Resident assessments; tuberculosis testing – Ohio Admin. Code 3701-17-10

Each nursing home must require a written initial and periodic assessment of all residents.  Prior to admission of a resident, a nursing home must obtain the current medical history and physical of the prospective resident, including the discharge diagnosis, admission orders for immediate care, the physical and mental functional status of the prospective resident, and sufficient additional information to assure that the care needs of and preparation for the prospective resident can be met.  Each nursing home must conduct a written initial comprehensive assessment of each resident, which will include documentation of the following:

• Medical diagnoses;
• Psychological, and mental retardation and developmental diagnoses and history, if applicable;
• Health history and physical, including cognitive functioning, and sensory and physical impairments;
• Psycho-social history and the preferences of the resident;
• Prescription and over-the-counter medications;
• Nutritional requirements and need for assistance and supervision of meals;
• Height and weight;
• A functional assessment evaluating the resident’s ability to perform activities of daily living;
• Vision, dental and hearing function; and
• Any other alternative remedies and treatments the resident is taking or receiving.

The nursing home must reassess each resident every three months, or whenever there is a change in the resident’s physical or mental health or cognitive abilities.  This periodic reassessment will include documentation of the following:

• Changes in medical diagnoses;
• Updated nutritional requirements and needs for assistance and supervision of meals;
• Height and weight;
• Prescription and over-the-counter medications;
• A functional assessment;
• Any changes in the resident’s psycho-social status or preferences; and
• Any changes in cognitive, communicative or hearing abilities or mood and behavior patterns.