those in a coma, cause
physical harm or pain, or mental anguish
o Verbal abuse: the use of oral, written, or gestured language that willfully includes
disparaging and derogatory terms to residents or their families, or within their
hearing distance, regardless of their age, ability to comprehend, or disability.
Examples of verbal abuse include, but are not limited to, threats of harm and
saying things to frighten a resident such as telling a resident that he/she will never
be able to see his/her family again
o Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion,
or sexual assault
o Physical abuse includes, but is not limited to, humiliations, harassment, and
threats of punishment or deprivation
PROCEDURE
1. Staff Screening:
All applicants for employment in the facility shall, at a minimum, have the following
screening checks conducted:
a. Reference checks with the current and/or past employer(s).
b. Appropriate licensing board or registry check.
c. Criminal background check pursuant to facility policy or state law.
2. Staff and Volunteer Training:
a. Upon hire, each new employee is informed of the obligation to report alleged
violations.
b. Training includes appropriate interventions to deal with aggressive and/or
catastrophic reactions of residents, definitions, alleged violations, and caregiver
stress. Training also includes examples of reportable incidents to assist staff in
detection of such incidents (the how to, to whom, and what to report).
c. Training for volunteers takes place during orientation.
d. All employees will receive training no less frequently than annually on the
requirements of the facility’s policies and procedures regarding alleged violations and
the requirements of state and federal law.
3. Prevention:
a. Staff, families, and residents are encouraged to report incidents of suspected abuse,
neglect, or misappropriation of resident property without fear of reprisal.
© Health Dimensions Group 2008 Abuse Prevention/Resident Treatment—HDGR
Page 2 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
b. The administrator and director of nursing services (DNS) identify, intervene, and
correct in situations in which abuse, neglect, or misappropriation of resident property
is more likely to occur.
4. Identification: Incidents of possible abuse or neglect will be identified through ongoing
assessment of resident conditions, incidents, resident interviews, family or resident
councils, and verbal or written report of observations.
5. Investigation:
a. Any person who knows or has reasonable cause to suspect that a resident has been or
is being abused, neglected, or exploited shall immediately report such knowledge or
suspicion to their supervisor, charge nurse, designee, or administrator to assuring
resident protection.
b. Allegations are to be reported to the supervisor, charge nurse, or designee. The person
receiving the report is to immediately inform the administrator. If the administrator is
unavailable, report to the appropriate designee.
c. The administrator, director of nursing, or designee will notify the appropriate
regulatory, investigative, or law enforcement agencies, in accordance with state
regulations.
d. Allegations of abuse, neglect, or exploitation will be thoroughly investigated. The
investigation will be initiated upon receipt of the allegation. The administrator, or
designee, will complete the investigation process.
e. The investigation can include, but is not limited to:
i. The names(s) of the resident(s) involved
ii. The date and time the incident occurred
iii. The circumstances surrounding the incident
iv. Where the incident took place
v. The names of any witnesses
vi. The name of the person(s) alleged with committing the act
6. Resident Protection:
a. If the circumstances require it, the DNS or his/her designee removes a resident
suspected of being the subject of an alleged violation to an environment where the
resident’s safety can be protected.
© Health Dimensions Group 2008 Abuse Prevention/Resident Treatment—HDGR
Page 3 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
If the suspected
perpetrator is…
Another resident
An employee, family,
friend, or visitor
THEN…
The DNS or designee separates the residents so they do not have
access to each other until the circumstances of the alleged incident
can be determined.
The administrator places the employee on immediate investigatory
suspension while completing the investigation. It is explained to the
employee that if the investigation results do not require suspension or
termination, the employee may be allowed to return to work and any
scheduled days missed during the suspension time may be paid. If it is
a family member, visitor, or friend, they will not be allowed to visit the
resident until the investigation is completed. The results of the
investigation will determine the future contact with the resident.
b. Where the circumstances of the alleged violation warrants, the DNS or designee
initiates a physical and mental assessment of the resident and documents the findings.
Only factual information is documented, not assumptions. The DNS also notifies the
attending physician regarding the alleged violation and findings and documents the
contact.
7. Reporting:
a. Any employee who suspects an alleged violation immediately notifies the
administrator or designee. The administrator notifies the appropriate state agency in
accordance with state law.
b. The results of all investigations are reported to the administrator or designee and to
the appropriate state agency, as required by state law and/or within five working days
of the alleged violation.
c. The facility reports to the State Nurse Aide Registry and licensure authorities any
knowledge it has of any actions by a court of law which would indicate an employee
does not or may not meet the requirements to work in a skilled nursing facility.
d. The administrator, or his/her designee, notifies the resident’s representative regarding
the alleged violation and assessment findings and reassures the resident’s
representative that an investigation has been initiated and appropriate action will be
taken. This contact is documented.
© Health Dimensions Group 2008 Abuse Prevention/Resident Treatment—HDGR
Page 4 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Accidents/Falls - HDGR
F Tag
F323
Quality Standard RSC26
Origination Date April 1, 2008
Revision Date
POLICY
The facility strives to promote safety, dignity, and overall quality of life for its residents by
providing an environment that is free from any hazards for which the facility has control and
by providing appropriate supervision and interventions to prevent avoidable accidents.
DEFINITIONS
A fall is defined as an occurrence characterized by the failure to maintain an appropriate
lying, sitting, or standing position resulting in an individual’s abrupt, undesired relocation to
the ground. The definition of a fall extends to include the following factors:
• An episode in which a resident has lost his/her balance and would have fallen were it not
for staff intervention
• The presence or absence of a resultant injury; a fall without injury is a fall
• The distance does not determine the incidence of a fall. Examples include resident rolling
out of bed on to floor or mat, resident slips out of wheelchair on to foot pedals, etc.
An injury of unknown origin/source is defined as any injury when both of the following
conditions are met:
• The source of the injury was not observed by any person or the source of the injury could
not be explained by the resident; and
• The injury is suspicious because of the extent of the injury or the location of the injury
(e.g., the injury is located in an area not generally vulnerable to trauma) or the number of
injuries observed at one particular point in time or the incidence of injuries over time
PROCEDURE
1. For all residents, a fall risk assessment will be conducted upon admission, readmission
from the hospital, quarterly, and with any significant change to the resident’s status
which puts them at a greater risk for falls.
2. An immediate/initial care plan for fall risk will be developed for any newly admitted
residents whose assessment indicated that the resident was at greater risk for
falls/accidents. This plan of care is communicated to all appropriate staff.
3. Some examples of interventions for the resident’s plan of care include:
a. Low bed
© Health Dimensions Group 2008 Accidents/Falls—HDGR
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
b. Lipped mattress
c. Landing strip or floor mat
d. Variety of alarms, sensor pads, laser, etc.
e. Anti-tip bars on wheelchair
f. Anti-skid strips
g. Gripper socks or non-skid shoes
h. Therapy evaluation
i. Bowel/Bladder reassessment
j. Revision of toileting schedule
k. Nutrition consultation
l. Medical consultation
m. Labs
n. Vision exam
o. Night lights or increased lighting
p. Assistive/Adaptive equipment
q. Mini-mental examination
4. Resident care plans should be evaluated and updated quarterly and/or with significant
change of condition as needed. Documentation of the risks and interventions, with the
focus on prevention and maintaining a safe environment, should be made.
5. If a fall or other incident/accident should occur, nursing/emergency care is to be provided
to the resident per the facility’s policy/standard of practice. Neurological observations
(Neuros) will be conducted following any observation of a resident hitting their head
during a fall/incident/accident or if it is unknown/not observed whether a resident
actually hit their head or not during a fall/incident/accident.
6. Any episode of a fall or other incident/accident should be documented on the incident
accident report. The information should be recorded in factual observed detail and not
supposition of what may have occurred. Each incident/accident or fall must be
investigated and/or assessed to determine the cause of the episode to prevent any further
injury. Witness statements should be obtained as applicable. The administrator should
have knowledge of all reports, and the interdisciplinary team should review all
incident/accident reports whenever possible.
7. The resident’s physician and family/responsible person should be notified post
fall/incident/accident with contact documented in the resident’s medical record.
© Health Dimensions Group 2008 Accidents/Falls—HDGR
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
8. A post-fall assessment will be conducted following any fall episode within 24 hours post
fall. Once the post-fall assessment is completed by nursing, the director of nurses or
designee will seek additional input from the interdisciplinary team and other staff
whenever possible. The completed post-fall assessment will be maintained in the
resident’s medical record.
9. The resident’s individualized care plan is to be updated with any changes or new
interventions post fall/incident/accident, communicated to appropriate staff, and
implemented.
10. Post fall/incident/accidents will have continued follow-up on the 24 hour report/alert
charting for 48-72 hours so as to continue assessment for possible injuries as well as to
further evaluate the interventions put into place.
11. A collective review of incident/accident reports will be conducted monthly by the
facility’s quality council to identify and analyze any trends throughout the facility
(confidential information). These reports will be logged on an incident/accident/fall log.
The incident/accident reports will be destroyed per facility policy. These reports are used
primarily for quality improvement purposes.
© Health Dimensions Group 2008 Accidents/Falls—HDGR
Page 3 of 3

Fall Assessment Protocols - EDUCATION
Pre-admission:
• Complete the pre-admission intake form/assessment
• Determine if the potential resident has a history of falling and what strategies are currently
used to prevent falling
• Communicate to the IDT, if there is a known potential for falls
• Assure that the appropriate fall prevention equipment is available and in place prior to the
resident’s admission
Admission/Re-admission from hospital:
• Complete the fall risk assessment
• Develop the immediate/initial care plan based upon the individual risk factors for the
resident
• Communicate to all appropriate staff
• Implement interventions
Quarterly and with any significant change to the resident’s status that puts them at greater
risk for falls:
• Follow procedures for admission/re-admission from hospital
If a fall occurs:
• Provide nursing/emergency care as needed
• Complete the incident/accident report
• Notify the physician and resident’s family
• Complete a post-fall assessment within 24 hours post fall
• Review and update the resident’s care plan
• Implement and communicate any new interventions to the appropriate staff
• Post fall/incidents/accidents will have continued follow-up charting for 48-72 hours to
assess for possible injuries as well as to further evaluate the interventions put into place
• The completed post-fall assessment should be given to the director of nurses/designee
• The director of nurses/designee will seek additional input from the IDT. The completed
post-fall risk assessment will then be maintained in the resident’s medical record
© Health Dimensions Group 2008 Accidents/Falls-Education Fall Assessment Protocols
Page 1 of 1

Fall Risk Assessment - HDGR
Date: Resident: MR#: Rm#:
Fall History
No falls
1-3 falls in 3 months
3 or more falls in last 6
months
Underlying Diseases or Conditions
Changes in orthostatic blood
pressure or hypotension
Psychiatric or cognitive
conditions
Dizziness or vertigo
Cardiac diagnosis or pacemaker
Orthopedic/joint/arthritis
Neuromuscular/ functional loss
CVA
Loss of limb
Seizures
Diabetes
Other
Medications
Is the resident taking any of these
medications that may predispose
them to falling?
Hypoglycemics
Narcotics
Psychotropics
Sedatives/Hypnotics
Anti-seizures
Antihistamines
Antihypertensives
Benzodiazepines
Cathartics
Diuretics
Has the resident
recently started a new
medication/change in
medications?
No
explain):
Yes (if yes,
Functional Status
Observe mobility, standing and sitting balance. Any problems noted?
No
Yes (if yes, explain):
Does the resident use any assistive devices/adaptive equipment?
No
Yes (if yes, explain):
Is the resident receiving Rehab Therapy?
No
Yes (if yes, explain):
Is the resident continent of bladder? No Yes
Is the resident continent of bowel? No Yes
Is the resident able to toilet themselves?
Yes
No (if no, explain):
Have there been recent changes in the resident’s bowel or bladder
continence?
No
Yes (if yes, explain):
Is the resident able to use a call light independently? No Yes
© Health Dimensions Group 2008 Accidents/Falls-HDGR Falls Risk Assessment
Page 1 of 2

Fall Risk Assessment - HDGR
Date: Resident: MR#: Rm#:
Sensory, Cognitive, Psychological Status
Does the resident have problems with cognition, judgment, memory, or safety awareness?
No Yes (if yes, explain):
Is the resident able to communicate their needs? No Yes
Does a resident have conditions that affect vision or hearing?
No Yes (if yes, explain):
Does the resident express, have signs of any pain or take pain medications?
No Yes (if yes, explain):
Does the resident have any symptoms of depression?
No Yes (if yes, explain and/or medications):
Other
Are any physical restraints in use?
No Yes (if yes, explain type and medical symptoms for use):
Based on the information you have collected/assessed do you believe this resident is or is not at a
greater risk for falls?
No (summarize your reasoning):
Yes (summarize your reasoning):
If YES then proceed to the resident’s immediate/initial care plan to indicate which interventions are
needed to reduce the risk for falls for this resident. Communicate these interventions to all
appropriate staff and implement.
Some examples of interventions for the resident’s plan of care may include:
▪
▪
▪
▪
▪
Low bed
Lipped mattress
Landing strip or floor
mat
Variety of alarms,
sensor pads, laser etc.
Labs
▪
▪
▪
▪
▪
Anti-tip bars on
wheelchair
Anti-skid strips
Gripper socks or nonskid
shoes
Therapy evaluation
Medical consultation
▪
▪
▪
▪
Bowel/Bladder
reassessment
Revision of toileting
schedule
Nutrition consultation
Vision exam
▪
▪
▪
Nightlights or
increased lighting
Assistive/Adaptive
equipment
Mini-mental
examination
Nurse’s Signature:
Date:
© Health Dimensions Group 2008 Accidents/Falls-HDGR Falls Risk Assessment
Page 2 of 2

Falls Risk Post Fall Assessment - HDGR
Date: Resident: MR#: Rm#:
Date fall occurred:
Time fall occurred:
Location where fall occurred:
What was the resident doing prior to the fall, if known? (interview resident)
Did resident sustain an injury?
Date/Time family notified:
Date/Time physician notified:
Fall interventions currently being used:__________________________________________________________
_________________________________________________________________________________________
FALL HISTORY
No falls 1-3 falls in 3 months 3 or more falls in last 6 months
List dates of falls:
UNDERLYING DISEASES OR CONDITIONS
Possible Intervention(s)
Does the resident have any of these diagnosis or conditions?
Changes in orthostatic blood pressure or hypotension
Psychiatric or cognitive conditions
Dizziness or vertigo
Cardiac diagnosis or pacemaker
Orthopedic/joint/arthritis
Neuromuscular/ functional loss
CVA
Loss of limb
Seizures
Diabetes
Other
MEDICATIONS
Is the resident currently taking any of these types of medications?
Hypoglycemics
Narcotics
Psychotropics
Sedatives/Hypnotics
Anti-seizures
Antihistamines
Antihypertensives
Benzodiazepines
Cathartics
Diuretics
Has the resident recently started a new medication/change in
medications?
No Yes (explain):
Resident/family teaching
Medical intervention
Therapy intervention
Labs
Evaluate blood pressure
Evaluate oxygen stats
Check blood sugars
Check pulse
Possible Intervention(s)
Medication/Pharmacy evaluation
Medication change
Labs
Evaluate blood pressure
Evaluate oxygen stats
Check blood pressure
Check Pulse
© Health Dimensions Group 2008 Accidents/Falls-HDGR Post Fall Assessment
Page 1 of 3

Post Fall Assessment - HDGR
Date: Resident: MR#: Rm#:
FUNCTIONAL STATUS
Observe mobility, standing and sitting balance. Any problems noted?
No
Yes (explain):
Does the resident use any assistive devices/adaptive equipment to
ambulate?
No Yes (explain):
Is the resident receiving Rehab Therapy?
No Yes (explain):
Is the resident continent of bladder?
No Yes
Is the resident continent of bowel?
No Yes
Is the resident able to toilet themselves?
No Yes (explain):
Have there been recent changes in the resident’s bowel or bladder
continence?
No Yes (explain):
Is the resident able to use a call light independently?
No Yes
Have there been recent changes in food or fluid intake?
No Yes (explain):
Is the resident currently using restraints?
No
Yes (describe):
SENSORY/COGNITIVE/PSYCHOLOGICAL STATUS
Does the resident have problems with cognition, judgment, memory, or
safety awareness?
No
Yes (explain):
Is the resident able to communicate their needs? Yes No
Does resident have conditions that affect vision or hearing?
No Yes (explain):
Have there been any changes in resident’s pain level and/or frequency
in pain in the last 30 days?
No Yes (explain):
Does the resident have any symptoms of depression?
No
Yes (explain/medications):
Possible Intervention(s)
Therapy evaluation/treatment
Assistive/adaptive devices
Bowel and bladder reassessment
Toileting schedule or schedule
changes
Dietary consult
Resident/family teaching
Lipped mattress
Low bed
Landing strip/floor mat
Sensor pads/alarms
Change in room or furniture order
Anti-tip bars on wheelchair
Anti-skid strips
Gripper socks/non-skid shoes/proper
fit shoes
Body pillow
Assist with all transfers
Restraint reassessment
Restorative program
Possible Intervention(s)
Reorient to surroundings
Activities reassessment
Mini-mental exam
Depression screening
Vision/hearing exam
Hearing aid check
Resident/family teaching
Pain assessment/pain management
Night light or increase in lighting
Therapy evaluation
Psychological exam
Has resident recently returned from hospitalization? No Yes
© Health Dimensions Group 2008 Accidents/Falls-HDGR Post Fall Assessment
Page 2 of 3

Post Fall Assessment - HDGR
Date: Resident: MR#: Rm#:
ENVIRONMENTAL STATUS/EQUIPMENT FACTORS
Are there any environmental factors that may have contributed to the
fall?
No
Yes (explain):
Possible Intervention(s)
Room modifications/changes
Environmental/equipment
assessment
Therapy evaluation
Gripper socks/anti-skid shoes
Review the information completed above and summarize post-fall findings:
Interventions to be implemented as a result of the assessment:
Referrals made to:
Please make any changes to nursing assistant assignment sheets/guides; communicate to all appropriate staff
Date assessment completed
Nurse’s signature
RETURN THIS COMPLETED FORM TO DIRECTOR OF NURSES/CLINICAL MANAGER
Any additional information/interventions to be communicated to staff along with changes to the
resident’s care plan include:
Signatures of IDT
Date:
Date:
Date:
Date:
Interdisciplinary Review: WHEN COMPLETED PLEASE RETURN TO RESIDENT’S MEDICAL RECORD. The
IDT reviews the information from the post-fall assessment.
© Health Dimensions Group 2008 Accidents/Falls-HDGR Post Fall Assessment
Page 3 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Accomodation of Needs
F Tag
F246, F247
Quality Standard All RCS Quality Standards Apply
Origination Date April 1, 2008
Revision Date
POLICY
A resident has the right to:
• Reside and receive services in the facility with reasonable accommodations for individual
needs and preferences, except when safety of the individual or other residents would be
endangered; and
• Receive notice before the resident’s room or roommate is changed.
© Health Dimensions Group 2008 Accommodation of Needs
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Activities
F Tag
F248, F249
Quality Standard RCS48, FP85
Origination Date April 1, 2008
Revision Date
POLICY
The facility must provide for an ongoing program of activities designed to meet, in
accordance with the comprehensive assessment, the interests, and the physical, mental, and
psychosocial well-being of every resident.
The activities program is directed by a professional who:
• Is a qualified therapeutic recreational specialist or an activities professional who:
- Is licensed or registered, if applicable, by the state in which practicing; and
- Is eligible for certification as a therapeutic recreation specialist or as an activities
professional by a recognized accrediting body on or after October 1, 1990; or
• Has two years of experience in a social or recreational program within the last five years,
one of which was full time in a patient activities program in a health care setting; or
• Is a qualified occupational therapist or occupational therapy assistant; or
• Has completed a training course approved by the state.
PROCEDURE
1. Within 14 days of admission, an admission assessment of activity needs is to be
completed based on the resident’s individual preferences, lifestyle, and past activities.
2. An individualized activity program for each resident will be developed. This will be
included on the resident’s care plan along with goals.
3. Activities staff, along with nursing and others, are to work together to ensure that the
program is implemented.
© Health Dimensions Group 2008 Activities
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Activities of Daily Living - ADL
F Tag
F310, F311, F312
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A resident’s abilities in activities of daily living do not diminish unless circumstances of the
individual’s clinical condition demonstrate that diminution was unavoidable. This includes
the resident’s ability to:
• Bathe, dress, and groom;
• Transfer and ambulate;
• Toilet;
• Eat; and
• Use speech, language, or other functional communication systems.
A resident who is unable to carry out activities of daily living receives the necessary services
to maintain good nutrition, grooming, and personal hygiene.
© Health Dimensions Group 2008 Activities of Daily Living - ADL
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Adjudicated Incompetent Residents
F Tag
N/A
Quality Standard FP59
Origination Date April 1, 2008
Revision Date
POLICY
In case of a resident adjudicated incompetent under laws of the State, the rights of the
resident are exercised by the person appointed to act upon the resident’s behalf.
PROCEDURE
1. Legal papers indicating appointed persons will be obtained and are kept in resident’s
medical record upon admission or change in status.
2. All appropriate documents and/or consents are signed by appointed conservator or
guardian(s).
3. Communication as needed to appropriate persons regarding resident status will be
documented in medical record.
© Health Dimensions Group 2008 Adjudicated Incompetent Residents
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Administrator
F Tag
F493
Quality Standard HR1
Origination Date April 1, 2008
Revision Date
POLICY
The administrator of the facility is appointed by the governing body and is licensed by the
state and is responsible for the management of the facility.
Through meetings and reporting mechanisms, the administrator maintains ongoing liaison
with the governing body, medical and nursing staff, and other professional and supervisory
staff of the facility. He/she ensures that public information describing services of the facility
is accurate and fully descriptive.
The administrator is responsible for enforcement of the rules and regulations relative to the
level of health care and safety of residents. The administrator is responsible for assuring the
protection of personal and property rights. The administrator plans, organizes, and directs
those responsibilities delegated to him/her by the governing body. In the absence of the
administrator, he/she will designate an individual authorized to act on his/her behalf.
© Health Dimensions Group 2008 Administrator
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Admission of a Resident
F Tag
Quality Standard FP91, FP93, RCS13, RCS14, RCS56
Origination Date April 1, 2008
Revision Date
POLICY
The facility will provide an introduction of the nursing home to the resident/family and will
collect critical health care information from the resident and/or family.
PROCEDURE
1. The room the resident will occupy should be ready to receive the resident (clean and
neat).
2. Gather items to be placed in bedside table.
3. Provide water at bedside if resident is able to consume water.
4. If the resident will be getting in bed soon after arrival, open the bed (fold down covers); if
not, leave the bed closed.
5. Lower the bed height to the lowest available.
6. Follow all infection control standards of practice.
7. When resident arrives, greet by name, and introduce self.
8. Ask what name the resident prefers to be called by staff; and note on admission sheet.
9. Briefly explain your role.
10. Introduce new resident to roommate if present. If the roommate is not present, tell the
resident the name of his/her roommate.
11. Provide privacy. Ask whether the resident wants family member to stay during the
admission procedure.
12. Ensure resident’s comfort whether in bed or chair.
13. Obtain vital signs, height, and weight—explaining all procedures.
14. Begin and/or complete all appropriate admission assessments as per facility policy.
15. Assure resident’s clothing and personal items are properly identified.
16. With the resident’s and/or family’s permission, place clothing and care items in their
respective places.
17. Place suitcase in bottom of closet, if family does not take it home.
© Health Dimensions Group 2008 Admission of a Resident
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
18. Complete possession and valuables list and have it signed by the appropriate person (as
per facility specific policy).
19. Ascertain who will do resident’s laundry (facility or family); and note on admission
sheet.
20. Provide denture cup if needed.
21. Orient resident to the new environment:
a. Identify/demonstrate use of call light and show how it works.
b. Show the bathroom.
c. Explain how phone calls can be received and/or made.
d. Explain visiting hours.
e. Tour unit to locate dining room, nurse’s station, etc.; note meal hours and routine.
f. Secure call light within reach.
22. Be certain resident is left in safe condition.
23. Take picture of resident (receive written permission if it is the facility’s policy).
24. Apply name tag outside door, if permission has been granted (if it is the facility’s policy).
25. Document all appropriate information as required.
© Health Dimensions Group 2008 Admission of a Resident
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Admission Orders
F Tag
F271
Quality Standard RCS1
Origination Date April 1, 2008
Revision Date
POLICY
At the time a resident is admitted to the facility, the facility has physician orders for the
resident’s immediate care.
At minimum, these orders include: dietary, medications, and the routine care required to
maintain or improve the resident’s functional abilities until the staff can conduct an in-depth
assessment and an individualized care plan.
© Health Dimensions Group 2008 Admission Orders
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Admission Policy for Medicare Resident - HDGR
F Tag
F208
Quality Standard RCS13, FP93
Origination Date April 1, 2008
Revision Date
POLICY
The facility will follow all Medicare guidelines for admission to a Medicare A bed.
PROCEDURE
1. Medicare residents need three days of prior hospitalization and must need skills,
knowledge, and judgment of a therapist or a licensed nurse and meet one of the following
Medicare-defined skilled care requirements:
a. Rehabilitation services following fracture or joint replacement. These include postoperative
internal fixation, external fixation devices, traction devices, and
casts/splints/slings with closed reductions;
b. Rehabilitation services following acute illness with planned discharge back to
home/previous living situation;
c. Rehabilitation services for stroke rehabilitation;
d. Intravenous therapy involving antibiotics, antifungal, morphine, or other medications;
e. Subcutaneous injections (patients with diabetes need documentation that they are
unable to give their own insulin) and have two or more order changes in the past 14
days;
f. Wounds needing ongoing skilled nursing for treatment. These can be pressure ulcers
(Stage III-IV) or post-operative wounds that are open (e.g., burns, skin grafts,
draining malignancies).
g. Total parenteral nutrition (TPN);
h. Enteral nutrition via nasogastric (NG), percutaneous endoscopically placed
gastrostomy (PEG), gastrostomy, or jejunostomy tubes without oral diet. Must have
minimum of 26% or calories plus 501cc of fluid; or
i. Conditions that require regular nursing observations with regular interventions such
as respiratory therapy, oxygen therapy, etc.
2. Residents must be diagnosed at the time of transfer. (Terminally ill residents with a “Do
Not Resuscitate” order may be deteriorating at the time of transfer.)
3. Residents with psychiatric diagnoses need documented stability of their psychiatric
disease process along with the need for other skilled services.
4. Must meet RUG III classification.
© Health Dimensions Group 2008 Admission Policy for Medicare Resident
Page 1 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
5. The following are considered technical requirements and must be completed at time of
admission to a Medicare A bed:
Medicare Check-off List:
1. Available benefit period
2. Medicare determination
3. Verification of three acute overnights
4. Physician certification/recertification
5. Medicare secondary payer screen
6. Assignment of benefits
7. Medicare card
8. Physician orders
Available benefit period:
Benefit Period: All beneficiaries are entitled to up to 100 days of Medicare Part A per benefit
period. A benefit period encompasses the consecutive days beginning with the first day a
Medicare resident receives covered Medicare A SNF services and ends when the resident is
discharged from a covered SNF Medicare A service. A new benefit period is established
when a beneficiary has remained at a non-covered skilled level of care in the SNF for 60
consecutive days or out of the SNF and hospital for 60 consecutive days. A beneficiary may
access additional Medicare A days within a 30-day window from the day of discharge (as
long as there is a need and there are days available). Between days 31 and 60 there must be a
new hospital stay before it is possible to readmit to the SNF as Medicare A stay. The balance
for the prior benefit period would be the amount of potential time the resident could be
covered (not to exceed 100 days per benefit period). Facility must verify Medicare eligibility
and days available by contacting the common working file. Social services or the business
office generally completes this verification and documentation is expected to be present in
the medical record. The facility will decide where this information is to be retained.
Medicare determination of non-coverage denial letter (if they do not meet Medicare
guidelines):
1. Denial letters (Medicare Determination of Non-Coverage) are generally located in the
business or admissions office.
2. Must be completed upon admission (if applicable) or on the date that the facility
determines Medicare benefits end.
3. May be signed by resident or legal representative.
4. Must indicate whether the resident wants the bill submitted to Medicare.
5. Must include reasons for non-coverage.
© Health Dimensions Group 2008 Admission Policy for Medicare Resident
Page 2 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
Verification of three acute overnights:
A three-day hospital stay must include three midnights in the hospital, resident admitted or
resumption of covered level of care within 30 days of last Medicare covered day.
Physician certification (see attached form):
1. Must be signed on or before admission or as soon thereafter as possible by the physician,
nurse practitioner, or clinical nurse specialist that has knowledge of the case, but is not an
employee of the facility.
2. Must be dated by the physician.
3. Must state reason extended SNF inpatient care is required. (Diagnosis is not acceptable).
The individual certifying or re-certifying has the option of certifying either that the
beneficiary meets the existing SNF level of care definition or that the beneficiary’s
assignment to one of the top 35 RUG groups is correct.
Re-certification:
1. First re-certification must be signed by the physician on or before the 14th day after
admission.
2. Subsequent re-certification must be signed at intervals not to exceed 30 days from the
date of the previous certification.
3. Must be dated by the physician.
4. Re-certification must contain a reason for the continued stay, an estimate for how long
skilled care will be needed, and discharge plans.
Certification/Re-Certification
Certification
Time Frame
Signed and dated by a physician on or before
admission or timely thereafter.
1 st Re-Certification Must be signed and dated by a physician on or
before the 14 th day after admission. This may be
signed at the same time as the certification.
All Additional Re-Certifications
Must be signed and dated by a physician at least
every 30 days from the previous re-certification.
© Health Dimensions Group 2008 Admission Policy for Medicare Resident
Page 3 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
Medicare secondary payer screen (see attached form).
Medicare Secondary Payer (MSP): Medicare always considers itself as a secondary payer
source if there is another payer. Medicare is not the primary payer in the following situations:
1. Workers’ compensation claim
2. Automobile medical insurance
3. No-fault insurance, and or
4. If the resident and/or the resident’s spouse has primary health insurance
5. Other liability insurance; facility must inquire about these potential situations and
document on Medicare Secondary Payer Screening Form.
Assignment of Benefits (AOB) (see attached form).
The Assignment of Benefits Agreement is a form that the resident or responsible party is to
have signed on admission. It allows the facility to receive payment from Medicare directly
rather than payment made directly to the resident. The form may be located in the business
office or maintained by the Admissions person.
Copy of Medicare card (front and back).
The copy of the Medicare card must include both the front and back of the card. If resident is
unable to provide Medicare card, verify that benefits are available by valid alternate means,
e.g., contact Medicare for verification.
In addition, ask the resident where he/she has been cared for during the last sixty days. The
alternate form of verification used must be documented as well as the date of verification and
the signature of the individual.
Physician orders must state that the resident needs “Daily Skilled Care.”
1. Skilled nursing care must be provided on an in-house basis in a SNF.
2. The resident must be admitted to a Medicare A certified bed. In many facilities, all beds
are certified and in others, a dedicated number are certified.
© Health Dimensions Group 2008 Admission Policy for Medicare Resident
Page 4 of 4

PHYSICIAN’S CERTIFICATION AND RECERTIFICATION
Skilled Nursing Facility – Level of Care
______________________________ ___________________ _________________________
(Patient Name) (Admission Date) (Medicare Number)
CERTIFCATION I certify that SNF services are required to be given on an inpatient basis
Completed on or because of the above-named patient’s need for skilled nursing and/or
before SNF admission skilled rehabilitation on a continuing basis.
_________________________________ __________________
(Physician’s Signature)
(Date Signed)
RECERTIFICATION I certify that continued inpatient skilled care is necessary for the following:
continued need for Nursing Observation Wound/Skin Care Tube Feeding
inpatient skilled care Physical Therapy Occupational Therapy Speech Therapy
Due on or before 14 day. Dialysis Pulmonary Care Chemotherapy
Radiation Therapy
Special Catheter
Other: ___________________________________________________
I estimate that the duration of inpatient skilled care will be _____ days.
Plans for post skilled care are: Home Health Agency Office Care
Long Term Care Other: __________________________.
Continued skilled care is for the condition the patient received inpatient hospital care
and/or the treatment of conditions that developed or were treated as a result of the stay in
the hospital or the SNF.
Date Due: __/__/__ ______________________________________
(Physician Signature)
___________________
(Date Signed)
RECERTIFICATION I certify that continued inpatient skilled care is necessary for the following:
of continued need for Nursing Observation Wound/Skin Care Tube Feeding
inpatient skilled care; Physical Therapy Occupational Therapy Speech Therapy
Due on or before the Dialysis Pulmonary Care Chemotherapy
30 day after last cert. Radiation Therapy Special Catheter
Other: ___________________________________________________
I estimate that the duration of inpatient skilled care will be _____ days.
Plans for post skilled care are: Home Health Agency Office Care
Long Term Care Other: __________________________.
Continued skilled care is for the condition the patient received inpatient hospital care
and/or the treatment of conditions that developed or were treated as a result of the stay in
the hospital or the SNF.
Date Due: __/__/__ ______________________________________
(Physician Signature)
___________________
(Date Signed)
RECERTIFICATION I certify that continued inpatient skilled care is necessary for the following:
continued need for Nursing Observation Wound/Skin Care Tube Feeding
inpatient skilled care; Physical Therapy Occupational Therapy Speech Therapy
Due on or before the Dialysis Pulmonary Care Chemotherapy
30 day after last cert. Radiation Therapy Special Catheter
Other: ___________________________________________________
I estimate that the duration of inpatient skilled care will be _____ days.
Plans for post skilled care are: Home Health Agency Office Care
Long Term Care Other: __________________________.
Continued skilled care is for the condition the patient received inpatient hospital care
and/or the treatment of conditions that developed or were treated as a result of the stay in
the hospital or the SNF.
Date Due: __/__/__ ______________________________________ ___________________
(Physician Signature)
(Date Signed)
© Health Dimensions Group 2008 Admission Policy for Medicare Residents–HDGR Form A–Physician’s Certification and Recertification
Page 1 of 1

Medicare Secondary Payer Screen
Patient Name:____________________________________
Date of Admission:________________________________
Medicare:_________________________
(attach a copy of Medicare Card)
Pay type at time of admission: Private Medicaid Medicare VA or Other
Prior Stay Information
Has the patient been confined to a hospital, hospital-based nursing home, or skilled nursing facility
during the past year?
Yes
No
If yes, complete the following information for each stay:
_________________________ _________________________ _________________________
Facility Name Facility Name Facility Name
_________________________ _________________________ _________________________
Address Address Address
_________________________ _________________________ _________________________
Admission Date Admission Date Admission Date
_________________________ _________________________ _________________________
Discharge Date Discharge Date Discharge Date
1. Is the illness or injury due to any kind of accident (including automobile, personal injury, or work)?
Yes
No
If yes, proceed to Section 1.
2. Does the patient or spouse have coverage through any other form of insurance (including VA,
Department of Labor’s Black Lung Program, employer, HMO, or other federal agency)?
Yes
No
If yes, proceed to Section 1.
3. Is the patient entitled to Medicare coverage solely on the basis of End Stage Renal Disease (ESRD)?
Yes
No
If yes, give patient’s date of coverage as shown on the Medicare Card. ____________________
4. Is the patient under the age of 65 and entitled to Medicare solely on the basis of disability?
Yes
No
5. Has the patient elected Hospice instead of Medicare Part A and B benefits?
Yes
No
© Health Dimensions Group 2008 Admission Policy for Medicare Residents–HDGR Form B–Medicare
Page 1 of 2

Section 1: Complete only if answering Yes to questions 1 or 2 on the previous page.
1. If Yes to question 1, Medicare may be secondary. Check the appropriate box below (A – E) and
answer the questions associated with it.
a. Motor Vehicle: Auto insurance is primary.
Name of Auto Insurer____________________________ Policy #__________________
b. Motor Vehicle: Liability may be primary. Bill Medicare (unless patient’s automobile
insurer can pay first) and attach copies of all pertinent documentation.
Name of third party’s liability insurer__________________________________________
Policy #________________________
Phone_________________________
c. Work related: Worker’s Compensation Insurance is primary.
Worker’s Compensation Carrier:
Policy #_____________________
Phone_________________________
Address_______________________________
__________________________________________
Address_______________________________
d. Slip and Fall: Explain where fall occurred. __________________________________
If fall occurred at place other than patient’s home, determine if liability claim or suit will
be filed, or if any kind of compensation can be made. Yes No
Give information on third party insurer_________________________________________
e. Other Accidents: No third party can pay.
Give description of accident and location.
________________________________________________________________________
2. If Yes to question 2, complete the following:
Name of Insurance Company
Address of Insurance Company
Insured Name & Policy Number
Employer’s Name (if applicable)
Beneficiary or Responsible Party Signature_________________________________ Date
If this is the responsible party’s signature, what is the relationship to the beneficiary?
Name and title of person assisting with form completion: ____________________________________
© Health Dimensions Group 2008 Admission Policy for Medicare Residents–HDGR Form B–Medicare
Page 2 of 2

Assignment of Benefits
Your Facility Name
123 Named Street
City, State ZIP Code
Policy Holder’s Name:___________________________________________
Provider’s Name: Your Facility Name
Except where my health care benefit plan(s) provide for automatic payment
to the provider of services, I authorize payments of benefits, otherwise
payable to me, for services rendered by the health care provider(s) classified
above and/or as indicated on the enclosed bill or claim.
I understand that I am financially responsible to the provider for all charges
not covered on my health care benefit plan. Until notified in writing, by me,
this Assignment of Benefits is to remain in effect.
_____________________________________________________________
Signature – Policy Holder
Date
_____________________________________________________________
Signature – Legal Representative
Date
_____________________________________________________________
Signature – Power of Attorney
Date
© Health Dimensions Group 2008 Admission Policy for Medicare Residents–HDGR Form C–Assignment of Benefits
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Admission Policy Waiving Medicare/Medicaid Benefits
F Tag
F208
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility does not require residents or potential residents to waive their rights to Medicare
or Medicaid.
The facility does not require oral or written assurance that residents or potential residents are
not eligible for, or will not apply for, Medicare or Medicaid benefits.
The facility does not require a third party guarantee of payment as a condition of admission,
expedited admission, or continued stay in the facility.
The facility may require an individual, other than the resident, to sign a contract to provide
facility payment from the resident’s income or resources if the individual has legal access to
a resident's income or resources, which are available to pay for facility care. Such individual
will not be required to incur personal financial liability.
In the case of a person eligible for Medicaid, the facility does not charge, solicit, accept, or
receive, in addition to any amount required to be paid under the State plan, any gift, money,
donation, or other consideration, as a precondition of admission, expedited admission, or
continued stay in the facility.
However, the facility may charge a Medicaid eligible resident for items and services the
resident has requested and received and that are not specified in the State plan as included in
the term “nursing facility services.” The facility gives residents notice of the availability and
cost of these services and does not condition the resident’s admission or continued stay on
the request for and receipt of such additional services.
The facility may solicit, accept, or receive charitable, religious, or philanthropic contributions
from an organization or from a person unrelated to a Medicaid eligible resident or potential
resident. The contribution can not be a condition of admission, expedited admission, or
continued stay in the facility for a Medicaid-eligible resident.
Note: To prohibit discrimination against individuals entitled to Medicaid, states or political
subdivisions may apply stricter admissions standards under state or local laws than are
specified in this policy.
© Health Dimensions Group 2008 Admission Policy Waiving Medicare–Medicaid Benefits
Page 1 of 1

Resident Care Policies and Procedures – skilled nursing facility
Policy Title Admission, Transfer and Discharge (General)
F Tag
F177, F201, F202, F203, F204, F271
Quality Standard FP101, FP94
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility policy to follow all state and federal regulations regarding admissions,
transfers, and discharges to and from the skilled nursing facility.
PROCEDURE
1. Admission:
a. Residents are admitted to the facility on the advice/orders of his/her physician. In the
case of a resident who is eligible for admission under Medicare, the admitting
physician will certify the necessity for daily skilled care.
b. Residents are accepted without regard to race, religious affiliation, color, creed,
handicap, national origin, age, or chronic illness. Persons needing subacute medical
care, post-surgical residents, and accident victims who need continued care and
rehabilitation may also be admitted to the skilled nursing facility.
c. Residents are prepared and oriented to the facility upon admission.
2. Transfer:
a. This facility has in effect a transfer agreement with hospital(s), which will admit and
transfer residents in accordance with such agreement. A transfer agreement provides
reasonable assurance that transfers of residents are medically appropriate, as
determined by the attending physician. The basis for the transfer is documented in the
medical record.
b. The effective date of the transfer and the origin and destination locations of the
transfer are noted in the medical record.
c. A transfer will not be performed when the attending physician documents or orders in
the medical record that such a transfer will be harmful to the physical or mental
health of the resident. The attending physician will also provide written notification to
the resident/family that such transfer will not occur.
3. Discharge:
a. Residents of the skilled nursing facility are discharged as directed by the attending
physician. Suitable plans for follow-up care are developed by the interdisciplinary
team, as needed. If a resident leaves the facility without physician consent, a release
of responsibility form shall be signed by the resident or responsible party.
© Health Dimensions Group 2008 Admission, Transfer and Discharge (General)
Page 1 of 2

Resident Care Policies and Procedures – skilled nursing facility
b. Residents are given sufficient time to prepare for discharge. The length of this time is
determined by their medical diagnosis.
c. Orientation: residents are prepared and oriented for safe and orderly transfer or
discharge from the facility.
4. Timings of notice:
a. The notice of transfer or discharge is made by the facility at least 30 days before the
resident is to be transferred or discharged.
b. Notice is made as soon as practicable before transfer or discharge when:
i. The safety of the individuals in the facility would otherwise be endangered;
ii. The resident's health improves sufficiently to allow immediate transfer or
discharge;
iii. An immediate transfer or discharge is required by the resident’s urgent medical
needs; or
iv. A resident has not resided in the facility for 30 days.
c. Medicare residents are given written notice of the end of their skilled service.
5. Residents are notified in writing of his/her right to appeal this action. Written notification
includes the address and telephone number of the state long-term care ombudsman.
6. Content of notice includes:
a. The reason for transfer or discharge;
b. The effective date of transfer or discharge;
c. The location to which the resident is transferred or discharged;
d. A statement that the resident has the right to appeal the action to the state;
e. For residents with developmental disabilities, the mailing address and telephone
number of the agency responsible for the protection and advocacy of developmentally
disabled individuals established under Part C of the Developmental Disabilities
Assistance and Bill of Rights Act; and
f. For nursing facility residents who are mentally ill, the mailing address and telephone
number of the agency responsible for the protection and advocacy of mentally ill
individuals established under the Protection and Advocacy for Mentally Ill
Individuals Act.
© Health Dimensions Group 2008 Admission, Transfer and Discharge (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Advance Directives
F Tag
F155
Quality Standard RCS5
Origination Date April 1, 2008
Revision Date
POLICY
Residents are asked, upon admission, their preferences regarding health care choices. In
circumstances where the resident is unable to express these choices themselves, the resident’s
legal designated representative is asked.
An advance directive can be in the form of a living will, durable power of attorney for health
care decisions (DPOAHC), or a health care treatment directive.
PROCEDURE
1. Prior to or upon admission, Social Services/designee discusses the resident’s advance
directive status with the resident or their DPOA or family representative.
2. Prior to or upon admission, the Social Services/designee should also ask for a copy of the
residents advance directive if applicable.
3. If the resident has an advance directive, it is reviewed with the resident and their DPOA
and/or family. A copy should be put in the resident chart. The chart should be identified
alerting staff of the advance directive.
4. A do not resuscitate (DNR) order is also reviewed as part of the advance directive review.
A physician’s order must be obtained for all DNR orders.
5. If the resident does not have an advance directive, the Social Services/designee offers the
resident (if alert and oriented) and/or the resident’s DPOA/family resources, along with
samples, to initiate an advance directive.
6. An advance directive is reviewed yearly or more often as necessary.
DOCUMENTATION
• All discussions with the family and resident are documented in a Social
Services/designee note.
• DNR and advance directive status is noted on the care plan.
© Health Dimensions Group 2008 Advance Directives
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Aggression - Resident
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident aggression includes resident-to-resident altercations and resident-initiated assaults
on others. It is the facility’s policy to protect the resident(s) and intervene on behalf of the
residents to prevent further aggression.
PROCEDURE
1. Action is promptly taken to mediate the aggression and separate the residents.
Preliminary preventive interventions are taken, as determined by the licensed nurse on
site.
2. The physician and the family of both residents are notified.
3. A nursing note with a description of the incident is made in the charts of both residents.
In the aggressor’s note, the identity of the person assaulted is not to be listed, and
reference to the incident report is not to be made. In the resident victim’s note, the
identity of the aggressor is not to be listed, and reference to the incident report is not to be
made. Care plans are revised as needed.
4. All State reporting requirements are followed.
5. An investigation is completed per State requirements.
6. The administrator reviews the appropriateness of retention of the aggressor within the
facility. The administrator seeks guidance from the nursing director, the resident’s
personal physician, and the medical director of the facility. Outside consultation by a
psychiatrist will be requested, as appropriate. If the resident appears to be inappropriately
placed, a request will be made to the consulting psychiatrist to prepare a realistic
discharge plan.
7. An incident report is filed on the facility’s standard form with a full description of the
incident and the persons involved.
8. All appropriate staff is made aware of any care plan changes and/or interventions.
© Health Dimensions Group 2008 Aggression–Resident
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Allergic Reaction
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
When signs of allergic reactions appear, the staff will provide emergency medical
interventions as needed.
PROCEDURE
1. When signs of allergic reaction appear, such as:
a. Profuse watery nasal discharge.
b. Swollen mucous membrane lining of nasal cavity.
c. Watery discharge from the eyes.
d. Labored breathing characterized by a wheezing, gasping sound and by a prolonged
phase of expiration.
e. Production of thick, stringy white mucous coughed up with difficulty.
f. White raised lesions surrounded by redness of the skin.
g. Reddened edematous areas of skin or red rash on skin which may be located in
contact areas.
h. Severe anxiety and restlessness.
2. Consult chart for source of allergic reaction and prescribed antidote, if present.
3. Notify physician immediately and/or poison control as needed.
4. Administer prescribed antidote, if indicated by physician and/or poison control.
5. Observe closely for signs of loss of consciousness or need for resuscitation.
6. Call paramedics and transfer to acute hospital as needed. If resident is in acute distress
and breathing ceases, initiate CPR in accordance with facility’s procedure.
7. Document event in nurse’s notes.
© Health Dimensions Group 2008 Allergic Reaction
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Allergies
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident allergies will be identified and documented to protect the resident as much as
possible from adverse consequences from medications, food, etc., that can cause a negative
outcome.
PROCEDURE
1. Review physician notes, transfer sheets, etc., for any allergies (medications, food, etc.).
2. Note allergies on allergy sticker and apply to front of chart.
3. Notify pharmacy of known allergies, and document the notification.
4. Ensure that all allergies are noted at the bottom of all medication and treatment
administration records and physician order sheets.
© Health Dimensions Group 2008 Allergies
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Anti-Coagulant Use (Coumadin, Warfarin) - HDGR
F Tag
F329
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents who require anticoagulant therapy will receive appropriate monitoring to ensure
resident safety.
PROCEDURE
1. An order for Warfarin must have an accompanying order for prothrombin time
(PT)/international normalization ratio (INR).
2. Residents require INR monitoring while on Warfarin. The time between labs should
never exceed four weeks and will be more frequent with fluctuating lab values.
3. INR is monitored after any dose adjustment; do not assume the next scheduled INR is
adequate if a dose is changed. This includes holding therapy if INR is too high.
4. All health care professionals are alerted to Warfarin therapy (dentists, therapists,
physicians, pharmacist, and/or other designee).
5. Signs of bruising and bleeding are monitored routinely. Examples of common signs of
bleeding include: black-tarry or red-looking stool, dark orange or red discolored urine,
excessive bleeding from the gums or teeth, uncontrollable nose bleeds, cuts or scratches
that continue to bleed despite pressure/bandages, sudden change in cognition or mental
status, and excessive bruising of the skin and extremities.
6. Notify physician or designee of all INR lab results to obtain appropriate order for
Warfarin.
7. INR values greater than 3.5 must be promptly reported to the physician or designee for
adjustment in therapy.
8. INR values greater than 5 indicate a high risk of bleeding. Resident’s activity is restricted
to reduce incidence of falls and injuries until INR has returned to normal.
9. Results of INR are called to physician or designee to obtain order for Warfarin prior to
administering the daily dosage.
© Health Dimensions Group 2008 Anti-Coagulant Use (Coumadin, Warfarin)–HDGR
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
EDUCATION
Monitoring: Use must be monitored by PT/INR, with frequency determined by clinical
circumstances, duration of use, and stability of monitoring results.
Adverse Consequences:
Multiple medication interactions exist which may:
• Significantly increase PT/INR results to levels associated with life-threatening bleeding;
• Decrease PT/INR results to ineffective levels;
• Increase or decreased the serum concentration of the interacting medication.
Warfarin (Coumadin) Indications and Use
Treatment
Deep Venous Thrombosis (DVT)
Pulmonary Embolism (PE)
Arterial Thrombosis
Acute Myocardial Infarction
Stroke due to Thromboembolism
Cardioversion to Normal Sinus Heart Rhythm
Prevention
Risk of DVT
Prosthetic Heart Valve Replacement
Poor Ambulation
Post-orthopedic Surgery
Prosthetic Joint Replacements
Atrial Fibrillation
Warfarin Dosing:
Warfarin is typically dosed once daily. The average daily dose for elderly residents is
between 1 to 5 mg of Warfarin per day. Dosing of this medication is highly variable and may
involve a complex regimen requiring different strengths of medication given on different
days of the week. Warfarin dosing varies from resident to resident with little predictability.
Therefore, frequent dose changes are necessary and based off PT/INR tests. PT/INR tests
measure the time it takes for a resident’s blood to form a clot. The PT/INR test is reported as
an INR to standardize treatment due to variability in lab testing materials and equipment. To
individualize a resident’s Warfarin dosing, the physician or designee will look for a
therapeutic INR range depending on the resident’s diagnosis.
Common Therapeutic INR Ranges
INR 2.0 – 3.0
INR 2.5 – 3.5
DVT, PE, Atrial fibrillation, Post-surgery,
Stroke
Mechanical Heart Valve Replacement,
Acute post-myocardial infarction.
Warfarin is among the most potent medications given to residents of long-term care facilities.
The administration and monitoring of the drug is critical for resident safety. There is a
narrow therapeutic index.
© Health Dimensions Group 2008 Anti-Coagulant Use (Coumadin, Warfarin)–HDGR
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
• Typical physician interventions include: holding therapy, reducing Warfarin dose, using
Vitamin K to reverse the anticoagulation, and blood transfusions to restore clotting
function. PT/INR is properly ordered for any change in therapy.
• Residents that are anticoagulated from Warfarin have a high risk for drug interactions.
Because of the narrow therapeutic range of Warfarin, even a small alteration in Warfarin
blood levels can increase the risk for bleeding. Common drug interactions include:
- Non-steroidal anti-inflammatory drugs
- Ibuprofen (Motrin, Advil)
- Naproxen (Naprosyn, Aleve)
- Aspirin
- Clopidogrel (Plavix)
- Amiodarone (Cordarone, Pacerone)
- Digoxin (Lanoxin)
- Phenobarbital
- Phenytoin (Dilantin)
- Antibiotics (Cipro, Flagyl, Bactrim, Septra, etc.)
Summary:
Warfarin therapy requires continual, intensive monitoring to ensure resident safety. Small
changes in dosing due to drug interactions, missed doses, or changes in overall health will
affect the balance of anticoagulation. Change in INR can be unpredictable with irregular
fluctuations even after years of steady therapy.
This information is for educational purposes. Please consult the resident’s physician or
designee for direct patient care issues.
© Health Dimensions Group 2008 Anti-Coagulant Use (Coumadin, Warfarin)–HDGR
Page 3 of 3

PT/ INR Flow Sheet - HDGR
Date: Resident: MR#: Rm#:
Supporting Diagnosis:
Desired PT/ INR Range:
Date
PT/INR
Anti-coagulant
dose
Date next lab
ordered
Initials of
person taking
order
Comments
Signature:
Date:
© Health Dimensions Group 2008 Anti-Coagulant Use PT/ INR Flow Sheet - HDGR
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Assessments (General)
F Tag
N/A
Quality Standard RCS57
Origination Date April 1, 2008
Revision Date
POLICY
The facility will conduct assessments upon admission and ongoing assessments for all
residents.
PROCEDURE
1. Upon admission the following overall assessments will be completed:
a. Nursing
b. Activities
c. Dietary
d. Social services
e. Other disciplines as appropriate
2. Nursing completes the following assessments upon admission and as indicated per each
individual policy/procedure:
a. Bowel and bladder
b. Fall risk
c. Hydration risk
d. Elopement risk
e. Skin at risk
f. AIMS or DISCUS if using an antipsychotic medication
g. Pain
3. Activities staff completes the following assessments upon admission and as indicated per
each individual policy/procedure:
a. [Facility to insert assessments as appropriate.]
4. Dietary staff completes the following assessments upon admission and as indicated per
each individual policy/procedure:
a. [Facility to insert assessments as appropriate.]
© Health Dimensions Group 2008 Assessments (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
5. Social Services staff completes the following assessments upon admission and as
indicated per each individualized policy/procedure:
a. Mini mental status exam
b. Depression scales
6. Documentation will be completed, signed, and dated as appropriate.
© Health Dimensions Group 2008 Assessments (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bandages
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will apply/use dressings appropriately.
• Types of bandages may include:
- Adhesive
- Elastic
- Roller gauze
- Triangular
- Kling or Kerlix
- Elastoplast
- Montgomery straps
- Maltese Cross
- Butterfly
PROCEDURE
1. Preparation:
a. Wash hands
b. Put on new gloves prior to removing old dressing
c. Remove old dressing
d. Put soiled dressing in appropriate bag for disposal
e. Remove gloves
f. Wash hands/sanitize
g. Put on new gloves
h. Apply appropriate bandage, as follows, following proper infection control techniques:
i. Adhesive:
a. Commonly used to secure dressings on traumatic, post-operative, and other
type areas.
b. If the patient is allergic to this bandage, use hypoallergenic tape.
© Health Dimensions Group 2008 Bandages
Page 1 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
c. Remember that adhesive can pull hair and abuse the skin when it is removed.
Shave the site, if appropriate. Monitor resident’s tolerance.
d. Cut the necessary length of adhesive tape from the roll. To firmly secure, it is
applied to adhere to the dressing edge and the skin.
e. Use tape wide enough to avoid cutting into the resident’s skin and apply
loosely enough to give security without constriction.
ii. Elastic:
a. Commonly used for support and immobilization.
b. Roll bandage evenly to facilitate application before attempting to apply.
c. Application is begun distally and progressed proximally.
* Hold roll so that it unrolls against the surface being covered.
d. Application should be uniformly smooth, but not tight.
* Check each lap to verify that it is not too tight.
iii. Roller Gauze:
a. Commonly used to secure dressings in place.
b. Begin by anchoring the bandage over itself and apply so as to conform to the
area.
c. Secure with adhesive tape.
iv. Triangular:
a. Usually prepared from unbleached muslin, cut diagonally on the bias and
hemmed at the edges; or it can be bought commercially already prepared.
b. A sling is provided for support of the forearm and shoulder by placing one
tail, “a”, over the shoulder of the affected arm. Bring the second tail, “b”,
around the back to meet tail “a”; pull the tails to slightly elevate the hand
above the elbow and tie the tails securely with a square knot. Fold the third
tail, “c”, to cover the elbow in order to keep elbow from slipping out of
bandage and provide a neat appearance. Pin tail “c” with a safety pin.
c. Commercially made arm slings may be used instead of the above. Follow
instructions provided.
v. Kling (Kerlix):
a. This type of roller gauze is so woven that it clings to itself.
b. Apply it loosely over dressings and secure with adhesive tape.
c. When applying on extremity, apply from the distal to the proximal ends.
© Health Dimensions Group 2008 Bandages
Page 2 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
vi. Elastoplast:
a. Apply Elastoplast in the same manner as adhesive, only stretching the
bandage slightly when applying it to the skin. This provides tension on the
affected area.
b. Remember that adhesive will pull hair when removed, and this bandage can
be applied too tightly if not done carefully. Shave the area, if appropriate.
Monitor resident’s tolerance.
vii. Montgomery Straps:
viii.
a. Made commercially and also may be made by the nurse.
b. Used to facilitate convenience and comfort when frequent changes of dressing
are necessary.
c. Construct the straps by cutting an appropriate length of 1 or 2” adhesive tape.
Fold over approximately one-third of the length of the tape so that it adheres
to itself. At the distal end of the folded portion, cut a small hole by folding the
tape in quarters and snipping the end. Make as many straps as necessary to
secure the dressing.
d. Place the straps on opposite sides of the part to be covered, with the folded
sections inward. Provide a lacing between the straps by utilizing 1” roller
gauze. Tie each opposing set of straps separately.
e. Change these often, as they are easily soiled.
Maltese Cross:
a. Make from adhesive tape to cover stumps or finger tips.
b. Cut a square of adhesive the size necessary to cover the proposed area.
c. Cut toward the center of each corner, approximately one-third of the diameter.
d. Stretch the four sections slightly and apply to the area. Place so that the
middle section is over the tip of the area.
e. Secure one section at a time until all four sections are used.
ix. Butterfly:
a. Make from adhesive tape, the width depending upon the size of the lacerated
or incised area.
b. Cut the appropriate length of adhesive tape. At approximately one-third of the
distance from each end, cut diagonally inward on each side of the tape to a
point approximately one-third the width of the tape. Fold over each midportion
to form a non-adhering center.
c. * Paint the non-adherent center with an antiseptic solution before application.
© Health Dimensions Group 2008 Bandages
Page 3 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
2. After care:
d. Apply one adherent portion to one side of the inside area, and holding the skin
in direct apposition, apply the other adherent portion to the other side of the
inside area.
e. This holds the opposing skin together and promotes healing when suturing is
determined unnecessary.
f. Butterfly bandages are also manufactured commercially and may be utilized,
if available.
a. Remove the gloves; dispose of properly.
b. Wash hands.
c. Place your initial and the date on dressing, or as per facility’s policy.
3. Chart the type of dressing and site of application on the treatment administration record.
Any unusual observations should be noted in the medical record with physician notified
as needed.
4. Make out the necessary charge slips, if applicable.
© Health Dimensions Group 2008 Bandages
Page 4 of 4

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bath in Bed
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The resident will be provided a bed bath if unable to receive a routine shower/tub and/or at
the request of resident, during morning or evening cares.
PROCEDURE
Note: Allow the resident to do as much washing of their self as possible. Assist only where
necessary. The order of bathing may differ from resident to resident.
1. Wash hands.
2. Explain procedure to resident and provide privacy.
3. Assemble equipment.
4. Fill basin with warm water and bring to bedside.
5. Remove clothing of areas to be bathed only. Use bath blanket (or other cover) to cover
the exposed area.
6. While bathing the resident, observe any skin problems, e.g., wounds, abrasions, rashes,
and bruises.
7. Place towel across the resident’s chest. Proceed to wash and then rinse the face, neck, and
ears.
8. Wash and rinse the shoulder, underarms, arms, hands, and chest.
9. When water becomes cool, change it.
10. Wash back, rinse, and dry.
11. Wash legs, feet, and in between toes.
12. Rinse and dry legs, feet, and in between toes.
13. Change rinse water.
14. Perineal area:
a. Put on gloves.
b. Wash from front to back.
c. Clean, rinse, and dry.
d. Remove gloves.
© Health Dimensions Group 2008 Bath in Bed
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
e. Wash hands/sanitize.
15. Apply lotion or powder, as needed.
16. Apply deodorant to underarms, as needed.
17. Apply clothing; have resident assist whenever possible.
18. Perform or assist with oral care.
19. Perform hair and nail care, as needed.
20. Shave or assist with shaving, as needed.
21. Rinse out basin.
22. Dispose of soiled linen and clothing, as needed, according to sanitary procedures.
23. Wash hands.
24. Store all clean bathing supplies.
25. Document amount of assist on ADL sheet, if it’s the facility’s policy.
26. Report any skin problems to the charge nurse or designee.
© Health Dimensions Group 2008 Bath in Bed
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bath in Shower
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
To provide the resident the opportunity to bathe at least weekly and/or as per residents
request or as needed
PROCEDURE
Note: Allow the resident to do as much washing of their self as possible. Assist only where
necessary. Never leave a resident alone in the shower room (unless physician’s order).
1. Assemble all equipment in the shower room.
2. Wash hands.
3. Explain procedure to the resident and ensure privacy.
4. If possible, undress the resident in privacy in the shower room. Otherwise, in the
resident’s room, change the resident to a robe/cover and cover the resident with the bath
blanket while assisting the resident to the shower, keeping the resident covered at all
times.
5. Provide privacy.
6. Draw the cubicle curtains around resident and shower area to be used, if applicable.
7. Start the shower and adjust water to a comfortable temperature.
8. Remove resident’s clothes (or robe and blanket), or assist as needed, and place the
resident in shower. If the resident is able to stand, encourage use of the grab bars for
additional support. If the resident is unable to stand, use a shower chair.
9. While bathing the resident, observe any skin problems, e.g., wounds, abrasions, rashes,
and bruises. Alert nurse as needed.
10. Wash and rinse the shoulder, underarms, arms, hands, and chest.
11. Wash back.
12. Wash legs, feet, and in between toes.
13. Perineal area:
a. Put on gloves.
b. Wash from front to back.
c. Clean, rinse.
© Health Dimensions Group 2008 Bath in Shower
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
d. Remove gloves.
e. Wash hands.
14. Turn water off and remove resident from shower.
15. Towel dry.
16. Apply lotion or powder, as needed.
17. Apply deodorant to underarms, as needed.
18. Assist with dressing, as needed.
19. Perform or assist with oral care.
20. Perform hair and foot care, as needed.
21. Shave or assist with shaving, as needed.
22. Return resident to room. Items 16-21 may be done in resident’s room.
23. Remove all shower/cleaning items from shower room.
24. Take resident’s personal belongings to room.
25. Dispose of dirty clothes and linens according to sanitary procedures.
26. Wash hands.
27. Apply gloves. Clean shower area with disinfectant. Remove gloves.
28. Document amount of assist on ADL sheet, if it is the facility’s policy.
© Health Dimensions Group 2008 Bath in Shower
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bath in Tub
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
To provide the resident the opportunity to bathe at least weekly and/or as per resident’s
request or as needed.
PROCEDURE
Note: Allow the resident to do as much washing of their self as possible. Assist only where
necessary. Never leave a resident alone in the tub room (unless physician’s order).
1. Explain procedure to resident and ensure privacy.
2. Fill tub with appropriate level of water.
3. Adjust temperature of water.
4. Wash hands.
5. If possible, undress the resident in privacy in the tub room. Otherwise, in the resident’s
room, change the resident to a shower robe and cover the resident with the bath
blanket/cover while assisting the resident to the shower, keeping the resident covered at
all times.
6. Use wheelchair if necessary.
7. Do not leave the resident alone.
8. Instruct the resident in use of grab bars, as appropriate.
9. Assist resident into tub (obtain assistant as required per resident’s plan of care).
10. While bathing the resident, observe any skin problems, e.g., wounds, abrasions, rashes,
and bruises. Contact nurses as needed.
11. Wash and rinse the shoulder, underarms, arms, hands, and chest.
12. Wash back.
13. Wash legs, feet, and in between toes.
14. Perineal area:
a. Put on gloves.
b. Wash from front to back.
c. Clean, rinse.
© Health Dimensions Group 2008 Bath in Tub
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
d. Remove gloves.
e. Wash hands.
15. Turn water off and remove resident from tub.
16. Towel dry.
17. Apply lotion or powder as needed.
18. Apply deodorant to underarms, as needed.
19. Assist with dressing, as needed.
20. Perform or assist with oral care.
21. Perform hair and foot care, as needed.
22. Shave or assist with shaving, as needed.
23. Return resident to room. Items 17-22 may be completed in resident’s room.
24. Remove all shower or cleaning items from shower/tub room.
25. Take resident’s belongings to room.
26. Dispose of dirty clothes and linens according to sanitary procedures.
27. Wash hands.
28. Apply gloves. Drain tub and clean with disinfectant. Remove gloves.
29. Clean bathing area and store all supplies.
30. Document amount of assist on ADL sheet, if it’s the facility’s policy.
© Health Dimensions Group 2008 Bath in Tub
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bath in Whirlpool
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
To provide the resident the opportunity to bathe at least weekly and/or as per resident’s
request or as needed
PROCEDURE
Note: Allow the resident to do as much washing of their self as possible. Assist only where
necessary. Never leave the resident alone in the tub room (unless physician’s order).
1. Wash hands.
2. Explain the procedure to the resident and ensure privacy.
3. Assemble equipment in the whirlpool.
4. If possible, undress the resident in privacy in the shower/tub room. Otherwise, in the
resident’s room, change the resident to a shower robe/cover and cover the resident with
the bath blanket/cover while assisting the resident to the whirlpool, keeping the resident
covered at all times.
5. Assist the resident to the tub room (covered appropriately).
6. Fill the whirlpool tub as directed. Check water temperature to be no greater than 105
degrees.
7. Assist resident into tub per resident’s plan of care. Using whirlpool chair as
recommended. When in the tub, turn on whirlpool.
8. While bathing the resident, observe any skin problems, e.g., wounds, abrasions, rashes,
and bruises. Report/contact nurses as needed.
9. Wash and rinse the shoulder, underarms, arms, hands, and chest.
10. Wash back.
11. Wash legs, feet, and in between toes.
12. Perineal area:
a. Put on gloves.
b. Wash from front to back.
c. Clean, rinse.
d. Remove gloves.
© Health Dimensions Group 2008 Bath in Whirlpool
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
e. Wash hands.
13. Turn water off and remove resident from shower.
14. Towel dry.
15. Apply lotion or powder, as needed.
16. Apply deodorant to underarms, as needed.
17. Assist with dressing, as needed.
18. Perform or assist with oral care.
19. Perform hair and foot care, as needed.
20. Shave or assist with shaving, as needed.
21. Return resident to room.
22. Remove all shower or cleaning items from shower/tub room.
23. Take resident’s belongings to room.
24. Dispose of dirty clothes and linens according to sanitary procedures.
25. Wash hands.
26. Apply gloves. Drain tub and clean with disinfectant. Remove gloves.
27. Clean bathing area and store all supplies.
28. Document type of bath and amount of assist on ADL sheet, if it is the facility’s policy.
© Health Dimensions Group 2008 Bath in Whirlpool
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bed Changing While Occupied
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents will be provided with clean linens.
PROCEDURE
1. Wash hands.
2. Assemble all equipment in room and place on nearby chair.
3. Explain the procedure to the resident.
4. Adjust bed height to comfort.
5. Have the resident turn to side away from you (utilize adaptive equipment such as side
rails/trapeze, as assessed).
6. Loosen the top bedding at the bottom of the bed and place over the turned resident.
7. Loosen the bottom sheets from the side you are standing on and tuck under the resident.
8. Place a clean bottom sheet on the mattress on your side (one-half way over) using the
middle creased line on the sheet as a guide for the center (side hem at the top) and tuck in
at the top (mitered corners*) and along the side you are standing on. If draw sheet is used,
do the same for it.
* Refers to non-fitted bottom sheet.
9. Ask the resident to roll over to your side.
10. Go to other side of the bed. Remove soiled linen and put in receptacle. Pull out clean
linen from under the resident and tuck in bottom sheet at the top (mitered corners*) and
sides and then the draw sheet on the side. Make the sheets as tight as possible.
* Refers to non-fitted bottom sheet.
11. Have the resident roll flat. Remove spread and place on chair.
12. Cover old top sheet with a fresh sheet with wide hem facing down. Instruct resident to
hold the fresh sheet at the top. Pull out old sheet from underneath. Tuck in at the bottom
of the bed. Allow room for foot movement. (Unless sheet is grossly soiled.)
13. Apply spread over top sheet and tuck in at the bottom.
14. Turn down edges of both covers at top.
15. Remove pillow from under head and remove case and discard in soiled linen container.
© Health Dimensions Group 2008 Bed Changing While Occupied
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
16. Grasp new pillowcase and pull open edges down to closed. Grasp pillow by end with
hand holding pillowcase.
17. Pull pillow case on. Do not shake. Place under resident’s head.
18. Adjust bed to correct height for resident.
19. Place call light within resident’s reach.
20. Place linens in the laundry receptacles.
21. Wash hands.
© Health Dimensions Group 2008 Bed Changing While Occupied
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bed Changing While Unoccupied
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents will be provided with clean linens.
PROCEDURE
1. Wash hands.
2. Assemble equipment in resident’s room.
3. Explain the procedure to the resident.
4. Place the clean linen on a chair or clean area.
5. Adjust bed height to comfort.
6. Remove pillowcase and all dirty linen from the bed. Put in soiled linen container. Do not
carry close to your body.
7. Wash hands.
8. If the bedspread is to be reused, place on chair.
9. Place the bottom sheet in the center of the bed. The wide hem of the sheet should be at
the head of the bed and the narrow end at the bottom of the bed (if not fitted sheets).
10. Tuck in the bottom sheet at the head of the bed, miter the corner, and tuck in the sheet on
your side (if not fitted sheets).
11. If draw sheet is used, place in center of bed and tuck in on your side.
12. Go to other side of bed and tuck in bottom sheet at the top and miter corner. Tuck in draw
sheet.
13. Place top sheet over sheets with wide hem at the top facing downward and the sheet just
coming to the mattress edge.
14. Place spread over top sheet to come to about four inches from the top sheet at the head of
the bed. Tuck in the top sheet and spread at the bottom of the mattress. Do not miter
corners.
15. Remove pillowcases and dispose of in soiled linen barrel. Put on clean pillowcase by
grasping closed end in hand and with same hand grasp pillow at end and apply to pillow.
16. Adjust bed to correct height for resident.
17. Place call light appropriately within reach of resident.
© Health Dimensions Group 2008 Bed Changing While Unoccupied
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
18. Place old/soiled linens in laundry receptacles.
19. Wash hands.
© Health Dimensions Group 2008 Bed Changing While Unoccupied
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bed Cradle
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A bed cradle can be used to remove the weight and presence of the bed cover on the body
surfaces and provide for resident comfort.
PROCEDURE
1. Wash hands.
2. Assemble needed equipment in the resident’s room.
3. Explain the procedure to the resident.
4. Pull the cubicle curtain for privacy.
5. Loosen top linen on the bed, and remove the blanket and bedspread.
6. Place the bed cradle at the foot of bed, and secure it to the bed frame with the attached
clip or as per manufacturer guidelines.
7. Bring the top sheet over the cradle. Avoid unnecessary exposure of the resident.
8. Replace the blanket and the bedspread over the cradle.
9. Position the resident appropriately.
10. Leave the resident comfortable with call light in reach.
11. When bed cradle is removed, clean cradle with disinfectant solution and return to the
proper storage place.
12. Notify charge nurse of any unusual observations or resident reactions.
13. Charge nurse or designee makes the necessary notations on the resident care plan.
14. Document on treatment record as needed.
© Health Dimensions Group 2008 Bed Cradle
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bed Hold and Re-Admission
F Tag
F205, F206
Quality Standard FP65
Origination Date April 1, 2008
Revision Date
POLICY
Before a resident is transferred to a hospital or placed on therapeutic leave, written
notification is provided to the resident, and/or a family member, or legal representative that
specifies:
• Bed hold: The duration of the bed hold period. The policy regarding bed hold periods is
consistent with the law permitting a resident to return and, in the case of Medicaid, the
State plan.
• Bed hold transfer: At the time of transfer for hospitalization or leave, written notice that
specifies the duration of the facility bed hold period is provided to the resident and/or a
family member, or legal representative. A copy and/or documentation of the notice is
placed in the resident’s medical record.
• Resident return: Any resident whose hospitalization or therapeutic leave exceeds the
bed hold period will be readmitted to the first available bed in a semi-private room, if the
resident requires the services provided and is eligible for services, including Medicaid
services.
Note: The bed hold policy does not apply to dedicated Medicare beds.
© Health Dimensions Group 2008 Bed Hold and Re-Admission
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bed Making - Mitered Corners
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
EDUCATION
To make mitered corners for non-fitted sheets.
PROCEDURE
1. Tuck in sheet at bottom or top of bed.
2. Grab sheet about 12 inches from the edge and bring up on the bed to form a triangle.
Tuck in the part of the sheet hanging down.
3. Tuck in the triangle area after folding down over side of mattress.
© Health Dimensions Group 2008 Bed Making–Mitered Corners
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bedpan or Urinal Use and Storage
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The resident will be provided the use of a bedpan or urinal when elimination on the toilet is
not feasible and/or deemed appropriate per resident assessment and/or per resident request.
PROCEDURE
1. Bring all equipment to the resident’s room.
2. Wash hands.
3. Apply gloves.
4. Explain the procedure to the resident.
5. Ensure privacy.
6. To give a bedpan:
a. With head of bed lowered, put bedpan under the covers, and ask the resident to flex
his/her knees and push on the mattress with heels to help raise his/her hips.
b. Support lower back with one hand and slip bedpan into place.
c. If the resident is unable to lift his/her hips, roll him/her to one side and place the
bedpan against the buttocks and roll the resident over onto his/her back onto the
bedpan.
d. Raise head of the bed for comfort. Provide toilet tissue.
7. To remove a bedpan:
a. Wash hands and apply gloves.
b. Help resident with use of toilet tissue to wipe self. Wipe from front to back.
c. Support the resident as before, lifting hips or rolling to the side to remove the bedpan.
d. Cleanse perineal area as needed.
e. Take bedpan to hopper and remove waste. Rinse with water and return to resident’s
room. and store in bedside table or in bathroom.
f. Remove gloves and wash hands.
© Health Dimensions Group 2008 Bedpan or Urinal Use and Storage
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
8. To give a urinal: Position the urinal under the covers between the resident’s legs so that
the penis is in the urinal.
9. To remove a urinal:
a. Ask the resident to hand it to you. Do not tip it.
b. Dump urine out in toilet and rinse with water.
c. Clean perineal area as needed.
d. Remove gloves and wash hands.
10. Bedpan and urinal storage:
a. Must be covered and labeled (if sharing a bathroom).
b. Urinals must be capped whenever possible.
c. Neither bedpan nor urinal may be stored on the floor.
11. Note urine amount on intake and output sheet as appropriate.
© Health Dimensions Group 2008 Bedpan or Urinal Use and Storage
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bedside Commode - Chair Use
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A commode may be used to provide the resident the ability to toilet at the bedside, if deemed
appropriate.
PROCEDURE
1. Position resident on commode. Do not leave resident unattended if not appropriate.
2. Put call light within reach, if needed.
3. Provide privacy.
4. Assist resident with cleaning, if needed.
5. Assist resident back to bed, as needed.
6. Note amount and color of urine or bowel movement on ADL sheet, if it is the facility’s
policy.
7. Notify charge nurse or designee of any problems.
© Health Dimensions Group 2008 Bedside Commode–Chair Use
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bedside Commodes - Cleaning
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Whenever bedside commodes are used, they will be cleaned following infection control
standards/measures.
PROCEDURE
1. Apply gloves.
2. Empty contents into toilet in resident room, rinse.
3. Wash hands.
4. Cover and take to dirty utility room.
5. Re-apply gloves, if needed; clean thoroughly with approved cleaner disinfectant solution.
6. Rinse cleaned equipment, as needed.
7. Place on clean cloth to dry or dry thoroughly with a clean cloth.
8. Remove gloves, as needed.
9. Wash hands.
10. When dry, return to resident room or store in appropriate place in clean utility room.
© Health Dimensions Group 2008 Bedside Commodes–Cleaning
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Body Mechanics
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Staff will utilize appropriate body mechanics to prevent injury and/or discomfort to the
employee and/or resident.
EDUCATION
• Properly fitting shoes will be worn at all times.
- The shoes you wear influence your posture and may contribute to low back pain and
fatigue.
- Note: To demonstrate the effect of high-heeled shoes: stand with bare feet in front of
a full length mirror. Note the curve in the small of your back. Raise your heels by
putting on a pair of your high heels or stand on the telephone book (heels on book and
toes on floor) and again note the low back curve which is increased.
- A shoe with an unyielding sole is the worst you can wear. When thick-soled shoes are
worn and the ankle twists, there is a long fall of the ankle to the floor, which increases
the potential damage.
- Wear shoes that are flexible and give good support.
• The law of physics and how it applies to body mechanics:
- Stemming from some basic laws of physics, good body mechanics are necessary in
the performance of the acts of moving, lifting, and carrying. If used correctly, good
body mechanics reduce effort exerted and prevent injury.
- Basic guidelines:
o
o
o
o
Use of the longest and the strongest muscles on the arms and legs help to provide
the power needed in activities.
Use of the internal girdle and a long midriff to stabilize the pelvis and to protect
the lining of the abdomen when bending, reaching, lifting, and pulling.
Work as close as possible to the object being moved. The center of gravity moves
closer to your body permitting most of the weight to be borne by the large muscle
groups.
Use body weight as a force for pulling or pushing by rocking on the feet or
leaning forward or backward. The amount of strain on the arms and back is
decreased by this maneuver.
© Health Dimensions Group 2008 Body Mechanics
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
o
o
o
o
Slide, roll, push, or pull an object rather than lift it. This reduces the energy
needed to lift the weight against the pull of gravity.
Use body weight to push an object by falling or rocking backward and to pull an
object by falling or rocking forward.
Place the feet apart in order to provide a wide base of support.
Flex the knees and come down close to an object when it is to be lifted.
• General principles of body mechanics:
- Alignment of the body needs to be correct. Various parts of the body should be in
proper relationship to each other. This also applies to the nursing assistant and the
resident.
- When standing, the feet should be far enough apart to provide a good base to maintain
balance. This also permits shifting of weight from one foot to the other. Placing one
foot in front of the other will assist in moving a resident toward you. This enables you
to shift weight forward and backwards as you move the resident.
- An object should be moved toward rather than away from the mover.
- The use of large muscle masses causes less strain and fatigue than the use of small
muscle groups.
- Use the muscles of the legs, arms, and shoulders instead of the abdomen or middle
back.
- An object put into motion gains speed and continues its movement until stopped.
This principle is important in turning a resident.
- When moving a dependent resident, a pull sheet can be used.
PROCEDURE
Proper body mechanics applied to resident care are outlined in these procedures.
1. General reminders in handling residents:
a. Always tell the resident what is to be done.
b. Know the resident’s disabilities and abilities.
c. Ask the resident to assist. Tell him/her how to do so.
d. Handle gently but firmly. Avoid pressure around joints or bony prominences.
e. Use coordinated movements.
f. Plan before moving.
g. If resident begins to fall:
i. Support at waist.
ii. Ease resident to the floor. Bend your hips and knees as you lower the resident.
© Health Dimensions Group 2008 Body Mechanics
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
2. Standing
a. All body segments are laid over one another and the weight is distributed over the
broad base when you are standing correctly.
b. Stand with feet slightly apart, shoulders back, and buttocks tucked under.
3. Lifting—do not lift if you can push, pull, roll or slide.
a. Lower your body by flexing your hips and knees. Do not bend from your waist.
b. Keep the upper part of your body and back straight.
c. Maintain your balance by placing your feet so that the base is broad.
d. Stand close to the object to be lifted.
e. Thrust your pelvis forward as you lift the object so that your legs do the lifting.
4. Carrying
a. Carry the object close to your body at waist level.
b. Tuck your pelvis forward so the curve in your back is decreased.
c. Use mechanical devices to carry objects if possible.
5. Reaching
a. Stand close to your work.
b. Place your feet slightly apart to form a good base.
c. Use a footstool when reaching for high objects (objects should not be brought down
from over your head).
© Health Dimensions Group 2008 Body Mechanics
Page 3 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Bowel and Bladder Management - HDGR
F Tag
F315
Quality Standard RCS23
Origination Date April 1, 2008
Revision Date
POLICY
There is a system to ensure that each resident with bowel or bladder incontinence will receive
appropriate treatment and services to achieve or maintain as much normal functioning as
possible.
PROCEDURE
1. All residents are assessed for bowel and bladder function upon admission, annually, and
with a decline in continence status (Bowel and Bladder Functional Evaluation Tool).
2. A three-day bowel and bladder tracking tool will be completed for incontinent residents
upon admission, annually, with any decline in continence, and after a Foley catheter is
discontinued. From the three-day bowel and bladder tracking tool, note any patterns.
3. An individualized toileting schedule will be established for all incontinent residents and
noted on care plan.
4. The bowel and bladder assessments will be reviewed quarterly for residents assessed to
be incontinent of bowel or bladder.
© Health Dimensions Group 2008 Bowel and Bladder Management–HDGR
Page 1 of 1

Bowel and Bladder Functional Evaluation Tool - HDGR
Date: Resident: MR#: Rm#:
□ Admission (all residents) □ Quarterly (as needed) □ Annually (all residents)
□ Significant Change □ New Onset Incontinence □ Discontinued Foley Catheter
Resident/Responsible Party Interview
The resident is continent of urine □ YES □ NO The resident is continent of bowel □ YES □ NO
The resident has an indwelling catheter □ YES □ NO Size:
Medical diagnosis for the use of catheters:
If resident is continent of bowel and bladder, no further assessment is necessary at this time
Elimination History
Months/years incontinent of urine ________ □ Unknown Months/years incontinent of bowel ______ □ Unknown
Resident wakes at night to void □ YES □ NO
Number of times ______ other patterns:
Adequate fluid intake □ YES □ NO
Resident consumes excessive caffeine □ YES □ NO
Recent catheter discontinuation □ YES □ NO
Resident “leaks” urine □ YES □ NO
Cause: □ Laughing □ Coughing □ Position Change □ Sneezing □ Exercising
Normal Bowel Pattern
□ Regular □ Irregular Time of day ________ Number per day / week (circle one)
Resident has constipation □ YES □ NO
If “yes”, bowel program:
Bowel sounds: □ Present in four quadrants □ Present in _____ quadrants □ Diminished □ Hyperactive □ Active
Resident has history of hemorrhoids □ YES □ NO
Current Elimination Symptoms
□ Voids often/small amounts □ Unable to void □ Urgency □ Difficulty stopping stream □ Dysuria
□ Difficulty starting stream □ Burning pain □ Hematuria □ Dribbles constantly □ Fever
□ Dribbles when voids □ Recent fall □ Edema □ Dribbles with cough or standing up
□ Unable to feel urge sensation □ Functionally disabled □ Other
Cognitive Status
Resident displays: □ Short-term memory loss □ Long-term memory loss □ Alert / oriented
The resident is able to identify the need to void/defecate □ YES □ NO □ Some of the time
The resident is able to use the nurse call light □ YES □ NO □ Some of the time
The resident is able to ask to go to the bathroom □ YES □ NO □ Some of the time
The resident is unable to sit on the toilet □ YES □ NO □ Some of the time
The resident is able to sit on the toilet □ YES □ NO □ Some of the time
Visual Inspection of Perineum
□ Abnormalities noted:
□ None
© Health Dimensions Group 2008 Bowel and Bladder Functional Evaluation Tool - HDGR
Page 1 of 3

Bowel and Bladder Functional Evaluation Tool - HDGR
Date: Resident: MR#: Rm#:
Diagnoses (Check all that apply to the resident)
□ Atrophic Urethitis/Vaginitis □ Dementia/Alzheimer’s □ History of UTI □ Urinary disorder
□ Cancer □ Depression □ Kidney disease □ Recent surgery
□ CHF □ Diabetes □ MS □ Abnormal lab value
□ CVA □ Edema □ Parkinson’s Disease (calcium, glucose,
□ Dehydration □ Prostate problems □ Pelvic organ prolapse BUN, creatinine)
□ Delirium □ History of bowel obstruction/impaction □ other
Medications (Check all that apply to the resident)
□ Ace inhibitors (Captopril, Lisinopril) □ Calcium channel blockers □ Parkinson’s meds
□ Anti-Parkinson’s (Verapamil, Diltizen, Nifedipine) □ Psychoactive/Hypnotic
□ Antihistamines □ Diuretics □ Stimulants
□ Antispasmodic □ Narcotics □ Tricyclic antidepressants
(Amitriptylline, etc.)
Mobility Status
□ Requires assist with ambulation □ Requires assist to transfer to toilet/commode □ Chairfast
□ Requires mechanical lift □ Bathroom is not easily accessible for the resident □ Bedfast
□ Uses adaptive equipment to toilet
List equipment used:
Pain Status
Resident has, or is being treated, for pain □ YES □ NO Comments:
Pain affects resident’s ability to void/defecate □ YES □ NO Comments:
Retraining Potential (cannot base on cognitive status alone)
Resident is a candidate for retraining □ YES □ NO
Toileting – Resident Self Performance
(How resident uses toilet, bedpan, and transfers on/off bed pan, toilet, cleanses, changes pads, adjusts clothes)
□ Independent
□ Requires non-weight bearing assist, resident highly involved
□ Supervision, encouragement or cueing □ Requires weight bearing assist, resident somewhat involved
□ Resident requires total assist
Toileting Patterns from Three-day Bowel and Bladder Tracking Tool Evaluation
Resident shows patterns of continence □ NO □ YES - Describe interval pattern:
Resident patterns reflect dribble of urine □ YES □ NO
Resident able to use the toilet majority of time □ YES □ NO
Environmental Assessment (Barriers that may impede toileting)
Bathroom: Y N Bedroom: Y N Bed: Y N Wheelchair/chair: Y N Lighting: Y N
Suspected Type(s) of Incontinence
□ Urge (sudden urgency) □ Stress (leaks with cough/sneeze) □ Mixed (combination urge and stress)
□ Overflow (leakage of small amounts of urine when bladder is full – frequent dribbling, bladder “fullness”)
□ Functional (decreased mental awareness, decreased or loss of mobility or personal unwillingness)
□ Transient (temporary episodes of urinary incontinence that are reversible once casual factors are treated)
© Health Dimensions Group 2008 Bowel and Bladder Functional Evaluation Tool - HDGR
Page 2 of 3

Bowel and Bladder Functional Evaluation Tool - HDGR
Date: Resident: MR#: Rm#:
Summary of findings:
Nurse’s signature:
Date:
Summary of findings:
Nurse’s signature:
Date:
Summary of findings:
Nurse’s signature:
Date:
Summary of findings:
Nurse’s signature:
Date:
© Health Dimensions Group 2008 Bowel and Bladder Functional Evaluation Tool - HDGR
Page 3 of 3

Three-Day Bowel and Bladder Tracking Tool Evaluation - HDGR
Date: Resident: MR#: Rm#:
If resident is alert and can state “continent,” no tracking is necessary.
Date
No Void
Incontinent
Urine
Continent Urine
Incontinent
Bowel
Continent Bowel
No Void
Incontinent
Urine
Continent Urine
Incontinent
Bowel
Continent Bowel
No Void
Incontinent
Urine
Continent Urine
Incontinent
Bowel
Continent Bowel
Midnight
1:00 am
2:00 am
3:00 am
4:00 am
5:00 am
6:00 am
7:00 am
8:00 am
9:00 am
10:00 am
11:00 am
Noon
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
9:00 pm
10:00 pm
11:00 pm
Other times resident toileted/voided
Signature:
Date:
© Health Dimensions Group 2008 Three-Day Bowel and Bladder Tracking Tool - HDGR
Page 1 of 1

Bowel and Bladder Management Education - Types, Symptoms, and Management of Urinary Incontinence
Type Definition Symptoms Treatment Options
Dietary
Approaches
Drink 6-8 oz glasses
of water
Adjunct Therapy
Acute
Acute
or
Transient
Temporary episodes of UI that are
reversible once the underlying cause(s)
is/are identified and treated
Sudden onset of involuntary
loss of urine from dribbling to
large amounts
Behavioral-use of toileting
devices
Pharmacologic-review
meds/dosaging/
interactions/side effects
Medical-treat underlying
condition, e.g., delirium
Reduce caffeine and
intake of diuretic
fluids: (coffee, tea,
colas)
▪ Bedside commode
▪ Urinal/bedpan
▪ Skin care
▪ Absorbent products
Urge
(Overactive
Bladder)
Associated with detrusor muscle, over
activity; excessive contractions of the
smooth muscle in the wall of the urinary
bladder resulting in sudden, strong urge
(also know as urgency) to expel
moderate to large amounts of urine
before the bladder is full.
Abrupt urgency, frequency,
and nocturia. Can feel the
need to void but unable to
inhibit voiding long enough
to reach and sit on
commode.
Behavioral-Bladder training
Pelvic muscle exercises
Biofeedback
Electrical stimulation (PT)
Pharmacologic-review
timing of diuretics, consider
anticholinergics or
antispasmodics
Behavioral-Pelvic muscle
exercises
Biofeedback/Sommatic
innervation
Pharmacologic-Alphaadrenergics,
Estrogen
Surgical-Retropubic
suspension
Sling operation
Needle suspensions
Collagen injections
Behavioral-prompted
voiding
Double voiding
Crede maneuvers
Surgical-Relieve obstruction
Drink 6-8 oz glasses
of water
Eliminate caffeine
and intake of diuretic
fluids: (coffee, tea,
colas)
▪ Bedside commode
▪ Urinal/bedpan
▪ Skin care
▪ Condom catheter
▪ Absorbent products
Chronic Urinary Incontinence
Stress
Associated with impaired urethral
closure (malfunction of the urethral
sphincter) which allows small amounts
of urine leakage when intra-abdominal
pressure on bladder is increased. Small
amounts of incontinence with any
physical exertion (mostly in women who
have had children).
Small amount of urine loss
during physical exertion,
coughing, laughing,
sneezing, standing from a
sitting position, lifting,
climbing stairs
Drink 6-8 oz glasses
of water
▪ Pessary
▪ Weight loss
▪ Skin care
▪ Absorbent products
Overflow
Leakage of small amounts of urine
when the bladder has reached its
maximum capacity and has become
distended. Can occur from outlet
obstruction from BPH, prostate ca, or
urethral stricture. May also be caused
by hypotonic bladder (outlet
obstruction) or impaired/absent
contractility or neurogenic bladder.
Weak stream, hesitancy, or
intermittency, dysuria,
nocturia, frequency,
incomplete voiding.
PVR-5-1- min after void =
200mi (Dx-Overflow U.I.)
** If 150-200 - retest
Drink 6-8 oz glasses
of water
▪ Intermittent straight
catheterization
▪ Indwelling Foley
catheter
▪ Skin care
▪ Absorbent products
© Health Dimensions Group 2008 Bowel and Bladder Management Education
Types, Symptoms, and Management of Urinary Incontinence
Page 1 of 2

Bowel and Bladder Management - HDGR Education-Types, Symptoms, and Management of Urinary Incontinence
Chronic Urinary Incontinence
Type Definition Symptoms Treatment Options
Mixed
Functional
Combination of urge incontinence and
stress incontinence. Many elderly
people (especially women) will
experience symptoms of both stress
and urge
Incontinence that is secondary to
factors other than inherently abnormal
urinary tract function. May be related to
physical weakness or poor mobility or
dexterity (e.g., d/t visual deficits,
arthritis, stroke, contractures), cognitive
defects (e.g., confusions, dementia,
unwillingness to toilet), medications
(e.g., diuretics) or environmental
impediments (e.g., excessive distance,
poor lighting, low chairs, restraints, and
toilets difficult to access).
Small amounts of urine with
physical exertion, laughing,
sneezing, etc., along with
abrupt urgency (“got to go
right now”).
UI when there is impairment
of physical or cognitive
functions.
F315 Urinary Tract Infections: Do not treat Asymptomatic UTI
Indications to treat a UTI without a catheter should have 3 of the following:
Fever >2°F or single measurement of oral temperature >100°F
New or increased burning, pain on urination, frequency or urgency
New flank pain or tenderness
Change in character of urine (new bloody urine, foul smell or amount of sediment), lab
report (new pyuria or hematuria), positive leukocyte estrase and nitrates – recommended
use dipstick urine test as applicable)
Worsening of mental or functional status (confusion, lethargy, recent onset incontinence,
decreased activity or appetite)
#1 goal is prevention! Assess, good hand washing and pericare, increase fluids.
Asymptomatic bacteria should NOT be treated
Behavioral-Pelvic muscle
exercises
Biofeedback
Pharmacologic- Alphaadrenergics,
Estrogen,
review timing of diuretics,
consider anticholinergics or
antispasmodics
Surgical-Retropubic
suspension
Sling operation
Needle suspensions
Collagen injections
Behavioral-Scheduled
toileting
Bladder retraining
Physical therapy
Pharmacologic-Lower
dosages or change
medications
Dietary
Approaches
Drink 6-8 oz glasses
of water
Drink 6-8 oz glasses
of water
Consult dietitian
Eliminate caffeine
and intake of diuretic
fluids: (coffee, tea,
colas)
Adjunct Therapy
▪ Bedside commode
▪ Urinal/bedpan
▪ Environmental
modifications
▪ External collection
devices
▪ Skin care
▪ Absorbent products
▪ Bedside commode
▪ Urinal/bedpan
▪ Skin care
▪ Environmental
modifications
▪ External collection
devices
▪ Absorbent products
F315 Urinary Tract Infections: Do not treat Asymptomatic UTI
Indications to treat a UTI with a catheter should have 2 of the following:
Fever or chills
New flank pain or Suprapubic pain/tenderness
Change in character of urine
Worsening of mental or functional status (confusion, lethargy, recent onset
incontinence, decreased activity or appetite)
Local findings such as obstruction, leakage, or hematuria may also be present
NOTE: Catheters will always have bacteria; change catheter prior to obtaining
culture. Do not use catheters unless medically justified.
Asymptomatic bacteria should NOT be treated
© Health Dimensions Group 2008 Bowel and Bladder Management Education
Types, Symptoms, and Management of Urinary Incontinence
Page 2 of 2

Bowel and Bladder Treatment Plan - Sample
Date: Resident: MR#: Rm#:
Treatment Plan
Bladder
(monitor as needed)
Bowel
(monitor as needed)
Product
Type
□ Resident independent
toileting
□ Resident is alert, needs
assistance to BR
□ Scheduled toileting
Program
• Cognitively impaired
• Functionally disabled
• Caregiver dependent
□ Check and Change
Program
• Unable to sit on toilet
• Behaviors
• Cognitive impairment
□ Prompted Voiding Program
• Able to use toilet
• Able to feel sensation
• Able to request toileting
□ Recent discontinuation of
Foley catheter
□ Encourage resident
independence
□ Toilet per request
□ Toilet Q 2 hours & change
PRN
□ Toilet Q __hours & change
PRN
□ Other________________
□ Check Q 2 hours & Change
PRN
□ Provide assist to toilet PRN
□ Ask Q ___ hours if need to
use bathroom
□ Other ________________
□ Toilet per request
□ Toilet Q 2 hours & change
PRN
□ Toilet Q __hours & change
PRN
□ _____________________
□ Check q 2 hours & Change
PRN
□ Provide assist to toilet PRN
□ Ask ___ hours if need to use
bathroom
□ Other ________________
□ None
□ Depends
□ Brief
□ Pull-Up
□ Panty liner
□ Other
Size:
□ Small
□ Medium
□ Large
□ XL
□ Training/Retraining to
return to previous pattern
• Oriented
• Able to feel sensation
• Able to understand and
learn to inhibit the urge
• Toilet independently, or
with minimal assist
□ Ask to hold urine for 2
hours and extend time as
resident becomes
successful
□ Other ________________
□ Other _________________
N/A
□ Indwelling Catheter
□ Last Removal Attempt
□ Medical Diagnosis
_______________________
□ Physician Order
_______________________
□ Change _______________
N/A
Size: __________
Once completed, proceed to resident’s care plan document and update individualized plan.
Signature:
Date:
© Health Dimensions Group 2008 Bowel and Bladder Treatment Plan - Sample
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Cardiopulmonary Resuscitation (CPR)
F Tag
N/A
Quality Standard FP98
Origination Date April 1, 2008
Revision Date
POLICY
The facility must determine whether it provides Cardiopulmonary Resuscitation (CPR)
services within the facility or not, and inform all residents of their policy prior to or at the
time of admission.
PROCEDURE
1. Prior to or at the time of admission, all residents will be made aware of the facility’s
policy on CPR services at the facility.
2. The resident/family will document their understanding/agreement of such policy. A copy
of this document will be maintained in the resident’s record.
3. The facility will offer training to staff regarding CPR per facility-specific training
policies when applicable.
4. All certifications for CPR will be maintained in the staff’s personnel file, if indicated.
© Health Dimensions Group 2008 Cardiopulmonary Resuscitation (CPR)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Care Plans - Comprehensive
F Tag
F279, F280, F281, F282
Quality Standard RCS57, RCS58
Origination Date April 1, 2008
Revision Date
POLICY
The facility uses the results of the resident assessments to develop and revise the resident’s
comprehensive plan of care. The facility develops a comprehensive care plan for each
resident. This care plan includes measurable objectives and timetables designed to meet the
resident’s medical, nursing, mental, and psychosocial needs, as identified in the
comprehensive assessments.
The care plan describes the following:
• Services that are furnished to attain or maintain the resident’s highest practicable
physical, mental, and psychosocial well-being; and
• Any services that would be furnished but are not provided due to the resident’s exercise
of rights including the right to refuse treatment.
The resident has the right to, unless adjudged incompetent or otherwise found to be
incapacitated under the laws of the State, participate in the planning care and treatment or in
changes to care and treatment.
A comprehensive care plan is:
• Developed within seven days after the completion of the comprehensive assessment
• Prepared by an interdisciplinary team that includes the physician, nursing, other
appropriate staff, and disciplines as determined by the resident’s needs, and to the extent
practicable, the resident and his/her family or legal representative
• Periodically reviewed and revised by a team of qualified persons after each assessment
PROCEDURE
1. Identify needs and problems of resident based on nursing history and assessment,
physician’s orders, inter-facility transfer forms (when available), past history, physical
examination, resident and/or family interviews, and any other available information.
2. Formulate objectives in terms that are behaviorally observable and measurable.
3. Write approaches or actions in terms of staff behavior, e.g., what the staff will do to
accomplish an objective.
4. Set re-assessment and revelation dates. Dates will depend on severity of problem with no
more than three months between dates.
© Health Dimensions Group 2008 Care Plans–Comprehensive
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
5. When a need/problem is resolved or re-assessed, write the date and the health care team
member’s initial. The facility may also choose to utilize a highlighter in addition to
delineate a change in the care plan. Note: The highlighter does usually not copy well.
6. Signatures to identify the initials of the health team members are available as needed.
© Health Dimensions Group 2008 Care Plans–Comprehensive
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Care Plan - Reviews/Conferences
F Tag
N/A
Quality Standard RCS59
Origination Date April 1, 2008
Revision Date
POLICY
The facility will conduct a care plan review/conference at least quarterly, and as needed, that
is interdisciplinary, provides an in-depth review of the resident’s plan of care, and provides
an opportunity for resident and family discussions/input.
PROCEDURE
Note: Care plan meetings are typically composed of the resident, family, and/or the
resident’s durable power of attorney, the charge nurse or unit manager, the nursing assistant
principally responsible for the resident, the social worker, activities director, and dietitian or
dietary manager. The resident physician, appropriate therapist, and the medical director may
also be in attendance (this may vary).
1. Care plan may be written prior to the care plan meeting, knowing that input from resident
or family may require it to be revised.
2. Care conferences are scheduled routinely per facility schedule.
3. Each resident’s plan of care is reviewed at least quarterly.
4. All attendees are documented.
5. The resident and/or family are invited to attend the care conference. A written invitation
is sent to the families by Social Services or designee.
© Health Dimensions Group 2008 Care Plan–Reviews/Conferences
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Cast Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Any resident with a cast will be provided with appropriate cast care.
PROCEDURE
1. Explain procedure to the resident.
2. Keep the cast dry (moisture deteriorates the cast material, harbors microorganisms, and
creates an unpleasant odor).
3. Check for looseness of the cast and report looseness to the physician (looseness inhibits
the effectiveness and can lead to skin problems).
4. Note any cracks in the cast, especially at the joints, and any abnormal mobility.
5. Prevent deformities due to incorrect or prolonged adduction, rotation, or flexion by
proper use of pillow, foot boards, bed positioning, and exercises. Obtain specific
instructions from the physician.
6. Give good skin care to all parts of the body.
7. If allowed, change the position of the resident frequently and inspect pressure areas for
signs of breakdown.
8. When placing the resident who is in a body or spica cast on a bedpan, elevate the upper
trunk and cast. This prevents urine from wetting the cast.
9. Prevent urine or feces soiling the cast by covering the perineal edges of the cast with
plastic.
10. Maintain a frequent check for impaired circulation in extremities, soiling of the cast,
elevation of temperature of any body parts, and pressure produced by cast edges cutting
into the skin.
11. Assess for increased pain and edema of extremity; contact physician as needed, and treat
as ordered.
12. Assess distal pulses, record, and notify physician of any abnormalities or increased pain.
13. Chart on the nurse’s notes the type of cast, condition of the cast, any complaints of the
resident, any discoloration of the skin or cast, or any unusual odor.
© Health Dimensions Group 2008 Cast Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Catheter - Drainage Bag Change-Closed System
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Urinary drainage bags are changed per physician orders and facility standards.
PROCEDURE
1. Identify resident, introduce yourself, and explain the procedure to the resident.
2. Wash hands.
3. Gather equipment:
a. Alcohol sponge
b. Gloves
c. New drainage bag
4. Provide privacy.
5. Raise bed to a workable height.
6. Open new drainage bag wrapping.
7. Wash hands.
8. Put on gloves.
9. Cleanse junction point between the old drainage bag and the urinary catheter with alcohol
sponge.
10. Disconnect at junction. Use caution not to contaminate the end of the catheter.
11. Connect the new drainage bag.
12. Assure that drainage bag outlet is closed.
13. Position drainage bag lower than the resident’s bladder.
14. Remove gloves.
15. Wash hands.
© Health Dimensions Group 2008 Catheter–Drainage Bag Change–Closed System
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Catheter - External Condom/Texas Catheter
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A condom catheter may be used with a physician’s order to enhance the resident’s quality of
life.
PROCEDURE
1. Wash hands.
2. Explain procedure to the resident.
3. Ensure privacy.
4. Bring equipment to bedside.
5. Apply gloves.
6. Position resident lying down in bed.
7. Provide privacy.
8. Expose penis.
9. Assist resident to wash, rinse, and dry the shaft of his penis.
10. Roll the catheter over the penis to about two inches behind the head of the penis.
11. Leave about 1-2 inch slack in the connecting end to prevent rubbing or chafing.
12. Remove paper backing from adhesive.
13. Apply adhesive strip at area where catheter meets the skin at the top of the penis and
wrap around the penis.
14. Connect adapter to tubing end of urine collection bag or leg bag. Tubing should be taped
to the thigh to prevent pulling on the catheter.
15. Attach leg bag as needed. Regular Foley bag should be used at night to prevent reflux
back to the catheter.
16. Empty urine bag as needed by unclipping the tubing on the end and allowing the urine to
drain into the toilet or a collecting device at least once each shift.
17. Remove gloves.
18. Wash hands.
19. Report unusual observations to charge nurse or designee.
20. Wash penis after removal of external catheter.
© Health Dimensions Group 2008 Catheter–External Condom/Texas Catheter
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Catheter - Leg Bag Cleaning
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Nursing staff will cleanse the leg bag every day and/or as needed. This procedure is for
residents who use a leg bag routinely.
PROCEDURE
1. Identify resident, introduce yourself, and explain to the resident what you are going to do.
2. Wash hands.
3. Gather equipment and clean towel.
4. Put on gloves.
5. Rinse leg bag with normal tap water.
6. Allow to dry before reapplying plugs to end of bag.
7. Remove gloves.
8. Wash hands after procedure.
9. Store leg bag when not in use in a clean and dry area.
© Health Dimensions Group 2008 Catheter–Leg Bag Cleaning
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Catheter - Management
F Tag
N/A
Quality Standard FP52, RCS21
Origination Date April 1, 2008
Revision Date
POLICY
The facility will have a system for the management of urinary catheters.
PROCEDURE
1. There will be a medical necessity/justification for the use of a urinary catheter which is
identified in the physician’s order.
2. Only licensed nurses or physicians may insert a urinary catheter.
3. Bladder assessments are completed on admission and annually, with a significant change,
and/or removal of a catheter.
4. Accommodation of resident needs will be provided as indicated on the assessment and
reflected on the care plan.
5. All catheter bags are covered with privacy bags at all times.
6. Monitoring of urinary output will be done at least each shift
7. Correct positioning of catheter will be maintained.
8. Signs/symptoms of possible or actual urinary tract infections will be monitored and staff
educated as necessary.
9. The resident’s care plan will reflect the use of a catheter, the type indicated for use, the
bag(s) utilized, and any facility protocols for the need to change the catheter bag and/or
tubing.
10. Residents will be provided with adequate fluids.
© Health Dimensions Group 2008 Catheter–Management
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Catherization of a Resident or Intermittent Catherizations
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A resident will only be catheterized with a physician’s order and medical justification for
use, utilizing proper infection control techniques.
PROCEDURE
1. To catheterize a female resident:
a. Wash hands.
b. Take equipment to resident’s room and place in convenient location.
c. Explain procedure to the resident.
d. Provide privacy.
e. Secure a good light.
f. If resident is uncooperative, secure assistance.
g. Place resident in dorsal recumbent position with legs well separated and drape
resident with blanket.
h. Open catheter tray and place between resident’s legs, or nearby, so that articles can be
easily reached.
i. When all equipment is ready for use, put on sterile gloves.
j. Put sterile plastic lined towel under resident’s hips. Be careful not to contaminate
gloves when placing towel under resident’s hips.
k. Open lubricant container and place small amount on tip of catheter.
l. Pour antiseptic over cotton balls.
m. Place sterile specimen container in convenient location and place label aside for later
use.
n. Keep one gloved hand sterile. With other hand, separate labia and locate meatus.
Keep labia separated until after insertion of catheter. Meatus is small indentation
appearing between clitoris and vagina.
o. Take one cotton ball at a time soaked with antiseptic agent and make one swipe
downward over area to be cleaned and discard cotton ball. Wipe downward only, to
prevent contamination with micro-organisms from anal area.
© Health Dimensions Group 2008 Catherization of a Resident or Intermittent Catherizations
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
p. Pick up catheter, with fingers two inches away from the eye of the catheter, and insert
gently, 1½ to 2 inches or until urine begins to flow. Use no force while inserting the
catheter.
q. If a sterile specimen is to be collected, pinch the catheter momentarily and allow a
small amount to flow into a sterile container, then redirect the flow into a larger
container until the bladder is emptied.
r. Dry the perineal area well.
s. Remove drape and towel from under resident’s hips.
t. Recover the resident.
u. Leave the resident comfortable with the call light button in reach.
v. Remove gloves and wash hands.
2. To catheterize a male resident:
a. Preparation for this procedure is the same as for a female procedure from steps 1a to
1m.
b. Hold the penis in one hand, and with the other hand cleanse the end of the penis with
cotton balls soaked with antiseptic agent.
c. Lubricate the catheter about seven inches from the tip and insert slowly and gently
into the urethra, holding the penis in one hand and keeping it at an angle of 60
degrees. This keeps the channel of the urethra straight to allow passage of the
catheter.
d. The remainder of the procedure is the same as for the female in steps 1p to 1v.
3. After care:
a. Measure the urine specimen collected.
b. If a specimen is to be sent to the laboratory, label it with the correct identification
information.
c. Discard disposable equipment in the waste can in the utility room.
d. Place soiled linen in the soiled linen container.
e. Wash hands.
f. Chart in the nurse’s notes this procedure, the date, time it was done, and the amount
of urine obtained.
g. If any unusual observations were made during the process, they should be noted in
the nurse’s notes.
h. Make out the necessary charge slips and laboratory slip(s).
© Health Dimensions Group 2008 Catherization of a Resident or Intermittent Catherizations
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Clinical Records (General)
F Tag
F514, F515, F516
Quality Standard FP11, FP76a
Origination Date April 1, 2008
Revision Date
POLICY
There is an organized system for the maintenance of resident information in the clinical
record.
PROCEDURE
1. The clinical record contains at least the following:
a. Activity/social service assessment
b. Admission face sheet
c. Advance directive sheet(s)
d. Any consent forms
e. Care plan
f. Consultant notes
g. Dietary assessment
h. Dietary, activity, and Social Service and nursing progress notes
i. Laboratory data
j. MDS and RAPs
k. Medication/Treatment/ADL sheets
l. Nursing assessment
m. Nursing notes
n. Others as per facility policy
o. Physician orders
p. Physician progress notes
q. Rehabilitation notes
r. Restorative program assessments
s. Social Service assessment
© Health Dimensions Group 2008 Clinical Records (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
2. Clinical records are maintained on each resident in accordance with accepted professional
standards and practice. Records are:
a. Complete
b. Accurately documented
c. Readily accessible
d. Systematically organized
3. Clinical records are retained for:
a. The period of time required by State law
b. Five years from the date of discharge when there is no requirement in State law
c. For a minor, three years after a resident reaches legal age under State law
d. Clinical record information is safeguarded against loss, destruction, and unauthorized
use
© Health Dimensions Group 2008 Clinical Records (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Colostomy Care
F Tag
N/A
Quality Standard RCS22
Origination Date April 1, 2008
Revision Date
POLICY
Residents who have colostomy bags will be provided care and services to maintain their
colostomy and to protect the skin from drainage as well as controlling odor as much as
possible.
PROCEDURE
1. Wash hands and apply gloves.
2. Explain procedure to the resident.
3. Provide privacy.
4. Position resident in supine position or standing position if able and chooses.
5. Remove old pouch and dispose of properly.
6. Remove gloves; wash hands.
7. Clean area with soap and water. Rinse and dry well.
8. Apply protective skin barrier or other ordered creams and dressings.
9. Observe condition of skin, stoma, and surrounding area. Also observe color and
consistency of fecal return in pouch.
10. Remove backing from adhesive area of pouch and apply to previously prepared skin.
11. Remove gloves; wash hands.
12. Make resident comfortable.
13. Clean and return equipment to appropriate place.
14. Wash hands.
15. Chart appearance of stoma and surrounding skin. Note color consistency and appearance
of contents of pouch.
© Health Dimensions Group 2008 Colostomy Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Colostomy Irrigation
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Colostomy irrigations will be done with a physician’s order.
PROCEDURE
1. Explain the procedure to the resident.
2. Provide privacy.
3. The resident should be encouraged to carry out this procedure by him/herself when
possible.
4. Position and drape the resident on the toilet or on the bedside commode in the resident’s
room or on a chair in the bathroom. Otherwise, have resident lie on the side opposite the
colostomy when in bed.
5. Wash hands.
6. Apply gloves.
7. Place the colostomy bag with sleeve (irrigation bag) over the stoma, being certain one
end of the sleeve is on the toilet or bedpan.
8. Fill the enema bag ¾ full with water or solution, as ordered by the physician, and check
the temperature of water or solution for comfort.
9. Lubricate the end of the rectal tube and expel air from tubing.
10. Insert the rectal tube gently 5-6 inches into the stoma. Do not use force.
11. Open the clamp of the tubing and allow solution to flow into the opening.
12. After a small amount of solution is introduced, clamp the irrigating tube for a few
minutes to allow resident to rest.
a. As no sphincter control is present, run the solution in slowly to avoid cramping and
discomfort.
b. If a commercial return flow apparatus is used, follow instructions on the label.
13. The resident should be encouraged to massage the abdomen, bend forward, and to bend
from side to side, if possible. Be sure to allow ample time for the resident to expel all the
solution.
© Health Dimensions Group 2008 Colostomy Irrigation
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
14. Remove colostomy bag with sleeve (irrigation bag) and apply resident’s regular
colostomy bag or a small dressing.
15. Remove gloves.
16. Assist the resident to return to his/her bed or to a place of comfort.
17. Leave the resident comfortable with the call light button in reach.
18. Wash hands.
19. Return unused equipment to the proper storage area.
20. Discard any disposable equipment in a trash can in the utility room.
21. Wash and rinse any reusable equipment
22. Discard any soiled linen in the soiled linen container, using sanitary procedures.
23. Wash hands.
24. Chart in the nurse’s notes the date, time, procedure, results, unusual observations, or
resident’s reactions.
25. If the resident is learning self care, chart progress made in the nurse’s notes.
26. Make out the necessary charge slips, if applicable.
© Health Dimensions Group 2008 Colostomy Irrigation
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Complaints/Grievances - Filing with the State
F Tag
F156
Quality Standard FP22
Origination Date April 1, 2008
Revision Date
POLICY
Upon admission the resident is informed, in writing, how he/she may file a complaint with
the State survey and certification agency concerning abuse, neglect, and misappropriation of
property in the facility.
The resident and/or family are also provided with information regarding the facility’s
policy/procedure on how to file a grievance/concern with the administration. The grievance
policy/procedure will be posted in the facility with any necessary forms accessible to
residents/families who wish to file a grievance/concern.
© Health Dimensions Group 2008 Complaints/Grievances–Filing with the State
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Comprehensive Assessments MDS (General)
F Tag
F272, F273, F274, F275, F276, F285, F286, F287
Quality Standard RCS57
Origination Date April 1, 2008
Revision Date
POLICY
The facility conducts an initial and periodic comprehensive assessment that is an accurate,
standardized, and reproducible appraisal of each resident’s functional capacity per CMS
guidelines.
PROCEDURE
1. The comprehensive assessment of a resident is:
a. Based on a uniform data set and standards, and is an instrument that is specified by
the State; and
b. Describes the resident’s capability to perform daily life functions and significant
impairments in functional capacity.
2. The assessment includes the following, as a minimum:
a. Activity pursuit
b. Cognitive patterns
c. Communication
d. Continence
e. Customary routine
f. Dental and nutritional status
g. Discharge potential
h. Disease diagnosis and health conditions
i. Documentation of summary information regarding the additional assessment
performed through the resident assessment protocols
j. Documentation of participation in the assessment
k. Identification and demographic information
l. Medications
m. Mood and behavior patterns
n. Physical functioning and structural problems
o. Psychosocial wellbeing
© Health Dimensions Group 2008 Comprehensive Assessments MDS (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
p. Skin conditions
q. Special treatments and procedures
r. Vision
3. The facility conducts a comprehensive assessment within 14 days of admission,
excluding readmissions with no significant change in the resident’s physical or mental
condition.
4. Within 14 days after the facility has determined, or should have determined, that there
has been a significant change in the resident’s physical or mental condition, a
comprehensive assessment is initiated.
5. Once every 90 days, the facility assesses a resident using the quarterly review instrument
specified by the State and approved by CMS.
6. At the minimum, the facility conducts a comprehensive assessment once every 12
months.
7. The facility retains all resident assessments completed for the previous 15 months in the
resident’s active record.
8. The facility encodes all data within 7 days after completion of the assessment which
includes: admission, annual, significant change, quarterly, transfer, re-entry, discharge,
death, and face sheets tracking forms.
9. The facility transmits data per CMS requirements once the resident’s assessment is
completed. The facility maintains the capability to transmit to the State information for
each resident contained in the MDS in a format that conforms to standard record layouts
and data dictionaries and that passes standardized edits defined by CMS and the State.
10. The facility will ensure that all MDS data is accurate and is coordinated and signed by a
registered nurse. Any other discipline that completes a section of the MDS signs the
MDS certifying its accuracy. The facility understands that there is a penalty for
knowingly falsifying an MDS.
© Health Dimensions Group 2008 Comprehensive Assessments MDS (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Compress - Cold Moist
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Cold, moist compresses may be used to prevent and reduce congestion and swelling in a part
of the body, and to relieve pain.
PROCEDURE
1. Wash hands.
2. Fill basin half full of ice and a small amount of water. It may not be possible to do this as
a sterile procedure. Keep it as clean as possible, if there are any open areas being treated.
3. Carry equipment to resident’s bedside.
4. Explain procedure to resident.
5. Provide privacy.
6. Avoid chilling the resident as much as possible.
7. Protect the bed with plastic sheet and towel(s) under the part of the body to be treated, if
applicable.
8. Place wash cloth, towel, or draw sheet in basin; wring out excessive moisture and apply
to area being treated.
9. Apply ice bag or freezer bag wrapped in towel. Leave in place for the time ordered by the
physician.
a. Watch skin carefully for discoloration and mottling.
b. Remove ice bag or freezer bag before this happens, and apply a thicker padding.
10. Dry area when treatment is discontinued.
11. Leave resident warm and comfortable with call light button in reach.
12. If procedure is to be repeated often, the equipment may be stored in the resident’s room
between treatments.
13. Sign off treatment on the treatment sheet and/or note observations and resident’s
reactions in the nurse’s notes.
© Health Dimensions Group 2008 Compress–Cold Moist
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Computers and Software
F Tag
N/A
Quality Standard FP71
Origination Date April 1, 2008
Revision Date
POLICY
Computers used in maintaining clinical records, resident identifiable information, and
protected health information are:
• Protected against unauthorized access to data
• Protected from data loss, corruption, and attack
• Appropriate to applications that the system supports
Software is appropriately current, certified for secure use, and supports safe operation that
avoids unauthorized access and infection by viruses, Trojan horses, and other malicious
programs.
Network, dial-up, and other data transfers are secure according to applicable standards and
meet required transmission standards.
Data storage is protected from unauthorized access and loss through malicious action,
disasters, and unauthorized user access.
Computer and software users are trained in computer system use, security, privacy
requirements, and proper use of assigned software.
Unauthorized software is removed from computer systems.
Loss of data and critical computer support is included in disaster and emergency planning for
the facility.
© Health Dimensions Group 2008 Computers and Software
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Conformity with Federal, State, and Local Laws
F Tag
F492
Quality Standard FP21
Origination Date April 1, 2008
Revision Date
POLICY
The facility complies with all federal, state, and local laws and regulations regarding skilled
nursing facilities.
These laws/regulations relate, but are not limited to:
• The Age Discrimination Act of 1975 which prohibits discrimination because of age
(excluding employment)
• Communicable and Reportable Diseases
• Fire, Safety, and Disaster
• Health and Safety Requirements for Employees
• Life Safety Code, 2000
• Post Mortem Procedures
• Rehabilitation Act of 1973 which prohibits discrimination based on mental or physical
handicap
• Resident abuse and neglect, and protection of human subjects in research
• Sanitation
• Title VI of the Civil Rights Act of 1964 and its implementing regulation which prohibits
discrimination on the basis of race, color, or national origin
• Title XVIII and XIX: Medicare and Medicaid laws and provider participation issues
including corporate compliance
© Health Dimensions Group 2008 Conformity with Federal, State and Local Laws
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Corporate Compliance Program (General)
F Tag
N/A
Quality Standard FP16, HR41
Origination Date April 1, 2008
Revision Date
POLICY
The facility has a corporate compliance program that is coordinated by_________________
to prevent Medicare and Medicaid fraud and abuse.
See Medicare Compliance Policy
© Health Dimensions Group 2008 Corporate Compliance Program (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Cultures - Wound
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Wound cultures should not be done on a routine basis and should only be obtained with a
physician’s order.
PROCEDURE
1. Wash hands.
2. Explain procedure to resident.
3. Provide privacy.
4. Set up clean field area.
5. Expose area to be cultured (avoid unnecessary exposure of resident).
6. Wash hands and apply gloves.
7. Peel open culturette package and drop on clean field.
8. Remove old dressing and dispose in plastic bag.
9. Remove and dispose of gloves; wash hands; and put on clean gloves.
10. Moisten gauze with normal saline and clean wound thoroughly. Place dirty gauze in bag.
11. Remove and dispose of gloves; wash hands; and put on clean gloves.
12. Remove cap/swab stick from tube.
13. Take sample and return cap/swab to tube.
14. Write resident identification on package.
15. Hold cap end down. Crush ampoule at mid point by squeezing tube through package.
16. Push cap to bring swab into contact with moistened culture tip.
17. Remove gloves.
18. Wash hands.
19. Send to laboratory with appropriate lab slip.
20. Note in nurse’s notes the date and time culture was taken, the site cultured, and
disposition of the specimen.
21. Make out necessary charge slips.
© Health Dimensions Group 2008 Cultures–Wound
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Deep Breathing Exercises
F Tag
N/A
Quality Standard RCS30
Origination Date April 1, 2008
Revision Date
POLICY
Residents who require deep breathing exercises to promote adequate and optimal expansion,
aeration, and prevention of circulatory stasis through proper flow and oxygenation will be
provided them, per physician’s requirements.
PROCEDURE
1. Instruct resident, and assist as needed, to bring self erect whether sitting or standing and
breathe deeply five times.
2. If resident has difficulty with bringing self erect, assist by placing open hand on upper
front chest and gently but firmly push backward.
3. Simultaneously place other open hand on buttocks and push inward while explaining
rationale.
4. Have resident raise head to a straight forward position.
5. Step 1 is also applicable when in standing position.
6. Document resident response in medical record.
7. Notify physician as needed.
© Health Dimensions Group 2008 Deep Breathing Exercises
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dental Services (General)
F Tag
F411, F412
Quality Standard RCS3
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides or obtains, from an outside resource, routine and emergency dental
services to meet the need of each resident.
The facility may charge a Medicare resident an additional amount for routine and emergency
dental services.
The facility will assist the resident in making appointments by arranging transportation to
and from the dentist’s office and will promptly refer residents with lost or damaged dentures
to a dentist.
© Health Dimensions Group 2008 Dental Services (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Denture Care Oral Hygiene
F Tag
N/A
Quality Standard RCS20
Origination Date April 1, 2008
Revision Date
POLICY
Residents will be provided denture care/oral hygiene as determined by resident’s needs.
PROCEDURE
1. Wash hands.
2. Instruct resident on procedure.
3. Ensure privacy. Allow resident to do as much of the procedure as possible.
4. Assemble equipment at bedside or at the sink.
5. The resident should be in a seated position.
6. Apply gloves. Remove dentures from resident’s mouth by placing forefinger over the
center of the top ridge of the upper denture, and push down and out; grasp the lower
denture between thumb and the forefinger under the lower center, and pull up and out.
Allow resident to do if able. Place in denture cup.
7. Cleanse the dentures with the denture cleaner. Use the denture brush or toothbrush and
cool running water at the sink. Place clean, cool water in the denture container and place
the cleaned dentures in it after rinsing.
8. Assist the resident to rinse mouth.
9. Return the dentures to the resident and ask him/her to place them in his/her mouth. Use
denture adhesive as needed. You may assist as needed.
10. If dentures are not to be worn, store in cool water in denture case. Place denture case in
bedside table.
11. Encourage the resident not to remove dentures in bed or place on tray, to avoid risk of
losing the dentures.
12. Remove gloves.
13. Wash hands.
14. Note procedure on ADL sheet, if it is the facility’s policy.
15. Report any abnormalities to the charge nurse or designee.
© Health Dimensions Group 2008 Dental Care Oral Hygiene
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dietary Menu and Nutritional Adequacy (General)
F Tag
N/A
Quality Standard RCS41
Origination Date April 1, 2008
Revision Date
POLICY
The facility menus meet the nutritional needs of residents in accordance with recommended
dietary allowances of the Food and Nutrition Board of the National Research Council and
National Academy of Sciences.
© Health Dimensions Group 2008 Dietary Menu and Nutritional Adequacy (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dietary Services (General)
F Tag
F360
Quality Standard FP79, RCS42, RCS55
Origination Date April 1, 2008
Revision Date
POLICY
Each resident receives a nourishing, palatable, well-balanced diet. This diet meets the daily
nutritional and special dietary needs of each resident.
© Health Dimensions Group 2008 Dietary Services (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dietary Supplements
F Tag
N/A
Quality Standard RCS44
Origination Date April 1, 2008
Revision Date
POLICY
Dietary supplements will be used to provide additional nutritional support due to weight loss
and/or poor oral intake.
PROCEDURE
1. The dietitian will document the rationale for recommending a dietary supplement.
2. A physician’s or designee’s order for a dietary supplement will be obtained.
3. The supplement is recorded on the medical administration record when given, along with
the amount consumed.
4. The care plan reflects the use of supplements.
© Health Dimensions Group 2008 Dietary Supplements
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dietitian Qualified (General)
F Tag
F361
Quality Standard HR7a
Origination Date April 1, 2008
Revision Date
POLICY
The facility employs a qualified dietitian either full time, part time or on a consultant basis.
If the qualified dietitian is not employed full time, the facility designates a person to serve as
the director of food services. The director of food services receives frequent and scheduled
consultation from a qualified dietitian.
A qualified dietitian is either registered by the Commission on Dietetic Registration of the
American Dietetic Association or has completed education, training, or experience in
identification of dietary needs, planning, and implementation of dietary programs.
© Health Dimensions Group 2008 Dietician Qualified (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Diets Therapeutic
F Tag
N/A
Quality Standard RCS41
Origination Date April 1, 2008
Revision Date
POLICY
All therapeutic diets are designed by a dietitian, which includes at least three meals daily and
snacks, which are individualized for residents’ specific needs. All therapeutic diets are
ordered by a physician.
PROCEDURE
1. All residents have a written physician order for their diet that includes the type of diet,
consistency, and the need for adaptive equipment, as applicable.
2. Specific diets used by this facility include: (list all diets)
© Health Dimensions Group 2008 Diets Therapeutic
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dignity Quality of Life (General)
F Tag
F241
Quality Standard FP50, RCS11
Origination Date April 1, 2008
Revision Date
POLICY
In full recognition of his or her individuality, the facility promotes care for residents in a
manner and in an environment that maintains or enhances each resident’s dignity and respect.
This includes staff:
• Assisting with grooming care of hair, nails, and face
• Assisting with choosing the clothes the resident will wear
• Assisting the resident to attendance of activities of their choice
• Promoting independence in eating and dining
• Respecting private space and property
• Respecting social status by speaking and acting respectfully
• Focusing, through speech and action, on residents as individuals
© Health Dimensions Group 2008 Dignity Quality of Life (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dining and Food Service
F Tag
N/A
Quality Standard FP78, FP79, RCS43, RCS55
Origination Date April 1, 2008
Revision Date
POLICY
The facility will enhance the resident’s dining experience to promote their quality of life and
to support the resident’s needs.
The facility will ensure that each resident is provided with nourishing, palatable, and
attractive meals that meet the resident’s daily nutritional and special dietary needs.
PROCEDURE
Note: Serving size should be adjusted to the resident’s specific needs, eating habits, and/or
physician’s orders.
1. Observe percent eaten at each meal and offer substitute if resident eats less than 50% of
the food.
2. Verify diet delivered matches MD orders, including resident preferences and serving size.
3. Assess residents with eating problems for possible restorative dining programs.
4. Consult therapies for appropriate interventions and use of adaptive equipment.
5. Assess the dining room environment to provide an area conducive to eating, including
noise, lighting, and staff availability to assist resident needs and home-like environment.
6. Assess resident positioning (upright in a chair), and accessibility to food, adaptive
equipment, and table height, etc.
7. Encourage the resident’s ability to “walk to dine”, when appropriate.
8. If the resident uses a wheelchair, possibly transferring the resident to a regular chair
while the resident dines, when appropriate.
9. Prior to eating, assess resident’s appearance at meals for hygiene issues, as needed.
10. Review care plan for individualized interventions.
11. Document percent eaten per facility policy.
12. Notify charge nurse or designee if resident eats less than 50%.
13. Care plan reflects resident’s needs and preferences.
© Health Dimensions Group 2008 Dining and Food Service
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dining Assistive Devices (General)
F Tag
F369
Quality Standard RCS55
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides special eating equipment and utensils for residents who need them as
recommended by a therapist and/or a physician.
© Health Dimensions Group 2008 Dining Assistive Devices (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Director of Nursing
F Tag
N/A
Quality Standard HR2
Origination Date April 1, 2008
Revision Date
POLICY
There is a full-time director of nursing who is a qualified registered nurse.
PROCEDURE
There are designated responsibilities for the position of the director of nursing.
The following components, including all related policies/procedures, must be in place to
consider the standard met:
1. Develops and maintains annually updated departmental:
a. Vision/Goals
b. Nursing services staff job descriptions
c. Resident care and nursing policies and procedures
2. Monitors the schedules/assignments of all nursing staff.
3. Interacts appropriately with residents and families.
4. Coordinates nursing care with other disciplines.
5. Ensures that care practices meet federal and state regulations/practice guidelines.
6. Communicates regularly with medical director, attending physicians, consultants, and
other clinical service providers.
7. Conducts daily rounds to assure the monitoring of nursing staff on an ongoing basis by
direct observation of skills/tasks performed so as to assure services provided meet
professional standards of quality care.
8. Maintains professional appearance and conduct; monitors dress code and compliance of
nursing staff.
9. Assures the provision/scheduling of orientation/continuing education for employees and
volunteers who perform nursing service functions is provided.
© Health Dimensions Group 2008 Director of Nursing
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Disaster and Emergency Preparedness
F Tag
F517, F518
Quality Standard FP32
Origination Date April 1, 2008
Revision Date
POLICY
The facility has a detailed written plan and procedure to meet all foreseeable, potential
emergencies and disasters, such as:
• Chemical spills
• Earthquakes, if applicable to area
• Explosion
• Fire
• Flood
• Gas leaks and explosions
• Loss of communication systems (telephone, computer network)
• Loss of critical records and computer data
• Loss of fresh water supply
• Loss of heating source, e.g., natural gas
• Loss of the nurse call system
• Missing residents
• Power outages
• Severe weather, including tornadoes, blizzards, high winds, etc.
The facility periodically performs a disaster/emergency audit to ensure that all foreseeable
disasters/emergencies are addressed.
The facility trains all employees in emergency procedures when they begin to work in the
facility and periodically reviews the procedures with staff. The facility periodically holds
disaster drills for all employees and, to the extent practicable, for residents.
The facility maintains a current list of emergency contacts (names and phone numbers) and
an on-site disaster/emergency chain-of-command list.
The facility works with local, state, and federal officials in the planning for, and reacting to,
disasters and emergencies.
© Health Dimensions Group 2008 Disaster and Emergency Preparedness
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
The facility develops plans for safe placement of residents if disaster requires evacuation of
residents. The facility works with community disaster planning officials in planning for and
supporting disasters and emergencies affecting the community.
The plans are accessible to all staff.
© Health Dimensions Group 2008 Disaster and Emergency Preparedness
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Discharge Summary
F Tag
F283, F284
Quality Standard RCS61
Origination Date April 1, 2008
Revision Date
POLICY
A discharge summary is prepared by the interdisciplinary team upon discharge and includes:
• At the time of discharge, a recapitulation of the resident’s stay; a final summary of the
resident’s status that is available for release to authorized persons and agencies, if
needed, with the consent of the resident or legal representative.
• A post-discharge plan of care that is developed with the participation of the resident and
his or her family, which will assist the resident to adjust to his or her new living
environment. This plan includes, but is not limited to:
- A description of the resident’s and family’s preferences for care
- How the resident and family will access services
- How care can be coordinated if continuing treatment involves multiple caregivers
- Identification of specific resident needs such as personal care, sterile dressings,
physical therapy, and medications
- A description of the resident/caregiver education needs and ability to meet care needs
after discharge
© Health Dimensions Group 2008 Discharge Summary
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Discharging a Resident
F Tag
N/A
Quality Standard FP94, RCS60
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to facilitate a smooth transition for the resident upon leaving the
facility.
PROCEDURE
1. Verify that Social Services or designee has reviewed the discharge plan with the resident
and family. Verify that Social Services or designee has ensured that the resident has
received any education that the discharge plan specifies.
2. Identify the resident to verify that he/she is the one to be discharged.
3. Verify the arrangement and time (who will pick up, transportation, etc.).
4. Explain to the resident what is to occur.
5. Wash your hands.
6. Provide privacy (close room door, draw privacy curtain).
7. Assist resident as needed in assembling personal items and in dressing.
8. If family is present, defer to them as needed.
9. Gather clothing and pack neatly in container(s) provided.
10. Be sure all drawers, cupboards, and closets are free of the resident’s items.
11. Check laundry for items sent recently to be washed.
12. Check off inventory list, if it is facility’s policy.
13. Inform charge nurse that the resident is ready for instructions, if needed.
14. Remind the resident/family that valuables need to be retrieved from the safe, when
applicable.
15. If resident is leaving by stretcher, have the resident lying on the bed.
16. If leaving by wheelchair, bring one to bedside.
17. Assist with transporting belongings and resident to the car.
18. Assist resident into car.
© Health Dimensions Group 2008 Discharging a Resident
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
19. If the resident is leaving by ambulance, not to return, decide on the belongings that the
ambulance attendants will take. Pack remainder of clothing in bags and label. Notify
family to pick up belongings. Transport belongings to storage area per facility protocol.
© Health Dimensions Group 2008 Discharging a Resident
Page 2 of 2

Discharging a Resident - Instructions for Care of Resident upon Discharge -
Sample
Date: Resident: MR#: Rm#:
Physician:
Date of Discharge:
Physician’s address:
Next Appointment:
Phone:
Current medications (include name, amount, and time of day to be given):
(Use back of sheet for further medications)
Current physical status:
AMBULATION:
ACTIVITIES:
IND NA UN IND NA UN
Bed-to-Chair
Bathes Self
Walking
Dresses Self
Stairs
Feeds Self
Wheelchair
Brushes Teeth
Crutches
Shaves Self
Cane
Toileting
Bed Rest
Comments:
Comments:
Key: IND = Independent / NA = Needs Assistance / UN = Unable
Psycho-social needs:
Other nursing needs (exercise program, ROM):
Special instructions:
Level of consciousness:
Skin condition:
Nutritional status:
Community Agency Contact (e.g. local VNA, home health agency, family services, etc):
Agency:
Contact:
Address:
Phone:
Nurse’s Signature:
Date:
© Health Dimensions Group 2008 Instructions for Care of a Resident upon Discharge - Sample
Page 1 of 1

Discharging a Resident - Planning Instructions for Discharge - Sample
Date: Resident: MR#: Rm#:
Physician:
Phone:
MEDICATIONS – The following medications have been ordered for you by your physician:
Name of medication How often to take How long to take
Special instructions/
precautions
√ if sent with resident
I have explained the above medications and precautions to the resident/family.
Nurse:
Date:
PROCEDURES AND TREATMENTS – To be continued after discharge:
1) 1)
2) 2)
3) 3)
4) 4)
5) 5)
PHYSICIAN APPOINTMENTS – Follow-up visits:
PHYSICIAN NAME TELEPHONE NUMBER WHEN SCHEDULED
© Health Dimensions Group 2008 Planning Instructions for Discharge - Sample
Page 1 of 2

Discharging a Resident - Planning Instructions for Discharge - Sample
Date: Resident: MR#: Rm#:
DIETARY
Type of Diet:
Copy of diet given and explained to resident/family?
Yes __________
No__________
Special Instructions:
Dietary Director:
Date:
COMMUNITY RESOURCES
Social Worker:
Date:
LEISURE COUNSELING
Therapeutic Recreation Coordinator:
Date:
This will certify that all financial obligations are satisfied:
_____TRUST ACCOUNT _____ ROOM & BOARD _____ OTHER CHARGES
BOOKKEEPER:
DATE:
RESIDENT/RESPONSIBLE PARTY:
DATE:
I have received all my personal belongings and valuables:
RESIDENT/RESPONSIBLE PARTY:
STAFF PERSON DISCHARGING RESIDENT:
DATE:
DATE:
PLEASE FEEL FREE TO CONTACT US IF YOU HAVE ANY FURTHER QUESTIONS:
Director of Nursing:
Telephone Number:
Social Worker:
Telephone Number:
© Health Dimensions Group 2008 Planning Instructions for Discharge - Sample
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Disposal of Needles and Syringes
F Tag
N/A
Quality Standard FP35, FP54, FP55, HR34
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to properly dispose of needles and syringes to prevent spread of
infection.
PROCEDURE
1. After giving injection, leave needle and syringe intact. Do not recap needle.
2. Slide needle safety cover over needle whenever applicable.
3. Without disassembling, place the syringe/needle into Sharps container.
4. When the Sharps container is full, notify housekeeping/maintenance to remove and
dispose of appropriately.
© Health Dimensions Group 2008 Disposal of Needles and Syringes
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Dressing a Resident
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The resident should have the opportunity to dress in clothing of their choice as much as
possible. Assistance in dressing will be provided as needed.
PROCEDURE
1. Assemble clean clothing and equipment, as needed, at bedside.
2. Wash hands.
3. Explain procedure to resident.
4. Ensure privacy.
5. Check the name tag on clothing, verifying that the clothing belongs to the resident, if
questionable.
6. Place the clothing where resident is able to reach if dressing independently.
7. Assist the resident to sit on the side of the bed or in a chair, as needed.
8. Remove the resident’s gown or pajamas but only on the area to be dressed first.
Note: The following is a suggested order. If the resident prefers a different order or a
different method, follow the order or method they prefer, if at all possible.
9. Assist the resident in putting on his/her underwear. Start with underpants and then bra or
T-shirt. Allow the resident to do as much as possible for him/herself. The paralyzed or
weak limb is always dressed first. If a woman, proceed with hose.
10. Assist the resident in putting on street clothes. Try pants or skirt and then shirt or blouse
or dress.
11. Have the resident stand up to tuck in clothes at the waist and adjust tightness of belt, if
possible.
12. Document on the ADL sheet amount of assist needed, if it is the facility’s policy.
© Health Dimensions Group 2008 Dressing a Resident
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Drug Regimen Review (DRR) and Services Consultation
F Tag
F428, F431
Quality Standard FP7
Origination Date April 1, 2008
Revision Date
POLICY
A licensed pharmacist performs a drug regimen of each resident at least once a month. The
pharmacist reports any irregularities to the attending physician and the director of nursing
(DON), and these reports are acted upon. The facility employs or obtains the services of a
licensed pharmacist who:
• Establishes a system of records of receipt and disposition of all controlled drugs in
sufficient detail to enable an accurate reconciliation; and
• Determines that drug records are in order and that an account of all controlled drugs is
maintained and periodically reconciled.
PROCEDURE
1. Consultant pharmacist reviews, for regulation compliance, all resident charts on a
monthly basis.
2. The drug regimen review (DRR) focuses on the following:
a. Adverse reactions
b. Duplicate therapy
c. Excessive dose
d. Excessive duration
e. Inadequate monitoring
3. Consultant pharmacist presents a written report to the facility, noting any irregularities
and recommendations for correcting the irregularities.
4. Written report submitted and signed by the consultant pharmacist to the DON.
5. DON ensures follow-up of pharmacist recommendations and appropriately documents
the follow-up.
© Health Dimensions Group 2008 Drug Regimen Review (DRR) and Services Consultation
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Drugs and Biological Storage - Labeling
F Tag
F431, F432
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Labeling of Drugs and Biologicals:
Drugs and biologicals are labeled in accordance with current accepted professional standards,
including the appropriate accessory and cautionary instructions and the expiration data when
applicable.
Storage of Drugs and Biologicals:
In accordance with state and federal laws, all drugs and biologicals are stored in locked
compartments under proper temperature controls. Key access is limited to authorized
personnel.
The facility provides separately locked, permanently affixed compartments for storage of
controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and
Control Act of 1976 and other drugs subject to abuse, except when the facility uses singleunit
package drug distribution systems in which the quantity stored is minimal and a missing
dose can be readily detected.
See also, Pharmacy Manual
© Health Dimensions Group 2008 Drugs and Biological Storage–Labeling
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Ear - Instillation of Medications
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All ear medications will be applied with a physician’s order. The medications are ordered to
help relieve dryness, combat infection, soften cerumen, or relieve pain.
PROCEDURE
1. Wash hands.
2. Take equipment to resident’s room.
3. Explain procedure to resident.
4. Have resident lie on side with affected ear upward, whenever possible. Procedure remains
the same if resident prefers sitting up.
5. Straighten the ear canal by grasping the outer, upper part of the ear and gently pulling
upward and backward.
6. Instill drops as ordered.
7. Place a small amount of cotton in the ear to hold the medication in the ear.
8. Wipe excess medication from the outer ear with a Kleenex.
9. Leave the resident comfortable with the call light in reach, as applicable.
10. Wash hands.
11. Watch for nausea, dizziness, or pain.
12. Return medication to proper place. Make sure the outside of the bottle is clean.
13. Sign off time and medication used on the medication sheet.
14. Licensed staff charts in the nurse’s notes any reaction of the resident and observations.
© Health Dimensions Group 2008 Ear–Instillation of Medications
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Ear - Irrigation of
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Ear irrigations will be conducted with physician’s orders.
PROCEDURE
1. Check physician’s order, and verify if any prior use of Ceromenex or other softener.
2. Position the resident in a sitting/lying position with head tipped so unaffected ear is
toward shoulder.
3. Explain the procedure to the resident.
4. Wash hands.
5. Examine ear canal and note amount of wax or obstruction.
6. Place towel on shoulder of ear to be irrigated and ask resident to hold basin under ear.
7. Fill reservoir of water pic or syringe with warm water.
8. Use largest diameter of water pic, if used.
9. Insert pic or syringe into ear canal approximately 1 inch.
10. Turn on water pic (should be set on low setting). Turn pic in ear canal. If syringe used,
force water into ear canal.
11. Allow for rest period. Examine ear for status of obstruction.
12. Repeat steps 8 and 9 until wax or obstruction has been removed.
13. Dry ear.
14. Disinfect water pic or syringe and rinse reservoir. Dispose of any disposable equipment
used.
15. Wash hands.
16. Document in nurse’s note outcome of irrigation and any side affects or abnormalities.
17. Document treatment completion date, time, and medication used on treatment sheet.
18. Report any adverse reactions to the physician.
© Health Dimensions Group 2008 Ear–Irrigation of
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Elastic Anti-Embolic Hose Application (TED)
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Anti-embolic hose will be utilized for residents with diminished circulation to prevent the
formation or movement of blood clots in the lower extremities. They must be physician
ordered.
PROCEDURE
1. Explain procedure to be done.
2. Wash hands.
3. Ensure privacy.
4. The resident must be measured by a licensed nurse to assure proper size of stockings.
5. Resident should be lying down in bed for application. The best time to apply the hose is
prior to the resident getting up in the morning and/or after resident having had legs
elevated.
6. Expose legs only.
7. Turn stocking inside out to heel.
8. Slip the stocking foot over toes, foot, and heel.
9. Grasp top of stocking, slipping it over the foot and heel, and pull it up the leg.
10. Be sure it is crease and wrinkle free.
11. Repeat for the other leg.
12. Document on ADL sheet, if it is the facility’s policy.
13. Notify charge nurse or delegate of any change in temperature, redness, pain, or lesions on
legs.
© Health Dimensions Group 2008 Elastic Anti-Embolic Hose Application (TED)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Electric Razors - Cleaning
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All electric razors are cleaned after each use. If a razor is used for more than one resident, the
blades must be disinfected as well.
PROCEDURE
1. Take the razor to the utility room, if possible.
2. Wash hands.
3. Apply gloves, as needed.
4. Hold the razor over a waste can or paper towel.
5. With a brush, thoroughly clean the area between blades of all debris.
6. Remove head containing blades from razor, as needed.
7. Wash with soap and water. Disinfect as needed.
8. Place head on a clean dry cloth or paper towel and allow to air dry.
9. When dry, reattach head to shaver.
10. Remove gloves if used. Wash hands.
11. Check the label on the razor for legible identification. If not legible, remark.
12. If razor cannot be stored safely in the resident’s room, store in the designated area.
© Health Dimensions Group 2008 Electric Razors–Cleaning
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Elopement/Missing Resident
F Tag
N/A
Quality Standard RCS40
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to implement all possible measures to protect/minimize any resident
who attempts to elope.
DEFINITION
Elopement, for purposes of this policy and procedure, is defined as that situation where a
resident with impaired decision-making ability, who is oblivious to his/her own safety needs,
and therefore at risk for injury outside the confines of the facility, has left the facility without
the knowledge of staff.
PROCEDURE
1. Upon admission, all residents will be assessed for risk of elopement.
2. If a resident is found to be at risk for elopement, the resident’s care plan will include
interventions for the prevention of elopement. The resident’s picture will be located at
stations or reception areas to alert staff of the possible risk of elopement.
3. Residents will be re-assessed for elopement risk if the resident makes attempts to elope
and/or as needed.
4. If the resident is thought to have eloped, the charge nurse or designee will notify staff to
do a room-to-room search including bathrooms, shower rooms, storage areas, kitchen, all
resident rooms, the basement, etc. A facility-wide alert may be initiated.
5. If the resident is not found, the administrator and director of nursing are notified. The
police and family are notified by the administrator or designee.
6. When the resident is found, an in-depth physical assessment is completed by the charge
nurse or designee with a specific focus on hypothermia, injuries, etc., and treated as
ordered by the physician. The physician is notified along with the family and police, as
needed. An incident report is completed. Documentation in nurse’s notes is made.
7. Care plan interventions are documented and/or revised.
8. An immediate intervention is implemented to prevent further elopement. This may
include 15-30 minute checks for at least eight hours or more, placement to secured unit,
or use of a wander-guard.
9. An incident report is competed. The investigation of the incident includes a timeline of
resident’s whereabouts and staff interactions with the resident prior to the elopement.
© Health Dimensions Group 2008 Elopement/Missing Resident
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
10. Each shift, nurse’s notes are written following the elopement to reflect resident’s
response to the intervention(s).
11. The director of nursing completes an investigation of the elopement, including possible
causes, the timeline, witness statements, immediate interventions, any permanent
interventions, or any prevention measures.
12. The State is notified according to state regulations.
© Health Dimensions Group 2008 Elopement/Missing Resident
Page 2 of 2

Education
Elopement/Missing Resident - Education
“Elopement” is the term used for a resident leaving the facility without staff knowledge.
Most residents who elope are either confused or have some degree of memory
impairment or dementia. While elopement is not a common occurrence, the consequences
to the resident can be very serious, even resulting in death.
Many residents live in nursing homes because it is unsafe for them to stay at home alone.
If the resident tried to leave their home without supervision, chances are, they will try it
at the facility, too. By determining the risk, preventative measures can be taken to protect
the resident from this danger.
Risk Factors
Some risk factors include:
• Prior history of leaving their home or another facility unsupervised
• Tendency to wander without purpose or direction
• Dementia or Alzheimer’s disease
• Any illness causing confusion
• History of depression
• Feeling unhappy at the facility
• Trouble adjusting to new surroundings
• Problems seeing or hearing
• Increased confusion in the evening
• Poor sense of safety
• Feeling abandoned
© Health Dimensions Group 2008 Elopement/Missing Resident - Education
Page 1 of 2

Prevention
Not all elopements are preventable; however, often interventions can be undertaken and a
quality of life consistent with the family’s wishes can be achieved. When possible, the
best way to care for a resident at risk for elopement is to try and prevent the problem
from occurring, which, depending on the circumstances, may include one or more of the
following:
• Identify resident’s risk for elopement
• Redirect the resident’s activities that are geared at focusing them away from thoughts
of leaving or wandering
• Evaluate the need for a wandering management program, which may include wearing
a bracelet or other device intended to alert staff when the resident attempts to leave a
safe area
• Introduce the resident to other residents in the facility
• Help the resident to make choices where possible, e.g., what to where, when to bathe
• Communicate with the resident, when possible, to determine the reason for the
behavior
• Observe the resident for events that trigger wandering or elopement behaviors
Discuss with Family
Talk to the family about past behavior such as:
• What factors may be causing or contributing to the problem
• What prior elopement behavior has occurred, and what has been done in the past to
stop the behavior
• Encourage the family to talk positively about the nursing facility placement when
visiting
• Have the family bring in personal items to help the resident feel more comfortable in
their new environment
• Ask that the family let facility staff know when their visit has ended
• Ensure accurate family telephone numbers for family members or responsible parties
are on file
• Identify/label the resident’s clothing and personal items
© Health Dimensions Group 2008 Elopement/Missing Resident - Education
Page 2 of 2

Elopement/Missing Resident - Elopement Risk Assessment - Sample
Date: Resident: MR#: Rm#:
(Circle yes or no.)
1. Does resident have diagnosis of dementia/Alzheimer’s/confusion? Yes = 2 No = 0
2. Is resident able to be independently mobile? Yes = 3 No = 0
3. Does resident pace, wander, try to get out the door, find family
or friend, perceive they need to be doing something other than Yes = 5 No = 0
what they are doing (e.g., go to work, get home, fix supper,
do the chores)?
4. Does resident exhibit signs of sundowners? Yes = 5 No = 0
5. Does resident have a history of elopement, wandering off, getting
lost, etc.? Yes = 5 No = 0
6. Does resident not readily accept nursing home placement? Yes = 5 No = 0
TOTAL ______ ______
If you answered “yes” to one or more of the above questions, the resident may be at risk. If the
score is 5 or greater, the resident is at risk.
1. Address elopement precautions on care plan:
a. Implement routine monitoring of resident’s whereabouts.
b. Apply elopement security bracelet. (Type: ).
c. Involve in psychosocial programs/activities, especially during periods of restlessness.
(Activity department notified: ).
d. Redirect efforts to elope.
e. Consider placement in a secured unit? ( ).
2. Notify family; request background information/suggestions. (
).
Reviewed:
Wander-guard in place?
Activities notified?
Care plan updated?
Family involved?
Signature:
Date Date Date Date Signature
Date:
© Health Dimensions Group 2008 Elopement Missing Resident - Elopement Risk Assessment - Sample
Page 1 of 1

Elopement/Missing Resident Report Form - Sample
Date: Resident: MR#: Rm#:
Admission Date: Physician: Date of Birth:
Gender: Male Female Height: Weight:
Hair Color: Eye Color: Race/Ethnicity:
Diagnosis:
Resident Status and Information Prior to Elopement
Date and time resident was last seen?
Where was resident last seen?
Any noted mood or behavior issues when resident was last seen?
What was resident’s cognitive status when last seen?
Resident medical concerns (medication needs, physical condition):
Clothing worn when resident last seen?
History of previous elopements and intervention plan:
Suspected method of leaving facility?
Did resident wear a personal alarm/device?
Were door alarms in place and working at the time?
Weather conditions at time of elopement:
Potential outside safety concerns for resident (traffic, lakes):
Other information regarding resident status prior to elopement:
Post Elopement Information
Date and time resident was noted as missing?
By whom?
When was facility ground search completed?
Who (facility staff) completed the search?
Family notified of elopement – Whom?
When?
By whom?
Physician notified of elopement – Whom?
When?
By whom?
Police department notified? yes no When? By whom?
DO & PSC notified of incident? yes no When? By whom?
© Health Dimensions Group 2008 Elopement – Missing Resident Report Form - Sample
Page 1 of 2

Elopement/Missing Resident Report Form - Sample
Date: Resident: MR#: Rm#:
Elopement Follow-up
Where was resident found?
Date and time resident found?
Resident’s physical condition when found?
Resident’s mental status when found?
Was resident sent to hospital for evaluation?
If sent to the hospital, resident’s reported status?
Family notified when found? Whom?
When?
By whom?
Physician notified when found? Whom?
When?
By whom?
State regulatory agency notified? yes no When? By whom?
Risk management notified? yes no When? By whom?
Elopement Prevention
Prevention plan implemented for resident:
Are personal or door alarms used?
Care plan updated for elopement risk?
Associate education of care plan update?
Contact Information
Contact person:
Facility name:
Facility address:
Facility phone number:
Space for resident’s photo
• Make copy for law enforcement. Keep original for facility.
Signature:
Date:
© Health Dimensions Group 2008 Elopement – Missing Resident Report Form - Sample
Page 2 of 2

Elopement/Missing Resident - Risk for Wandering and Elopement Assessment - Sample
Date: Resident: MR#: Rm#:
Potential problems to be reviewed in evaluating wandering and elopement risks:
1. Is there a previous history of wandering? Yes No
If yes, explain:
2. Describe attitude toward admission and/or behavioral issues:
3. Cognition (including long- and short-term memory strengths and weaknesses):
4. Mobility:
5. Family input:
Conclusion:
At risk for aimless wandering? Yes No
At risk for intentional wandering (elopement)? Yes No
Plan:
Wander-guard placed: Yes No – Date_______________
Pictures taken: Yes No – Date_______________
Wander-guard check scheduled on treatment record: Yes No – Date_______________
Care plan for wandering: Yes No – Date_______________
Other:
Signature:
Date:
© Health Dimensions Group 2008 Elopement/Missing Resident - Risk for Wandering
and Elopement Assessment - Sample
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Emergency Power
F Tag
F455
Quality Standard FP34
Origination Date April 1, 2008
Revision Date
POLICY
In the event normal electrical power is interrupted, an emergency electrical power system
supplies, as a minimum, adequate power to:
• Light all entrances and exit pathways;
• Operate all fire detection equipment, alarms, and extinguishing systems; and
• Operate all life support systems.
© Health Dimensions Group 2008 Emergency Power
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Enema - Disposable or Oil Retention
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will utilize an enema to cleanse the rectum and colon in preparation for surgery,
x-ray or examination, aid in stimulating peristals and evacuation of feces, and/or to relieve
flatulence (gas). A physician’s order is required.
PROCEDURE
1. Take equipment to resident’s room.
2. Explain procedure to resident.
3. Follow directions on label of box in assembling the disposable enema.
4. Wash hands.
5. Apply gloves.
6. Prepare resident as for cleansing enema. See procedure on enema tap water.
7. Lubricate and insert tip gently, and squeeze all of the fluid slowly out of the container.
This prevents the urge to expel the solution.
8. Withdraw the tip slowly; wipe the anal region with toilet tissue.
9. Place soiled items in proper disposal bags.
10. Remove gloves.
11. Wash hands.
12. Urge the resident to retain the solution 3–5 minutes.
13. Prepare the resident for the evacuation process, as with the tap water enema.
14. Return equipment to proper place.
15. Dispose of containers in utility room trash can.
16. Chart type of enema, time given, and results in the nurse’s notes.
17. If BM book or list is used, note in the appropriate area that an enema was given and the
results.
18. If resident is on a bowel training program, note results in the appropriate area on the B &
B charting forms.
19. Make the necessary notation on the ADL sheet, if it is the facility’s policy.
© Health Dimensions Group 2008 Enema–Disposable or Oil Retention
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
20. Make out charge slips, as necessary.
21. Notify the physician of any abnormalities.
© Health Dimensions Group 2008 Enema–Disposable or Oil Retention
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Enema - Tap Water
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will utilize an enema to cleanse the rectum and colon in preparation for surgery,
x-ray or examination, aid in stimulating peristals and evacuation of feces, and/or to relieve
flatulence (gas). A physician’s order is required.
PROCEDURE
1. Wash hands.
2. Gather equipment in the utility or bathroom, if possible. Close the clamp on the tubing;
fill the bag with solution as ordered, and take to bedside.
3. Provide privacy, i.e., draw curtain and close the door.
4. Explain the procedure to the resident.
5. Have the resident lie flat if possible. Solution has less difficulty entering colon with head
flat.
6. Turn the resident to his/her left side with knees flexed (the right knee should be flexed
higher than the left knee, if possible).
7. Drape the resident. Do not expose the resident any more than necessary.
8. Put the bedpan on the chair beside the bed or foot of bed, if desired for easier access.
9. Put Chux/pad under resident’s buttocks.
10. Open clamp and allow a small amount of solution to run into the bedpan to expel air from
tubing.
11. Apply gloves.
12. Pinch tubing off with your fingers and insert the tubing (lubricated) gently 2 inches into
the rectum at an angle pointing toward umbilicus.
13. Allow the fluid to flow; then insert the tubing 1–2 inches above the level of the resident’s
rectum.
14. Hold the rectal tubing in place.
15. Hold the enema solution container not more than 20 inches above the level of the
resident’s rectum.
© Health Dimensions Group 2008 Enema–Tap Water
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
16. Allow the solution to flow slowly (5–10 minutes). Turn flow off and on at intervals, as
tolerated by the resident. Have the resident breathe deeply and relax the abdominal
muscles.
17. When most of the solution has been taken, close the clamp before air enters the tubing.
Wrap tissue around tube.
18. Remove gloves.
19. Wash hands.
20. If possible, have resident sit on toilet, or if unable, place resident on bedpan, elevating the
head of the bed if permitted. If the resident should have difficulty holding the enema
solution, it may be necessary to place him/her on the bedpan before or during the
procedure and thus give the enema with the resident on his/her back.
21. Place call light within the resident’s reach, and provide toilet tissue as needed.
22. Do not leave resident alone if he/she is not alert.
23. Cover the equipment and remove it from the room.
24. After the enema has been expelled, remove the pan, and cleanse and dry the resident.
25. Leave the resident comfortable with the call light in reach.
26. Place the soiled linen in soiled linen container.
27. Wash hands.
28. Document the time, amount, type, and strength of solution, amount and appearance of
results, and reaction of the resident in the nurse’s notes.
29. If a BM book or list is utilized, a notation that an enema was given should be made in the
appropriate place.
30. Make the necessary notation on the ADL sheet, if it is the facility’s policy.
31. If the resident is on bladder and bowel retraining, make necessary entry on the B & B
charting form.
32. Notify physician of any abnormalities.
© Health Dimensions Group 2008 Enema–Tap Water
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Enteral Feeding Pumps - Cleaning
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All equipment will be cleaned routinely to prevent the spread of infection.
PROCEDURE
1. The pumps and stands will be cleaned by staff with a disinfectant per facility schedule.
2. Apply gloves.
3. Wash machine with disinfectant.
4. Dispose of linen.
5. Remove gloves.
6. Wash hands.
© Health Dimensions Group 2008 Enteral Feeding Pumps–Cleaning
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Environment - Cleaning of Equipment (General)
F Tag
F252
Quality Standard FP51, FP76
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides a clean, safe, comfortable, and homelike environment, allowing the
resident to use his or her personal belongings to the extent possible.
All unit equipment (e.g., refrigerators, commodes, water pitchers, water glasses, urinals, lifts,
wheelchairs, respiratory equipment, suction equipment, and enteral equipment) is cleaned on
a routine basis.
© Health Dimensions Group 2008 Environment–Cleaning of Equipment (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Environment - Quality of Life (General)
F Tag
F240, F252, F253, F254, F255, F256, F257, F258
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility cares for its residents in a manner and in an environment that promotes
maintenance or enhancement of each resident’s quality of life.
The facility provides a safe, clean, comfortable, and homelike environment, allowing the
resident to use his/her personal belongings to the extent possible.
Housekeeping and maintenance services necessary to maintain sanitary, orderly, and
comfortable interior are provided and include:
• Clean bed and bed linens that are in good condition;
• Private closet space in each resident’s room;
• Adequate and comfortable lighting levels in all areas;
• Comfortable and safe temperature levels (71-81 degrees F); and
• Comfortable sound levels.
© Health Dimensions Group 2008 Environment–Quality of Life (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Equal Access to Quality Care (General)
F Tag
F207
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All residents are treated equally in the provision of services, including transfers and
discharges, regardless of payment service.
© Health Dimensions Group 2008 Equal Access to Quality Care (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Evening Care
F Tag
N/A
Quality Standard RCS17, RCS20
Origination Date April 1, 2008
Revision Date
POLICY
All residents will be provided evening care with assistance, as needed.
PROCEDURE
1. Wash hands.
2. Explain procedure to resident.
3. Change necessary linens.
4. Provide privacy.
5. Wash hands.
6. Assemble equipment.
7. Oral care, as needed.
8. Assist to bathroom, as needed.
9. Apply gloves. Check for incontinence, as needed. If necessary, wash perineal area and
change linen. Remove gloves/wash hands.
10. Assist with nightwear, as needed.
11. Adjust the bed to the height and position indicated for the resident.
12. Position pillow to support resident’s head and shoulders, as needed.
13. Straighten top covers. Provide extra blanket, if desired.
14. Adjust position of resident for comfort, as needed.
15. Ensure that resident has fresh drinking water within reach, as needed. Offer to those that
are unable to assist themselves.
16. Give any special attention the resident may need; attend to all reasonable requests.
17. Remove all unnecessary equipment.
18. Adjust lighting.
19. Leave room in order with call light within easy reach of resident.
20. Wash hands.
21. Chart and report any unusual reaction or condition.
© Health Dimensions Group 2008 Evening Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Examination of Survey Results
F Tag
F167
Quality Standard FP21
Origination Date April 1, 2008
Revision Date
POLICY
The most recent results of the federal and state recertification survey conducted by the State
surveyors are available for review.
Results of the survey, including the statement of deficiencies, state citations, and plan of
correction, is posted in a place readily accessible to residents and the public. The right to
examine survey results is explained to each resident upon admission.
The facility’s results are located: ________________________________________________
© Health Dimensions Group 2008 Examination of Survey Results
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Exercise of Rights (General)
F Tag
F151
Quality Standard RCS6, RCS8
Origination Date April 1, 2008
Revision Date
POLICY
The resident has the right to exercise his or her rights as a resident of the facility and as a
citizen or resident of the United States.
In exercising his or her rights, the resident has the right to be free of interference, coercion,
discrimination, and reprisal from the facility.
© Health Dimensions Group 2008 Exercise of Rights (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Eye - Compresses
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Eye compresses will be used to relieve inflammation and congestion of the eyeball and
eyelids; to relieve pain; and to soften exudate and induce drainage.
PROCEDURE
1. Wash hands.
2. Assemble equipment at resident’s bedside.
3. Provide privacy.
4. Explain procedure to resident.
5. Place resident in dorsal recumbent or lateral position with head turned toward affected
side.
6. Place towel under resident’s head.
7. Wash hands.
8. Apply gloves.
9. For cold moist compresses:
a. Place basin of ice on the over-bed table/night stand.
b. Pour small amount of solution into small sterile basin, using aseptic technique, and
place small basin into ice in larger basin.
c. Allow solution to cool.
d. Place sterile 4 x 4s into solution.
e. Apply 4 x 4s over eyelid and/or place ice bag over 4 x 4s for time ordered.
10. For warm moist compresses:
a. Use microwave to warm solution in small sterile basin.
b. Apply Vaseline over eyelids, cheeks, and forehead to prevent excoriation.
c. Using aseptic technique, place 4 x 4s in solution.
d. Apply 4 x 4s over eyelid. Change 4 x 4s frequently, using new 4 x 4s each time for
length of treatment time ordered.
11. At the end of the treatment, dry eyes gently but thoroughly.
© Health Dimensions Group 2008 Eye–Compresses
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
12. Remove gloves.
13. Wash hands.
14. Reapply dressings, if needed.
15. Leave resident comfortable with call light within reach.
16. Discard soiled dressings and equipment in contaminated waste container.
17. Wash hands.
18. Document date, time, and solution used on the treatment sheet.
19. Document any unusual observations or resident reactions in the nurse’s notes and report
to physician, as needed.
© Health Dimensions Group 2008 Eye–Compresses
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Eye - Instillation of Medications
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All eye medications will be administered appropriately and with a physician’s order
following proper infection control techniques.
PROCEDURE
1. Assemble equipment.
2. Explain procedure to resident.
3. Wash hands and apply gloves, if it is the facility’s policy.
4. Have the resident tilt his head backward.
5. Draw the lower lid down.
6. Have the resident look up.
7. Drop one drop of medication every three to five minutes, or per manufacturer’s
recommendations, in the pouch of the lower lid. Avoid touching lashes, lids, or the
eyeball with container tip.
8. Ask resident to close his lids gently.
9. Wipe away any overflow from the inner to the outer angle of the eye, using one stroke to
prevent cross-infection.
10. Wash hands.
11. Leave the resident comfortable with call light in reach, if applicable.
12. Document the date and time on the medication sheet.
13. Document any unusual observations and resident reactions in the nurse’s notes, and
report to physician, as needed.
© Health Dimensions Group 2008 Eye–Instillation of Medications
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Eye - Irrigation
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All eye irrigations must be physician ordered and may be used to relieve pain and congestion,
to cleanse the eyelids of excess secretions, and to remove foreign bodies from the
conjunctiva sac.
PROCEDURE
1. Wash hands.
2. Warm the solution, not to be hot, by placing the container in a pan of warm water or
microwave, if necessary. Test the solution by putting a small amount over your wrist. Do
not contaminate the solution you are going to use.
3. Assemble all equipment needed at resident’s bedside.
4. Provide privacy.
5. Explain procedure to the resident.
6. Elevate the head of the bed so that the resident is in a sitting position.
7. Wash hands.
8. Turn the resident’s head to the side of the affected eye. Place the towel over the resident’s
chest and shoulder.
9. Apply gloves.
10. Place the emesis basin underneath the eye. Press the basin gently against the cheek and
the side of the head.
11. Using a clean cotton ball, wipe off any secretions from the lids, beginning at the inner
edge and wiping outward.
12. Gently separate the lids of the affected eye with the thumb and the index finger.
13. Draw the desired amount of solution into the bulb syringe. Holding the syringe almost
lateral to the eye, express the solution gently from the syringe into the inner canthus
allowing it to flow from the inside to the outside and into the emesis basin. Repeat this
process until all the secretions are removed or until all of the solution ordered by the
physician has been used.
14. Pat the eyelid dry with a cotton ball.
15. Remove gloves.
© Health Dimensions Group 2008 Eye–Irrigation
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
16. Wash hands.
17. If the other eye is to be treated, repeat steps 8 through 16.
18. Leave the resident comfortable with call light within reach.
19. Wash hands.
20. Discard disposable equipment in the utility room.
21. Put soiled linen in the soiled linen container.
22. Document the date, time, solution, strength, amount, and area of irrigation on the
treatment sheet.
23. Document any unusual observations or resident reactions in the nurse’s notes and report
to physician as needed.
© Health Dimensions Group 2008 Eye–Irrigation
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Eye - Prosthesis
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All eye prostheses will be cared for to maintain tissue structure of the orbit, to provide
cleanliness, and to provide physical and psychological comfort for the resident.
PROCEDURE
Note: Residents usually remove prostheses before going to bed. Encourage resident to do
as much for themselves as possible.
1. Wash hands.
2. Assemble equipment at bedside.
3. Explain procedure to resident.
4. Provide privacy.
5. Pad container with 4 x 4s and fill one-half full with tap water.
Note: Do not use alcohol, ether, or acetone as these dim the luster of glass prostheses and
dissolve the plastic ones.
6. To remove a prosthesis:
a. Apply gloves.
b. Tilt resident’s head backward.
c. Gently pull lower lid downward.
d. Place applicator under edge of prosthesis at lower, outer angle, and lift it up.
e. Grasp prosthesis between thumb and forefinger of hand holding lid down.
f. Lift prosthesis out of socket.
i. Cup your hand so prosthesis won’t roll out of it.
ii. If resident has his/her own rubber suction tip, it may be used to remove eye.
7. Wash prosthesis immediately in running water and place it in padded cup of water. Take
care to not scratch prosthesis.
8. To irrigate the eye socket:
a. Wash hands.
b. Apply new gloves.
© Health Dimensions Group 2008 Eye–Prosthesis
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
c. Place towel across shoulder.
d. Have resident hold emesis basin close under eye.
e. Hold eyelids apart with one hand while gently pouring prescribed solution into
socket.
f. Have resident move head so that all of solution drains out.
g. Dry resident’s face, as needed.
h. Remove gloves.
i. Wash hands.
9. To insert a prosthesis:
a. Apply new gloves.
b. Rinse prosthesis with fresh water.
c. Hold prosthesis between thumb and forefinger of one hand. Hold wider portion of
prosthesis toward the outer portion of the eye socket. Be careful not to drop it.
d. Using the other hand, gently raise the upper lid and slip the prosthesis under the lid.
e. Gently bring the lower lid forward and downward and allow prosthesis to drop behind
it.
f. Remove gloves.
10. Leave resident comfortable with call light button in reach.
11. Wash hands.
12. Place disposable items in the utility room trash can.
13. Place soiled linen in the soiled linen container.
14. Document on the treatment sheet the date, time, procedure, and solution used.
15. Document any unusual observations or resident reactions in the nurse’s notes and report
to physician as needed.
© Health Dimensions Group 2008 Eye–Prosthesis
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Fecal Impaction Removal
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility’s emphasis is the prevention of fecal impactions whenever possible. Removing
hardened fecal material from the lower bowel will be done only by licensed staff.
PROCEDURE
1. Wash hands.
2. Assemble equipment at bedside.
3. Explain procedure to resident to allay fears and gain resident’s cooperation.
4. Provide privacy.
5. Place resident on left side.
6. Place bed protector under resident’s buttocks.
7. Place bedpan on mattress near buttocks.
8. Drape resident to expose buttocks; do not overexpose resident.
9. Put on gloves and apply a liberal amount of lubricant. Remember that this procedure can
be painful and uncomfortable to resident.
10. Use one hand to expose anus and insert the index finger of the other hand gently into the
anus, directing it backward toward the sacrum.
11. Gently massage around the hardened feces to loosen and dislodge it. Be careful not to
injure bowel tissue. Some bleeding may occur.
12. As pieces are broken up, place them into the bedpan.
13. Change gloves, as needed.
14. When as much feces as is possible has been removed, use washcloth, soap, and warm
water to clean resident. Pat dry with towel.
15. Note amount and character of feces, and flush it down the toilet.
16. Remove gloves.
17. Wash hands.
18. Leave resident comfortable with call light in reach.
19. Place disposable items in utility room contaminated waste container.
© Health Dimensions Group 2008 Fecal Impaction Removal
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
20. Place soiled linen in soiled linen container. Rinse soiled waste off before placing the
linen in the hopper.
21. Wash hands.
22. Document date, time, procedure, resident reactions, and results in the nurse’s notes.
23. Document the appropriate notation in the bowel function section of the ADL sheet, if it is
the facility’s policy.
© Health Dimensions Group 2008 Fecal Impaction Removal
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Feeding Assistant - Paid
F Tag
F373
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility uses paid feeding assistants when the following criteria are met:
1. Staff employed as paid feeding assistants have completed a state-approved training
course.
2. The facility maintains a record of all individuals used by the facility as paid feeding
assistants and maintains documentation of successful completion of the state-approved
training course by these individuals.
3. A resident’s qualification for use of a paid feeding assistant is based upon a charge
nurse’s assessment and the resident’s latest assessment and care plan. The clinical record
of the resident shows evidence in the assessment and care plan that the resident is eligible
to receive assistance from a paid feeding assistant.
4. Paid feeding assistants work under the supervision of an RN or LPN and are required in
an emergency to call a licensed nurse for help.
5. Paid feeding assistants only assist residents who have no complicated health problems
related to eating or drinking that make them ineligible for these services. Complicated
eating problems include, but are not limited to, difficulty swallowing, recurrent lung
aspirations, and tube or parenteral/IV feedings.
Note: This policy does not apply to family who may be proving the resident with assistance
with eating.
© Health Dimensions Group 2008 Feeding Assistant–Paid
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Feeding the Total Care Resident
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents who are unable to feed themselves will be provided with total assistance, as
needed, to provide an adequate dietary intake and to encourage the resident to eat.
PROCEDURE
1. Wash hands.
2. Explain procedure to the resident.
3. Position the resident in a sitting position with good alignment of head and body. Head
should be elevated 90 degrees to facilitate swallowing, unless determined otherwise by
the physician and/or speech therapist.
4. Assure resident’s hands are clean.
5. Place a napkin in the resident’s lap and/or a clothing protector.
6. Place the tray/dish in front of the resident. Tell the resident what he/she will be eating.
7. Prepare food on plate by cutting meat, buttering bread, etc., as needed.
8. Present food to the resident on the utensil and ask him/her to open and then close mouth
to remove the food from the utensil. Do not introduce more food until the food you have
given him/her has been swallowed.
9. Present a wide variety of food in the order that is preferred by the resident. For instance, a
resident may want to eat a bite of meat, then green vegetable, then starch; or another
resident may prefer to eat all of the meat before eating the vegetables.
10. Offer fluids frequently. Watch for swallowing difficulties.
11. Wipe the mouth area with napkin/clothing protector at intervals and when the resident
has completed eating.
12. Remove the tray/dishes and store adaptive equipment.
13. Wash hands.
14. Document percent eaten and intake on ADL sheet, if it is the facility’s policy.
15. Notify the charge nurse or designee of any problems.
© Health Dimensions Group 2008 Feeding the Total Care Resident
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Burns
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Only minor burns will be treated at the facility per physician’s orders. All other burns will
require further emergency care per physician’s orders.
DEFINITION
A burn is a severe trauma to the skin and body. The severity of a burn varies according to the
extent and body area affected. Burns are placed in three categories: first degree–appears as a
reddened area; second degree–usually shows blisters and redness; and third degree–involves
a full thickness of skin including muscle, fat, and sometimes bone. It appears as black,
charred necrotic tissue. Infection is a serious threat in any burn.
PROCEDURE
1. If a person’s clothing is on fire:
a. Place him/her on the ground or floor and roll to smother the flames.
b. A large towel, blanket, or carpet may be used to smother the flames.
c. Do not remove the clothing unless it is burning or hot.
d. Have the victim lie down and cover with a blanket to prevent any additional loss of
body heat.
e. Watch the victim’s physical and mental status closely; provide oxygen.
f. Major burns require close observation for possible shock symptoms.
2. Examine the burn and note the extent of body involvement, the depth, and the agent
which caused the burn.
3. If the area is small, immediately apply cold such as ice or cold moist towels or place in
ice water for approximately 10 minutes. This may be repeated two or three times, if
necessary, especially when pain is present.
4. For severe burns:
a. Immediately contact emergency medical unit.
b. Make resident as comfortable as possible until emergency unit arrives. DO NOT use
ointments, salves, or antibiotics without a physician’s order.
5. For chemical burns, wash the area immediately with clean cold water—this includes the
eyes.
© Health Dimensions Group 2008 First Aid–Burns
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
6. Contact the physician immediately.
7. Document in the nurse’s notes signs, symptoms, and treatment given.
8. Complete incident report per policy. Do not reference the report in the nurse’s notes.
9. Investigation of the incident to be completed and documented.
© Health Dimensions Group 2008 First Aid–Burns
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Choking
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents who are choking will be provided with treatment as indicated.
PROCEDURE
1. Bed resident
a. If resident is on back, turn resident on side, roll resident up, and use suction machine
as needed.
b. If food is in mouth, remove, and dislodge obstruction in air passage by striking victim
sharply on back or use Heimlich procedure.
2. Ambulatory resident: Perform the Heimlich procedure by applying pressure under the
diaphragm to cause food to come up.
3. Call 911; transfer to hospital as per physician orders.
4. Notify physician and family.
5. Record follow-up in chart and on the incident report. No reference to the incident report
will be made in the chart.
6. Document in the nurse’s notes signs and symptoms and treatment.
7. Dietary and/or speech evaluation/consultation conducted as needed.
© Health Dimensions Group 2008 First Aid–Choking
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Falls (General)
F Tag
N/A
Quality Standard RCS34
Origination Date April 1, 2008
Revision Date
POLICY
Residents who fall shall be provided with care/treatment, as necessary.
PROCEDURE
When a resident falls, do not move the resident until a nurse examines him/her. The
nurse will determine if emergency action is needed.
1. Check to determine:
a. If the resident is breathing properly
b. If the resident is bleeding
c. Pulse
2. Look for injury such as bumps, bruises, and unnatural positions of the limbs.
3. If resident can tell you, ask resident how they fell and if they bumped their head.
4. Check part of body that resident tells you is painful.
5. If no need for first aid is found and if the resident is not injured, return resident to bed,
according to the instructions of a licensed nurse.
6. If resident has stopped breathing, is bleeding, or has fainted, give proper first aid
according to emergency procedures, and contact 911 and/or physician.
7. If the resident has painful areas, bumps, and/or limbs in unnatural position, keep resident
on the floor. Do not move or leave an injured person. Summon help to call physician and
then carry out physician’s orders.
8. If fractured hip, back, or other major injury is suspected, make resident comfortable until
emergency medical assistance arrives.
9. Document in the nurse’s notes signs and symptoms and treatment given.
10. Contact family.
11. Complete an incident report. Do not reference incident report in nurse’s notes.
12. Document any incidents in medical record.
© Health Dimensions Group 2008 First Aid–Falls (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Heimlich Maneuver
F Tag
N/A
Quality Standard
Origination Date April 1, 2008
Revision Date
POLICY
The Heimlich maneuver is performed to remove the cause of a resident’s choking.
PROCEDURE
1. Stand behind the victim and wrap your arms around the waist, allowing the choking
person’s torso to hang forward.
2. Make a fist with one hand and grasp it with the other. Place the fist against the victim’s
abdomen slightly above the navel and below the rib cage, and make a quick upward
thrust. This should expel the wind from the lungs and force the object from the windpipe.
3. Repeat as necessary.
4. If the victim is sitting, stand behind the chair and perform the maneuver.
5. If the victim is prone or unconscious, turn onto the back, kneel astride the torso, place
both hands again on the victim’s abdomen above the navel and below the rib cage, then
press with a quick upward thrust.
6. Have another staff member call emergency services. Transfer to hospital as per physician
orders.
7. Initiate CPR if breathing ceases (if it is the facility’s policy to perform CPR).
8. Document in the nurse’s notes signs and symptoms and treatment given.
9. Notify family.
10. Complete incident report (do not reference incident report in nurse’s notes).
© Health Dimensions Group 2008 First Aid–Heimlich Maneuver
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Hemorrhage
F Tag
N/A
Quality Standard
Origination Date April 1, 2008
Revision Date
POLICY
The facility will provide first aid to reduce the blood loss as much as possible until
emergency assistance arrives.
PROCEDURE
1. Locate the exact source of bleeding, if possible.
2. Apply pressure directly and continuously to the wound. A sterile bandage, if available,
clean cloth or handkerchief, or the bare hand can be used.
3. Have someone notify the attending physician.
4. Call 911, and transfer to acute care hospital immediately.
5. Document in the nurse’s notes signs and symptoms and treatment given.
© Health Dimensions Group 2008 First Aid–Hemorrhage
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Insulin Reaction
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
An insulin reaction occurs when the resident does not eat properly or has exercised
excessively after taking insulin.
Signs of insulin shock:
• Weakness
• Excessive nervousness
• Excessive hunger
• Tremors
• Excessive perspiration
• Confusion
• Aphasia
• Numbness of the legs and hands
• Delirium
• Dizziness
• Convulsions
• Unconsciousness
PROCEDURE
1. Check blood sugars.
2. Notify physician and/or 911.
3. Administer physician’s orders.
4. Document in the nurse’s notes signs and symptoms and treatment given.
5. Follow up, as needed.
© Health Dimensions Group 2008 First Aid–Insulin Reaction
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Seizure
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to keep the resident as safe as possible during a seizure.
PROCEDURE
1. Do not move resident unless he/she is in a dangerous position.
2. Protect the head from injury by placing pillow under it.
3. The resident may go into clonis or shaking stage of convulsion.
4. Do not try to hold body still.
5. Guide jerky movements to prevent resident from injury.
6. After clonic stage, resident may become limp, muscles relaxed, respirations may stop for
a few seconds, and cyanosis may be present. Do not leave resident alone.
7. If respirations cease, artificial or mouth-to-mouth resuscitation is used at once. Resident
should be turned to side lying position or have his/her face turned to side.
8. Call 911, if indicated.
9. When resident regains consciousness, confusion may be present.
10. Notify physician.
11. Notify family as needed.
12. Monitor resident for further seizure activity.
SAFETY MEASURES
When a resident is prone to convulsions:
1. Assist resident in care activities such as bathing, etc., to prevent injury in event of
seizure.
2. Observe and note any pre-convulsive patterns and communicate to caregivers.
3. Ensure staff awareness of resident’s history of seizures.
4. Document on plan of care and medical history.
© Health Dimensions Group 2008 First Aid–Seizure
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title First Aid - Suicidal
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will arrange or provide services and intervention for residents voicing and/or
displaying feelings or actions which indicate suicidal ideation in order to help them manage
these feelings and maintain their psychosocial wellbeing.
DEFINITION
Suicide: The process of purposely ending one’s own life; or the deliberate taking of one’s
own life.
Signals or Signs:
• Life circumstances that may immediately precede a suicide include a sudden change in
mood or a real or imagined loss.
• Acute mood and behavior changes may include verbal statements, sudden withdrawal,
physical displays of intentions to commit suicide, or other similar signs of depression.
PROCEDURE
1. Staff are responsible for monitoring acute mood and behavior changes which may
indicate potential suicidal ideation and for reporting these changes to their supervisor
and/or nursing supervisor for appropriate assessment and intervention.
2. In the event of an actual suicide attempt, a staff member will be assigned to remain with
the resident at all times until inpatient treatment and evaluation can be arranged.
3. If you enter resident’s room and find the resident perched on window sill, in process of
slashing their wrists, or any other attempt to harm self:
a. Remain calm.
b. Do not make sudden moves.
c. Call for help. 911 should be contacted immediately by another staff member.
d. Talk to resident and ask for sharp instrument or to walk back to bed.
e. Do not become frightened.
f. Show your concern for resident.
g. Demonstrate by your manner that you really want to help.
© Health Dimensions Group 2008 First Aid–Suicidal
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
h. If resident threatens to act if you come closer, stay where you are and encourage
resident to talk about their trouble.
i. Listen to the resident’s conversation carefully.
j. Accept the discussion of resident’s problems.
k. Offer assurance and tell resident how discouraging things might appear; then tell
resident the physician, nurse, etc., will help the resident.
l. Do not argue, disagree, or make idle promises. Keep yourself safe as well.
m. Convince the resident of your sincere desire to help.
n. Contact physician.
o. Contact family, as needed.
p. Document incident, recording exact time and events.
q. Document in the nurse’s notes signs, symptoms, and treatments.
4. When the resident is no longer considered suicidal, the facility will develop a
precautionary plan to provide ongoing monitoring and assessment of the resident’s mood
status and interventions to meet his/her needs.
© Health Dimensions Group 2008 First Aid–Suicidal
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Fluid Restriction
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A physician’s order must be obtained for fluid restriction.
PROCEDURE
1. The dietitian or designee reviews information and works with nursing for compliance
plan.
2. A resident does have a right to refuse a restriction. Document refusals and notify the
physician.
3. Document fluid intake.
4. Electrolytes are monitored as ordered by physician and, when stable, the intake should be
reviewed by the physician for continuation.
See also Hydration.
© Health Dimensions Group 2008 Fluid Restriction
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Foley Catheter - Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Proper care will be provided for the management of a Foley catheter to drain urine from the
bladder and to prevent reflux of urine back into the bladder.
PROCEDURE
1. The Foley catheter may be taped to the abdomen or inner thigh of a male and the inner
thigh of a female, if necessary (brown tubing).
2. If the resident is in bed, Foley tubing (clear) may be clipped to the bedding along the side
of the bed.
3. The Foley bag should be hooked to the metal bed frame when resident is in bed and
covered with a privacy bag.
4. A Foley bag should never be lifted above the level of the bladder.
5. The Foley bag should not be touching the floor.
6. Foley tubing should be free from kinks.
7. Note color of urine and any sediment (particles in the urine).
8. Gloves are used when emptying a Foley.
9. Collection devices are used for one resident only.
10. Perform perineal care as needed or daily.
11. Document amount, color, and the presence of sediment in the Foley bag and report to the
charge nurse or designee.
12. Record output per facility’s procedure.
© Health Dimensions Group 2008 Foley Catheter–Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title
Foley Catheter - Emptying and Measuring Urine from Drainage
Bag
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Drainage bags are emptied at least every eight hours and more frequently if urine output is in
larger amounts.
PROCEDURE
1. Wash hands.
2. Apply gloves.
3. Release drainage tube from urinary bag attachment.
a. Un-clamp tube and allow tube to drain into a clean container that is assigned for that
resident’s exclusive use.
b. Dedicating equipment for one resident’s exclusive use avoids the potential for
transfer of organisms to other residents.
4. After all urine has drained from the bag and tubing clamped, wipe drainage tube end with
alcohol.
a. Re-insert into bag attachment.
b. Disinfection (alcohol wipe) of tubing with a chemical and mechanical action will help
to prevent bacterial growth.
5. Measure urine amount, empty container, and rinse with cold water.
6. Observe and arrange drainage set-up to assure no kinks in tubing, no external pressure on
tubing, and catheter bag hanging below mattress and off the floor.
7. Report sediment, abnormal color, and odors. Tubing and catheter may need to be
changed.
8. Encourage resident to intake fluid, whenever possible.
9. Document amount of output.
10. Notify charge nurse of any changes in amount, color, and odor of resident’s urine.
© Health Dimensions Group 2008 Foley Catheter–Empyting and Measuring Urine from Drainage Bag
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Foley Catheter - Insertion
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A Foley catheter will only be inserted with a physician’s order and medical justification for
use.
PROCEDURE
1. Assemble equipment.
2. Provide privacy.
3. Explain the procedure to the resident.
4. Wash hands.
5. Apply gloves.
6. Proceed as for a regular catheterization, being careful not to contaminate equipment.
7. After inserting the Foley catheter, inject the correct amount of sterile water into the bulb,
and connect the end of the catheter into the drainage bag tubing. Use no force while
inserting the catheter.
8. Attach catheter tubing to thigh with tape or strap, unless contraindicated.
9. Remove gloves.
10. Hang the bag on the lower rung of the bed.
11. Make the resident comfortable; leave the call light within reach.
12. Wash hands.
13. Discard disposable equipment in the trash can in the utility room.
14. Render syringe unusable and dispose of properly.
15. Put soiled linen in the soiled linen container.
16. Wash hands.
17. Record the procedure, time of the insertion, and any observations on the nurse’s notes
and on the treatment sheet, as appropriate.
18. Document the necessary entry on the resident care plan. Note diagnosis for use,
monitoring for infection, and catheter care.
19. Make out the necessary charge slips, as per facility’s procedures.
© Health Dimensions Group 2008 Foley Catheter–Insertion
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
See also Catheterization of a Resident or Intermittent Catheterizations.
© Health Dimensions Group 2008 Foley Catheter–Insertion
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Foley Catheter - Irrigation
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Foley catheter irrigations are not routinely done and require a physician’s order.
PROCEDURE
1. Confirm physician’s order for irrigation.
2. Explain procedure to resident.
3. Provide privacy.
4. Wash hands.
5. Apply gloves.
6. Disconnect the catheter from the drainage tube and place a cap over the end of the
drainage tube to prevent contamination.
7. Cleanse inner tip of Foley at connection site with alcohol sponge.
8. Hold catheter over collection container, taking care not to allow the end of the catheter to
touch the container.
9. Draw ordered amount of solution at room temperature into syringe, expel air from
syringe, and insert tip into the catheter.
a. Use strict aseptic technique. Do not use too much force or pressure. Do not instill air
into the bladder.
b. Be sure that solution used for irrigation is returning.
10. Instill solution slowly.
a. Disconnect syringe from catheter and allow solution to flow into collection container.
b. If difficulty is encountered in irrigating catheter (fluid runs in under force, or not at
all), a new catheter should be introduced, if ordered by physician.
11. Reconnect catheter to tubing.
12. Remove gloves and wash hands.
13. Place disposable equipment in the trash.
14. Document the time, procedure, solution, amount used, and signature on treatment sheet.
© Health Dimensions Group 2008 Foley Catheter–Irrigation
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
15. Write and verify the date and time on bottle of irrigation when opened and discard in 24
hours or as indicated by the pharmacy.
16. Record any unusual observations in the nurse’s notes.
17. Make out necessary charge slips, per facility’s procedure.
© Health Dimensions Group 2008 Foley Catheter–Irrigation
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Foley Catheter - Removing
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A Foley catheter will be removed per physician’s orders.
PROCEDURE
1. Wash hands.
2. Apply gloves.
3. Explain procedure to resident.
4. Provide privacy.
5. Expose perineal area only.
6. Obtain any lab specimens as ordered.
7. Insert needle, if needed, into bulb opening of catheter and aspirate the water into the
syringe, or insert tip of syringe into appropriate opening of catheter and draw water off.
8. Remove the catheter.
9. Cleanse and dry the resident’s perineum.
10. Remove gloves and wash hands.
11. Leave resident with call light in reach.
12. Dispose of trash appropriately.
13. Dispose of needle properly.
14. Document in the nurse’s notes procedure, time, amount of urine, observations, and
resident reactions.
15. Make necessary notations on the resident care plan.
16. Make out necessary charge slips, if it is facility’s procedure.
17. Send any urine specimen to the lab, if ordered.
18. Place resident on a three-day bowel and bladder tracking tool to monitor urinary status.
© Health Dimensions Group 2008 Foley Catheter–Removing
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Food - Sanitary Conditions (General)
F Tag
F370, F371, F372
Quality Standard FP78, FP79, RCS42
Origination Date April 1, 2008
Revision Date
POLICY
• Food is stored, prepared, distributed, and served under sanitary conditions.
• Garbage and refuse are disposed of properly.
• Food is procured from sources approved or considered satisfactory by federal, state, or
local authorities.
© Health Dimensions Group 2008 Food–Sanitary Conditions (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Food Substitutes
F Tag
F366
Quality Standard RCS41
Origination Date April 1, 2008
Revision Date
POLICY
Substitutes of similar nutritive value are offered to residents who refuse food served.
© Health Dimensions Group 2008 Food Substitutes
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Foot Board - Bed
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A foot board may be utilized upon a physician’s order or therapist’s recommendation to
prevent foot drop, to maintain proper body alignment, and/or to promote resident comfort.
PROCEDURE
1. Assemble equipment in the resident’s room.
2. Provide privacy.
3. Wash hands.
4. Explain the procedure to the resident.
5. Remove the top linen from the bed by fan-folding it upward toward the resident’s knees,
leaving the resident’s feet exposed.
6. Cover the foot board with the draw sheet to protect the skin surface from unnecessary
irritation.
7. Properly insert the foot board on the mattress according to type of board being used.
8. Position the resident so that his/her feet are flat against the board at the foot of the bed,
with toes pointed up toward ceiling.
9. Replace the top linen over the foot board, tuck it at the foot of the bed, and miter the
corners.
10. Leave the resident comfortable with call light button in reach.
11. Wash hands.
12. When foot board is no longer in use, wash with germicidal solution, rinse and dry foot
board; then, replace the foot board to its proper storage area.
13. Record the date, time, and procedure in the nurse’s notes for application and
discontinuance of foot board.
14. Document any unusual observations or resident reactions in the nurse’s notes.
15. Make the necessary notation on the resident care plan.
16. If the foot board utilization is continuous, mark its daily presence on the treatment sheet.
© Health Dimensions Group 2008 Foot Board–Bed
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Foot Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents who require special foot care will be provided with the necessary treatment.
PROCEDURE
1. Assist resident into chair/wheelchair.
2. Wash hands.
3. Explain procedure to be done.
4. Provide privacy.
5. Remove shoes and stockings.
6. Partially fill basin with warm water, and place basin on towel near the resident’s feet.
7. Assist the resident to place his/her feet in the water.
8. Assist the resident in washing his/her feet. Soak feet, as needed, to soften nails and
calluses. Diabetic toenails should be trimmed only by a licensed professional.
9. Remove feet from basin.
10. Assist the resident with the drying of his/her feet thoroughly, especially on the bottom
and between toes.
11. Inspect feet and note any abnormalities.
12. Rub lotion well into both feet.
13. Put shoes and socks back on resident.
14. Clean and disinfect equipment.
15. Wash hands.
16. Document any abnormalities and report them to the charge nurse.
17. Notify physician, as needed, for any further follow-up with a podiatrist.
© Health Dimensions Group 2008 Foot Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Free Choice (General)
F Tag
F163
Quality Standard RCS8
Origination Date April 1, 2008
Revision Date
POLICY
A resident:
• May choose a personal attending physician;
• Is fully informed, in advance, about care and treatment and of any changes in care or
treatment that may affect the resident’s well-being; and
• Can participate in care planning and treatment or changes in care and treatment, unless
adjudged incompetent or otherwise found to be incapacitated under the laws of the State.
© Health Dimensions Group 2008 Free Choice (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Gait/Transfer Belt
F Tag
N/A
Quality Standard RCS17
Origination Date April 1, 2008
Revision Date
POLICY
Gait/transfer belts will be used to prevent injury to the employee and the resident when
transferring the resident.
PROCEDURE
1. If residents do not have personal gait belts, the employee wears a gait belt as part of their
uniform.
2. Wash hands.
3. Explain to the resident what you will be doing.
4. Apply the belt around the resident’s waist over his/her clothing, allowing enough room
between the belt and his/her clothing for a flat hand to be inserted.
5. After transferring the resident, remove the belt, place on your waist or in appropriate
storage area.
© Health Dimensions Group 2008 Gait/Transfer Belt
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Gloves, Non-Sterile
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Gloves should be worn to protect the employee from exposure to bloodborne pathogens and
other contaminants, as defined in the standard precautions.
PROCEDURE
1. Wash hands.
2. Apply gloves.
3. While wearing gloves, avoid handling personal items such as combs and pens that could
become soiled or contaminated.
4. Gloves that have become contaminated with blood or other body fluids for which
standard precautions apply are removed as soon as possible, taking care to avoid skin
contact.
5. Contaminated gloves are placed and transported in bags that prevent leakage.
6. No double-gloving.
7. Awareness of latex sensitivity should be reported to supervisor.
8. Wash hands upon removal of gloves.
© Health Dimensions Group 2008 Gloves, Non-Sterile
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Glucometer Blood Sugar Testing
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Blood sugars will be monitored for diabetic residents per physician’s orders or if, through
nursing judgment, condition warrants.
PROCEDURE
1. Wash hands.
2. Explain procedure to the resident. Set up a clean field.
3. Apply gloves.
4. Choose a finger for use.
5. Remove one strip from the container.
6. Place paper towel/Kleenex close to the resident.
7. Remove cap from skin puncture device. Wipe area with alcohol swab and allow area to
dry; or have resident wash their hands prior.
8. Puncture finger.
9. Massage finger toward nail to obtain a large drop of blood (may hold arm down).
10. Place this drop of blood on monitoring strips and place in the glucometer.
11. Apply pressure to puncture site with alcohol pad, cotton ball, or Kleenex.
12. At the end of timing, note results.
13. Dispose of puncture device in Sharps container, without recapping.
14. Dispose of blood-contaminated supplies in contaminated area according to bloodcontaminated
supply disposal procedures.
15. Clean glucometer as indicated.
16. Remove gloves.
17. Wash hands.
18. Document results in the nurse’s note/treatment sheet/medication sheet or diabetic sheet.
© Health Dimensions Group 2008 Glucometer Blood Sugar Testing
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Hair Brush and Comb Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Each resident has their own personal hairbrush and/or comb.
PROCEDURE
1. Combs and brushes are cleaned, as needed.
2. Apply non-sterile gloves, if desired.
3. Remove excessive hair from brush with comb.
4. Rinse items under hot running water.
5. Remove gloves, if applicable.
6. Place on clean dry cloth or paper towels to dry.
7. When thoroughly dry, return to resident’s bed stand.
8. Wash hands.
9. If equipment is heavily soiled, dispose of, and obtain new equipment.
© Health Dimensions Group 2008 Hair Brush and Comb Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Hair Care
F Tag
N/A
Quality Standard RCS20
Origination Date April 1, 2008
Revision Date
POLICY
Hair care will be provided to residents, as needed.
PROCEDURE
1. Explain the procedure to the resident.
2. Provide privacy.
3. Allow the resident to be as independent as possible. Encourage participation.
4. Wash hands.
5. Comb/brush the hair.
6. Comb/brush tangled, matted hair gently.
7. Barrettes, combs, ribbons, etc., may be used, if desired by the resident.
8. Remove hair from the comb and brush as needed.
9. Clean items per facility’s policy.
10. Document any changes in skin on scalp and notify charge nurse or designee.
© Health Dimensions Group 2008 Hair Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Hand Washing
F Tag
F444
Quality Standard FP56
Origination Date April 1, 2008
Revision Date
POLICY
The facility requires staff to wash their hands after each direct resident contact for which
hand-washing is indicated by accepted professional practice. Hand-washing is also conducted
as per recommendations from the CDC guidelines.
PROCEDURE
Note: Soap is the best sanitizing and cleansing agent. Sanitizer gels and liquids should be
used when soap is not available. They should not be the primary cleansing agent.
1. Turn on the faucet and regulate water temperature.
2. Wet hands and apply antiseptic soap.
3. Scrub well with soap and additional water as needed. Scrub all areas thoroughly for 10
seconds each, especially fingers and nails.
4. Do not touch any areas while cleaning hands.
5. Rinse thoroughly.
6. Dry hands with paper towel and discard.
7. Turn off faucets with a clean paper towel.
© Health Dimensions Group 2008 Hand Washing
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Hearing Aid Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents with hearing aids will be provided with assistance to care for them.
PROCEDURE
1. Explain procedure to the resident.
2. Provide privacy, as needed.
3. Wash hands.
4. Inspect hearing aid mold for any breaks or cracks.
5. Check ear mold for any wax and remove with applicator. Wipe clean with tissue.
6. Check volume control and batteries.
7. Clean and dry resident’s ear, if needed, and insert hearing aid in ear. Check for
effectiveness.
8. Discard any soiled materials.
9. Wash hands.
© Health Dimensions Group 2008 Hearing Aid Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Hospice Care
F Tag
N/A
Quality Standard RCS51
Origination Date April 1, 2008
Revision Date
POLICY
Palliative/supportive nursing care will be provided for residents and their families during the
end stages of life that enables them to participate in life choices. Hospice services will be
offered as appropriate.
PROCEDURE
1. A physician’s order will be obtained for hospice/palliative/comfort measures only if
deemed appropriate or requested by the resident/family.
2. The resident’s health care directive will be adhered to, as directed.
3. Hospice benefits will be explained to resident/family as needed/indicated.
4. Spiritual care will be provided as requested or needed.
5. Pain management will be provided as ordered by the physician.
6. Treatments and interventions focus on palliative and supportive measures that improve or
maintain quality of life to the greatest extent possible and are documented in the medical
record.
7. The resident and family participate in developing the plan of care, whenever
possible/appropriate.
8. If the resident receives hospice care, the facility’s care plan should be integrated with the
hospice agency’s plan of care.
© Health Dimensions Group 2008 Hospice Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Hydration - HDGR
F Tag
F327
Quality Standard RCS47
Origination Date April 1, 2008
Revision Date
POLICY
It is the policy of this facility to assess all patients/residents for their risk of hydration
problems at admission, quarterly, and with a significant change of condition. There is a
system for identification of those residents who require thickened liquids and/or fluid
restrictions as well as providing sufficient fluids to maintain proper hydration and health
(unless contraindicated) for all residents.
PROCEDURE
1. Fluids are encouraged for all residents unless contraindicated (for example, fluid
restriction).
2. Residents who are on thickened liquids are offered thickened fluids between meals.
3. Residents on fluid restrictions have a plan in place between Dietary and Nursing as to
how fluids are divided between the two departments.
4. Residents who require assistance to reach/pour or drink fluids are provided assistance as
needed during meals and between meals.
5. Residents are offered additional fluids during extremely hot weather.
6. Fluids are available at the bedside unless contraindicated.
7. Other strategies for providing additional fluids could include such things as:
a. Fluids provided during activities such as tea times and happy hours.
b. Fluid rounds mid-morning and late afternoon.
c. Offering fluids during and after therapy sessions.
EDUCATION
Individual risk factors for hydration problems include:
• Coma or decreased sensorium
• Uncontrolled diabetes
• Fluid restriction
• Functional impairments
• Cognitive impairments (e.g., forgetting to drink)
© Health Dimensions Group 2008 Hydration—HDGR
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
• Refusal of fluids
• Resident’s need for assistance or assistive devices
• Medication that could affect hydration status
• History of dehydration
• Overall health status
• Physical signs of dehydration such as normal skin elasticity, muscle weakness, increased
confusion, vomiting, fever, deep rapid breathing, etc.
Assessment will address the individual’s usual fluid intake pattern such as:
• Estimated daily fluids needs
• Do they consume most of their fluids during meals?
• At what time of the day do they consume the most fluids?
• What types of fluids are preferred?
• Resident’s ability to obtain fluids independently
• Resident’s ability to drink fluids independently
Care plan is developed to address risk factors for hydration problems as indicated.
Additional attention to hydration may be required during periods of acute conditions such as:
• UTI
• Fever
• Nausea/vomiting
• Diarrhea
• Flu
• Presence of signs/symptoms of dehydration such as: dry skin and mucous membranes,
cracked lips, poor skin turgor, thirst, and abnormal laboratory values (i.e., elevated
hemoglobin and hematocrit, potassium, chloride, sodium, albumin, transferring, BUN, or
urine specific gravity).
© Health Dimensions Group 2008 Hydration—HDGR
Page 2 of 2

Hydration Assessment - Sample
Date: Resident: MR#: Rm#:
1. Is resident on diuretics, laxatives, or cardiovascular medication? □ Yes □ No
2. Is resident comatose? □ Yes □ No
3. Is resident diagnosed to have dementia, Alzheimer’s, or mental retardation? □ Yes □ No
4. Did resident have diarrhea in last seven days? □ Yes □ No
5. Did resident have episodes of vomiting in last seven days? □ Yes □ No
6. Does resident have a body temperature (2.4° above normal) or 101° in the past
seven days?
□ Yes □ No
7. Is resident diagnosed to have uncontrolled diabetes? □ Yes □ No
8. Has physician placed resident on fluid restrictions? □ Yes □ No
9. Does resident require use of adaptive equipment to drink? □ Yes □ No
10. Does resident have an order for thickened liquids? □ Yes □ No
11. Is resident able to reach and drink fluids without assistance? □ Yes □ No
12. Is resident able to communicate needs? □ Yes □ No
13. Does resident refuse fluids? □ Yes □ No
14. Is resident on an IV? □ Yes □ No
15. Is resident on enteral feedings? □ Yes □ No
16. Does resident have abnormal lab results in past three months?
NA □ Yes □ No
K+ □ Yes □ No
Chloride □ Yes □ No
Carbon dioxide □ Yes □ No
Anion Gap □ Yes □ No
Glucose □ Yes □ No
BUN □ Yes □ No
Creatinine □ Yes □ No
BUN/Creat ratio □ Yes □ No
17. Does resident have dry mouth? □ Yes □ No
18. Does resident have cracked lips? □ Yes □ No
19. Does resident have sunken eyes? □ Yes □ No
20. Does resident have darkened urine? □ Yes □ No
21. Does resident have a change in skin turgor? □ Yes □ No
22. Does resident have a history of dehydration? □ Yes □ No
23. Does resident consume most of their fluids during meals? □ Yes □ No
24. What type of fluids does the resident prefer? Describe:
ASSESSMENT CONCLUSION AND RECOMMENDATION:
Based on the professional judgment of the assessor, is resident at risk for dehydration? □ Yes □ No
If yes, proceed with the following notifications:
Has physician been notified? □ Yes □ No
Has dietician been notified? □ Yes □ No
- I & O
- Regularly offer fluids
If resident is determined to be at risk for dehydration, a temporary care plan and/or
- Weekly weights
updated care plan is developed. Recommendations may including the following:
- Monitor vital signs every
shift
Nurse’s Signature:
Date:
© Health Dimensions Group 2008 Hydration Assessment - Sample
Page 1 of 1

Hydration Risk Interim Care Plan - Sample
Date: Resident: MR#: Rm#:
PROBLEM OR NEED GOAL INTERVENTION PROGRESS
Date:
At risk for fluid volume
deficit related to:
__
__
__
a. Dementia
b. Hx of refusing
fluids
a. Neuro (head
injury)
b. Decline in ADLs
c. Dependent on
staff for fluids
a. Low oral intake
b. Fluid restriction
c. Dysphasia
d. Weight loss
1. Resident will remain
free of signs and
symptoms of
dehydration through
______________
2. Resident’s signs and
symptoms of
dehydration will
subside by
______________
If checked 1-2 of the
risks:
1. Encourage resident
to drink all fluids po
2. Identify and provide
fluids of choice
3. Offer substitutions
for fluids not taken
If checked 3 or more of
the risks:
1. Initiate interventions
1-3
__
__
__
__
__
Medications:
a. Diuretics
b. Laxatives
c. Cardiovascular
Abdominal Fluid
Loss:
a. Vomiting
b. Diarrhea
c. Fever
Fecal impaction
a. Recent Hx of
dehydration
b. New dx of
dehydration
c. Infections (UTI)
Abnormal labs:
Elevated Na,
BUN, Creat, nct
(that differ from
baseline)
2. Complete a physical
assessment on
resident r/t
dehydration (VS,
skin turgor, oral
mucosa, cognitive
status, etc.)
3. Consider intake
and/or output for
resident
4. Call MD and family
© Health Dimensions Group 2008 Hydration Risk Interim Care Plan - Sample
Page 1 of 2

Hydration Risk Interim Care Plan - Sample
Date: Resident: MR#: Rm#:
Based on review of data collection from hydration assessment:
□ Resident continues to be at risk for dehydration – continue to implement CP interventions.
□ Resident continues to not be at risk for dehydration
Signature/Title:
ASSESSMENT COMPLETED BY:
Date:
Based on review of data collection from hydration assessment:
□ Resident continues to be at risk for dehydration – continue to implement CP interventions.
□ Resident continues to not be at risk for dehydration
Signature/Title:
ASSESSMENT COMPLETED BY:
Date:
Based on review of data collection from hydration assessment:
□ Resident continues to be at risk for dehydration – continue to implement CP interventions.
□ Resident continues to not be at risk for dehydration
Signature/Title:
ASSESSMENT COMPLETED BY:
Date:
Based on review of data collection from hydration assessment:
□ Resident continues to be at risk for dehydration – continue to implement CP interventions.
□ Resident continues to not be at risk for dehydration
Signature/Title:
ASSESSMENT COMPLETED BY:
Date:
© Health Dimensions Group 2008 Hydration Risk Interim Care Plan - Sample
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Hypoglycemia—HDGR
F Tag
F157, F309
Quality Standard RCS62
Origination Date April 1, 2008
Revision Date
POLICY
Residents who require insulin and/or other hypoglycemic agents will receive necessary
monitoring to identify and treat hypoglycemic episodes.
DEFINITION
Hypoglycemia is defined as a blood glucose level

Resident Care Policies and Procedures – Skilled Nursing Facility
SIGNS AND SYMPTOMS OF HYPOGLYCEMIA
Typical signs/symptoms of hypoglycemia include hunger, nervousness, shakiness,
perspiration, dizziness, and lightheadedness.
Hypoglycemia may present in the elderly with atypical symptoms such as confusion or
disorientation, drowsiness, generalized weakness, altered behavior, aggression, falls, and
hallucinations.
PROCEDURE
1. Residents with physician’s orders for insulin and/or oral hypoglycemic agents have their
blood glucose routinely monitored according to the physician’s order.
2. Glucose monitoring, meal plan, treatment with oral antidiabetic agents and/or insulin are
clearly documented in the physician’s orders as indicated for diabetic residents.
3. Diabetic residents are provided a regular diet that contains consistent amounts of
carbohydrates at meals and snacks or as ordered by physician.
4. The nutritional status of diabetic residents is regularly reviewed and monitored by the
dietitian.
5. Orders for blood glucose monitoring include parameters for physician notification of
finger stick results. The facility may have standing orders regarding parameters for
physician notification of blood glucose readings which are in effect in absence of a
specific individual parameter.
6. In the absence of individual parameters, it is recommended that the physician is called as
soon as possible when the resident has a blood glucose value

Resident Care Policies and Procedures – Skilled Nursing Facility
b. Wait 15 minutes and recheck the blood sugar. If the resident continues to have
hypoglycemic symptoms or has a blood sugar level below 70mg/dL, repeat the 15
gram carbohydrate oral feeding.
c. Recheck the blood sugar every 15 minutes and repeat the 15 gram oral feeding until
there are no longer symptoms or until the blood sugar level rises above 70mg/dL.
d. If it will be an hour or more before the next meal, offer a light snack.
9. If the resident is unconscious/unable to take food/fluids by mouth, follow emergency
protocol including calling 911 and administration of glucagon.
10. Notify family of the event, if indicated. Notify dietary.
© Health Dimensions Group 2008 Hypoglycemia—HDGR
Page 3 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Immunization: Influenza - HDGR
F Tag
F334
Quality Standard FP51b, HR35, HR36
Origination Date April 1, 2008
Revision Date
POLICY
All residents are encouraged to obtain the influenza immunization unless contraindicated.
There is a system to offer, provide, and document influenza immunizations to all residents.
PROCEDURE
1. Ensure that the resident has a physician’s order for the immunization.
2. Check all allergies on the chart to eggs and egg products. Verify with legal guardian or
the resident.
3. Provide educational materials to the resident and legal representative regarding the
benefits and potential risks of the immunization. Notify the resident and legal
representative they have a right to refuse the immunization.
4. Influenza immunization is offered and given annually between October 1 and March 31
unless it is documented that this is contraindicated due to medical issues, allergies, etc.
5. Consent for the immunization, including resident education regarding the risks and
benefits of the immunization, is documented.
6. The medication administration record should reflect that the resident either received or
refused the immunization. This should also be recorded on the resident’s immunization
record.
7. If immunization provided, monitor resident’s response to vaccination, such as
temperature, s/s redness, and swelling at site of injection. Any adverse reactions should
be reported to the physician.
© Health Dimensions Group 2008 Immunization: Influenza - HDGR
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Immunizations: Pnuemococal Vaccine - HDGR
F Tag
F334
Quality Standard FP51b
Origination Date April 1, 2008
Revision Date
POLICY
All residents are encouraged to obtain the pneumococcal vaccine unless contraindicated.
There is a system to assure that all eligible residents are offered the pneumococcal vaccine at
the time of admission.
PROCEDURE
1. Upon admission, each resident is offered the pneumococcal vaccination. Unless
contraindicated, this will be documented in the resident’s medical record.
2. The resident or resident’s legal representative will receive education regarding the
benefits and potential side effects of the immunization. Documentation that the resident
or resident’s legal representative received this information will be placed in the resident’s
medical record.
3. Prior to administration of the vaccine, the resident or resident’s legal representative will
sign a consent form. The signed consent form will be placed in the resident’s medical
record.
4. Unless contraindicated, the pneumococcal vaccine will be administered and documented
on the MAR and/or the resident’s immunization record in the medical record.
5. If the resident is offered the vaccine and refuses, education of risks and benefits will be
reviewed with the resident; if the resident still refuses, the refusal will be documented in
the medical record. A care plan for “Refusal of Immunizations” will be developed and
reviewed at least quarterly by the interdisciplinary team (IDT).
6. If the resident/responsible party indicates the vaccine has already been administered, the
date of administration, month and/or year, will be verified and recorded on the
immunization record.
7. When the pneumococcal vaccination process is complete, the nurse will document
completion on the admission check-off list.
8. Orders to administer the vaccine, unless contraindicated, will be reflected on the facility’s
standing house orders.
9. No later than 14 days after admission, the MDS coordinator will verify administration of
the vaccine. If the resident has refused the vaccine, or the vaccine is contraindicated at
this time, a note will be made in the medical record and a copy of the education received
will be part of the medical record.
© Health Dimensions Group 2008 Immunizations–Pnuemococal Vaccine–HDGR
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Incompetent Resident
F Tag
F152
Quality Standard FP59
Origination Date April 1, 2008
Revision Date
POLICY
In the case of a resident who is legally adjudged incompetent, the rights of the resident are
exercised by the person appointed under state law to act as guardian on the resident’s behalf.
PROCEDURE
1. The medical record provides information regarding the resident’s legal guardian and how
the facility and guardian interact on behalf of the rights of the resident adjudged
incompetent. A copy of the legal document establishing guardianship is on file in the
facility.
2. If a resident has been adjudged to be incompetent, resident rights and responsibilities are
explained and given to his/her guardian by Social Services or designee.
3. The guardian documents on the verification form that the resident’s rights have been
explained. This form is maintained in the resident’s medical record.
4. For residents incapable of understanding their rights, documentation of such is made by
the physician.
See also Adjudicated Incompetent Resident
© Health Dimensions Group 2008 Incompetent Resident
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Infection Control (General)
F Tag
F441, F442, F443
Quality Standard FP8, FP35, FP51, FP51b, FP53, FP54, FP55, FP56, HR36
Origination Date April 1, 2008
Revision Date
POLICY
An infection control program is designed and implemented in order to provide a safe,
sanitary, and comfortable environment and to help prevent the development and transmission
of disease and infection.
Infection Control Program
• Investigates, controls, and prevents infections in the facility;
• Determines the procedures, such as isolation, to be applied to an individual resident;
• Maintains a record of incidents and corrective actions related to infections; and
• Prohibits employees with a communicable disease or infected skin lesions from direct
contact with residents or their food, if direct contact will transmit the disease.
Preventing the Spread of Infection
When the Infection Control Program determines a resident needs isolation to prevent the
spread of infection, the resident is isolated.
See also, Infection Control Manual
© Health Dimensions Group 2008 Infection Control (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Injection of Medication
F Tag
N/A
Quality Standard RCS33
Origination Date April 1, 2008
Revision Date
POLICY
Medications given by injection will be physician ordered and will be administered following
professional standards of practice.
PROCEDURE
1. Check medication record to medication to be given, per standards of practice.
2. Assemble needed equipment.
3. Wash hands.
4. Apply gloves.
5. For solution in a bottle:
a. Remove cap on the bottle, to expose rubber seal.
b. Cleanse rubber stopper of medication vial with alcohol sponge.
c. Remove cover from needle. Pull air into syringe to equal volume of medication to be
given. Insert needle through rubber top, and inject air.
d. Invert bottle. Draw exact amount of medication. Withdraw needle.
e. Remove any remaining air from syringe by holding it and needle upright. Tap barrel
to dislodge air bubbles.
6. For solution in an ampoule:
a. Shake or lightly tap ampoule to force all solution out of tip and break tip off.
b. Remove the cap from the syringe.
c. Insert needle into solution without touching the edges of ampoule; draw up solution
into syringe.
d. Expel any air.
7. Cap the syringe.
8. Clean area.
9. Remove gloves.
10. Wash hands.
11. Carry medicine sheet, or verify prior to administering syringe
© Health Dimensions Group 2008 Injection of Medication
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
12. Identify resident.
13. Explain the procedure to the resident.
14. Provide privacy.
15. Position resident for injection.
16. Wash hands and apply non-sterile gloves.
17. Clean area for injection from center outward with alcohol sponge.
18. Expel all air from syringe so solution reaches point of needle, if needed.
19. Insert needle quickly at 90 degrees for injection or as required.
20. Withdraw plunger slightly and if no blood appears in syringe, inject slowly. If blood is
obtained, remove, change needle and choose another site and repeat procedure.
21. Remove needle. Massage part gently with alcohol sponge to hasten absorption and
prevent bleeding.
22. Band-Aid may be applied.
23. Remove gloves.
24. Wash hands.
25. Dispose of syringe and needle properly in the Sharps container. Do not recap needle;
slide safety lock, if applicable.
26. Wash hands.
27. Leave the resident comfortable, with the call light in reach.
28. Sign off treatment on treatment/medication sheet and note site used.
29. Document in the nurse’s notes any unusual reactions or observations.
© Health Dimensions Group 2008 Injection of Medication
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title In-Service Programs (General)
F Tag
F497
Quality Standard HR20
Origination Date April 1, 2008
Revision Date
POLICY
An ongoing, planned education program is conducted for the development and improvement
of necessary skills and knowledge for all facility personnel. Training may include, but is not
limited to:
• Accident prevention and safety measures;
• Choking prevention and intervention;
• Confidentiality of resident information;
• Fire prevention and safety;
• Interpersonal relationships and communications skills;
• Prevention and control of infections;
• Preservation of resident dignity, including provisions for privacy;
• Problems and needs of the aged, chronically ill, acutely ill, and disabled resident;
• Resident rights;
• Restraints; and
• Signs and symptoms of cardiopulmonary distress:
- All licensed nurses are trained in cardiopulmonary resuscitation, if facility policy
- Each nursing assistant attends a minimum of 12 documented hours per year of inservice
education programs. Such programs may include, but are not limited to:
i. Activities programs;
ii. Bladder and bowel training and management;
iii. Disaster preparedness;
iv. Emergency procedures for the relief of choking;
v. Environmental safety including fire and accident prevention;
vi. Improving skills in observation, reporting, recording, and maintaining
confidentiality of resident information;
vii. Infection control;
viii. Maintenance of healthy skin, including prevention of skin breakdown, body
positioning, and range of motion;
© Health Dimensions Group 2008 In-Service Programs (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
ix. Nursing care relevant to body systems including, but not limited to, fractures,
diabetes, cardiac disorders, brain syndrome, cerebrovascular accidents, arthritis,
and pulmonary disorders;
x. Nutritional need of residents and related nursing interventions;
xi. Oral hygiene;
xii. Psychosocial aspects of aging and/or chronic illness as relevant to the
individual, family, and community;
xiii. Resident care elements including planning and organizing work while
individualizing resident care, measuring blood pressure, and administering nonmedicated
enemas;
xiv. Resident’s rights;
xv. Signs, symptoms, and probable causes of resident distress with procedures to be
followed for alleviating distress;
xvi. Use of adaptive equipment relevant to nutrition and physical dysfunction;
xvii. Working with residents who have special problems such as blindness, deafness,
confusion, or communication disabilities; and
xviii. Working with the dying resident and the family.
Each employee is responsible for attending the minimum required hours and the required
programs.
© Health Dimensions Group 2008 In-Service Programs (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Insulin Administration
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Medications given by injection will be physician ordered and will be administered following
professional standards of practice by a licensed professional.
PROCEDURE
1. Check the physician’s order to make sure of the correct type, dosage, and time of
administration.
2. Check blood sugars, as needed or ordered.
3. Wash hands.
4. Roll the vial between palms of hands to mix solution, as needed.
5. Utilizing the medication sheet, check the label of the medication. Make sure expiration
date on vial has not passed.
6. Cleanse the rubber cap of the insulin vial with an alcohol wipe.
7. Withdraw the piston of the syringe to the mark which indicates the desired dose, and
inject air into vial.
8. Draw the insulin slowly until the correct dose is measured, making sure there are no air
bubbles in the syringe.
9. Return the vial of insulin to the refrigerator, if indicated, or to medication cart.
10. Replace the needle cover over the needle. (This is to prevent contamination of the needle
when transporting it to the resident.)
11. Identify the resident verbally and by looking at the resident’s identification band, if
applicable, or resident’s picture.
12. Explain procedure to resident.
13. Provide privacy.
14. Wash hands.
15. Apply non-sterile gloves.
16. Expose the area of injection. Vary the sites of injection each time. Utilize the arms,
thighs, and lower abdomen.
17. Cleanse the area with the alcohol wipe and administer the insulin at a 90 degree angle.
© Health Dimensions Group 2008 Insulin Administration
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
18. Wipe again with alcohol, as needed.
19. Dispose of syringe and needle properly in the Sharps container. Do not recap needle;
slide safety lock, if applicable.
20. Remove gloves.
21. Wash hands.
22. Leave the resident comfortable, with the call light in reach.
23. Document the date, time, type of, strength, and dosage of insulin, and site of injection on
the medication sheet.
24. Document in the nurse’s notes any unusual observations and resident reaction.
© Health Dimensions Group 2008 Insulin Administration
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Insulin Storage
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Insulin will be properly stored to maintain potency of insulin.
PROCEDURE
1. Prior to drawing insulin, note the date the vial was opened. This date is marked on the
box or the insulin label.
2. When opening a new vial of insulin, date either the box or the vial’s label with the date
the insulin vial was opened.
3. All expired insulin is disposed of according to manufacturer’s guidelines or pharmacy
recommendations.
© Health Dimensions Group 2008 Insulin Storage
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Intravenous Fluids (IV) (General)
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
EDUCATION
This procedure is included for general knowledge. Please refer to either an IV facility policy
manual or the pharmaceutical manual for specific information.
1. Explain the procedure to the resident. Ask if the resident is right- or left-handed, and try
to avoid that side of the body (arm).
2. Provide privacy.
3. Wash hands.
4. Remove outer cover or cap from IV bottle or bag. Do not use solution if seal is broken.
5. Label bottle with date and time started. Note with vertical tape the flow rate.
6. Observing sterile technique, open the sterile tubing and insert drip chamber into
bottle/bag. Make sure the flow clamp is closed or off.
7. Invert bottle/bag on IV pole. Remove covering over outlet at resident end.
8. Turn control to allow fluid to flow. Squeeze drip chamber so it becomes 50% full. Allow
fluid to flow out end and then turn off and recap.
9. Select site and apply tourniquet above site of infusion.
10. Apply gloves.
11. Palpate vein to be used.
12. Encourage resident to make a fist to increase visualization of a vein.
13. Disinfect site with antiseptic swab. Swab in circles beginning at the site of insertion
outward.
14. Hold the catheter to be inserted at a 45 degree angle with the bevel up, and insert through
the skin.
15. When blood appears in the tubing, uncap IV tubing end and insert into catheter end.
16. Release tourniquet.
17. Open IV fluid gauge and allow fluid to run for 10-15 seconds.
18. Secure IV site with supplies in kit or with gauze and tape. Allow a loop of tubing to
permit flexibility.
© Health Dimensions Group 2008 Intravenous Fluids (IV) (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
19. Remove gloves.
20. Insert tubing through pump and set at rate.
21. Position resident with call light within reach.
22. Wash hands.
23. Check resident and flow rate at frequent intervals.
To Discontinue an IV:
1. Wash hands.
2. Explain the procedure to the resident.
3. Turn off pump and flow clamp.
4. Apply gloves.
5. Remove tape and dressing from the IV site.
6. Grasp catheter and pull back at a 45 degree angle.
7. Apply pressure to decrease bleeding for 30-45 seconds.
8. When bleeding has stopped, apply Band-Aid.
9. Remove gloves and dispose of all items as per universal precautions.
10. Wash hands.
11. Note in nurse’s notes, the fluid started, where, flow rate, amount absorbed, and time.
12. If treatment was discontinued, note site, time, and reason why.
13. Note any unusual findings in nurse’s notes.
14. Note amount infused on intake and output sheets, if applicable.
See also Pharmaceutical IV Manual for specific policies and procedures.
© Health Dimensions Group 2008 Intravenous Fluids (IV) (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Irrigating Solutions
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Irrigating solutions are to be used in accordance with their labeled directions for storage, use,
and expiration.
PROCEDURE
1. All bottles of irrigation solutions, when opened, are to be labeled with the date and time
opened.
2. Irrigating solutions which have been prepared by the pharmacy are to be labeled with an
expiration date and be used according to specific directions provided by the pharmacy.
Many of these will require refrigeration in the medication refrigerator.
3. Any irrigating solution prepared within the facility expires within 24–48 hours and must
be disposed of at that time. Follow solution instructions when applicable.
4. When expired, the unused portion of irrigation solution is to be disposed of by pouring
down the drain or toilet/hopper.
© Health Dimensions Group 2008 Irrigating Solutions
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title K Pad - Aqua
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
An Aqua K pad may be used with a physician’s order to provide heat at a constant
temperature for an extended period of time, to stimulate circulation, and to relieve
inflammation.
PROCEDURE
1. Explain the procedure to the resident.
2. Provide privacy.
3. Assemble equipment at the resident’s bedside:
a. Connect the tubing to the pump.
b. Fill the container with distilled water to the designated level on the container.
c. Screw on the top.
d. Loosen the cap one quarter of a turn to allow for proper functioning.
e. Connect the plug into the electrical socket. Aqua K gauge setting is not to exceed
105 degrees Fahrenheit, unless so ordered by the physician. The temperature
gauge is to be set only by the charge nurse.
4. Wash hands.
5. Expose the area of application.
6. Cover the body area with a towel to prevent trauma to skin.
7. Place the Aqua K pad over the towel to prevent trauma to tissue.
8. Secure the pad over the body area with an additional towel and wrap securely. Do not
constrict circulation. No pins are to be used on the Aqua K pad.
9. Turn the pump switch to "ON".
10. Check the condition of the skin and equipment at 30 minute intervals to insure proper
functioning to prevent burning and to maintain proper water level.
11. Leave the resident comfortable with call light button in reach.
12. Wash hands.
© Health Dimensions Group 2008 K Pad–Aqua
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
13. When the Aqua K pad is discontinued:
a. Remove the plug from the electrical socket.
b. Empty the water container.
c. Wipe off all parts of the equipment.
14. When the Aqua K pad is discontinued, clean all parts with disinfectant solution, dry, and
return to the proper storage area.
15. Document in the nurse’s notes the date, time, procedure, observations, and resident
reactions.
16. Sign off treatment on treatment sheet.
© Health Dimensions Group 2008 K Pad–Aqua
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Labeling Resident Clothing and Personal Items
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to label and/or identify resident’s belongings upon admission, and as
able, throughout their stay.
© Health Dimensions Group 2008 Labeling Resident Clothing and Personal Items
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Laboratory Results - Reporting
F Tag
F505
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All examination results, whether abnormal, normal or stat, are telephoned, faxed, or
otherwise promptly and reliably transmitted to the facility by the laboratory.
Upon receiving the information, the charge nurse or designee verbally notifies the physician
by phone; then transmits, via fax to the physician, all laboratory results as indicated by the
clinic policy. This notification is documented in the nurse’s notes and/or on the laboratory
data sheets.
© Health Dimensions Group 2008 Laboratory Results–Reporting
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Laboratory Services
F Tag
F502, F503, F504, F505, F506, F507
Quality Standard RCS2
Origination Date April 1, 2008
Revision Date
POLICY
Laboratory services are provided to meet the needs of the residents. The facility monitors and
maintains the quality and timeliness of the services.
If the facility provides its own laboratory services, the services meet the applicable
requirements for approved laboratories.
If the facility provides blood bank and transfusion services, it meets the applicable
requirements for such laboratories.
If the facility does not provide laboratory services on site, it has an agreement to obtain these
services from a laboratory that meets the applicable requirements.
If the laboratory chooses to refer specimens for testing to another laboratory, the referral
laboratory shall be certified in the appropriate specialties and subspecialties services in
accordance with the requirements.
The facility:
• Provides or obtains laboratory services only when ordered by the attending physician;
• Promptly notifies the attending physician of the findings;
• Assists the resident in making transportation arrangements to and from the source of
service, if the resident needs assistance; and
• Files in the resident’s clinical record laboratory reports that are dated and contain the
name and address of the testing laboratory.
© Health Dimensions Group 2008 Laboratory Services
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Leaving the Facility - Resident (LOA)
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
When a resident leaves the facility, it will be documented as to when the resident left, with
whom, and the expected time of return.
PROCEDURE
1. A physician order is required for a resident to leave the facility.
2. The resident or responsible party should notify the charge nurse or designee when they
are leaving and sign the sign-in/out sheet.
3. The nurse logs in the nurse’s note when the resident left, with whom, any medications
that were sent with the resident or other information sent, and expected time of return.
© Health Dimensions Group 2008 Leaving the Facility–Resident (LOA)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Lift - Sit to Stand
F Tag
N/A
Quality Standard RCS17
Origination Date April 1, 2008
Revision Date
EDUCATION
This procedure is for illustration only. Refer to instructions for the facility equipment to be
used. Staff must be trained in lift use and safety precautions.
PROCEDURE
1. Obtain correct lift and sling as specified in the resident’s care plan.
2. Check the lift and sling condition and working order. Do not use a lift or sling that is not
in good working order or damaged.
3. Introduce self to the resident.
4. Wash hands.
5. If the resident is in bed, bring resident to side of the bed, with correct bed height adjusted,
as needed.
6. Ensure the resident is wearing shoes and socks.
7. Place feet on foot area of lift.
8. Place padded sling around the resident and secure just above the resident’s waist.
9. Ask the resident to grab the bar area on the lift.
10. Lift the resident to a full standing position.
11. If the resident is unable to hold themselves up, lower the resident back to the bed. This
may/may not be the appropriate lift. Assure resident’s safety. Inform charge nurse or
designee to re-evaluate.
12. Follow equipment guidelines for maintenance reviews and cleaning.
© Health Dimensions Group 2008 Lift - Sit to Stand
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Lift - Total Body/Maxi Lift
F Tag
N/A
Quality Standard RCS17
Origination Date April 1, 2008
Revision Date
EDUCATION
This procedure is for illustration only. Refer to instructions for the facility equipment to be
used. Staff must be trained in lift use and safety precautions.
PROCEDURE
1. Obtain correct lift and sling as specified in the care plan.
2. Check the lift and sling condition and working order. Do not use a lift or sling that is not
in good working order or is damaged.
3. Explain procedure to the resident.
4. Provide privacy.
5. Wash hands.
6. Roll resident on his/her side away from you in bed.
7. Place narrow part of sling just above the lower part of the resident’s back.
8. Roll resident toward you and position sling comfortably.
9. Elevate the head of the bed to facilitate hook-up.
10. Move lift to the bedside with the base under the bed. Attach "S" hooks of the lift to the
loops on the seat hanger.
11. Attach the ends of the lift to the swivel bar hooks.
12. Close release valve by turning the knob to the right. Use gentle pressure until valve is
closed. If electric, push up/down controls as needed.
13. Keep resident’s arms inside the sling.
14. Position the wheelchair and lock brakes.
15. Swing resident’s feet off the bed.
16. When resident has cleared the bed, grasp bar and move to chair.
17. Turn release valve slowly to the left. Push gently on knees as the resident is being
lowered into the chair.
18. When resident is seated, open release valve approximately two turns and press down;
remove sling.
© Health Dimensions Group 2008 Lift–Total Body/Maxi Lift
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
19. Position resident with call light within reach.
20. Return lift to storage site.
21. Reverse the procedure when moving the resident from chair to bed.
© Health Dimensions Group 2008 Lift–Total Body/Maxi Lift
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Linens - Handling
F Tag
F445
Quality Standard FP49
Origination Date April 1, 2008
Revision Date
POLICY
When handling, storing, processing, and transporting linens, facility personnel use
procedures designed to prevent the spread of infection.
PROCEDURE
1. Wash hands.
2. Apply gloves.
3. Soiled linen is immediately removed from the resident’s room and taken to the
laundry/utility room.
a. If blood is present, transport and clean as per OSHA guidelines.
b. Rinse linen in cold running tap water, if needed.
c. Rinse, flush residue, and wring out excess moisture.
4. Take soiled linen container/bag to the laundry room when full.
5. Dirty laundry should not be held close to a person’s body.
6. Hands are washed after handling dirty laundry and prior to handling clean laundry.
7. Dirty laundry is sorted in laundry room.
© Health Dimensions Group 2008 Linens–Handling
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Lost Clothing and Personal Items
F Tag
N/A
Quality Standard FP38
Origination Date April 1, 2008
Revision Date
POLICY
The facility will implement a system to prevent, as much as possible, lost resident clothing
and personal items.
Whenever a resident/family reports lost clothing or personal items, the facility will conduct
an investigation for the items and report findings to all concerned parties.
© Health Dimensions Group 2008 Lost Clothing and Personal Items
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Married Couples
F Tag
F175
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The resident has the right to share a room with his or her spouse when married residents live
in the same facility and both spouses consent to the arrangement.
© Health Dimensions Group 2008 Married Couples
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Mattresses - Specialty
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Specialty mattress may include various types which help protect residents at risk of skin
breakdown.
PROCEDURE
1. Wash hands.
2. Provide privacy.
3. Explain procedure to resident.
4. Remove resident completely from bed.
5. Place mattress on bed surface as indicated in the following procedures.
6. Document on the resident’s care plan the type of mattress in use.
Air Mattress
1. Apply deflated mattress over bed mattress according to the specific directions of brand
used.
2. Position tubing around corners and secure to prevent disconnection.
3. Place pump cabinet on floor underneath bed.
4. Attach connective tubing from mattress to inflation pump.
5. Connect to power and turn on according to directions for specific brand.
6. Allow air chambers of mattress to inflate fully.
7. Cover mattress with cover provided according to policy of home.
8. Remake bed; drawsheets should be tucked in.
9. Avoid wrinkles underneath resident.
Flotation Pad/Mattress
1. Remove bed mattress and store appropriately.
2. Place support for flotation pad on bed.
3. Place flotation pad in center of cut out portion of support frame.
4. Remake bed, being careful to cover entire frame with bottom sheet.
© Health Dimensions Group 2008 Mattresses - Specialty
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Water Mattress
1. Apply empty water mattress to bed.
2. Bring water source such as hose or water pump reservoir to bedside or take bed to water
source.
3. Begin filling mattress with water. Check closely for leaks or other problems. If no leaks
present, continue to fill until all chambers are full and will support up to whatever limit
specific mattress instructions contain.
4. Make bed, per specific mattress instructions.
Water/Gel Mattress
1. Apply empty water/gel mattress over bed mattress.
2. Be sure gel is placed in mattress according to manufacturer’s instructions.
3. Attach to water source and fill with water according to manufacturer’s instructions.
4. Make bed, per specific mattress instructions.
© Health Dimensions Group 2008 Mattresses - Specialty
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Meals - Frequency
F Tag
F368
Quality Standard RCS41, RCS42, RCS 43, RCS44, RCS55
Origination Date April 1, 2008
Revision Date
POLICY
At least three meals are served each day at fixed and regularly scheduled hours unless the
facility has a special dining meal schedule (follow schedule). No more than 14 hours are
permitted to elapse between the evening meal and the following morning’s breakfast.
Between meals, nourishments are always available to all residents except when specifically
contraindicated by the attending physician.
A snack is offered to all residents at bedtime.
The facility’s meal schedule is:
• Breakfast (approximate time)
• Lunch (approximate time)
• Dinner (approximate time)
© Health Dimensions Group 2008 Meals–Frequency
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Measuring Height
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will accurately measure a resident’s height, as best able.
PROCEDURE
1. Resident Bedridden:
a. Wash hands.
b. Ensure privacy.
c. Explain procedure to the resident.
d. Position the resident lying flat in bed.
e. Extend a tape measure along side the resident from the top of their head to their feet.
f. Add up inches and convert into feet and inches.
g. Record height in resident’s medical record.
2. Stand Up Scale:
a. Have resident stand straight on the scale as though you were going to weigh them.
b. Extend arm of height bar above resident’s head.
c. Extend arm of bar over the resident’s head.
d. Lower the arm of the bar until it touches the top of the resident’s head (push down on
hair). Bar should be parallel to the floor and not tilted.
e. Note height in inches and convert to feet and inches.
f. Record height in resident’s medical record.
3. Wall Markings:
a. Bring resident to marked area on wall.
b. Remove shoes.
c. Have them stand straight with back against the wall markings.
d. Note height in inches and convert into feet and inches.
e. Record height in resident’s medical record.
© Health Dimensions Group 2008 Measuring Height
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Measuring Weight
F Tag
N/A
Quality Standard RCS16
Origination Date April 1, 2008
Revision Date
POLICY
The facility will obtain an accurate recording of a resident’s weight.
PROCEDURE
1. Wash hands.
2. Assemble equipment.
3. Explain procedure to the resident.
4. Balance scale to be used (balanced on 0).
Floor Scale (regular or digital):
1. Assist resident to stand on scale. Ask resident not to hold on to scale.
2. Adjust weights until bar is balanced. With digital scale wait until the numbers stop
fluctuating.
3. Assist resident to step off of the scale.
4. Record weight.
Chair Scale:
1. Fold foot rest up on wheelchair to prevent injury.
2. Assist resident into chair.
3. Fold floor rest down and place resident’s feet on it.
4. Adjust weights until bar balances.
5. Read and record weight.
6. Remove resident’s feet from foot rest.
7. Lift foot rest.
8. Assist resident from chair.
© Health Dimensions Group 2008 Measuring Weight
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Hoyer Lift Scale and Whirlpool Stretcher Scale:
1. Follow procedure for getting resident into lift.
2. Raise resident safely off bed.
3. Read weight and record.
4. Replace resident in bed and remove lift.
Wheelchair Scale (regular or digital):
1. Use wheelchair which has been weighed and specifically used for weights.
2. Transfer resident to wheelchair.
3. Adjust weights until bar balances or digital reading remains constant.
4. Note reading and record.
5. Assist the resident back to own wheelchair.
6. Subtract wheelchair weight from total weight; the difference will be the resident’s
weight.
7. Report weight to charge nurse or designee.
© Health Dimensions Group 2008 Measuring Weight
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medicaid Benefits - How to Apply
F Tag
F156
Quality Standard
Origination Date April 1, 2008
Revision Date
POLICY
This facility:
1. Prominently displays directions describing:
a. The application for and use of Medicare and Medicaid benefits; and
b. Receipt of refunds for previous payments covered by such benefits.
2. Provides to residents and admission applicants oral and written information and
directions describing:
a. The application for and use of Medicare and Medicaid benefits; and
b. Receipt of refunds for previous payments covered by such benefits.
3. For each resident entitled to Medicaid benefits, the facility informs, in writing, at the time
of admission or when the resident becomes eligible for Medicaid, of:
a. The items and services that are included in nursing facility services under the state
plan and for which the resident may not be charged;
b. Those other times and services that the facility offers and for which the resident may
be charged, and the amount of charges for those services; and
c. Changes made to the items and services specified.
© Health Dimensions Group 2008 Medical Benefits–How to Apply
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medical Director and Responsibilities
F Tag
F501
Quality Standard FP17, FP18
Origination Date April 1, 2008
Revision Date
POLICY
The facility designates a physician to serve as medical director. The medical director is
responsible for:
• Implementation of resident care policies.
• The coordination of medical care in the facility.
Additional support includes:
1. Assisting in development of staff education programs.
2. Communicating to the medical staff additions and revisions to policies, rules, and
regulations.
3. Conducting periodic reviews of resident medical records and interviewing residents
concerning quality of care.
4. Developing written policies, procedures, rules, and regulations; and the review and
approval of same.
5. Providing recommendations on the admission and discharge of residents.
6. Participating in the Medicare compliance.
7. Recommending corrective actions to administration when appropriate.
8. Recommending resident-specific interventions to the interdisciplinary care team.
9. Reviewing incident reports.
10. Reviewing pertinent information concerning health status of employees.
Medical Director
Name:
Address:
Phone number:
© Health Dimensions Group 2008 Medical Director and Responsibilities
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medical Record Inspection (General)
F Tag
F153
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The resident has the right to inspect and purchase photocopies of all records pertaining to
his/her records.
• A request for inspection of medical records is made in writing.
• The resident is charged prevailing community rates for copies made of the medical
record. The resident is informed of this charge when initiating the request.
See Protected Health Information, Resident’s Right to Access, HIPAA
© Health Dimensions Group 2008 Medical Record Inspection (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medicare Compliance Triple Check/Pre-Billing Audit - HDGR
F Tag
N/A
Quality Standard FP16, HR41
Origination Date April 1, 2008
Revision Date
POLICY
The following policy is used to provide a structure for developing and maintaining a
compliance program related to clinical reimbursement. It contains specifics about when and
how often to perform the audits associated with a compliance program as well as outlining
who might participate in the audits and why.
The objective is to establish and monitor a compliance program and accomplish the
following:
• Comply with Medicare regulations associated with reimbursement and its related
recordkeeping.
• Ensure that regular compliance audits are completed and the information obtained in
those audits is used to educate and monitor further reimbursement and compliance
efforts.
• Provide your reimbursement compliance monitoring team with tools essential for
maintaining an effective clinical reimbursement compliance plan.
• The reimbursement compliance monitoring team will include representatives from the
following disciplines: Minimum Data Set (MDS) completion, billing, medical records,
and therapy.
PROCEDURE
The steps to conduct an interdisciplinary team audit prior to submitting the Medicare bill are
included in this procedure. Forms needed: Pre-screening form, Triple Check/Pre-Billing
audit, Medicare Tracking log.
Pre-screening Process
1. The admissions team will initiate the pre-screening form (first line of compliance).
2. All look-back information (LBI) must have as much detail as possible.
a. Location of data
b. Dose
c. Name
(Example: IV NaCL at 100 cc per hour- on June 1, 2007, in MAR)
© Health Dimensions Group 2008 Medicare Compliance Triple Check/Pre-Billing Audit - HDGR
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
3. After admission, supporting documentation for all LBI should be copied and attached to
back of pre-screening form by admissions or MDS coordinator and kept as part of
medical record.
a. Medicare team meetings will be held to assure appropriate RUG levels are obtained.
MDS coordinator, in cooperation with Medicare team, will direct and lead discussion.
b. Medicare team members should include the following:
i. MDS and appropriate unit nurses
ii.
iii.
iv.
Dietary
Therapy
Social Services
v. Billing
vi.
Medical Records
vii. Activities
viii. Administrator
ix.
DON
4. Pre-screening form to be given MDS coordinator by admissions coordinator.
5. All items checked on pre-screening form must be verified by MDS coordinator.
6. LBI will be coded on the Medicare tracking log with dates by MDS coordinator prior to
setting the assessment reference date (ARD) and establishing the appropriate resource
utilization group (RUG) level.
7. Once the ARD has been set, the Medicare tracking log will be updated by the MDS
coordinator and confirmed by the Medicare team.
8. After the above process has been completed, the ARD should not be changed without
notifying Medicare team.
9. Grace days should only be used when necessary.
10. The MDS coordinator and a representative from therapy will meet daily when possible to
review all new admissions and set ARDs based on the pre-screening information.
MDS Completion
1. The MDS coordinator/completer will review and document all LBI on the MDS. This
will include, but is not limited to IV fluids and amounts, as well as all other nursing areas
prior to signing the MDS as complete.
2. The MDS coordinator will verify all LBI and place a copy with the prescreening form,
and it will be kept as part of the medical record and brought to the pre-billing audit
(PBA).
© Health Dimensions Group 2008 Medicare Compliance Triple Check/Pre-Billing Audit - HDGR
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
3. Any items coded on the MDS will have supporting documentation in the medical record
and the coder will sign, date, and list sections completed on front page of MDS.
Triple Check/Pre-Billing Audit
1. Continue with pre-billing audit that includes comparing days and minutes of therapy,
diagnosis, RUG levels, the medical record, therapy logs, MDS, and the UB04.
2. The new pre-billing process will now include verifying supporting documentation of IVF
and IV medications:
a. Medical records representative to provide and verify diagnosis codes and
certification/re-certifications.
b. Billing representative will verify logs and UB04.
c. MDS coordinator will verify Look back information, ARD, appropriate RUGS and
ADLs.
d. Therapy representative will verify logs with days and minutes.
© Health Dimensions Group 2008 Medicare Compliance Triple Check/Pre-Billing Audit - HDGR
Page 3 of 3

Medicare Triple Check/Pre-Billing Audit - HDGR
Resident Name & Medical
Record Number
Medical Records
Certification
Medical Dx Codes
Nursing
IV Meds
IV Fluids
Treatment
ADL
RUG Score
Therapy
OMRA
ARD Date
Discipline (PT,OT,ST)
Therapy Minutes
Tx Code
Business Office
Insurance Card
Obtained
UB 04 Matches
Ancillary Charges
Signatures:
Medical Records: Therapy Director:
MDS Nurse: Business Office:
Administrator:
© Health Dimensions Group 2008 Medicare Triple Check/Pre-Billing Audit-HDGR
Page 1 of 1

53 RUG III Pre-Screening Tool
Name: Medicare # SNF Days Available: Date:
Dates of Three Acute Overnights:
Diagnosis/Procedures:
Medical Necessity:
Potential Clinical Indicators:
Discharge Plan:
Comments:
Previous RUGs III:
Assessor’s Name:
Bed Mobility Transferring Toilet Use Eating
Independent/Supervision 1 Independent/Supervision 1 Independent/Supervision 1 Independent/Supervision 1
Limited 3 Limited 3 Limited 3 Limited 2
1 Person 4 1 Person 4 1 Person 4 1 Person 3
2 Person 5 2 Person 5 2 Person 5 Total:
Rehabilitation (R)
YES
1. Does the patient have a physician’s order for one of the three therapies (PT, OT, or Speech) at least five times a week for a total of at least 150
minutes?
Ultra High
(720 min + five and three
days)
Very High
(500 min + five days)
High
(325 min + five days)
Medium
(150 min + any five days)
Low
(45 min three days + two
nurse reh.)
Diagnosis: CVA, swallowing
concerns and complicated +
ortho, spinal cord/brain stem
injuries, neuro-muscular, other:
(need the skills, knowledge of
therapist)
Diagnosis: complex orthos,
multi-complex medical with
swallowing concerns, other:
(need the skills, knowledge of
therapist)
Diagnosis: orthos de-condition
patients from acute, post op,
cognitive deficits, Parkinson’s,
M.S., other (need the skills,
knowledge of therapist)
Diagnosis: cognitive
impaired/weight bearing
orthoss, COPDs, pneumonias,
medical conditions that need
the skills, knowledge of
therapist.
Diagnosis: cognitive impaired,
chronic conditions, MS, slow
progress but still needs therapy.
Extensive (SE)
In the last 14 days has the patient received: YES In the last seven days did the patient receive: YES
1. Suctioning 5. IV fluids/Hydration/Parenteral Feeding
2. Tracheotomy Care Impaired Cognition: (ST memory, decision, self understood, eating) (only adds to SE)
3. Ventilator/Respirator Treatment
Enter date and location of supporting data:
4. IV Medications
Special Care (SS)
Does the patient currently have: YES YES
1. Quadriplegia with ADL sum above ten?
2. Multiple Sclerosis with ADL sum greater than ten?
7. Surgical wounds or open lesions with one of the following: wound
care or skin care treatments, special applications, ointments, or
medications.
3. Cerebral Palsy with ADL sum greater than ten? 8. Respiratory therapy daily over the last seven days.
4. Fever with dehydration, pneumonia, vomiting, weight loss or tube
feeding*?
5. A stage three or four pressure ulcer or two ulcers across all
stages?
6. A feeding tube* and aphasia (Feeding tube minimum of 26% of
calories + 501 cc fluid)
9. In the last 14 days, did the patient have radiation treatments?
Enter Date and location of data:
Clinically Complex (C)
Does the patient currently have: YES In the last 14 days, did the patient receive: YES
1. Coma? 11. Transfusions?
2. Dehydration? 12. Dialysis?
3. Pneumonia? 13. Oxygen Therapy?
4. Internal Bleeding? 14. Chemotherapy?
5. Septicemia?
6. Burns?
7. Hemiplegia?
15. In the first week will the patient be medically unstable enough to
require physician’s exam and/or order changes at least two
days?
8. Diabetes with daily injections and two order changes in past seven
days?
Location of data:
9. Foot wounds?
10. Tube feeding*? (Feeding tube min of 26% of calories + 501cc)
© Health Dimensions Group 2008 53 RUG III-Pre-Screening Tool – HDGR
Page 1 of 2

53 RUG III Pre-Screening Tool
Name: Medicare # SNF Days Available: Date:
Mark Appropriate RUG Grouper
Rehab Ultra ADL Rehab Very ADL Rehab High ADL Rehab Medium ADL
Rehab
Low
ADL
RUX
Anything in
SE and
ADL of 16-
18
RVX
Anything in
SE and
ADL of 16-18
RHX
Anything in
SE and
ADL of 13-18
RMX
Anything in SE
and
ADL of 15-18
RUL
Anything in
SE and
ADL of 7-15
RVL
Anything in
SE and
ADL of 7-15
RHL
Anything in
SE and
ADL of 7-12
RML
Anything in SE
and
ADL of 7-14
RUC
ADL of 16-
18
RVC ADL of 16-18 RHC ADL of 13-18 RMC ADL of 15-18 RLX
Anything
in SE and
7-18
RUB ADL of 9-15 RVB ADL of 9-15 RHB ADL of 8-12 RMB ADL of 8-14 RLB 14-18
RUA ADL of 4-8 RVA ADL of 4-8 RHA ADL of 4-7 RMA ADL of 4-7 RLA 4-13
Extensive SE
(ADLs >6)
0 point for the
following:
__Suctioning
__Trach Care
__Vent/Resp.
Add 1 point for each of
the following:
___IV Parenteral/
feeding
___IV Medication
Add 1 point if
Triggered
anything in
___Special
Add 1 point if
Triggered
anything in
___Complex
Add 1 point if
Triggered anything
in ____
Impaired Cognition:
(ST memory,
decision, self
understood, eating)
ADL>6
1 Point
SE1
ADL>6
2-3 Points
SE2
ADL>6
4-5 Points
SE3
Special SS
(ADL > 6)
ADL 17-18
SSC
ADL 15-16
SSB
ADL 4-14
SSA
Complex C
Will be a 2 if symptoms of depression
ADL 17-18
CC2
ADL 12-16
CB2
ADL 4-11
CA2
Complex C
No S/S depression
ADL 17-18
CC1
ADL 12-16
CB1
ADL 4-11
CA1
Proposed RUGs III
24 Hour Proposed RUGs III
Recommended Assessment Reference Date:
Actual RUG post completion of MDS (if different
explain):
14 Day Proposed RUGs III
Proposed: 30, 60, or 90 Day RUGs III
Comments:
© Health Dimensions Group 2008 53 RUG III-Pre-Screening Tool – HDGR
Page 2 of 2

Medicare Tracking Log
Resident Name and
Room #
Admit Date
Pre-Sc.
Score
Payor/Co-Ins.
RUG Level/
Reason for
Skilled
Cert
Date/ReCert
Date
MDS
ADL
5 14 30 60 90
Denial
Letter
As of
1/31
Day
Available
Therapy D/C
Date
Estimated LOS
D/C
Destination
PT
OT
ST
PT
OT
ST
PT
OT
ST
PT
OT
ST
PT
OT
ST
PT
OT
ST
PT
OT
ST
PT
OT
ST
© Health Dimensions Group 2008 Medicare Tracking Log-Sample
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medication Administration from a Cart
F Tag
N/A
Quality Standard FP97, RCS29
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to administer all medications and treatments in a safe and effective
manner.
PROCEDURE
1. Wash hands.
2. Place all blister pack containers needed for that medication pass on cart, if applicable.
3. Gather other required equipment.
4. Refrigerated drugs are placed in the cart as appropriate.
5. Place medication book on top of cart; when unattended, book should be closed for
privacy.
6. If the cart is left at any time during medication pass, it is locked.
7. Proceed with cart to resident’s room area and identify resident.
8. Read medication orders on medication sheet and have medication cup ready.
9. For solid medications, remove medication container (blister pack or bottle) and compare
label with medication sheet. Place appropriate dosage into medication cup. Re-read label
and medication sheet, and return drug to its proper location (triple check).
10. For liquid medications, remove prescribed liquid medications and compare label with
medication sheet. Pour prescribed amount into calibrated cup. Pour away from label
and check label. Re-read label and medication sheet and return drug to its proper
location (triple check). Certain medications may be required to be calibrated with a
syringe.
11. Crush medications as needed with appropriate equipment (if medication can be crushed
and is by physician’s order).
12. Lock cart.
13. Administer medication to resident, with water or juice.
14. Be sure that the resident has swallowed all medications.
15. Sign off medication given on the medication sheet, after giving the medication.
16. Properly wash hands and leave resident comfortable.
© Health Dimensions Group 2008 Medication Administration from a Cart
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
17. Repeat procedure with each resident who is to receive medications.
18. Return cart to designated area, and replace refrigerated medications as necessary. Clean
and restock cart after each use.
19. Medication cart is stored in the locked medication room designated only for storage of
medications when not in use.
See also, Pharmacy Manual for further information.
© Health Dimensions Group 2008 Medication Administration from a Cart
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medication Administration Record
F Tag
F331
Quality Standard RCS29
Origination Date April 1, 2008
Revision Date
POLICY
All medications prescribed by the physician are listed on the medication administration
record (MAR). This listing includes the medication, name, dose, route of administration,
time, and other necessary information. All medications have a specific reason for use.
PROCEDURE
1. The admission MAR is completed by the charge nurse admitting the resident. The proper
times are placed in the hour column.
2. Routine MARs are completed at the beginning of each month and placed in the
medication notebook after review by licensed staff (pharmacy generated).
3. At the time of dispensing, each medication received by the resident is checked in its
corresponding square and the record is initialed by the nurse giving the medication.
Refused medication is noted by circling the nurse’s initials and writing an explanation on
the back of the form. If the medication is refused, the physician is notified. This is to be
recorded in the nurse’s notes.
4. Out on pass is noted by placing OOP in the appropriate squares or noted per facility
specific procedures. All PRNs (pro re nata), i.e., as needed, are charted on the back of the
medication sheet with a record of the date, hour, medication, dosage, route, reason for
being given, results or response, hour response noted, and the nurse’s signature. The PRN
is also recorded in the nurse’s notes. If given by a medication aide, then the nurse giving
permission as well as the signature of the medication aide is recorded.
5. All initials are properly identified in the space provided with the nurse’s full name and
title. All squares on the front are charted with the nurse’s. Medications are signed off
after being given to resident.
6. When a resident is discharged to the hospital, a new MAR must be initiated upon
readmission.
7. PRN medications/treatments must be recorded in the medical record at the time of
administration and not before. The recording in the medical record includes the reason for
administration, what medication/treatment given, time the medication/treatment given,
and the resident’s response.
See also, Pharmacy Manual for additional information.
© Health Dimensions Group 2008 Medication Administration Record
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medications - Controlled
F Tag
F331
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Schedule II or higher controlled substances are kept under double lock either in the
medication room or the medication cart. Controlled substances are signed out upon
dispensing of the medication. A count of controlled drugs is maintained by charge nurses of
the off-going and oncoming shifts. Any irregularities are reported to the director of nursing.
Keys to the area housing controlled substances are held by the charge nurse only.
PROCEDURE
1. Storage of all controlled substance drugs includes:
a. Kept behind a double lock;
b. Charge nurse or designee is responsible for controlled drugs for their shift; and
c. Verified by inventory every 8 hours, at each shift change.
2. Controlled documentation:
a. A separate controlled substance administration control record is kept on all scheduled
II, III, and IV drugs. It contains the amount verifiable by inventory.
b. Disposition of unused portion of prescriptions is documented.
c. If the resident is discharged and their physician wants the medication to go home with
the resident, the charge nurse charts this and signs their name.
d. If the medication is not discharged with the resident or in the event of death, the
medication nurse takes the unused portion of the medication and the control record to
the nursing director’s office. The nursing director or designee notes the disposition of
the unused portion and signs their name on the bottom of the control record.
3. Administration:
a. When using the unit dose cart system, the drug is carried to the resident’s room on the
cart in the appropriate locked container.
b. Remove the medication from the locked container.
c. Verify medication and dosage with medication sheet.
d. Remove proper dose from container and place in medication cup.
e. Sign out full name in appropriate space provided.
© Health Dimensions Group 2008 Medications–Controlled
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
f. Subtract amount given from total and verify amount remaining.
g. Replace medication in locked container and secure lock.
h. Take medication to resident’s bedside, wash hands, identify resident and administer
medication as prescribed.
i. Chart medication in appropriate area of medication administration record.
4. If resident refuses medication:
a. Do not replace in container.
b. Circle initials on MAR and write explanation on the back of sheet.
c. Destroy drug in accordance with policies of facility for destruction of refused
medication.
d. Chart full explanation in nurse’s notes, if indicated.
5. When resident is discharged or deceased:
a. If the doctor has given an order, the medication may be sent with the resident on
discharge.
i. Have resident or responsible family member count drug with you and sign the
bottom of the sheet to acknowledge that the count is correct.
ii. Give remaining drug to resident or responsible party.
iii. Write full explanation in nurse’s notes.
b. If doctor has not given the order:
i. Remove drug and control sheet from cart and medication book.
ii. Verify drug count and complete the necessary records for discontinued/discharged
medications.
iii. Take drug and control sheet to director of nurses or designee to be locked up until
time for destruction in accordance with State Pharmacy Board.
c. If resident is deceased:
i. Remove drug and control sheet from cart and medication book.
ii. Verify drug and complete the necessary records for discontinued/discharged
medications.
iii. Take drug and control sheet to director of nurses to be locked up until time for
destruction in accordance with State Pharmacy Board.
See also Pharmacy Manual for additional information.
© Health Dimensions Group 2008 Medications–Controlled
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medications - Crushing
F Tag
N/A
Quality Standard RCS29
Origination Date April 1, 2008
Revision Date
POLICY
Only appropriate medications will be crushed with physician’s orders.
PROCEDURE
1. Only medications approved to be crushed by the manufacturer are crushed.
2. All crushed medications are documented with a physician’s order.
See also Pharmacy Manual for additional information.
© Health Dimensions Group 2008 Medications–Crushing
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title
Medications - Discontinued for Deceased or Discharged
Residents
F Tag
N/A
Quality Standard RCS29
Origination Date April 1, 2008
Revision Date
POLICY
All medications which are no longer being administered to the residents will be removed and
appropriately discarded.
PROCEDURE
1. All medication of deceased or discharged residents is given to the director of nurses or
designee, for proper disposal as soon as possible following death or discharge.
2. All discontinued medications are kept locked until destroyed.
3. All medications which have passed the expiration date on the label are given to the
director of nursing or designee for proper disposal and re-ordered, if necessary.
4. Rarely used PRN (pro re nata), i.e., as needed, medications are not kept longer than one
year from the date of issue on the label, unless it has an earlier expiration date. The PRN
medication must be available until the order is discontinued.
5. Medications are disposed of in accordance with state and federal regulations.
6. Medications are not given to the resident’s family unless there is a physician’s order to do
so.
See also Pharmacy Manual for additional information.
© Health Dimensions Group 2008 Medications–Discontinued for Deceased or Discharged Residents
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medications - Errors
F Tag
F332, F333
Quality Standard RCS29
Origination Date April 1, 2008
Revision Date
POLICY
• This facility is free of medication error rates of 5 percent or greater
• Residents are free of any significant medication errors
PROCEDURE
1. Report all medication errors to the attending physician and the director of nursing or
designee.
2. Assess the resident for side affects: vital signs, physical assessment, etc.
3. Complete medication error report. Do not reference the error report in medical record.
4. Contact family as indicated.
© Health Dimensions Group 2008 Medications–Errors
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medications - Labeling
F Tag
N/A
Quality Standard RCS29
Origination Date April 1, 2008
Revision Date
POLICY
The facility will label all medications to ensure compliance with state and federal laws.
PROCEDURE
1. All drug container labels are completed by a pharmacy, including label changes.
2. Label includes the resident’s name, drug name, dose, frequency, route instructions for
use, and expiration date.
3. Label change stickers should be utilized to identify any medication dose changes until a
new pharmacy label is obtained.
See also Pharmacy Manual for additional information.
© Health Dimensions Group 2008 Medications–Labeling
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medications - Ordering/Reordering/Receiving
F Tag
N/A
Quality Standard RCS29
Origination Date April 1, 2008
Revision Date
POLICY
The facility will ascertain that ordered medication is present in the facility and is available to
be given to each resident according to the physician’s specific instructions and in accordance
with state and federal regulations.
PROCEDURE
1. Ordering New Medication:
a. Call pharmacy of resident’s choice as recorded on the admission sheet in the current
medical record.
b. Give specific instructions directly from new physician’s order, being sure to include
the dose, strength, and times of administration. Note: the order may be faxed (if
facility’s procedure).
c. Record name of resident and drug ordered on the appropriate form.
2. Reordering Medication:
a. Take medication container and check chart to ascertain that no changes have occurred
since previous order.
b. Record resident’s name, name of pharmacy, prescription number, and other pertinent
information directly from label or order if changed on appropriate form. Group
medications according to pharmacy.
c. Call all pharmacies listed; order drugs as listed. Note: the order may be faxed.
d. Date and sign in appropriate place.
e. Replace medication container in usual storage place after ordering medication. Be
sure to flag to indicate drug was reordered.
3. Receiving Medication:
a. When medication arrives from the pharmacy it is checked for accuracy, counted, and
checked off on the appropriate form by the nurse receiving the medication.
b. Any errors in labeling or medication are reported immediately to the dispensing
pharmacy and the director of nurses.
See also Pharmacy Manual for additional information.
© Health Dimensions Group 2008 Medications–Ordering/Reordering/Receiving
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Medications - Sublingual
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Medications ordered for sublingual use are administered appropriately.
PROCEDURE
1. Physician order is required for medication to be given sublingual.
2. Medications ordered sublingual are placed under the resident’s tongue and are dissolved
over time in this area.
3. If a resident does not allow the medication to be given as ordered (swallows the
medication), the route may be changed. Notify the physician for direction.
4. Document on the medication administration record after medication is given or if refused.
© Health Dimensions Group 2008 Medications–Sublingual
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing facility
Policy Title Minimum Data Set (MDS) Completion (General)
F Tag
N/A
Quality Standard RCS57
Origination Date April 1, 2008
Revision Date
POLICY
The minimum data set (MDS) will be completed upon admission, quarterly, with a
significant change, a significant correction of a prior assessment, annually, and as per
Medicare Part A schedule for all residents.
PROCEDURE
1. Explain the procedure to the resident.
2. Complete MDS tool for appropriate discipline.
3. The facility conducts a comprehensive assessment within 14 days of admission,
excluding readmissions where there is no significant change in the resident’s physical or
mental condition (non-Medicare residents).
4. Within 14 days after the facility has determined that there has been a significant change
in the resident’s physical or mental condition, a comprehensive assessment is initiated.
5. The facility also conducts a comprehensive assessment at least once every 12 months.
6. The facility assesses a resident using the quarterly review instrument specified by the
State and approved by CMS at least once every 90 days.
7. The facility maintains, in the resident’s active record, all resident assessments completed
for the previous 15 months.
8. The facility encodes all data per CMS regulations after completing the assessment which
includes: admission, annual, significant change, quarterly, transfer, reentry, discharge,
death, and face sheets tracking forms.
9. The facility transmits data, per CMS regulations, after the facility completes a resident’s
assessment. The facility is capable of transmitting to the State information for each
resident contained in the MDS in a format that conforms to standard record layouts and
data dictionaries, and that passes standardized edits defined by CMS and the State.
10. The facility electronically transmits, per CMS regulations, encoded, accurate, complete
MDS data to the State for all assessments.
11. The facility ensures that all MDS data is accurate, is coordinated by a registered nurse
(RN), and signed by an RN. Any other discipline that completes a section of the MDS
signs the MDS certifying its accuracy. The facility understands that there is a penalty for
knowingly falsifying an MDS.
© Health Dimensions Group 2008 Minimum Data Set (MDS) Completion (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing facility
12. Each discipline that completes a section of the MDS signs, dates, and notes the section(s)
completed.
13. When the MDS is completed, the registered nurse coordinator or designee signs the
MDS.
© Health Dimensions Group 2008 Minimum Data Set (MDS) Completion (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Mobility - Ambulation
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents assessed to be mobile will be provided ambulation opportunities either through
therapy, independence, or assistance by nursing staff.
PROCEDURE
1. All residents who are declared safe for ambulation with nursing staff should be mobilized
by this method, using the appropriate device assigned by physical therapy (if on physical
therapy program) to the individual (e.g., walker, cane, etc.).
2. Those who are admitted with walking device continue to use it unless contraindicated.
3. Beginning ambulators may tire quickly; thus, these residents may be able to walk only a
short distance. In these cases partial wheelchair use is permissible/desirable.
4. A gait belt is used when ambulating with staff assistance.
5. Be certain to determine from physical therapy (if on physical therapy program) whether
resident is to be a supervised or assisted ambulator.
a. Supervised means someone accompanying the resident.
b. Assisted means to hold the resident by the waistband/gait belt. Contact intensity is
decreased gradually as the resident becomes stronger and endurance increases.
6. Remind the ambulator to walk tall; this provides isometric muscle toning, promotes
circulation, allows fuller lung expansion, provides full muscle length, and improves body
image and self esteem.
7. Remind the resident to look ahead, not down.
8. Be sure that all ambulation equipment that is assigned to the resident, (e.g., a brace, sling,
or cone) are in use and properly applied.
9. Observe resident for any signs of pain. If assessed/ordered, resident may benefit from a
mild PRN (as needed) pain medication prior to ambulation.
10. Have resident place their equipment (e.g., walker) within reach after getting into bed or
chair.
11. Always mobilize residents by means of their highest level of mobility.
© Health Dimensions Group 2008 Mobility–Ambulation
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
12. Walker specifics:
a. Height is correct when elbows are at 30 degree angles when hands are placed on
handles.
b. Walker must be advanced only 2 inches ahead of tip of shoe.
c. Both feet, with entire body, must then be inside walker before again advancing.
Posterior of body must never drag behind.
d. Front wheels should be used if the resident has difficulty picking up the walker.
13. Cane specifics:
a. Cane must be advanced only 2 inches ahead of tip of shoe.
b. Cane is positioned on the affected side when the corresponding upper extremity is
intact; it is positioned on the unaffected side when there is a hemiplegic condition
affecting the function of the upper extremity as well.
c. Cane should be advanced parallel and simultaneous to the weaker extremity.
14. Document distance walked, how tolerated, and assistive devices used.
15. Check with care plan regarding use of assistive devices. Assure accuracy.
16. Notify charge nurse or designee of any changes in ambulatory status.
© Health Dimensions Group 2008 Mobility–Ambulation
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Mobility - Assisted Transfers
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will establish a safe, efficient movement of a resident from one place to another
with optimum level of skill.
PROCEDURE
1. Stand pivot transfer with hemiplegic resident.
a. Position wheelchair close to the bed at a slight angle so that the resident will be
moving toward the unaffected side in order to utilize strength of unaffected side.
b. Prepare the wheelchair by locking brakes; moving foot or leg rests; and removing arm
rests, if possible and/or necessary, to facilitate safety and mobility.
c. As a precaution, especially during the first few transfers, get standby assistance from
another staff member, as needed.
d. Secure transfer/gait belt around resident’s waist, or per facility’s policy.
e. Primary mover positions self directly in front of resident with elbows and knees bent,
holding resident laterally by the transfer belt. Secondary standby assist mover stands
between bed and wheelchair.
f. Prepare resident for transfer by instructing the resident in proper method to move
from supine to sitting. Once upright, position resident squarely on the edge of the bed,
with feet flat on floor approximately 6-8 inches apart.
g. Instruct the resident to stand up by pushing down with the unaffected arm on the bed,
as able. As resident is beginning to stand, stabilize trunk with the transfer belt, and
stabilize the knees, if necessary, with own knees.
h. Wait for the resident to assume the most erect posture before instructing to pivot.
You can assist by pushing in buttocks.
i. Instruct resident to reach for the opposite arm rest and pivot on the unaffected leg
while maintaining hold on the belt and moving with the resident.
j. Once the resident is positioned squarely in front of the wheelchair, with back of legs
touching chair, instruct the resident to bend trunk forward and slowly lower self into
seat.
© Health Dimensions Group 2008 Mobility–Assisted Transfers
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
k. If secondary assistance is needed, the second person may:
i. Assist resident in grasping arm rest.
ii. Assist in stabilizing and lifting hips.
iii. Assist in pivoting hips in direction of wheelchair.
iv. Assist in lowering resident and adjusting final sitting position.
2. Standing pivot transfer with head injury resident (procedure is the same, with the
following considerations):
a. Possible bilateral involvement, so move the resident toward the least affected side;
b. Ataxia with cerebella involvement (comprehension and ability to follow directions);
and
c. Spasticity.
3. Standing pivot transfer with total hip resident (procedure is the same, with the following
considerations):
a. Avoiding excessive hip flexion and adduction to prevent dislocation of prosthesis;
and
b. Always check physician’s specific orders or therapist’s recommendations.
4. Document amount of assistance on the activities of daily living (ADL) sheet and the
resident’s care plan per facility’s policy.
5. Transfer resident per resident care plan.
© Health Dimensions Group 2008 Mobility–Assisted Transfers
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Mobility - Rolling Over in Bed
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will promote residents’ independence and self care and increase each resident’s
independence with moving self in bed.
PROCEDURE
1. Wash hands.
2. Explain procedure to the resident.
3. Ensure privacy.
4. The resident should be positioned on the opposite side of the bed you want him to turn to.
5. Instruct the resident to cross his left leg over his right leg as far as possible (if able).
6. Cross left arm over chest and reach for the mattress or side rail, if assessed appropriate (it
may be helpful to clasp hands together to increase gravity with turning).
7. The resident then pulls with their arms to roll all the way over.
8. Use positioning devices as needed.
9. Notify charge nurse or designee of any problems.
© Health Dimensions Group 2008 Mobility - Rolling Over In Bed
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Mobility - Transfer from Bed to Stretcher
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to follow correct body mechanics and to transfer a resident safely.
PROCEDURE
1. General considerations:
a. Remember proper body mechanics.
b. Position resident as close to you as possible.
c. Keep resident’s body level.
d. Move as a team with other lifters.
e. Consider use of mechanical lift, if indicated.
2. Bed to stretcher, using a draw sheet:
a. Stretcher position: parallel to bed. Be sure it is locked.
b. Staff position of lifters:
i. All stand on opposite side of bed.
ii. Assume broad base; brace elbows against bed.
iii. Lean forward from hips and keep back straight.
iv. Brace elbows against bed.
v. Support should be given at head, shoulders, hips, and legs.
3. Discuss with charge nurse the amount of assistance a resident might require during
transfer.
4. Get the help you might need.
5. Note transfer ability on the activities of daily living (ADL) sheet per facility’s policy.
© Health Dimensions Group 2008 Mobility–Transfer from Bed to Stretcher
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Mobility - Turning a Total Assist Resident
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to follow correct body mechanics and to transfer a resident safely.
PROCEDURE
1. Wash hands.
2. Face the resident being turned.
3. Follow concepts of good body mechanics.
4. Use your legs to give force-push off with forward leg and rock onto your back leg as you
try to lift.
5. Keep your back straight and tilt your pelvis.
6. The resident should be flat in bed. Lift the resident by inserting both arms, palm up under
the resident, and pull him/her toward you in segments (legs, trunk, and head).
7. Cross the resident’s leg (topmost over other leg). Push the resident away from you onto
his/her side.
8. A draw sheet should be used whenever possible.
9. Record turning on turn schedule or activities of daily living (ADL) sheet per facility’s
policy.
10. Notify charge nurse or designee of any skin conditions or changes in condition.
© Health Dimensions Group 2008 Mobility–Turning a Total Assist Resident
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Morning Care
F Tag
N/A
Quality Standard RCS17, RCS20
Origination Date April 1, 2008
Revision Date
POLICY
All residents will be provided morning (AM) care with assistance as needed.
PROCEDURE
Flexibility of tasks per resident’s needs/requests:
1. Wash hands.
2. Gloves used for pericare/incontinent cares.
3. Explain procedure to resident.
4. Provide privacy.
5. Assemble equipment.
6. Assist to bathroom, as needed.
7. Hair care as needed; assist as needed.
8. Hands/face washed as needed; assist as needed.
9. Shaving as needed; assist as needed.
10. Wash body as needed; assist as needed.
11. Deodorant as needed; assist as needed.
12. Assist with dressing as needed (range of motion as dictated by facility policy).
13. Remove gloves as needed.
14. Wash hands.
15. Room order, as needed.
© Health Dimensions Group 2008 Morning Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nail Care
F Tag
N/A
Quality Standard RCS20
Origination Date April 1, 2008
Revision Date
POLICY
It is the facility’s policy to keep a resident’s fingernails and toenails cleaned and trimmed.
PROCEDURE
1. Fingernails and toenails are checked daily and cleaned as necessary.
2. Fingernails are trimmed weekly during bathing or more often, if necessary.
3. A licensed professional does toenail trimming, calluses, and bunions on diabetic
residents.
4. Notify the charge nurse or designee of any abnormalities.
© Health Dimensions Group 2008 Nail Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nasogastric/Gastrostomy Tube - Administration of Medications
F Tag
N/A
Quality Standard RCS24
Origination Date April 1, 2008
Revision Date
POLICY
Medications administered via tube will be done appropriately and with physician’s order.
PROCEDURE
1. Wash hands.
2. Set up appropriate medications per physician’s order and per standard of practice.
3. Crush all medications that are not in liquid form (if appropriate). Obtain liquid
medications whenever possible.
4. Identify and explain procedure to resident.
5. Check for correct placement of tube.
6. Clear tube with the injection of approximately 10–30 cc of water.
7. Dissolve dry crushed medications in water.
8. Instill by flow of gravity.
9. Medications are not to be mixed and are to be given one at a time followed by water as
needed.
10. Re-clear tube after last medication with approximately 30–60 cc of water or as per
physician’s order.
11. Clamp tube and position resident comfortably.
12. Wash hands.
13. Observe for drug reactions and chart it, as needed.
14. Sign off medications administered on the medication record.
© Health Dimensions Group 2008 Nasogastric/Gastrostomy Tube–Administration of Medications
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nasogastric/Gastrostomy Tube Feeding - Bolus
F Tag
N/A
Quality Standard RCS24
Origination Date April 1, 2008
Revision Date
POLICY
Bolus feeding is only done per specific physician’s order and is not routinely done.
PROCEDURE
1. Check physician’s order.
2. Wash hands.
3. Assemble equipment.
4. Protect clothing with towel. Place resident in semi-fowlers position.
5. Apply gloves if desired.
6. Remove screw clamp from tubing and check tube for proper placement.
a. Aspirate gently to see if stomach contents are returned. Note amount.
b. With stethoscope on abdomen below sternum, insert catheter tip syringe into end of
tube and insert small amount of air, listening with stethoscope for a cracking sound to
assure tube is in proper place.
7. If tube is in proper place, proceed with feeding. Remove plunger using outer part of
syringe as a funnel. Instill 30–50 cc of water. Clear tubing by gravity.
8. Holding syringe funnel approximately 12–18 inches above resident, pour in ordered
amount of formula and allow feeding to flow in by gravity. Do not use plunger to apply
force.
9. Follow feeding with ordered volume of water to clear tubing.
10. Remove syringe. Apply screw clamp to tube when procedure is finished.
11. Wash syringe after each feeding and rinse well. Leave at bedside.
12. Remove gloves.
13. Syringe is replaced every 24 hours (should be dated).
14. If gastrostomy tube, check and change dressing as needed.
15. If nasogastric tube, check tape on nose holding tube. Remove, clean site, and replace as
needed.
16. Dispose of equipment and supplies appropriately.
© Health Dimensions Group 2008 Nasogastric/Gastrostomy Tube Feeding–Bolus
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
17. Wash hands.
18. If canned formula is used, it is discarded after 24 hours. (Must be kept covered.)
19. If prepared formula is used, it is to be carefully measured and only the amount needed for
the current feeding taken to the bedside. The remaining formula has to be properly
refrigerated and covered at all times.
20. Use only the amount of fluid as ordered by the physician.
21. Be sure to chart the entire amount of water used at each feeding.
22. Perform oral care, as needed.
23. Document amount and type of feeding delivered to the resident on the treatment sheet.
24. Note that placement was checked prior to feeding on medication/treatment sheet or in the
nurse’s notes for the resident.
© Health Dimensions Group 2008 Nasogastric/Gastrostomy Tube Feeding–Bolus
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nasogastric/Gastrostomy Tube Feeding - Pump
F Tag
N/A
Quality Standard RCS24
Origination Date April 1, 2008
Revision Date
POLICY
Nasogastric/Gastrostomy tube feeding utilizing a pump for infusion requires a physician’s
order.
PROCEDURE
1. Wash hands.
2. Explain the procedure to the resident.
3. May use paper towel or towel to prevent leakage and/or spills.
4. Put on gloves.
5. Attach tubing to bag/bottle and allow feeding to run to end of tubing.
6. Thread tubing through pump as per company directions for use.
7. Make sure the drip chamber is only ¼ to ½ full so sensor can read drips.
8. Turn machine on.
9. Set drip dial to correct rate.
10. Check tube placement.
11. Unplug tube end from resident and attach to bag tubing.
12. Monitor for correct drip rate and flow through the tubing.
13. Secure tubing as needed.
14. Remove gloves.
15. Wash hands.
© Health Dimensions Group 2008 Nasogastric/Gastrostomy Tube Feeding–Pump
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nebulizer Therapy
F Tag
N/A
Quality Standard RCS30
Origination Date April 1, 2008
Revision Date
POLICY
Nebulizer treatment is administered as ordered by a physician’s order.
PROCEDURE
1. Review physician’s order for medications and nebulizer treatment. Physician’s order
should contain:
a. Medication.
b. Amount to be administered.
c. Frequency/duration of treatment.
2. Assemble equipment.
3. Wash hands and apply gloves, as needed.
4. Explain procedure to resident.
5. Provide privacy.
6. Check for any contraindications prior to positioning resident.
7. Position resident for optimal effectiveness of therapy:
a. Sitting upright in a chair.
b. Elevated 45 to 90 degrees in bed.
8. Attach one end of the tubing to the bottom of the nebulizer inlet stem and the other end of
the tubing to the nebulizer compressor or to the oxygen/compressed air source.
9. Turn on the nebulizer compressor machine.
10. Adjust the flowmeter until an aerosol is visible through the reservoir if using
oxygen/compressed air.
a. Flow rate will usually need to be adjusted to between 6–8 liters per minute and/or per
physician’s order.
b. Treatment duration is usually 10–12 minutes or longer depending upon the amount of
medication being administered.
© Health Dimensions Group 2008 Nebulizer Therapy
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
11. Start therapy.
a. If resident is using a mouthpiece, then instruct and/or assist, when necessary, the
resident in placing the mouthpiece between the teeth and sealing the lips over it.
b. If the resident is using a mask, then place the mask over the resident’s nose and
mouth and slip the elastic strap around the back of the head.
c. If the resident has a tracheostomy, use a trach collar.
12. Encourage a breathing pattern that includes:
a. Slow and deep inspirations with mouth open if using mask.
b. 2–3 second breath hold.
c. Normal exhalation.
13. Take pulse during treatment, if indicated.
14. Discontinue treatment, assess the resident, and contact the physician if the following
occur:
a. Palpitations
b. Tremors
c. Increased nervousness
d. Increased blood pressure
e. Ventricular arrhythmias
f. Tachycardia (pulse increase of more than 20 pbm during treatment)
15. Turn off the nebulizer compressor machine. If using oxygen or compressed air, turn off
the flowmeter and close the valve.
16. Assist, when necessary, the resident to cough and/or suction as ordered by the physician.
17. Assist resident, as needed, into a comfortable position.
18. Disconnect tubing.
19. Shake out excess liquid.
20. Air dry nebulizer cup.
21. Wash hands.
22. Place nebulizer in a clean plastic bag or according to facility-specific procedure.
23. Document in the medical record the procedure and any pertinent observations.
24. Replace nebulizer and tubing every 7 days or per facility-specific policy.
© Health Dimensions Group 2008 Nebulizer Therapy
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Neurological Observations
F Tag
N/A
Quality Standard RCS30
Origination Date April 1, 2008
Revision Date
POLICY
Neurological observations will be conducted by a licensed nurse to provide for uniform
observation and recording of essential signs and symptoms and to ensure appropriate care of
a person with a suspected head injury.
PROCEDURE
This procedure is to be done by licensed personnel only. It is to be performed on all residents
with a suspected or known head injury. Checks are to be performed at 15-minute intervals for
a minimum of one hour. Thereafter, they are to be done every 30 minutes for one hour; then
every hour for two hours; then once a shift for 72 hours or as ordered by the attending
physician.
1. Assemble equipment.
2. Wash hands.
3. Provide privacy.
4. Identify the resident by calling his/her name or by checking the identification bracelet.
5. Make a note of how the resident responds.
6. Explain the procedure to the resident, even if he/she appears unconscious.
7. Determine the state of consciousness. Check all three spheres (person, place, and time).
Observe the speech pattern.
8. Check the pupil reaction; both pupils should react fully to light.
a. Darken the room, turn the flashlight on but do not shine it directly into the resident’s
eyelids, open gently with your fingers. Observe the size and reaction of the pupil.
b. Shine the light beam directly into the resident’s eye and observe the reaction of the
pupil. Repeat this on the other eye.
9. Take the resident’s blood pressure. Blood pressure normally increases with increased
intracranial pressure.
10. Take the resident’s temperature as applicable. Determine if an oral temperature is safe
with this type of resident, if not axcillary.
11. Take the pulse rate. Pulse rate normally decreases with increased intracranial pressure.
12. Determine the respiratory rate. Respirations are increased and shallow with increased
intracranial pressure.
© Health Dimensions Group 2008 Neurological Observations
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
13. Check the strength of hand grasp in both extremities. The grasp will be unequal with
cerebral damage.
14. Check the movement of all extremities. Have the resident move his/her extremities
themselves. Movement may be nonexistent if cerebral damage has occurred.
15. Leave resident comfortable with call light in reach.
16. Wash hands.
17. On the initial check, indicate specifically all the checks performed and the results, along
with the date and time, in the nurse’s notes.
18. Make the necessary notation on the resident care plan.
19. Notify the physician of any changes in neurological status.
© Health Dimensions Group 2008 Neurological Observations
Page 2 of 2

Neurological Observation Checklist - Sample
Date: Resident: MR#: Rm#:
This checklist should be used at the following intervals for follow-up of all falls. Any change in resident condition requires a phone call to the primary care physician.
• Initial assessment followed by q15 min x 4, q30 min x 2
• Every hour x 2
• Once per shift for 72 hours
Date
Time
Orientation
Place
Person
Date/Time
Eyes Open
Description Baseline q15 x 4 q30 x 2 q1 x 2 24 hours 48 hours 72 hours
4 = Resident opens eyes spontaneously and purposely
3 = Resident open eyes only in response to speech (“Please open your eyes.”)
2 = Resident opens eyes in response to pain (apply blunt pressure with an object such as a pencil to the fingernail where it enters the skin of the finger)
1 = Resident does not open eyes when painfully stimulated
U = Un-testable
Eye Score
Hands, Right/Left: Check if right and left responses are the same.
4 = Normal power 3 = Mild weakness 2 = Severe weakness 1 = No response
Right Hand
Left Hand
© Health Dimensions Group 2008 Neurological Observation Checklist - Sample
Page 1 of 2

Neurological Observation Checklist - Sample
Date: Resident: MR#: Rm#:
Description Baseline q15 x 4 q30 x 2 q1 x 2 24 hours 48 hours 72 hours
Arms, Right/Left: Check if right and left responses are the same. It is necessary to know the resident’s baseline ability for arm and leg strength.
4 = Normal power 3 = Mild weakness 2 = Severe weakness 1 = No response
Right Arm
Left Arm
Legs, Right/Left: Check if right and left responses are the same. It is necessary to know the resident’s baseline ability for arm and leg strength.
4 = Normal power 3 = Mild weakness 2 = Severe weakness 1 = No response
Right Leg
Left Leg
Vital Signs
• Assess blood pressure for increase or decrease
• Assess pulse for slowing or widening pulse, then increase rate
• Assess respirations for change in rate, rhythm, pattern, and rate of expiration
Blood pressure
Pulse
Respirations
Pupils: Assess size, equality, reaction to light, and unilaterally dilated pupils. Some residents will normally have unequal pupils.
(+) = Reactive (-) = Non Reactive (c) = Closed In Millimeters 1 2 3 4 5 6 7 8
Right Size
Right Reaction
Left Size
Left Reaction
Signature: Date:
© Health Dimensions Group 2008 Neurological Observation Checklist - Sample
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title
Notification to Physician/Family of Change in Resident Health
Status - HDGR
F Tag
F157
Quality Standard RCS18, RCS19
Origination Date April 1, 2008
Revision Date
POLICY
The facility will consult the resident’s physician, nurse practitioner, or physician assistant,
and if known, notify the resident’s legal representative or an interested family member when
there is:
• An accident (including falls) which results in injury and has the potential for requiring
physician intervention.
• Acute illness or a significant change in the resident’s physical, mental, or psychosocial
status (i.e., deterioration in health, mental, or psychosocial status in either life-threatening
conditions or clinical complications).
• A need to alter treatment significantly (i.e., a need to discontinue an existing form of
treatment due to adverse consequences or to commence a new form of treatment).
• A decision to transfer or discharge the resident from the facility.
• Expected or unexpected deaths.
Nursing judgment is an integral part of the skilled care provided in this facility; therefore,
such judgment must be applied in a case-by-case basis in keeping with acceptable nursing
practice.
Criteria:
• Life-threatening conditions are such things as a heart attack or stroke. Clinical
complications are such things as development of a stage 2 pressure sore when no ulcers
were previously present at stage 2 or higher, onset or recurrent periods of delirium,
recurrent urinary tract infection, or persistent decline in psychosocial status. Appropriate
notification time: immediate (as soon as possible/no longer than 24 hours).
• A need to alter treatment significantly means a need to stop a form of treatment because
of adverse consequences (e.g., an adverse drug reaction), or commence a new form of
treatment to deal with a problem (e.g., the use of any medical procedure or therapy that
has not been used on that resident before). Notification: depending on the nursing
assessment, appropriate notification may be immediate to 48 hours.
© Health Dimensions Group 2008 Notification to Physician/Family of Change
In Resident Status - HDGR
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
PROCEDURE
1. The facility will contact the resident’s physician with changes as described above.
2. The facility will notify an interested family member, if known, with changes as described
above.
3. Resident fact sheet will designate a family member to receive phone calls if they wish to
be informed of changes.
4. In the case of a resident who is incapable of making decisions, the representative would
make any decisions that have to be made, but the resident should still be told what is
happening to him/her.
5. In the case of the death of a resident, the resident’s physician is to be notified
immediately (as soon as possible/no longer than 24 hours) in accordance with state law.
© Health Dimensions Group 2008 Notification to Physician/Family of Change
In Resident Status - HDGR
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nurse Staffing - Required Posting
F Tag
F356
Quality Standard FP77
Origination Date April 1, 2008
Revision Date
POLICY
The facility posts the following information on a daily basis:
• Facility name
• Current date
• Total number and the actual hours worked by the following categories of licensed and
unlicensed nursing staff directly responsible for resident care per shift:
- Registered nurses
- Licensed practical nurses
- Certified nurses aides
• Resident census
Public access: This facility will provide, upon oral or written request, nurse staffing data for
review at a cost not to exceed the community standard.
Data retention: This facility will retain the posted daily nurse staffing for a minimum of 18
months or a period required by state law (whichever is greater).
PROCEDURE
1. Data noted above is posted at the beginning of each shift.
2. Data is in a clear and readable format.
3. Data is in a prominent place readily accessible to residents and visitors.
© Health Dimensions Group 2008 Nurse Staffing–Required Posting
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nursing Administration Staffing
F Tag
F353, F354, F355
Quality Standard
Origination Date April 1, 2008
Revision Date
POLICY
The facility ensures that services are provided by sufficient numbers of staff 24 hours a day,
7 days a week. A registered nurse is on site for a least 8 consecutive hours a day, 7 days a
week, except when under a waiver from the state.
PROCEDURE
1. Director of nursing oversees the nursing budget, including staffing.
2. A staffing ratio for each shift is set for the facility.
3. Staffing coordinator or designee establishes schedules for the facility, using the staffing
ratios.
4. Designated nursing staff is educated on how to fill staffing vacancies when call-ins occur.
© Health Dimensions Group 2008 Nursing Administration Staffing
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nursing Clinical Records (General)
F Tag
F514
Quality Standard FP11
Origination Date April 1, 2008
Revision Date
POLICY
Nursing notes are the nurse’s records of observations, treatment, services rendered, and
subjective information stated by the resident. The level of care required by the resident is
verified by the documentation in the nurse’s notes.
PROCEDURE
All entries include date, time of entry, signature, and title of the nurse writing the note.
1. The admission note includes the following:
a. Accompanied by whom, name, and relationship.
b. Disposition of medications brought by resident to the facility.
c. General condition.
d. General comments and complaints by the resident.
e. Method of admission (wheelchair, stretcher, ambulatory, etc.).
f. Observations by the nurse, including objective information such as:
i. Scars
ii. Cast
iii. Sutures
iv. Pressure areas
v. Foot drop
vi. If catheterized, the type of catheter type and how draining
g. Orientation to the facility.
h. Physician notification (name, time, and response).
i. Reason for admission.
j. Skilled criteria and need.
k. Source of admission (home, acute facility, other skilled nursing facility, etc.).
l. Vital signs.
m. Weight and height.
© Health Dimensions Group 2008 Nursing Clinical Records (General)
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
2. Nurse’s notes include but are not limited to:
a. Skin condition:
i. Turning schedule and position, as indicated.
ii. Type of skin care provided, including observations and treatments.
iii. Pressure ulcer care including weekly status, stage, and progress or lack of
progress.
b. Physical status: any items on the resident care plan that are identified as resident
issues.
c. Functional status:
i. Transfers: movement of a resident from bed to chair or wheelchair or to a
standing position, and the resident’s ability to transfer independently, with
assistance, partial weight bearing, non-weight bearing, and use of assistive
devices.
ii. Ambulation: the resident’s ability to ambulate (e.g., independent, with assistance,
with assistive devices), and a summary of the resident’s progress or lack of
progress in a structured program being taught by the restorative aide, as
applicable.
iii. Hearing.
iv. Vision.
v. Oral assessment and care.
vi. Eating and nutrition: the resident’s eating pattern, weight loss or gain, special
programs or meal training, swallowing training, appetite, type of diet, and
assistance needed.
vii. Personal hygiene, grooming, and activities of daily living (ADLs): assistance, no
assistance, or total care for bathing, dressing, toileting, and grooming; and
occupational therapist involvement in the personal hygiene program.
d. Sleeping.
e. Elimination habits.
f. Mental: the three spheres of orientation to consider when assessing the resident are:
i. Oriented: the resident is oriented in all three spheres.
ii. Occasionally disoriented: the resident is disoriented in one or two spheres and/or
occasionally in all three spheres.
iii. Disoriented: the resident is usually disoriented in all three spheres.
© Health Dimensions Group 2008 Nursing Clinical Records (General)
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
g. Resident behavior is described as:
i. The resident behavior.
ii. The resident’s behavior pattern may be inappropriate to the environment but is not
harmful to resident or to others.
iii. The resident’s behavior pattern is inappropriate and is harmful either to resident
or to others.
h. Psychosocial:
i. Description of the resident’s involvement in activities.
ii. Acute conditions and changes.
i. Other: description of any other existing problems or needs.
© Health Dimensions Group 2008 Nursing Clinical Records (General)
Page 3 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nursing Documentation (General)
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will provide documentation in a standardized manner of the care and services
provided to a resident.
PROCEDURE
1. Admission nursing assessments completed per individual assessment.
2. Admission and quarterly assessments include: elopement, falls, hydration, skin, pain, and
others as required and/or deemed necessary by the facility.
3. Minimum data set (MDS) completion as per CMS and Medicare guidelines. Back-up
documentation from the nursing staff is also completed.
4. Incident reports as appropriate not referenced in the nurse’s notes.
5. Any communications with family, durable power of attorney (DPOA), or physician noted
in nurse’s notes.
6. All laboratory data noted that it was reviewed on the data and the physician notified for
abnormal data. This should be noted in the nurse’s notes.
7. Care plans completed quarterly as per CMS guidelines and updated, as needed.
8. Nurse’s notes are dated, timed, and signed when written.
9. Nurse’s notes address resident leaving the facility, when and with whom, and time of
return, along with any medications sent.
10. Medication administration records and treatment administrator records are completed
with each medication or treatment completed.
11. Glucose measuring completed and documented as per physician’s order.
12. Licensed nurse documents the outcomes of all pain medications administered, whether
routine or PRN (as needed).
13. All Class II or higher medications are counted each shift with documentation.
© Health Dimensions Group 2008 Nursing Documentation (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nursing Rounds
F Tag
N/A
Quality Standard FP73, FP74
Origination Date April 1, 2008
Revision Date
POLICY
A system is in place to monitor resident care and staff interactions daily and is to be
conducted by director of nursing or designee for each shift.
© Health Dimensions Group 2008 Nursing Rounds
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nursing Services: Quality of Resident Care (General)
F Tag
F309
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Each resident, upon admission, is given an orientation to the facility services, routines, and
layout.
Each resident is provided care that promotes good personal hygiene, including care of the
skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, and
cleaning and cutting of fingernails and toenails. The resident is free of offensive odors. Pain,
if present, is managed.
Each resident is encouraged and, as necessary, assisted to achieve and maintain the highest
level of self-care and independence. Every effort is made to keep residents active and out of
bed for reasonable periods of time, except when contraindicated by a physician’s order.
Each resident is given care to prevent formation and progression of pressure sores,
contractures, and deformities. Such care includes:
• Changing position of bedfast and chair-fast residents with preventive skin care in
accordance with the needs of the resident;
• Encouraging, assisting, and training in self-care and activities of daily living;
• Maintaining proper body alignment and joint movement to prevent contractures and
deformities;
• Using pressure-reducing devices where indicated;
• Providing care to maintain clean, dry skin free from feces and urine;
• Changing of linens and other items in contact with the resident; and
• Carrying out of physician’s order for treatment. The facility notifies the physician when a
pressure ulcer first occurs, as well as when treatment is not effective. The facility
documents such notification in the medical record.
Upon admission and re-admission the resident is screened for pain. If pain is present, the
following occurs:
• In-depth pain assessment is completed.
• Facility views pain as the fifth vital sign.
• Pain is appropriately managed; graded less than a 2 on the minimum data set (MDS).
• Care plan reflects pain management.
© Health Dimensions Group 2008 Nursing Services: Quality of Resident Care (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
• Pain management is assessed during wound dressing changes.
• Use of opiods includes a routine bowel program, as needed.
Each resident requiring help in eating is provided with assistance and is provided training or
adaptive equipment in accordance with identified needs. The identified needs are based upon
the resident’s assessment and are designed to encourage independence in eating.
Each resident is provided good nutrition and necessary fluids for hydration.
An atmosphere is created that is conducive to providing quality resident care.
Quality resident care is comprised of an approach that meets the physical, psychological,
social, and spiritual needs of the facility’s residents, as determined through use of the nursing
process.
Sufficient nursing staff is available to provide nursing and related services to attain or
maintain the highest practicable physical, mental, and psychosocial wellbeing of each
resident, as determined by resident assessments and individual plans of care.
© Health Dimensions Group 2008 Nursing Services: Quality of Resident Care (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Nutrition (General)
F Tag
F325, F326
Quality Standard FP6, RCS41, RCS42, RCS43, RCS44, RCS55
Origination Date April 1, 2008
Revision Date
POLICY
The facility maintains acceptable parameters of nutritional status, such as body weight and
protein levels, unless the resident’s clinical condition demonstrates that this is not possible.
Residents receive a therapeutic diet and/or modified diet when there is a nutritional need.
© Health Dimensions Group 2008 Nutrition (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Ombudsman Program
F Tag
F156
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The state ombudsman representative is welcome to visit any resident in the facility in order
to monitor care and review facility services.
The facility allows representatives from the state ombudsman program to examine a
resident’s clinical records with the permission of the resident or his/her legal guardian per
HIPAA laws.
The name, address, and telephone number of the regional long-term care ombudsman is
clearly posted in the facility for residents and visitors.
Location:
_____
© Health Dimensions Group 2008 Ombudsman Program
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Oral Hygiene of Unconscious or Total Care Resident
F Tag
N/A
Quality Standard RCS20
Origination Date April 1, 2008
Revision Date
POLICY
Residents who are unable to perform daily oral hygiene will receive assistance (residents in
bed).
PROCEDURE
1. Wash hands.
2. Apply gloves.
3. Explain procedure to resident.
4. Provide privacy.
5. Assemble equipment at resident’s bedside.
6. Position the resident with his/her head turned to the side.
7. Place a towel under the resident’s cheek.
8. Brush teeth, if able.
9. Cleanse the inside surfaces of the oral cavity with swabs.
10. Lubricate the lips.
11. Remove gloves.
12. Discard supplies.
13. Wash hands.
14. Notify charge nurse or designee of any abnormalities or choking.
© Health Dimensions Group 2008 Oral Hygiene of Unconscious or Total Care Resident
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Oxygen Administration
F Tag
N/A
Quality Standard RCS30
Origination Date April 1, 2008
Revision Date
POLICY
Oxygen will be safely administered per physician’s orders.
PROCEDURE
1. "No Smoking" signs are posted on the room door.
2. Equipment must be free of alcohol, oil, or grease at all times.
3. Only sterile distilled water is to be used in the humidifier.
4. Residents who need oxygen often breathe easier when the head of the bed is raised to a
30–45 degree angle.
5. Nasal cannula:
a. Connect the cannula to the tubing from the oxygen tank and humidifier.
b. Turn on the oxygen flow and flush the tubing.
c. Regulate flow in accordance with physician’s order.
d. Place the nasal cannula into position by having one prong in each nostril. Adjust the
strap for proper fit. Be sure that you are not placing too much pressure on any one
place. Be sure that the cannula is not too tight.
e. Remove the cannula and cleanse the prongs and the resident’s nostrils with a damp
cloth, as needed.
f. Replace the oxygen tubing at least weekly.
6. Mask:
a. Connect the mask to the tubing which goes to the humidifier and the gauge.
b. Turn the flow to 8–10 liters per minute, and check the mask for leakage.
c. Have the resident exhale into the mask as it is applied.
d. Fit the mask snugly, but not tightly, over the resident’s nose and mouth. Adjust the
head strap.
e. Regulate the flow of the oxygen according to the physician’s order.
f. Remove the mask every 2–4 hours or so and give skin care.
© Health Dimensions Group 2008 Oxygen Administration
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
7. Change humidifier bottle every 7 days, or as needed. Label with date and initial. Fill
bottle with sterile distilled water as often as needed to keep at proper level marked on
bottle.
8. Wash with disinfectant, rinse, and dry non-disposable equipment and return it to its
proper storage area.
9. If oxygen tank is used, be sure that the tag attached to the tank is accurate in the
indication as to the amount of oxygen remaining in the tank.
10. When oxygen is discontinued permanently, return the oxygen tank to its proper storage
area immediately.
11. Oxygen cylinders used should be stabilized and stored properly in oxygen storage area
when not in use.
12. Document the date, time, and method of administration, number of liters per minute,
observations, and resident reactions in the nurse’s notes.
13. Make the necessary notation on the resident care plan.
14. Make out the necessary charge slips.
© Health Dimensions Group 2008 Oxygen Administration
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Pain Management - HDGR
F Tag
N/A
Quality Standard RCS28
Origination Date April 1, 2008
Revision Date
POLICY
There is a system in place to identify, monitor, and evaluate resident’s pain.
PROCEDURE
1. A comprehensive pain assessment will be completed for each resident upon admission,
quarterly, and when indicated by a resident’s change in condition or when resident’s pain
level changes.
2. Residents are also screened for pain regularly through observing the resident during daily
care and/or observing for signs and symptoms of pain.
3. A numerical pain scale and/or a non-verbal pain scale will be used to measure pain. For
residents with advanced dementia, complete either the pain assessment in advanced
dementia form or the assessment for pain in cognitively impaired.
4. The resident’s descriptive words regarding the type, location, and intensity of pain will be
used to evaluate the pain and to identify changes in pain.
5. For the resident who has difficulty communicating, physical signs such as grimacing,
restlessness, moaning, vital sign changes, or behavioral changes will be monitored.
6. Determine the appropriate interventions such as relaxation, heat, cold, massage,
positioning, and distraction that may be used to supplement pharmacologic interventions.
7. Obtain physician’s order for interventions as indicated.
8. The level of pain will be measured prior to administration of pain intervention, and the
pain level will be measured for effectiveness after administration and documented on the
MAR.
9. Any identified pain issues at the time of admission will be addressed on the
initial/immediate care plan.
10. The resident or the resident’s representative will be involved in the development of the
overall plan of care that addresses pain management, and the plan will be reviewed and
revised as needed.
11. Individual differences among residents, including behavioral and/or cultural beliefs
regarding pain, will be included in the plan of care.
12. Potential side effects related to pain medications will be identified in the care plan (e.g.,
falling, constipation).
13. Pain that is unresolved or worsening will be reported to the physician.
© Health Dimensions Group 2008 Pain Management—HDGR
Page 1 of 1

Pain Management - Pain Data Collection and Assessment - HDGR
Date: Resident: MR#: Rm#:
Complete upon admission, quarterly, when indicated by a resident’s change in condition, and/or when resident' pain level changes.
Data Collected From: Resident Family/Other Medical Record Other
Verbalizes Pain? No Yes * If Yes, date of onset:
Aching Burning Splitting Radiating Stabbing
Stinging Tingling Throbbing Shooting Other
Heavy Dull Pressure Exhausting Other
Diagnosis which could be associated with pain: No Yes
If Yes, describe:
Identify type, frequency, and intensity of pain:
Identify sites of pain on body diagram:
Type Site A Site B Site C
A = Acute
C = Chronic
Frequency Site A Site B Site C
1 = Less than daily
2 = Daily
FRONT
BACK
Check any of the following changes in daily activities or habits:
Insomnia Loss of appetite Decreased ability to concentrate
Withdrawal from activities Withdrawal from relationships Change in physical activity
Constipation Weight Loss Change in mood Sleep disturbances
What causes or increases pain?
What relieves the pain?
What is the resident’s pain goal?
Check each of the following signs exhibited by the resident:
Grimace/distorted face Moaning Rubbing body parts
Clenched teeth Grunting Altered gait/posture
Frowning/scowling Gasping/crying Pulled up knees
Tightly shut lips Resistive to care Fidgeting/restlessness
Glazed eyes Screaming Pacing
Wrinkled brow Swearing/cursing Irritability
Clenched fist Striking out at others Tense body language
DATA COLLECTION COMPLETED BY:
Signature/Title:
Date:
© Health Dimensions Group 2008 Pain Management - Pain Data Collection and Assessment - HDGR
Page 1 of 2

Pain Management - Pain Data Collection and Assessment - HDGR
Date: Resident: MR#: Rm#:
Based on review of data collected from pain data collection and assessment:
Resident exhibits no signs or symptoms of pain.
Resident exhibits signs and/or symptoms of pain.
Notify physician for evaluation / re-evaluation of pain management interventions.
ASSESSMENT COMPLETED BY:
Signature/Title:
Date:
Based on review of data collected from pain data collection and assessment:
Resident exhibits no signs or symptoms of pain.
Resident exhibits signs and/or symptoms of pain.
Notify physician for evaluation / re-evaluation of pain management interventions.
ASSESSMENT COMPLETED BY:
Signature/Title:
Date:
Based on review of data collected from pain data collection and assessment:
Resident exhibits no signs or symptoms of pain.
Resident exhibits signs and/or symptoms of pain.
Notify physician for evaluation / re-evaluation of pain management interventions.
ASSESSMENT COMPLETED BY:
Signature/Title:
Date:
Based on review of data collected from pain data collection and assessment:
Resident exhibits no signs or symptoms of pain.
Resident exhibits signs and/or symptoms of pain.
Notify physician for evaluation / re-evaluation of pain management interventions.
ASSESSMENT COMPLETED BY:
Signature/Title:
Date:
© Health Dimensions Group 2008 Pain Management - Pain Data Collection and Assessment - HDGR
Page 2 of 2

Pain Management - Pain Assessment in Advanced Dementia (PAIN-AD) - HDGR
Date: Resident: MR#: Rm#:
ITEMS 0 1 2 Score
Breathing
Independent of
Vocalization
Normal
Occasional labored
breathing.
Short period of
hyperventilation.
Noisy labored breathing.
Long period of
hyperventilation.
Cheyne-stokes respirations.
Negative
Vocalization
None
Occasional moan or
groan. Low level speech
with a negative or
disapproving quality.
Repeated troubled calling
out.
Loud moaning or groaning.
Crying.
Facial
Expression
Smiling or
inexpressive
Sad. Frightened. Frown.
Facial grimacing.
Body Language
Relaxed
Tense.
Distressed pacing.
Fidgeting.
Rigid. Fists clenched.
Knees pulled up.
Pulling or pushing away.
Striking out.
Consolability
No need to
console
Distracted or reassured
by voice or touch.
Unable to console, distract,
or reassure.
TOTAL
Add total points and compare to 0-10 pain scale to determine where resident falls on the scale.
Nurse’s signature:
Date:
© Health Dimensions Group 2008 Pain Management - Pain Assessment in Advanced Dementia (PAIN-AD) - HDGR
Page 1 of 3

Pain Management - Pain Assessment in Advanced Dementia (PAIN-AD) - HDGR
Date: Resident: MR#: Rm#:
DEFINITIONS
Breathing:
1. Normal breathing. Normal breathing is characterized by effortless, quiet, rhythmic (smooth)
respirations.
2. Occasional labored breathing. Occasional labored breathing is characterized by episodic bursts of
harsh, difficult, or wearing respirations.
3. Short period of hyperventilation. Short period of hyperventilation is characterized by intervals of rapid,
deep breaths lasting a short period of time.
4. Noisy labored breathing. Noisy labored breathing is characterized by negative sounding respirations on
inspiration or expiration. They may be loud, gurgling, wheezing. They appear strenuous or wearing.
5. Long period of hyperventilation. Long period of hyperventilation is characterized by an excessive rate
and depth of respirations lasting a considerable time.
6. Cheyne-Stokes respirations. Cheyne- Stokes respirations are characterized by rhythmic waxing and
waning of breathing from very deep to shallow respirations with periods of apnea (cessation of breathing).
Negative Vocalization:
1. None. None is characterized by speech or vocalization that has a neutral or pleasant quality.
2. Occasional moan or groan. Occasional moaning is characterized by mournful or murmuring sounds,
wails or laments. Groaning is characterized by louder than usual inarticulate involuntary sounds, often
abruptly beginning and ending.
3. Low level speech with a negative or disapproving quality. Low level speech with a negative or
disapproving quality is characterized by muttering, mumbling, whining, grumbling, or swearing in a low
volume with a complaining, sarcastic, or caustic tone.
4. Repeated troubled calling out. Repeated troubled calling out is characterized by phrases or words being
used over and over in a tone that suggests anxiety, uneasiness, or distress.
5. Loud moaning or groaning. Loud moaning is characterized by mournful or murmuring sounds, wails or
laments in much louder than usual volume. Loud groaning is characterized by louder than usual
inarticulate involuntary sounds, often abruptly beginning and ending.
6. Crying. Crying is characterized by an utterance of emotion accompanied by tears. There may be
sobbing or quiet weeping.
Facial Expression:
1. Smiling or inexpressive. Smiling is characterized by upturned corners of the mouth, brightening of the
eyes and a look of pleasure or contentment. Inexpressive refers to a neutral, at ease, relaxed, or blank
look.
2. Sad. Sad is characterized by an unhappy, lonesome, sorrowful, or dejected look. There may be tears in
the eyes.
3. Frightened. Frightened is characterized by a look of fear, alarm, or heightened anxiety. Eyes appear
wide open.
© Health Dimensions Group 2008 Pain Management - Pain Assessment in Advanced Dementia (PAIN-AD) - HDGR
Page 2 of 3

Pain Management - Pain Assessment in Advanced Dementia (PAIN-AD) - HDGR
Date: Resident: MR#: Rm#:
4. Frown. Frown is characterized by a downward turn of the corners of the mouth. Increased facial
wrinkling in the forehead and around the mouth may appear.
5. Facial grimacing. Facial grimacing is characterized by a distorted, distressed look. The brow is more
wrinkled as is the area around the mouth. Eyes may be squeezed shut.
Body Language:
1. Relaxed. Relaxed is characterized by a calm, restful, mellow appearance. The person seems to be
taking it easy.
2. Tense. Tense is characterized by a strained, apprehensive, or worried appearance. The jaw may be
clenched. (Exclude any contractures.)
3. Distressed pacing. Distressed pacing is characterized by activity that seems unsettled. There may be a
fearful, worried, or disturbed element present. The rate may by faster or slower.
4. Fidgeting. Fidgeting is characterized by restless movement. Squirming about or wiggling in the chair
may occur. The person might be hitching a chair across the room. Repetitive touching, tugging, or
rubbing body parts can also be observed.
5. Rigid. Rigid is characterized by stiffening of the body. The arms and/or legs are tight and inflexible.
The trunk may appear straight and unyielding. (Exclude any contractures.)
6. Fists clenched. Fists clenched is characterized by tightly closed hands. They may be opened and closed
repeatedly or held tightly shut.
7. Knees pulled up. Knees pulled up is characterized by flexing the legs and drawing the knees up toward
the chest. An overall troubled appearance. (Exclude any contractures.)
8. Pulling or pushing away. Pulling or pushing away is characterized by resistiveness upon approach or to
care. The person is trying to escape by yanking or wrenching him or herself free or shoving you away.
9. Striking out. Striking out is characterized by hitting, kicking, grabbing, punching, biting, or other form
of personal assault.
Consolability:
1. No need to console. No need to console is characterized by a sense of wellbeing. The person appears
content.
2. Distracted or reassured by voice or touch. Distracted or reassured by voice or touch is characterized by
a disruption in the behavior when the person is spoken to or touched. The behavior stops during the
period of interaction with no indication that the person is at all distressed.
3. Unable to console, distract, or reassure. Unable to console, distract, or reassure is characterized by the
inability to soothe the person or stop a behavior with words or actions. No amount of comforting, verbal,
or physical, will alleviate the behavior.
© Health Dimensions Group 2008 Pain Management - Pain Assessment in Advanced Dementia (PAIN-AD) - HDGR
Page 3 of 3

Pain Management - Assessing for Pain in the Cognitively Impaired - HDGR
Date: Resident: MR#: Rm#:
Ideas for non-pharmacological interventions:
Repositioning
Dim lighting/quiet environment
Hot/warm compresses to:___________________
Cold compresses to:_______________________
Soft, relaxing music/books on tape
Gentle soothing massage to:________________
Immobilization of:_________________________
Exercise
Relaxation technique/visualization
Aromatherapy
Objective Signs
Change in mental status
Back
Bone
Audible sounds of distress: moaning, crying, whimpering, grinding of teeth
Wt. bearing painful
New incision
Change in anatomical alignment
Headache
Hip
Facial expressions: grimaces, furrows of brow, tears, fearful facial expression
Change in ambulatory status
Change in ADLs
Restlessness, agitation, thrashing, fidgeting
Tremors
Verbal/physical resistance to ADL
Splinting, rubbing, distorted posture
Vocal or visual signs of pain on movement
Change in affect, insomnia, change in sleep pattern
Nausea/vomiting, diminished oral intake
Decrease in level of activity
Other: _____________
Diagnosis
DJD
CVA
Arthritis
Contractures
Neurolgia
Recent Fx/surgery/trauma
Compression Fx
Cancer/Hx of
Shingles
Hx joint replacement/pinning
Amputation
Fall
Osteoporosis
Chronic leg cramps
Oral or dental pathology
Dementia/Alzheimer’s
(For residents with cognitive impairment;
one or more objective signs = high probability of pain)
© Health Dimensions Group 2008 Pain Management - Assessment for Pain in Cognitively Impaired - HDGR
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Perineal Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents will be provided with perineal care to promote adequate skin integrity to ensure
clean, dry skin and to control odor.
PROCEDURE
1. Wash hands.
2. Explain procedure to the resident.
3. Ensure privacy.
4. Bring all equipment to room.
5. Apply gloves.
6. Remove soiled clothing and place in soiled clothing bag/hamper.
7. Remove gloves.
8. Wash hands.
9. Apply new gloves.
Note: The following steps are performed regardless of the void (urine or BM).
10. For a female, spread labia. Clean with warm soap and water. Wash from urethral area
toward the rectum and then the inner aspect of thighs.
11. For male residents uncircumcised, retract foreskin to cleanse, making sure to pull skin
forward over penis after cleansing.
12. If the resident has a Foley, clean as above and also around tubing and down tubing using
soap and water.
13. For a supine resident, assist the resident to turn on side. With the resident’s back turned
toward you, expose the buttocks.
14. Remove fecal material with toilet tissue and discard in toilet or soiled tissue disposal bag.
15. Clean the area from the rectal area over the buttocks using warm soap and water and
toilet tissue. Always wash front to back.
16. As applicable, place the soiled tissues into the soiled bag or flush.
17. Wash and rinse area if soap and water was used. Towel dry.
© Health Dimensions Group 2008 Perineal Care
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
18. Apply barrier cream to the area, if indicated.
19. Reapply brief and/or clothing.
20. Bring soiled linen and disposable trash to the utility room and rinse as needed.
21. Remove gloves.
22. Wash hands.
© Health Dimensions Group 2008 Perineal Care
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Personal Inventory and Resident's Belongings
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident’s personal items will be documented upon admission.
PROCEDURE
1. Explain the procedure to the resident and/or family.
2. Complete facility form documenting all the resident’s personal items, clothes, shoes,
jewelry, furniture, etc.
3. Label/identify all items per facility’s procedure.
4. Sign and date the form. Have resident or guardian co-sign the form.
5. Place completed form in resident’s chart and update when new items are brought for the
resident, whenever possible.
© Health Dimensions Group 2008 Personal Inventory and Resident’s Belongings
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Pet(s)
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
This facility allows or does not allow pets.
If this facility allows pets, they must be seen by a veterinarian on a regular basis and be
current with immunizations. The facility must maintain a file on the care of pets, and pets are
not allowed to be in the dining area(s) of the facility.
© Health Dimensions Group 2008 Pet(s)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Pharmacy Services (General)
F Tag
F425
Quality Standard FP7
Origination Date April 1, 2008
Revision Date
POLICY
The ___________________________ pharmacy provides routine and emergency drugs and
biologicals to the residents. The facility may permit unlicensed personnel (with training) to
administer drugs if state law permits but only under the general supervision of a licensed
nurse.
The facility provides pharmaceutical services (including procedures that assure the accurate
acquisition, receipt, dispensing, and administering of all drugs and biologicals) to meet the
needs of each resident.
© Health Dimensions Group 2008 Pharmacy Services (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Dining and Activities (General)
F Tag
F464
Quality Standard FP41, FP85
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides one or more rooms designated for resident dining and activities. These
rooms are well lighted, well ventilated, adequately furnished, and have sufficient space to
accommodate all activities. Smoking areas are identified.
© Health Dimensions Group 2008 Physical Environment–Dining and Activities (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Emergency Water Supply (General)
F Tag
F466
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides potable water to all essential areas and has procedures to ensure that
water is available to these essential areas when there is a loss of normal water supply.
The facility provides water for bathing, laundry, and toileting to all essential areas and has
procedures to ensure that water is available to these essential areas when there is a loss of
normal water supply.
© Health Dimensions Group 2008 Physical Environment–Emergency Water Supply (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Handrails (General)
F Tag
F468
Quality Standard FP40, FP41
Origination Date April 1, 2008
Revision Date
POLICY
The facility equips corridors with firmly secured handrails on each side. The handrails will
be monitored routinely.
© Health Dimensions Group 2008 Physical Environment–Handrails (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Life Safety (General)
F Tag
F454
Quality Standard FP30
Origination Date April 1, 2008
Revision Date
POLICY
The facility is designed, constructed, equipped, and maintained to protect the health and
safety of residents, personnel, and the public.
The facility meets the applicable provisions of the 2000 edition of the Life Safety Code of the
National Fire Protection Association (NFPA), unless waivers are granted for specific
provisions in the code by CMS, the state fire marshal, and the local fire marshal. Such
waivers do not adversely affect the health and safety of the residents.
The facility is in compliance with emergency lighting requirements.
Other issues addressed:
• Use of alcohol based hand rub dispensers does not conflict with any state or local codes
that prohibit or otherwise restrict the placement of alcohol based hand rub dispensers in
health care facilities. The dispensers are installed in a manner that minimizes leaks and
spills that could lead to falls. The dispensers are installed in a manner that adequately
protects against access by vulnerable populations and are installed in accordance with life
safety code manual instructions.
• Smoke detectors are installed in all resident sleeping rooms and public areas. The smoke
detectors are tested and maintained in accordance with National Fire Alarm Codes.
• The facility has a sprinkler system throughout that is installed, tested, and maintained in
accordance with NFPA 13, automatic sprinklers.
© Health Dimensions Group 2008 Physical Environment–Life Safety (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Outside Ventilation (General)
F Tag
F467
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility has adequate outside ventilation by means of windows or mechanical ventilation
or a combination of the two.
© Health Dimensions Group 2008 Physical Environment–Outside Ventilation (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Pest Control (General)
F Tag
F469
Quality Standard FP44
Origination Date April 1, 2008
Revision Date
POLICY
The facility maintains an effective pest control program. The facility is free of pests and
rodents.
PROCEDURE
Staff will notify maintenance/housekeeping if any pest problems are observed.
© Health Dimensions Group 2008 Physical Environment–Pest Control (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Resident Room (General)
F Tag
F457, F458, F459, F460, F461, F462
Quality Standard FP41
Origination Date April 1, 2008
Revision Date
POLICY
Resident rooms are designed and equipped for adequate nursing care, comfort, and privacy of
residents.
• Bedrooms do not accommodate more than four residents.
• Bedrooms measure at least 80 square feet per resident in multiple resident bedrooms; and
at least 100 square feet in single resident rooms.
• Bedrooms have direct access to exit corridors.
• Bedrooms are designed or equipped to assure full visual privacy for each resident.
• Bedrooms have at least one window to the outside.
• Bedrooms have a floor at or above grade level.
• The facility also provides each resident with a separate bed of proper size and height for
the convenience of the resident. Each bed has a clean and comfortable mattress and
bedding appropriate to the weather and climate.
• A resident may decline the use of the facility’s bed and bedding and supply his/her own
bed, if such bed meets the health requirements for the resident, has a clean and
comfortable mattress, fits in the space available to the resident, and meets the applicable
life safety codes.
• The facility also provides furniture appropriate to the resident’s needs and individual
closet space in the resident’s bedroom with clothes racks and shelves accessible to the
resident.
• A resident may provide his/her own furniture subject to space and safety considerations.
• Each resident room must be equipped with or located near toilet facilities.
© Health Dimensions Group 2008 Physical Environment–Resident Room (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physical Environment - Space and Equipment (General)
F Tag
F456
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides sufficient space and equipment in dining, health services, recreation,
and program areas to enable staff to provide residents with needed services as identified in
each resident’s plan of care and required by CMS and state standards.
The facility maintains all essential mechanical, electrical, and patient care equipment in
safety operating condition.
© Health Dimensions Group 2008 Physical Environment–Space and Equipment (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physician Availability - Emergency Care
F Tag
F389
Quality Standard RCS12
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides or arranges for the provision of physician services 24 hours a day, in
case of an emergency. The medical director or the medical director’s designee serves in this
capacity.
© Health Dimensions Group 2008 Physician Availability–Emergency Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physician Information - Resident Rights
F Tag
F156
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility verbally informs each resident of the name, specialty, and method of contacting
the physician responsible for his or her care.
© Health Dimensions Group 2008 Physician Information–Resident Rights
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physician Services - Supervision, Visits and Frequency of Visits
F Tag
F385, F386, F387
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A physician shall write the order admitting the resident to the facility. Each resident shall
remain under the care of a physician.
The medical care of each resident is supervised by a physician; and another physician
supervises the medical care of residents when their attending physician is unavailable.
The Medicare skilled resident is seen by a physician at least once every 30 days.
A nursing facility resident is seen by a physician at least once every 30 days for the first 90
days after admission, and at least once every 60 days thereafter. A physician visit is
considered timely if it occurs not later than 10 days after the date the visit was required.
© Health Dimensions Group 2008 Physician Services–Supervision, Visits, and Frequency of Visits
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physician's Order
F Tag
N/A
Quality Standard RCS1
Origination Date April 1, 2008
Revision Date
POLICY
All residents will have current, dated, and signed physician’s order. All care given to the
resident must have a direct order from an attending physician.
PROCEDURE
The following format is recommended:
1. Medications
a. All ordered medications are listed, with specified dosage. Dosage ambiguities are
avoided.
b. Full directions for administration are provided. Directions are fully spelled out and
abbreviations (qid, prn, bid, etc.) are avoided, whenever possible.
c. All vital signs related to drugs are listed directly below the drug for which it is given.
2. Treatments and nursing procedures which require physician’s order are listed. They
include the following:
a. Treatment orders with medications given on a routine scheduled basis, i.e., bid, qid,
or PRN treatments which the resident receives on a frequent basis;
b. Vital signs and blood pressure unless these are related to a specific medication. In that
case, the ordered blood pressure should be listed directly below the medication to
which it is related;
c. Weights on monthly or more frequent basis;
d. Restraints which are used on a consistent or routine basis. List the specific type of
restraints used and the medical symptom for its use. PRN restraint orders are not
permitted;
e. All ostomy care, with orders to change the tubes, as applicable;
f. Oral suction if needed on a routine basis;
g. Oxygen or inhalation therapy given on a routine basis;
h. Laboratory procedures ordered on a routine basis;
i. Nasogastric/gastric tube care; and
j. Chemsticks, Accuchecks, Fingersticks, etc.
© Health Dimensions Group 2008 Physician’s Order
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
3. Notations
a. Rehabilitation potential; social activity orders.
b. Recertification, using the statement: "I certify that the resident continues to require
SNF or NF level of care."
4. All orders are dated, and include the resident’s name, admission information, and
signature of nurse completing the form.
5. Any other physician’s order noted.
6. Telephone orders:
a. Blank forms are in all charts, on top of the current signed orders. This allows a
visiting physician, as well as the nurses who record telephone and verbal orders, to
write the orders in the chart in an organized manner. All telephone orders are filed in
the chart in chronological date order.
b. Once the order is received, the nurse places all identifying information on the form. If
this is a new diagnosis, or new problem, the order is added to the care plan.
c. The telephone orders are placed on top of the current updated orders in the
chronological order received. Original telephone orders, when returned by physician,
will be placed in charts.
7. Licensed nurses, pharmacists, or other physicians may take and record verbal or
telephone orders from the physician. Registered dietitians may take and record diet orders
and diet order changes.
© Health Dimensions Group 2008 Physician’s Order
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physician's Order - Recording
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
There is a consistent system of documenting the physician’s order—which is maintained in
the medical record to ensure it is followed.
PROCEDURE
Telephone orders and recording physician’s orders:
1. When taking orders from a physician, by any method:
a. Review existing orders for possible conflicting or duplication of orders. Inform the
physician of any conflicts or duplications.
b. Check for allergies.
c. Make certain orders are complete:
i. If PRN (as needed), the order must state why and frequency.
ii. If treatment, body part to be treated and duration of therapy.
d. Inform physician of any applicable automatic stop order policy.
2. If Telephone Order (T.O.):
a. Write order on T.O. slip.
b. Place pink sheet in chart on Physician's Telephone Orders Record
c. Place other sheet in T.O. box to be routed to physician for signature.
3. Noting Orders: For all orders write "Noted", your first initial, last name and title, date,
and time.
If Pharmacy is involved:
1. Check physician’s order sheet to see which pharmacy is used.
2. Complete a pharmacy order sheet for the new medication.
3. Call pharmacy and place the new order.
4. Write "Phoned In" and time on pharmacy order sheet which has been filled out for the
new medication or on facility communication record for pharmacy orders.
5. Write the new order on medication or treatment sheet.
© Health Dimensions Group 2008 Physician’s Order–Recording
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
6. If change in dosage/directions, place sticker on medication reading: "Directions change
and Refer to Chart,” and place on the medication label.
7. If medication is discontinued, remove medication immediately from circulation. Label
"DC'd and Date.” Place in holding area. If DC'd medication is a control drug, give
control sheet and medication to director of nurses or designee as soon as possible.
If Laboratory is involved:
1. Make out lab slip.
2. Notify lab.
3. Enter notation on calendar for any future labs to be drawn. Indicate any special
instructions (NPO for test).
4. If culture is specified:
a. Take culture.
b. Notify lab for pick-up of culture.
c. Document in nurse’s notes.
d. Notify kitchen if NPO
If X-Ray is involved:
1. Make out x-ray slip.
2. Call x-ray.
3. Document as indicated.
If Outside appointment:
1. Call to arrange appointment time or have durable power of attorney (DPOA)/family make
the appointment. Follow up with family member to confirm time and date of the
appointment.
2. Arrange for transportation, as needed.
3. Enter appointment on calendar.
4. Notify resident.
If Diet Change:
1. Notify kitchen, using a dietary slip.
2. Note change on appropriate forms.
3. If indicated, write a nursing note on actions taken.
© Health Dimensions Group 2008 Physician’s Order–Recording
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Physician's Order Sheet
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
There is a consistent system of documenting the physician’s order—which is maintained in
the medical record to ensure it is followed.
PROCEDURE
1. All orders initially received on admission are written on the Facility Physician Order
Sheet.
2. All subsequent orders received are written on the full-page form and/or telephone orders.
In addition to the orders, the following demographic information is completed by the
licensed nurse:
a. Resident name:
b. Room and bed number;
c. Physician name; and
d. Facility name.
3. All orders include the following information:
a. Order date–the date the order is written.
b. Order text–this includes specific orders and instructions regarding administration of
medications, treatments, activities, diet, diagnostic tests, therapy(s), restraints, other
special procedures, discharges, and transfers.
c. Frequency is entered reflecting the frequency that the order is carried out.
4. The monthly physician’s order is reviewed by a licensed nurse for accuracy prior to
obtaining the physician’s signature. The nurse will sign and enter a date to indicate when
this review took place. These orders should be double-checked by another nurse or
medical records professional and co-signed.
5. All monthly orders are signed and dated by the physician.
6. Prior to placing the signed orders in the resident record, a licensed nurse will review the
contents for any additions, changes, or deletions in the orders. To indicate the review has
occurred, the nurse will sign and date the area on the physician’s orders titled “Above
orders noted by:”.
© Health Dimensions Group 2008 Physician’s Order Sheet
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
7. Distribution of copies of the physician’s order:
a. White original is sent to the physician for signature.
b. A copy is sent to the pharmacy.
c. A copy is placed in the resident’s medical record until the white original is returned
from the physician with the appropriate signature.
8. The pharmacist signs and dates the orders to indicate he has completed his monthly
review or indicates on a facility-specific form.
© Health Dimensions Group 2008 Physician’s Order Sheet
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Positioning (General)
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Positioning the resident will be done to prevent hip flexion contractures, knee flexion
contractures, and plantar flexion contractures (foot drop); and to treat pressure ulcers on
lateral and posterior body areas.
PROCEDURE
A. Pronating the hemiplegic:
1. Bring the resident to edge of the bed with the affected side toward you and feet at
lower edge of the mattress.
2. Position unaffected arm close to body with hand tucked slightly under the thigh.
3. Cross legs at ankles, placing affected leg on top of strong leg.
4. Reach well under the back and buttocks of the resident (supporting shoulder), and roll
resident to abdomen.
5. Position head.
6. Straighten legs.
7. Place affected arm in slight abduction with elbow and wrist extended.
8. Place pillows under shoulders, chest, abdomen, thighs, and calves.
9. Un-pronate the resident in reverse manner.
10. If present, the Foley catheter should drain freely.
11. Document position and the amount of time tolerated and note use of pillows for
positioning (numbers and where); and include in care plan.
B. Pronating the amputee:
1. Roll the resident toward unaffected side and support the stump.
2. Position the arm near the body on affected side.
3. Position the resident’s head facing unaffected side.
4. Above-knee amputee: adducts and internally rotates stump. Hip hyper-extended by
placing stump on pillows or bath blankets.
5. Below-knee amputee: extends knee and holds stump down with draw sheet or
comfortable strap.
© Health Dimensions Group 2008 Positioning (General)
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
6. Document position and the amount of time tolerated and note use of pillows for
positioning (numbers and where); and include in care plan.
© Health Dimensions Group 2008 Positioning (General)
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Post Mortem Care
F Tag
N/A
Quality Standard RCS52
Origination Date April 1, 2008
Revision Date
POLICY
After the death of a resident, the resident’s body will be treated in a dignified and respectful
manner.
PROCEDURE
1. Wash hands.
2. Apply gloves.
3. Provide privacy.
4. Place body flat on back with arms at sides and one pillow under head.
5. Assemble equipment at bedside.
6. Wash, rinse, and dry the body.
7. Make sure eyes are closed.
8. Place dentures in resident’s mouth (if they fit, or send to funeral home with resident).
9. Remove all jewelry. Give to charge nurse.
10. Change sheet under resident, if soiled.
11. Change to fresh clothing.
12. Comb and arrange hair.
13. Cover with clean top sheet.
14. Remove gloves.
15. Wash hands.
16. Leave identification bracelet on resident.
17. Notify charge nurse or designee when completed.
18. Document effects sent with body (e.g., dentures, glasses, rings).
19. Complete valuables and clothing list as per discharge procedure.
© Health Dimensions Group 2008 Post Mortem Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Postural Drainage
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Postural drainage will be done by licensed staff only and upon a physician’s order to remove
secretions from the bronchial tree by using percussion, vibrating, and the force of gravity to
move secretion to an area where they can be coughed up, prevent secretions from pooling in
the lungs, and/or obtain specimens for laboratory examinations.
PROCEDURE
1. Determine if a specific segment of the lung is involved and if clapping is to be carried out
(procedure is to be done before meals or at least two hours after meals).
2. If medication is ordered in conjunction with the procedure, give it 15 to 20 minutes prior
to treatment.
3. Provide privacy. Pull cubicle curtain and close room door.
4. Wash hands.
5. Apply gloves.
6. Explain procedure to resident and instruct the resident to breathe deeply using the
diaphragm, ballooning the upper abdomen, and to exhale through mouth with force.
7. When placing resident in a specific position, observe their tolerance to it and modify
position as necessary.
8. Techniques:
a. To perform "clapping", position the resident to present the part to be drained
(reference locations in paragraph 8.c. below) to the therapist or nurse. With cupped
hands, by extension and flexion of the wrists, gently clap the chest wall over the
involved area. Clap over the same area for 1 or 2 minutes using alternating hands or
one hand at a time.
b. To accomplish "vibrating", ask the resident to take a deep breath and while he/she is
exhaling, place one hand on top of the other (or one hand on either side of the
resident’s rib cage) in the area to be vibrated. Contract and tense your shoulder and
upper arm muscles, compressing and gently vibrating the indicated area during the
exhalation. Repeat 3 or 4 times with periods of rest.
© Health Dimensions Group 2008 Postural Drainage
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
c. Locations:
i. Lower Lobes - Anterior Segment:
(1) Have resident on his/her back with no pillow under his head and with head
positioned slightly lower than feet.
(2) Clap the lower, anterior bottom part of the rib cage.
ii. Left Lingual Segment:
(1) Have resident on right side with head slightly lower than feet.
(2) Place pillow under left side of back and bend left shoulder back (45 degrees)
over pillow.
(3) Clap over left nipple.
iii. Left Lower Lobe:
(1) Have resident on right side with head slightly lower than feet.
(2) Arms forward from shoulder.
(3) Clap over ribs on left side.
iv. Lower Lobes - Posterior Segment:
(1) Have resident lying on abdomen with head slightly lower than feet.
(2) Clap over ribs of lower thorax.
v. Right Lower Lobe - Lateral Segment:
(1) Have resident lying on right side with head slightly lower than feet.
(2) Clap over ribs of right side.
vi. Right Middle Lobe:
(1) Have resident lying on left side with head slightly lower than feet.
(2) Place pillow under right side of back.
(3) Bend right shoulder back (45 degrees) supported by pillow.
(4) Clap over right nipple.
vii. Upper Lobes - Anterior Apical Segments:
viii.
(1) Elevate head of bed 45 degrees.
(2) Sit resident up against it.
(3) Clap both uppermost parts of the anterior chest wall simultaneously.
Upper Lobes - Posterior Apical Segments:
(1) Have resident sitting and leaning forward on the over-bed table.
© Health Dimensions Group 2008 Postural Drainage
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
(2) Clap uppermost part of the back with both hands simultaneously.
9. Encourage resident to cough deeply, using abdominal muscles. Allow the resident to rest
occasionally.
10. Unless a specimen is required, have resident expectorate in tissues and place them in
trash bag. If specimen is required or measured amount needed, have resident expectorate
into a specimen cup.
11. If the resident is to have postural drainage without clapping or vibrating, place the
resident in the prescribed position for 15–20 minutes and encourage coughing.
12. If the resident has a tracheostomy, suction between steps of the procedure and after
treatment.
13. Return the resident to a comfortable position.
14. Assist the resident with oral hygiene.
15. Leave resident comfortable with call light in reach.
16. Place trash bag of soiled tissues in contaminated trash can in utility room.
17. Remove gloves.
18. Wash hands.
19. Replace reusable items in the proper storage area.
20. Record time, date, and procedure on the treatment sheet.
21. Record unusual observations and resident reactions in the nurse’s notes.
22. Notify physician as needed.
23. Send any lab specimens, if ordered.
© Health Dimensions Group 2008 Postural Drainage
Page 3 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title
Pre-Admission Screening for Mental Illness and Retardation
(PASSAR)
F Tag
F285
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
An individual requesting admission to the facility is not admitted with:
• A serious mental illness, unless prior to admission:
- The state mental health authority determines that the physical and mental condition of
the individual requires the level of services provided by the facility;
- The state mental health authority determines whether or not the individual requires
specialized services for mental illness; and
- These determinations are based on an independent* physical and mental evaluation
that is performed prior to admission.
* An independent evaluation is an evaluation performed by a person or entity other
than the state mental health authority.
• Mental retardation, unless prior to admission:
- The state mental retardation or developmental disability authority determines that the
physical and mental condition of the individual requires the level of services provided
by the facility; and
- The state mental retardation or developmental disability authority determines whether
or not the individual requires specialized services for mental retardation.
© Health Dimensions Group 2008 Pre-admission Screening for Mental Illness and Retardation (PASSAR)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Pre-Admission Screening of Resident - HDGR
F Tag
F208
Quality Standard RCS13
Origination Date April 1, 2008
Revision Date
POLICY
The facility will use a pre-screening tool to determine the feasibility of admission and
expected resource utilization group (RUG) the person will be assigned to.
• A pre-admission screening process will be completed for all admissions to assure
appropriate placement
• The pre-screening form will be completed by Admissions or designee prior to admission
The pre-screening form will be current and will meet Medicare prospective payment system
(PPS) guidelines and requirements for RUG classification and documentation.
PROCEDURE
1. The admissions team will initiate the pre-screening form (first line of defense).
2. The information obtained from the transferring agency that can be counted on the prescreening
form to assist in determining the RUG III grouper (look back information
[LBI]) must have as much detail as possible:
a. Location of data
b. Dose
c. Name
(Example: IV NaCL at 100 cc per hour - on June 1, 2007, in MAR)
3. After admission, supporting documentation of all LBI should be copied and attached to
the back of the pre-screening form by MDS coordinator and kept as part of medical
record.
4. MDS coordinator, in cooperation with Medicare team, will direct and lead discussion to
assure appropriate RUG levels are obtained. Medicare team members should include the
following:
a. MDS and appropriate unit nurses
b. Dietary
c. Therapy
d. Social Services
e. Billing
f. Medical Records
© Health Dimensions Group 2008 Pre-admission Screening of Resident–HDGR
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
g. Activities
h. Administrator
i. Director of Nursing (DON)
5. Pre-screening form to be given MDS coordinator by admissions coordinator.
6. All items checked on pre-screening form must be verified by MDS coordinator.
7. LBI will be coded on the Medicare log with dates by MDS coordinator, prior to setting
the assessment reference date (ARD) and establishing the appropriate RUG level.
8. Once the ARD has been set, the Medicare log will be updated by the MDS coordinator
and confirmed by the Medicare team.
9. The ARD should not be changed after the above process has been completed without
notifying Medicare team.
10. Grace days should only be used when necessary.
FORM INSTRUCTIONS
The format on the following page (RUG III Pre-Screening Tool) has been designed to group
resident as well as capture essential MDS information and support MDS coding. The preadmission
screening document can provide the supporting documentation needed for the
MDS LBI time periods on key RUGs items.
The transferring facility provides the information on the tool. This can be done via phone,
fax, or in person. Dependent on the time factors and availability of personnel, a visit to the
prospective resident and review of the hospital record will give added assurance for the
accuracy of the information.
Factual data can be transferred to the MDS. Obtain a copy of the data needed to validate the
MDS.
Following completion of the MDS, comparison can be made to the prescreening admission
intake form, providing a potential to improve quality of future inquiries.
Note: When requesting information about extensive services category, be sure to document
not only if the services were/are being provided, but also the dates and location regarding
them. It is preferable to retain copies of the data from acute to support marking the items on
the MDS. The MDS Section P1 is a 14-day look back and includes those services that were
provided by the transferring facility.
© Health Dimensions Group 2008 Pre-admission Screening of Resident–HDGR
Page 2 of 2

53 RUG III Pre-Screening Tool
Name: Medicare # SNF days available: Date:
Dates of Three Acute Overnights:
Diagnosis/Procedures:
Medical Necessity:
Potential Clinical Indicators:
Discharge Plan:
Comments:
Previous RUGs III:
Assessor’s Name:
Bed Mobility Transferring Toilet Use Eating
Independent/Supervision 1 Independent/Supervision 1 Independent/Supervision 1 Independent/Supervision 1
Limited 3 Limited 3 Limited 3 Limited 2
1 Person 4 1 Person 4 1 Person 4 1 Person 3
2 Person 5 2 Person 5 2 Person 5 Total:
Rehabilitation (R)
YES
1. Does the patient have a physician’s order for one of the three therapies (PT, OT, or Speech) at least five times a week for a total of at least 150
minutes?
Ultra High
(720 min + five and three
days)
Very High
(500 min + five days)
High
(325 min + five days)
Medium
(150 min + any five days)
Low
(45 min three days + two
nurse reh.)
Diagnosis: CVA, swallowing
concerns and complicated +
ortho, spinal cord/brain stem
injuries, neuro-muscular, other:
(need the skills, knowledge of
therapist)
Diagnosis: complex orthos,
multi-complex medical with
swallowing concerns, other:
(need the skills, knowledge of
therapist)
Diagnosis: orthos de-condition
patients from acute, post op,
cognitive deficits, Parkinson’s,
M.S., other (need the skills,
knowledge of therapist)
Diagnosis: cognitive
impaired/weight bearing
orthoss, COPDs, pneumonias,
medical conditions that need
the skills, knowledge of
therapist.
Diagnosis: cognitive impaired,
chronic conditions, MS, slow
progress but still needs therapy.
Extensive (SE)
In the last 14 days has the patient received: YES In the last seven days did the patient receive: YES
1. Suctioning 5. IV fluids/Hydration/Parenteral Feeding
2. Tracheotomy Care Impaired Cognition: (ST memory, decision, self understood, eating) (only adds to SE)
3. Ventilator/Respirator Treatment
Enter date and location of supporting data:
4. IV Medications
Special Care (SS)
Does the patient currently have: YES YES
1. Quadriplegia with ADL sum above ten?
2. Multiple Sclerosis with ADL sum greater than ten?
7. Surgical wounds or open lesions with one of the following: wound
care or skin care treatments, special applications, ointments, or
medications.
3. Cerebral Palsy with ADL sum greater than ten? 8. Respiratory therapy daily over the last seven days.
4. Fever with dehydration, pneumonia, vomiting, weight loss or tube
feeding*?
5. A stage three or four pressure ulcer or two ulcers across all
stages?
6. A feeding tube* and aphasia (Feeding tube minimum of 26% of
calories + 501 cc fluid)
9. In the last 14 days, did the patient have radiation treatments?
Enter Date and location of data:
Clinically Complex (C)
Does the patient currently have: YES In the last 14 days, did the patient receive: YES
1. Coma? 11. Transfusions?
2. Dehydration? 12. Dialysis?
3. Pneumonia? 13. Oxygen Therapy?
4. Internal Bleeding? 14. Chemotherapy?
5. Septicemia?
6. Burns?
7. Hemiplegia?
15. In the first week will the patient be medically unstable enough to
require physician’s exam and/or order changes at least two
days?
8. Diabetes with daily injections and two order changes in past seven
days?
Location of data:
9. Foot wounds?
10. Tube feeding*? (Feeding tube min of 26% of calories + 501cc)
© Health Dimensions Group 2008 53 RUG III-Pre-Screening Tool – HDGR
Page 1 of 2

53 RUG III Pre-Screening Tool
Name: Medicare # SNF days available: Date:
Mark Appropriate RUG Grouper
Rehab Ultra ADL Rehab Very ADL Rehab High ADL Rehab Medium ADL
Rehab
Low
ADL
RUX
Anything in
SE and
ADL of 16-
18
RVX
Anything in
SE and
ADL of 16-18
RHX
Anything in
SE and
ADL of 13-18
RMX
Anything in SE
and
ADL of 15-18
RUL
Anything in
SE and
ADL of 7-15
RVL
Anything in
SE and
ADL of 7-15
RHL
Anything in
SE and
ADL of 7-12
RML
Anything in SE
and
ADL of 7-14
RUC
ADL of 16-
18
RVC ADL of 16-18 RHC ADL of 13-18 RMC ADL of 15-18 RLX
Anything
in SE and
7-18
RUB ADL of 9-15 RVB ADL of 9-15 RHB ADL of 8-12 RMB ADL of 8-14 RLB 14-18
RUA ADL of 4-8 RVA ADL of 4-8 RHA ADL of 4-7 RMA ADL of 4-7 RLA 4-13
Extensive SE
(ADLs >6)
0 point for the
following:
__Suctioning
__Trach Care
__Vent/Resp.
Add 1 point for each of
the following:
___IV Parenteral/
feeding
___IV Medication
Add 1 point if
Triggered
anything in
___Special
Add 1 point if
Triggered
anything in
___Complex
Add 1 point if
Triggered anything
in ____
Impaired Cognition:
(ST memory,
decision, self
understood, eating)
ADL>6
1 Point
SE1
ADL>6
2-3 Points
SE2
ADL>6
4-5 Points
SE3
Special SS
(ADL > 6)
ADL 17-18
SSC
ADL 15-16
SSB
ADL 4-14
SSA
Complex C
Will be a 2 if symptoms of depression
ADL 17-18
CC2
ADL 12-16
CB2
ADL 4-11
CA2
Complex C
No S/S depression
ADL 17-18
CC1
ADL 12-16
CB1
ADL 4-11
CA1
Proposed RUGs III
24 Hour Proposed RUGs III
Recommended Assessment Reference Date:
Actual RUG post completion of MDS (if different
explain):
14 Day Proposed RUGs III
Proposed: 30, 60, or 90 Day RUGs III
Comments:
© Health Dimensions Group 2008 53 RUG III-Pre-Screening Tool – HDGR
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Pressure Ulcers/Skin Integrity/Wound Management - HDGR
F Tag
F314
Quality Standard FP5, RCS 15, RCS15a
Origination Date April 1, 2008
Revision Date
POLICY
A system is in place for the prevention, identification, treatment, and documentation of
pressure and non-pressure wounds.
DEFINITIONS
Definitions are provided to clarify clinical terms related to pressure ulcers and their
symptoms and treatment.
• Pressure Ulcer: A pressure ulcer is any lesion caused by unrelieved pressure that results
in damage to the underlying tissue(s). Although friction and shear are not primarily
causes of pressure ulcers, friction and shear are important continuing factors to the
development of pressure ulcers.
• Avoidable/Unavoidable Pressure Ulcers:
- Avoidable means that the resident developed a pressure ulcer and that the facility did
not do one or more of the following:
o Evaluate the resident’s clinical condition and pressure ulcer risk factors;
o Define and implement interventions that are consistent with resident needs,
resident goals, and recognized standards of practice;
o Monitor and evaluate the impact of the interventions; and/or
o Revise the interventions as appropriate.
- Unavoidable means that the resident developed a pressure ulcer even though the
facility had:
o Evaluated the resident’s clinical condition and pressure ulcer risk factors;
o Defined and implemented interventions that are consistent with resident needs,
goals, and recognized standards of practice;
o Monitored and evaluated the impact of the interventions; and
o Revised the approaches as appropriate.
• Cleansing/Irrigation:
- Cleansing refers to the use of an appropriate device and solution to clean the surface
of the wound bed and to remove the looser foreign debris or contaminants in order to
decrease microbial growth.
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 1 of 8

Resident Care Policies and Procedures – Skilled Nursing Facility
- Irrigation refers to a type of mechanical debridement, which uses an appropriate
solution delivered under pressure to the wound bed to vigorously attempt to remove
debris from the wound bed.
• Colonized/Infected Wound:
- Colonized refers to the presence of bacteria on the surface or in the tissue of a wound
without the signs and symptoms of an infection.
- Infected refers to the presence of micro-organisms in sufficient quantity to
overwhelm the defenses of viable tissues and produce the signs and symptoms of
infection.
• Debridement: Debridement is the removal of devitalized/necrotic tissue and foreign
matter from a wound to improve or facilitate the healing process. Various debridement
methods include:
- Autolytic debridement: The use of moisture retentive dressings to cover a wound and
allow devitalized tissue to self-digest by the action of enzymes present in the wound
fluid;
- Enzymatic (chemical) debridement: The topical application of substances (e.g.,
enzymes to break down devitalized tissue);
- Mechanical debridement: The removal of foreign material and devitalized or
contaminated tissue from a wound by physical rather than by chemical or autolytic
means;
- Sharp or surgical debridement: The removal of foreign material or devitalized tissue
by a surgical instrument; and
- Maggot debridement therapy (MDT) or medicinal maggots: A type of sterile
intentional biological larval or biosurgical debridement that uses disinfected (sterile)
maggot(s) to clean wounds by dissolving the dead and infected tissues and by killing
bacteria.
• Eschar/Slough:
- Eschar is described as thick, leathery, frequently black or brown in color, necrotic
(dead) or devitalized tissue that has lost its usual physical properties and biological
activity. Eschar may be loose or firmly adhered to the wound.
- Slough is necrotic/avascular tissue in the process of separating from the viable
portions of the body and is usually light in colored, soft, moist, and stringy (at times).
• Exudate: Any fluid that has been forced out of the tissues or its capillaries because of
inflammation or injury. It may contain serum, cellular debris, bacteria, and leukocytes.
• Purulent exudate/drainage/discharge: Any product of inflammation that contains pus
(e.g., leukocytes, bacteria, and liquefied necrotic debris).
• Serous drainage or exudate: Watery, clear, or slightly yellow/tan/pink fluid that has
separated from the blood and presents as drainage.
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 2 of 8

Resident Care Policies and Procedures – Skilled Nursing Facility
• Friction/Shearing:
- Friction is the mechanical force exerted on skin that is dragged across any surface.
- Shearing is the interaction of both gravity and friction against the surface of the skin.
Friction is always present when shear force is present. Shear occurs when layers of
skin rub against each other or when the skin remains stationary and the underlying
tissue moves and stretches and angulates or tears the underlying capillaries and blood
vessels causing tissue damage.
• Granulation Tissue: The pink-red moist tissue that fills an open wound when it starts to
heal. It contains new blood vessels, collagen, fibroblasts, and inflammatory cells.
• Tunnel/Sinus Tract/Undermining: (Tunnel and Sinus Tract are often used
interchangeably)
- Tunneling is a passageway of tissue destruction under the skin surface that has an
opening at the skin level from the edge of the wound.
- Sinus Tract is a cavity or channel underlying a wound that involves an area larger
than the viable surface of the wound.
• Undermining: The destruction of tissue or ulceration extending under the skin edges
(margins) so that the pressure ulcer is larger at the base than at the skin surface.
Undermining often develops from shearing forces and is differentiated from tunneling by
the larger extent of the wound edge involved in undermining and the absence of a
channel or tract extending from the pressure ulcer under the adjacent intact skin.
STAGES OF PRESSURE ULCERS
The staging system is one method of summarizing certain characteristics of pressure ulcers,
including the extent of tissue damage. This is the system used within the RAI.
Stage I pressure ulcers may be difficult to identify because they are not readily visible and
they present with greater variability. Advanced technology (not commonly available in
nursing homes) has shown that a State I pressure ulcer may have minimal to substantial
tissue damage in layers beneath the skin’s surface, even when there is no visible surface
penetration. The Stage I indicators identified below will generally persist or be evident after
the pressure on the area has been removed for 30-45 minutes.
The definitions for the stages of pressure ulcers identified below are from the NPUAP and
used with permission.
• Stage I: An observable, pressure-related alteration of intact skin, whose indicators as
compared to an adjacent or opposite area on the body may include changes in one or
more of the following parameters:
- Skin temperature (warmth or coolness)
- Tissue consistency (firm or boggy)
- Sensation (pain, itching)
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 3 of 8

Resident Care Policies and Procedures – Skilled Nursing Facility
- A defined area of persistent redness in lightly pigmented skin, whereas in darker skin
tones, the ulcer may appear with persistent red, blue, or purple hues
• Stage II: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an abrasion, blister, or shallow crater.
• Stage III: Full thickness skin loss involving damage to, or necrosis of, subcutaneous
tissue that may extend down to, but not through, underlying fascia. The ulcer presents
clinically as a deep crater with or without undermining of adjacent tissue.
• Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis, or damage
to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and
sinus tracts also may be associated with Stage IV pressure ulcers.
Note: If eschar and necrotic tissue are covering and preventing adequate staging of a pressure
ulcer, the RAI User’s Manual, Version 2, instructs the assessor to code the pressure ulcer as a
Stage IV. These instructions must be followed for MDS coding purposes until they are
revised. Although the AHCPR and NPUAP system for staging pressure ulcers indicates that
the presence of eschar precludes accurate staging of the ulcer, the facility must use the RAI
directions in order to code the MDS, but not necessarily to render treatment.
PROCEDURE
1. Wound Assessment
a. Upon Admission:
i. A “head to toe” skin assessment will be conducted by a licensed nurse. It is
recommended that this assessment is completed within the shift that the resident
was admitted; however, it must be completed within 24 hours of admission. A
tissue tolerance test (both lying and sitting) must be completed per state
requirements and/or facility policy within 24 hours of admission. Assessment
information should identify specific factors that might increase the risk of
pressure ulcer development or affect healing of a pressure ulcer. A Norton or
Braden skin assessment will also be completed within the ARD reference period.
ii. All residents are preventatively placed on pressure reduction mattresses and
cushions in wheelchairs based on the skin assessments. Those residents who
represent a high risk will have further preventative interventions put in place.
Appropriate turning and repositioning schedules will also be put in place per
assessment. An initial/immediate care plan will be initiated.
b. Weekly:
i. A weekly skin check will be conducted and documented for at-risk residents.
ii. This is a hands-on, direct visual assessment.
c. Quarterly:
i. A Norton or Braden skin assessment will be completed in conjunction with the
RAI/care plan process.
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 4 of 8

Resident Care Policies and Procedures – Skilled Nursing Facility
ii. Assessment information should identify specific factors that might increase the
risk of pressure ulcer development or affect healing of a pressure ulcer and
documentation to reflect reassessment including any changes to the care plan.
d. Re-admission or Significant Change in Condition per MDS:
i. Follow process for admission, and complete all admission assessments.
ii. All residents are preventatively placed on pressure reduction mattresses and
cushions in wheelchairs based on the skin assessments. Those residents who
represent a high risk will have further preventative interventions put in place.
Appropriate turning and repositioning schedules will also be put in place per
assessment. An initial/immediate care plan will be initiated.
e. Annually:
i. A Norton or Braden skin assessment will be completed as per the RAI/care plan
process.
ii. A tissue tolerance test (both lying and sitting) will be completed as state required
and/or facility policy.
2. Assessment and Treatment
It is important that each existing pressure ulcer be identified, whether present on
admission or developed after admission, and that factors that may have influenced its
development, the potential for development of additional ulcers, or for the deterioration
of the pressure ulcer(s) be recognized, assessed, and addressed as follows:
a. Differentiate the type of ulcer (pressure-related versus non-pressure-related) because
interventions may vary depending on the specific type of ulcer;
b. Determine the ulcer’s stage;
c. Describe and monitor the ulcers characteristics;
d. Monitor the progress toward healing and for potential complications;
e. Determine if infection is present;
f. Assess, treat, and monitor pain, if present; and
g. Monitor dressings and treatments.
3. Treatment/Management
a. Residents with risk for or who have a loss of skin integrity will receive the
appropriate treatment/services, and residents who are determined to be at risk for or
who have loss of skin integrity will receive the appropriate treatment/services which
may include:
i. Specific physician ordered medications/treatment;
ii. Pressure relieving equipment;
iii. Repositioning or “off-loading” as per resident assessment and care plan;
iv. Nutritional support/vitamins as indicated/ordered;
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 5 of 8

Resident Care Policies and Procedures – Skilled Nursing Facility
v. Dietary consultation;
vi. Physician consultation;
vii. Rehabilitative services;
viii. Specific nursing measures such as cleansers, skin barriers, moisturizers;
ix. Assessments for pain;
x. Assessments/care to prevent infections; and/or
xi. No massaging over bony prominences.
b. All interventions and treatments should be evaluated for efficacy and
modified/changed as needed.
4. Documentation
a. Assessment:
i. Assessment information should identify specific factors that might increase the
risk of pressure ulcer development or affect healing of a pressure ulcer such as:
(1) Decreased mobility;
(2) Cognitive impairment;
(3) Significant weight loss in a resident who also has mobility/positioning
concerns;
(4) Use of restraints;
(5) Impaired nutrition or history of impaired nutrition;
(6) Non-compliance or history of non-compliance;
(7) Altered sensory perception;
(8) Incontinence;
(9) Significant abnormal lab values;
(10) History of pressure ulcers; and
(11) Any decline in clinical status or co-morbid diagnoses affecting
mobility/positioning or tissue tolerance.
ii. For a resident who was admitted with a pressure ulcer or who developed one
within one to two days, the admission documentation should include at least the
following:
(1) Ulcer site and characteristics at the time of admission, including
measurements;
(2) Possibility of underlying tissue damage because of immobility or illness
prior to admission;
(3) Skin condition on and within a day of admission if suspected deep tissue
injury (DTI). The skin was purple, discolored, or maroon in color. Any
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 6 of 8

Resident Care Policies and Procedures – Skilled Nursing Facility
blood-filled blisters present or tissue that is painful, mushy, boggy, or
warmer or cooler compared to the adjacent tissue;
(4) History of any impaired nutrition; and
(5) History of previous pressure ulcers.
b. Care Planning:
i. For new admission/readmissions, an immediate plan of care will be developed
to address the immediate interventions to preserve and/or treat skin integrity
issues. This should be communicated to staff.
ii.
iii.
For the resident at risk for developing a pressure ulcer or who has a pressure
ulcer, an individualized care plan will be developed per the RAI/care plan
timelines.
The care plan should address prevention of any skins breakdown, including
sheering or friction, repositioning or “off-loading;” pressure relief equipment;
and the care and treatment to be provided to the resident for a pressure ulcer or
non-pressure wound behaviors and preferences.
iv. If a resident refuses or resists staff interventions, the care plan should reflect
efforts to seek alternatives as well as education to resident and/or family
regarding the risks. This education should be documented.
v. All care plan interventions should be revised if there is recurring pressure
ulcers, a lack of progress toward healing, or if the resident acquires a new ulcer.
c. Routine/Ongoing Documentation:
i. Daily and/or routine ongoing documentation should be conducted by the licensed
nurse related to the resident’s skin condition and the resident’s response to the
care and treatment of the skin. This includes non-pressure wounds as well.
ii. Measurements of all pressure ulcers and non-pressure wounds will be done at
least weekly and with any noticeable change by a licensed nurse.
iii. At least weekly, an evaluation of the pressure ulcer wound should be documented
and must be transferable into the resident’s record upon discharge. At a minimum,
documentation should include the date the ulcer or wound was observed and:
(1) Location and staging;
(2) Size, (perpendicular measurements of the greatest extent of length and width
of ulceration), depth; and the presence, location and extent of any
undermining or tunneling/sinus tract;
(3) Exudate, if present; type (such as purulent/serous), color, odor, and
approximate amount;
(4) Pain, if present; nature and frequency (e.g., whether episodic or continuous);
(5) Wound bed; color and type of tissue/character including evidence of healing
(e.g., granulation tissue) or necrosis (slough or eschar); and
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 7 of 8

Resident Care Policies and Procedures – Skilled Nursing Facility
(6) Description of wound edges and surrounding tissue (e.g., rolled edges,
redness, hardness/induration, maceration) as appropriate.
d. Dietary Assessment:
i. The dietician will assess the nutritional status of the residents, initiate nutritional
interventions as needed, and continue to monitor these residents on a regular
basis. The nutritional documentation should include at least the following:
(1) Verification of current diet orders;
(2) Wound condition as reported by nursing and progress toward healing;
(3) Total calories and protein provided by food along with food/fluid intake;
(4) Appropriateness of current nutritional interventions;
(5) Review of the labs; and
(6) Review and update as needed of the care plan problems, goals, and
interventions.
ii. The RAI should also reflect the resident’s skin condition.
e. Monitoring:
i. There is a skin monitoring interdisciplinary team (IDT) which meets weekly and
could include:
(1) Clinical nurse manager or charge nurse;
(2) Infection control nurse;
(3) Dietician;
(4) Rehabilitative services representative; and/or
(5) Any other team member selected.
ii.
iii.
iv.
The purpose of the skin monitoring team is to discuss and review the
documentation and to assist in the development of a comprehensive prevention
and wound management plan for each resident who has a pressure ulcer or a
non-pressure wound, as well as new admissions and any other resident deemed
appropriate. This information must be communicated to appropriate staff and
integrated into the plan of care.
The skin monitoring team will inform the director of nurses weekly of these
findings and provided copies of reports, minutes, etc.
All pressure ulcers will be reviewed monthly by the Quality Council (see
Facility Practices/Continuous Quality Improvement Standards).
© Health Dimensions Group 2008 Pressure Ulcers/Skin Integrity/Wound Management–HDGR
Page 8 of 8

Pressure Ulcers Education – Your Skin
Informing residents and families about pressure ulcers;
and how to assist health care providers in preventing them.
What is a pressure ulcer?
A pressure ulcer, sometimes called a “bedsore,” is injury to the skin and underlying tissue usually caused
by unrelieved pressure.
These ulcers usually occur on the shoulders, elbows, hips, buttocks, and heels (areas found over bony
parts of the body that sustain pressure when lying in bed or sitting for long periods of time). They begin
as reddened areas, but can damage skin and muscles if not treated promptly.
What causes a pressure ulcer?
Pressure ulcers occur by unrelieved pressure on the skin squeezing tiny blood vessels which supply the
skin with nutrients and oxygen. When the skin is starved of nutrients and oxygen for too long, the tissue
dies and a pressure ulcer forms.
Pressure ulcers can also be caused by sliding down in a bed or chair. This stretches or bends blood
vessels, causing pressure ulcers. Even slight rubbing or friction on the skin may cause minor pressure
ulcers that can quickly worsen.
The following increase the risk for pressure ulcers:
• Inability to change positions.
• Continuous or periodic loss of bowel and/or bladder control.
• Poor nutrition and hydration.
• Lowered mental awareness.
Pressure ulcers are serious problems and can lead to:
• Pain.
• Slower recovery from health problems.
• Possible complications such as infection.
Pressure ulcers may be preventable.
By assisting your health care team in lowering your risk factors, most pressure ulcers can be prevented.
If you or your loved one are receiving hospice and/or palliative care, it is important that you discuss the
goals of care for pressure ulcer management and prevention with your health care provider. When turning
and repositioning during end-of-life care, the goal should be comfort, thus the turning schedule should be
made in consultation with you and/or your family.
Be sure that you:
• Ask questions
• Explain your needs, wants, and concerns
• Understand what and why things are being done
• Know what is best for you
• Find out how you can help prevent pressure ulcers:
- in the nursing home
- in the hospital
- at home
© Health Dimensions Group 2008 Pressure Ulcers Education–Your Skin
Page 1 of 2

Pressure Ulcers Education - Your Skin
Keys steps to pressure ulcer prevention:
Protect your skin from injury:
Limit Pressure:
• If you are in bed, your position should be changed at least every two hours.
• If you are in a chair, your position should be changed at least every hour. If you are able to shift your
own weight, you should do so every 15 minutes while sitting.
Reduce Friction:
• When shifting position or moving in your bed, don’t pull or drag yourself across the sheets. Also,
don’t push or pull with your heels. Avoid repetitive movements such as rubbing your foot on the
sheets to scratch an itchy spot.
• Avoid the use of doughnut-shaped cushions–they can actually cause injury to deep tissues.
Take care of your skin:
• Allow a member of your health care team to inspect your skin at least once per day.
• If you notice any abnormal areas, notify your nurse as soon as possible.
• Your skin should be cleaned thoroughly as soon as possible after soiling.
• Prevent dry skin by using creams or oils.
• Don’t rub or massage skin over bony parts of your body.
Safeguard your skin from moisture:
• Use absorbent pads while in bed and briefs while out of bed that pull moisture away from your body.
• Apply a cream or ointment to protect your skin from urine and/or stool.
If you are confined to bed for long periods of time:
• Talk to your nurse about getting a special mattress or overlay.
• Try to keep the head of your bed as low as possible (unless other medical conditions do not permit it).
If you need to raise the head of the bed for certain activities, try to raise it to the lowest point possible
for as short a time as possible.
• Pillows or foam wedges should be used to keep your knees or ankles from touching each other.
• Avoid lying directly on your hip bone when lying on your side. Also, a position that spreads weight
and pressure more evenly should be chosen if possible—pillows may help.
• If you cannot move at all, pillows should be placed under your legs from mid-calf to ankle to keep
your heels off the bed. Never place pillows behind the knee.
If you are in a chair or wheelchair:
• Talk to your nurse about getting a chair cushion to reduce pressure while sitting.
• Remember that comfort and good posture are important.
Improve your ability to move:
Ask your nurse if you qualify for a rehabilitation program designed to help you regain independence and
improve movement.
Be Active in Your Health Care!
Reduce your risk of getting pressure ulcers. Get your family and health care team involved in pressure
ulcer prevention.
© Health Dimensions Group 2008 Pressure Ulcers Education–Your Skin
Page 2 of 2

Pressure Ulcers Weekly Skin Assessment - Sample
Date: Resident: MR#: Rm#:
Describe skin conditions observed. Mark the affected area on the diagram. Specific wound
measurements to be recorded on Admission/Weekly Wound Assessment. Notify physician of
conditions of new onset or if indicated by change in condition.
FRONT
Describe skin condition observed:
BACK
FRONT
Describe skin condition observed:
BACK
Signature: Date: Signature: Date:
FRONT
Describe skin condition observed:
BACK
FRONT
Describe skin condition observed:
BACK
Signature: Date: Signature: Date:
© Health Dimensions Group 2008 Pressure Ulcers – Weekly Skin Assessment – Sample
Page 1 of 1

Pressure Ulcers – Weekly Wound Report - Sample
Patient Name
Wound
Type
Adm or
Inhouse
Date of
Onset
Location
of wound
Initial
Stage
Current
Stage
Size Appearance Treatment
Dx
cont.
factors
Prevent/
Intervent
Nourishment
Comment
Nurse Signature: Date:
© Health Dimensions Group 2008 Pressure Ulcers – Weekly Wound Report – Sample
Page 1 of 1

Step One: Assess skin condition
Yes
Document
• Length
• Width
• Depth
• Location
• Stage
• Exudate
• Tunneling
• Necrosis
v
`
• Granulation
• Undermining
• Sinus Tracts
Report
findings to
physician
Obtain order
for treatment
from physician
Notify
family
Go to
Step
Two
Patient is admitted or
readmitted to SNF
Head-to-toe
assessment
Does the patient have
a pressure ulcer?
Pressure Ulcers -Prediction, Prevention, and Treatment Pathway
No
Document
• Color
• Temperature
• Moles
• Bruises (M)*
• Incisions
• Scars
• Intact
• Burns
Report anything
abnormal to
physician
Notify
family
Go to
Step Two
Remember: If a patient is at risk or has a
pressure ulcer, repeat Step One on a weekly
basis.
*(M) Measure the bruise
Complete head-to-toe
assessment weekly
Address possible risk factors
Step Two: Complete risk assessment to identify risk
factors and care plan interventions
Yes
Care Plan
actual skin
problem
No
Care Plan
potential skin
problem
Possible care planning interventions
© Health Dimensions Group 2008 Pressure Ulcers – Prediction, Prevention, and Treatment Pathway – Sample
Page 1 of 1
Yes
Complete care plan problem statement.
Skin integrity, impaired, actual as
evidenced by (wound-specific description,
location, stage and measurements)
related to (R/T) identified risk factors
Bed/Chair
mobility
Friction
and/or
shear
B/B
incontinence
and
moisture
Nutrition
and body
weight
Other
residentspecific
risk
factors
Yes
Complete
skin risk
assessment
At risk? Remember, those with a
pressure ulcer are automatically at risk
Does the patient
have a pressure
ulcer?
No
Repeat skin risk
assessment at least
every 90 days and at
significant change or
per facility protocol
Complete care plan problem statement.
Potential for impaired skin integrity as
evidenced. Risk assessment indicates that
the resident is at risk for skin breakdown;
related to (RT) identified risk factors
Bed
• Turn/repositioning schedule
• Pressure reducing or relieving device
• Therapy consult
Chair
• Repositioning schedule
• Pressure relieving cushion
• Assessment of chair fit
Friction/Shear
• Padding to prevent skin contact
• Booties/heel protectors
• HOB in lowest position possible-unless
contraindicated by medical condition
• Positioning device
Incontinence
• Peri care at least every two hours
• Clean as soon as possible after soiling
• Barrier cream
• Incontinence pads
• Incontinence briefs
Moisture
• Fan
• Light powder
Nutrition and body weight
• Weekly weight
• Dietician consult
• Labs
• Food supplements
• Vitamin/medication supplements
• Hydration
• Feeding assistance
• Assessment for chewing and
swallowing problem
Other
• Add any/all interventions related to
indentified specific risk factors
Perform Step Two at least every 90 days and with any
significant change. Adjust care plan as needed.

Pressure Ulcers Skin Grid - Sample
Date: Resident: MR#: Rm#:
One site per page, complete weekly, when wound is resolved; enter “healed” in comments section.
Was wound present on admission?
Yes
No
Site (location) Pressure Stasis
Other
Stage
Dimensions (In cm)
Length Width Depth
Drainage Color Odor Tunneling/
Undermining
Amount of
Drainage
Was physician notified?
RN/LPN signature:
Yes Date:
Right Bottom
FRONT
BACK
Left Bottom
I. Persistent area of skin redness (without a break in the skin)
that DOES NOT DISAPPEAR WITHIN 30 MINUTES when
pressure is relieved. (In darker skin tones, the ulcer may
appear with persistent red, blue, or purple hues.)
II. Partial thickness loss of skin layers that presents clinically as
an abrasion, blister, or shallow crater.
Date Stage Visualized
Stage
Length
in cm.
Width
In cm
Depth
in cm
STAGING DESCRIPTIONS
Color of
Drainage
(S,P or O)
Color
(P,R,Y
N or B)
III. Full thickness of skin is lost, exposing the subcutaneous
tissues. Presents as a deep crater with or without
undermining adjacent tissue.
IV. Full thickness of skin and subcutaneous tissues is lost
exposing the muscle and/or bone.
If there is eschar, do not stage; note as “E” in stage column
Odor
(O,M
or F)
Tunneling/
Undermining
Depth
12
Tunneling/
Undermining
Depth
Comments
(address pain, drainage amt, peri
wound & healed status only
RN/LPN
initials
9
3
6
12
9
3
6
12
9
3
6
12
9
3
6
12
9
3
6
DOCUMENTATION KEY
Drainage: S = Serosanquineous
Color: P = Pink R = Red
P = Purulent
Y = Yellow
B = Black (eschar)
O = None
N = Necrotic/Slough
Odor: O = None M = Mild F = Foul Tunneling: Use clock to indicate location
Signature:
Date:
© Health Dimensions Group 2008 Pressure Ulcers - Skin Grid - Sample
Page 1 of 1

Pressure Ulcers Tissue Tolerance Assessment While Sitting or Lying - Sample
Date: Resident: MR#: Rm#:
Complete on all residents who are unable to reposition themselves while sitting or lying. The
assessment will start at a one-hour interval. If the initial one-hour interval is tolerated, increase to
one- and one-half hours, if that is tolerated, increase to two hours. If two hours are tolerated, stop the
assessment and add turning interval to the care plan and nursing assistant assignment sheet.
The assessment would stop if a bony prominence remains red at the time of any assessment.
Reposition the resident off the reddened area and recheck after one hour. If the redness resolved, the
repositions interval was appropriate. If area remains red, initiate pressure ulcer protocol for Stage I
ulcers and decrease repositioning time by half-hour increments, until appropriate interval is
determined.
Does the resident have a pressure reduction device on the wheelchair/sitting or lying surface?
(Circle one) YES NO *If no, contact Occupational Therapy
Initial observations of bony prominences (e.g., hips, scrum, coccyx, ischial tuberosities, heels, ankle bones, spine,
shoulders, shoulder blades, head, ears)
Date and time
Skin observations and any modifications to
turning and repositioning due to skin concerns:
Nurse’s Signature:
2 nd Step – 1 hour after initial observations – resident has been sitting or lying without interruption
Date and time
Skin observations results:
redness/discoloration: location
consistency (firm or mushy): location
temperature change (cold or warm): location
sensation changes (pain or irritation): location
breaks in skin: location
Nurse’s Signature:
3 rd Step – 1-½ hours after initial observations – resident has been sitting or lying without interruption
Date and time
Skin observations results:
redness/discoloration: location
consistency (firm or mushy): location
temperature change (cold or warm): location
sensation changes (pain or irritation): location
breaks in skin: location
Nurse’s Signature:
4 th Step – 2 hours after initial observations – resident has been sitting or lying without interruption
Date and time
Skin observations results:
redness/discoloration: location
consistency (firm or mushy): location
temperature change (cold or warm): location
sensation changes (pain or irritation): location
breaks in skin: location
Nurse’s Signature:
* If determined that there are no reddened areas after two hours, the care plan could address repositioning every two hours is appropriate.
© Health Dimensions Group 2008 Pressure Ulcers - Tissue Tolerance Assessment While Sitting or Lying - Sample
Page 1 of 1

Pressure Ulcers Tissue Tolerance Test While Seated - Sample
Date: Resident: MR#: Rm#:
Complete a Norton Scale
o Moderate risk score 15–19
o High risk score 14 or less
Complete a Tissue Tolerance Test
Observe for color alteration:
o Redness for light skin tone
o Blue or purple hues in darker skin tones
Resident seated in chair/wheelchair or in bed with head elevated 30 degrees or more:
Color alteration observed after one hour:
No
Yes (go no further)
Nurse’s Signature Date Time
Color alteration observed after one hour:
No
Yes (go no further)
Nurse’s Signature Date Time
Color alteration observed after one hour:
No
Yes (go no further)
Nurse’s Signature Date Time
© Health Dimensions Group 2008 Pressure Ulcers - Tissue Tolerance Test While Seated - Sample
Page 1 of 1

Pressure Ulcers Braden Assessment - Sample
Date: Resident: MR#: Rm#:
Use as a guide to identify risk factors and appropriate interventions. Should be done in conjunction with the Braden
RISK FACTORS
Overall Braden Risk score of:
Scored 3 or lower in Sensory Perception
Scored 3 or lower in Moisture
Incontinent of Bowel
Incontinent of Bladder
Scored 3 or lower in Activity
Bedfast
Chairfast
Scored 2 or lower in Mobility
Scored 2 or lower in Nutrition
Scored 2 or lower in Friction & Shear
OTHER RISK FACTORS:
Cognitively impaired
Contractures of
HOB elevated majority of day
Assists with ADLs
Low Albumin or Pre-albumin level (circle)
Poor skin turgor
Non-compliance
Restraint use
Pain
Psychotropic drug use
Steroid, chemo, or radiation therapy
Contributing diagnosis of:
Cardiovascular disease
PVD
Pulmonary disease
Diabetic
CVA
Paraplegia or Quadriplegia (circle)
Terminal cancer
Chronic/end stage renal, liver or heart disease (circle)
Immunosuppression
Fracture
Hx of pressure ulcers
Cognitive impairment (Alzheimer’s, Dementia)
Parkinson’s
Other diagnosis:
OTHER RISK FACTORS:
*Resident has actual open area (describe type and location):
LOWER EXTREMITY CONCERNS:
S/S of Arterial Disease (PVD): Circle those that apply: no
pedal pulse; cold extremity; thin, shiny, taut skin; lack of hair
to extremity, complaints of lower extremity pain with exercise
or when lying in bed. Other:
S/S of Venous Insufficiency (Stasis): Circle those that apply:
edema, brown discoloration of lower extremities, history of
cellulitis.
Other:
S/S of Neuropathy: Circle those that apply: loss of
sensation to lower extremity, foot deformities. Other:
INTERVENTIONS
BRADEN ASSESSMENT INTERVENTIONS:
Sensory Perception Concerns:
Pad, protect and/or apply skin prep to fragile skin
Position body with pillows/support devices, protect bony prominences
Moisture Concerns:
B & B program
4x4s/wash clothes in-between skin folds and/or corn starch to wick up moisture
Keep skin clean and dry
Peri care after each incontinent episode
Barrier cream to areas exposed to moisture/incontinence
Foley catheter to prevent maceration
Fecal tube/pouch to prevent maceration
Activity and/or Mobility Concerns:
Turn and reposition q________
Encourage mobility and ambulation
Pressure reduction support surface in bed, type & date applied
Pressure reduction sitting/wheelchair surface, type & date applied:
Elevate heels off the bed
PT/OT referral
Check restraints q30min, release q
Nutritional Concerns:
Dietary referral
Provide supplements, calories, and vitamins as ordered (circle)
Monitor labs, weight, and/or intake (circle)
Friction & Shear Concerns:
Keep linen dry & wrinkle free
Knee catch bed before raising head of bed
Lift, do not slide, resident/use assistive devices to decrease friction
OTHER INTERVENTIONS FOR RISK FACTORS NOT ON BRADEN:
Inspect skin daily
Weekly skin assessment by licensed staff
Moisturize dry skin
Bathe with mild soap, gently dry
No more then 30° side lying positioning and/or head elevation in bed (unless
contraindicated)
Psychosocial support as appropriate
Risk assessment per protocol
Monitor pain and administer pain medications/treatments as ordered
Podiatrist as appropriate
Wound care consultation as ordered
Monitor/manage diabetes
Assess lower extremity for arterial insufficiency and/or neuropathy
Appropriate foot and nail care
Involve/educate resident and/or family members
LOWER EXTREMITY CONCERNS:
Arterial insufficiency (PVD)
Optimize blood flow to extremity, keep legs in neutral position
Revascularization if possible
Medications to improve RBC transit through narrowed vessels
Prevent trauma, proper fitting footwear, pressure reduction to heels
Encourage lifestyle changes (cessation of smoking, caffeine)
Hydration
Venous Insufficiency (stasis)
Optimize venous return, compression therapy and leg elevation
Lubricate dry skin
Ambulate to tolerance
Neuropathy/Diabetic Wounds
Prevent trauma, proper fitting footwear, pressure relief to heels
Optimize blood flow to extremity, keep legs in neutral position
Tight glucose control
Signature:
Date:
© Health Dimensions Group 2008 Pressure Ulcers – Braden Assessment Sample
Page 1 of 2

Pressure Ulcers Braden Assessment - Sample
Date: Resident: MR#: Rm#:
Review Findings:
Signature:
Date:
Review Findings:
Signature:
Date:
Review Findings:
Signature:
Date:
© Health Dimensions Group 2008 Pressure Ulcers – Braden Assessment Sample
Page 2 of 2

Braden Scale For Predicting Pressure Sore Risk - Sample
Resident: MR#: Rm#: SCORE
DATE DATE DATE DATE
SENSORY PERCEPTION ability
to respond meaningfully to
pressure-related discomfort
1. Completely Limited Unresponsive
(does not moan, flinch, or grasp) to
painful stimuli, due to diminished level
of consciousness or sedation. OR
limited ability to feel pain over most of
body.
2. Very Limited Responds only to painful
stimuli. Cannot communicate discomfort
except by moaning or restlessness OR
has a sensory impairment which limits the
ability to feel pain or discomfort over onehalf
of body.
3. Slightly Limited Responds to verbal
commands, but cannot always
communicate discomfort or the need to be
turned. OR has some sensory impairment
which limits ability to feel pain or
discomfort in 1 or 2 extremities.
4. No Impairment Responds to
verbal commands. Has no
sensory deficit which would limit
ability to feel or voice pain or
discomfort.
MOISTURE degree to which skin
is exposed to moisture
1. Constantly Moist Skin is kept moist
almost constantly by perspiration,
urine, etc. Dampness is detected every
time patient is moved or turned.
2. Very Moist Skin is often, but not always
moist. Linen must be changed at least
once a shift.
3. Occasionally Moist Skin is
occasionally moist, requiring an extra linen
change approximately once a day.
4. Rarely Moist Skin is usually
dry. Linen only requires changing
at routine intervals.
ACTIVITY degree of physical
activity
1. Bedfast Confined to bed. 2. Chairfast Ability to walk severely
limited or non-existent. Cannot bear own
weight and/or must be assisted into chair
or wheelchair.
3. Walks Occasionally Walks
occasionally during day, but for very short
distances, with or without assistance.
Spends majority of each shift in bed or
chair.
4. Walks Frequently Walks
outside room at least twice a day
and inside room at least once
every two hours during waking
hours.
MOBILITY ability to change and
control body position
1. Completely Immobile Does not
make even slight changes in body or
extremity position without assistance.
2. Very Limited Makes occasional slight
changes in body or extremity position but
unable to make frequent or significant
changes independently.
3. Slightly Limited Makes frequent
though slight changes in body or extremity
position independently.
4. No Limitation Makes major
and frequent changes in position
without assistance.
NUTRITION usual food intake
pattern
1. Very Poor Never eats a complete
meal. Rarely eats more than one-third
of any food offered. Eats 2 servings or
less of protein (meat or dairy products)
per day. Takes fluids poorly. Does not
take a liquid dietary supplement OR is
NPO and/or maintained on clear liquids
or IVs for more than 5 days.
2. Probably Inadequate Rarely eats a
complete meal and generally eats only
about one-half of any food offered. Protein
intake includes only 3 servings of meat or
dairy products per day. Occasionally will
take a dietary supplement OR receives
less than optimum amount of liquid diet or
tube feeding.
3. Adequate Eats over half of most meals.
Eats a total of 4 servings of protein (meat,
dairy products) per day. Occasionally will
refuse a meal, but will usually take a
supplement when offered OR is on a tube
feeding or TPN regimen which probably
meets most of nutritional needs.
4. Excellent Eats most of every
meal. Never refuses a meal.
Usually eats a total of 4 or more
servings of meat and dairy
products. Occasionally eats
between meals. Does not require
supplementation.
FRICTION & SHEAR
1. Problem Requires moderate to
maximum assistance in moving.
Complete lifting without sliding against
sheets is impossible. Frequently slides
down in bed or chair, requiring frequent
repositioning with maximum
assistance. Spasticity, contractures, or
agitation leads to almost constant
friction.
2. Potential Problem Moves feebly or
requires minimum assistance. During a
move skin probably slides to some extent
against sheets, chair, restraints, or other
devices. Maintains relatively good position
in chair or bed most of the time but
occasionally slides down.
3. No Apparent Problem Moves in bed
and in chair independently and has
sufficient muscle strength to lift up
completely during move. Maintains good
position in bed or chair.
Total Score
Nurse’s Initials
Nurse’s Signature: Date: Nurse’s Signature: Date:
Nurse’s Signature: Date: Nurse’s Signature: Date:
© Barbara Braden and Nancy Bergstrom, 1988. All rights reserved. Pressure Ulcers-Braden Scale for Predicting Pressure Sores Risk-Sample
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Privacy and Confidentiality
F Tag
F164
Quality Standard RCS11
Origination Date April 1, 2008
Revision Date
POLICY
The resident is treated with consideration and respect and full recognition of his/her dignity
and individuality, including privacy in treatment and in care for personal needs. The resident
is encouraged to do as much for him/herself as possible in terms of personal needs. Nursing
assistance is available to augment self-care limitations.
The resident is assured confidential treatment of personal and medical records. Release of
information to outside parties is made only upon written approval of the resident or guardian
or as permitted by law.
All matters pertaining to resident care are strictly confidential. These matters are discussed
with appropriate health care team members only when necessary to facilitate professional,
physical, social, emotional, or spiritual care of the resident.
Resident records are limited to the use of the staff and will be safeguarded at all times to
ensure confidentiality.
Photography of residents is not permitted without written consent of the resident or
guardian/family member.
It is the policy of the facility to provide privacy for the residents upon request. A room for
privacy will be assigned a "Do Not Disturb" sign placed on the door. Areas that may be used:
• Resident’s room
• Activity room
• Quiet room
• Dining room when not in use
• Office space when not in use
© Health Dimensions Group 2008 Privacy and Confidentiality
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Private Duty Nursing Staff
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
There is a system in place to ensure that the standard of care is maintained for all residents if
the family or resident retains private duty nursing staff.
PROCEDURE
1. Upon notification that the resident has retained private duty staff, director of nursing or
designee initiates collection of all credentials, licenses, insurance, background checks,
health, and other documentation required of the facility staff position that is equivalent
the private duty staff person’s duties.
2. The facility informs the resident and the resident’s DPOA (durable power of attorney) of
the conditions and restrictions that apply to the private duty staff person. The facility
obtains written confirmation and agreement from the resident and the DPOA that such
conditions and restrictions are acceptable. The private duty staff person is not allowed to
practice in the facility until the resident and/or his/her DPOA have been informed and
agree to the conditions.
3. The facility obtains permission from the resident to release Protected Health Information
(PHI) to the private duty staff person, as appropriate.
4. If the private duty staff person does not pass the checks above, that person is not allowed
to practice in the facility, regardless of the resident’s preference.
5. The responsibilities and duties of the private duty staff person are recorded in resident’s
care plan.
6. The private duty staff person shall agree, in writing, to follow the facility’s standard of
care, to follow the resident’s care plan, and conform to all of the facility’s policies,
procedures, and protocols that apply to the resident. The private duty staff person will
complete an orientation in the facility.
7. The private duty staff person follows the resident’s plan of care, documents, and reports
to the charge nurse, at the direction of the charge nurse.
8. The private duty staff person shall not be allowed to practice in the facility if the private
duty staff person fails to follow the facility’s standards of care, fails to follow the
resident’s care plan, or fails to conform to the facility’s policies, procedures, and
protocols that apply to the resident.
© Health Dimensions Group 2008 Private Duty Nursing Staff
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title
F Tag
Quality Standard
Origination Date April 1, 2008
Revision Date
Quality Council - Assurance and Improvement
F520, F521
FP1, FP2, FP3, FP4, FP5, FP6, FP7, FP8, FP9, FP10, FP11,
FP13, FP14, FP15, FP16, FP19, HR37
POLICY
The facility maintains a Quality Council that consists of at least the following:
• Director of nursing;
• Administrator;
• Medical director;
• Leadership team;
• Pharmacist; and
• Others as designated by the facility.
PROCEDURE
The Quality Council:
1. Meets monthly to identify issues with respect to necessary quality assessment, quality
assurance, and improvement activities.
2. Develops and implements appropriate plans of action to correct identified quality
deficiencies.
A state may not require disclosure of the records of such a committee except insofar as such
disclosure is related to the compliance of such committee with the requirements of this
section.
Good faith attempts by the Quality Council to identify and correct quality deficiencies will
not be used as a basis for sanctions.
© Health Dimensions Group 2008 Quality Council–Assurance and Improvement
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Quality Council Health Dimensions Group Values – HDGR
F Tag
N/A
Quality Standard FP1 through FP11, FP13, FP14, FP15, FP16, FP19, HR37
Origination Date April 1, 2008
Revision Date
Health Dimensions Group is committed to the core values of hospitality, stewardship,
integrity, respect, and humor. These values, in addition to the significance and impact on the
service we provide, determine our priorities, inform our decisions, and represent stability to
those we serve.
Hospitality
• Creating a climate that promotes teamwork while valuing the uniqueness of the
individual.
• Listening and responding sensitively to all.
• Extending warmth and acceptance to each other and to all we serve.
• Creating a welcoming atmosphere personally and organizationally.
• Welcoming new ideas and being open to change.
Stewardship
• Utilizing human resources responsibly.
• Providing wise and respectful use of all material and monetary resources.
• Promoting conservation of resources and energy.
• Representing the value and worth of the company.
Integrity
• Creating a daily practice of doing the right things.
• Being responsible for the commitments we have made.
• Being honest in personal and business communications and actions that build trust.
• Commitment to honesty, reliability, and confidentiality.
Respect
• Cherishing and promoting the worth of all human life.
• Treating all persons with dignity and respect without regard to age, gender, race,
minority, or economic status.
• Valuing the dignity of all work.
© Health Dimensions Group 2008 Quality Council Health Dimensions Group Values—HDGR
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
• Promoting participation of all persons in the decisions affecting their lives.
Humor
• Providing creativity and a willingness to consider and embrace new ideas.
• Encouraging communication.
• Reminding us that no one is perfect.
• “Laughter is the shortest distance between two people.”
• Having fun at work!
© Health Dimensions Group 2008 Quality Council Health Dimensions Group Values—HDGR
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing facility
Policy Title Radiology and Other Diagnostic Services (General)
F Tag
F508, F509, F510, F511, F512, F513
Quality Standard RCS2, RCS32
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides or obtains radiology and other diagnostic services to meet the needs of
all residents. The facility is responsible for the quality and timeliness of the services.
If the facility provides its own diagnostic services, the services meet the applicable
conditions of participation for hospitals.
If the facility does not provide its own diagnostic services, it must have an agreement to
obtain these services from a provider or supplier that is approved to provide these services
under Medicare.
Radiology and other diagnostic services are provided or obtained only when ordered by the
attending physician.
The facility promptly notifies the attending physician of the findings.
The facility assists the resident in making transportation arrangements to and from the source
of service, if the resident needs assistance.
The facility files in the resident’s clinical record signed and dated reports of x-ray and other
diagnostic services.
© Health Dimensions Group 2008 Radiology and Other Diagnostic Services (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing facility
Policy Title Range of Motion
F Tag
F317, F318
Quality Standard RCS31
Origination Date April 1, 2008
Revision Date
POLICY
Based on the comprehensive assessment of a resident, the facility ensures that:
• A resident who enters the facility without a limited range of motion (ROM) does not
experience reduction in range of motion unless the resident’s clinical condition
demonstrates that a reduction in range of motion is unavoidable; and
• A resident with a limited range of motion receives appropriate treatment and services to
increase range of motion and/or to prevent further decrease in range of motion.
PROCEDURE
1. Wash hands.
2. Promote privacy.
3. Explain the procedure to the resident.
4. Start at neutral position; resident lying on back with arms at side (if in bed).
5. ROM by joint:
a. Head
i. Bend head toward chest and back.
ii. Turn head to each side.
iii. Tilt head to each side.
iv. Curve back up to touch chin to chest.
b. Shoulder
i. Raise arm above head and return to side.
ii. Move arm away from body and return to side.
iii. Bring arm across chest and hand touches opposite ear.
c. Elbow
i. Bend arm at elbow until fingertips touch shoulder.
ii. Rotate arm with palm up and palm down.
© Health Dimensions Group 2008 Range of Motion
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing facility
d. Forearm
i. Hold wrist or hand, as in handshake.
ii. First turn palm of the hand up, and then turn palm of the hand down.
e. Wrist
i. Bend wrist toward body and away from body.
ii. Tip wrist to right and left.
f. Fingers
i. Spread thumb away from rest of fingers.
ii. Bring thumb into palm.
iii. Separate all fingers.
iv. Make a fist of hand.
g. Legs–hips and knees
i. Raise leg straight up and down, keeping leg straight.
ii. Rotate leg in and back.
iii. Rotate leg out and back.
iv. Bend knee to chest and back.
v. Move leg to side and back.
vi. Cross leg over other leg above it.
h. Ankle and foot
i. Bend foot toward head and back.
ii. Bend foot pointing toes.
iii. Turn foot to right.
iv. Turn foot to left.
v. Curl toes downward.
6. Note completion of ROM on activities of daily living (ADL) sheet or according to
facility-specific procedures.
7. Notify charge nurse or designee of any problems.
8. Notify physician and/or therapist, as needed.
© Health Dimensions Group 2008 Range of Motion
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Rectal (Digital) Examination
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A rectal examine may be performed by a licensed nurse to examine resident’s rectum and
lower colon, to palpitate prostate or other organs, and to examine the resident for fecal
impaction.
PROCEDURE
1. Wash hands.
2. Take equipment to room.
3. Provide privacy.
4. Explain procedure to resident.
5. Place resident in position ordered by physician; usually Sim’s left lateral.
6. Place towel under buttocks and drape resident. Avoid unnecessarily exposing resident.
7. Apply gloves.
8. Squeeze lubricant onto glove.
9. Use one hand to expose anus and insert index finger of the other hand gently into anus
directing it backward toward sacrum to feel for stool.
10. Cleanse resident’s rectum with toilet paper to remove lubricant, wash as needed.
11. Discard toilet paper in applicable waste disposal container.
12. Remove gloves.
13. Wash hands.
14. Replace covers.
15. Leave resident comfortable, with call light in reach.
16. Wash hands.
17. Document procedure, time, by whom done, and care of specimen, if one was obtained, on
the nurse’s notes.
© Health Dimensions Group 2008 Rectal (Digital) Examination
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Refusal of Transfer
F Tag
F177
Quality Standard FP101
Origination Date April 1, 2008
Revision Date
POLICY
Resident has a right to refuse a transfer to another room if the purpose is to only relocate:
• From a certified Medicare bed to a non-certified bed; or
• From a non-certified to a certified bed.
The resident is informed in writing prior to a transfer. The written notification includes the
medical reason for the transfer and specifies the methods and types of payment for the type
of bed usage.
PROCEDURE
1. Contact Social Services or designee with any questions.
2. Social Services will meet with resident/family to review information.
© Health Dimensions Group 2008 Refusal of Transfer
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Rehabilitation Services Orders
F Tag
N/A
Quality Standard RCS31
Origination Date April 1, 2008
Revision Date
POLICY
The facility provides physical, occupational, or speech therapy to attain or maintain function
and/or prevent decline with a physician-ordered treatment plan.
PROCEDURE
1. Obtain physician order for rehabilitation services, with specific discipline, treatment, and
duration.
2. Contact the Therapy Department to notify of any physician orders.
3. Note rehabilitation on the resident’s care plan.
© Health Dimensions Group 2008 Rehabilitation Services Orders
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Call System
F Tag
F463
Quality Standard FP29
Origination Date April 1, 2008
Revision Date
POLICY
All residents have call system access while in bed or while sitting at their bedside or in the
bathroom.
Residents who are unable to use their call system, due to decreased physical or mental
ability, are so identified with needs anticipated to best of abilities.
All staff responds promptly when the call system is activated.
© Health Dimensions Group 2008 Resident Call System
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing facility
Policy Title Resident Council/Family Council
F Tag
F243, F244, F245
Quality Standard FP82, FP84
Origination Date April 1, 2008
Revision Date
POLICY
A resident has the right to organize and participate in resident groups in the facility.
A resident’s family has the right to meet in the facility with the families of other facility
residents.
The facility will provide private meeting space to a resident or family group.
Staff or visitors may attend meetings at the group’s invitation.
The facility designates staff member to be responsible for assisting group meetings and
responding to any written requests that result from group meetings.
When a resident or family group exists, the facility listens to the views and acts upon the
concerns and recommendations of residents and families concerning policy and operational
decisions affecting resident care and life in the facility.
A resident has the right to participate in social, religious, and community activities that do
not interfere with the rights of other residents in the facility.
© Health Dimensions Group 2008 Resident Council/Family Council
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Funds - Protection
F Tag
F158, F159
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The resident has the right to manage his/her own financial affairs. In the event that he/she is
not able to do so, a member of the family, the responsible party, or a court-appointed
guardian will assume responsibility.
The facility arranges to hold, safeguard, manage, and account for the personal funds of
residents that provide written authorization to do so.
© Health Dimensions Group 2008 Resident Funds—Protection
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Health Status - Informed Choice
F Tag
F154, F155
Quality Standard RCS6
Origination Date April 1, 2008
Revision Date
POLICY
Each resident has the right to be informed (in a language that resident understands) of his/her
total health status, including, but not limited to the following:
• Medical care
• Nursing care
• Nutritional status
• Rehabilitation and restorative potential
• Activities potential
• Cognitive status
• Oral health status
• Psychosocial status
• Sensory and physical impairments
The resident is involved in the assessment and care planning process and is allowed choices
based on information provided. The resident is encouraged to attend the care plan meeting if
desired.
The physician indicates, as evidenced by documentation in the medical record, that resident
has discussed the medical condition and rehabilitation potential with the resident.
Social Services or designee explains the process of the interdisciplinary team conference and
requests input from the resident regarding care prior to each or at the time of the conference.
Following the conference, if families/residents are not present, the information will be
communicated to them.
Prior to any treatment, the procedure and expected outcomes are explained to the resident.
As appropriate, explanations are given to residents concerning medications they are taking.
The resident and/or family are invited to participate in the care plan conference. The social
worker or designee addresses the resident and/or family regarding attendance.
© Health Dimensions Group 2008 Resident Health Status—Informed Choice
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Mail
F Tag
F170, F171
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All mail addressed to the resident is delivered to him/her promptly and unopened.
Residents have access to stationary, postage, and writing instruments by notifying the social
worker or designee.
Residents are assisted, as necessary, with written communication by the social worker or
designee.
© Health Dimensions Group 2008 Resident Mail
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights
F Tag
F150
Quality Standard FP50, RCS6, RCS
Origination Date April 1, 2008
Revision Date
POLICY
Residents in the facility have a right to:
• Personal privacy and confidentiality of his/her personal and clinical records;
• Refuse release of personal and clinical records except as provided by law;
• Reside and receive services in the facility with reasonable accommodation of individual
needs and preferences;
• Exercise his/her rights as a resident of the facility and as a citizen or resident of the
United States;
• Upon written request, inspect and purchase photocopies of all records pertaining to the
resident;
• Be fully informed of his/her total health status, including but not limited to his/her
medical condition;
• Refuse treatment and refuse to participate in experimental research;
• Choose a personal attending physician;
• Be fully informed in advance about care and treatment and of any changes in that care or
treatment that may affect the resident’s well being;
• Participate in care planning and treatment or changes in care and treatment;
• Be free of interference, coercion, discrimination, or reprisal from the facility in exercising
his/her rights;
• Be free from verbal, sexual, physical or mental abuse, corporal punishment, and
involuntary seclusion;
• Be free from any physical restraints imposed or psychoactive drug administered for the
purposes of discipline or convenience and not required to treat the resident’s medical
symptoms;
• Examine the results of the most recent survey of the facility conducted by federal or state
surveyors and any plan of correction in effect with respect to the facility;
• Receive information from agencies acting as client advocates and be afforded the
opportunity to contact these agencies;
© Health Dimensions Group 2008 Resident Rights
Page 1 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
• Privacy in written communications, including the right to send and receive mail promptly
that is unopened and to have access to stationary, postage, and writing implements at the
resident’s own expense;
• Receive visitors and have access to such visitors at any reasonable hour;
• Immediate access by:
- Any representative of the secretary of Health and Human Services;
- Any representative of the state;
- The resident’s individual physician;
- The state’s long-term care ombudsman;
- The agency responsible for the protection and advocacy system for developmentally
disabled individuals;
- The agency responsible for the protection and advocacy system for mentally ill
individuals;
- Immediate family or other relatives of the resident subject to the resident’s right to
deny or withdraw consent at any time; or
- Others who are visiting with the consent of the resident subject to reasonable
restrictions and the resident’s right to deny or withdraw consent at any time.
• Have regular access to the private use of a telephone;
• Share a room with his/her spouse when married residents live in the same facility and
both spouses consent to the arrangement;
• Participate in social, religious, and community activities that do not interfere with the
rights of other residents in the facility;
• Organize and participate in resident groups in the facility;
• Choose activities, schedules, and health care consistent with his/her interests,
assessments, and plans of care;
• Interact with members of the community both inside and outside the facility;
• Make choices about aspects of his/her life in the facility that are significant to the
resident;
• Refuse to perform services for the facility;
• Perform services for the facility, if he/she chooses, with appropriate approvals and
compensation as included in the resident’s plan of care;
• Retain and use personal possessions, including some furnishings and appropriate clothing
as space permits, unless to do so would infringe upon the rights or health and safety of
other residents;
• Voice grievances with respect to treatment or care that is, or fails to be, furnished without
discrimination or reprisal for voicing the grievances;
© Health Dimensions Group 2008 Resident Rights
Page 2 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
• Prompt efforts by the facility to resolve grievances the resident may have, including those
with respect to behavior of other residents;
• Manage his/her financial affairs and the facility may not require residents to deposit their
personal funds with the facility; and
• To self-administer drugs, unless this is determined to be an unsafe practice.
© Health Dimensions Group 2008 Resident Rights
Page 3 of 3

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Access and Visitation
F Tag
F172, F173
Quality Standard RCS4
Origination Date April 1, 2008
Revision Date
POLICY
The resident may associate and communicate privately with other persons of resident’s
choice.
PROCEDURE
1. Areas for privacy are provided to residents upon request.
2. The facility provides immediate access to any resident by:
a. Any representative of the state.
b. The resident’s physician.
c. The state long-term care ombudsman.
d. Any visitor.
© Health Dimensions Group 2008 Resident Rights—Access and Visitation
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Accounting and Records
F Tag
F159
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility has established and maintains a system that assures a full, complete, and separate
accounting of each resident’s personal funds entrusted to the facility on the resident’s behalf.
The accounting system conforms to generally accepted accounting principles.
© Health Dimensions Group 2008 Resident Rights—Accounting and Records
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Assurance of Financial Security
F Tag
F161
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will purchase a surety bond or otherwise provide assurance, satisfactory to the
State Secretary of Licensing and Certification that all personal funds of residents deposited
with the facility are secure and will be maintained by the facility’s business office,
administrator, or designee.
© Health Dimensions Group 2008 Resident Rights—Assurance of Financial Security
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Conveyance Upon Death (General)
F Tag
F160
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Within 30 days of the death of a resident who had personal funds deposited with the facility,
the facility conveys to the individual or probate jurisdiction administering the resident’s
estate the resident’s funds and a final accounting of those funds.
© Health Dimensions Group 2008 Resident Rights—Conveyance Upon Death (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Deposit of Funds (General)
F Tag
F159
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident’s personal funds in excess of $50 are deposited in an interest-bearing account(s)
and are separate from any of the facility’s operating accounts. Each account is credited all
interest earned to that account. (In pooled accounts, there is a separate accounting for each
resident’s share.)
Resident’s personal funds that do not exceed $50 are maintained in either a non-interestbearing
account, interest-bearing account, or a petty cash fund.
Regardless of the account type, records are maintained of a resident’s deposits, withdrawals,
and balance.
© Health Dimensions Group 2008 Resident Rights—Deposit of Funds (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Limitation of Charges to Personal Funds
F Tag
F162
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
This facility does not impose a charge against the personal funds of a resident for any item or
services for which payment is made under Medicaid or Medicare (except for applicable
deductible and coinsurance amounts).
The facility may charge the resident for requested services.
The facility should not charge bank services fees to the resident accounts.
© Health Dimensions Group 2008 Resident Rights—Limitation of Charges to Personal Funds
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Notices of Balances
F Tag
F159
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility notifies each resident that receives Medicaid benefits:
• When the amount in the resident’s account reaches $200 less than the SSI resource limit
for one person; or
• If the amount in the account, in addition to the value of the resident’s other nonexempt
resources, reaches the SSI resource limit for one person and the resident may lose
eligibility for Medicaid or SSI.
© Health Dimensions Group 2008 Resident Rights—Notices of Balances
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights - Work
F Tag
F169
Quality Standard RCS7
Origination Date April 1, 2008
Revision Date
POLICY
The resident has the right to:
1. Refuse to perform services for the facility.
2. Perform services in the facility, if resident chooses, when:
a. The facility has documented the desire for work in the plan of care.
b. The plan specifies the nature of the services performed and whether the services are
voluntary or paid.
c. Compensation for paid services is at or above prevailing rates, if agreed to be
monetarily compensated.
d. The resident agrees to the work arrangement described in the plan of care.
© Health Dimensions Group 2008 Resident Rights—Work
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Rights and Services included in Medicare and Medicaid
F Tag
F162
Quality Standard FP64, FP95
Origination Date April 1, 2008
Revision Date
POLICY
During the course of a covered Medicare or Medicaid stay, the facility may not charge a
resident for the following categories of items and services:
• Nursing services
• Dietary services
• An activities program
• Room/bed maintenance services
• Routine personal hygiene items and services as required to meet the needs of residents,
including, but not limited to:
- Hair hygiene supplies, comb, brush (facility stock supply)
- Bath soap, disinfecting soaps, or specialized cleansing agents when indicated to treat
special skin problems or to fight infection
- Razor, shaving cream, toothbrush, toothpaste, denture adhesive, and denture cleanser
- Moisturizing lotion, tissues, cotton balls, and cotton swabs
- Deodorant
- Sanitary napkins and related supplies
- Towels, washcloths
- Hospital gowns
- Over the counter drugs (facility stock supply)
- Hair and nail hygiene services
- Bathing
- Personal laundry
• Medically related social services
© Health Dimensions Group 2008 Resident Rights and Services included in Medicare and Medicaid
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title
Resident Rights and Services not included in Medicare and
Medicaid
F Tag
F162
Quality Standard FP64, FP95
Origination Date April 1, 2008
Revision Date
POLICY
For a resident covered under Medicare or Medicaid, the following list identifies general
categories and examples of items and services that the facility may charge to resident funds if
they are requested by resident. The facility informs the resident that there will be a charge
and that reimbursement will not be made by Medicare or Medicaid.
• Telephone, long distance phone calls;
• Television or radio for personal use;
• Personal comfort items including smoking materials, notions and novelties, and
confections;
• Cosmetic and grooming items and services, not in facility stock items;
• Personal clothing;
• Personal reading matter;
• Gifts purchased on behalf of a resident;
• Flowers and plants;
• Social events and entertainment offered outside the scope of the activities program;
• Non-covered special care services such as privately hired nurses or aides;
• Private room, except when therapeutically required (e.g., isolation for infection control);
and
• Specially prepared or alternative food requested instead of the food generally prepared by
the facility.
© Health Dimensions Group 2008 Resident Rights and Services not included in Medicare and Medicaid
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Resident Trust Account Availability
F Tag
N/A
Quality Standard FP62
Origination Date April 1, 2008
Revision Date
POLICY
The facility must have a system which allows the resident access to their money during nonbanking
hours in the facility.
© Health Dimensions Group 2008 Resident Trust Account Availability
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Restorative Program
F Tag
F221, F222, F309, F328, F329, F330, F331
Quality Standard RCS31
Origination Date April 1, 2008
Revision Date
POLICY
While in this facility, all residents are supported to maintain or attain their highest level of
functioning. All residents are assessed upon admission and at each care plan meeting for
possible inclusion in restorative programs. Restorative programs are individualized to meet
resident needs with short- and long-term achievable goals documented. Restorative programs
are noted as:
• Incontinence management
• Range of motion (ROM), active and passive
• Splint or brace use
• Training and skill practice in:
- Bed mobility
- Transfers
- Ambulation
- Dressing and bathing
- Eating
- Communication
- Prosthesis use
© Health Dimensions Group 2008 Restorative Program
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Restraint Free Care - HDGR
F Tag
F221, F222
Quality Standard RCS25
Origination Date April 1, 2008
Revision Date
POLICY
Physical restraints are only used when they are used appropriately—to treat the resident’s
medical symptoms and to promote an optimal level of function for the resident. A restraint
may never be used for the purpose of discipline or staff convenience.
DEFINITION
A physical restraint includes all devices and practices used that restrict freedom of movement
or normal access to one’s body. This may include side rails, beds against walls, tucking in
sheets, etc.
PROCEDURE
1. If resident is restrained, an assessment will be completed by a licensed nurse or therapist
upon admission and thereafter, quarterly and/or prior to an application of any restraint, to
determine the appropriateness.
2. The least restrictive device should be used with documentation of all other alternatives
tried prior to the implementation of a restraint. The resident’s physical environment
should be assessed and the facility should adapt the environment as appropriate to
minimize restraint use.
3. There must be a physician’s order for the use of the restraint which includes:
a. Medical symptoms for use
b. Frequency of use
c. Type of restraint
d. Release protocols
e. Plan for reduction, when applicable
4. Notification to the resident and/or family/legal representative of the risks of physical
restraints and documentation of informed consent/education on use must be obtained any
time there is a restraint applied and/or type changed.
5. For twenty-four hours post-application of a restraint, a physical restraint post application
observation tool must be completed.
6. Prior to the use of any side rails, a bed mobility assessment must be conducted by a
therapist or licensed nurse. The resident must be able to demonstrate that they are capable
© Health Dimensions Group 2008 Restraint Free Care—HDGR
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
of using them for bed mobility; complete the half side rail bed bar assessment. If side
rails are utilized, they must meet the requirements of above if used for a restraint. All side
rails used must be fitted appropriately to the bed.
7. An assessment must be conducted prior to the use of any other device such as a Broda
chair or lap tray that might be considered a restraint.
8. A restraint reduction tool is to be completed at the start of a restraint reduction trial to
evaluate the progress/effectiveness of the restraint reduction.
© Health Dimensions Group 2008 Restraint Free Care—HDGR
Page 2 of 2

Restraint Free Care Education on Use of Physical Restraints – HDGR
Informed Consent
Date: Resident: MR#: Rm#:
I have been informed of my physician’s recommendations for physical restraints. The type of physical restraints
recommend is
and the proposed frequency and duration are
.
This physical restraint is recommended for me for the following reason: (medical symptoms).
This physical restraint is intended to assist me in reaching the highest level of physical and psychosocial wellbeing,
and without its use, the physician believes that I may be unable to attain such levels. I have been
informed of the available reasonable alternative treatments and their risks and why this physical restraint is
recommended.
I have been informed of the nature, degree, duration, and probability to the commonly known side-effects and
significant risks of this treatment. Such risks include, but are not limited to:
o Decline in physical functioning and muscle condition
o Contracture
o Increase incidence of infections
o Development of pressure sores
o Delirium
o Agitation
o Incontinence
o Depression
o Falls
o Accidents such as strangulation
o Feelings of humiliation and loss of dignity
o Increased stress
o Decreased quality of life
o Isolation
o Withdrawal
o Learned dependence
o Bone loss and muscle mass loss
o Change in blood chemistry
o Decreased respiratory efficiency
o Reduced appetite and dehydration
I have read this form and I understand it. I have been given an opportunity to ask questions and I have had my
questions answered to my satisfaction.
I understand that I have the right to accept or refuse this treatment/intervention at any time. I consent to the use
of a physical restraint as prescribed by my physician.
.
Resident/Representative Signature
Witness Signature
Date
Date
Physician Name
© Health Dimensions Group 2008 Education on Use of Physical Restraints- Informed Consent-HDGR
Page 1 of 1

Restraint Free Care - Physical Restraints Assessment - HDGR
Date: Resident: MR#: Rm#:
Reason For Assessment:
□ Admission, if resident admitted with restraint
□ Quarterly, if resident is restrained
□ Prior to application of any restraint or other device
which may be considered a restraint
Briefly describe the risk behavior(s):
Assessors (Interdisciplinary Team)
What alternatives to restraints have been tried; length of time tried; resident response to alternative:
1. Are there physical factors affecting the resident’s behavior? (Check all that apply)
□ Drug changes in last month
□ Electrolyte imbalance
□ Change in baseline vital signs
□ Possible infection
□ Toxic drug levels
□ Recent trauma
2. Physical problem considerations: (Check all that apply)
□ Slides in chair
□ Slumps in chair
□ Falls forward
□ Falls backwards
3. Contributing factors–physiological: (Check all that apply)
□ Sleep disturbance
□ Need to toilet
□ Seizure activity
□ Rigidity/arthritis
□ Change in health
status
□ Mobility deficit
□ General weakness
□ Sensory deficit
(e.g., hearing and
vision)
□ Communication
deficit
□ Discomfort/pain
□ Orthostatic
hypotension
4. Contributing factors–psychological: (Check all that apply)
□ Fear
□ Loneliness □ Agitation
□ Anger
□ Boredom
□ Depression
□ Stress
□ Sun-downing □ Disorientation/
□ Altered thought
□ Language barrier confusion
process
□ Culture
□ Aphasia/dysphasia
5. Contributing factors–treatment related: (Check all that apply)
□ Medication side effect
□ Medication change in last 48 hours
□ Invasive tubing (e.g., catheter)
6. Contributing factors–environmental: (Check all that apply)
□ Poor lighting □ Cluttered room
□ Uncomfortable
□ Noise level □ Recent room
seating
□ Crowding
change
□ Dehydration
□ Acute hypoxia
□ Other______________________
□ Unable to maintain balance
□ Other______________________
□ Urinary retention
□ Constipation
□ Dehydration
□ Hunger
□ Thirst
□ Infection
□ Delirium
□ Memory
impairment
□ Admitted within 90
days
□ Postoperative
interventions
□ Hypoglycemia or
hyperglycemia
□ Other__________
________________
□ Unpredictable
behavior
□ Other__________
________________
□ Other______________________
____________________________
□ Inappropriate
footwear
□ Other__________
________________
© Health Dimensions Group 2008 Physical Restraints Assessment-HDGR
Page 1 of 2

Restraint Free Care - Physical Restraints Assessment - HDGR
Date: Resident: MR#: Rm#:
7. Mental Status:
□ Always oriented □ Sometimes confused □ Confused at all times
8. Referral to therapy?
□ Yes □ No □ PT □ OT
If yes, list recommendations:
9. Was the attending physician consulted? □ Yes □ No (if No, notify physician)
If yes, list orders and medical symptoms:
10. Was the family notified? □ Yes □ No (if No, notify family)
11. Are there mental, social, or emotional factors affecting the resident? (Check all that apply)
□ Recent loss due to own illness
□ Recent change in room (e.g.,
roommate)
□ Recent room transfer
□ Change in financial status
□ Loss of loved one
□ Loss of control
□ New admission
□ Disagreement/argument with
another person
□ Other______________________
____________________________
12. Referral to psychologist?
□ Yes
If yes, list recommendations:
□ No
13. Sensory impairment?
□ Vision
14. Bladder status?
□ Continent
15. Bowel status?
□ Continent
16. Does resident need assist with toileting?
□ Yes
17. Does resident have a history of falls?
□ Yes
18. Actions indicated:
□ Hearing
□ Incontinent
□ Incontinent
□ No
□ No
19. Other concerns:
20. Are the medical symptoms present primarily at specific times of the day?
□ Yes
□ No
Explain:
Presented to multidisciplinary team on: (date)
Form completed by:
Date:
© Health Dimensions Group 2008 Physical Restraints Assessment-HDGR
Page 2 of 2

Restraint Free Care - Physical Restraint Post Application Observation Tool - HDGR
Date: Resident: MR#: Rm#:
This observation tool is to be completed by a licensed nurse every shift for 24 hours post application of a restraint.
Day Shift
_________________________________
Nurse Signature
Date:_____________________________
Evening Shift
_________________________________
Nurse Signature
Date:_____________________________
Night Shift
_________________________________
Nurse Signature
Observe The Resident For The Following:
o Appropriate type of restraint as ordered by the
physician
o The resident’s reaction/response to the restraint
o The restraint applied appropriately
o The restraint affects position and body alignment and
resident is positioned appropriately
o Summarize the observation
Observe The Resident For The Following:
o Appropriate type of restraint as ordered by the
physician
o The resident’s reaction/response to the restraint
o The restraint applied appropriately
o The restraint affects position and body alignment and
resident is positioned appropriately
o Summarize the observation
Observe The Resident For The Following:
o Appropriate type of restraint as ordered by the
physician
o The resident’s reaction/response to the restraint
o The restraint applied appropriately
o The restraint affects position and body alignment and
resident is positioned appropriately
o Summarize the observation
Date:_____________________________
To be reviewed at 24 hour report and IDT.
© Health Dimensions Group 2008 Physical Restraint Post-Application Observation Tool - HDGR
Page 1 of 1

Restraint Free Care - Restraint Reduction Tool - HDGR
Date: Resident: MR#: Rm#:
1. Start of reduction trial:
2. Current equipment order:
3. Order obtained for proposed trial? Yes □ No □
4. Family made aware of reduction trial? Yes □ No □
5. Care card/nursing assistant assignment sheet updated to reflect change? Yes □ No □
6. Resident added to 24 hour report for duration of trial? Yes □ No □
7. Alternative safety devices used during trial:
LN Signature:
Date:
8. Date trial ended:
9. Evaluation for each week completed? Yes □ No □
10. Was reduction successful? Yes □ No □
11. Resident response to equipment change:
12. Revised physician’s order to reflect change? Yes □ No □
13. Care plan and care card/nursing assistant assignment sheet
updated to reflect change? Yes □ No □
14. Family updated on success of trial used during trial: Yes □ No □
LN Signature:
Date:
Evaluation of restraint reduction and plan:
Signature Signature Signature Signature
Date Trial Completed or Suspended:
© Health Dimensions Group 2008 Restraint Reduction Tool - HDGR
Page 1 of 1

Restraint Free Care – Half Side Rail/Bed Bar Assessment - HDGR
Date: Resident: MR#: Rm#:
Resident Condition Yes No
1. Is the resident ambulatory?
2. Does the resident transfer independently?
3. Does the resident have an alteration in safety awareness due to
cognitive deficit? MDS (B-4)
4. Does the resident have a history of falls? MDS (J-4)
5. Has the resident demonstrated poor bed mobility, difficulty moving
to the sitting position on the side of the bed, or impaired balance or
trunk control? MDS {G-1(a)(b) G3 (a)(b)}
6. Is the resident on any medications which would require increased
safety precautions?
7. Does the resident use the half side rail or bed bar for positioning,
turning, or support? If yes, explain:
8. Based on this assessment, is the use of half side rail or bed bar
indicated?
9. What type would benefit? (please circle one)
HALF SIDE RAIL BED BAR
10. Does the half side rail or bed bar prevent the resident from any
activity she/he would be able to perform without the rail (even if
activity is considered unsafe?)
If yes, consider a restraint and proceed to a restraint
evaluation.
11. If rails are to be used, do rails fit against mattress with no more
than 2” gap?
Evaluator’s Signature:
Date:
© Health Dimensions Group 2008 Half Side Rail/Bed Bar Assessment—HDGR
Page 1 of 2

Restraint Free Care – Half-Side Rail/Bed Bar Assessment - HDGR
Date: Resident: MR#: Rm#:
Based on review of data collected from half side rail/bed bar assessment:
Resident continues to require use of half side rail/or bed bar.
Resident continues to not need half side rail/bed bar.
ASSESSMENT COMPLETED BY:
Signature/Title:
Date:
Based on review of data collected from half side rail/bed bar assessment:
Resident continues to require use of half side rail/or bed bar.
Resident continues to not need half side rail/bed bar.
ASSESSMENT COMPLETED BY:
Signature/Title:
Date:
Based on review of data collected from half side rail/bed bar assessment:
Resident continues to require use of half side rail/or bed bar.
Resident continues to not need half side rail/bed bar.
ASSESSMENT COMPLETED BY:
Signature/Title:
Date:
© Health Dimensions Group 2008 Half Side Rail/Bed Bar Assessment—HDGR
Page 2 of 2

Restraint Free Care - Is the Intervention a Physical Restraint?
Information Supplied by the Center for Medicare and Medicaid Services
Can the device be easily removed?
→ YES Not a physical restraint
by the resident?
↓ NO
Does the device restrict the resident’s freedom of movement?
→ NO Not a physical restraint
or normal access to body?
↓ YES
The device may be a physical restraint.
Explanations:
Physical restraint: The use of any device (i.e., physical or mechanical device, material,
equipment attached or adjacent to the resident’s body) that the resident cannot easily remove and
that restricts freedom of movement or normal access to his or her body.
Easily: Easily removed needs to be described as skill based as well as time based. Does the
resident have the ability/skill to remove the device in a reasonable time span?
Freedom of Movement: Is the resident’s freedom to move when the device is in place less than
their freedom to move without the device?
Normal Access: Is the resident’s access to their body when the device is in place less than their
access to their body without the device?
Risk/Benefit: Evaluation of a device must include how the device benefits the resident, whether a
less restrictive device could offer the same benefit at less risk.
Assessment for the device used should include at a minimum:
• The risk of what might happen if the device is not used
VERSUS
• The risk the device poses as a restraint
Restraint use is to be based on an individualized assessment of the resident’s clinical needs,
therefore, even if the restraints are implemented at the resident’s request or voluntarily, it does
not alter the need for a comprehensive and ongoing assessment of the need for the device.
All restraints should:
o Have a physician’s order
o Have a plan of care
o Be applied in accordance with safe and appropriate technique
o Be continually assessed, monitored, re-evaluated, and documented
o Be evaluated for alternative options for use of the device
o Have an ongoing staff training program for use of the device
© Health Dimensions Group 2008 Is the Intervention a Physical Restraint? - Sample
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Safe Medical Device Act
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will establish a process for determining if a medical device, instrument, or
appliance was the cause of a serious illness, injury, or death of a resident or staff member.
PROCEDURE
1. All serious illnesses, injuries, or death of a resident or staff member will be investigated
along with the completion of an incident report.
2. If a medical device, instrument, or appliance is involved, it will be removed immediately
from use, tagged as “not in use,” and separated.
3. Any reports are sent either to the FDA or manufacturer, or both.
4. The state authorities will be contacted per state laws by the administrator or designee.
5. Physician and family notification per facility policy.
See also Physical Environment
© Health Dimensions Group 2008 Safe Medical Device Act
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Self Administration of Medications
F Tag
F176
Quality Standard RCS35
Origination Date April 1, 2008
Revision Date
POLICY
An individual resident may self administer medication if the resident requests and the
interdisciplinary team has determined that the resident is safe in this practice.
PROCEDURE
1. Explain procedure to the resident.
2. Ensure privacy.
3. Complete self administration of medication assessment. If resident does not wish to selfadminister
medications, the assessment is completed. If the resident requests to self
administer medications, proceed.
4. Review tool with the interdisciplinary team.
5. If the team determines that the resident is capable and safe in the procedure, obtain a
physician’s order for resident to self administer each specific medication that the resident
has been qualified to self administer.
6. The resident’s care plan is revised to enable the resident to self administer the specific
medications.
7. Nursing staff performs weekly/monthly checks of the resident’s accuracy in self
administration and notes this on medication treatment record or nurse’s notes.
8. If at any time, the interdisciplinary team decides that the resident has become unsafe to
administer medication, the procedure may be discontinued.
9. The self administration of medications is reviewed quarterly by the interdisciplinary
team.
© Health Dimensions Group 2008 Self Administration of Medications
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Shampooing the Bedridden Resident's Hair
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
A resident who is bedridden will be provided with services to keep the resident’s hair clean
and well groomed.
PROCEDURE
1. Provide privacy.
2. Explain the procedure to the resident.
3. Wash hands.
4. Apply gloves.
5. Arrange equipment near resident.
6. Place waterproof pad under resident’s head and shoulders. Place bed shampoo bowl
under resident’s head.
7. Place rolled towel or pillow under resident’s neck.
8. If resident is able to participate, ask him/her to hold face towel or washcloth over face.
9. Slowly pour water from water pitcher over hair until completely wet. Apply small
amount of shampoo.
10. Work up lather with both hands. Massage scalp, lift head slightly, and wash back of head.
11. Rinse hair with remaining water from pitcher. Be sure water goes into basin. Continue to
rinse hair until all shampoo is removed.
12. Apply conditioner or other products as requested by resident.
13. Rinse hair thoroughly.
14. At completion carefully remove shampoo basin.
15. Wrap resident’s head in bath towel.
16. Remove waterproof pad and any soiled linen.
17. Dry resident’s hair and scalp.
18. Remove any soiled clothing and make resident comfortable
19. Assist resident to dry and style hair as desired.
20. Dispose of used or soiled items into the applicable containers.
© Health Dimensions Group 2008 Shampooing the Bedridden Resident’s Hair
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
21. Remove gloves.
22. Clean equipment and return to its proper place.
23. Wash hands.
24. Document completion on the activities of daily living (ADL) sheet, per facility’s
procedure.
25. Notify charge nurse or designee of any problems.
© Health Dimensions Group 2008 Shampooing the Bedridden Resident’s Hair
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Shaving - Electric Razor
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident will be provided care and services daily which includes shaving as per resident
needs and/or care plan.
PROCEDURE
1. Assemble equipment at bedside.
2. Wash hands.
3. Apply gloves.
4. Explain the procedure to resident.
5. Provide privacy.
Note: If practical, teach the resident to do procedure himself by doing one step at a time.
6. Place a small amount of beard prep on hands and rub into beard, as desired or indicated;
may use soap and water.
7. Check the setting on razor and functioning of the razor.
8. Start shaving under one sideburn and then other sideburn area, then the chin, and cheeks.
9. Use a gentle back and forth motion. Do not press hard.
10. Have the resident pull his mouth to one side and shave the opposite side and then reverse.
11. Have the resident pull the top lip down and shave under the lip using short gentle strokes.
12. Have the resident hold his head up and shave neck.
13. Use your hand to check for rough areas and re-shave as necessary.
14. Allow the resident to assess with a mirror, if desired.
15. Apply aftershave as desired.
16. Remove the top cover of the razor over wastebasket and use the brush to remove hair.
17. Replace the lid on razor.
18. Remove gloves.
19. Wash hands.
20. Document shave on ADL sheet, per facility’s procedure.
21. Report any problems to the charge nurse or designee.
© Health Dimensions Group 2008 Shaving–Electric Razor
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Shaving - Safety Razor
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident will be provided care and services daily which includes shaving as per resident
needs and/or care plan.
PROCEDURE
1. Assemble equipment at the resident’s bedside.
2. Wash hands.
3. Apply gloves.
4. Explain procedure to the resident.
5. Ensure privacy.
6. Position resident in a chair in front of the sink or over the bed table.
7. Fill the basin with warm water and place the washcloth in the water or fill the sink with
warm water and place washcloth in the water.
8. Place a towel under the resident’s chin.
9. Wring out the wash cloth and apply over the area to be shaved on the face.
10. Make sure the blade is in the razor securely. Dip the razor in the warm water.
Note: If practical, teach the resident to do procedure himself by doing one step at a time.
11. Apply shaving cream to areas of the face to be shaved.
12. Begin shaving the resident at a side burn area using light downward strokes. Hold the
area you are shaving tight. Rinse the razor after each stroke by dipping it in the warm
water and shaking the shaving cream off.
13. Proceed over the face, chin, lip, and neck. Clean the razor as you go along.
14. Rinse face with wash cloth and towel dry gently.
15. Apply aftershave as desired.
16. Discard razor blade in the sharps container or as facility policy states. Do not discard in
trash can.
17. Clean reusable items as needed.
18. Remove gloves.
© Health Dimensions Group 2008 Shaving–Safety Razor
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
19. Wash hands.
20. Document the shave on the activities of daily living (ADL) sheet, per facility’s
procedure.
21. Notify the charge nurse or designee of any problems.
© Health Dimensions Group 2008 Shaving–Safety Razor
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Shift to Shift Report
F Tag
N/A
Quality Standard FP72
Origination Date April 1, 2008
Revision Date
Policy
The facility nursing staff will conduct shift to shift reports to ensure communication among
staff related to resident needs.
Procedure
1. A face-to-face or recorded report regarding resident needs, changes, etc., will be
conducted between each shift, which includes all nursing staff and any other staff deemed
appropriate.
2. The clinical supervisor, director of nurses, or designee will also receive regular daily
reports of resident status.
© Health Dimensions Group 2008 Shift to Shift Report
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Smoking
F Tag
N/A
Quality Standard FP27
Origination Date April 1, 2008
Revision Date
POLICY
The facility allows does not allow smoking.
PROCEDURE
1. Prior to or upon admission, the resident is made aware of the facility’s smoking policy
and procedures.
2. In orientation, all new employees are made aware of the facility’s smoking policies and
procedures regarding residents, families, and staff.
3. If the facility allows smoking, there will be designated areas for smoking that are posted.
4. All residents who smoke will be assessed for their safety at time of admission, quarterly,
and/or when there is a change in resident’s condition.
5. The designated smoking area(s) will have the following:
a. “No Oxygen” signs.
b. Smoking blankets.
c. Fire extinguishers.
d. Approved cigarette receptacles.
6. If the facility decides to become smoke free for all residents, those that were admitted as
smokers are offered smoking cessation programs. If this is refused, then a designated
space is provided for these residents until they are discharged (grandfathered in). Any
new residents would not be allowed to smoke.
© Health Dimensions Group 2008 Smoking
Page 1 of 1

Smoking Safety Assessment - Sample
Date: Resident: MR#: Rm#:
Cognition Skills For Decision-Making:
Independent Modified independence Moderately impaired Severely impaired
Indicators of Delirium:
Not present Easily distracted Restlessness Lethargy
Mental function varies Disorganized speech Periods of altered perception
Communication:
Clear speech Unclear speech No speech
Is the resident able to communicate the need for help if lit material falls on them? Yes No
Functional Status:
Cane/walker/crutch
Wheelchair primary mode of locomotion
Wheeled self Other person wheeled None of the above
Is the resident able to move without assistance to/from designated smoking area? Yes No
Visual Limitations:
No limitation Side vision impairment Other:
Range of Motion:
No limitation
Limitation:
Disease/diagnosis impacting ability to smoke: None
Neurological Psychiatric Sensory
Devices and Restraints:
Not used Trunk restraint Limb restraint Chair that prevents rising
Tremors to hands: Yes No Uses oxygen: Yes No
Manual Dexterity:
Fine motor control Gross motor control No control
Ability to use ashtray to self-extinguish cigarette: Yes No
Fire Safety: Can use lighter or matches safely Can use lighter safely only
Can use matches safely only
Can not use fire safely
History of smoking-related incidents: Yes No
If yes: Burned clothing Smoking in bed
Burned furniture
Drops ashes on self
Throws lighted tobacco products in trashcans
Other
Interventions:
Independent
Smokes safely with minimal supervision
Smoking apron Facility storage of fire materials only
Assistance to hold cigarette
Supervised smoking by staff
Facility storage of tobacco products and fire materials
Assistance with lighting tobacco products only
Assistive devices needed: Yes No
If yes, list devices:
Resident instructed and understands facility smoking policy? Yes No
Care Plan concern: Yes No
Nurse’s Signature:
Date:
© Health Dimensions Group 2008 Smoking Safety Assessment - Sample
Page 1 of 2

Smoking Safety Assessment - Sample
Date: Resident: MR#: Rm#:
QUARTERLY SMOKING SAFETY REVIEW
Change to initial smoking assessment: None Yes, Interventions:
Independent
Smokes safely with minimal supervision
Smoking apron
Facility storage of fire materials only
Assistance to hold cigarette
Supervised smoking by staff
Facility storage of tobacco products and fire materials
Assistance with lighting tobacco products only
Nurse’s Signature:
Date:
QUARTERLY SMOKING SAFETY REVIEW
Change to initial smoking assessment: None Yes, Interventions:
Independent
Smokes safely with minimal supervision
Smoking apron
Facility storage of fire materials only
Assistance to hold cigarette
Supervised smoking by staff
Facility storage of tobacco products and fire materials
Assistance with lighting tobacco products only
Nurse’s Signature:
Date:
QUARTERLY SMOKING SAFETY REVIEW
Change to initial smoking assessment: None Yes, Interventions:
Independent
Smokes safely with minimal supervision
Smoking apron
Facility storage of fire materials only
Assistance to hold cigarette
Supervised smoking by staff
Facility storage of tobacco products and fire materials
Assistance with lighting tobacco products only
Nurse’s Signature:
Date:
© Health Dimensions Group 2008 Smoking Safety Assessment - Sample
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Social Services (General)
F Tag
F250, F251
Quality Standard HR6, RCS38
Origination Date April 1, 2008
Revision Date
POLICY
The facility:
• Provides medically related social services to attain or maintain the highest practicable
physical, mental, and psychosocial wellbeing of each resident;
• Employs a qualified social worker on a full-time basis if the facility has 120 beds or
more; and
• Provides a qualified social worker with:
- A bachelor’s degree in social work or a bachelor’s degree in a human services field
including, but not limited to, sociology, special education, rehabilitation counseling,
and psychology constituting minimum qualifications of a social worker.
- At least one year of supervised social work experience in a health care setting.
© Health Dimensions Group 2008 Social Services (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Special Consent (General)
F Tag
F155
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
For a prescribed treatment and medication not included in the admission consent for care, a
written consent form with the dated signature of the resident or resident’s representative is
required. Special consent is required for, but not limited to, the following:
• Use of any approved medications in unapproved application;
• Special procedures (e.g., thoracentesis, paracenteses, invasion, and drainage of a wound
or debridement of a wound);
• Release of confidential information;
• Participation in a research project;
• Photographs except for documentation of skin conditions and for identification purposes;
and
• Others where applicable.
© Health Dimensions Group 2008 Special Consent (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Special Needs (General)
F Tag
F328
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility ensures that residents receive proper treatment and care for the following special
services:
• Infections
• Parenteral and enteral fluids
• Colostomy, urostostomy, or ileostomy care
• Tracheostomy care
• Tracheal suctioning
• Respiratory care
• Foot care
• Prosthetic care
© Health Dimensions Group 2008 Special Needs (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Specimen Collection - Clean Urine Void Female
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will obtain an uncontaminated (sterile) urine specimen for all physician-ordered
urinary tests.
PROCEDURE
1. Wash hands.
2. Explain procedure to the resident.
3. Ensure privacy.
4. Bring all necessary equipment to bathroom
5. Place resident on toilet.
6. Remove lid from container. Do not touch the inside of the cup or the inside of the lid.
7. Wash hands.
8. Apply gloves.
9. Separate labia and hold open during entire procedure.
10. Using commercial antiseptic wipes, swab and cleanse perineal area from front to back
with one towelette per wipe. Repeat 3 times. Dispose of the towelette and any other
soiled material in the applicable container.
11. Ask the resident to start voiding and catch the middle of the stream in the cup. Place the
lid securely on specimen container without touching the inside of the lid or container.
12. Release labia. Dry perineum.
13. Secure the resident’s clothing.
14. Remove gloves.
15. Wash hands.
16. Label specimen and deliver to designated area so that it may be delivered to the lab.
17. If applicable, enter a note in the output record.
18. Document in nurse’s notes the specimen obtained.
© Health Dimensions Group 2008 Specimen Collection–Clean Urine Void Female
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Specimen Collection - Clean Urine Void Male
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility will obtain an uncontaminated (sterile) urine specimen for all physician-ordered
urinary tests.
PROCEDURE
1. Wash hands.
2. Bring equipment to the resident’s room.
3. Explain the procedure to the resident.
4. Ensure privacy.
5. Allow the resident to do as much of the procedure as possible. Ask resident to wash his
hands.
6. Wash hands.
7. Apply gloves.
8. Expose penis (in bathroom whenever possible), and retract foreskin, if necessary. Clean
area with antiseptic towelette.
9. Remove the lid from the sterile container. Do not touch the inside of the cup or the inside
of the top.
10. Instruct the resident to start voiding into the toilet.
11. Collect the mid-stream urine in the cup.
12. Cover specimen and label without touching inside of lid or inside of container.
13. Dry penis and replace foreskin.
14. Place towelette and other used materials in the applicable container.
15. Secure the resident’s clothing.
16. Remove gloves.
17. Wash hands.
18. Label specimen and deliver to designated area so that it may be delivered to the lab.
19. If applicable, enter a note on the output record.
20. Document in nurse’s notes the specimen obtained.
© Health Dimensions Group 2008 Specimen Collection–Clean Urine Void Male
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Specimen Collection - Sputum
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Sputum collection will be obtained upon a physician’s order by a licensed professional. The
purpose is to provide a sample which can be examined by laboratory personnel to aid in the
diagnosis and correct treatment of respiratory tract diseases.
PROCEDURE
1. Wash your hands.
2. Assemble equipment at resident’s bedside.
3. Label container properly.
4. Provide privacy.
5. Explain procedure to the resident to allay fears and gain cooperation.
6. Apply gloves.
7. Have resident hold the sputum container close to the mouth and spit the coughed sputum
into the container. Discard tissues properly. Collect at least one to two tablespoons of
sputum. Early in the morning after resident drinks a cup of hot liquid is the best time for
obtaining sputum.
8. Close the specimen container.
9. Remove gloves.
10. Wash hands.
11. Leave the resident comfortable with call light in reach.
12. Prepare laboratory requisition.
13. Place container in plastic bag and attach requisition. If there is any delay in laboratory
pick-up, place the specimen in the refrigerator.
14. Wash your hands.
15. Chart procedure, time, date, disposition of specimen, amount, and description of sputum
in the nurse’s notes.
© Health Dimensions Group 2008 Specimen Collection–Sputum
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Spiritual Care
F Tag
N/A
Quality Standard RCS54
Origination Date April 1, 2008
Revision Date
POLICY
The facility assesses the resident’s spiritual needs and ensures services are available.
PROCEDURE
1. Upon admission and as needed, resident’s spiritual preferences and requests will be
assessed and documented.
2. Spiritual services and programs will be offered and communicated to residents and
families.
3. Document in resident’s medical record, as indicated.
© Health Dimensions Group 2008 Spiritual Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Staff Qualifications (General)
F Tag
F499
Quality Standard HR18
Origination Date April 1, 2008
Revision Date
POLICY
The facility employs on a full-time, part-time, or consultant basis, those professionals
necessary to carry out the proper resident care in the facility.
Professional staff is licensed, certified, or registered in accordance with applicable state and
federal laws.
All nursing assistants are certified and registered according to state and federal laws.
© Health Dimensions Group 2008 Staff Qualifications (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Suctioning
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Suctioning may be provided to a resident by a licensed professional only with a physician’s
order.
PROCEDURE
1. Wash hands.
2. Assemble equipment.
3. Provide privacy.
4. Explain the procedure to the resident.
5. Attach the suction catheter to the connection tubing on the rubber tubing of the suction
machine.
6. Position the resident for ease in carrying out the procedure.
7. Wash hands.
8. Apply gloves.
9. Remove the suction catheter from its covering and hold it about 6 inches from the end (or
as designated by the equipment used).
10. Turn the suction machine on.
11. Place the end of the suction catheter in the container of tap water to make sure that the
machine is working properly.
12. Pinch the catheter between your thumb and index finger and gently direct the catheter
into the nostril to the desired depth. Release the pressure of your thumb and finger and
suction the mucus into the container. Compress the catheter with your thumb and index
finger and gently remove it.
13. Place the catheter in the container of tap water and allow the catheter and tubing to be
rinsed.
14. Repeat the suction procedure until the airway is clear.
15. Clean the catheter by suctioning tap water through it several times.
16. Disconnect the catheter from tubing.
17. Empty the suction machine bottle as needed, or at least once each shift.
© Health Dimensions Group 2008 Suctioning
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
18. Remove gloves.
19. Wash hands.
20. Leave the resident comfortable with the call light in reach.
21. Do not allow drainage to fill above the caution mark on the collection bottle of the
suction machine.
22. Take the collection bottle off of the machine, empty it into a flushable commode, rinse
and dry the bottle, and replace it in the proper manner on the suction machine.
23. When the bottle has been replaced on the machine, make sure that all connections are
firmly in place so that the vacuum can be formed, and turn the machine switch to the ON
position.
24. Wash hands.
25. When the machine is being discontinued from use permanently:
a. Apply gloves.
b. Empty the drainage bottle in a flushable commode/sink, wash in disinfectant, rinse,
and replace on the machine.
c. If the suction catheter is disposable, dispose of it in the contaminated waste container.
d. Wash, rinse, and replace connecting tube.
e. Reassemble the machine and place it in its proper storage area.
f. Discard disposable equipment in the appropriate manner.
g. Discard the soiled linen appropriately.
h. Remove gloves.
i. Wash hands.
26. Chart date, time, procedure, description of the return material, resident reactions, and
unusual observations in the nurse’s notes.
27. Contact physician, as needed.
© Health Dimensions Group 2008 Suctioning
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Suppositories - Rectal
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Suppositories are given to stimulate evacuation of feces from the rectum; to relieve pain
caused by hemorrhoids, rectal abscess, diarrhea, etc.; and to administer medication when it is
contraindicated to be given by mouth.
Suppositories require a physician’s order and are given by licensed nurses or trained
medication aides.
PROCEDURE
1. Assemble equipment and take it to the resident’s bedside.
2. Provide privacy.
3. Explain the procedure to the resident.
4. Position the resident by having him/her turn on the left side; flex the left knee slightly and
the right knee acutely.
5. Pull the top covers back and expose the rectal area. Do not overexpose the resident.
6. Wash hands.
7. Put on gloves.
8. Remove the covering from the suppository and lubricate the tip. Some suppositories are
lubricated with water.
9. Grasp the sides of the suppository between the thumb and the middle finger. Place the
index finger on the un-lubricated end of the suppository (the index finger would be
utilized as a plunger).
10. Separate the buttocks, gently insert the suppository into the rectum. Push the suppository
as high as possible with the index finger.
11. Place the suppository wrap into the applicable container.
12. Remove gloves.
13. Wash hands.
14. Explain to the resident the necessity to rest quietly for 30-45 minutes, if possible (activity
tends to increase the desire to evacuate the bowel).
15. Leave the resident comfortable with the call light in reach.
© Health Dimensions Group 2008 Suppositories–Rectal
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
16. Examine the resident after the suppository has been inserted to make sure it has not been
expelled in the bed.
17. After some time, take the resident to the toilet or offer the bedpan.
18. Follow toileting procedure.
19. Wash hands.
20. If a PRN order, chart the date, time, type of suppository, reason for instillation, result of
instillation, resident’s reactions, unusual observations, and your signature on the
medication sheet.
21. Make the appropriate notation on the activities of daily living (ADL) sheet, per facility’s
procedure, if given for bowel care, and note suppository given.
22. Chart unusual observations or resident’s reactions in the nurse’s notes.
© Health Dimensions Group 2008 Suppositories–Rectal
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Suprapubic Catheter Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
To keep the suprapubic catheter stable and clean, catheter care will be provided, as ordered.
PROCEDURE
1. Gather equipment.
2. Wash hands.
3. Explain procedure to resident.
4. Provide privacy.
5. Apply gloves.
6. Remove all dressings around suprapubic catheter and dispose of dressings.
7. Remove gloves.
8. Sanitize hands.
9. Reapply new gloves.
10. Cleanse area with soap and water, and dry thoroughly.
11. Observe for redness or irritation.
12. Remove old gloves and apply new gloves.
13. Fold 4 X 4 gauze pad below and place around catheter or use specific dressing for
suprapubic catheters.
14. Apply dressing on top and secure with adhesive tape.
15. Check tubing to be sure it is draining and free of kinks.
16. Make resident comfortable.
17. Dispose of soiled dressing appropriately.
18. Remove gloves.
19. Wash hands.
20. Document on treatment/medication sheet.
21. Document in nurse’s notes any abnormalities.
22. Notify physician, as needed.
© Health Dimensions Group 2008 Suprapubic Catheter Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Teeth - Flossing
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Teeth flossing may be done during resident care if requested, or assessed as needed, to
remove debris between the teeth during cleaning and remove bacteria that causes gum
disease and bad breath; and/or performed prior to brushing teeth.
PROCEDURE
1. Wash hands.
2. Ensure privacy.
3. Explain procedure to resident. Allow him/her to do the procedure if able.
4. Position resident at sink or over bed table (will need kidney basin, water, glass, and
towel).
5. Place towel over chest.
6. Wash hands.
7. Apply gloves.
8. Remove floss from the container.
9. Wrap each end of the floss around fingers on each hand.
10. Begin at the back of the mouth; insert string between teeth down and below the gum line.
Move the string back and forth.
11. Advance between teeth to the other side of the mouth.
12. Have resident rinse mouth, if possible, with mouthwash or fresh water.
13. Dispose of floss in appropriate container.
14. Remove gloves.
15. Wash hands.
16. Clean up area as needed.
17. Record completion on activities of daily living (ADL) sheet, per facility’s procedure.
18. Notify charge nurse or designee of any odors or bleeding.
© Health Dimensions Group 2008 Teeth–Flossing
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Telephone - Resident Access to
F Tag
F174
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The resident has the right to have reasonable access to the use of a telephone where calls can
be made without being overheard.
© Health Dimensions Group 2008 Telephone–Resident Access to
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Thickened Liquids
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Residents who have been assessed by a licensed professional may request a physician’s order
for thickened liquids.
PROCEDURE
Thicken all liquids according to therapy directions.
© Health Dimensions Group 2008 Thickened Liquids
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Tracheotomy Care
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Clean technique tracheotomy care is provided to keep the airway open and free of obstruction
from dried secretions, as ordered by physician. Tracheotomy care is to be performed by
licensed professionals or the resident if found competent.
PROCEDURE
A. Inner cannula:
1. Wash hands.
2. Apply gloves.
3. Explain procedure and purpose to resident.
4. Remove inner cannula; place in small basin.
5. Clean outer tube by suctioning.
6. Clean inner tube by soaking 10 minutes in solution of equal parts hydrogen peroxide
and water. Rinse and cleanse thoroughly with track brush or pipe cleaners. Check to
be sure no mucus remains. Rinse again and dry carefully.
7. Lock in place by turning flag downward.
8. Clean lip of outer tubing with hydrogen peroxide.
9. Apply tracheotomy tape. Apply clean tape before removing soiled tape.
10. Change sponge under lip of outer cannula.
11. Leave resident comfortable.
12. Clean equipment.
13. Remove gloves.
14. Wash hands.
B. Outer cannula:
1. The outer cannula is replaced, when necessary, by a properly trained licensed nurse or
physician. The tracheotomy care tray is used, with the addition of a sterile
replacement tracheotomy tube.
2. Docuument appearance, amount, and odor of secretions and any complications on the
treatment record.
© Health Dimensions Group 2008 Tracheotomy Care
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Transferring a Resident to Another Facility or Hospital
F Tag
N/A
Quality Standard FP101
Origination Date April 1, 2008
Revision Date
POLICY
The facility will aid the resident to make his/her departure as safe, comfortable, and
convenient, as possible.
PROCEDURE
1. In an emergency situation:
a. Call the physician and obtain an order to transfer the resident.
b. Notify the necessary nursing personnel to get the resident ready for transfer.
c. Call the ambulance.
d. Notify the resident’s family or responsible party of the pending transfer.
e. Notify the business and administrative offices.
f. Complete the transfer form and bed hold information to be sent with resident.
g. Notify other departments of the resident’s transfer, whenever possible.
2. In a non-emergency situation:
a. Initiate transfer plans upon obtaining a physician’s order.
i. A resident is transferred or discharged only with the permission of the physician.
ii. The business office and administrative office are notified of the
transfer/discharge.
b. The social worker and licensed nurse prepares a transfer/discharge plan and reviews
the plan with the resident and the family.
c. As specified in the transfer/discharge plan, the resident and/or family receive
necessary instruction and training by assigned staff.
d. The resident and/or family sign the transfer/discharge plan, as acknowledgement that
they have received the plan and have received the specified instruction and training.
e. Have the resident bathed and dressed at the correct time of departure.
f. Have all belongings packed. An inventory sheet may be completed, signed, and
duplicated and a copy given to the resident and/or family, upon request.
g. Have all appliances such as canes, walkers, wheelchairs, etc., ready to go.
h. Have all medications that are to go with the resident/family in a labeled paper bag. An
order from the physician is required for medications to be released.
© Health Dimensions Group 2008 Transferring a Resident to Another Facility or Hospital
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
i. Complete a transfer/discharge form. Place a copy of the transfer/discharge form on
the chart.
j. Get the necessary signatures for all valuables, medications, clothing, and equipment
sent with the resident.
k. Assist the resident.
l. Complete the chart.
m. Chart the date, time, method of transfer, name of person accompanying resident, what
was sent with the resident, place of transfer, unusual observations, and resident
reactions in the nurse’s notes.
© Health Dimensions Group 2008 Transferring a Resident to Another Facility or Hospital
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Transferring a Resident within the Facility
F Tag
N/A
Quality Standard FP101, RCS9
Origination Date April 1, 2008
Revision Date
POLICY
The facility will move the resident and their belongings safely and with the least possible
confusion for the resident. Whenever a resident is transferred from one room to another
within the facility, a notice of transfer must be given to resident and/or family prior to the
move, according to state law.
PROCEDURE
1. Notify and explain the reason for transfer to the resident and/or family or responsible
party of the resident.
2. Obtain the resident’s/DPOA’s (durable power of attorney) agreement to the transfer.
Document the approval in the nurse’s notes and/or on a facility-specific form.
3. Notify the attending physician of the transfer.
4. Before moving the resident, notify the unit to which the resident is being transferred.
Give the unit’s charge nurse or designee an oral report on the condition of the resident.
5. Transfer by bed or wheelchair; or ambulate as condition demands.
6. The following are transferred with the resident:
a. Furniture will be moved according to the facility policy;
b. Chart, as applicable;
c. Medications, as applicable;
d. Clothing;
e. Personal belongings and personal furniture, as space and safety permits; and
f. Special equipment used by the resident.
7. Notify the dietitian and business office of the room number changes in writing. Notify the
Activities Department, the administrator and director of nursing office, and the Therapy
Departments orally or on the form used by facility. Note the move in the daily
census/report.
8. Document the date, time, where the resident was transferred to, the mode of travel, who
was notified, and what was taken with the resident, in the nurse’s notes.
© Health Dimensions Group 2008 Transferring a Resident within the Facility
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Treatment Record (General)
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
All treatments provided to the resident must be ordered by the physician and documented.
PROCEDURE
1. Treatment orders received on admission may be initially handwritten onto the treatment
record.
2. Enter one treatment per space. Include the treatment, dosage, route, and frequency (the
specific hour/time the treatment is to be given).
3. The licensed staff places their initials in the appropriate box under date and time to
indicate that the treatment has been done.
4. The nurse identifies his/her initials with their signature.
5. Record the following:
a. Reasons for refusal of treatments.
b. Reasons and results for PRN (as needed) treatments.
c. Progress or decline of condition for which PRN/routine treatment is given.
6. Each entry includes the following:
a. Date;
b. Time (indicate when treatment was done/refused or when nurse is making progress
entry);
c. Initials of the nurse documenting the information;
d. Treatment; and
e. Record reasons and results of PRN or progress or decline of treatments.
7. When the treatments are refused, circle the initial and state reason for refusal.
See Pharmacy Manual for additional information.
© Health Dimensions Group 2008 Treatment Record (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Unnecessary Drugs (General)
F Tag
F329
Quality Standard RCS37
Origination Date April 1, 2008
Revision Date
POLICY
Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is
any drug when used:
• In excessive doses (including duplicate therapy);
• For excessive duration;
• Without adequate monitoring;
• Without adequate indications for its use;
• In the presence of adverse consequences which indicate the dose should be reduced or
discontinued; or
• Any combinations of the reasons above.
© Health Dimensions Group 2008 Unnecessary Drugs (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Unecessary Drugs - Antipsychotic Drugs - HDGR
F Tag
F329
Quality Standard RCS37, RCS50
Origination Date April 1, 2008
Revision Date
POLICY
Psychotropic drug therapy shall be used only when it is necessary to treat a specific condition
as diagnosed and documented in the clinical record.
PROCEDURE
A. Antipsychotic Drug Usage Determination
1. Residents who have not used antipsychotic drugs will not be given such drugs unless
antipsychotic drug therapy is necessary to treat a specific condition, as diagnosed and
documented in the clinical record.
2. Antipsychotic drugs should not be used unless the resident’s medical record clearly
indicates that the resident has one or more of the following specific conditions:
a. Schizophrenia
b. Schizo-affective disorder
c. Delusional disorder
d. Psychotic mood disorders (including mania and depression with psychotic
features, bipolar disorder and treatment, refractory major depression)
e. Acute psychotic episodes
f. Brief reactive psychosis
g. Schizophreniform disorder
h. Atypical psychosis
i. Demented illnesses with associated behavioral symptoms
j. Medical delirium with manic or psychotic symptoms or treatment related
psychosis or mania
3. Use of an antipsychotic medication must meet the criteria and applicable, additional
requirements.
a. Criteria: Since diagnoses alone do not warrant the use of antipsychotic
medications, the clinical condition must also meet at least one of the following
criteria:
i. Symptoms are identified as being due to mania or psychosis (such as:
auditory, visual, or other hallucinations; delusions (such as paranoia or
grandiosity); or
© Health Dimensions Group 2008 Unnecessary Drugs–Antipsychotic Drugs—HDGR
Page 1 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
ii. Behavioral symptoms present a danger to the resident or to others; or
iii. Symptoms are significant enough that the resident is experiencing one or more
of the following: inconsolable or persistent distress (e.g., fear, continually
yelling, screaming, distress associated with end-of-life, or crying); a
significant decline in function; and/or substantial difficulty receiving needed
care (e.g., not eating resulting in weight loss, fear, and not bathing leading to
skin breakdown or infection).
b. Short-term seven days symptomatic treatment of hiccups, nausea, vomiting, or
pruritus. Residents with nausea and vomiting secondary to cancer or cancer
chemotherapy can be treated for longer periods of time
4. Antipsychotic drugs should not be used if one or more of the following is/are the only
indications:
a. Wandering
b. Poor self care
c. Restlessness
d. Impaired memory
e. Anxiety (mild)
f. Depression
g. Insomnia
h. Unsociability
i. Indifference to surroundings
j. Fidgeting
k. Nervousness
l. Uncooperativeness
m. Verbal expressions or behaviors that are not listed under indicators which do not
represent danger to the resident or others.
5. Prior to the administration of a PRN antipsychotic, an evaluation of the justification
for use of the medication must be documented in the resident’s record. It should
include:
a. Specific reasons why the medication was to be given
b. What other non-pharmaceutical interventions were tried prior
c. What other clinical conditions were ruled out, such as pain, UTI, etc.
6. New medication order as an emergency measure: when a resident is experiencing an
acute medical problem or psychiatric emergency (e.g., the resident’s behavior poses
an immediate risk to the resident or others), medications may be required. In these
situations, it is important to identify and address the underlying causes of the problem
or symptoms.
© Health Dimensions Group 2008 Unnecessary Drugs–Antipsychotic Drugs—HDGR
Page 2 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
a. Once the acute phase has stabilized, the staff and prescriber consider whether
medications are still relevant.
b. Subsequently, the medication is reduced or discontinued as soon as possible or the
clinical rationale for continuing the medication is documented.
c. When psychopharmacological medications are used as an emergency measure,
adjunctive approaches, such as behavioral interventions and techniques should be
considered and implemented as appropriate.
d. Longer term management options should be discussed with the resident and/or
representative(s).
B. Antipsychotics on Admission or Re-admission
1. If the resident is admitted or readmitted to the facility with antipsychotic medication,
the following must be completed:
a. Appropriate diagnosis made that meets the criteria for the use of a antipsychotic;
b. Target behaviors documented for the continued use; and
c. AIMS or DISCUS assessment must be completed within the initial assessment
period.
2. Document informed consent, including the risks and benefits, in the medical record.
C. Antipsychotics Currently in Use
1. Residents who are currently receiving antipsychotic medications must meet the
criteria for the use.
2. There must be an AIMS or DISCUS assessment completed every six months and/or
prior to any increase in medication.
3. Document informed consent, including the risks and benefits, in the medical record.
4. All target behaviors must be quantitatively and objectively documented in the
resident’s medical record and/or on the medication administrative record, to monitor
the effectiveness or the side effects of the antipsychotic. Minimal effective dose must
be achieved.
D. Prior to the Introduction of an Antipsychotic Medication
1. The following steps must be completed prior to the introduction of an antipsychotic
medication:
a. Complete the antipsychotic medication evaluation tool to determine if the use of
the medication is indicated and to review other non-pharmaceutical interventions
attempted, as well as any clinical condition that might explain the resident
behavior.
b. If it is determined that the use of an antipsychotic medication may help promote
or maintain the resident’s highest practicable mental, physical, and psychosocial
wellbeing, contact the physician.
© Health Dimensions Group 2008 Unnecessary Drugs–Antipsychotic Drugs—HDGR
Page 3 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
2. A physician must determine if/what medication is justified by evaluating the
resident’s clinical condition, risks, existing medication regiment, and other related
factors. The physician’s order must include diagnosis (that meets the criteria) for use
of the medication, along with the dosage and frequency.
3. Complete Tardive Dyskinesia – AIMS or DISCUS assessment prior to initiation of
medication and within six months thereafter and/or prior to any increase in
medication.
4. Establish target behavior sheet which must include quantitative and objective
information in the resident’s medical record or medication administrative record.
5. Monitor side effects of medications.
a. If resident experiences a decline in functional status, it may be a side effect of the
medication.
b. Review side effects, contact physician if indicated.
E. Reduction
1. The regulation addressing the use of antipsychotic medications identifies the process
of tapering as a gradual dose reduction (GDR) and requires a GDR, unless clinically
contraindicated.
2. Within the first year in which a resident is admitted on an antipsychotic medication or
after the facility has initiated an antipsychotic medication, the facility must attempt a
GDR in two separate quarters (with at least one month between the attempts), unless
clinically contraindicated. After the first year, a GDR must be attempted annually,
unless clinically contraindicated.
3. For any individual who is receiving any antipsychotics medication to treat behavioral
symptoms related to dementia, the GDR may be considered clinically contraindicated
if:
a. The resident’s target symptoms returned or worsened after the most recent
attempt at a GDR within the facility; and
b. The physician has documented the clinical rationale for why any additional
attempted dose reduction at that time would be likely to impair the resident’s
function or increase distressed behavior.
4. For any individual who is receiving an antipsychotic medication to treat a psychiatric
disorder other than behavioral symptoms related to dementia (e.g., schizophrenia,
bipolar mania, or depression with psychotic features), the GDR may be considered
contraindicated, if:
a. The continued use is in accordance with relevant current standards of practice and
the physician has documented the clinical rationale for why any attempted dose
reduction would be likely to impair the resident’s function or to cause psychiatric
instability by exacerbating an underlying psychiatric disorder; or
b. The resident’s target symptoms returned or worsened after the most recent
attempt at a GDR within the facility and the physician has documented the
© Health Dimensions Group 2008 Unnecessary Drugs–Antipsychotic Drugs—HDGR
Page 4 of 5

Resident Care Policies and Procedures – Skilled Nursing Facility
clinical rationale for why any additional attempted dose reductions at the time
would be likely to impair the resident’s function or cause psychiatric instability by
exacerbating an underlying medical or psychiatric disorder.
F. Dosage
1. Doses for acute indications (e.g., delirium) may differ from those used for long-term
treatment, but should be the lowest possible to achieve the desired therapeutic effects.
2. Daily dose thresholds for antipsychotic medications used to manage behavioral
symptoms related to dementing illnesses as indicated in the table below:
Generic Medication
Chlorpromazine
Fluphenazine
Haloperidol
Loxapine
Molindone
Perphenazine
First Generation
Dosage
75 mg
4 mg
2 mg
10 mg
10 mg
8 mg
Pimozide *
Prochloroperazine *
Thioridazine
Thiothixene
Trifluperazine
Aripiprazole
Clozapine
Olanzapine
Quetiapine
Risperidone
Second Generation
75 mg
7 mg
8 mg
10 mg
50 mg
7.5 mg
150 mg
2 mg
Ziprasidone *
* Not customarily used for the treatment of behavioral symptoms.
© Health Dimensions Group 2008 Unnecessary Drugs–Antipsychotic Drugs—HDGR
Page 5 of 5

UNECESSARY DRUGS FACT SHEET: Catastrophic Reactions
Description/Definition:
Emotional outburst, usually in response to failure or feeling overwhelmed manifested by
crying, sudden mood change, anger, or fighting.
Causes/Contributing Factors:
Most often occurs during morning hours when daily care activity is the highest and more
demand on the resident (e.g., bathing, dressing, grooming). Can also occur later in the
day when over-tired and ability to handle stress is compromised.
Key Points for Immediate Management:
1. Stay calm and use a firm voice. When possible, seek help from an associate the
resident is comfortable with.
2. If necessary to protect yourself, use a pillow or padding in the chest or shoulder area
to shield yourself from possible blows or injuries. Use folded towels under your
uniform to protect shoulders and chest while cleaning up an incontinent resident who
is striking out.
3. Do not use gestures that could startle or frighten the resident.
4. Stay a safe distance from the resident and respect his/her need for personal space.
5. Do not confront or accuse the resident of wrongdoing.
6. Do not argue or try to reason with the resident.
7. Whenever possible, take the resident away from the triggering event or person to a
quiet, controlled space. This can be the resident’s room, a utility room, or any area
that can serve as a "time-out" space. Give the resident time to calm down.
8. If a restraint is needed to keep the resident and others safe, use the least amount
possible for the shortest time period.
9. Offer reassurance through gentle touch and express support when the resident is able
to hear you. (e.g., "I know you're upset. You're ok. I'm here to help you. Sit down in
this chair. I'll sit with you.”)
Key Points for Long-Term Management:
1. After the reaction is over, assess the event to see if altering the environment or
situation can prevent future reactions
2. A family conference may help with evaluating the event and providing input in
techniques that have been successful in the past.
3. In extreme cases you may need to call the physician to discuss the use of medicines.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Catastrophic Reactions
Page 1 of 1

Description/Definition:
UNECESSARY DRUGS FACT SHEET: Disrobing
This type of behavior involves the attempt or actual removal of clothing in public areas.
Causes/Contributing Factors:
Disrobing is usually due to infections, temperature (too warm), rashes, ill-fitting clothing,
discomfort related to dampness, texture of clothing, physical pain, soap/detergent allergy
or irritation, etc. It is very rarely sexual in nature.
Key Points for Immediate Management:
1. Check to insure the resident is not wet, or in pain.
2. Do tests to rule out UTI or peri infections as indicated.
3. Check for rashes.
4. Check the soap in the laundry to rule out sensitivity to type of soap.
Key Points for Long-Term Management:
1. Use clothing that fastens in the back.
2. Use lap objects resident can hold on to.
3. Use apron.
4. Work with family to ensure clothing is in good repair and fits well.
5. If the resident is a female, sometimes wearing pants works better that skirts or
dresses.
6. Stretch waist bands and pull-on tops can be more comfortable that form-fitting
clothing with waist bands that do not give, or clothing with closures such as zippers,
buttons, snaps, or hook and eyes.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Disrobing
Page 1 of 1

UNECESSARY DRUGS FACT SHEET: Fecal Smearing and Other Inappropriate
Use of Excrement
Description/Definition:
Resident behavior consists of smearing fecal material on his/her body or environment and
may include eating fecal matter.
Causes/Contributing Factors:
Possible contributing factors may be dementia, regression, anger with need for control,
attention seeking, or need for sensory stimulation.
Key Points for Immediate Management:
1. Intervene as soon as behavior is observed.
2. Redirect the resident’s behavior to acceptable alternative.
3. Take a matter-of-fact approach. Do not chastise the resident.
Key Points for Long-Term Management:
1. Attempt to determine causation and develop management plan based on cause of
possible.
2. Provide sensory stimulation.
3. Provide structured, supervised activities if appropriate.
4. Reinforce positive behaviors.
5. Maintain resident’s hygiene.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Fecal Smearing and
Other Inappropriate Use of Excrement
Page 1 of 1

Description/Definition:
UNECESSARY DRUGS FACT SHEET: Fighting
Fighting can be a physical or verbal struggle to try to gain control or overcome a
perceived threat from a person or an object. It is a severe behavioral symptom because of
the potential harm to self or others.
Causes/Contributing Factors:
It often occurs when a personal space or privacy is threatened. In a nursing home,
residents are asked to share almost everything, and they give up the right to keep others
out of their personal space. Fighting among roommates is common. Fights may occur
because a resident with a hearing loss may misunderstand what is said. Residents with
cognitive loss often do not have the skills to end conflicts in better ways. Fighting may
also occur when the staff presses a fixed schedule of care onto the resident. Feelings of
powerlessness can also contribute to fighting behavior. There may also be personality
conflicts.
Key Points for Immediate Management:
1. Separation is the first concern. Use more than one staff member if necessary.
Remove the person(s) from the situation to a quiet place for time out.
2. When personal space is the concern, stay back a few feet from the resident. Give the
resident time and space to calm herself/himself.
3. Do not try to shame the resident. Tell the resident clearly what is and is not
acceptable.
4. Use techniques for approaching and dealing with the resident as outlined in
immediate management for Catastrophic Reactions.
Key Points for Long-Term Management:
1. Once the event is over, assess the situation to see if alterations in the environment or
situation can prevent future occurrences.
2. Help the resident have more privacy and a sense of personal space. Knock on the door
before entering. State your purpose. Add personal items from home.
3. Change roommates if the conflict does not improve.
4. Avoid situations known to cause conflict.
5. Provide other chances or alternatives for the resident to use energy to get rid of
aggression and assertiveness.
6. If the resident is not cognitively impaired, set clear limits for what is acceptable
behavior. Frequently reinforce acceptable behavior.
7. Adjust staff demands to provide the resident with more control over his/her life.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Fighting
Page 1 of 1

Description/Definition:
UNECESSARY DRUGS FACT SHEET: Hoarding
This behavior is the repetitive placing of objects aside or storing said objects in a safe or
hidden place for a perceived later need.
Causes/Contributing Factors:
Hoarding may be a result of recent or past history of multiple losses, fear of not having
needs met, or jealousy. It can be a learned behavior related to a cultural practice or a
continuation of past patterns. In the case of food, it may be that they want control over a
snack later in the evening. Rarely is it due to a true psychotic diagnosis, although this
behavior is normal in Alzheimer’s and related disorders.
Key Points for Immediate Management:
1. Review health and safety issues with the resident if able to understand or with the
family/friend.
2. Offer sealed containers for storage if insistent on storing food in room.
3. Assess and address reasons for hoarding.
4. Check for hoarding of perishable items and dispose as necessary.
Key Points for Long-Term Management:
1. If the cognitive level is ok, the use of a contract with the resident is preferred that
spells out expectation from both the resident and the facility.
2. Set a routine for checking for hoarded items. If at all possible, this should be done
with the resident present to help develop a trusting relationship rather than have the
resident “discover” that some of his/her objects are missing.
3. Reinforce positive behavior.
4. Anticipate needs so perceived need is met.
5. The use of a busy box in the room through repeated use helps the resident remember
where objects are located and also helps the associate locate missing items faster.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Hoarding
Page 1 of 1

UNECESSARY DRUGS FACT SHEET: Manipulative Behavior
Description/Definition:
The resident can be demanding, dishonest, aggressive, and even hurtful at times. If the
resident has dementia, the behavior is a result of cognitive loss and is not from conscious
manipulation.
Causes/Contributing Factors:
If the resident has adequate cognitive function, the manipulative behavior is likely the
result of feelings powerlessness, helplessness, and hopelessness.
Key Points for Immediate Management:
1. Give choices whenever possible about daily routine, schedule of activities, or
treatments.
2. Provide information and encourage residents to ask questions. Explain what you need
to do and why it is important.
3. Help residents to make decisions, take action, and see results. Encourage personal
responsibility.
4. Provide positive reinforcement or rewards for healthy appropriate behaviors.
Key Points for Long-Term Management:
In some cases, a behavior modification plan may be helpful. This type of plan is based on
consistent patterns of reinforcement for chosen behaviors. It requires participation by all
staff members in order to work. Use this method only with residents who have full
cognitive function.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Manipulative Behavior
Page 1 of 1

UNECESSARY DRUGS FACT SHEET: Resisting Care
Description/Definition:
Resistance to care may be verbal or physical secondary to feelings of fear, powerlessness,
loss of control, or the inability to comprehend the need for care and treatment.
Causes/Contributing Factors:
Resistance to care may be caused by fear, loss of control over the physical or
environment, dementia, depression (clinical or situational), or personal conflict with the
timeframe for care and treatments.
Key Points for Immediate Management:
Undertake immediate management if resistance to care included key points outlined
under the Catastrophic Reaction Fact Sheet.
Key Points for Long-Term Management:
1. Whenever possible, provide a consistent caregiver that he/she is able to develop a
rapport and trust with.
2. Use a calm, gentle reassuring approach.
3. When met with resistance, leave and return later if possible.
4. Do not personalize negative behavior.
5. Give as many choices as possible.
6. Use distracting techniques, such as objects to hold.
7. Reward, praise, and/or encourage appropriate behavior.
Activities that often cause resistance to care are: bathing, dressing, medication
administration, and eating. Techniques are described for each.
Bathing
1. To reduce the stress of frequent bathing, give baths only when they are actually
needed. Learn about state and nursing home policy. Elderly persons may not need a
complete bath more than once a week.
2. Try to adjust the bath schedule to the person’s former habits. Remember that
residents may have strong feelings about nudity. Try to create a feeling of privacy.
For example, if the resident refuses to take a gown off before a shower, leave it on,
and when it becomes wet and uncomfortable, the person may then agree to remove it;
or wrap a towel around the person’s shoulders while you wash the lower half of the
body (and vise versa).
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Resisting Care
Page 1 of 3

FACT SHEET: Resisting Care
3. Use either the bath or the shower depending on which causes less resistance.
4. Try to make the water temperature, room temperature, and water depth in a bathtub
agreeable for the resident.
5. Make sure the sex of the caregiver is acceptable to the person.
6. Do not ask the resident to undress ahead of time. Wait until the resident is in the
shower room or about to get in the tub.
7. It may help to let the person hear the noise of running water first. Then start washing
the feet and work up slowly (especially if there is a fear of water on the head).
8. Use a sponge bath at the bedside if needed.
9. Don’t argue with the person over the need for a bath. When necessary, proceed
calmly, one step at a time, with a matter-of-fact approach. If there is severe
resistance, stop and try again later.
10. Residents with advanced Alzheimer’s disease may have strong fears of bathing and
water. It may help to switch to a new method of bathing or to begin a program such
as the following:
a. Take the person to the shower room and just sit with her/him;
b. Next, let her/him hear the noise of the water running in the shower or bath;
c. Then let her/him get her/his toes wet and slowly work up the body a little more
each time; and
d. Reward the person for each step with praise and give encouragement.
11. Try to make the bathroom or shower area look familiar. It may be that the whirlpool
or shower area does not remind the resident of anything from the past and causes a
fear of the unknown.
Dressing
1. Limit the choices that the resident has to make.
2. Lay clothes out in the order that the person will put them on.
3. Simplify clothing and closures. Use pants with elastic waistbands and slipover
blouses. Use ties and Velcro instead of buttons, zippers, and snaps. Instead of tie
shoes, use slip-on shoes with no-skid soles.
Medication Administration
1. Change the way you approach the person and what you say before giving the
medicine.
2. Use the drug in liquid form.
3. Crush the pill in applesauce or other foods for easier swallowing.
4. When permitted by regulations and guidelines, give medicines in the way the person
likes, such as taking a pill after lunch instead of before lunch. You may need to ask
the physician to rewrite the order.
5. Explain that the doctor or a family member wants the resident to have the medicine.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Resisting Care
Page 2 of 3

FACT SHEET: Resisting Care
Eating
1. Try different textures of food. The person’s sense of smell may be gone. Texture
may be the only way she/he has of judging the food.
2. Give foods that are familiar and reflect cultural and ethnic habits.
3. While giving the person as much control as possible, remember that she/he may not
know how to eat. She/he may not know what is edible and what is not. Remind
her/him gently and begin the action for her/him.
4. Give finger foods that the resident can pick up easily.
5. Remove noise and activity that may distract the person. Arrange eating in small
groups if the person is easily distracted.
6. Limit the number of foods and utensils you put in front of the person. Try one food at
a time. Offer one utensil instead of all three.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Resisting Care
Page 3 of 3

Description/Definition:
UNECESSARY DRUGS FACT SHEET: Sleep Problems
Sleep problems are identified as the inability to fall asleep or frequent awakening during
the night. This sleep disruption is outside the normal sleep pattern of the resident (e.g.,
the resident who worked the night shift for years and thus awakens at night would not
necessarily have the same sleeping pattern of someone who worked the day shift.) The
team needs to assess the resident’s routine and customary habits to determine if the sleep
disturbance is a problem.
Causes/Contributing Factors:
Some of the factors that may contribute to sleep disturbances/problems may include one
or a combination of the following factors: reduced need for sleep; poor sleep hygiene;
elimination need (fear of being incontinent); discomfort (from an incontinent episode or
due to pain); overstimulation from lights; environmental noises; disturbed by caregiver
routines; discomfort from sleeping surface or height of bed; new environment; stimulants
such as caffeine, chocolate, food, drinks, and medications, and an uncomfortable
environmental temperature.
Key Points for Immediate Management:
1. Reorient to person, place, or time of the resident is confused. Explain that it is time
for sleep.
2. If the person is frightened when he/she awakens, give comfort and reassurance by
telling her he/she is safe. Use a quiet, soothing tone of voice. Use touch if helpful.
3. When the person insists on getting out of bed or makes loud noises, guide him/her out
of the room to an area where he/she cannot disturb other residents.
4. Bring the person close to the nurse’s station. Provide interaction or activities that may
distract him/her. Provide busy boxes of interesting objects and textures. Ask the
person to do a simple repetitive task like folding linens. Provide music by earphones.
Use TV or offer a snack.
5. Reorient resident to the new environment or roommate.
6. Personalize the room.
7. Support group for new residents.
8. Encourage family to visit frequently and to assist with effective measures they have
tried if possible.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Sleep Problems
Page 1 of 2

Key Points for Long-Term Management:
FACT SHEET: Sleep Problems
1. Provide regular period of exercise and reduce daytime napping.
2. Remove food or drinks with caffeine from the resident’s late afternoon and evening
menu.
3. Make a routine for bathroom use with the resident. Use extra lighting at night, make a
safe path to the bathroom, or use a bedside commode.
4. Give a bedtime snack for hunger.
5. Create a bedtime routine that is relaxing to the resident, such as giving warm milk.
6. Do not set bedtime too early. The older person who only needs six hours of sleep and
goes to bed at 8:00 or 9:00 in the evening will awaken at 2:00 or 3:00 in the morning.
7. Allow the person to sleep in a recliner either in his/her room or near the nurse’s
station if he/she wants.
8. Allow the resident to be up at night with supervision.
9. Discourage action-packed TV shows late in the evening.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Sleep Problems
Page 2 of 2

UNECESSARY DRUGS FACT SHEET: Unjustified Complaining
Description/Definition:
Unjustified complaining consists of complaining to staff, family, or others about personal
concerns that have no basis in fact. Unjustified complaining is not dangerous but can be
especially bothersome for the staff because it reflects negative feelings about the care that
the resident is receiving, which may upset the resident’s family. This complaining may
often take the form of constant concern about health.
Causes/Contributing Factors:
Complaining may result from a variety of reasons such as low self-esteem, need for
attention, lack of stimulation, or depression. Both complaining and over-concern with
health may reflect a life-long pattern of behavior that is very difficult for the resident to
change.
Key Points for Immediate Management:
1. Listen. Be sure that the resident feels he/she is being heard.
2. Assure resident that an appropriate and complete medical evaluation has been done.
3. Set limits on how many times you will listen to the same concern.
4. Don’t ask the resident how he/she feels. This doesn’t mean ignore—this type of
resident’s concerns must be evaluated. Ask specific questions about the resident’s
health rather than general questions.
Key Points for Long-Term Management:
1. Reinforce those aspects of the resident’s health that are good. Build in positive
rewards like praise, treats, and comfort measures when the person does not complain.
2. If complaining is from a lack of stimulation, provide more time for human contact.
Ask the entire staff to take turns visiting the person.
3. Make a list of the positive things the resident likes to talk about for all caregivers to
use. Change the conversation to one of these topics to help break the resident’s
pattern of complaining.
4. Designate a point person for the resident to communicate with.
5. Involve the resident in leisure-time activities as a group leader or co-leader based on
interest.
6. Have a friendly visitor (volunteer) visit on a routine basis.
7. Assign this resident a job to do that is based upon interest or past occupation.
8. Possible psychological evaluation to determine if this behavior is related to
depression—clinical or situational.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Unjustified Complaining
Page 1 of 1

Description/Definition:
UNECESSARY DRUGS FACT SHEET: Unsafe Movement
A movement that could cause or lead to harm or injury to the resident or others.
Causes/Contributing Factors:
It may be an impulsive behavior relating to a CVA that is uncontrollable. The resident
may have dementia and be unaware that the movement could lead to injury. It may be
related to neurological impulses such as twitching. There may be an unmet basic need
such as clothing too tight, wet or soiled brief or clothing, hunger, thirst, pain, too cold or
hot, and waiting too long for the staff to take them to the toilet or bed. It may be related to
stubbornness (e.g., trying to reach a shelf that is too high or too low). The resident may
not want to bother the staff and feels that they can do it themselves.
Key Points for Immediate Management:
1. Be aware of residents at risk of unsafe movement.
2. Don’t rush these residents, as this puts them at an increased risk for falls or injury.
3. Make sure clothing and shoes are safe.
4. Keep environment free of debris or spills.
5. Observe and determine when resident is at risk and provide help at those times.
6. Check the safety of furniture or equipment with wheels.
7. Use a night light or a bedside commode at night.
8. Make sure resident knows how to use the call light and that it is within reach.
9. Determine if resident is wet or has a full bladder and toilet or clean the resident as
needed.
Key Points for Long-Term Management:
1. Check and/or install handrails, ensure there is ample lighting, and make sure that
changes in the floor or steps are clearly marked.
2. Use of mobility monitor to indicate when resident is up or down.
3. Use a low bed or mats on the floor to reduce the chance of injury.
4. The use of an inclined chair or bean bag cushions will discourage resident from
getting up without assistance.
5. If necessary, restraints can be used for a specific time while assessments or
reevaluations are completed.
6. Teach safe transfer techniques and gait train if resident has the cognitive abilities to
learn.
7. Provide regular supervised periods of physical movement.
8. If the resident is agitated, provide mats for them to move around on.
9. Place a ribbon across doorways showing areas that are off limits.
10. Use task segmentation where activities can be broken up into mini-steps.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Unsafe Movement
Page 1 of 1

Description/Definition:
UNECESSARY DRUGS FACT SHEET: Verbal Aggression
Verbal aggression is behavior that is exhibited by arguing, cursing, and/or using angry or
accusatory remarks to staff and other residents or at self.
Causes/Contributing Factors:
Verbally aggressive behavior may be caused by anger, fighting with staff or other
residents, resisting care, a reaction to someone or a situation, and can be an outburst or
separate episode. Contributing factors include: physical losses (inability to walk, loss of
limb, etc.), depression, dementia, cognitive losses, stress incurred secondary to an
inability to complete tasks, a change in routine, and a loss of control over daily routine.
Key Points for Immediate Management:
1. Remain calm when speaking to resident.
2. Use distracting techniques; remember frequently it is difficult to reason with the
resident.
3. Use separation, especially if it is necessary to keep away from other resident.
4. Use non-threatening body language–sit at resident’s level.
5. Use touch if able–if not, stay out of their personal space.
6. Leave if the resident is safe, and explain that you will return later.
Key Points for Long-Term Management:
1. Recognize positive behavior when you return.
2. Try distraction when you return to resident later—can come in with a different
approach area.
3. Have another caregiver approach the resident.
4. Remind staff not to take the resident’s remarks to heart or personally.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Verbal Aggression
Page 1 of 1

Description/Definition:
UNECESSARY DRUGS FACT SHEET: Wandering
Wandering is a behavior manifested by movement without purpose or regard for safety
that interferes with the functioning or health of the resident. It may be a means of coping
with feelings of stress, boredom, and/or restlessness.
Causes/Contributing Factors:
Causes include exit seeking, the need to search, feeling lost, a means of stimulation,
copying others, or a need to act out past roles.
Key Points for Immediate Management:
1. Keep pathways safe and free of clutter.
2. If the resident is in a wheelchair, use a wheelchair bar to keep resident from entering
other resident’s rooms.
3. Place individualized identifying objects or pictures outside of resident’s door.
4. Ask family/friendly visitor to visit resident at time of day resident is most prone to
wander.
5. Redirect resident to a specific task if observed entering another resident’s room.
6. Distract and redirect resident away from unsafe areas.
Key Points for Long-Term Management:
1. Include resident in small groups of short duration.
2. Have structured, supervised walking schedules.
3. Pay attention to resident’s personal agenda.
4. Familiarize staff with the resident’s past habits (e.g., rest periods, use music headset,
routine).
5. Ask family to record a reassuring message on tape.
6. Make room home-like with familiar photos and furniture.
7. Place a ribbon across the doorway of other resident’s rooms as a reminder that the
room is off limits.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Wandering
Page 1 of 1

UNECESSARY DRUGS FACT SHEET: Yelling and Screaming
Description/Definition:
Yelling and screaming can be described as loud continuous noises that are unpleasant to
other residents, staff, and visitors. It can be repetitive sounds, words, or phrases.
Causes/Contributing Factors:
Yelling and screaming can result from overstimulation (noise, bright lights, too many
demands/commands to complete tasks that are overwhelming, crowds, etc.). At the other
end of the spectrum, yelling and screaming can be caused by under-stimulation
(boredom, inactivity). It can be a method of communicating an unmet need such as fear,
pain, hunger, warmth, needing to be kept clean and dry, etc. It can be related to
depression (clinical or situational) or may be a way of seeking attention. Occasionally the
resident is not aware of the yelling due to a hearing problem. Often this behavior has
been reinforced or learned over a long period of time and is very difficult for the person
to change.
Key Points for Immediate Management:
1. Give the person something to eat or suck on, such as hard candy (depending upon
their swallowing abilities, diet needs, and level of cognitive functioning).
2. Distract the person by bringing up a favorite topic or by getting the resident involved
in a favorite activity.
3. Provide comfort in the following way:
• Touch, such as holding hands, back rubs, or hugs;
• Music or a soothing tone of voice; and
• Comfort objects such as dolls or stuffed animals.
4. Address unmet needs, such as the need for pain management, hunger, warmth, etc.
Key Points for Long-Term Management:
1. If the cause is overstimulation, move the person to a quieter environment with less
noise or stimulation. Reduce the demands by the staff and from other residents during
daily care and activities.
2. If the cause is too little stimulation, give more chances for human contact. Involve all
associates so the bulk of the interactions do not fall on one or two associates. Do not
isolate the resident in his/her room. Try other forms of stimulation such as a
walkman, tapes of favorite music or a loved one’s voice, or increased social activities
for the resident.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Yelling and Screaming
Page 1 of 2

FACT SHEET: Yelling and Screaming
3. Break the cycle of negative interaction between staff and the resident. For example, if
the person yells and the staff does not respond, the person yells louder, disturbing
everyone until the staff finally responds. The staff has just reinforced the undesired
behavior. Instead, we want to start a program of reinforcing/rewarding the desired
behavior with social or tangible objects that means something to the resident.
• Talk to the resident when he/she is not yelling.
• Reward the quiet times with social interaction, favorite food, or things he/she
enjoys.
4. If the cognitive level of the resident is intact, you may ask the resident to form the
plan with you and sign a contract. This will take some time and all (resident, staff,
other residents affected, etc.) involved need to be aware of the time and consistent
involvement necessary to make this a success. Support should be offered to all
involved.
© Health Dimensions Group 2008 Unnecessary Drugs - Fact Sheet - Yelling and Screaming
Page 2 of 2

Unnecessary Drugs – Antipsychotic Medication Evaluation Tool - HDGR
Date: Resident: MR#: Rm#:
For which of the following specific conditions/diagnoses is an antipsychotic being considered?
□ Schizophrenia □ Delusional disorder □ Schizo-affective disorder
□ Acute psychotic episodes □ Brief reactive psychosis □ Schizophreniform disorder
□ Psychotic mood disorders
(including mania and depression
with psychotic features)
□ Medical delirium with manic or
psychotic symptoms or treatment
related psychosis or mania
□ Atypical psychosis
□ None of the above
If any of these specific conditions are present, note current symptoms identified, e.g., auditory hallucination, visual
hallucinations, delusions (such as paranoia or grandiosity).
If any of these specific conditions are present, consult with MD regarding appropriate medication order if indicated.
If antipsychotic is being considered due to dementia with behavioral symptoms, continue evaluation below.
1. Do the behavioral symptoms present a danger to the resident or to others? □ Yes □ No
If yes, describe:
2. Are the symptoms significant enough that the resident is experiencing one or more of the following:
□ Inconsolable or persistent distress □ Substantial difficulty receiving needed care
Describe:
If one or more of these boxes are checked, antipsychotic use may be warranted; continue with evaluation. If no boxes
checked, antipsychotic is not appropriate.
Address the following as possible contributing factors to behaviors or distress:
Pain: □ No □ Yes Explain:
Any symptoms of acute illness (e.g., UTI, pneumonia)? □ No □ Yes Explain:
Decline in function or cognition? □ No □ Yes Explain:
Symptoms of depression? □ No □ Yes Explain:
Environmental stressors such as noise? □ No □ Yes Explain:
Psycho-social stressors such as grief, new admission, new roommate, relocation?
□ No □ Yes Explain:
___________
Delirium? □ No □ Yes Explain:
New medications? □ No □ Yes Explain:
Hydration status? □ No □ Yes Explain:
Hunger status? □ No □ Yes Explain:
Recent abnormal labs? □ No □ Yes Explain:
Allergies? □ No □ Yes Explain:
Communication barriers? (e.g., language, aphasia) □ No □ Yes Explain:
Hearing, vision impairment? □ No □ Yes Explain:
If one or more above contributing factors are checked yes, address plan for these issues prior to initiation of
antipsychotic.
PLAN:
CONCLUSION:
Contact physician if indicated.
Nurse’s Signature:
Date:
© Health Dimensions Group 2008 Unnecessary Drugs - Antipsychotic Medication Evaluation Tool - HDGR
Page 1 of 1

Unnecessary Drugs – Antipsychotic Medication Risk and Benefit - Sample
Date: Resident: MR#: Rm#:
Category
Anti-depressant
Anti-anxiety
Anti-psychotic
Sedatives/Hypnotics
Gastro-intestinal agent
(Reglan)
Potential Side Effects
Drowsiness, dry mouth, urinary retention, irregular heartbeat, blurred
vision, trouble sleeping, tremors, dizziness, low blood pressure.
Excess sedation, symptoms of low blood pressure (e.g.,
unsteadiness, dizziness), memory loss, headache, nausea, and
vomiting. Most side effects are uncommon and are more likely to
occur at higher doses.
Sedation, drowsiness, dry mouth, constipation, blurred vision.
Abnormal movement disorder, weight gain, edema, decreased blood
pressure with position changes, sweating, loss of appetite, urinary
retention.
Excess sedation, next-day dizziness, headache, short-term memory
loss, nausea, vomiting, and paradoxical excitement.
Restlessness, drowsiness, abnormal movement disorders (more likely
with older adults than younger adults), diarrhea, weakness.
Category
Anti-depressants
Anti-anxiety
Anti-psychotics
Sedatives/Hypnotics
Gastro-intestinal agent
(Reglan)
Potential Benefits
Energy level may increase. May feel more hopeful. May feel more
likely to engage in usual activities. May feel less “down.” May help
with sleeplessness.
May feel less “nervous” or “worried.” May feel less fearful. May be
able to breathe more easily. May be able to relax and more easily fall
asleep.
May decrease or eliminate paranoid thoughts. May decrease or
eliminate hallucinations and/or delusions. May become less fearful
and feel more comfortable and safe. May become less irritable and
agitated.
May be able to fall asleep more easily. May be able to return to sleep
more easily after being awakened. May not be awakened by
disturbances such as noises during the night. May be able to catch up
on rest if he/she has not been able to sleep for extended periods.
Reglan is used for symptomatic treatment of diabetic gastric stasis,
hiccups, gastroesophageal reflux, prevention of nausea associated
with chemotherapy or post surgery.
© Health Dimensions Group 2008 Unnecessary Drugs - Antipsychotic Medication
Risk and Benefit / Information Record – Sample
Page 1 of 2

Unnecessary Drugs – Antipsychotic Medication Information Record - Sample
Date: Resident: MR#: Rm#:
Medication:
Class of Medication:
Reason for Use:
Risks, Benefits have been explained:
Date of telephone/verbal contact:
Signature of RN/LPN:
Resident/Family:
Medication:
Class of Medication:
Reason for Use:
Risks, Benefits have been explained:
Date of telephone/verbal contact:
Signature of RN/LPN:
Resident/Family:
Medication:
Class of Medication:
Reason for Use:
Risks, Benefits have been explained:
Date of telephone/verbal contact:
Signature of RN/LPN:
Resident/Family:
Medication:
Class of Medication:
Reason for Use:
Risks, Benefits have been explained:
Date of telephone/verbal contact:
Signature of RN/LPN:
Resident/Family:
© Health Dimensions Group 2008 Unnecessary Drugs - Antipsychotic Medication
Risk and Benefit / Information Record – Sample
Page 2 of 2

Unnecessary Drugs – Abnormal Involuntary Movement Scale (AIMS) - HDGR
Date: Resident: MR#: Rm#:
Current Medications and Total Mg/Day
Med#1 Total mg/Day Med#2 Total mg/Day
Instructions: Complete the examination procedure before entering these ratings.
Rating: 1-None or Normal 2-Minimal (extreme normal) 3-Mild 4-Moderate 5-Severe
Facial and Oral Movements
1. Muscles of facial expression (e.g., movements of forehead, eyebrows, periorbital
area, cheeks; include frowning, blinking, smiling, grimacing).
1 2 3 4 5
2. Lips and periorbital area (e.g., puckering, pouting, smacking). 1 2 3 4 5
3. Jaw (e.g., biting, clenching, chewing, mouth opening, lateral movement). 1 2 3 4 5
4. Tongue (Rate only increases in movement both in and out of mouth, NOT inability
to sustain movement).
1 2 3 4 5
Extremity Movements
5. Upper extremities (arms, wrists, hands, fingers). Include choreic movements (e.g.,
rapid, objectively purposeless, irregular, spontaneous); athetoid movements (e.g.,
slow, irregular, complex, serpentine). DO NOT include tremor (e.g., repetitive,
1 2 3 4 5
regular, rhythmic).
6. Lower extremities (legs, knees, ankles, toes) (e.g., lateral knee movement, foot
tapping, heel dropping, foot squirming, inversion, and aversion of foot).
1 2 3 4 5
Trunk Movements
7. Neck, shoulders, hips (e.g., rocking, twisting, squirming, pelvic gyrations). 1 2 3 4 5
Overall Severity
8. Severity of abnormal movements. 1 2 3 4 5
9. Incapacitation due to abnormal movements. 1 2 3 4 5
10. Patient's awareness of abnormal movements (rate only patient's report). 1 2 3 4 5
Scoring:
• Score the highest amplitude or frequency in a movement on the scale, not the average;
• Score activated movements the same way; do not lower those numbers as was proposed at one time;
• A positive AIMS examination is a score of 2 in two or more movements or a score of 3 or 4 in a single movement.
• Do not sum the scores (e.g., a patient who has scores 1 in four movements does NOT have a positive AIMS score
of 4.)
Dental Status
11. Current problems with teeth and/or dentures? Yes No
12. Does patient usually wear dentures? Yes No
Comments:
Signature
Next Exam Date
© Health Dimensions Group 2008 Unnecessary Drugs - Abnormal Involuntary Movement Scale (AIMS)
and Examination Procedure - Sample
Page 1 of 2

Unnecessary Drugs – Abnormal Involuntary Movement Scale (AIMS) - HDGR
Date: Resident: MR#: Rm#:
AIMS Examination Procedure
Should be completed before entering the ratings on the AIMS form.
Either before or after completing the examination procedure, observe the patient unobtrusively at rest
(e.g., in waiting room).
The chair to be used in this examination should be a hard, firm one without arms.
1. Ask patient whether there is anything in his/her mouth (e.g., gum, candy) and if there is, remove it.
2. Ask patient about the current condition of his/her teeth. Ask patient if he/she wears dentures. Do teeth
or dentures bother patient now?
3. Ask patient whether he/she notices any movements in mouth, face, hands, or feet. If yes, ask to
describe and to what extent they currently bother patient or interfere with his/her activities.
4. Have patient sit in chair with hands on knees, legs slightly apart, and feet flat on the floor. Look at
entire body for movements while in this position.
5. Ask patient to sit with hands hanging unsupported. If male, between legs; if female and wearing a
dress, over knees. Observe hands and other body areas.
6. Ask patient to open mouth. Observe tongue at rest within mouth. Do this twice.
7. Ask patient to protrude tongue. Observe abnormalities of tongue movement.
8. *Ask patient to tap thumb with each finger as rapidly as possible for 10-15 seconds; separately, with
right hand, then with left. Observe facial and leg movements.
9. Flex and extend patient’s left and right arms, one at a time. Note any rigidity and rate it.
10. Ask patient to stand up. Observe profile. Observe all body areas again, including hips.
11. *Ask patient to extend both arms outstretched in front with palms down. Observe trunk, legs, and
mouth.
12. *Have patient walk a few paces, turn, and walk back to chair. Observe hands and gait. Do this twice.
*Activated movements.
© Health Dimensions Group 2008 Unnecessary Drugs - Abnormal Involuntary Movement Scale (AIMS)
and Examination Procedure - Sample
Page 2 of 2

Unnecessary Drugs – Dyskinesia Identification System – Condensed User Scale (DISCUS) Sample
Date: Resident: MR#: Rm#:
Previous DISCUS Score/Data
(If any)
Exam Type
Codes:
1. Baseline
2. Annual
3. Semi-Annual
4. D/C – 1 Month
5. D/C – 2 Month
6. D/C – 3 month
7. Admission
8. Other
Cooperation
Codes:
1. None
2. Partial
3. Full
Current Psychotropics/
Anticholinergic and Total MG/Day
Discuss 0 - NOT PRESENT (movements not observed or some movements observed but not
mg
considered abnormal)
Scoring:
1 - MINIMAL (abnormal movements are difficult to detect or movements are easy to
mg
detect but occur only one or twice in a short non-repetitive manner)
4 - SEVERE (abnormal movements occur almost continuously and are easy to detect)
N/A - NOT ASSESSED (an assessment for an item is not able to be made)
2 - MILD (abnormal movements occur infrequently and are easy to detect)
3 - MODERATE (abnormal movements occur frequently and are easy to detect)
mg
mg
ASSESSMENT (Score each DISCUS item using scoring above)
EVALUATION (See reverse side for more information)
EXAM DATES: 1 2 3 4 EXAM DATES: 1 2 3 4
Exam Type Codes:
1. Greater than 90 day’s
Cooperation Codes:
neuroleptic exposure? Y N Y N Y N Y N
FACE 1. Tics 2. Scoring/intensity level met? Y N Y N Y N Y N
2. Grimaces
3. Other diagnostic conditions?
EYES 3. Blinking
(If yes, specify below) Y N Y N Y N Y N
ORAL 4. Chewing/lip smacking a.
5. Puckering/sucking/
thrusting lower lip
b.
c.
LINGUAL
6. Tongue thrusting/
4. Last Exam Date:
tongue in cheek
Last Total Score:
7. Tonic tongue Last Conclusion:
8. Tongue tremor Preparer’s signature and title for items:
9. Athetoid/myokymic/
1. 3.
lateral tongue 2. 4.
HEAD/ 10. Retrocollis/torticollis 5. Conclusion (check one per exam date)
NECK/
TRUNK 11. Shoulder/hip torsion a. No TD (if scoring prerequisite met,
UPPER
LIMB
LOWER
LIMB
Comments
12. Athetoid/myokymic
finger-wrist-arm
b. Probable TD
13. Pill rolling c. Masked TD
list other diagnostic conditions or
explain in comments.)
14. Ankle flexioni/
foot tapping
d. Withdrawal TD
15. Toe movement e. Persistent TD
TOTAL SCORE 1 2 3 4 f. Remitted TD
(Items 1 – 15 only)
g. Other (specify in comments)
Comments
Rater Signature and Title
1
Rater Signature and Title
2
Rater Signature and Title
3
Rater Signature and Title
4
Next Exam Date
Next Exam Date
Next Exam Date
Next Exam Date
Physician’s Signature
1
Physician’s Signature
2
Physician’s Signature
3
Physician’s Signature
Resident Name I.D. # Physician Room #
4
Date
Date
Date
Date
© Health Dimensions Group 2008 Unnecessary Drugs - Dyskinesia Identification System-Condensed User Scale (DISCUS)
and Simplified Diagnoses for Tardive Dyskinesia (SD-TD) Sample
Page 1 of 2

Unnecessary Drugs – Dyskinesia Identification System – Condensed User Scale (DISCUS) Sample
Date: Resident: MR#: Rm#:
Simplified Diagnoses for Tardive Dyskinesia (SD-TD)
PREREQUISITES
The three prerequisites are as follows: (exceptions may occur)
1. A history of at least three months’ total cumulative neuroleptic exposure. Include amoxapine and metoclopramide in all
categories below as well.
2. SCORING/INTENSITY LEVEL: The presence of a TOTAL SCORE OF FIVE OR ABOVE. Also be alert for any change
from baseline or scores below five which have at least as “moderate” (3) or “severe” (4) movement on any item or at
least two “mild” (2) movements on two items located in different body areas.
3. Other conditions are not responsible for the abnormal involuntary movements.
DIAGNOSIS
The diagnosis is based upon the current exam and its relation to the last exam. The diagnosis can shift depending upon: (a) whether
movements are present or not, (b) whether movements are present for three months or more (six months if on a semi-annual
assessment schedule), and (c) whether neuroleptic dosage changes occur and affect movement.
• NO TD – Movements are not present on this exam or movements are present, but some other condition is responsible for them.
The last diagnosis must be NO TD, PROBABLE TD, or WITHDRAWAL TD.
• PROBABLE TD – Movements are present on this exam. This is the first time they are present or they have never been present
for three months or more. The last diagnosis must be NO TD or PROBABLE TD.
• PERSISTENT TD – Movements are present on this exam and they have been present for three months or more with this exam
or at some point in the past. The last diagnosis can be any except NO TD.
• MASKED TD – Movements are not present on this exam but this is due to a neuroleptic dosage increase or reinstitution after a
prior exam when movements were present. Also use this conclusion if movements are not present due to the addition of a nonneuroleptic
medication to treat TD. The last diagnosis must be PROBABLE TD, PERSISTENT TD, WITHDRAWAL TD, or
MASKED TD.
• REMITTED TD – Movements are not present on this exam but PERSISTENT TD has been diagnosed and no neuroleptic
dosage increase or reinstitution has occurred. The last diagnosis must be PERSISTENT TD or REMITTED TD. If movements reemerge,
the diagnosis shifts back to PERSISTENT TD.
• WITHDRAWAL TD – Movements are not seen while receiving neuroleptics or at the last dosage level but are seen within
eight weeks following a neuroleptic reduction or discontinuation. The last diagnosis must be NO TD or WITHDRAWAL TD. If
movements continue for three months or more after the neuroleptic dosage reduction or discontinuation, the diagnosis shifts to
PERSISTENT TD. If movements do not continue for three months or more after the reduction or discontinuation, the diagnosis
shifts to NO TD.
INSTRUCTIONS
OTHER CONDITIONS (partial list)
1. The rater completes the assessment according to the
standardized exam procedure. If the rater also completes
evaluation items 1-4, he/she must also sign the preparer
box. The form is given to the physician. Alternatively, the
physician may perform the assessment.
2. The physician completes the evaluation section. The
physician is responsible for the entire evaluation and its
accuracy.
3. It is recommended that the physician examine any
individual who meets the three prerequisites or who has
movements not explained by other factors. Neurological
assessments or differential diagnostic tests which may
be necessary should be obtained.
4. File form according to policy or procedure.
1. Age
2. Blind
3. Cerebral Palsy
4. Contact lenses
5. Dentures/no teeth
6. Down’s Syndrome
7. Drug intoxication
(specify)
8. Encephalitis
9. Extrapyramidal
side-effects (specify)
10. Fahr’s Syndrome
11. Heavy metal intoxication
(specify)
12. Huntington’s Chorea
13. Hyperthyroidism
14. Hypoglycemia
15. Hypoparathyridism
16. Idiopathic Torsion
Dystonia
17. Meige Syndrome
18. Parkinson’s Disease
19. Steriotypies
20. Syndenham’s Chorea
21. Tourette’s Syndrome
22. Wilson’s Disease
23. Other (specify)
© Health Dimensions Group 2008 Unnecessary Drugs - Dyskinesia Identification System-Condensed User Scale (DISCUS)
and Simplified Diagnoses for Tardive Dyskinesia (SD-TD) Sample
Page 2 of 2

Unnecessary Drugs – Daily Behavior Observation Tool - Sample
Date: Resident: MR#: Rm#:
A.
B.
Target Behavior
(Indicate up to two target behaviors from completed
behavior assessment log that has the most impact on
resident daily life.)
Interventions
(Indicate up to three individualized
interventions as identified by the IDT.)
1.
2.
3.
4. Other-Report to Nurse additional interventions
Outcome of Intervention
+ Improvement
0 No Change
- Worsened
Target
Behavior
# of
Episodes
NIGHTS DAYS EVENINGS
Intervention Out-
Target # of Intervention Out-
Target # of
Initials
Initials
Code come
Behavior Episodes Code come
Behavior Episodes
1 1 1
2 2 2
3 3 3
4 4 4
5 5 5
6 6 6
7 7 7
8 8 8
9 9 9
10 10 10
11 11 11
12 12 12
13 13 13
14 14 14
15 15 15
SIGNATURES FOR WEEKLY NURSING SUMMARY:
Week 1: Date: Week 2: Date:
Intervention
Code
Outcome
Initials
© Health Dimensions Group 2008 Daily Behavior Observation Tool-Sample
Page 1 of 1

Unnecessary Drugs – Psychotropic Drugs Monitor - Sample
Date: Resident: MR#: Rm#:
Description of behavior(s) to be managed:
A.
B.
C.
Date:
Occurrence of
Behavior
Enter a tally mark in the appropriate
box each time a target behavior
occurs on your shift. If a behavior is
continuous, or is of unusual
intensity, place an * in the box and
document the occurrence in the
nurse’s notes. If the behavior does
not occur on your shift, chart a
zero.
Side-effects codes:
1. Anticholinergic 6. Loss of balance 11. Urinary retention 15. Trembling fingers/hands
2. Rigid/slow movement 7. Tardive dyskinesia 12. Muscle spasms 16. Muscle stiffness arms/legs
3. Drooling 8. Abnormal B/P 13. Shuffling walk 17. No side-effects noted
4. Restlessness 9. Dizziness 14. Abnormal movement 18. Other:
5. Mask-like face 10. Lethargy/drowsiness
(eye/jaw/tongue)
▲ Initial to verify accuracy of shift documentation
initial▲
11-7 Behavior Code(s)
# of times
behavior occurred
initial▲
7-3 Behavior Code(s)
# of times
behavior occurred
initial▲
3-11 Behavior Code(s)
# of times
behavior occurred
Side-effects
Record code(s) in the appropriate
box for each side-effect observed
on your shift. If a side-effect is of
unusual intensity, place an * in the
box and document the occurrence
in the nurse’s notes.
11-7
7-3
3-11
initial▲
Code(s)
initial▲
Code(s)
initial▲
Code(s)
Dose Per Shift
Record total number of milligrams
of drug received during your shift in
the appropriate box. (Include both
scheduled and pm doses).
Designate a shift responsible for
totally doses and record the daily
does in the box provided.
11-7
7-3
3-11
Total Dose
Medication Pertinent Diagnosis Signature
© Health Dimensions Group 2008 Psychotropic Drugs Monitor-Sample
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Urinals/Bedpans - Cleaning
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
To prevent the spread of infection, urinals/bedpans that require cleaning will be cleaned.
Disposable products can be used.
PROCEDURE
1. Apply gloves.
2. Bring all bedpans/urinals to the utility room.
3. Clean bedpan/urinal in the hopper.
4. Clean bedpan/urinals with disinfectant.
5. Allow to air dry.
6. Remove gloves.
7. Wash hands.
8. Return to storage area for each resident.
© Health Dimensions Group 2008 Urinals/Bedpans–Cleaning
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Vaginal Instillation/Irrigation
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Applying medications to the lining of the vagina will be done with a physician’s order and
administered by a licensed nurse or trained medical aide.
PROCEDURE
1. Wash hands.
2. Provide privacy.
3. Explain procedure to resident.
4. Drape resident. Have resident lie on back with knees flexed.
5. Put on gloves.
6. Insert tube applicator, with required amount of medication, into the vagina according to
directions on container; or if suppository, insert suppository into vagina with index finger
as high as possible (hold vulva around nozzle while medication is being instilled to aid
retention).
7. Have resident lie in bed for at least one-half hour following procedure, if possible.
8. Wipe and dry off perineum.
9. Discard disposable equipment in utility room trash can.
10. Remove gloves.
11. Wash hands.
12. Leave resident with call light in reach.
13. Cleanse, dry, and return equipment to proper place.
14. Chart date, time, procedure, type, and amount of medication instilled on the treatment
sheet.
15. Chart unusual observations and resident reaction in the nurse’s notes.
16. Notify physician, as needed.
© Health Dimensions Group 2008 Vaginal Instillation/Irrigation
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Vaginal Suppository - Insertion
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Applying medications to the lining of the vagina will be done with a physician’s order and
administered by a licensed nurse or trained medical aide.
PROCEDURE
1. Explain the procedure to the resident.
2. Provide privacy.
3. Make sure the resident is draped appropriately.
4. Position should be on back with legs spread apart.
5. Wash hands.
6. Apply gloves.
7. Remove medication from wrapper.
8. Spread labia. Visualize vagina. Insert medication with finger to end of vaginal canal.
9. Remove gloves.
10. Wash hands.
11. Reposition resident; make comfortable.
12. Wash hands.
13. Note medication given on medication record.
14. Note any side affects in nurse’s notes.
15. Notify physician, as needed.
© Health Dimensions Group 2008 Vaginal Suppository - InsertionVaginal Suppository–Insertion
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Vision and Hearing (General)
F Tag
F313
Quality Standard RCS36
Origination Date April 1, 2008
Revision Date
POLICY
Residents receive proper treatment and assistive devices to maintain vision and hearing
abilities; the facility assists the resident, as necessary:
1. In making appointments; and
2. By arranging for transportation to and from the office of a practitioner specializing in the
treatment of vision or hearing impairment or the office of a professional specializing in
the provision of vision or hearing assistive devices.
© Health Dimensions Group 2008 Vision and Hearing (General)
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Vital Signs - Measuring Pulse, Respiration and Blood Pressure
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident’s vital signs will be monitored routinely and/or as needed to note any abnormalities
in the three cardinal signs and to obtain accurate pulse, respiration, and blood pressure.
PROCEDURE
1. Pulse:
a. Wash hands.
b. Ensure privacy.
c. Place the resident’s hand and forearm in a semi-prone position.
d. Place the second, third, and fourth fingers along the course of the radial artery of the
resident’s arm on thumb side of hand. Do not use your thumb as it has its own pulse.
e. Count the pulse rate for one minute; note the rate, regularity, and force (may count for
30 seconds and multiply by 2).
f. Record your findings on a piece of paper.
g. Wash hands.
2. Respiration:
a. Wash hands.
b. Ensure privacy.
c. Respiration may be counted by watching the rise and fall of the chest; by placing the
hand on the chest or abdomen and feeling the rise and fall; or by listening to the
breathing if it is audible.
d. Count the respiration for one minute (the rise and fall of the chest/abdomen is
considered one respiration).
e. Record readings on a piece of paper.
f. Wash hands.
3. Blood pressure:
a. Wash hands.
b. Ensure privacy.
© Health Dimensions Group 2008 Vital Signs–Measuring Pulse, Respiration, and Blood Pressure
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
c. The resident should be sitting or lying down.
d. Explain the procedure to the resident.
e. Cleanse ear pieces of stethoscope with alcohol sponge.
f. Expose the arm, preferably the left one; place the cuff on the upper arm in the proper
way over the brachial artery at the level of the heart. Secure the cuff and place the
gauge where you can read it properly.
g. Feel the bend of the elbow for the pulse and place the bell of the stethoscope over the
pulsating area.
h. Place the ear plugs of the stethoscope into your ears.
i. Tighten the needle valve on the inflation bulb and pump bulb to at least 180 mm of
mercury. If you can still hear a heart beat, pump until manometer indicates a 5 to 10
mm above the point the beat disappears.
j. Release the bulb pressure slowly and evenly.
k. Listen for heart beats and note the level of the mercury when the beat is first heard.
This is the systolic or top number. Keep listening until the beats disappear and note
the mercury reading. This is the diastolic or bottom number.
l. Record readings on a piece of paper.
m. Wash hands.
4. Record results and notify charge nurse or designee of readings.
© Health Dimensions Group 2008 Vital Signs–Measuring Pulse, Respiration, and Blood Pressure
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Vital Signs - Temperature Measurement
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Resident’s vital signs will be monitored routinely and/or as needed to obtain an accurate
body temperature and note any abnormalities in body temperature.
PROCEDURE
1. Oral temperature:
a. Wash hands.
b. Obtain necessary equipment. Be sure you are using the right type of thermometer.
c. Explain the procedure to the resident emphasizing the need to keep lips closed and
not to talk (oral).
d. Place a sheath on the thermometer, according to package directions.
e. Resident should be sitting or lying down. Be sure the resident has not smoked
recently (past 15 minutes) or has had something very cold or hot to eat or drink within
the past 30 minutes.
f. Allow the thermometer to remain in place until the machine beeps (if electronic).
g. Remove the thermometer probe from the resident’s mouth. If sheath was used,
remove so sheath is inside out and discard in trash. Read temperature.
h. Wash hands.
2. Axillary temperature:
a. Wash hands.
b. Place thermometer under the resident’s arm.
c. Bring the arm close to the chest, across the body.
d. Leave the thermometer in place until it beeps.
e. Remove, wipe with a tissue, and read.
f. Wash hands.
3. Ear thermometer:
a. Wash hands.
b. Place cap over equipment end to be inserted in ear.
© Health Dimensions Group 2008 Vital Signs–Temperature Measurement
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
c. Apply gloves.
d. Pull lobe of ear down and back and insert probe into ear as far as it will go.
e. Remove when machine beeps (if electronic) and read temperature in display area.
f. If cap is disposable, discard cap into the appropriate container.
g. Remove gloves.
h. Wash hands.
4. Use of IVAC for temperature:
a. Obtain IVAC and make sure it is charged.
b. Wash hands.
c. Remove probe (oral and rectal available) and decide method of temperature (oral,
rectal, or axillary). Insert in sheath container. Sheath should click on over probe.
d. Place probe in area (mouth-under tongue, under arm or rectum) and keep in place
until beeper sounds.
e. Note the reading on monitor.
f. Push button on end of probe to release sheath and discard sheath in trash.
g. Remove gloves.
h. Wash hands.
i. Record the monitor reading, as noted above.
j. Notify charge nurse or designee of results.
5. Record temperature on vital signs record and/or ADL sheet.
6. Note route of temperature (i.e., oral, axillary, or ear).
7. Notify charge nurse or designee of any elevations. When recording vital signs the
temperature always comes first.
8. All thermometers should be cleaned with each use.
© Health Dimensions Group 2008 Vital Signs–Temperature Measurement
Page 2 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Water Pass
F Tag
N/A
Quality Standard RCS47
Origination Date April 1, 2008
Revision Date
POLICY
Residents will be provided with fresh water daily.
PROCEDURE
1. Wash hands initially.
2. Fill ice bucket with ice; obtain an ice spoon and additional cups. Place all items on a cart.
3. Proceed to each resident’s room and ask the resident if he/she wants ice or just water or
both.
4. Remove pitcher and empty contents. Fill with desired ice and water.
5. Replace used cups.
6. Wash hands between each resident’s rooms.
7. Repeat procedure from room to room.
© Health Dimensions Group 2008 Water Pass
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Water Pitchers and Glasses - Cleaning
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Water pitchers and/or glasses are cleaned on a routine basis.
PROCEDURE
1. All water pitchers and glasses are picked up daily and delivered to the kitchen.
2. A new set of pitchers and/or glasses is obtained and distributed when the first set is
picked up.
3. Water pitchers and glasses are run through the dishwasher and stored.
4. Disposable glasses may be used and distributed daily.
© Health Dimensions Group 2008 Water Pitchers and Glasses–Cleaning
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Weight Loss
F Tag
F309, F325
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
The facility ensures that residents who enter the facility will not fall below their ideal body
weight range, unless the weight loss is viewed as unavoidable.
PROCEDURE
1. Residents assessed for “at risk.”
2. Those residents “at risk” noted on care plan with individualized interventions.
3. Charts contain current weight, ideal body weight, and lab data regarding nutritional
issues.
4. Dietary consult completed and suggestions implemented.
5. MD aware of “at risk” with documentation in clinical record.
6. Monitor dining room for environmental issues related to eating (noise, etc.).
7. Monitor percent eaten, fluids consumed, and substitutes offered.
8. Identify any adaptive equipment and restorative programs that can benefit the resident.
9. MDS change of condition completed if weight loss meets criteria.
10. OT, Speech or Psychiatric consult for issues (swallowing, adaptive equipment, or
depression).
11. Medical workup for infection, terminal disease, bowel obstruction, and denture/mouth
issues to be assessed.
12. MDS and care plans updated as appropriate.
13. Dietary or designee, social services, and nurse’s notes address weight loss issues.
© Health Dimensions Group 2008 Weight Loss
Page 1 of 1

Resident Care Policies and Procedures – Skilled Nursing Facility
Policy Title Wounds Irrigation
F Tag
N/A
Quality Standard N/A
Origination Date April 1, 2008
Revision Date
POLICY
Wound irrigations are usually done to soften and aid removal of necrotic tissues, and/or to
remove exudate. They are done only with a physician’s order and by a licensed professional.
PROCEDURE
1. Assemble equipment at resident’s bedside including solution as ordered by physician.
2. Explain procedure to the resident.
3. Provide privacy.
4. Wash hands.
5. Place protective cover on bed under wound area.
6. Apply gloves.
7. Remove soiled dressing and put in bag as needed.
8. Change gloves/sanitize hands.
9. Direct the stream of solution against the upper edge of the wound. This insures that the
contents of the wound will be carried with the stream of solution into the basin and thus
out of the wound. Use enough pressure to reach the desired area but not enough to cause
discomfort.
10. Continue flushing the wound until the amount of solution ordered by the physician has
been used, or until the return flow is clear.
11. Dry the area well with sterile sponges. Aseptic technique is used at all times. Pat the area
gently. Do not spread infection from one area to another. Use new sponges when
necessary.
12. Remove gloves
13. Wash hands.
14. Apply new gloves.
15. Apply new dressings in aseptic manner.
16. Dispose of soiled dressing appropriately.
17. Remove gloves.
© Health Dimensions Group 2008 Wounds Irrigation
Page 1 of 2

Resident Care Policies and Procedures – Skilled Nursing Facility
18. Wash hands.
19. Chart procedure, solution, and time on treatment sheet.
20. Note any observations and resident’s reactions in the nurse’s notes.
21. Make out the necessary charge slips.
© Health Dimensions Group 2008 Wounds Irrigation
Page 2 of 2

FEDERAL TAG NUMBERS
RESIDENT RIGHTS – 483.10
F151 – Exercise of rights
F152 – Resident competency
F153 – Access records and photocopy
F154 – Right to be informed of health status
F155 – Right to refuse treatment
F156 – Informed Medicaid benefits
F157 – Notification of changes
F158 – F161 – Resident funds
F162 – Limitation on charges to personal funds,
Items and services that may be charged to res.
F163 – Choose a personal attending physician
F164 – Privacy and confidentiality
F165 – Voice grievances
F166 – Resolve grievances
F167 – Examine survey results
F168 – Agencies acting as advocates
F169 – Work
F170 – F171 – Mail
F172 – Access and visitation rights
F173 – Ombudsman access to records
F174 – Telephone, reasonable access without
being overheard
F175 – Married couples
F176 – Self administration of drugs
F177 – Refusal of certain transfers
ADMISSION, TRANSFER, DISCHARGE
RIGHTS – 483.12
F201 – Transfer and discharge requirements
F202 – Documentation
F203 – Notice before transfer
F204 – Orient re-transfer and readmission
F205 – Notice of bed hold policy and readm
F206 – Permitting resident to return to facility
F207 – Equal access to quality care
F208 – Admission policy
RESIDENT BEHAVIOR AND FACILITY
PRACTICES – 483.3
F221-F222 – Restraints
F223 – Abuse
F224 – F226 - Staff treatment of residents
F225 – Background checks
F226 – Reporting
QUALITY OF LIFE – 483.15
F240 – Promotes maintenance or enhancement
of each res. Quality of life
F241 – Dignity
F242 – Self-determination and participation
F243 & F244 – Participation in resident and
family groups
F245 – Participation in other activities (social,
religious, community)
F246 – Accommodation of need
F247 – Written notice before room or roommate
change
F248 – Activities
F249 – Qualifications of activity director
F250 – Social service
F251 – Qualification of social worker
(Environment):
F252 – Clean, comfortable and homelike
environment
F253 – Housekeeping and maintenance services
F254 – Clean bed and linens in good condition
F255 – Private closet space
F256 – Adequate and comfortable lighting level
F257 – Comfortable and safe temperatures (71 –
81 degrees F)
F258 – Comfortable sound level
RESIDENT ASSESSMENT – 483.20
F271 – Admission orders
F272 – Comprehensive assessments (RAI)
F273 – When MDS required –adm &readm
F274 – Significant change
F275 – Annual
F276 – Quarterly review assessment
F277 – Coordination with PASARR
F278 – Accuracy of assessment
F279 – Comprehensive care plans
F280 – Care plan requirements
F281 – Services provided meet professional
standards of quality
F282 – Services provided by qualified persons in
accordance with plan of care
F283 – Discharge summary
F284 – Post-discharge plan of care
F285 – Pre-admission screening
F286 – 15 months of MDS in active record
F287 – Electronic transmission
QUALITY OF CARE – 483.25
F309 – Attain or maintain highest practicable
well-being
F310 – Abilities in ADL do not diminish
F311 – Appropriate treatment and services to
maintain or improve
F312 – Maintain nutrition, grooming and
personal and oral hygiene
F313 – Vision and hearing
F314 – Pressure sores
F315 – Catheter, incontinence and UTI
F317 – Decrease ROM
F318 – Services and treatment to increase ROM
or prevent further decrease
1

(Quality of Care, continued)
F319 – Appropriate treatment and services for
mental and psychosocial needs
F320 – No decreased social interaction or
increase behaviors unless.
F321 – Nasogastric tubes
F322 – Nasogastric or G-tubes
F323 – Accident and supervision guidance
F325 – Nutrition
F326 – Therapeutic diet
F327 – Hydration
F328 – Proper tx and care for special services-
(injections, parenteral, enteral, ostomy, trach,
footcare, prosthesis)
F329 – Free from unnecessary drugs
F332 – Medication error rates of 5%
F333 – Significant medication errors
F334 – Influenza & Pneumococcal immunization
NURSING SERVICES – 483.30
F353 – Sufficient nursing staff
F354 – RN, DON requirements
F355 – Nursing wavers
F356 – Nursing staffing
DIETARY SERVICES – 483.35
F360 – Well-balanced diet
F361 – Dietitian services
F362 – Sufficient dietary staff
F363 – Meals and nutritional adequacy
F363 – Menus prepared in advance and followed
F364 – Food – flavor, appearance, temp
F365 & F366 – Substitutes offered
F367 – Therapeutic diets
F368 – Frequency of meals
F369 – Assistive devices and paid feeding
assistants
F370 – Sanitary conditions
F371 – Store, prepare, distribute and serve food
under sanitary conditions
F372 – Dispose of garbage and refuse properly
(covered)
PHYSICIAN SERVICES – 483.40
F385 – Physician supervision, approval of
admission
F386 – Review total program of care each visit –
write progress note, sign and date all orders
F387 – Frequency of visits
F388 – Physician assistant, nurse practitioner, or
clinical nurse specialist
F389 – Availability of physicians for emergency
care
F390 – Physician delegation of tasks
SPECIALIZED REHABILITAION
SERVICES – 483.45
F406 – Provision of services
F407 – Qualifications
DENTAL SERVICES – 483.55
F411 – Routine and emergency dental services
F412 – Transportation, lost/damaged dentures
PHARMACY SERVICES – 483.60
F425 – Pharmacy services
F427 – Consultation
F428 – Drug regimen review
F431 – Labeling of drugs (and expiration)
F432 – Storage of drugs
INFECTION CONTROL – 483.65
F441 – Infection control program
F442 – Preventing spread of infection
F443 – Prohibit employees with communicable
disease from direct contact
F444 – Handwashing
F445 – Linens
PHYSICAL ENVIRONMENT – 483.70
F454 – Protect the health and safety, Life safety
from fire
F455 – Emergency power
F246 – Sufficient space and equipment
F456 – Maintain equipment in safe operating
condition
F457 – Bedrooms
F458 – Size
F459 – Access to an exit corridor
F460 – Privacy
F461 – Window
F246 – Bed of proper size and height, functional
furniture
F462 – Toilet facilities
F463 – Resident call system
F464 – Dining and resident activities rooms
F465 – Adequately furnished, sufficient space
F466 – Water available (emergency)
F467 – Adequate ventilation
F468 – Handrails firmly secured
F469 – Pest control programs
ADMINISTRATION – 483.75
F490 – Certain deficiencies – defined as
substandard
(Administration, continued)
F491 – Licensure (problems with care provided
by licensed personnel)
F492 – In compliance with laws, regulations, and
codes r/t health, safety & sanitation
2

F493 & F494 – Required training of nursing
aides
F495 – Competency
F496 – Registry verification
F497 – Regular inservice education
F498 – Proficiency of nurse aides
F499 – Staff qualifications – temporary staff
F500 – Use of outside resources - consults
F501 – Medical Director
F502 – F504 – Laboratory services
F505 – Promptly notify physician of lab findings
F506 – Assist with transportation arrangements
F507 – Lab – medical records
F508 – F513 – Radiology and other diagnostic
services
F514 – Clinical records – complete, accurately
documented, readily accessible and
systematically organized
F515 – Retention of clinical records
F516 – Safeguard the clinical record
F164 – Confidential information
F514 – Medical record
(EMERGENCY PREPAREDNESS)
F517 – Written plans and procedures
F518 – Train all employees in emergency
procedures, staff drills
F519 – Transfer agreement
(QA&A)
F520 – Committee – Quality assessment and
assurance
F522 – Disclosure of ownership
3

Resident Care Policies and Procedures – Skilled Nursing Facility
REFERENCES
Center for Disease Control and Prevention (CDC), http://www.cdc.gov
Center for Medicare and Medicaid Services (CMS), Regulations and Guidance,
http://www.cms.hhs.gov
Department of Human Resources, Division of Health Care Financing and Policy – MDS
Supportive Documentation Guidelines. Nevada Medicaid
Department of Human Resources, Division of Health Care Financing and Policy – MDS
Supportive Documentation Guidelines. Nevada Medicaid
Guy W: ECDEU Assessment Manual for Psychopharmacology - Revised (DHEW Publ No
ADM 76-338), US Department of Health, Education, and Welfare; 1976
ICD-9-CM Guidelines
Long Term Care Facility Resident Assessment Instrument (RAI) user's Manual. CMS
authors, John N Morris, Katherine Murphy and Sue Nonemeaker, Updated by Diane L
Brown
Revised Long-Term Care Resident Assessment Instrument User’s Manual
Skilled Nursing Facility Manual (Publication 12 of the Department of Health & Human
Services paper-based manual archives)
Social Security Administration, Omnibus Budget Reconciliation Act of 1993, www.ssa.gov
State Operations Manual (Publication 100-07 of the CMS Online Manual System). Also
included in this section is the following appendix from the State Operations Manual
(Publication 100-07 of the CMS Online Manual System)
Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys (Rev. 1, 05-21-
04)
US Department of Health and Human Services, Public Health Service Agency for Heath
Care Policy and Research
© Health Dimensions Group 2008 z2_Reference Page
Page 1 of 1