Vocabulary
Define Assisted Living
type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility
What must an Admission Order contain?
A physician must personally approve in writing a recommendation that an individual be admitted to a facility, proper authentication is required for all physician signatures
Who needs to conduct or coordinate each assessment?
Registered nurse with other health professionals
Each person signing off on what they completed of the assessment
What is the first section of the CRA?
Identification Info
Physician's order must include what 4 things?
Frequency and duration
scope of treatment
Date
Signature
Example of Activities of Daily Living
Toilet hygiene, eating, walking, bathing/showering, getting dressed, getting up or out of bed/chair, etc
Physician Visit Documentation includes
orders for the resident's immediate care and needs by a physician, physician assistant, nurse practitioner, or clinical nurse specialist
MDS assessments are required for?
All residents in nursing home certified to participate in Medicare or Medicaid
T or F
Bladder, bowel, swallowing/nutritional, and restraints are all part of the CRA
True
What does MAR stand for?
Medication Administration Records
What are Resident Assessment Protocols (RAPs)
problem-orientated frameworks for additional assessments based on triggered conditions. (trigger extra assessments for people who have conditions in which an additional assessment would be needed)
What can be included in the History and Physical?
Diagnoses
Medications
Allergies
Prognosis
Limitations
Communications status
level of pain
etc
What is included in the MDS?
What is Functional Status?
the need for assistance with ADLs, altered gait and balance, and decreased range of motion
When must initial nursing assessments be completed?
No later than 14 days after admission
Define Nursing Facility
provides skilled nursing care and related services for residents who require medical or nursing care of injured, disabled, or sick persons on a regular basis because of their mental or physical condition require care and services
What is included in Physician Order?
Medications (pharmacy orders)
Treatment such as dressing changes
Services such as therapies
Ancillary test such as blood draws, cultures, or diet orders
What is the CAA process designed to do?
Help the assessor interpret information on the MDS and helps the clinician focus on key issues identified during the assessment so that decisions can be explored with the resident
TRUE OR FALSE
Only one person needs to sign off on an assessment
FALSE
Each person needs to sign off on the part of the assessment they completed
What is the IMPACT Act of 2014?
requires SNF to complete clinical assessments that standardize uniform data across the industry
Define Skilled Nursing Facility
provides skilled nursing care to residents who require care for rehabilitation of injured, disables, or sick persons and is NOT primarily for the care and treatment of mental disease and has a transfer agreement in effect
What is a discharge summary and what is included?
Summary of the residents stay and a finale review of the resident's status at the time of discharge
Details of the patient stay that would assist the next care provider to continue treatments that are needed by the resident
What are the 3 basic components of the RAI?
MDS
CAA
RAI Utilization
How many sections are in the CRA?
27
Accidents/Incidents must be reported via what report?
Accident of incident report
this report records facts of the events that could be needed in the future