Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 1
Subtitle 07 - HOSPITALS
Chapter 10.07.14 - Assisted Living Programs
Section 10.07.14.27 - Resident Record or Log
Universal Citation: MD Code Reg 10.07.14.27
Current through Register Vol. 51, No. 19, September 20, 2024
A. The assisted living manager shall ensure that an individual record or log is maintained at the facility for each resident in a manner that ensures security and confidentiality, and which includes at a minimum:
(1) The documentation required by Regulations
.21 and .26 of this chapter;
(2)
Medical orders;
(3) Rehabilitation
plans, if appropriate;
(4) The
service plan;
(5) Care notes as
indicated in §D of this regulation; and
(6) The emergency data sheet as described in
Regulation .33D of this chapter.
B. Readmission of a Resident.
(1) A resident shall be reassessed by the
delegating nurse within 48 hours of readmission to the program if the following
occurs:
(a) Hospitalizations or a 15 day or
greater stay in any skilled facility; or
(b) There is a significant change in the
resident's mental or physical status upon return to the program after an
absence from the program.
(2) When the delegating nurse determines in
the nurse's clinical judgment that the resident does not require a full
assessment within 48 hours, the delegating nurse shall:
(a) Document the determination and the
reasons for the determination in the resident's record; and
(b) Ensure that a full assessment of the
resident is conducted within 7 calendar days.
C. The assisted living manager shall develop policies and procedures to ensure that all information relating to a resident's condition or preferences, including any significant change as defined in Regulation .02B of this chapter, is documented in the resident's record and communicated in a timely manner to:
(1) The
resident;
(2) The resident's health
care representative, if appropriate; and
(3) All appropriate health care professionals
and staff who are involved in the development and implementation of the
resident's service plan.
D. Resident Care Notes.
(1) Appropriate staff shall write care notes
for each resident:
(a) On admission and at
least weekly;
(b) With any
significant changes in the resident's condition, including when incidents occur
and any follow-up action is taken;
(c) When the resident is transferred from the
facility to another skilled facility;
(d) On return from medical appointments and
when seen in home by any health care provider;
(e) On return from nonroutine leaves of
absence; and
(f) When the resident
is discharged permanently from the facility, including the location and manner
of discharge.
(2) Staff
shall write care notes that are individualized, legible, chronological, and
signed by the writer.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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