Title: Section 415.12 - Quality of care
415.12 Quality of care. Each resident shall receive and the facility shall 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 subject to the resident's right of self-determination.
(a) Activities of daily living. Based on the comprehensive assessment of a resident, the facility shall 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;
(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 (1) of this subdivision; 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 shall, if necessary, assist the resident:
(1) in making appointments;
(2) by arranging for transportation to and from the office of a medical 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 if such services are not provided on-site; and
(3) by promoting the safekeeping, maintenance, and use of vision or hearing assistive devices which the resident needs.
(c) Pressure sores. Based on the comprehensive assessment of a resident, the facility shall 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 despite every reasonable effort to prevent them; 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 shall ensure that:
(1) a resident who is incontinent of bladder receives the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible; and
(2) a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary.
(e) Range of motion. Based on the comprehensive assessment of a resident, the facility shall 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 shall 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 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) Enteral feeding tubes. (1) Based on the comprehensive assessment of a resident, the facility shall ensure that a resident who has been able to eat alone or with assistance is not fed by an enteral feeding tube unless the resident's clinical condition demonstrates that use of such a tube was unavoidable.
(2) A resident who is fed by an enteral feeding tube shall receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, significant regurgitation, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal feeding function.
(3) Following consideration of possible alternatives for short term nutritional therapy, nasogastric tubes and feeding formulations may be used for feeding purposes when determined clinically appropriate by the attending physician and interdisciplinary care team which includes a health care professional with training in diagnosis and management of swallowing disorders. Nasogastric tube feedings shall be used to promote a therapeutic program to maintain adequate nutrition and hydration and include a plan to help the resident develop or regain eating skills. (4) Residents receiving nasogastric tube feedings shall be reassessed at a minimum by the registered professional nurse, social worker, and dietitian as needed, but no less than once every six weeks, for the ability to return to normal feeding function. If the nasogastric feeding is continued, the reasons for continuation shall be documented in the resident's clinical record. If nasogastric feedings are to be continued longer than 95 days, permanent enteral feeding procedures such as surgical gastrostomy or jejunostomy shall be considered.
(5) Nasogastric tube feeding formulations shall be given in accordance with the manufacturer's instructions or at a rate appropriate to the physical size of the resident and the amount of fluid and nutrients necessary to meet the assessed caloric and fluid needs of the resident.
(6) To minimize resident discomfort, nasogastric tubes used for resident feeding purposes shall:
(i) be the smallest gauge appropriate for the patient and shall not exceed 3.96 millimeters (#12 French) in outside diameter unless medically indicated;
(ii) be made of a soft, flexible material such as medical grade polyurethane or silicone; and
(iii) be specifically manufactured for nasogastric feeding purposes.
(7) The facility shall develop and follow policies and procedures for nasogastric tube feedings which are written in accordance with prevailing standards of professional practice and in consultation with the medical, nursing, dietary and pharmacy services of the facility. Medical practitioners shall be informed of such policies and procedures governing the use of nasogastric tubes for resident feeding. The policies and procedures shall address as a minimum:
(i) types and sizes of nasogastric tubes and the various types of feeding formulations available at the facility;
(ii) the need to assess each resident's clinical and nutritional status to determine the size of the nasogastric tube and type of feeding appropriate for that individual;
(iii) standard techniques for inserting a nasogastric tube and confirming the correct placement of the tube;
(iv) procedures for administering nasogastric feedings including positioning the resident and the need for resident observation and monitoring before, during and following the feeding; and
(v) infection control policies related to tube feedings.
(h) Accidents. The facility shall ensure that:
(1) the resident environment remains as free of accident hazards as is possible; and
(2) each resident receives adequate supervision and assistive devices to prevent accidents.
(i) Nutrition. Based on a resident's comprehensive assessment, the facility shall 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 shall provide each resident with sufficient fluid intake to maintain proper hydration and health.
(k) Special needs. The facility shall ensure that residents receive proper treatment and care for the following special services:
(2) parenteral and enteral fluids;
(3) colostomy, ureterostomy or ileostomy care;
(4) tracheostomy care;
(5) tracheal suctioning;
(6) respiratory care;
(7) podiatric care; and
(l) Drug therapy. (1) Unnecessary drugs. Each resident's drug regimen shall include only those medications prescribed to treat a specific documented illness or condition and not otherwise contraindicated for a given resident. The drug regimen shall be monitored for evidence of both adverse actions and therapeutic effect. Dose changes or discontinuation of the drug must be made if the drug is ineffective and/or is causing disabling or harmful side effects and/or the condition for which it was prescribed has resolved.
(2) Psychotropic drugs. Based on a comprehensive assessment of a resident and consistent with the provisions of subdivision (a) of section 415.4 of this Part, the facility shall ensure that:
(i) the use of psychotropic drugs shall:
(a) meet all conditions of paragraph (1) of this subdivision;
(b) be ordered by a physician who, in accordance with generally accepted standards of care and services, specifies the problem for which the drug is prescribed;
(c) be used, except in emergencies, only as an integral part of a resident's comprehensive care plan and only after alternative methods for treating the condition or symptoms have been tried and have failed; and
(d) be discontinued if harmful effects of the medication outweigh the beneficial effects of the drug. (ii) residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs and assist the resident to attain and maintain optimum physical and emotional functioning.
(m) Medication errors. The facility shall 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.
VOLUME C (Title 10)