Connecticut Nursing Home Laws
"The burning candle of life is such a precious light in anyone's existence that no one has the right to extinguish it before it flickers out into perpetual darkness and oblivion". Valdez v. Lyman-Roberts Hosp., Inc., 638 S.W. 2d 111, 116 (Tex. Ct. App., 1982).
I. The Structure of a Nursing Home:
A nursing home is a facility licensed by the Connecticut Department of Public Health/ Commission on Hospitals and Health Care for patients who have "uncontrolled and/or unstable and/or chronic conditions requiring continuous skilled nursing services and/or nursing supervision or have chronic conditions requiring substantial assistance with personal care on a daily basis." This is different from a rest home which is for patients that have "controlled and/or stable chronic conditions which require minimal skilled nursing services, nursing supervision, or assistance with personal care on a daily basis." Connecticut Regulations 19-13-D8t(d)(1)(A). The license will specify, among other things, the patient capacity for each level of care, the services provided and the names of the Administrator, the Medical Director and the Director of Nurses. Connecticut Regulations 19-13-D8t(b)(2)-(3).
Each facility must have a "governing body" which shall have the responsibility of adopting written facility by-laws; providing sufficient staff to comply with state and federal statutes and regulations; adopting written policies to assure the protection of patient rights; and the appointment of a qualified administrator, among other responsibilities. Connecticut Regulations 19-13-D8t(e)(2).
The Administrator must be licensed as such by the Department of Public Health and is responsible for the enforcement of State and federal regulations; submission of reports for "reportable events" as defined in Connecticut Regulations 19-13-D8t(g); employing qualified staff in sufficient numbers to meet patient needs; developing a coordinated program of orientation, training and education for staff to improve patient care; protecting patients' personal rights; maintaining a patient roster and annual census; and appointing a Medical Director and a Director of Nurses, among other responsibilities. Connecticut Regulations 19-13-D8t(f).
The Medical Director must be a physician licensed in Connecticut with at least one(1) year of clinical practice in adult medicine(a specialty in gerontology is not required although it is the opinion of this writer that it should be). The Medical Director has the responsibility to enforce the facility's by-laws regarding medical care; assure that quality medical care is provided to patients; approve or disapprove of a patient admission based on the facility's ability to provide adequate care for that patient; assure that each patient has an assigned personal physician; and visit the facility at least once every 7 days if a nursing home, or once every 30 days if a rest home. A record must be kept of these visits which includes the names of patients who have been audited. Connecticut Regulations 19-13-D8t(h).
Each facility must have an "organized medical staff" which at a nursing home(as opposed to a rest home) must include at least three(3) physicians. The Medical Director approves or denies applications to be on the medical staff. The medical staff meets at least quarterly to discuss patient care topics and minutes must be kept of these meetings. The organized medical staff must adopt written by-laws governing medical care of the facility's patients. Connecticut Regulations 19-13-D8t(i).
The Director of Nurses for a nursing home(as opposed to a rest home) must be a licensed nurse with one(1) year of rehabilitative or geriatric nursing and one(1) year of nursing administration and a full-time employee. The Director of Nurses is responsible for developing and maintaining written nursing standards of practice for the facility; recommending to the administrator the number and levels of nurses and nurse aides to be employed; the selection of nurses and nurse aids; designation of a nurse in charge for each unit for all shifts("nurse supervisor"); and developing a schedule of daily rounds and assignment of duties, among other responsibilities. Connecticut Regulations 19-13-D8t(j).
All designated nurse supervisors must be registered nurses and are responsible for notifying the patient's personal physician of any significant changes in the patient's medical condition or the need for immediate care; and if the patient's personal physician does not respond promptly, then to notify the Medical Director. Connecticut Regulations 19-13-D8t(k).
All nurse aides employed by either a nursing or rest home must have completed a Nursing Aide Training Program and a Competency Evaluation Program approved by the Department of Public Health. Upon completion the nurse aide is registered on a registry maintained by the department which will contain a listing of any complaints of patient neglect or abuse which may arise in the course of the nurse aide's employment.
II. Staffing: A Critical Link:
Both the federal and Connecticut regulations provide that each facility shall employ sufficient nurses and nurse aides to provide appropriate care for patients all day, every day. 42 CFR 483.30; Connecticut Regulation 19-13-D8t(m)(1). The federal regulation does not specify a mandatory minimum number of nurses or nurse aide hours per patient but the Connecticut regulation does. Connecticut Regulation 19-13-D8t(m)(5). The regulation sets forth the minimum paid productive hours(these are hours actually worked by the employee during which patient care is provided as opposed to vacation time, sick time or other paid non-productive time) for both nurses and nurse aides at both nursing homes and rest homes and for both the day and night shifts. Further the Connecticut regulations provide that a nursing home shall have one licensed nurse on each patient floor at all times; while the federal regulations provide that a registered nurse must be used for 8 consecutive hours each day of the week. Connecticut Regulation 19-13-D8t(m)(4)(A); 42 CFR 483.30(b)(1). It is important to remember that the Connecticut regulation although setting forth a mandatory minimum number of paid productive nursing and nursing aide hours per patient, specifically states that this is not the actual required number; rather the actual number of paid productive hours required is a function of the patients needs and the number of hours necessary to provide "appropriate care". The federal regulation is more strongly worded and states that "the facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessments and individual plans of care".
It has been suggested by gerontological research that 2.9 hours of nurse aid time per patient per day is an average adequate amount of care time to complete five basic core needs such as toileting, repositioning and assistance with eating; and that 4.55 hours of total nursing time(registered nurse, licensed practical nurse and nurse aide) per patient per day is on average adequate for good care.
III. Statutes, Regulations and Standards:
The applicable body of law consists mostly of the Connecticut Regulation 19-13-D8t(a)-(v) entitled Chronic and Convalescent Nursing Homes and Rest Homes with Nursing Supervision which is part of The Public Health Code; C.G.S. 19a-550 entitled the Patient's Bill of Rights; 42 CFR 483.1-483.75 entitled Requirements for Long Term Care Facilities as promulgated by Health Care Financing Administration, Department of Health and Human Services; and various sections of the Social Security Act, 42 U.S.C 1302, 1395i-3(a)-(f), 1395x(j) and (l), 1395z, 1395hh, 1396a(a)(28), 1396d(a),(c), and (d) and 1396r(a)-(f)(Nursing Home Reform Act).
There are various sources of standards which are not statutory or regulatory. For instance, doctors which specialize in care of the elderly are known as gerontologists. The American Board of Internal Medicine certifies physicians with an Added Qualification in Geriatric Medicine if they meet certain competency requirements. A gerontologist should be consulted as to appropriate standards of care for medical treatment of nursing home patients. Nurses which specialize in the care of the elderly are certified in geriatric care by the American Nurses Association( ANA). The ANA publishes a booklet entitled "Scope and Standards of Gerontological Nursing Practice" which is helpful in understanding geriatric nursing standards of care.
In addition many nursing homes are accredited by the Joint Commission on the Accreditation of Healthcare Organizations(JCAHO) because private insurance companies typically require this for payment eligibility. JCAHO has a Long Term Care Survey Manual which sets forth criteria for accreditation which can be evidence of appropriate standards of care which a nursing home has agreed to comply with as a condition for accreditation.
There are also guidelines published by the federal Department of Health and Human Services and the Agency for Health Care Quality and Research on various common problem areas in nursing homes such as decubitus ulcers, dehydration, malnutrition and fall risks which can be helpful in understanding prevailing standards of care.
It is important that the Connecticut Department of Public Health and the Nursing Home Ombudsman Office(See C.G.S. 17b-400,et seq. and Connecticut Regulations 17-136d-1,et seq.) of the Connecticut Commission on Aging be notified of negligent and reckless conduct of a nursing home. This will lead to appropriate investigation and regulatory citations and further discourage ongoing misconduct. It will establish an official record of the misconduct which is accessible to others when investigating a nursing home for their loved ones. See C.G.S. 19a-536.
Upon admission the RAI will document the status of any pressure sores which the patient already had, and quarterly assessments previously mentioned will likewise document the continuing status of the sores. Importantly, most facilities maintain more frequent reports which document the status of pressure sores called Decubitus Ulcer Reports or some similar name and also photograph these sores, typically by Polaroid, and append the photos to the weekly reports. These photographs should be requested and can often provide compelling evidence of neglect.