Course Content
Module 1 — Medication Administration / MAR / TAR Documentation
Frequency: Upon hire and annually
0/1
Medication Administration / MAR / TAR Documentation
Module 2 — Change of Condition / SBAR / Physician Notification
Frequency: Annual
0/1
Change of Condition / SBAR / Physician Notification
Module 3 — Skilled Documentation for Medicare Residents
Frequency: Annual
0/1
Skilled Documentation for Medicare Residents
Module 4 — Wound Assessment and Pressure Injury Prevention
Frequency: Annual
0/1
Wound Assessment and Pressure Injury Prevention
Module 5 — Fall Assessment and Neuro Checks After Fall
Frequency: Annual
0/1
Fall Assessment and Neuro Checks After Fall
Module 6 — Pain Assessment and Pain Management
Frequency: Annual
0/1
Pain Assessment and Pain Management
Module 7 — Anticoagulants, Insulin, Opioids, and High-Risk Medications
Frequency: Annual
0/1
Anticoagulants, Insulin, Opioids, and High-Risk Medications
Module 8 — Controlled Substance Handling and Reconciliation
Frequency: Annual
0/1
Controlled Substance Handling and Reconciliation
Module 9 — Psychotropic Medications and Gradual Dose Reduction
Frequency: Annual
0/1
Psychotropic Medications and Gradual Dose Reduction
Module 10 — Infection Surveillance and Antibiotic Stewardship
Frequency: Annual
0/1
Infection Surveillance and Antibiotic Stewardship
Module 11 — UTI Criteria, Respiratory Infection, and Sepsis Recognition
Frequency: Annual
0/1
UTI Criteria, Respiratory Infection, and Sepsis Recognition
Module 12 — Tube Feeding / G-Tube Care
Frequency: Competency on hire and annually
0/1
Tube Feeding / G-Tube Care
Module 13 — Oxygen Safety and Respiratory Care
Frequency: Annual
0/1
Oxygen Safety and Respiratory Care
Module 14 — IV Therapy / PICC / Midline Care
Frequency: Competency before assignment
0/1
IV Therapy / PICC / Midline Care
Module 15 — TPN Training
Frequency: Competency before assignment if facility accepts TPN residents
0/1
TPN Training
Module 16 — Dialysis Resident Care
Frequency: Competency before assignment if accepting hemodialysis residents
0/1
Dialysis Resident Care
Module 17 — Hospice, Palliative Care, and Comfort Medications
Frequency: Annual
0/1
Hospice, Palliative Care, and Comfort Medications
Module 18 — Advance Directives, DNR, POLST, and Code Status
Frequency: Annual
0/1
Advance Directives, DNR, POLST, and Code Status
Module 19 — Incident Investigation and Root-Cause Documentation
Frequency: Annual
0/1
Incident Investigation and Root-Cause Documentation
Private: Nurse RN/LPN Training

Incident documentation must be objective, timely, complete, and focused on resident safety. The purpose is to identify what happened, assess resident outcome, prevent recurrence, and support QAPI.

Required Elements

  • Date/time/location of incident.
  • Witnessed or unwitnessed.
  • Resident statement, if available.
  • Objective assessment.
  • Injury description.
  • Vital signs and pain.
  • Notifications.
  • Immediate interventions.
  • Contributing factors.
  • Follow-up monitoring.
  • Care plan update.
  • Root cause and prevention plan.

Root-Cause Questions

  • What was the resident doing immediately before the incident?
  • What staff were present?
  • Were care plan interventions in place?
  • Was equipment used correctly?
  • Were medications, infection, weakness, behavior, toileting, environment, footwear, lighting, or supervision contributing factors?
  • What intervention will reduce recurrence?

CMS staff training guidance also ties staff education to QAPI goals, communication of concerns, and updating training when facility QAPI goals or standards change.

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