Current through Register Vol. 50, No. 9, September 20, 2024
A. The facility
shall provide an organized nursing service with a sufficient number of licensed
and unlicensed qualified nursing personnel to meet the total nursing needs of
all residents in accordance with the resident care policies of the facility on
a 24 hour basis.
1. The facility shall
provide:
a. policies that are designed to
ensure that each resident:
i. receives
treatments, medications, diets as prescribed, rehabilitative nursing care as
needed;
ii. receives care to
prevent pressure sores and deformities;
iii. is kept comfortable, clean, and
well-groomed;
iv. is protected from
accident, injury, and infection; and
v. is encouraged, assisted, and trained in
self-care and group activities.
b. Assurance that all nursing personnel are
assigned duties consistent with their education and experience and based on the
characteristics of the resident load; and
c. Weekly time schedules which indicate the
number and classification of nursing personnel, including relief personnel who
worked in each unit for each tour of duty.
B. Director of Nursing Services. all nursing
facilities shall have a director of nursing (DON) who is a qualified registered
nurse employed full-time and regularly assigned to the day shift.
1. The director of nursing must have, in
writing, administrative authority, responsibility and accountability for the
functions, activities, and training of the nursing services staff.
2. The director of nursing may serve only one
facility in the capacity of director of nursing.
3. If a change occurs in the individual who
is the director of nursing, notice shall be provided by the facility
administrator (or governing body in absence of administrator) to BHSF/HSS at
the time the change occurs. Notice shall include the identity of all
individuals involved and the specific changes which have occurred. Failure to
provide written notice by certified mail within 30 calendar days from the date
a change occurs, will result in a Class C civil money penalty. (Refer to
Subchapter L Sanctions.)
4. The
Bureau shall allow long term care facilities 30 days from the date of change in
the position of director of nursing to fill a resulting vacancy. In the
interim, an RN must be assigned the responsibility of the DON position. Waiver
of the 30 day time limit may be granted by the Bureau if:
a. The facility demonstrates to the
satisfaction of the bureau that the facility has been unable, despite diligent
efforts (including offering wages at the community prevailing rate for nursing
facilities) to recruit a director of nursing.
b. The Bureau determines that a waiver of the
director of nursing will not endanger the health and safety of individuals
staying in the facility.
5. Failure to fill a vacancy or to notify the
Bureau in writing that the director of nursing position (where no waiver has
been granted) has been filled by the thirty-first day of vacancy (or expiration
of any waiver granted) shall result in a class C civil money penalty. (Refer to
Sanctions.)
6. The bureau shall
retain the right to apply any other applicable remedies.
C. Assistant Director of Nursing. If the
director of nursing has administrative responsibilities or the nursing facility
has a licensed bed capacity of 101 or more, the facility shall have a full-time
assistant director of nursing (ADON).
D. RN Coverage. A nursing facility shall use
the services of an RN for at least 8 consecutive hours a day, seven days a
week. When seven-day RN coverage cannot be provided, the facility must notify
Health Standards Section following guidelines outlined for the separation of
the director of nursing.
E. Waiver.
If a facility is unable to obtain the seven-day RN coverage the facility may
request a waiver. To obtain a waiver for the seven-day RN coverage, the
facility shall submit a written request to the regional office which includes:
1. proof that diligent efforts have been made
to recruit appropriate personnel. Newspaper invoices with the ad attached shall
be submitted and the hourly salary offered and any other benefits
offered;
2. names and phone numbers
of RN's interviewed for the job.
a. Upon
receipt of this information, the regional office will review the level of care
of the residents in the facility and make a determination that approval of the
waiver would/would not endanger the health or safety of the residents staying
in the facility. The regional office will make a recommendation to the state
office to approve/deny the waiver.
b. The facility will be notified, in writing,
as to the approval/denial of the waiver by state office. Although a facility is
granted a waiver, the facility shall continue to recruit for an RN on a
continuous basis to fill the position.
c. A waiver approval will expire after one
year or upon the next standard survey.
d. The nursing facility that is granted such
a waiver by the state notifies residents of the facility (or where appropriate,
the guardians or legal representatives of such residents) and members of their
immediate families of the waiver.
e. When a waiver for seven-day RN coverage
has been granted, the facility cannot train nursing assistants.
F. Waiver in a Skilled
Nursing Facility or Dually Certified SNF/NF. The secretary of DHHS may waive
the requirement that a SNF provide the services of a registered nurse for more
than 40 hours a week, including a director of nursing if the secretary finds
that the facility:
1. is located in a rural
area and the supply of SNF services in the area is not sufficient to meet the
needs of individuals residing in the area;
2. has one full-time registered nurse who is
regularly on duty at the facility 40 hours a week; and
3. has only residents whose physicians have
indicated through written orders that they do not require the services of a
registered nurse or physician for a 48 hour period, or has made arrangements
for a registered nurse or physician to spend time at the facility to provide
necessary skilled nursing services on days when the regular full-time
registered nurse is not on duty.
a. To apply
for a waiver of registered nurse coverage in a skilled nursing facility, the
provider should send a written request to: Health Care Financing
Administration, Regional Office VI, 1200 Main Tower Building, Dallas, Texas
75202, attn: Mr. Mitchell Chunn.
b.
Facilities providing the following levels of care may not request a waiver for
seven-day RN coverage:
i. skilled -
NRTP;
ii. skilled - ID;
or
iii. skilled - TDC.
G. Charge
Nurse. A registered nurse, or a qualified licensed practical (vocational) nurse
shall be designated as charge nurse by the DON for each tour of duty and is
responsible for supervision of the total nursing activities in the facility
during each tour of duty.
1. A director of
nursing may not serve as charge nurse in a facility with an average daily total
occupancy of 60 or more residents.
2. The charge nurse delegates responsibility
to nursing personnel for the direct nursing care of specific residents during
each tour of duty on the basis of staff qualifications, size/physical layout of
the facility, characteristics of resident load, and emotional, social, and
nursing care needs of the residents.
H. Certified Nursing Assistants (CNA). A
nursing facility shall not use any individual who is not a certified nursing
assistant in the facility on or after October 1, 1990 for more than four months
unless the individual has completed a training and competency evaluation
program or competency evaluation program approved by the state agency. For
additional information, refer to the Chapter on nurse aide training.
I. Clerical Staff. Effective September, 1991
all facilities shall employ two full-time clerical employees.
J. Other Nursing Services. Nursing services
shall be provided to the resident to ensure that the needs of the resident are
met. These services include the following:
1.
Drug Administration. Medications shall be administered only by a licensed
physician, licensed/applicant nurse, or the resident (with the approval of the
ID team as documented in the comprehensive care plan.)
2. The facility should be cognizant of the
mental status of the resident's roommate(s) or other potential problems which
could result in abuses with drugs used for self-administration.
3. Medications shall be administered in
accordance with the facility's established written procedures and the written
policies of the pharmaceutical services committee to ensure the following
criteria are met:
a. Drugs to be administered
are checked against physician's orders.
b. The resident is identified before
administering the drug.
c. All
medications/treatments are administered and properly charted in accordance with
nursing practice standards. The reason for each medication omission shall be
recorded in the resident's active medical record.
i. The drug dosage shall be prepared,
administered, and recorded by the same person.
ii. Medications prescribed for one resident
shall not be administered to any other person.
iii. Medication errors and adverse drug
reactions shall be immediately reported to the attending physician and recorded
in the medical record.
iv. Current
medication reference texts or sources shall be kept in all
facilities.
4. Automatic Stop Orders. Medications not
specifically limited as to time or number of doses when ordered shall be
controlled by automatic stop orders or other methods in accordance with written
policies. The attending physician must be notified of an automatic stop order
prior to the last dose so that (s)he may decide if the administration of the
drug or biological is to be continued or altered.
5. Self Administration. Self administration
of medication is allowed only in accordance with orders of resident's attending
physician, in conjunction with the ID team, when documented in the
comprehensive care plan.
6. Drug
Orders. Medications shall be ordered by the attending physician verbally or in
writing.
a. Verbal medication orders shall
be:
i. given only to a licensed/applicant
nurse, pharmacist, physician's assistant, nurse practitioner, clinical nurse
specialist or another physician;
ii. immediately recorded, fully dated, and
signed by the individual receiving the order;
iii. fully dated and signed by the physician
within seven days; and
iv. Category
II controlled substances must be confirmed in writing within 72 hours and may
be given only in an emergency (controlled substance as of 1970).
7. Standing orders, if
used, shall be placed in each resident's record and shall be signed by the
resident's attending physician and fully dated. These orders shall be reviewed,
signed, and fully dated at least annually.
8. Activities of Daily Living (ADL). Based on
the comprehensive assessment of a resident, the facility shall ensure that:
a. a resident's abilities in activities of
daily living (ADLs) do not diminish unless circumstances of the individual's
clinical condition demonstrate that diminution was unavoidable;
b. activities of daily living (ADLs) include
the ability to do the following:
i. bathe,
dress and groom;
ii. transfer and
ambulate;
iii. toilet;
iv. eat; and
v. to use speech, language or other
functional communication system.
c. A resident who is unable to carry out
activities of daily living shall receive the necessary services to maintain
good nutrition, grooming and personal/oral hygiene.
d. A resident is to be given the appropriate
treatment and services to maintain or improve his/her functional status and
abilities to perform their ADLs.
9. Vision and Hearing. The residents shall
receive proper treatment and assistive devices to maintain vision and hearing
abilities. The facility shall assist the resident in making appointments and
arranging for transportation to and from appointments and in locating
assistance from community and charitable organizations when payment is not
available through Medicaid, Medicare, or private insurance.
10. Pressure Sores. A resident who enters a
facility without pressure sores does not develop pressure sores unless the
individual's clinical condition demonstrates that they are unavoidable. A
resident having pressure sores shall receive necessary treatment and services
to promote healing, prevent infection, and prevent sores from developing unless
the individual's clinical condition demonstrates that they were
unavoidable.
11. Urinary
Incontinence. A resident who enters the facility without an indwelling catheter
is not catheterized unless the resident's clinical condition demonstrates that
catheterization was necessary. A resident who is incontinent of bladder
receives appropriate treatment and services to prevent urinary tract infections
and to restore as much normal bladder function as possible and prevent skin
breakdown.
12. Restorative Nursing
Care. Nursing services shall be provided in accordance with the needs of the
residents and restorative nursing care is provided to each resident to achieve
and maintain the highest possible degree of function, self-care, and
independence. Restorative nursing care services must be performed daily for
those residents who require such service.
13. Range of Motion. A resident who enters
the facility with full range of motion (ROM) should not experience reduction in
ROM unless the resident's clinical condition demonstrates that a reduction in
range of motion is unavoidable. A resident with limited ROM must receive
appropriate treatment and services to increase/maintain or prevent further
decrease in range of motion.
14.
Psychological Functioning. A resident who displays psychosocial adjustment
difficulty shall receive appropriate treatment and services to achieve as much
remotivation and reorientation as possible. A resident whose assessment did not
reveal a psychosocial adjustment difficulty should not display a pattern of
decreased social interaction and/or increased withdrawn, angry, or depressive
behavior unless the resident's clinical condition demonstrates that such a
pattern was unavoidable.
15.
Naso-Gastric-Gastrostomy Tubes. A resident who has been able to eat an adequate
diet with assistance should not be fed by naso-gastric (NG) tube unless the
resident's clinical condition demonstrates that the use of NG tube was
unavoidable.
a. A resident who is fed by NG
or gastrostomy tubes shall receive the appropriate treatment and services to
prevent:
i. aspiration pneumonia;
ii. diarrhea and vomiting;
iii. dehydration and metabolic
abnormalities;
iv. nasal pharyngeal
ulcers.
b. Feedings
shall be provided to restore normal feeding function if possible.
16. Accidents. The resident's
environment shall remain as free of accident hazards as possible. Each resident
shall receive adequate supervision and assistive devices to prevent
accidents.
17. Nutrition. Each
resident shall be maintained within acceptable parameters of nutritional states
such as body weight and protein levels unless the resident's clinical condition
demonstrates that this is not possible. In instances where a nutritional
problem has been identified, the resident shall be assessed for the need of a
therapeutic diet. A therapeutic diet must be prescribed by the attending
physician.
18. Hydration. Each
resident must receive sufficient fluid intake to maintain proper hydration and
health.
19. Special Needs.
Residents must receive proper treatment and care for the following:
a. injections;
b. parenteral and enteral fluids;
c. colostomy, ureterostomy, or ileostomy
care;
d. tracheostomy
care;
e. tracheal
suctioning;
f. respiratory
care;
g. podiatric care;
and
h. prosthesis.
NOTE: Resident's rights and/or advance directives may
supersede the above standards.
K. Release of a Body by a Registered Nurse.
In the absence of a physician in a setting other than an acute care facility,
when an anticipated death has apparently occurred, registered nurses may have
the decedent removed to the designated funeral home in accordance with the
standing order of a medical director/consultant setting forth basic written
criteria for a reasonable determination of death. This is not applicable in
cases where the death was unexpected.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
46:153.
