If all goes according to plan, facilities that receive a fine will stop, pause-- and think about the type of care that they provide to patients because the fine imposed against them remains enough of a sting for the facility to improve its patient care.

The trouble that I continually see with the overwhelming number of monetary fines imposed against nursing homes is that the fines are rarely commensurate with the degree of inadequate care provided.  Moreover, when the fines imposed against offending nursing homes are evaluated in the context of a facilities business operations, they amount to little more than the cost of doing business.

Poor care, meager fines

Perhaps a recent string of fines imposed the Connecticut Department of Health against several nursing homes in the state is about as good an example of these simply inadequate fines as one can find?

***According to a recent article in The Middletown Press, the DPH handed over the following fines.

• $650 to a Aurora Senior Living of Cromwell after a patient patient choked to death on marshmellows.  The patient was known to have dysphagia and the treating physician ordered that the patient was not to receive solid foods.
• $600 fine imposed The Apple Rehabilitation West Haven following a state investigation where 15 patients with various ailments were not given their prescribed medications for approximately one year.
• $510 to New London Rehabilitation and Care of Waterford after a patient was injured during a transfer with a Hoyer lift.
• $815 following a situation at Masonic Health Center of Wallingford involving two residents who were injured while being transported improperly in wheelchairs and for the drastic weight loss in two other patients.
• $510 when staff at Apple Rehabilitation Laurel Woods of East Haven transferred a patient in the bathroom with one staff member when their care plan indicated that they were to be transferred with two employees

From the perspective of acting as a deterrent, regulatory agencies and legislatures need begin flexing far more regulatory muscle--- or episodes of poor care such as this will always plague the industry. 

Maybe some of these state agencies need to confer with officials at the NBA, who seem quite capable of using fines to get players behavior in line with the leagues values?  Incidentally, no elderly people were neglected, abused or injured in relation to these incidents.

• $25,000 fine imposed a against a player who posted the photo of a scatily clad woman on Twitter.
• $35,000 fine to a player who was either licking blood off an injured finger or gesturing to the crowd
• $500,000 fine to the owner of an NBA team who issued a one sentence response to a fan during the NBA lockout
• $40,000 fine to Kobe Bryant for missing to appearences during and All-Star Game weekend

Related Nursing Homes Abuse Blog Entries:

Illinois Lawmaker Seeks To Tighten Reigns On Nursing Homes

What good are nursing home fines when they're not enforced?

Shouldn't Nursing Home Fines Be Reflective Of The Type Of Violation Committed?

How Much Do Nursing Home Need To Be Fined In Order To Clean Up Their Acts?

While an assembly line approach to staffing can yield increased productivity in an industrial setting, the technique is inappropriate in situations where--- heaven forbid, more individualized care is required.  While I regularly hear from nursing home staff how overwhelming their superiors expectations are of them, it frankly can be difficult to accurately quantify how such working conditions impact the patients.

A recent episode of blatant nursing home neglect, reported by WCCO in Minneapolis caught my attention, for both the tragic outcome of the situation, but also because a closer review of the circumstances highlights the dangers situations of under-staffing at nursing homes. 

Recognizing that they were short-staffed one evening, officials at Adams Health Care Center called a night nurse in early to assist with the distribution of meals to patients.  After distributing a meal tray to an elderly man and positioning him in his bed, the nurse went about to distribute the remaining trays to other patients.  Unfortunately, in her haste to complete her responsibilities, the nurse failed to abide by specific instructions set forth in the patient's medical chart.

With a history of pneumonia and breathing difficulties, staff had identified the man as being a higher risk for choking and implemented the precautionary measures such as:

• Verbally instructing the patient to swallow each bite two times
• Instructing the patient to eat slowly and regularly clear his throat
• Position the bed at a 90-degree angle while he was eating and lower to a 45-degree elevation following the meal to help with digestion

Shortly after the patient was left with his meal--- and without the safety protocols in place, he began coughing.  Shortly after nursing home staff were summoned to his assistance, his heart stopped.  An investigation into the incident concluded that the patient's death was related to his choking on food.

While an appropriate sanction is being considered by officials, this incident highlights the dangers posed to vulnerable nursing home patients when there is inadequate staffing levels in place at facilities to satisfy each patients care needs. 

As opposed to placing all responsibility for this episode of nursing home negligence on the back of the single employee who acted inappropriately, I hope that officials delve deeper into this incident and evaluate the number of staff members on duty at the time of this incident and the number of patients they were responsible for caring for.

Related Nursing Homes Abuse Blog Entries:

Class Action Lawsuit Alleges Golden Living Failed To Provide Adequate Staffing For Patients

Study Demonstrates Nursing Home Workers Earn Less Than Minimum Wage

Less Patients, Happier Staff, Healthier Patients. Research Shows Less May Actually Be More When It Comes To Patient Loads For Nurses

'Poor Judgment' To Blame For CNA's Failure To Implement Fall Precautions In Minnesota Nursing Home Death

The State Journal-Register reported that the investigation into the choking death was triggered by the Morgan County Coroner who was conducting an examination of the patient's body.

Nearly two years before this incident, the same facility (then known as Golden Moments Senior Care Center) a similar incident occurred at the facility when a patient who was to be on a pureed food diet, choked to death on a pieces of ham that were intentionally cut for him by staff at the facility.  That incident resulted in an original fine of $50,000 that was subsequently reduced to $32,500 after the facility appealed the sanction.

My take:

I can appreciate the different levels of facility culpability involved in the two choking incidents--- and hence the significantly different fines imposed.  Nonetheless, I find the similarities between these incidents occurring at the same facility within a relatively short period of time--- to be extremely concerning.

As a lawyer who has representing families in nursing home lawsuits involving patients who have choked on food, I seriously question why a facility should seemingly be let off the hook when they failed to learn their lessons just a short while before.  If nursing home fines are going have their intended effect of improving patient care, I would hope that regulators look at episodes such at this, with a more critical eye--- the second time around.

Related Nursing Homes Abuse Blog Entries:

Golden Moments Senior Care Center Continues To Accumulate Fines Related To Providing Poor Care To Its Patients

Failure To Follow Doctor's Orders Results In The Choking Death Of Hospital Patient

Nursing Home Blamed For Resident Choking To Death On Raw Cukes

Toothless Patient Chokes To Death After Nursing Home Staff Ignores Doctor's Order

Nursing Home Responsible For Choking Death Of Patient

Even after Mr. Polombski's choking was identified by staff, there was a significant delay in the process of attempting to clear his airway.  In fact, evidence at the trial suggested that the facility waiting approximately 12 minutes from the time the choking was identified until they contacted paramedics.  The delay in obtaining care to clear the airway was alleged to have exacerbated the situation.

Choking is a disturbingly common type of injury that threatens the safety of nursing home patients-- particularly those who have sustained a stroke or other neurological injury.  In order to minimize a patient's risk of choking, facilities frequently utilize the skills of a speech therapist to conduct a swallowing test to determine what type of dietary modifications need to be made to the patient's food: served cut up, ground, chopped, pureed, or in another manner which meets the patients physical abilities.

In patients with extensive swallowing difficulties, restrictions may me implemented on the type of food or drink that the patient can have.  In extreme circumstances, a doctor may categorize the patient as "NPO".  NPO stands for Nothing Per Orem which means nothing by mouth. Doctors use this on orders when they do not want the patient to take in any type of food or liquid by mouth.

Once the dietary restrictions have been put into place, it is up to nursing home staff to carefully implement the orders and keep the dietary orders in place until they receive alternative orders from the patients physicians.  

However, even in circumstances where patients have dietary restrictions in place, it is important for staff to monitor all patients during meal times to help patients safely enjoy their food.  At all times, staff should always incorporated basic choking precautions:

• Encourage patients to sit upright
• Always keep a beverage within reach
• Don't rush patients while they eat
• Warn patients about food that may have bones or skin that may not be apparent
• Train staff on how to dislodge food / Heimlich maneuver

Related:

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

Swallowing Therapy of Neurologic Patients- Correlation of Outcome with Pretreatment Variables and Therapeutic Methods (pdf) Dysphagia 10:1-5(1995)

Toothless Patient Chokes To Death After Nursing Home Staff Ignores Doctor's Order

Choking Death Just Latest Problem At California Nursing Home

Jury awards $2.35 million for death caused by choking on meatball in Warren nursing home Daily Tribune

According to both state inspection reports and news reports regarding the incident, the patient had swallowing problems which resulted in staff giving her a diet of pureed food.  It was during the feeding process that the patient began to choke on the pureed food. 

However, upon hearing a 'gurgling' sound from the patient--- a clear indication of her choking-- the nurse elected to clean a dirty suction machine as opposed to summoning a clean suction machine from an available on a nearby 'crash cart' at the facility.

A remarkable 15-20 minutes were apparently spent cleaning the dirty machine as the nursing home patient laid in her bed--- choking.  Further, during the choking situation, the nurse failed to notify other staff at the facility because she assumed that the patient was dead.

Currently, the nurse's license is under investigation.

Situations such as this, highlight the need for nursing home staff to provide extra care while feeding patients with swallowing difficulties.  Patients with swallowing difficulties typically require extra encouragement and patience on the staff's end in order to safely consume their meals. 

Given the fact that some patients with swallowing difficulties have problems with the muscles that control the swallowing process and may have diminished sensory perception, it is also important that staff who provide care have proper training about how to clear an airway when a patient begins choking.

Certainly, in the case of this Kentucky nursing home, it appears as though the nurse involved exercised some horrible judgment.  However, I would be curious as to the the training Johnson Mathers provided staff feeding patients who have swallowing difficulties as well as how many patients this nurse was responsible for caring for during this time period?

Related:

Failure to Follow Orders Results In Death Of Patient & Hefty Fine

Lawsuit filed against nursing home where resident choked to death, by Valerie Honeycutt Spears, Kentucky.com June 11, 2011

Elderly Patients Are At Higher Risk For Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

Particularly, when its a situation involving a patient eating solid vs. soft foods, it is crucial that a doctor or professional with experience relating to patients swallowing and digestive abilities, carefully evaluate each patients individual needs. Further, it is crucial that staff at the nursing home strictly adhere to the orders set forth by the physician.

When staff fail to adhere to the physician orders relating to dietary restrictions, disaster may ensue.

An example of the problems associated with staff ignoring physician orders-- or just plain common sense-- happened at a California nursing home when a toothless patient choked to death on a pork chop.  Following an investigation into the incident at Goldstar Rehabilitation and Nursing Center, it was concluded that staff at the facility ignored physician orders specifying a soft-food diet, when they allowed the patient to consume a pork chop.

The incident resulted in a $100,000 fine.

Related:

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

Failure To Follow Doctor's Orders Results In The Choking Death Of Hospital Patient

Choking Death Just Latest Problem At California Nursing Home

Nursing Home Injury Laws: California

Santa Monica nursing home fined 100K in death The Examiner

Certainly, not to make light out of a serious issue, there are similar swallowing-related dangers facing patients who may not be able to appreciate the dangers.  I have worked on a number of cases involving disabled patients who have swallowed foreign objects during admissions to nursing homes, hospitals and group homes. 

Most of these foreign-object cases involve patients with Alzheimer’s and other psychiatric conditions who remain unable to appreciate the dangers associated with swallowing materials that may be on hand in their rooms.

Commonly encountered swallowed foreign objects including:

• Plastic knives and forks
• Food packaging
• Sterile gloves
• Pens
• Toothbrushes
• Coins
• Razorblades
• Dental implants / dentures

What makes many of the foreign object ingestion cases particularly horrific for the patient is the fact that many of the foreign objects are extremely dangerous is the fact that many objects go undetected by staff until a problem manifests itself in the form of a severe medical complication -- such as choking or internal bleeding.

Given the prevalence in ingesting foreign materials or objects amongst Alzheimer’s, dementia and psychiatric patients, facilities need to be mindful of this real tendency and take steps toward minimizing the chances a patient can access these materials:

• Facilities should take steps towards identifying which patients have a history of ingesting foreign materials
• Medical devices should be kept under locked conditions
• Staff should remove non-edible food wrappers and coverings from meals prior to serving staff
• Staff should supervise patients with a swallowing proclivity

Due to the fact that many of these patients are simply unable to perceive the dangers associated with ingesting foreign objects, facilities need to be mindful of the inherent risks associated with keeping materials accessible to their patients and implement safeguards to prevent patients susceptible to this type of behavior from accessing materials.

Resources:

Intentional Swallowing of Foreign Bodies and Its Impact on the Cost of Health Care, Science Daily, November 4, 2010

Foreign body aspiration in dentistry- a review (PDF) The Journal Of The American Dental Association 1996;127;1224-1229 by SM Cameron, WL Whitlock and MS Tabor

CT Features of Esophageal Emergencies (PDF) Radiographics by Catherine A. Young, MD, JD • Christine O. Menias, MD • Sanjeev Bhalla, MD • Srinivasa R. Prasad, MD (2008)

Barry Community Care Center is a 75-bed nursing home located in Barry, IL. On January 22, 2010, the Illinois Department of Public Health (IDPH) fined Barry Community Care Center $35,000 for violations in the area of policy and procedure. Even with this significant fine, Medicare rated the facility as a three-star or average nursing home facility, with only one health deficiency between February 2009 and April 2010.

This episode demonstrates that even well-regarded skilled nursing facilities can have very serious problems for patients. Barry Community Care Center’s single deficiency involved its failure to provide each resident the care and services required to achieve or maintain the highest quality of life possible, which resulted in immediate jeopardy to resident health or safety. 

This example serves to reinforce how important it is to thoroughly research a potential nursing home because looking at the total number of health deficiencies is not enough. Not all health deficiencies are equal with regard to the level of harm presented to residents. In this case, the facility’s deficiencies and violations were very serious, resulting in the choking death of one resident. (See other Nursing Homes Abuse Blog articles on choking)

A survey conducted by IDPH on November 25, 2009 revealed that Barry Community Care Center failed to provide adequate supervision to a resident during mealtime, which resulted in the resident choking on food. Then, the nursing home did not call 911 for another hour, which led to the resident’s death at the hospital later in the day. 

The resident was known to have impaired cognition and limited range of motion for neck, arm, and hand. The facility’s care plan for the resident required one person to physically assist and supervise with meals. 

On September 26, 2009 at 1:00 pm, the resident was found in her room with a half-full plate of food from lunch in front of her. The resident was having trouble breathing and her face was ashen. A Licensed Practical Nurse (LPN) was called to the resident’s room. The nurse increased the oxygen and encouraged resident to cough. The resident coughed out some food but became too weak to continue. At that point, the nurse began to suction the resident while another nurse called the physician and power of attorney (POA). When the POA arrived, she requested that the resident be sent to the emergency room (ER). 

The ambulance was called at 1:56 pm, almost one hour after the facility found her having trouble breathing and choking on her food. When the ambulance took the resident to the hospital at 2:27, the resident had a rapid pulse and was still having trouble breathing. When the ambulance arrived at the hospital at 2:41 pm, the resident was unresponsive, suffering from major respiratory distress. The resident died at the hospital with a diagnosis of aspiration pneumonia (inflammation of the lungs from breathing foreign matter into your lungs), atrial fibrillation (irregular, rapid heartbeat), hypertension (high blood pressure), Type 2 diabetes, and history of chronic obstructive pulmonary disease (COPD). (See “Elderly Patients Are At Higher Risk for Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs”)

The facility never should have left the resident alone with her food tray, especially because the resident’s care plan called for her to have someone assist her with eating and drinking. In addition, the staff knew that the resident had trouble eating her breakfast on the morning of her death. One of the nurses had to physically remove pieces of egg and toast from her mouth before returning the resident to her room. Furthermore, the nurse should have immediately called 911 when she found the resident choking on food and having difficulty breathing. 

The choking death of the resident at Barry Community Care Center is a sad reminder of how quickly a nursing home resident can suffer injury, or in this case, death, when they do not receive proper care and supervision. It took only 30 minutes for the resident to choke on food, when she should have had a staff member helping her eat, which would have prevented her death. 

Thanks to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog entry

Sources:

Illinois Department of Public Health: Nursing Homes in Illinois Quarterly Report

IDPH: Barry Community Care Center

IDPH: Barry Community Care Center - Quarterly Report

Nursing Homes Abuse Blog: Elderly Patients Are At Higher Risk for Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

Nursing Homes Abuse Blog: Choking

Choking Death Just Latest Problem At California Nursing Home

This nursing home committed several serious 4^th quarter violations relating to the area of policy and procedure. (See “42 Illinois Nursing Homes Cited in 4^th Quarter of 2009 for Violations Related to Patient Care”) The Illinois Department of Public Health (IDPH) fined the nursing home $25,000 on November 17, 2009. The facility provides services for persons suffering from mental retardation. These residents require more care than average residents because of reduced mental capacities. 

First, the facility failed to conduct quarterly fire drills for the 2^nd shift personnel, which endangered the lives of all residents. In the case of an emergency, including fire emergency, staff members should be trained and prepared. As evidenced by the IDPH report, this did not occur with all personnel. 

The most serious of the violations involve the choking death of a 28-year old nonverbal male resident who was ambulatory (capable of walking), mentally retarded, and also suffered from autism and cerebral palsy. This resident died after choking on food unsupervised. (See “Failure to Follow Orders Results in Death of Patient & Hefty Fine”) The facility’s failures include: 

• Failure to implement policy on neglect
• Failure to ensure that resident’s behavior program was fully documented with certain behaviors of taking food from kitchen
• Failure to ensure that enough staff were available to manage and supervise resident in accordance with his behavior plan which allowed him to eat unsupervised

The violation report completed on September 17, 2009 notes that the facility’s own policy on abuse and neglect defines abuse/neglect as to include “any willful failure to respond to an individual’s obvious needs or to provide the appropriate supervision and care that the individual served should have.” The facility’s failure to provide adequate medical or personal care or maintenance for the resident resulted in physical injury. 

Before his death, the facility’s program charts (completed on May 7, 2009) had the resident on a program to ensure that he ate at a slower pace. To support this goal, a staff member sat next to him at meals to provide verbal cues and physical prompts to slow down. In the weeks before his death, staff members noticed that he was eating even more quickly and was stealing food, which suggested increased agitation. 

AT 7:00 AM, the Director of Nursing found the resident in the living room on his back with chewed up food next to him. The director of nursing called paramedics and performed CPR (cardio pulmonary resuscitation) until they arrived. Despite these measures, the resident died. The cause of death was asphyxiation caused by a sausage found lodged in his throat. It turns out that the resident had stolen a sausage wrap from the food that had been prepared for breakfast. A tray of food covered with foil was left on the kitchen counter. 

One of the direct service providers (DSP) even saw the resident walking out of the kitchen and noticed that the foil on the food had been disturbed. Even though the resident had no documented history of stealing food from the kitchen, he did have a history of stealing food from other residents. However, the facility personnel did not put together his presence near the kitchen, the disturbed food, and the history of stealing food. 

The facility’s assessment for the resident stated that he required 24-hour supervision including assistance with diet, portion control, and eating rate. The DSP who saw the resident coming from the kitchen admitted that it was not unusual to catch residents in the kitchen area. The DSP also stated that the resident had stolen food from the kitchen before but she failed to document this. 

The resident’s Individual Habilitation Plan states that the staff should report all issues of concern to their supervisor and/or the nurse. However, the DSP never reported seeing the resident stealing food from the kitchen. This failure resulted in the resident’s care plan not being updated to include measures to prevent him from stealing food, especially in light of his problems controlling how quickly he consumes food. The DSP also admitted that mornings at the facility were “hectic,” and the facility could benefit from additional staff. In addition, on the morning in question, the kitchen was left unsupervised even though there was food left out on the counter.

The facility’s failure to properly monitor the resident and update his care plan allowed him to steal food from the kitchen unsupervised and ultimately choke to death. Unfortunately, the fines assessed will do nothing to benefit this resident. However, hopefully, it will do something to change the behavior and procedures of the facility in the future in order to protect the other residents. 

Stories like this highlight the fact that there are problems with small nursing homes as well as large nursing homes. Even with fewer residents to care for, oversights and mistakes can occur, and these mistakes can be deadly. In this situation, Milestone-Elmwood East did not properly monitor and care for a young, 28 year-old resident. If you or a loved one have suffered injury at the hands of Milestone, Inc, you may be entitled to compensation. 

Sources:

Illinois Department of Public Health (IDPH); Milestone-Elmwood East

IDPH: Milestone-Elmwood East – 4^th Quarter Violations

IDPH: Nursing Homes in Illinois – Quarterly Report (October-December 2009)

Nursing Homes Abuse Blog: Failure to Follow Orders Results in Death of Patient & Hefty Fine

Nursing Homes Abuse Blog: Topic – Choking

Nursing Homes Abuse Blog: 42 Illinois Nursing Homes Cited in 4th Quarter of 2009 for Violations Related to Patient Care

Elderly nursing home residents are at increased risk for a variety of dangerous conditions, diseases, and injuries. Even mealtimes can be dangerous, especially if you suffer from dysphagia (difficulty swallowing). Dysphagia can lead to dangerous food obstructions, aspiration of food into the lungs, pneumonia, or other upper respiratory infections. 

People with dysphagia have difficulty swallowing and may be accompanied by pain. Dysphagia can vary in severity. If you suffer from only mild dysphagia, you might have to stop eating for a minute or two, especially if you do not chew your food well enough or eat too fast. However, severe dysphagia is a serious medical condition that could prevent you from consuming adequate calories, which can require medical attention or even a feeding tube.

The act of swallowing requires the coordination of about 50 pairs of muscles and nerves. When you swallow, your tongue pushes the food to the back of your throat (oropharynx), where muscle contractions move the food through your pharynx to the top of your esophagus, then past your windpipe into your esophagus, where sphincters (bands of muscles) open and close to let food into your stomach. [ – picture of throat] [– diagram showing the act of swallowing]

Symptoms of dysphagia include: not being able to swallow, pain when swallowing, feeling as if food is stuck in your throat or chest, drooling, hoarseness, throwing up food, heartburn, unexpected weight loss, and coughing or gagging when swallowing. 

Causes of dysphagia

Dysphagia can be caused by many different conditions that interfere with swallowing. Esophageal dysphagia is difficulty passing food down the esophagus. It gives the feeling of food being caught in your throat or chest. This can be caused by:

• Achalasia – the lower esophageal muscle does not relax properly to allow food to pass into your stomach
•  Aging – the esophagus loses muscle strength and coordination as you age
• Diffuse spasm – after you swallow, you experience multiple, high-pressure, poorly coordinated esophageal contractions
• Esophageal stricture – narrowing of the esophagus, which makes it easier for food to get caught
• Esophageal tumors
• Gastroesophageal reflux disease (GERD) – stomach acid backs up into your esophagus, which damages the tissue
• Eosinophilic esophagitis – overpopulation of cells in the esophagus
• Scleroderma – development of scar-like tissue, causing stiffening and hardening of tissues
• Radiation therapy – can lead to inflammation and scarring of the esophagus

Oropharyngeal dysphagia is difficulty emptying material from your oropharynx (back of the mouth) into the esophagus. It is caused by problems relating to your nerves and muscles which weaken your throat muscles, making it more difficult to swallow. This can be caused by:

• Neurological disorders – post-polio syndrome, multiple sclerosis (MS), muscular dystrophy, Parkinson’s disease
• Neurological damage – stroke, brain injury, or spinal cord injury can cause certain neurological damage
• Pharyngeal diverticula – a small pouch forms and collects food pieces in your throat
• Cancer

With some cases of dysphagia, there is no anatomical cause. This can present itself as difficulty taking oral medications or the sensation of a lump in your throat when no lump exists.

Consequences of untreated dyphagia

Severe dysphagia can lead to malnutrition and dehydration if you cannot eat enough food or drink enough liquids to stay healthy. Dysphagia can also lead to respiratory problems if food or liquid enters your airway. This can lead to respiratory problems and infections including pneumonia or upper respiratory infections (URIs). 

Treatment of dysphagia is usually directed at the specific cause. However, if complete obstruction occurs, a doctor will perform an emergent upper endoscopy to see inside the upper GI tract. The doctor can then treat any masses or lesions, or even remove an impacted food mass. A barium x-ray can also be performed to allow the doctor to see changes in your esophagus and assess your esophageal muscles. 

Some people who suffer from dysphagia benefit from changes in how they eat including changing head position, doing dry swallows, and doing strength and coordination exercises for the tongue. Some people with severe dysphagia require the use of a gastronomy tube in order to receive adequate nutrition. 

Older adults are particularly at risk for dysphagia

Dysphagia is more common in older adults because of decreased muscle strength, including the muscles in the esophagus. As many as 22% of adults over 50 years of age suffer from dysphagia. The esophagus suffers normal wear and tear as you age, which can make swallowing more difficult. Also, older adults are more likely to suffer from conditions (listed above) that can make swallowing difficult, including stroke, Parkinson’s disease, and cancer. Dysphagia can potentially compromise an elderly resident’s nutritional status, which increases the risk of aspiration pneumonia. 

Because older adults have an increased risk for dysphagia and choking, nursing home staff should take extra care to monitor residents, who have a history of problems swallowing, during mealtimes. Staff members should also take the time to supervise chewing and swallowing exercises to encourage residents to take small bites, focusing on chewing and swallowing. This requires a great deal of supervision by nursing home staff, which might be difficult when numerous residents have dysphagia or trouble swallowing. 

Dysphagia or difficulty swallowing can be a dangerous condition for elderly nursing home residents. This is because they often have weakened esophageal muscles, which makes choking more likely. It is important to notify nursing home staff if your family member has difficulty swallowing, so staff can closely monitor them during mealtimes. 

Special thanks to Heather Keil, J.D. for her assistance with this Nursing Homes Abuse Blog entry.

Sources:

Medicine Net: Dysphagia

National Institute on Deafness and Other Communication Disorders

American Family Physician: Evaluating Dysphagia

American Speech-Language-Hearing Association: Communication Facts: Special Populations: Dysphagia-2008 Edition

Aspiration pneumonia occurs when you aspirate foreign matter (usually food or vomit) into your lungs. Elderly adults are particularly susceptible to aspiration pneumonia because they are more likely to suffer from predisposing factors (including illness or disease that compromises the ability to swallow) or they might be too weak to cough, which can let foreign material enter the windpipe, allowing bacteria to enter the lungs. This can result in severe lung infections, which can require hospitalization, especially in older adults who are already weak because of age, illness, or disease.

Aspiration pneumonia can be caused by:

• stomach content entering your lungs after you throw up;
• a brain injury or other condition that affects your normal gag reflex;
• diseases such as ALS (amyotrophic lateral sclerosis), Parkinson’s disease or strokes, which can make swallowing difficult; or
• throwing up when passed out due to over-medication 

There are two types of aspiration pneumonia syndromes:

• Chemical pneumonia (CP) – aspiration of gastric acid
• Bacterial pneumonia (BP) – aspiration of bacteria from the mouth and throat
• Aspiration of gastric acid can cause acid burns when the stomach acid passes down the windpipe, which can leave lung tissue vulnerable to infection. 

Bacterial pneumonia occurs when a person suffers from an illness or condition that compromises their ability to cough or swallow (see causes above) and aspirates foreign material allowing bacteria to enter the lungs, resulting in infection. 

Chemical pneumonia usually has an acute onset, with symptoms occurring within a few minutes to two hours of the aspiration event. Symptoms include: respiratory distress, rapid breathing, wheezing, fever, and cough with pink or frothy sputum. Bacterial pneumonia, on the other hand, has a sub-acute onset, with symptoms occurring after a couple days to weeks after the aspiration event. Symptoms include: bad breath, putrid odor of sputum, fever, and weight loss. 

Aspiration pneumonia is a serious concern in the elderly. This is because swallowing is a complex activity, requiring coordinated opening and closing of the mouth and lips, chewing while inhaling and exhaling, mixing saliva with food, moving food to the back of the tongue, and having the swallow reflex send food down the esophagus. If any of these steps does not occur properly, you can be at risk of chocking, aspirating, or suffocating. 

The number of hospitalizations for aspiration pneumonia has been increasing, with the largest increase in the very old. From 1991 to 1996, the number of hospital discharges of Medicare patients, whose reason for admission was reported to be aspiration pneumonia, increased by 76% (while the number of elderly persons covered by Medicare grew by less than 7%). 

Nursing home staff must take care to closely monitor the food given to residents who have difficulty swallowing. Usually, thicker, colder liquids are easier to swallow. Thin liquids, including water, can be dangerous because they are difficult to control within the mouth. Straws can help a person swallow by limiting the amount of liquid that can be taken at a time and directing the liquid to the back of the mouth. 

Nursing home facilities can also craft special menus for people with difficulty swallowing so that the food resembles normal food, but still has a soft pureed consistency (for example, chicken cooked and pureed with thickening agent and molded into a chicken leg shape, meatloaf, and casseroles). However, this would require the facility to design different meals for some residents, which would require additional time and efforts, which not all facilities are willing to undertake. 

Nursing home staff should consult the doctor if a resident has difficulty swallowing. The physician might recommend that the resident be placed on a liquid or pureed diet or even use a feeding tube in severe situations. Many residents would probably prefer a diet of solid foods because it is more pleasurable to eat and does not insult their pride by basically having them eat baby food. 

Staff can also have residents who have difficulty swallowing do a “dry swallow” (swallow without any food or liquid in their mouth) after taking a bite of food. However, this requires expensive supervision, which isn’t always possible at crowded nursing homes, where several residents might need monitoring during mealtimes. 

Aspiration pneumonia can result in serious lung infections in elderly nursing home residents. Many of these residents already suffer from underlying illness or disease, which makes it more difficult for them to fight infection. Infections can be dangerous and often require hospitalization. Therefore, nursing home staff should take extra precautions to prevent aspiration pneumonia in order to maintain the best possible health of residents. 

Sources:

Huntington Disease: Swallowing, Coughing, Choking, & Aspiration Pneumonia

Respiratory Reviews: Is Aspiration Pneumonia Epidemic in Elderly Americans?

eMedicine: Pneumonia, Aspiration

Health Resources: Guidelines Aspiration Pneumonia

Ignoring doctors orders, an employee at Mayers Memorial Hospital gave a meat and cheese sandwhich to an Alzheimer's patient who was unable to eat solid food.  Left unattended with the sandwhich, the patient literally 'inhaled' the sandwhich.  Five days later, the patient died from pneumonia caused by inhaling food.

According to California Department of Public Health Director, Dr. Mark Horton, "The facility failed to protect the heath of a patient when the prescribed diet ordered by the phyisician and in the patient's care plan was not followed.  As a result, the patient died."

The California Department of Public Health issued a AA citation and a $50,000 fine to the hospital following its investigation.

Read more about this choking incident here.

Pneumonia from inhaling food?

Yes.  Many nursing home and hospital patients develop 'aspiration pneumonia' when food or foreign materials enter the bronchial tree (lungs). Aspiration pneumonia may result after oral or gastric contents (including food, saliva, or nasal secretions) are inhaled. Depending on the acidity of the materials inhaled, a chemical pneumonitis can develop, and bacteria may add to the inflammation.

In times of need, locating necessary information regarding the legal rights and resources for nursing home patients can be difficult and imposing.  In this respect, we are proud to introduce a new resource for patients, families and practitioners looking for a concise compilation of information regarding nursing home laws.  Nursing Home Injury Laws, provides every states':

• Nursing Home Laws
• Medical Malpractice Laws
• State Resources
• Applicable State Code
• Common Nursing Home Injuries
• Glossary
• Recognized Books & Journals
• Nursing Home FAQ

Additionally, we will be posting regular updates regarding important developments relevant to nursing home care within each state.  Here is a link to Nursing Home Injury Laws.

Feeding tube use amongst dementia patients is extremely common.  According to a Business Week article, more than one-third of dementia patients in nursing homes currently have feeding tubes, with the majority of those being inserted during an acute care-hospitalization.

One reason possible reason for the frequency in the insertion of feeding tubes during acute hospitalizations may be due to the fact that when dementia patients enter a new environment-- such as an acute-care hospital, they have a difficult time adjusting to the new environment and may not immediately eat.

"They often get very stressed out, have disruptive behavior, get medications to treat that behavior, which leads them to developing bed sores and problems with eating, which leads to having a feeding tube inserted," according to Teno. "Part of what we need to do is align the incentives to keep frail older dementia patients in the least restrictive setting that will provide the best medical care."

As an alternative to feeding tubes, some experts suggest 'spoon feeding' patients.  Using a spoon feeding method, a person literally feeds the person with a spoon at his or her own pace.  Some experts suggest that spoon feeding may not necessarily prolong the life of the individual, but it can improve the quality of it. 

Patients who have feeding tubes in a nursing home or hospital setting are at risk for a variety of medical complications including:

Gastroesophageal reflux caused from gastric juices being forced back into the esophagus can occur with feeding tubes because the tubes sometimes cause a delay in the emptying of the stomach. This means that a person has to have more frequent, smaller feedings.

Clogging: Most feeding tubes are very narrow, and commercial tube feeding formulas such as Ensure, are designed so that they will not clog the tube; they are not too thick and do not leave a residue. Most formulas are designed to have water added to them to ensure that the patient is receiving enough dietary water, and to further thin the formula for ease of use. Staff should flush the tube with water before and after feedings, or after medications have been administered through the tube.  The use of noncommercial formulas is discouraged, because there is a greater likelihood that they will contribute to clogging. After the tube is placed, a registered dietitian or a nurse who specializes in nutrition should assess the patient to determine their nutritional needs, the amount of calories, protein, and fluids that will be necessary, as well as the most appropriate nutritional formula and how much of that formula will be needed each day. 

Nausea and vomiting is a common problem with feeding tubes. It occurs when liquid food is administered to an individual through a tube too quickly, or when the formula provided through the tube is too high in protein and/or calories. Migration (shifting) of the tube, bacterial infections and air in the stomach can cause nausea and vomiting as well.

Leakage is a complication of feeding tubes that occurs typically because the size of the stoma around the tube has increased, or because the position of the tube is improper due to bad placement or general shifting. This problem sometimes requires replacement of the tube, and it forces an individual or attending physician to keep the stoma clean with protective gauze and ointment.

Constipation occurs frequently with feeding tubes because the liquids that are administered through the tubes don't always have as much bulk or fiber as normal foods. Without fiber, an individual's digestive system has trouble retaining enough fluid and staying regular enough to produce frequent bowel movements. This problem means that the individual either has to find a way to introduce liquids that are higher in fiber through the tube (which can increase the risk of the tube clogging), or she has to take medications to relieve constipation.

Choking / Aspiration can occur if an individual is administered food through a feeding tube while in an improper position. This can result in choking, coughing and pneumonia. These, in turn, can aggravate the stoma, because the abdominal wall is forced to engage forcefully during a cough or sneeze. The aggravation of the stoma can lead to further infection. Most medical professionals suggest feeding patients when they are as up-right as possible to avoid aspiration on the food.

Many of these problems can be avoided when facilities employ adequate numbers of properly trained staff.  Consequently, if you have a loved one who require tube feeding, it is important to check with the facility to make sure they are accustomed to handling patients with these medical needs.

Resources:

Too Many With End-Stage Dementia Get Feeding Tubes, BusinessWeek, February 9, 2010

Common Complications of Tube Feeding

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes

The Exceptional Care nursing home is a small 55 bed nursing home located in Burbank, IL. According to the government’s Medicare website, the facility received only one out of five stars, which is a much below average rating. The facility received only two out of five stars for health inspections, which is a below average rating.

Exceptional Care is not living up to its name.  In the past year, the nursing home had five health deficiencies, which is three less than the average number of health deficiencies in Illinois and in the United States. This is down from the twelve health deficiencies in the previous year.

Every nursing home has an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to achieve and maintain the highest level of well-being for its residents. Nursing homes must meet the Requirements for States and Long Term Care Facilities outlined in 42 CFR Part 483.

According to survey reports, Exceptional Care received violations for failing to:

• Provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident
• Provide or arrange services that meet professional standards of quality

According to survey reports, the facility failed to provide an ongoing program of activities as required under federal law. Many nursing home residents have activity care plans to help treat conditions, especially depression.

Several residents with activity care plans calling for one-on-one programs or group activity were never taken out of their rooms to attend group activity. In addition, the facility did not have adequate activities scheduled on several afternoons. Furthermore, several planned activities never occurred, had very low attendance, or had no staff to resident interaction.

The survey also revealed that the services provided or arranged by the facility did not meet professional standards of quality. Nursing home staff failed to properly administer medications as ordered for several residents and failed to clarify orders to provide proper treatment for residents.

The facility also failed to ensure a medication error rate of less than 5%. During the survey, 45 medication opportunities were observed, with four medication errors, resulting in a medication error rate of 8.88% for four of fourteen residents observed. The facility also failed to ensure that residents are free of any significant medication errors when staff failed to administer an ordered anti-psychotic medication for two weeks to a resident suffering from Bipolar disorder resulting in disruptive behavior.

The facility also failed to thoroughly investigate unwitnessed and unknown injuries for a resident who was found with bruises on multiple areas of the body. Nursing home staff failed to conduct an investigation into the cause of the bruises.

Nursing homes are charged with providing the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of its residents. The facility failed to meet this requirement by failing to follow swallow precautions for a resident who was identified with a high risk of choking.

Exceptional Care received only one out of five stars for nursing home staffing. The facility has 37 total residents, compared to the national average of 94.7 and the Illinois average of 103.9. Each resident received 59 minutes of nursing home staff time per day, which is less than the Illinois average (1 hour 12 minutes) and less than the national average (1 hour 24 minutes).

This two-star rated facility has many deficiencies, which might be a troubling sign that nursing home residents might not be receiving the proper care and attention they need and deserve.

Sources:
Medicare website
IDPH website

Related:

When Bruises Can't Speak For Themselves: The Difficulty Proving Abuse Of Disabled Nursing Home Residents 

Who Should Manage Administration Of Medication?

Welcome To The Nursing Home. Let's Begin Our Assessment and Care Planning

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Subpart B—Requirements for Long Term Care Facilities

Source: 54 FR 5359, Feb. 2, 1989, unless otherwise noted.

§ 483.1 Basis and scope.

(a) Statutory basis. (1) Sections 1819 (a), (b), (c), and (d) of the Act provide that—

(i) Skilled nursing facilities participating in Medicare must meet certain specified requirements; and

(ii) The Secretary may impose additional requirements (see section 1819(d)(4)(B)) if they are necessary for the health and safety of individuals to whom services are furnished in the facilities.

(2) Section 1861(l) of the Act requires the facility to have in effect a transfer agreement with a hospital.

(3) Sections 1919 (a), (b), (c), and (d) of the Act provide that nursing facilities participating in Medicaid must meet certain specific requirements.

(b) Scope. The provisions of this part contain the requirements that an institution must meet in order to qualify to participate as a SNF in the Medicare program, and as a nursing facility in the Medicaid program. They serve as the basis for survey activities for the purpose of determining whether a facility meets the requirements for participation in Medicare and Medicaid.

[56 FR 48867, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992; 60 FR 50443, Sept. 29, 1995]

§ 483.5 Definitions.

(a) Facility defined. For purposes of this subpart, facility means a skilled nursing facility (SNF) that meets the requirements of sections 1819(a), (b), (c), and (d) of the Act, or a nursing facility (NF) that meets the requirements of sections 1919(a), (b), (c), and (d) of the Act. “Facility” may include a distinct part of an institution (as defined in paragraph (b) of this section and specified in §440.40 and §440.155 of this chapter), but does not include an institution for the mentally retarded or persons with related conditions described in §440.150 of this chapter. For Medicare and Medicaid purposes (including eligibility, coverage, certification, and payment), the “facility” is always the entity that participates in the program, whether that entity is comprised of all of, or a distinct part of, a larger institution. For Medicare, an SNF ( see section 1819(a)(1) of the Act), and for Medicaid, an NF ( see section 1919(a)(1) of the Act) may not be an institution for mental diseases as defined in §435.1010 of this chapter.

(b) Distinct part —(1) Definition. A distinct part SNF or NF is physically distinguishable from the larger institution or institutional complex that houses it, meets the requirements of this paragraph and of paragraph (b)(2) of this section, and meets the applicable statutory requirements for SNFs or NFs in sections 1819 or 1919 of the Act, respectively. A distinct part SNF or NF may be comprised of one or more buildings or designated parts of buildings (that is, wings, wards, or floors) that are: In the same physical area immediately adjacent to the institution's main buildings; other areas and structures that are not strictly contiguous to the main buildings but are located within close proximity of the main buildings; and any other areas that CMS determines on an individual basis, to be part of the institution's campus. A distinct part must include all of the beds within the designated area, and cannot consist of a random collection of individual rooms or beds that are scattered throughout the physical plant. The term “distinct part” also includes a composite distinct part that meets the additional requirements of paragraph (c) of this section.

(2) Requirements. In addition to meeting the participation requirements for long-term care facilities set forth elsewhere in this subpart, a distinct part SNF or NF must meet all of the following requirements:

(i) The SNF or NF must be operated under common ownership and control (that is, common governance) by the institution of which it is a distinct part, as evidenced by the following:

(A) The SNF or NF is wholly owned by the institution of which it is a distinct part.

(B) The SNF or NF is subject to the by-laws and operating decisions of a common governing body.

(C) The institution of which the SNF or NF is a distinct part has final responsibility for the distinct part's administrative decisions and personnel policies, and final approval for the distinct part's personnel actions.

(D) The SNF or NF functions as an integral and subordinate part of the institution of which it is a distinct part, with significant common resource usage of buildings, equipment, personnel, and services.

(ii) The administrator of the SNF or NF reports to and is directly accountable to the management of the institution of which the SNF or NF is a distinct part.

(iii) The SNF or NF must have a designated medical director who is responsible for implementing care policies and coordinating medical care, and who is directly accountable to the management of the institution of which it is a distinct part.

(iv) The SNF or NF is financially integrated with the institution of which it is a distinct part, as evidenced by the sharing of income and expenses with that institution, and the reporting of its costs on that institution's cost report.

(v) A single institution can have a maximum of only one distinct part SNF and one distinct part NF.

(vi) (A) An institution cannot designate a distinct part SNF or NF, but instead must submit a written request with documentation that demonstrates it meets the criteria set forth above to CMS to determine if it may be considered a distinct part.

(B) The effective date of approval of a distinct part is the date that CMS determines all requirements (including enrollment with the fiscal intermediary (FI)) are met for approval, and cannot be made retroactive.

(C) The institution must request approval from CMS for all proposed changes in the number of beds in the approved distinct part.

(c) Composite distinct part —(1) Definition. A composite distinct part is a distinct part consisting of two or more noncontiguous components that are not located within the same campus, as defined in §413.65(a)(2) of this chapter.

(2) Requirements. In addition to meeting the requirements of paragraph (b) of this section, a composite distinct part must meet all of the following requirements:

(i) A SNF or NF that is a composite of more than one location will be treated as a single distinct part of the institution of which it is a distinct part. As such, the composite distinct part will have only one provider agreement and only one provider number.

(ii) If two or more institutions (each with a distinct part SNF or NF) undergo a change of ownership, CMS must approve the existing SNFs or NFs as meeting the requirements before they are considered a composite distinct part of a single institution. In making such a determination, CMS considers whether its approval or disapproval of a composite distinct part promotes the effective and efficient use of public monies without sacrificing the quality of care.

(iii) If there is a change of ownership of a composite distinct part SNF or NF, the assignment of the provider agreement to the new owner will apply to all of the approved locations that comprise the composite distinct part SNF or NF.

(iv) To ensure quality of care and quality of life for all residents, the various components of a composite distinct part must meet all of the requirements for participation independently in each location.

(d) Common area. Common areas are dining rooms, activity rooms, meeting rooms where residents are located on a regular basis, and other areas in the facility where residents may gather together with other residents, visitors, and staff.

(e) Fully sprinklered. A fully sprinklered long term care facility is one that has all areas sprinklered in accordance with National Fire Protection Association 13 “Standard for the Installation of Sprinkler Systems” without the use of waivers or the Fire Safety Evaluation System.

[68 FR 46071, Aug. 4, 2003, as amended at 71 FR 39229, July 12, 2006; 71 FR 55340, Sept. 22, 2006]

§ 483.10 Resident rights.

The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights:

(a) Exercise of rights. (1) 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.

(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights.

(3) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf.

(4) In the case of a resident who has not been adjudged incompetent by the State court, any legal-surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law.

(b) Notice of rights and services. (1) The facility must inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility must also provide the resident with the notice (if any) of the State developed under section 1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the resident's stay. Receipt of such information, and any amendments to it, must be acknowledged in writing;

(2) The resident or his or her legal representative has the right—

(i) Upon an oral or written request, to access all records pertaining to himself or herself including current clinical records within 24 hours (excluding weekends and holidays); and

(ii) After receipt of his or her records for inspection, to purchase at a cost not to exceed the community standard photocopies of the records or any portions of them upon request and 2 working days advance notice to the facility.

(3) The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition;

(4) The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section; and

(5) The facility must—

(i) Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility 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 items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and

(ii) Inform each resident when changes are made to the items and services specified in paragraphs (5)(i) (A) and (B) of this section.

(6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate.

(7) The facility must furnish a written description of legal rights which includes—

(i) A description of the manner of protecting personal funds, under paragraph (c) of this section;

(ii) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels;

(iii) A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, the protection and advocacy network, and the Medicaid fraud control unit; and

(iv) A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, misappropriation of resident property in the facility, and non-compliance with the advance directives requirements.

(8) The facility must comply with the requirements specified in subpart I of part 489 of this chapter relating to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. If an adult individual is incapacitated at the time of admission and is unable to receive information (due to the incapacitating condition or a mental disorder) or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's family or surrogate in the same manner that it issues other materials about policies and procedures to the family of the incapacitated individual or to a surrogate or other concerned persons in accordance with State law. The facility is not relieved of its obligation to provide this information to the individual once he or she is no longer incapacitated or unable to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

(9) The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care.

(10) The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

(11) Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal respresentative or an interested family member when there is—

(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;

(B) A significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);

(C) 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); or

(D) A decision to transfer or discharge the resident from the facility as specified in §483.12(a).

(ii) The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is—

(A) A change in room or roommate assignment as specified in §483.15(e)(2); or

(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section.

(iii) The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.

(12) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5(c) of this subpart) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.12(a)(8).

(c) Protection of resident funds. (1) The resident has the right to manage his or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility.

(2) Management of personal funds. Upon written authorization of a resident, the facility must hold, safeguard, manage, and account for the personal funds of the resident deposited with the facility, as specified in paragraphs (c)(3)–(8) of this section.

(3) Deposit of funds. (i) Funds in excess of $50. The facility must deposit any residents' personal funds in excess of $50 in an interest bearing account (or accounts) that is separate from any of the facility's operating accounts, and that credits all interest earned on resident's funds to that account. (In pooled accounts, there must be a separate accounting for each resident's share.)

(ii) Funds less than $50. The facility must maintain a resident's personal funds that do not exceed $50 in a non-interest bearing account, interest-bearing account, or petty cash fund.

(4) Accounting and records. The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.

(i) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.

(ii) The individual financial record must be available through quarterly statements and on request to the resident or his or her legal representative.

(5) Notice of certain balances. The facility must notify each resident that receives Medicaid benefits—

(i) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and

(ii) That, 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, the resident may lose eligibility for Medicaid or SSI.

(6) Conveyance upon death. Upon the death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate.

(7) Assurance of financial security. The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.

(8) Limitation on charges to personal funds. The facility may not impose a charge against the personal funds of a resident for any item or service 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 that are more expensive than or in excess of covered services in accordance with §489.32 of this chapter. (This does not affect the prohibition on facility charges for items and services for which Medicaid has paid. See §447.15, which limits participation in the Medicaid program to providers who accept, as payment in full, Medicaid payment plus any deductible, coinsurance, or copayment required by the plan to be paid by the individual.)

(i) Services included in Medicare or Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities may not charge a resident for the following categories of items and services:

(A) Nursing services as required at §483.30 of this subpart.

(B) Dietary services as required at §483.35 of this subpart.

(C) An activities program as required at §483.15(f) of this subpart.

(D) Room/bed maintenance services.

(E) Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, hair hygiene supplies, comb, brush, 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, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry.

(F) Medically-related social services as required at §483.15(g) of this subpart.

(ii) Items and services that may be charged to residents' funds. Listed below are general categories and examples of items and services that the facility may charge to residents' funds if they are requested by a resident, if the facility informs the resident that there will be a charge, and if payment is not made by Medicare or Medicaid:

(A) Telephone.

(B) Television/radio for personal use.

(C) Personal comfort items, including smoking materials, notions and novelties, and confections.

(D) Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare.

(E) Personal clothing.

(F) Personal reading matter.

(G) Gifts purchased on behalf of a resident.

(H) Flowers and plants.

(I) Social events and entertainment offered outside the scope of the activities program, provided under §483.15(f) of this subpart.

(J) Noncovered special care services such as privately hired nurses or aides.

(K) Private room, except when therapeutically required (for example, isolation for infection control).

(L) Specially prepared or alternative food requested instead of the food generally prepared by the facility, as required by §483.35 of this subpart.

(iii) Requests for items and services. (A) The facility must not charge a resident (or his or her representative) for any item or service not requested by the resident.

(B) The facility must not require a resident (or his or her representative) to request any item or service as a condition of admission or continued stay.

(C) The facility must inform the resident (or his or her representative) requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be.

(d) Free choice. The resident has the right to—

(1) Choose a personal attending physician;

(2) 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; and

(3) Unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment.

(e) Privacy and confidentiality. The resident has the right to personal privacy and confidentiality of his or her personal and clinical records.

(1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident;

(2) Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility;

(3) The resident's right to refuse release of personal and clinical records does not apply when—

(i) The resident is transferred to another health care institution; or

(ii) Record release is required by law.

(f) Grievances. A resident has the right to—

(1) Voice grievances without discrimination or reprisal. Such grievances include those with respect to treatment which has been furnished as well as that which has not been furnished; and

(2) Prompt efforts by the facility to resolve grievances the resident may have, including those with respect to the behavior of other residents.

(g) Examination of survey results. A resident has the right to—

(1) 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. The facility must make the results available for examination in a place readily accessible to residents, and must post a notice of their availability; and

(2) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

(h) Work. The resident has the right to—

(1) Refuse to perform services for the facility;

(2) Perform services for the facility, if he or she chooses, when—

(i) The facility has documented the need or desire for work in the plan of care;

(ii) The plan specifies the nature of the services performed and whether the services are voluntary or paid;

(iii) Compensation for paid services is at or above prevailing rates; and

(iv) The resident agrees to the work arrangement described in the plan of care.

(i) Mail. The resident has the right to privacy in written communications, including the right to—

(1) Send and promptly receive mail that is unopened; and

(2) Have access to stationery, postage, and writing implements at the resident's own expense.

(j) Access and visitation rights. (1) The resident has the right and the facility must provide immediate access to any resident by the following:

(i) Any representative of the Secretary;

(ii) Any representative of the State:

(iii) The resident's individual physician;

(iv) The State long term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965);

(v) The agency responsible for the protection and advocacy system for developmentally disabled individuals (established under part C of the Developmental Disabilities Assistance and Bill of Rights Act);

(vi) The agency responsible for the protection and advocacy system for mentally ill individuals (established under the Protection and Advocacy for Mentally Ill Individuals Act);

(vii) Subject to the resident's right to deny or withdraw consent at any time, immediate family or other relatives of the resident; and

(viii) Subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, others who are visiting with the consent of the resident.

(2) The facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time.

(3) The facility must allow representatives of the State Ombudsman, described in paragraph (j)(1)(iv) of this section, to examine a resident's clinical records with the permission of the resident or the resident's legal representative, and consistent with State law.

(k) Telephone. The resident has the right to have reasonable access to the use of a telephone where calls can be made without being overheard.

(l) Personal property. The resident has the right to 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.

(m) Married couples. 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.

(n) Self-Administration of Drugs. An individual resident may self-administer drugs if the interdisciplinary team, as defined by §483.20(d)(2)(ii), has determined that this practice is safe.

(o) Refusal of certain transfers. (1) An individual has the right to refuse a transfer to another room within the institution, if the purpose of the transfer is to relocate—

(i) A resident of a SNF from the distinct part of the institution that is a SNF to a part of the institution that is not a SNF, or

(ii) A resident of a NF from the distinct part of the institution that is a NF to a distinct part of the institution that is a SNF.

(2) A resident's exercise of the right to refuse transfer under paragraph (o)(1) of this section does not affect the individual's eligibility or entitlement to Medicare or Medicaid benefits.

[56 FR 48867, Sept. 26, 1991, as amended at 57 FR 8202, Mar. 6, 1992; 57 FR 43924, Sept. 23, 1992; 57 FR 53587, Nov. 12, 1992; 60 FR 33293, June 27, 1995; 68 FR 46072, Aug. 4, 2003]

§ 483.12 Admission, transfer and discharge rights.

(a) Transfer and discharge—

(1) Definition: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility.

(2) Transfer and discharge requirements. The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless—

(i) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;

(ii) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;

(iii) The safety of individuals in the facility is endangered;

(iv) The health of individuals in the facility would otherwise be endangered;

(v) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or

(vi) The facility ceases to operate.

(3) Documentation. When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (a)(2)(i) through (v) of this section, the resident's clinical record must be documented. The documentation must be made by—

(i) The resident's physician when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section; and

(ii) A physician when transfer or discharge is necessary under paragraph (a)(2)(iv) of this section.

(4) Notice before transfer. Before a facility transfers or discharges a resident, the facility must—

(i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.

(ii) Record the reasons in the resident's clinical record; and

(iii) Include in the notice the items described in paragraph (a)(6) of this section.

(5) Timing of the notice. (i) Except when specified in paragraph (a)(5)(ii) of this section, the notice of transfer or discharge required under paragraph (a)(4) of this section must be made by the facility at least 30 days before the resident is transferred or discharged.

(ii) Notice may be made as soon as practicable before transfer or discharge when—

(A) the safety of individuals in the facility would be endangered under paragraph (a)(2)(iii) of this section;

(B) The health of individuals in the facility would be endangered, under paragraph (a)(2)(iv) of this section;

(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(ii) of this section;

(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(i) of this section; or

(E) A resident has not resided in the facility for 30 days.

(6) Contents of the notice. The written notice specified in paragraph (a)(4) of this section must include the following:

(i) The reason for transfer or discharge;

(ii) The effective date of transfer or discharge;

(iii) The location to which the resident is transferred or discharged;

(iv) A statement that the resident has the right to appeal the action to the State;

(v) The name, address and telephone number of the State long term care ombudsman;

(vi) For nursing facility 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

(vii) 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.

(7) Orientation for transfer or discharge. A facility must provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility.

(8) Room changes in a composite distinct part. Room changes in a facility that is a composite distinct part (as defined in §483.5(c)) must be limited to moves within the particular building in which the resident resides, unless the resident voluntarily agrees to move to another of the composite distinct part's locations.

(b) Notice of bed-hold policy and readmission —(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies—

(i) The duration of the bed-hold policy under the State plan, if any, during which the resident is permitted to return and resume residence in the nursing facility; and

(ii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (b)(3) of this section, permitting a resident to return.

(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy described in paragraph (b)(1) of this section.

(3) Permitting resident to return to facility. A nursing facility must establish and follow a written policy under which a resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, is readmitted to the facility immediately upon the first availability of a bed in a semi-private room if the resident—

(i) Requires the services provided by the facility; and

(ii) Is eligible for Medicaid nursing facility services.

(4) Readmission to a composite distinct part. When the nursing facility to which a resident is readmitted is a composite distinct part (as defined in §483.5(c) of this subpart), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of readmission, the resident must be given the option to return to that location upon the first availability of a bed there.

(c) Equal access to quality care. (1) A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all individuals regardless of source of payment;

(2) The facility may charge any amount for services furnished to non-Medicaid residents consistent with the notice requirement in §483.10(b)(5)(i) and (b)(6) describing the charges; and

(3) The State is not required to offer additional services on behalf of a resident other than services provided in the State plan.

(d) Admissions policy. (1) The facility must—

(i) Not require residents or potential residents to waive their rights to Medicare or Medicaid; and

(ii) Not require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits.

(2) The facility must not require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may require an individual who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.

(3) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise 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,—

(i) A nursing facility may charge a resident who is eligible for Medicaid 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” so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and

(ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident.

(4) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid.

[56 FR 48869, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992; 68 FR 46072, Aug. 4, 2003]

§ 483.13 Resident behavior and facility practices.

(a) Restraints. The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms.

(b) Abuse. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.

(c) Staff treatment of residents. The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

(1) The facility must—

(i) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

(ii) Not employ individuals who have been—

(A) Found guilty of abusing, neglecting, or mistreating residents by a court of law; or

(B) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and

(iii) Report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities.

(2) The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).

(3) The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress.

(4) The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

[56 FR 48870, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992]

§ 483.15 Quality of life.

A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.

(a) Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality.

(b) Self-determination and participation. The resident has the right to—

(1) Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care;

(2) Interact with members of the community both inside and outside the facility; and

(3) Make choices about aspects of his or her life in the facility that are significant to the resident.

(c) Participation in resident and family groups. (1) A resident has the right to organize and participate in resident groups in the facility;

(2) A resident's family has the right to meet in the facility with the families of other residents in the facility;

(3) The facility must provide a resident or family group, if one exists, with private space;

(4) Staff or visitors may attend meetings at the group's invitation;

(5) The facility must provide a designated staff person responsible for providing assistance and responding to written requests that result from group meetings;

(6) When a resident or family group exists, the facility must listen to the views and act upon the grievances and recommendations of residents and families concerning proposed policy and operational decisions affecting resident care and life in the facility.

(d) Participation in other activities. 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.

(e) Accommodation of needs. A resident has the right to—

(1) Reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered; and

(2) Receive notice before the resident's room or roommate in the facility is changed.

(f) Activities. (1) 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 each resident.

(2) The activities program must be directed by a qualified professional who—

(i) Is a qualified therapeutic recreation specialist or an activities professional who—

(A) Is licensed or registered, if applicable, by the State in which practicing; and

(B) 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

(ii) Has 2 years of experience in a social or recreational program within the last 5 years, 1 of which was full-time in a patient activities program in a health care setting; or

(iii) Is a qualified occupational therapist or occupational therapy assistant; or

(iv) Has completed a training course approved by the State.

(g) Social Services. (1) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

(2) A facility with more than 120 beds must employ a qualified social worker on a full-time basis.

(3) Qualifications of social worker. A qualified social worker is an individual with—

(i) 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; and

(ii) One year of supervised social work experience in a health care setting working directly with individuals.

(h) Environment. The facility must provide—

(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible;

(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

(3) Clean bed and bath linens that are in good condition;

(4) Private closet space in each resident room, as specified in §483.70(d)(2)(iv) of this part;

(5) Adequate and comfortable lighting levels in all areas;

(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71–81°F; and

(7) For the maintenance of comfortable sound levels.

[56 FR 48871, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992]

§ 483.20 Resident assessment.

The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity.

(a) Admission orders. At the time each resident is admitted, the facility must have physician orders for the resident's immediate care.

(b) Comprehensive assessments —(1) Resident assessment instrument. A facility must make a comprehensive assessment of a resident's needs, using the resident assessment instrument (RAI) specified by the State. The assessment must include at least the following:

(i) Identification and demographic information.

(ii) Customary routine.

(iii) Cognitive patterns.

(iv) Communication.

(v) Vision.

(vi) Mood and behavior patterns.

(vii) Psychosocial well-being.

(viii) Physical functioning and structural problems.

(ix) Continence.

(x) Disease diagnoses and health conditions.

(xi) Dental and nutritional status.

(xii) Skin condition.

(xiii) Activity pursuit.

(xiv) Medications.

(xv) Special treatments and procedures.

(xvi) Discharge potential.

(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).

(xviii) Documentation of participation in assessment.

The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2) (i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.

(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, “readmission” means a return to the facility following a temporary absence for hospitalization or for therapeutic leave.)

(ii) Within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purposes of this section, a “significant change” means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)

(iii) Not less often than once every 12 months.

(c) Quarterly review assessment. A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

(d) Use. A facility must maintain all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan f care.

(e) Coordination. A facility must coordinate assessments with the preadmission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and effort.

(f) Automated data processing requirement —(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:

(i) Admission assessment.

(ii) Annual assessment updates.

(iii) Significant change in status assessments.

(iv) Quarterly review assessments.

(v) A subset of items upon a resident's transfer, reentry, discharge, and death.

(vi) Background (face-sheet) information, if there is no admission assessment.

(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System 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.

(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:

(i) Admission assessment.

(ii) Annual assessment.

(iii) Significant change in status assessment.

(iv) Significant correction of prior full assessment.

(v) Significant correction of prior quarterly assessment.

(vi) Quarterly review.

(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.

(viii) Background (face-sheet) information, for an initial transmission of MDS data on a resident that does not have an admission assessment.

(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.

(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public.

(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

(g) Accuracy of assessments. The assessment must accurately reflect the resident's status.

(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

(i) Certification. (1) A registered nurse must sign and certify that the assessment is completed.

(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

(j) Penalty for falsification. (1) Under Medicare and Medicaid, an individual who willfully and knowingly—

(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or

(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty of not more than $5,000 for each assessment.

(2) Clinical disagreement does not constitute a material and false statement.

(k) Comprehensive care plans. (1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following—

(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.25; and

(ii) Any services that would otherwise be required under §483.25 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

(2) A comprehensive care plan must be—

(i) Developed within 7 days after completion of the comprehensive assessment;

(ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and

(iii) Periodically reviewed and revised by a team of qualified persons after each assessment.

(3) The services provided or arranged by the facility must—

(i) Meet professional standards of quality; and

(ii) Be provided by qualified persons in accordance with each resident's written plan of care.

(l) Discharge summary. When the facility anticipates discharge a resident must have a discharge summary that includes—

(1) A recapitulation of the resident's stay;

(2) A final summary of the resident's status to include items in paragraph (b)(2) of this section, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or legal representative; and

(3) 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.

(m) Preadmission screening for mentally ill individuals and individuals with mental retardation. (1) A nursing facility must not admit, on or after January 1, 1989, any new resident with—

(i) Mental illness as defined in paragraph (f)(2)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission,

(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and

(B) If the individual requires such level of services, whether the individual requires specialized services; or

(ii) Mental retardation, as defined in paragraph (f)(2)(ii) of this section, unless the State mental retardation or developmental disability authority has determined prior to admission—

(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and

(B) If the individual requires such level of services, whether the individual requires specialized services for mental retardation.

(2) Definition. For purposes of this section—

(i) An individual is considered to have mental illness if the individual has a serious mental illness as defined in §483.102(b)(1).

(ii) An individual is considered to be mentally retarded if the individual is mentally retarded as defined in §483.102(b)(3) or is a person with a related condition as described in 42 CFR 435.1010 of this chapter.

[56 FR 48871, Sept. 26, 1991, as amended at 57 FR 43924, Sept. 23, 1992; 62 FR 67211, Dec. 23, 1997; 63 FR 53307, Oct. 5, 1998; 64 FR 41543, July 30, 1999; 68 FR 46072, Aug. 4, 2003; 71 FR 39229, July 12, 2006; 74 FR 40363, Aug.11, 2009]

§ 483.25 Quality of care.

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

(a) Activities of daily living. Based on the comprehensive assessment of a resident, the facility must ensure that—

(1) 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—

(i) Bathe, dress, and groom;

(ii) Transfer and ambulate;

(iii) Toilet;

(iv) Eat; and

(v) Use speech, language, or other functional communication systems.

(2) A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section; and

(3) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

(b) Vision and hearing. To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident—

(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.

(c) Pressure sores. Based on the comprehensive assessment of a resident, the facility must ensure that—

(1) A resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and

(2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

(d) Urinary Incontinence. Based on the resident's comprehensive assessment, the facility must ensure that—

(1) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and

(2) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

(e) Range of motion. Based on the comprehensive assessment of a resident, the facility must ensure that—

(1) A resident who enters the facility without a limited range of motion 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

(2) 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.

(f) Mental and Psychosocial functioning. Based on the comprehensive assessment of a resident, the facility must ensure that—

(1) A resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem, and

(2) A resident whose assessment did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that such a pattern was unavoidable.

(g) Naso-gastric tubes. Based on the comprehensive assessment of a resident, the facility must ensure that—

(1) A resident who has been able to eat enough alone or with assistance is not fed by naso-gastric tube unless the resident's clinical condition demonstrates that use of a naso-gastric tube was unavoidable; and

(2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.

(h) Accidents. The facility must ensure that—

(1) The resident environment remains as free of accident hazards as is possible; and

(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

(i) Nutrition. Based on a resident's comprehensive assessment, the facility must ensure that a resident—

(1) 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; and

(2) Receives a therapeutic diet when there is a nutritional problem.

(j) Hydration. The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health.

(k) Special needs. The facility must ensure that residents receive proper treatment and care for the following special services:

(1) Injections;

(2) Parenteral and enteral fluids;

(3) Colostomy, ureterostomy, or ileostomy care;

(4) Tracheostomy care;

(5) Tracheal suctioning;

(6) Respiratory care;

(7) Foot care; and

(8) Prostheses.

(l) Unnecessary drugs —(1) General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used:

(i) In excessive dose (including duplicate drug therapy); or

(ii) For excessive duration; or

(iii) Without adequate monitoring; or

(iv) Without adequate indications for its use; or

(v) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

(vi) Any combinations of the reasons above.

(2) Antipsychotic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that—

(i) Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and

(ii) Residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

(m) Medication Errors. The facility must ensure that—

(1) It is free of medication error rates of five percent or greater; and

(2) Residents are free of any significant medication errors.

(n) Influenza and pneumococcal immunizations —(1) Influenza. The facility must develop policies and procedures that ensure that—

(i) Before offering the influenza immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization;

(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;

(iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and

(iv) The resident's medical record includes documentation that indicates, at a minimum, the following:

(A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and

(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

(2) Pneumococcal disease. The facility must develop policies and procedures that ensure that—

(i) Before offering the pneumococcal immunization, each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization;

(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;

(iii) The resident or the resident's legal representative has the opportunity to refuse immunization; and

(iv) The resident's medical record includes documentation that indicates, at a minimum, the following:

(A) That the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and

(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

(v) Exception. As an alternative, based on an assessment and practitioner recommendation, a second pneumococcal immunization may be given after 5 years following the first pneumococcal immunization, unless medically contraindicated or the resident or the resident's legal representative refuses the second immunization.

[56 FR 48873, Sept. 26, 1991, as amended at 57 FR 43925, Sept. 23, 1992; 70 FR 58851, Oct. 7, 2005]

§ 483.30 Nursing services.

The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.

(a) Sufficient staff. (1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

(i) Except when waived under paragraph (c) of this section, licensed nurses; and

(ii) Other nursing personnel.

(2) Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

(b) Registered nurse. (1) Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

(2) Except when waived under paragraph (c) or (d) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis.

(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

(c) Nursing facilities: Waiver of requirement to provide licensed nurses on a 24-hour basis. To the extent that a facility is unable to meet the requirements of paragraphs (a)(2) and (b)(1) of this section, a State may waive such requirements with respect to the facility if—

(1) The facility demonstrates to the satisfaction of the State that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities), to recruit appropriate personnel;

(2) The State determines that a waiver of the requirement will not endanger the health or safety of individuals staying in the facility;

(3) The State finds that, for any periods in which licensed nursing services are not available, a registered nurse or a physician is obligated to respond immediately to telephone calls from the facility;

(4) A waiver granted under the conditions listed in paragraph (c) of this section is subject to annual State review;

(5) In granting or renewing a waiver, a facility may be required by the State to use other qualified, licensed personnel;

(6) The State agency granting a waiver of such requirements provides notice of the waiver to the State long term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and mentally retarded; and

(7) The nursing facility that is granted such a waiver by a State notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.

(d) SNFs: Waiver of the requirement to provide services of a registered nurse for more than 40 hours a week. (1) The Secretary may waive the requirement that a SNF provide the services of a registered nurse for more than 40 hours a week, including a director of nursing specified in paragraph (b) of this section, if the Secretary finds that—

(i) The facility is located in a rural area and the supply of skilled nursing facility services in the area is not sufficient to meet the needs of individuals residing in the area;

(ii) The facility has one full-time registered nurse who is regularly on duty at the facility 40 hours a week; and

(iii) The facility either—

(A) Has only patients whose physicians have indicated (through physicians' orders or admission notes) that they do not require the services of a registered nurse or a physician for a 48-hours period, or

(B) Has made arrangements for a registered nurse or a physician to spend time at the facility, as determined necessary by the physician, to provide necessary skilled nursing services on days when the regular full-time registered nurse is not on duty;

(iv) The Secretary provides notice of the waiver to the State long term care ombudsman (established under section 307(a)(12) of the Older Americans Act of 1965) and the protection and advocacy system in the State for the mentally ill and mentally retarded; and

(v) The facility that is granted such a waiver notifies residents of the facility (or, where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.

(2) A waiver of the registered nurse requirement under paragraph (d)(1) of this section is subject to annual renewal by the Secretary.

(e) Nurse staffing information —(1) Data requirements. The facility must post the following information on a daily basis:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).

(C) Certified nurse aides.

(iv) Resident census.

(2) Posting requirements. (i) The facility must post the nurse staffing data specified in paragraph (e)(1) of this section on a daily basis at the beginning of each shift.

(ii) Data must be posted as follows:

(A) Clear and readable format.

(B) In a prominent place readily accessible to residents and visitors.

(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

[56 FR 48873, Sept. 26, 1991, as amended at 57 FR 43925, Sept. 23, 1992; 70 FR 62073, Oct. 28, 2005]

§ 483.35 Dietary services.

The facility must provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.

(a) Staffing. The facility must employ a qualified dietitian either full-time, part-time, or on a consultant basis.

(1) If a qualified dietitian is not employed full-time, the facility must designate a person to serve as the director of food service who receives frequently scheduled consultation from a qualified dietitian.

(2) A qualified dietitian is one who is qualified based upon either registration by the Commission on Dietetic Registration of the American Dietetic Association, or on the basis of education, training, or experience in identification of dietary needs, planning, and implementation of dietary programs.

(b) Sufficient staff. The facility must employ sufficient support personnel competent to carry out the functions of the dietary service.

(c) Menus and nutritional adequacy. Menus must—

(1) Meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences;

(2) Be prepared in advance; and

(3) Be followed.

(d) Food. Each resident receives and the facility provides—

(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

(2) Food that is palatable, attractive, and at the proper temperature;

(3) Food prepared in a form designed to meet individual needs; and

(4) Substitutes offered of similar nutritive value to residents who refuse food served.

(e) Therapeutic diets. Therapeutic diets must be prescribed by the attending physician.

(f) Frequency of meals. (1) Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community.

(2) There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in (4) below.

(3) The facility must offer snacks at bedtime daily.

(4) When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served.

(g) Assistive devices. The facility must provide special eating equipment and utensils for residents who need them.

(h) Paid feeding assistants —(1) State-approved training course. A facility may use a paid feeding assistant, as defined in §488.301 of this chapter, if—

(i) The feeding assistant has successfully completed a State-approved training course that meets the requirements of §483.160 before feeding residents; and

(ii) The use of feeding assistants is consistent with State law.

(2) Supervision. (i) A feeding assistant must work under the supervision of a registered nurse (RN) or licensed practical nurse (LPN).

(ii) In an emergency, a feeding assistant must call a supervisory nurse for help on the resident call system.

(3) Resident selection criteria. (i) A facility must ensure that a feeding assistant feeds only residents who have no complicated feeding problems.

(ii) Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral/IV feedings.

(iii) The facility must base resident selection on the charge nurse's assessment and the resident's latest assessment and plan of care.

(i) Sanitary conditions. The facility must—

(1) Procure food from sources approved or considered satisfactory by Federal, State, or local authorities;

(2) Store, prepare, distribute, and serve food under sanitary conditions; and

(3) Dispose of garbage and refuse properly.

[56 FR 48874, Sept. 26, 1991, as amended at 68 FR 55539, Sept. 26, 2003]

§ 483.40 Physician services.

A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician.

(a) Physician supervision. The facility must ensure that—

(1) The medical care of each resident is supervised by a physician; and

(2) Another physician supervises the medical care of residents when their attending physician is unavailable.

(b) Physician visits. The physician must—

(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

(2) Write, sign, and date progress notes at each visit; and

(3) Sign and date all orders with the exception of influenza and pneumococcal polysaccharide vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

(c) Frequency of physician visits. (1) The resident must be 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.

(2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

(3) Except as provided in paragraphs (c)(4) and (f) of this section, all required physician visits must be made by the physician personally.

(4) At the option of the physician, required visits in SNFs after the initial visit may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist in accordance with paragraph (e) of this section.

(d) Availability of physicians for emergency care. The facility must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.

(e) Physician delegation of tasks in SNFs. (1) Except as specified in paragraph (e)(2) of this section, a physician may delegate tasks to a physician assistant, nurse practitioner, or clinical nurse specialist who—

(i) Meets the applicable definition in §491.2 of this chapter or, in the case of a clinical nurse specialist, is licensed as such by the State;

(ii) Is acting within the scope of practice as defined by State law; and

(iii) Is under the supervision of the physician.

(2) A physician may not delegate a task when the regulations specify that the physician must perform it personally, or when the delegation is prohibited under State law or by the facility's own policies.

(f) Performance of physician tasks in NFs. At the option of the State, any required physician task in a NF (including tasks which the regulations specify must be performed personally by the physician) may also be satisfied when performed by a nurse practitioner, clinical nurse specialist, or physician assistant who is not an employee of the facility but who is working in collaboration with a physician.

[56 FR 48875, Sept. 26, 1991, as amended at 67 FR 61814, Oct. 2, 2002]

§ 483.45 Specialized rehabilitative services.

(a) Provision of services. If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and mental retardation, are required in the resident's comprehensive plan of care, the facility must—

(1) Provide the required services; or

(2) Obtain the required services from an outside resource (in accordance with §483.75(h) of this part) from a provider of specialized rehabilitative services.

(b) Qualifications. Specialized rehabilitative services must be provided under the written order of a physician by qualified personnel.

[56 FR 48875, Sept. 26, 1991, as amended at 57 FR 43925, Sept. 23, 1992]

§ 483.55 Dental services.

The facility must assist residents in obtaining routine and 24-hour emergency dental care.

(a) Skilled nursing facilities. A facility (1) Must provide or obtain from an outside resource, in accordance with §483.75(h) of this part, routine and emergency dental services to meet the needs of each resident;

(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

(3) Must if necessary, assist the resident—

(i) In making appointments; and

(ii) By arranging for transportation to and from the dentist's office; and

(4) Promptly refer residents with lost or damaged dentures to a dentist.

(b) Nursing facilities. The facility (1) Must provide or obtain from an outside resource, in accordance with §483.75(h) of this part, the following dental services to meet the needs of each resident:

(i) Routine dental services (to the extent covered under the State plan); and

(ii) Emergency dental services;

(2) Must, if necessary, assist the resident—

(i) In making appointments; and

(ii) By arranging for transportation to and from the dentist's office; and

(3) Must promptly refer residents with lost or damaged dentures to a dentist.

[56 FR 48875, Sept. 26, 1991]

§ 483.60 Pharmacy services.

The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.75(h) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

(b) Service consultation. The facility must employ or obtain the services of a licensed pharmacist who—

(1) Provides consultation on all aspects of the provision of pharmacy services in the facility;

(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

(c) Drug regimen review. (1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

(2) The pharmacist must report any irregularities to the attending physician and the director of nursing, and these reports must be acted upon.

(d) Labeling of drugs and biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

(e) Storage of drugs and biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

(2) The facility must provide 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 single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

[56 FR 48875, Sept. 26, 1991, as amended at 57 FR 43925, Sept. 23, 1992]

§ 483.65 Infection control.

The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection.

(a) Infection control program. The facility must establish an infection control program under which it—

(1) Investigates, controls, and prevents infections in the facility;

(2) Decides what procedures, such as isolation, should be applied to an individual resident; and

(3) Maintains a record of incidents and corrective actions related to infections.

(b) Preventing spread of infection. (1) When the infection control program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident.

(2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease.

(3) The facility must require staff to wash their hands after each direct resident contact for which handwashing is indicated by accepted professional practice.

(c) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

[56 FR 48876, Sept. 26, 1991, as amended at 57 FR 43925, Sept. 23, 1992]

§ 483.70 Physical environment.

The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public.

(a) Life safety from fire. (1) Except as otherwise provided in this section—

(i) The facility must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA 101®2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202–741–6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269. If any changes in this edition of the Code are incorporated by reference, CMS will publish notice in theFederal Registerto announce the changes.

(ii) Chapter 19.3.6.3.2, exception number 2 of the adopted edition of the LSC does not apply to long-term care facilities.

(2) After consideration of State survey agency findings, CMS may waive specific provisions of the Life Safety ode which, if rigidly applied, would result in unreasonable hardship upon the facility, but only if the waiver does not adversely affect the health and safety of the patients.

(3) The provisions of the Life safety Code do not apply in a State where CMS finds, in accordance with applicable provisions of sections 1819(d)(2)(B)(ii) and 1919(d)(2)(B)(ii) of the Act, that a fire and safety code imposed by State law adequately protects patients, residents and personnel in long term care facilities.

(4) Beginning March 13, 2006, a long-term care facility must be in compliance with Chapter 19.2.9, Emergency Lighting.

(5) Beginning March 13, 2006, Chapter 19.3.6.3.2, exception number 2 does not apply to long-term care facilities.

(6) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the contrary, a long-term care facility may install alcohol-based hand rub dispensers in its facility if—

(i) 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;

(ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls;

(iii) The dispensers are installed in a manner that adequately protects against inappropriate access;

(iv) The dispensers are installed in accordance with chapter 18.3.2.7 or chapter 19.3.2.7 of the 2000 edition of the Life Safety Code, as amended by NFPA Temporary Interim Amendment 00–1(101), issued by the Standards Council of the National Fire Protection Association on April 15, 2004. The Director of the Office of the Federal Register has approved NFPA Temporary Interim Amendment 00–1(101) for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the amendment is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD and at the Office of the Federal Register, 800 North Capitol Street NW., Suite 700, Washington, DC. Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269; and

(v) The dispensers are maintained in accordance with dispenser manufacturer guidelines.

(7) A long term care facility must:

(i) Install, at least, battery-operated single station smoke alarms in accordance with the manufacturer's recommendations in resident sleeping rooms and common areas.

(ii) Have a program for inspection, testing, maintenance, and battery replacement that conforms to the manufacturer's recommendations and that verifies correct operation of the smoke alarms.

(iii) Exception:

(A) The facility has system-based smoke detectors in patient rooms and common areas that are installed, tested, and maintained in accordance with NFPA 72, National Fire Alarm Code , for system-based smoke detectors; or

(B) The facility is fully sprinklered in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems .

(8) A long term care facility must:

(i) Install an approved, supervised automatic sprinkler system in accordance with the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, as incorporated by reference, throughout the building by August 13, 2013. The Director of the Office of the Federal Register has approved the NFPA 13 1999 edition of the Standard for the Installation of Sprinkler Systems, issued July 22, 1999 for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202–741–6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html . Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269.

(ii) Test, inspect, and maintain an approved, supervised automatic sprinkler system in accordance with the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, as incorporated by reference. The Director of the Office of the Federal Register has approved the NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition, issued January 16, 1998 for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202–741–6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html . Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02269.

(b) Emergency power. (1) An emergency electrical power system must supply power adequate at least for lighting all entrances and exits; equipment to maintain the fire detection, alarm, and extinguishing systems; and life support systems in the event the normal electrical supply is interrupted.

(2) When life support systems are used, the facility must provide emergency electrical power with an emergency generator (as defined in NFPA 99, Health Care Facilities) that is located on the premises.

(c) Space and equipment. The facility must—

(1) Provide sufficient space and equipment in dining, health services, recreation, and program areas to enable staff to provide residents with needed services as required by these standards and as identified in each resident's plan of care; and

(2) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.

(d) Resident rooms. Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

(1) Bedrooms must—

(i) Accommodate no more than four residents;

(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;

(iii) Have direct access to an exit corridor;

(iv) Be designed or equipped to assure full visual privacy for each resident;

(v) In facilities initially certified after March 31, 1992, except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains;

(vi) Have at least one window to the outside; and

(vii) Have a floor at or above grade level.

(2) The facility must provide each resident with—

(i) A separate bed of proper size and height for the convenience of the resident;

(ii) A clean, comfortable mattress;

(iii) Bedding appropriate to the weather and climate; and

(iv) Functional 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.

(3) CMS, or in the case of a nursing facility the survey agency, may permit variations in requirements specified in paragraphs (d)(1) (i) and (ii) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations—

(i) Are in accordance with the special needs of the residents; and

(ii) Will not adversely affect residents' health and safety.

(e) Toilet facilities. Each resident room must be equipped with or located near toilet and bathing facilities.

(f) Resident call system. The nurse's station must be equipped to receive resident calls through a communication system from—

(1) Resident rooms; and

(2) Toilet and bathing facilities.

(g) Dining and resident activities. The facility must provide one or more rooms designated for resident dining and activities. These rooms must—

(1) Be well lighted;

(2) Be well ventilated, with nonsmoking areas identified;

(3) Be adequately furnished; and

(4) Have sufficient space to accommodate all activities.

(h) Other environmental conditions. The facility must provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public. The facility must—

(1) Establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply;

(2) Have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two;

(3) Equip corridors with firmly secured handrails on each side; and

(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

[56 FR 48876, Sept. 26, 1991, as amended at 57 FR 43925, Sept. 23, 1992; 68 FR 1386, Jan. 10, 2003; 69 FR 49268, Aug. 11, 2004; 70 FR 15238, Mar. 25, 2005; 71 FR 55340, Sept. 22, 2006; 73 FR 47091, Aug. 13, 2008]

§ 483.75 Administration.

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

(a) Licensure. A facility must be licensed under applicable State and local law.

(b) Compliance with Federal, State, and local laws and professional standards. The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

(c) Relationship to other HHS regulations. In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of handicap (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455). Although these regulations are not in themselves considered requirements under this part, their violation may result in the termination or suspension of, or the refusal to grant or continue payment with Federal funds.

(d) Governing body. (1) The facility must have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility; and

(2) The governing body appoints the administrator who is—

(i) Licensed by the State where licensing is required; and

(ii) Responsible for management of the facility.

(e) Required training of nursing aides —(1) Definitions.

Licensed health professional means a physician; physician assistant; nurse practitioner; physical, speech, or occupational therapist; physical or occupational therapy assistant; registered professional nurse; licensed practical nurse; or licensed or certified social worker.

Nurse aide means any individual providing nursing or nursing-related services to residents in a facility who is not a licensed health professional, a registered dietitian, or someone who volunteers to provide such services without pay. Nurse aides do not include those individuals who furnish services to residents only as paid feeding assistants as defined in §488.301 of this chapter.

(2) General rule. A facility must not use any individual working in the facility as a nurse aide for more than 4 months, on a full-time basis, unless:

(i) That individual is competent to provide nursing and nursing related services; and

(ii)(A) That individual has completed a training and competency evaluation program, or a competency evaluation program approved by the State as meeting the requirements of §§483.151–483.154 of this part; or

(B) That individual has been deemed or determined competent as provided in §483.150 (a) and (b).

(3) Non-permanent employees. A facility must not use on a temporary, per diem, leased, or any basis other than a permanent employee any individual who does not meet the requirements in paragraphs (e)(2) (i) and (ii) of this section.

(4) Competency. A facility must not use any individual who has worked less than 4 months as a nurse aide in that facility unless the individual—

(i) Is a full-time employee in a State-approved training and competency evaluation program;

(ii) Has demonstrated competence through satisfactory participation in a State-approved nurse aide training and competency evaluation program or competency evaluation program; or

(iii) Has been deemed or determined competent as provided in §483.150 (a) and (b).

(5) Registry verification. Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless—

(i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or

(ii) The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.

(6) Multi-State registry verification. Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act the facility believes will include information on the individual.

(7) Required retraining. If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.

(8) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. The in-service training must—

(i) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year;

(ii) Address areas of weakness as determined in nurse aides' performance reviews and may address the special needs of residents as determined by the facility staff; and

(iii) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.

(f) Proficiency of Nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

(g) Staff qualifications. (1) The facility must employ on a full-time, part-time or consultant basis those professionals necessary to carry out the provisions of these requirements.

(2) Professional staff must be licensed, certified, or registered in accordance with applicable State laws.

(h) Use of outside resources. (1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or (with respect to services furnished to NF residents and dental services furnished to SNF residents) an agreement described in paragraph (h)(2) of this section.

(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for—

(i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and

(ii) The timeliness of the services.

(i) Medical director. (1) The facility must designate a physician to serve as medical director.

(2) The medical director is responsible for—

(i) Implementation of resident care policies; and

(ii) The coordination of medical care in the facility.

(j) Laboratory services. (1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.

(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

(ii) If the facility provides blood bank and transfusion services, it must meet the applicable requirements for laboratories specified in part 493 of this chapter.

(iii) If the laboratory chooses to refer specimens for testing to another laboratory, the referral laboratory must be certified in the appropriate specialties and subspecialties of services in accordance with the requirements of part 493 of this chapter.

(iv) If the facility does not provide laboratory services on site, it must have an agreement to obtain these services from a laboratory that meets the applicable requirements of part 493 of this chapter.

(2) The facility must—

(i) Provide or obtain laboratory services only when ordered by the attending physician;

(ii) Promptly notify the attending physican of the findings;

(iii) Assist the resident in making transportation arrangements to and from the source of service, if the resident needs asistance; and

(iv) File in the resident's clinical record laboratory reports that are dated and contain the name and address of the testing laboratory.

(k) Radiology and other diagnostic services. (1) The facility must provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.

(i) If the facility provides its own diagnostic services, the services must meet the applicable conditions of participation for hospitals contained in §482.26 of this subchapter.

(ii) 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.

(2) The facility must—

(i) Provide or obtain radiology and other diagnostic services only when ordered by the attending physician;

(ii) Promptly notify the attending physician of the findings;

(iii) Assist the resident in making transportation arrangements to and from the source of service, if the resident needs assistance; and

(iv) File in the resident's clinical record signed and dated reports of x-ray and other diagnostic services.

(l) Clinical records. (1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are—

(i) Complete;

(ii) Accurately documented;

(iii) Readily accessible; and

(iv) Systematically organized.

(2) Clinical records must be retained for—

(i) The period of time required by State law; or

(ii) Five years from the date of discharge when there is no requirement in State law; or

(iii) For a minor, three years after a resident reaches legal age under State law.

(3) The facility must safeguard clinical record information against loss, destruction, or unauthorized use;

(4) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is required by—

(i) Transfer to another health care institution;

(ii) Law;

(iii) Third party payment contract; or

(iv) The resident.

(5) The clinical record must contain—

(i) Sufficient information to identify the resident;

(ii) A record of the resident's assessments;

(iii) The plan of care and services provided;

(iv) The results of any preadmission screening conducted by the State; and

(v) Progress notes.

(m) Disaster and emergency preparedness. (1) The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.

(2) The facility must train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures.

(n) Transfer agreement. (1) In accordance with section 1861(l) of the Act, the facility (other than a nursing facility which is located in a State on an Indian reservation) must have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs that reasonably assures that—

(i) Residents will be transferred from the facility to the hospital, and ensured of timely admission to the hospital when transfer is medically appropriate as determined by the attending physician; and

(ii) Medical and other information needed for care and treatment of residents, and, when the transferring facility deems it appropriate, for determining whether such residents can be adequately cared for in a less expensive setting than either the facility or the hospital, will be exchanged between the institutions.

(2) The facility is considered to have a transfer agreement in effect if the facility has attempted in good faith to enter into an agreement with a hospital sufficiently close to the facility to make transfer feasible.

(o) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting of—

(i) The director of nursing services;

(ii) A physician designated by the facility; and

(iii) At least 3 other members of the facility's staff.

(2) The quality assessment and assurance committee—

(i) Meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and

(ii) Develops and implements appropriate plans of action to correct identified quality deficiencies.

(3) A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

(4) Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

(p) Disclosure of ownership. (1) The facility must comply with the disclosure requirements of §§420.206 and 455.104 of this chapter.

(2) The facility must provide written notice to the State agency responsible for licensing the facility at the time of change, if a change occurs in—

(i) Persons with an ownership or control interest, as defined in §§420.201 and 455.101 of this chapter;

(ii) The officers, directors, agents, or managing employees;

(iii) The corporation, association, or other company responsible for the management of the facility; or

(iv) The facility's administrator or director of nursing.

(3) The notice specified in paragraph (p)(2) of this section must include the identity of each new individual or company.

(q) Required training of feeding assistants. A facility must not use any individual working in the facility as a paid feeding assistant unless that individual has successfully completed a State-approved training program for feeding assistants, as specified in §483.160 of this part.

[56 FR 48877, Sept. 26, 1991, as amended at 56 FR 48918, Sept. 26, 1991; 57 FR 7136, Feb. 28, 1992; 57 FR 43925, Sept. 23, 1992; 59 FR 56237, Nov. 10, 1994; 63 FR 26311, May 12, 1998; 68 FR 55539, Sept. 26, 2003; 74 FR 40363, Aug. 11, 2009]

According to a an investigation by the California Department of Public Health, the man stumbled out of his room, pale and unable to speak after he was served whole meatballs.  A nurses attempt to do the Heimlich maneuver on the man was unsuccessful and he was pronounced dead a short time later at an area hospital.

This is a case where the facility admits that its staff failed to follow standing orders with this patient.  According to Antonio Sandoval, assistant administrator at Raintree Convalescent Center, the cook and the nursing assistant ignored the residents care plan when they served whole meatballs to the man for lunch.  "Neither of them did their job." he said.

This incident resulted in an $80,000 fine against the facility.  Further, this reinforces Raintree's poor Medicare rating.  Raintree received just one out of five stars according the Federal nursing home rating system.

Related Nursing Homes Abuse Blog Posts

Nursing Home Resident Chokes To Death On Dinner

The Truth Revealed: Nursing Home Tries To Cover-up Fact That Resident Choked To Death On Tuna Sandwich

What Is It Like To Live In A 1-Starred Nursing Home?

Perhaps the biggest risk posed to nursing home residents with dementia or other cognitive deficits is something rarely discussed and almost never considered harmful---food.  Food products and the packaging food is presented in, present significant hazards to residents who have swallowing or chewing difficulties and those who are cognitively impaired.

The OC Register recently reported about an incident involving an elderly man with dementia at the Anaheim Crest Nursing Center who choked to death on a tuna sandwich.  The incident reportedly took place on September 9, 2008 following two other choking episodes on the same day.  The first episode involved the nursing home staff inadvertently giving solid food to the unnamed resident despite the fact that his care plan set forth that he was only to receive pureed food.   The second episode involved the man grabbing a sandwich from an unattended food cart.

A state investigation into the matter confirmed that the man choked to death on a tuna sandwich-- the third choking incident on the same day.  The investigation further confirmed that the staff at Anaheim Crest did not try to clear his throat, check him for aspiration or provide any emergency treatment prior to his death. 

The investigation comes after the nursing home initially claimed that the resident died of a heart attack. State investigators were tipped off as to the suspicious circumstances regarding the man's death after a coroner concluded the death was related to choking. 

As a result of the nursing home's failure to follow the man's care plan (requiring pureed foods) and the facilities failure to provide care following his choking, the facility has been fined $75,000.

Supervision Is The Key

Nothing can take the place of supervision.  In facilities with residents who have dementia and Alzheimer's patients, it is crucial the staff not only follow the residents dietary restrictions (pureed foods, no commercially packaged foods, ect.).  Staff must provide assistance to ensure safety and to assure that each resident is consuming adequate nutrition and fluids.

Web Resources Regarding Nursing Home Resident's Dietary Restrictions

Anaheim nursing home faces $75,000 fine in choking death, By TONY SAAVEDRA, THE ORANGE COUNTY REGISTER

Alzheimer's Caregivers Guide, TIPS FOR CARING FOR A PERSON WITH ALZHEIMER'S DISEASE

Nursing Homes Abuse Blog Entries On Food Safety

Man Chokes To Death While Left Unattended At Nursing Home

Nursing Home Resident Chokes To Death On Dinner