Federal regulations require a comprehensive assessment on admission, annually, and upon significant change in condition, using the Resident Assessment Instrument. It covers cognition, mobility, continence, nutrition, skin, mood, and care needs.
The assessment drives the care plan and identifies triggered care areas.
Alternative Names:
Resident Assessment, Full Assessment
Why it Matters?
The assessment is what establishes what the facility knew about a resident's risks, which makes it the anchor of every liability analysis. Care area triggers generated by the assessment identify risks requiring care planning, and a triggered area with no corresponding plan intervention is a documented gap. The significant change requirement is separately important, since deterioration without a reassessment is itself a deviation.
Frequently Confused with
Related terms
Frequently asked questions
When is a comprehensive assessment required?
What are care area triggers?
