| (a) A nursing home's adoption and implementation of the best
practices for risk management and loss control set forth in this section should
focus on the following risk exposure areas, which are exposure areas that
appear often in claim lists and claim prevention materials published by leading
nursing home insurers, and any additional areas as may be determined to be
risk exposures. The list is not inclusive and the descriptions are illustrative
only, but a nursing home focusing initially in these areas may be more likely
to succeed with its program.
(1) Falls--Slips and trips by a resident in or about a nursing
home.
(2) Resident Abuse--Infliction of injury or mistreatment with
resulting physical harm or pain or mental anguish.
(3) Pressure Ulcers--A clinical risk, also referred to as bedsores
or decubitus ulcers, that is a result of unrelieved pressure on a part of
the body.
(4) Nutrition and Hydration--Providing adequate and nutritious
food and liquid to nursing home residents, including attention to individual
needs or clinical condition.
(5) Medication Management--Prevention of drug-related problems
including but not limited to over- or under-prescribing; improper drug selection;
and over-dosage.
(6) Restraints (if used)--Physical restraints such as manual
methods or physical devices that restrict freedom of movement or access to
a resident's body. Chemical restraints can be described as psychotropic or
behavior modifying drugs used to prevent a resident from exhibiting behavioral
symptoms.
(7) Infection Control--Preventing, containing, and treating
infections within a nursing home facility.
(8) Burns and Scalds--Injury due to exposure to heat, sun,
or chemicals.
(9) Elopement--To slip away or run away from a facility. For
risk management purposes this includes wandering or movement away from the
usual or normal place within the nursing home facility.
(b) The Commissioner of Insurance establishes the following
best practices for risk management and loss control that may be used by for-profit
and not-for-profit nursing homes. Risk management and loss control in this
section mean the examination, assessment, and evaluation of risks and an advice
process for the reduction of risks. The following elements are essential to
a loss control program.
(1) Personnel Responsible for Program Operation. The nursing
home should create an organizational structure that delegates authority to
specific personnel for the day-to-day operation of a loss control program
and which functions to ensure the program is established and implemented correctly.
The nursing home can show it has met this element by:
(A) Appointing a program lead or leads to be responsible for
the administration of the program in one or more exposure areas as identified
in subsection (a) of this section. The designated program lead(s) should report
to the administrator or the administrator's designee, such as the risk manager.
The program lead(s) should have the authority to recommend and take immediate
action upon observing a potential hazard, and this authority should be recognized
in the program lead's job description. A program lead(s) should have available
assistants and responsible parties to assist during off-hour periods.
(B) Appointing a Risk Management/Loss Control Committee.
(C) Appointing training instructors for new employees and in-service
training.
(2) Loss Prevention/Mitigation. The nursing home should make
a proactive effort to identify hazards and prevent losses before they occur.
This element can be demonstrated by:
(A) Establishing and implementing policies and procedures to
mitigate losses.
(i) Conducting ongoing analysis of actual and potential hazards
in each individual exposure area. Policies and procedures should be created
that will prevent situations that could give rise to an adverse event, which
is defined as an occurrence that has the potential to produce a claim, including
a minor event or situation with accident causing potential.
(ii) Conducting ongoing assessment to identify residents that
may be susceptible to events occurring in each exposure area.
(iii) Establishing facility maintenance and inspection procedures
that allow for preventive maintenance and inspections to be conducted on a
regularly scheduled basis, such as daily, weekly, or otherwise.
(B) Establishing and implementing policies and procedures for
responding to an adverse event.
(i) Establishing policies and procedures that allow for the
family and/or guardian to be informed as soon as possible in the event of
injury.
(ii) Including documentation in the resident's or other appropriate
record by noting interventions, injury, and prevention measures, and filing
an adverse event report with the program lead(s).
(C) Establishing and implementing policies and procedures for
conducting an investigation of an adverse event. The investigator will document
the event and recommend prevention efforts for the resident and report the
recommendation(s) to the Risk Management/Loss Control Committee and any other
committee responsible for quality assurance and assessment.
(D) Establishing and implementing policies and procedures for
training.
(i) Establishing a policy to orient new residents and families
to the facility and to each exposure area prevention program.
(ii) Establishing a training program for new hires and conducting
periodic in-service training to refresh and supply new information gathered
through the risk management/loss control tracking and trending process.
(3) Documentation. The nursing home should maintain documentation
of its risk management and loss control program, which documentation should
include but not be limited to the following:
(A) The Risk Management/Loss Control Committee should record
minutes of meetings and document any actions recommended or taken by the committee
or a program lead(s).
(B) Inspection/safety reports should be sent to the respective
program lead(s) and the facility manager.
(C) All individual and in-service training should be documented.
(D) Individual resident or other appropriate records, such
as a resident care plan, should be documented.
(E) Adverse events should be recorded as well as a follow-up
in risk management program records.
(4) Monitor Results. The nursing home should monitor the results
of the risk management and loss control program to evaluate the effectiveness
and overall performance of the program. Monitoring allows identification of
problem areas that are not producing desired results and can be demonstrated
by:
(A) Tracking adverse events and near adverse events.
(B) Documenting the adverse events and near adverse events
through the event response and investigation reports.
(C) Employing tracking methods through charting frequency,
location of events by facility area, and by category of event.
(D) Using the tracking process to identify trends in problem
areas for correction.
(5) Modify and Improve the Risk Management/Loss Control Program
Based on Results. The nursing home should timely modify and improve the program
based on monitoring to achieve loss control objectives of the program. This
element can be demonstrated by:
(A) Developing and implementing procedures for reporting risk
management and loss control improvement suggestions to the Risk Management/Loss
Control Committee and any other committee responsible for quality assurance
and assessment.
(B) Developing and implementing policies and procedures for
examining the event tracking and correction process for improvements in accuracy
and utility.
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