Nursing home regulations are designed to ensure that residents receive quality care while maintaining their dignity and independence. Two key regulations, F676 (Quality of Life) and F688 (Mobility), focus on monitoring a resident’s ability to perform Activities of Daily Living (ADLs) and implementing a restorative program when a decline in ADLs is identified.
Understanding F676 and F688
F676 Activities of Daily Living/Maintain Abilities requires that nursing facilities promote residents’ quality of life by supporting their physical, mental, and emotional well-being. This involves monitoring and supporting their ability to perform ADLs, such as bathing, dressing, eating, and walking. When a decline in ADLs is identified, it must be addressed immediately to prevent further deterioration.
F688 Increase/Prevent Decrease in ROM/Mobility emphasizes the importance of maintaining and improving residents’ mobility, ensuring that any decline is reversible if possible. Facilities must provide restorative nursing programs to help residents regain or maintain their ADL abilities, which enhances their independence and quality of life.
Identifying ADL Decline
Regular assessments are crucial in identifying early signs of ADL decline. Indicators such as difficulty with mobility, changes in personal hygiene habits, or increased dependence on staff should trigger prompt intervention. By recognizing these signs early, care teams can implement strategies to prevent further advancement of functional decline. Proactive communication helps ensure that a decline in ADLs is caught early, enabling care teams to act before the situation worsens. It also helps prevent unnecessary hospitalizations, reducing the risk of complications associated with mobility loss or other health issues.
Importance of Supportive Documentation
Supportive documentation in long-term care is essential for ensuring that residents receive the right care at the right time. Accurate documentation allows healthcare providers to monitor a resident’s condition and make necessary adjustments to care plans. Here’s why documentation is crucial:
- It ensures that all members of the care team are informed about a resident’s health status, treatments, and progress.
- Documentation must comply with professional standards and regulatory requirements, such as those outlined by F676 and F688.
- It is used by state surveyors, insurers, and administrators to evaluate the quality of care.
- Documentation serves as legal evidence that appropriate care was provided. Incomplete or inaccurate records can jeopardize legal rights and expose the facility to liability.
- Clear and concise documentation strengthens communication between nurses, other healthcare providers, patients, and their families.
In cases of medical negligence, plaintiffs’ lawyers may use a lack of proper documentation as evidence of substandard care. Therefore, maintaining thorough and accurate documentation is not only essential for care but also for protecting the legal rights of both patients and providers.
Without proper documentation of identifying, assessing, planning, implementation and evaluation addressing a resident’s decline in ADL’s, additional F tags could be cited including, but not limited to:
- F580 Notification of Changes: Facilities must promptly inform residents, consult with their physicians, and notify representatives when there is an accident-causing injury, a significant change in the resident’s health status, or the need to alter treatment plans. This ensures timely communication and coordinated care.
- F726 Nursing Services: Facilities must have adequate nursing staff with the necessary skills to ensure resident safety and well-being. Nurses must be competent in assessing, planning, and delivering care based on individual resident needs, including identifying changes in condition and providing restorative care.
- F842 Medical Records: Facilities must maintain complete, accurate, accessible, and organized medical records for each resident, adhering to professional standards to support effective care management and regulatory compliance.
Conclusion
By identifying declines in ADLs and implementing appropriate restorative programs, nursing homes can ensure that residents remain as independent as possible. Supportive documentation is key to identifying and addressing declines, tracking progress, maintaining compliance with regulations, and protecting facilities from legal risks. When done correctly, documentation enhances communication among the care team and ensures that residents receive consistent, high-quality care.
Please plan to join us for our upcoming webinar on October 15th ‘Documentation for ADL Care, Declines, & Restorative Nursing’ for more in depth documentation on this topic. Learn more at:
Documentation in Depth Webinar Series
Written by: Angie Hamer, RN, RAC-CT
Was this article helpful? Access weekly insights when you sign up for our weekly newsletter!