Every Georgia nursing home is required to conduct a comprehensive assessment of each resident, including evaluations on physical ability, pertinent diagnosis, and cognitive capacity. These assessments are then used to build care plans that act as the blueprint of care. On this week’s episode, we discuss five important things you need to know about nursing home assessments.
Schenk: Hi there. Welcome back to the podcast. My name is Rob, I’m going to be your host. Today, we’re going to be talking about nursing home assessments, essentially one of the critical, critical actions the nursing home takes in the care and treatment of a resident.
Before we get into it though, would love it if you could like an subscribe to this podcast wherever you get your podcast from, maybe even watch it on our YouTube channel, Nursing Home Abuse Podcast on YouTube. If you are wanting a particular subject covered by us, then let us know. Shoot us an email or hit us up on social media, leave a comment on YouTube, let us know what you want to hear about and we will cover that topic.
Today the topic is the nursing home assessment. The nursing home assessment is one of the critical components of case. Typically we boil down care to assessment, care plan and then monitoring the effectiveness of the care plan. That’s kind of the trifecta of the perfect storm of keeping residents safe. So the nursing home assessment is the first step in that three-step process.
So as we mentioned time and time again on this podcast, both federal regulation and state regulation guide what nursing homes are required to do. In this instance, we are going to be referring to the federal regulations. The federal regulations require that nursing homes assess every resident head to toe, and those regulations are found in 42-CFR-483.20 – that’s for the law nerds out there. That is where you can go and read along with me as we talk about what the requirements are for nursing home assessments, the five things you need to know.
The first thing is when are nursing home assessments required. So looking at the federal regulations, nursing home assessments are required at various intervals. So when we’re talking about assessments, we are either going to be talking about comprehensive assessments, which is like the head-to-toe, bumper-to-bumper, five-point inspection, okay? Then there are lesser assessments, what we call quarterly assessments. What we’re talking about right now is the comprehensive assessment.
So a comprehensive assessment is required within 14 calendar days of admission to that nursing home. So the resident should be assessed within 14 calendar days after admission into that nursing home. An assessment is also required within, a comprehensive assessment is required within 14 days of what’s called a significant change in condition. A significant change in condition is a term of art and it means if the resident has changed their baseline, so if they have lost cognitive capacity in some way, if they’ve developed a pressure ulcer, if they’ve fallen with an injury, things that are not within the ordinary clinical condition of that resident.
If that’s changed, the nursing home from the date of that significant change condition has 14 days to conduct a new assessment, and the reason why is we need to assess what’s going on with the resident’s condition, and based on that, they’ll have to redo the care plan possibly or put in new interventions to address whatever that change in condition is.
And then finally the comprehensive assessment needs to be done at least annually, at least annually. So you have an admission assessment, an assessment if there’s been a significant change in condition and then the annual assessment. So even if there’s been no change in condition, even though it’s been a long time since they’re admitted, it needs to be done at least annually.
And then as I mentioned, there are lesser assessments. There are many lesser assessments, discharge assessments and quarterly assessments, but these are not as all-inclusive as the normal comprehensive assessments, so we’ll get into that in another episode, but just know the comprehensive assessment is required to be done within 14 days of admission, whenever there’s a significant change in condition and at least annually thereafter.
So what about what is covered in a nursing home assessment? So again, the federal regulations guide us on this. I always say it’s head-to-toe, but let’s get a little bit more into it than that. So the nursing home assessment needs to cover the following topics, although this is the minimum threshold, but it has to have at least these. It has to identify the resident’s demographic information, name, background. There’s a slot in there for occupation, career – obviously they’re not working, well not obviously but oftentimes they’re not working now but whatever they feel their occupation was when they were working – customary routine, cognitive patterns, their communication abilities, vision, mood and behavior patterns, psychosocial wellbeing, physical functioning of structural problems, continence, disease diagnosis and health conditions, dental and nutritional status, skin condition, activity pursuit, medications, special treatments and procedures and planning for discharge. That’s the minimum that needs to be addressed in the assessment.
So by way of example, the nursing home should over the course of seven days, 14 days, whatever the look-back period may be, will figure out what are this resident’s mood and behavior patterns, for example? Are they rejecting care. If they are rejecting care, what care are they rejecting and how often is that happening? Or a skin condition – they look and do an assessment of the skin. “Everything looks fine here,” but based on their weight, their age, their medications, their diagnosis, they might be at risk for a degradation in skin integrity. So all those categories, there’s an assessment, an evaluation, a viewing, an observation period and then an assessment of the different risks or different characteristics that are specific to this resident.
So who is required to conduct nursing home assessments? According to the federal regulations, a registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. A registered nurse must also sign and certify that the assessment is complete.
So that’s really important. The interdisciplinary team at a nursing home, which typically consists of the physician, the registered nurse, dietitian and then CNAs that have direct care responsibilities for the resident are the ones who should be really developing the care plan and conducting the assessment. But at minimum, a registered nurse needs to supervise the assessments or conduct the assessments. And at the end of the day, the registered nurse signs off on the assessment. So it’s possible that you might have a CNA or an LPN doing an assessment, but it’s appropriate for the registered nurse to be supervising that assessment if it’s not being done by a registered nurse because at the end of the day, the registered nurse has to sign off on it.
We find oftentimes that the RN only signs the assessment. They’re not conducting it. They’re not supervising it. And that’s a problem because a registered nurse has certain training, certain experience levels and know-how that an LPN or a CNA do not have. A CNA is typically trained to observe, report and help with activities of daily living, whereas a nurse can assess wounds and is more aware based on training of what’s going on with a particular resident. So you want registered nurse supervising, coordinating or conducting the assessments, and unfortunately as I mentioned, that is not always the case, and because of that, typically the assessment suffers. The assessment misses things that it should not miss.
So how are assessments conducted? Assessments are conducted as I mentioned, they’re conducted through observations, through review of medical records, through interviews with the family. This is why we always preach that families should be involved in the assessment and care plan process because there’s going to be categories, for example, customary routine, communication, cognitive patterns, that they need family input for that. If the resident is new to the facility, like if this is the admission assessment, then you’re going to have at most 14 days of observation, and in that 14 days of observation, you don’t have eyeballs on that resident 24 hours a day. So the nursing home may miss certain things. That’s why the family can fill in those gaps. “Oh, Ms. Johnson typically eats her snack right before bed and she likes protein bars,” or whatever the case may be that allows the nursing home to fill in the gaps they miss in their observation period.
So again, reviewing the records helps the assessment. Typically the nursing home will get medical records possibly from the acute care facility if they’ve come in from a hospital, or maybe if there’s a primary care physician in that resident’s history, they’ll get those records. So medical records are in part used for the assessment but mostly it is literally putting eyeballs on the resident and doing a head-to-toe assessment physically in the nursing home. That’s where a lot of this information comes from, doing those eyeball, hands-on looks at the resident over the course of whatever the look-back period is, whether it’s seven days, 14 days, whatever the case may be. That’s how it’s done.
But again, like I said, it’s super helpful for the nursing home to have as much information as possible, so bring old medical records in, talk to the staff, that type of thing. That’s going to help make the assessment better and if the assessment is better, the care plan is better.
What are nursing home assessments used for? I just alluded to that and I talked about it at the top of the episode. Nursing home assessments are used to create care plans, so you have a comprehensive assessment, and then that comprehensive assessment is crunched into a care plan. The care plan itself is essentially the blueprint of care. It provides the specific interventions to address any problems with that resident. It provides objectives and goals, and you don’t know what someone’s objectives could be or what their goals could be or what the interventions should be if you haven’t done an assessment. So that’s what essentially the assessment is used for, is the end result is to get a treatment plan for this resident.
And people change and so that’s why it’s important that an assessment be done at least annually if not more than that based on if there’s a significant change in condition because the change in the person will most often require a change in how you care for that person, therefore the care plan must change. So essentially that’s what the nursing home assessment is for.
Nursing essentially is that three-step process – assessment, creation of a care plan and monitoring a care plan and revising the care plan where necessary. So the assessment is an extremely critical component to that.
This is going to be a short episode, five things that you need to know about nursing home assessments. The takeaway here though, folks, is that be involved in that process. “Hey, when is the next annual assessment?” or “When are you doing the admission assessment?” Be a part of that and be a part of the care planning activities.
So I believe that’s going to be it. New episodes twice a month on Mondays. If you’re enjoying the content, please be sure to like and subscribe wherever you get your podcasts from. If you have any suggestions on content, let us know. Reach out to us and we will try to address that in a future episode. And with that folks, we’ll see you next time.