Section 380.620  Health/Nursing Services

a)         The licensee shall ensure sufficient nursing services to meet the needs of all consumers being served by the facility.  Licensed nursing staff shall perform nursing services within the scope of their licenses, and the nursing services shall be consistent with the care requirements for each respective level of service, including time frames, as described in Subpart B. Services shall include, but not be limited to, the following:

1)         Nursing participation in the formulation of an interdisciplinary treatment plan, which shall include identification of nursing care needs based upon an initial written nursing evaluation of the consumer's needs with input, as necessary, from health professionals involved in the care of the consumer.  The initial nursing care needs, including the physical evaluation required in Section 380.610(b)(1), shall commence at the time of admission of the consumer and be completed within seven days after admission;

2)         The implementation of each consumer's treatment plan according to the methods indicated, with ongoing monitoring and documentation of the effectiveness of the plan, and participation in consumer treatment plan conferences for review and modification of each consumer's treatment plans;

3)         Ensuring that the dietary department receives dietary orders that are prescribed by physicians or dieticians;

4)         Obtaining and documenting physician orders for medical care, appointments and laboratory workups and tests, administration of medications, including pro re nata (PRN) and immediately authorized or emergency (STAT) medications;

5)         Implementation and evaluation of quality improvement policies and procedures;

6)         The writing, review and signoff of progress notes and notes regarding any change in a consumer's condition; and

7)         Notifying the physician promptly of:

A)        The admission of a consumer;

B)        Any sudden, marked or adverse change in signs, symptoms or behavior exhibited by a consumer;

C)        An unusual incident involving a consumer, as specified in Section 380.530;

D)        Any adverse response or reaction by a consumer to a medication or treatment;

E)        Any error in the administration of a medication or treatment to a consumer that is life threatening or that presents a risk to a consumer; and

F)         The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed.

b)         All attempts to notify physicians shall be noted in the consumer's record, including the time and method of communication and the name of the person acknowledging contact, if any.  If the physician is not readily available, emergency medical care shall be arranged immediately.

c)         If a facility orders transportation of a consumer of the facility by ambulance, then the facility must maintain a written record that shows the name of the person who placed the order for that transportation and the medical reason for that transportation.  (Section 3-212 of the Act)

d)         Under the supervision of licensed nursing staff, an RSA shall monitor the following:

1)         Assisting consumers with dressing, grooming, bathing and personal hygiene related activities, as needed; and

2)         Measuring and recording a consumer's height, weight and vital signs, including temperature, blood pressure and pulse, on admission. At a minimum, vital signs and weight shall be taken weekly for four weeks and then monthly. Weights and vital signs shall be charted in a format that allows for trending and patterning over time.  Any clinically significant worsening shall be reported to the physician to assess the need for increased monitoring.