F726
(Rev. 225; Issued: 08-08-24; Effective: 08-08-24; Implementation: 08-08-24)
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.71.
§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.
§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident’s needs.
§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents’ needs, as identified through resident assessments, and described in the plan of care.
INTENT §483.35(a)(3)-(4),(c)
To assure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents’ needs safely and in a manner that promotes each resident’s rights, physical, mental and psychosocial well-being.
DEFINITIONS §483.35
“Competency” is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully.
GUIDANCE §483.35(a)(3)-(4),(c)
Cite this Tag only if there are deficiencies related to the competency of nursing staff.
If the survey investigation reveals that there are concerns with the competency of staff in areas other than Nursing Services refer to;
• F741, §483.40(a) for any staff caring for residents with dementia or a history of trauma and/or post-traumatic stress disorder;
• F801, §483.60(a) for Food and Nutrition staff;
• F826, §483.65(b), Specialized rehabilitative services;
• F839, §483.70(e), Administration for any other staff not referenced above.
NOTE: The actual or potential physical, mental, or psychosocial resident outcomes related to noncompliance cited at F726, should be investigated at the relevant tags, such as Abuse, Quality of Life, and/or Quality of Care.
All nursing staff must also meet the specific competency requirements as part of their license and certification requirements defined under State law or regulations.
Many factors must be considered when determining whether or not facility staff have the specific competencies and skill sets necessary to care for residents’ needs, as identified through the facility assessment, resident-specific assessments, and described in their plan of care. A staff competency deficiency under this requirement may or may not be directly related to an adverse outcome to a resident’s care or services. It may also include the potential for physical and psychosocial harm.
As required under F838, §483.71, the facility’s assessment must address/include an evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population. Additionally, staff are expected to demonstrate competency with the activities listed in the training requirements per §483.95, such as preventing and reporting abuse, neglect, and exploitation, dementia management, and infection control. Also, nurse aides are expected to demonstrate competency with the activities and components that are required to be part of an approved nurse aide training and competency evaluation program, per §483.152.
Competency in skills and techniques necessary to care for residents’ needs includes but is not limited to competencies in areas such as;
• Resident Rights;
• Person centered care;
• Communication;
• Basic nursing skills;
• Basic restorative services;
• Skin and wound care;
• Medication management;
• Pain management;
• Infection control;
• Identification of changes in condition;
• Cultural competency.
Staff Competencies in Identifying Changes in Condition
A key component of competency is a nurse’s (CNA, LPN, RN) ability to identify and address a resident’s change in condition. Facility staff should be aware of each resident’s current health status and regular activity, and be able to promptly identify changes that may indicate a change in health status. Once identified, staff should demonstrate effective actions to address a change in condition, which may vary depending on the staff who is involved. For example, a CNA who identifies a change in condition may document the change on a short form and report it to the RN manager. Whereas an RN who is informed of a change in condition may conduct an in-depth assessment, and then call the attending practitioner.
These competencies are critical in order to identify potential issues early, so interventions can be applied to prevent a condition from worsening or becoming acute. Without these competencies, residents may experience a decline in health status, function, or need to be transferred to a hospital. Not all conditions, declines of health status, or hospitalizations are preventable. However, through the facility assessment (§483.71), facilities are required to address the staff competencies that are necessary to provide the level and types of care needed for the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. Furthermore, per §483.95, facilities must determine the amount and types of training based on the facility assessment. We also note that the curriculum of a nurse aide training program must include training on recognizing abnormal changes in body functioning and the importance of reporting such changes to a supervisor (§483.152(b)(2)(iv)).Therefore, facility staff are expected to know how to identify residents’ changes in conditions, and what to do once one is identified.
Facilities may adopt certain tools to aid staff with these competencies, as these tools have proven to be effective. For example, the Agency for Healthcare Research and Quality (AHRQ) has training modules for detecting and communicating resident changes in condition https://www.ahrq.gov/professionals/systems/long-term-care/resources/facilities/ptsafety/ltcmodule1.html. Also, Interventions to Reduce Acute Care Transfers (INTERACT) is a program with several resources aimed at improving staff competencies in this area https://interact2.net/tools_v4.html. Staff may inform surveyors of the tools they use to help show evidence of the required competencies. However, merely stating or referencing the tools is not enough on its own to verify compliance. Staff must also demonstrate that they possess the competency to use the tools in a manner that accomplishes their purpose, of aiding to effectively identify and address resident changes in condition.
Cultural Competencies
Cultural competencies help staff communicate effectively with residents and their families and help provide care that is appropriate to the culture and the individual. The term cultural competence (also known as cultural responsiveness, cultural awareness, and cultural sensitivity) refers to a person’s ability to interact effectively with persons of cultures different from his/her own. With regard to health care, cultural competence is a
set of behaviors and attitudes held by clinicians that allows them to communicate effectively with individuals of various cultural backgrounds and to plan for and provide care that is appropriate to the culture and to the individual.
The following resources are intended for informational purposes only:
• The National Center for Cultural Competency
https://nccc.georgetown.edu/index.html
• The National Standards for Culturally and Linguistically appropriate Services in Health and Health Care (developed by the Office of Minority Health in HHS) https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedCLASStandardsBlueprint.pdf
NOTE: References to non-CMS sources do not constitute or imply endorsement of these organizations or their programs by CMS or the U.S. Department of Health and Human Services and were current as of the date of this publication.
Demonstration of Competency
Competency may not be demonstrated simply by documenting that staff attended a training, listened to a lecture, or watched a video. A staff’s ability to use and integrate the knowledge and skills that were the subject of the training, lecture or video must be assessed and evaluated by staff already determined to be competent in these skill areas.
Examples for evaluating competencies may include but are not limited to:
• Lecture with return demonstration for physical activities;
• A pre- and post-test for documentation issues;
• Demonstrated ability to use tools, devices, or equipment that were the subject of training and used to care for residents;
• Reviewing adverse events that occurred as an indication of gaps in competency; or
• Demonstrated ability to perform activities that is in the scope of practice an individual is licensed or certified to perform.
Nursing leadership with input from the Medical Director should delineate the competencies required for all nursing staff to deliver, individualize, and provide safe care for the facility’s residents. There should also be a process to evaluate staff skill levels, and to develop individualized competency-based training, that ensure resident safety and quality of care and service being delivered. A competency-based program might include the following elements:
a. Evaluates current staff training programming to ensure nursing competencies (e.g. skills fairs, training topics, return demonstration).
b. Identifies gaps in education that is contributing to poor outcomes (e.g. potentially preventable re-hospitalization) and recommends educational programing to address these gaps.
c. Outlines what education is needed based on the resident population (e.g. geriatric assessment, mental health needs) with delineation of licensed nursing staff verses non-licensed nursing and other staff member of the facility.
d. Delineates what specific training is needed based on the facility assessment (e.g. ventilator, IV’s, trachs).
e. Details the tracking system or mechanism in place to ensure that the competency-based staffing model is assessing, planning, implementing, and evaluating effectiveness of training.
f. Ensures that competency-based training is not limited to online computer based but should also test for critical thinking skills as well as the ability to manage care in complex environments with multiple interruptions.
PROCEDURES AND PROBES §483.35(a)(3)-(4),(c)
For specific survey procedures see the Sufficient and Competent Staffing Critical Element Pathway.
Surveyors must determine through information obtained by observations, interviews and verified by record reviews, whether the facility employs competent nursing staff to provide care and services in assisting residents to attain or maintain their highest practicable level of physical, mental, functional and psychosocial well-being.
• How are staff competencies and skill sets evaluated upon their initial hire and routinely thereafter and when new technologies/equipment are put into use?
• Does the facility assessment describe the type of competencies required to meet each resident’s needs as required under §483.71. Do the competencies of the staff reflect the expectations described in the facility assessment?
• Is there evidence that staff are able to identify and address resident changes in condition? What are the practices or tools used that demonstrate this ability? Is there evidence of a lack of competency, such as:
o Adverse events that could have been prevented;
o Conditions that occurred that could have been identified and addressed earlier to prevent them from worsening; or
o Hospital transfers that could have been potentially avoided if the reason for the transfer had been identified and addressed earlier.
• How are staff evaluated to determine that they demonstrate knowledge of individual residents and how to support resident preferences?
• When observing the provision of care, does the nursing staff demonstrate:
o Necessary competencies and skill sets in accordance with current standards of practice? For example, if the resident requires a manual lift for transferring, do
staff demonstrate knowledge and skill in the proper use of the lift and perform the activity in a safe manner?
o The use of techniques and skills that maintain or improve the resident’s physical, mental or psychosocial functioning as identified through required assessments and the care plan such as, but not limited to, the following:
1. Providing mobility assistance, such as assistance with walking and transferring.
2. Assisting with Activities of Daily Living: eating, bathroom needs, bed mobility, bathing, oral care, incontinence care, dressing, etc.
3. Providing care to residents with communication needs and ensuring that devices are utilized per the care plan.
4. Demonstrating knowledge about residents’ condition and behavior and when to report changes to the licensed or registered nurse.
• Determine how agency/contract staff have been evaluated to ensure their competencies and skills to care for the facility’s resident population.
POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION §483.35(a)(3)-(4),(c)
If there are concerns with staff skills and competencies it may be necessary to review the facility’s assessment as required at F838, §483.71 to determine how competencies are evaluated. Also, review the facility’s process for assessing these competencies and skills and addressing staff performance for the effective application of knowledge and skill in the practice setting. It may also be necessary to review the Training requirements at §483.95.
KEY ELEMENTS OF NONCOMPLIANCE
To cite deficient practice at F726, the surveyor’s investigation will generally show that the facility failed to do the following:
• Ensure the licensed nurses and other nursing personnel have the knowledge, competencies and skill sets to provide care and respond to each resident’s individualized needs as identified in his/her assessment and care plan.
DEFICIENCY CATEGORIZATION
Once the survey team has completed its investigation, analyzed the data, reviewed the regulatory requirements, and determined that noncompliance exists, the team must determine the severity of each deficiency, based on the harm or potential for harm to the resident.
Examples of Level 4, immediate jeopardy to resident health and safety includes, but are not limited to:
• A resident sustained a serious injury that required hospitalization and surgery resulting from a fall from a mechanical lift due to an unsafe transfer by one staff member. When interviewed, this staff member stated that she was not familiar with how to use the mechanical lift. The facility failed to ensure the staff was competent to operate the equipment.
• Staff did not demonstrate competency in maintaining the airway of a resident with a tracheostomy when it became obstructed by a mucous plug. Staff were unable to act immediately to the situation resulting in the resident experiencing a respiratory arrest. Staff did not have the necessary skills to adequately meet the needs of the resident resulting in a life-threatening situation for the resident.
• A new resident was recently admitted to the nursing home with a diagnosis of diabetes. Upon interview several staff stated that they were not familiar with using this new blood sugar monitor. As a result the resident’s blood sugar levels were inaccurate and not reliable. The levels continued to fluctuate from very high to very low and in each case the amount of insulin administered to the resident was adjusted based on these results. As a result after 3 days the resident went into diabetic shock and was hospitalized.
• The facility failed to ensure that licensed nurses had the skills and knowledge to detect changes in a resident’s condition. After the nurse’s aide notified the nurse on duty that the resident has swelling in her feet, the nurse determined that the resident has 2+ pitting edema and documented the finding in the medical record. No further action was taken. The nurse did not review the medical record which identified the resident’s history of congestive heart failure (CHF). The next day the resident’s edema increased, the nurse notified the attending physician but did not inform the physician of the resident’s history of CHF. The nurse did not conduct any further assessment of the resident, secure orders from the physician, or document a request for intervention from the physician. On day three the resident experienced respiratory distress and was admitted to the hospital with CHF exacerbation. The inability of the nursing staff to conduct a thorough assessment and to recognize the signs and symptoms of CHF resulted in heart failure and placed the resident at risk for serious harm or death.
Examples of Level 3 actual harm that is not immediate jeopardy includes but are not limited to:
• An increase in facility acquired Stage 2 pressure injuries was noted over the past two months for residents with darker pigmentation. When interviewed, several nursing staff, including the Director of Nursing, stated that in residents with darker pigmentation, staff cannot identify pressure injuries until the skin is no longer intact. The facility failed to provide staff with the necessary skill set to identify and prevent pressure injuries and meet the residents’ needs.
• A resident who usually gets up at 6am and eats breakfast in the dining room every day has been getting up at 8am for the past few days. When interviewed he says he doesn’t want to eat breakfast and just wants to sleep. Staff have been letting him continue to sleep throughout the day. When interviewed they said they think he is just tired and this went on for several days. The resident then began to
decline to eat dinner and seems confused about his whereabouts. The nurse stated she thinks he is just tired and continues to let him sleep. In the morning, the resident is falling in and out of sleep, is incoherent and has a fever. The facility orders a hospital transfer where the resident is admitted with a high fever and a positive lab result for a Urinary Tract Infection.
• A 78 year old with a diagnosis of hypertension, Peripheral Vascular Disease, Diabetes and CVA (cerebrovascular accident) receives anticoagulant therapy. The resident developed a nose bleed. Since the resident is on anticoagulant therapy the MD was notified and an order for PT/INR was ordered and obtained. The INR was noted to be elevated requiring the resident to receive an injection of Vitamin K. When staff were interviewed CNA #1 stated that two days prior she had noted the resident’s gums were bleeding during oral care and thought that maybe he just needed his teeth cleaned but she did mention it to the nurse. CNA #2 reports that the resident had a medium black tarry stool the night before but she became busy and forgot to report it to the Charge Nurse. The facility failed to provide staff with the necessary skill set to identify residents at risk for bleeding related to anticoagulant therapy so therefore the facility staff did not meet the needs of the resident.
An example of Level 2 no actual harm with a potential for more than minimal harm that is not immediate jeopardy includes but is not limited to:
• Resident did not have pacemaker check performed via telephone due to lack of knowledge by staff on procedure.
Level 1 - Severity 1 does not apply for this regulatory requirement.