RESIDENT EVALUATION:

  1.             A resident evaluation shall be completed by an appropriate staff member within fifteen (15) days prior to admission to determine the level of assistance that is needed and if the level of services required by the resident can be met by the facility.
  2.             The initial resident evaluation shall establish a baseline in the resident’s functional status and thereafter assist with identifying resident changes.  The resident evaluation shall be reviewed and updated at a minimum of every six (6) months or when there is a significant change in the resident’s health status.
  3.             The resident’s evaluation shall be documented on a resident evaluation form and at a minimum include the following abilities, behaviors or status:

                                (1)           activities of daily living;

                                (2)           cognitive abilities; reasoning and perception; the ability to articulate thoughts, memory function or impairment, etc.;

                                (3)           communication and hearing; ability to communicate needs and understand instructions, etc.;

                                (4)           vision;

                                (5)           physical functioning and skeletal problems;

                                (6)           incontinence of bowel/bladder;

                                (7)           psychosocial well-being;

                                (8)           mood and behavior;

                                (9)           activity interests;

                                (10)         diagnoses;

                                (11)         health conditions;

                                (12)         nutritional status;

                                (13)         oral or dental status;

                                (14)         skin conditions;

                                (15)         medication use and level of assistance needed with medications;

                                (16)         special treatments and procedures or special medical needs such as hospice; and

                                (17)         safety needs/high risk behaviors; history of falls agitation, wandering, fire safety issues, etc.

  1.             The resident evaluation shall include a history and physical examination and an evaluation report by a physician or a physician extender within six (6) months of admission.  A resident shall have a medical evaluation by a physician or a physician extender at least annually.
  2.             The resident evaluation shall be reviewed and if needed revised by a licensed practical nurse, registered nurse or physician extender at the time the individual service plan is reviewed, at a minimum of every six (6) months or when a significant change in health status occurs.

[ NMAC – Rp, NMAC, 1/15/2010]