Falls and other accidents are a serious concern for nursing home residents. Almost 50 percent of nursing home residents fall annually. Over 10 percent of these falls result in serious injury, especially hip fractures.

The law requires nursing homes to examine risk factors that cause falls and accidents and take these steps to limit the risks including:

• Keeping the resident’s environment as free of 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.

The law mandates that nursing homes provide residents with all necessary assistance for bathing, dressing, eating and other personal needs. Unless it is medically unavoidable, the nursing home must ensure that residents’ abilities to carry out activities of daily living do not decline. Activities of daily living include bathing, dressing, grooming, eating, walking, communicating, using the toilet, and transferring to or from a bed or chair.

Some examples of care mandated for nursing home residents includes:

• Provide care to maintain clean, dry skin;
• Change soiled linens, clothing and other items so that residents’ skin is free from urine and feces;
• Provide needed personal care services including bathing, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, and cleaning and cutting of fingernails and toenails;
• Ensure that residents are free of offensive odors;
• Answer call signals promptly;
• Ensure privacy during treatments and personal care.

Nearly all nursing home residents receive medicine to treat illness and maintain their health. Detailed federal and state rules instruct nursing homes and physicians on how to properly order, record, store, administer and monitor medications. Some other common medication issues include the following topics.

Consent: Residents and their legal representatives have the right to consent to or to refuse any treatment, including use of medications. Physicians must seek consent before ordering or changing medications.

Choice of Pharmacy: Residents have the right to choose their own pharmacy, subject to certain limitations.

Timely Availability: Nursing homes must have 24–hour arrangements with one or more pharmacies to ensure that residents receive ordered medications on a timely basis.

A drug, whether prescribed on a routine, emergency, or as needed basis, must be provided in a timely manner. This requirement is not met if the late administration of a prescribed drug causes the resident discomfort or endangers his or her health and safety. Doses shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber.

Unnecessary Drugs: Over–prescribing medications is a dangerous but 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.

Restricted Drugs: Federal regulations place special restrictions on the use of certain drugs. Sedatives, tranquilizers and similar drugs can only be used if the medical need is clearly documented. Federal guidelines discourage nursing homes from using a detailed list of drugs that have a high potential for severe adverse outcomes when used to treat older persons.

Residents cannot be given antipsychotic drugs unless they are necessary to treat a mental illness that has been diagnosed and documented in the resident’s clinical record. If antipsychotic drugs are used, the nursing home must try to discontinue them by using behavioral interventions and gradual dose reductions, unless clinically contraindicated.

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. 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.

The law requires that nursing homes must have an organized infection control program that prevents diseases and infections from developing and spreading. This means that 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.
• Report to local and state health official cases of communicable disease and outbreaks of infectious or parasitic diseases or infestation.

If a resident has difficulty eating, the facility must establish an individualized care plan to maintain the resident’s ability to eat food orally. There are specific therapeutic programs which can be used to help improve a resident’s ability to swallow or to help a confused resident maintain a fixed eating routine.

If despite the above efforts a resident loses a significant amount of weight, the law has specific requirements. 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. Federal guidelines urge nursing homes 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.

Generally nursing homes must provide each resident a nourishing, palatable, well–balanced diet that meets daily nutritional and special dietary needs. Specific legal requirements include requiring the nursing home:

• 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.

Far too 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. If a resident requires help drinking or reminders to drink more fluids, then the nursing home must provide such prompts. Watch for dehydration and infections as classic symptom of neglect by understaffed or under-motivated facilities.

The law disfavors the use of feeding tubes. They are to be used only 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. Lack of staff time is not a legally acceptable reason to utilize a feeding tube.

Only where there is the resident’s consent can a feeding tube be used and then only if there is a demonstrated medical need to prevent malnutrition or dehydration. Additionally, residents fed by tube must receive the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, and other adverse symptoms. And 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.

Urinary incontinence is the inability to control the bladder. It is one of the most common reasons people seek nursing home care. Over half of California nursing home residents are considered incontinent. Incontinence and lack of toileting assistance cause many serious problems, including discomfort, skin rashes, pressure sores, falls, isolation and psychological harm.

Incontinence is not considered a normal part of aging and is often reversible. Many times it is due to medications or temporary, treatable health conditions. The law requires each resident with bladder or bowel control problems must be promptly assessed and be provided treatments and care that can improve the condition.

In particular, catheters cannot be used simply for the convenience of the staff and thus, without medical justification. Catheters cause discomfort, limit mobility and increase the risk of infection, bladder stones and cancer. If a catheter is used, the nursing home must provide appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

A large percentage of nursing home residents need help with toileting. The most common examples include a resident with limited mobility who may need help to reach the toilet or a resident with dementia who may need reminders to use the toilet on a regular basis. Nursing homes must help these residents use the toilet whenever needed.

General Legal Requirements

By law skilled nursing homes are required to help each resident attain or maintain the highest practicable physical, mental and psychosocial well–being. Unless it is medically unavoidable, nursing homes must ensure that a resident’s condition does not decline. Care, treatment and therapies must be used to maintain and improve health to the extent possible, subject to the resident’s right to choose and refuse services.

Specific Accommodation of Resident Needs

Resident have the right to receive services in the facility with reasonable accommodations of individual needs and preferences. This means that the facility 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.

Staffing Requirements

The overriding legal requirement is that nursing homes must have sufficient nursing and other employees to meet the needs of each resident in the nursing home at all times. Additionally, California requires skilled nursing facilities to provide a minimum of 3.2 hours of nursing care per resident per day. If this staffing level is not adequate to meet resident needs, the nursing home must employ as many licensed nursing and certified nursing assistants as are needed. In a clearly visible place, a facility must post daily, for each shift, the current number of licensed and unlicensed nursing staff directly responsible for resident care.

Care Planning

Care Plans are the instruction manual for how to properly care for each resident. Nursing homes must establish a comprehensive, individualized care plan for each resident that spells out exactly what their care needs are and how the facility will be meet them. Do not hesitate to ask to see your loved one’s Care Plan and discuss with the facility administrator or director of nurses the care needs of your loved one and whether they are being met.