be sufficient and identify the resident clearly, describe the resident’s condi- tion fully and justify treatment and the results of said treatment. 42 CFR § 483.25—Each resident shall
receive, and the facility shall provide, care and services to enable the resident to attain or maintain the highest practi- cable physical, mental and psychosocial well being, in accordance with the indi- vidual’s assessments and care plan. 42 CFR § 483.15—Each resident shall
be treated with dignity. 42 CFR § 483.75—Facility staff shall
be knowledgeable in caring for the aged, frail and disabled. Staff shall be properly trained in accident prevention. 42 CFR § 482.13(c)—Each resident
shall be free of abuse and neglect. 42 CFR § 483.13(c)(1)(i)—The facil-
ity must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of resi- dents and misappropriation of resident property. In Maryland, The Office of Health
Care Quality has included the following items for the annual surveyor’s inspec- tion of a nursing home regarding falls:
Falls/Injuries of Unknown Origin/Ac- cidents/Falls • Facility has a fall reduction program that includes the following: o Resident assessment for risk o Environmental assessments o Risk reduction strategies o In-service education o Resident/Family education pro- gram
o Development of transfer proto- cols
o Staff education of transfer proto- cols
o Environmental redesign o Restraint assessment/reduction
• Facility conducts comprehensive investigation for injury
• Facility has mechanism to review falls
• Facility has policy to refer falls to PT
• Facility has osteoporosis education program
Summer 2007
11 12
• Facility has osteoporosis screening program
• Facility has osteoporosis treatment program
• Facility has criteria for monitoring accidents and injuries
• Facility does not have high preva- lence of falls
• Facility has method for environ- mental assessment to deter time and place for accidents and injuries
• Facility has established time frame for referral to QA Committee for accidents and injuries
• Facility has plan for f/u for accidents and injuries9
Assisted Living Facilities (ALFs)
are not federally regulated. Each state has the authority to adopt regulations regarding the licensing and care in the facilities. Maryland has adopted regulations;10
a minimum, contain the preadmission assessment, medication orders, reha- bilitation plan, service plan, care notes and emergency data.13
Numerous other
services are required of ALFs including mobility, transfer, ambulation and as- sistance with other ADLs.14
incident or accident occurs, reporting is required under the Maryland statute.15 An “incident” includes a fall requiring medical treatment.16 Since by definition ALFs are lower
level care institutions and encourage independence of their residents, espe- cially with mobility, cases are often more difficult to litigate. However, many of the risk, assessment, planning and in- tervention issues are the same as nursing homes.17
Larger ALFs have developed however the forms for
risk assessments are not the same as the MDS, RAP, etc. in the nursing home context. Instead, the State of Maryland requires a Preadmission Assessment.11 This assessment requires a compre- hensive determination of the resident’s health problems, medical history, and other factors in determining the level of function in activities of daily living (ADL) and care required. Based on the Preadmission Assessment, a Service Plan for each resident “shall be developed in a manner that enhances the principles of dignity, privacy, resident choice, resident capabilities, individuality, and indepen- dence without compromising the health or reasonable safety of other residents.”12 The Service Plan must be done within 30 days of admission and then reviewed and updated every 6 months. A Resident Record or Log must be maintained for each ALF resident. This record must, at
9
State of Maryland, DHMH, OHCQ- Tech- nical Assistance Unit, 2006 Annual QA Survey
10
Code of Maryland Regulations (CO- MAR)10.07.14.00 et seq. and Annotated Code of Maryland, Health General Article, Title 19, Subtitle 18. COMAR 10.07.14.09 COMAR 10.07.14.18
Trial Reporter
13 14 15 16 17
their own screening tools. Unfortunately, there is usually less skilled nursing care at ALFs, so often residents’ conditions and required levels of care change and poor planning occurs to prevent falls. In Maryland there are three levels of care in ALFs- Level One being the most independent and Level Three the most dependent on staff in assistance with ADLs. Often a resident should really be in a nursing facility instead of an ALF, because the ALF staff could not meet a resident needs. A review of the complete resident
chart is vital to determining the merits of a case. In addition to the MDS, RAP and Care Plans, careful attention to the other documentation should be made. Often a health care worker notes a problem, but no one does any follow-up. Common documents include: • Records from health providers prior to admission
• Physician Orders • Fall Risk Assessment Worksheets • Medication records and flow sheets
• Physical Therapy notes
COMAR 10.07.14.19 COMAR 10.07.14.20 COMAR 10.07.14.22
COMAR 10.07.14.02 (B)(27)d
Rein Tideiksaar, Managing Falls in Assisted Living. 2006
27 When an
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