SECTION 5.1741. Best Practices for Risk Management and Loss Control

(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.

Source Note: The provisions of this §5.1741 adopted to be effective December 24, 2001, 26 TexReg 10600