Federal and State Nursing Home Regulations
FEDERAL NURSING HOME REGULATIONS - 42 CFR §483.00 et seq.
In exchange for Medicare and Medicaid payments, nursing homes agree to provide residents with the best possible care. Specifically, they are required to help each resident attain or maintain the highest practicable physical, mental and psychosocial well-being. 42 USC §1396r(b)(2). Unless it is medically unavoidable, nursing homes must ensure that a resident's condition does not decline. 42 CFR §483.25.
Federal nursing home regulations and Rhode Island state regulations establish specific care standards, including the following:
A.) Accommodation of Needs
Residents have the right to reside and receive services in nursing homes with reasonable accommodations of individual needs and preferences. 42 CFR 483.15(e). Facilities should attempt to adapt such things as schedules, call systems, staff assignments, and room arrangements to accommodate residents' preferences, desires and unique needs.
If language or communication barriers exist between residents and staff, the nursing home is required to use interpreters or other measures to ensure adequate communication. 42 CFR 483.10(b)(1).
B.) Adequate Staff
Nursing homes must have sufficient nursing and other employees to meet the needs of each resident in the nursing home at all times. 42 CFR §483.30.
C.) Care Planning
Nursing homes must establish a comprehensive, individualized care plan for each resident that spells out care needs and how they will be met.
D.) Continence and Help with Toileting
Urinary incontinence, the inability to control the bladder, is one of the most common reasons people seek nursing home care. Incontinence and lack of toileting assistance cause many serious problems, including discomfort, skin rashes, pressure sores, falls, isolation and psychological harm.
Incontinence is not a normal part of aging and is often reversible. Many times it is due to medications or treatable health conditions. Each resident with bladder or bowel control problems must be promptly assessed and be provided treatments and care that can improve the condition. 42 CFR §483.25(d)(2).
Many nursing home residents are not incontinent but do need help with toileting. Residents with limited mobility may need help to reach the toilet, and residents with dementia may need reminders to use the toilet on a regular basis. Nursing homes must help these residents use the toilet as often as needed. 42 CFR §483.25(a)(1).
E.) Feeding Tubes
Feeding tubes can only be used as a last resort because they lead to a loss of functioning and can cause serious medical and psychological problems. If a resident is able to swallow and can get adequate nutrition by eating, no matter how long it takes, then no tube should be used. 42 CFR §483.25(g)(1).
Lack of staff time is not an acceptable excuse.
If a feeding tube is being used, the nursing home must do what it can to help the resident take food by mouth again as soon as possible. 42 CFR §483.25(g).
F.) Fluids and Hydration
Many nursing home residents become dehydrated because they are not given sufficient fluids. Symptoms of dehydration include dizziness, confusion, constipation, fever, decreased urine output, and skin problems. Severe dehydration can lead to serious illness and death.
Nursing homes must provide each resident with sufficient fluids to maintain proper hydration and health. 42 CFR §483.25(j). Each resident should be provided a plentiful supply of fresh water or other beverages and be given any help or encouragement needed to drink.
G.) Food and Nutrition
Nursing homes must provide each resident a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs. 42 CFR §483.35 Additionally, nursing homes must:
- Serve at least three meals daily, at regular times, with not more than a 14-hour span between the evening meal and breakfast;
- Offer snacks at bedtime;
- Reasonably accommodate resident food and mealtime preferences;
- Offer a food substitute of similar nutritional value if a resident refuses food;
- Serve food attractively, at the proper temperature, and in a form to meet individual needs;
- Prepare and follow menus that meet national dietary standards;
- Plan menus with consideration of the residents' cultural backgrounds and food habits;
- Post the current and following week's menus for regular and special diets;
- Prepare food using methods that conserve nutritive value, flavor and appearance;
- Provide therapeutic diets to residents with nutritional problems, subject to physician orders;
- Ensure that a resident's ability to eat does not diminish unless it is medically unavoidable;
- Provide individualized help to residents who need assistance with meals, offering enough assistance and time so that residents can finish meals;
- Provide special eating utensils to residents who need them;
- Provide table service to all residents who desire it, served at tables of appropriate height;
- Store, prepare, distribute and serve food under sanitary conditions.
42 CFR §483.35
If a resident's ability to eat is compromised, the facility should establish an individualized care plan to maintain the resident's ability to eat food orally.17
Nursing homes must notify a resident's physician immediately if there are signs of malnutrition, such as a weight loss of 5 pounds or more within a 30 day period. Nursing homes are required to reassess nutritional status whenever a resident experiences unplanned or undesired weight loss of 5 percent or more in one month, 7.5 percent or more in three months, or 10 percent or more in 6 months. 42 CFR §483.25(i)(2).
H.) Infection Control
Nursing homes must have an organized infection control program that prevents diseases and infections from developing and spreading. 42 CFR §483.65. To meet this requirement, at a minimum, nursing homes must:
- Investigate, control and prevent infections in the facility;
- Screen residents and employees for tuberculosis;
- Decide what procedures should be applied to an individual resident;
- Isolate residents only to the degree needed to isolate infecting organisms, using the least restrictive method possible;
- Require staff members to wash their hands after each direct contact with a resident;
- Prohibit employees who have communicable diseases or infected skin conditions from having direct contact with residents or their food;
- Handle, store, process and transport linens in a way that prevents the spread of infections;
- Clean and disinfect contaminated articles and surfaces; and
- Maintain a record of infections and corrective actions.
42 CFR §483.25
I.) Medications
Most residents depend on medicine to treat illness and maintain their health. In order to ensure that medications are available and used safely, federal and state rules require nursing homes and physicians to properly order, record, store, administer and monitor medications. Despite the detailed standards, medication problems, such as over-prescribing drugs and medication errors, are common.
Residents and their legal representatives have the right to consent to or to refuse any treatment, including use of medications. 42 CFR §483.10(b)(4).
Over-prescribing medications is a common problem in nursing homes. Federal law addresses this problem by prohibiting nursing homes from using unnecessary drugs. An unnecessary drug is any drug given: (1) in excessive dose; (2) for an excessive period of time; (3) without adequate monitoring; (4) without adequate justification; or (5) in the presence of adverse consequences which indicate the dose should be reduced or discontinued. 42 CFR §483.25(l).
Drug use to treat behavior symptoms is highly restricted. Except in an emergency, it is generally illegal to chemically restrain a resident, which means to control a resident's behavior through drug use when other forms of care and treatment would be more appropriate. 42 USC §1396r(c)(1)(A)(ii), and 42 CFR §483.13(a). Nursing homes cannot sedate residents to cover-up behavioral symptoms caused by: (1) environmental conditions such as excessive heat, noise, and overcrowding; (2) psychosocial problems such as abuse, taunting, or ignoring a resident's customary routine; or (3) treatable medical conditions such as heart disease or diabetes.
Medications must be administered by licensed nurses or medical personnel. The person who administers the drug or treatment must record the date, time, and dosage in the resident's individual medication record.
Nursing homes must ensure that residents are free of any significant medication errors. A medication error is a discrepancy between the facility's actions and either physician's orders, manufacturer's specifications, or accepted professional standards. A medication error is considered significant when it causes the resident discomfort or jeopardizes his or her health and safety.
J.) Personal Care
Nursing homes must give residents necessary assistance with bathing, dressing, eating and other personal needs. 42 CFR 483.25(a)(3). Unless it is medically unavoidable, the nursing home must ensure that residents' abilities to carry out activities of daily living do not decline. 42 CFR 483.25(a). Activities of daily living include bathing, dressing, grooming, eating, walking, communicating, using the toilet, and transferring to or from a bed or chair.
K.) Physician Services
Each resident's care must be supervised by a physician selected by the resident or the resident's representative. 42 CFR §483.40, and 42 CFR §483.10(d)(1). A facility may not place barriers in the way of residents choosing their own physicians.
Physicians generally must see and evaluate residents at least every 30 days and more often if needed. 42 CFR §483.40(c). Face to face contact with residents is required, as is review of the resident's total program of care during required visits. Total program of care means all care the facility provides, including medical services, medication management, therapy, nursing care, nutritional interventions, social work and activity services. 42 CFR §483.40.
Attending physicians have a critical role in nursing home care. They authorize all aspects of residents' care and treatment.
Nursing homes are required to notify the resident's attending physician promptly of: (1) a sudden or marked adverse change in signs, symptoms or behavior; (2) an unusual occurrence involving the resident; (3) a change in weight of five pounds or more within a 30 day period; (4) an untoward response to a medication or treatment; (5) a life threatening medication or treatment error; or (6) a threat to the resident's health or safety caused by the facility's inability to timely obtain or administer prescribed drugs, equipment, supplies or services.
Nursing homes must have substitute doctors available to provide supervision and emergency medical care whenever residents' physicians are unavailable.
L.) Pressure Sores
People who lie or sit in one position for long periods are at risk of developing pressure sores, also known as bedsores or decubitus ulcers. They occur when pressure on the skin shuts off blood vessels, depriving skin tissue of oxygen and nutrients. If proper care is not given, large, deep sores can develop, sometimes exposing the muscle or bone below the skin. Untreated pressure sores can lead to infection, severe pain and death.
Almost all pressure sores are avoidable with proper care. Nursing homes must make sure that residents entering the facility do not develop pressure sores and that residents who have them are given treatment to promote healing and prevent infection. 42 CFR §483.25(c).
To prevent pressure sores, nursing homes must keep a resident's skin clean and dry, maintain good nutrition and hydration, and keep pressure off of vulnerable parts of the body. Pressure is relieved by changing the resident's position as often as necessary and using pressure relieving devices, such as pads and special mattresses.
A nursing home must notify the resident's physician immediately if he or she develops a pressure sore and must follow the doctor's treatment orders to clean and dress the wound. It is critical to relieve pressure from the wound and ensure that the resident receives proper nutrition and hydration. If the treatment is not effective, the nursing home must again notify the resident's physician.
M.) Preventing Accidents
Falls and accidents are a serious concern for nursing home residents. Approximately 50 percent of residents fall annually and 10 percent of these falls result in serious injury, especially hip fractures.
Nursing homes must examine risk factors that cause falls and accidents and take these steps to limit the risks:
- Keep the resident environment as free of accident hazards as possible;
- Give each resident adequate supervision to prevent accidents; and
- Use assistive devices that help improve resident safety.
If a resident has fallen or been injured, or is considered at risk, his or her care plan must individually address this concern and identify steps that will be taken to improve safety.
N.) Special Services
Nursing homes must ensure that residents receive proper treatment and care for the following special services: (1) Injections; (2) IV fluids; (3) colostomy, ureterostomy and ileostomy care; (4) tracheostomy care; (5) tracheal suctioning; (6) respiratory care; (7) foot care; and (8) prostheses. If residents need these services, federal law requires that they be provided, regardless of whether they are covered by Medicare or Medicaid. For services not covered, a nursing home is required to assist the resident in securing any available resources to obtain the needed services. 42 CFR §483.25(k).
O.) Therapies, Restorative Care and Range of Motion
Nursing home residents often need rehabilitative services to restore lost abilities caused by strokes, broken bones and other conditions. The nursing home must provide needed therapy services, no matter who is paying for the nursing home stay. 42 USC §1396r(c)(4)(A). Federal law requires that a resident receive the therapy needed to reach his or her highest practicable level of functioning. 42 USC §1395r(b)(4)(A)(i). The nursing home must provide or arrange needed therapy services such as physical therapy, occupational therapy, speech-language pathology and mental health rehabilitative services.
Formal therapy services require a doctor's order and an evaluation by a licensed therapist. Once the assessment for therapy services is completed, a care plan must be developed, followed and monitored by a licensed professional.
It is common, but illegal, for nursing homes to halt formal therapy services when a resident exhausts Medicare skilled nursing facility coverage.
Most therapy services do not last more than a few weeks or months. They stop when the doctor discontinues medical orders, therapy goals are met, treatment proves ineffective or the resident's needs can be met by the nursing staff.
Many nursing home residents need routine care to keep the ability to move their hands, arms, legs and feet. Without proper care, residents often lose some ability to move their joints (range of motion) or develop contractures - a freezing of the joint in a contracted position.
Nursing homes must ensure that residents do not lose range of motion unless it is unavoidable and must give appropriate treatment and services to residents who have limited range of motion. Preventive care may include exercise of the joints performed by the resident, by the staff, or by the resident with assistance from the staff. Range of motion exercises should never be used as a substitute for residents who need specialized therapies from licensed therapists. 42 CFR §483.25(e).
P.) Vision, Dental, and Hearing Care
A resident's care plan must comprehensively address his or her care needs, including needed dental, vision and hearing services.
Nursing homes must assist residents in obtaining routine and emergency dental care. 42 CFR §483.55. Routine care means an annual exam. An emergency involves an episode of pain or other dental problem that requires immediate attention.
Nursing homes can arrange services by hiring a dentist or by having an agreement with a dentist to treat residents. If a resident's dentures are lost or damaged, the nursing home is required to make a prompt referral to a dentist and to aggressively work at replacing the dentures.
Facilities must also arrange treatment that maintains residents' abilities to see and hear. If a resident needs hearing or vision care or assistive devices, the nursing home should make necessary appointments and arrange transportation if services are delivered away from the facility. Assistive devices means glasses, contact lenses, magnifying glasses and hearing aids.