Or. Admin. R. 411-086-0110 - Nursing Services: Resident Care

(1) Nursing Services Generally. Nursing services staff shall provide and document nursing services for each resident. Nursing staff shall provide services to attain and maintain the highest practicable physical, mental and psychosocial well-being, independence, self-direction, and self-care of each resident, including:

(a) Good grooming and cleanliness of body, skin, nails, hair, eyes, ears, and face, including removal or shaving of hair in accordance with resident wishes, and prompt assistance with toileting needs and care for incontinence;

(b) Good body alignment and adequate exercise or range-of-motion, including, when practicable, ambulation;

(c) Adequate fluid and nutritional intake:

(A) Assistance or supervision with eating and drinking shall be provided as required;

(B) Fluids shall be offered at least three times a day (in addition to meal times) to residents who are unable to help themselves; and

(C) Weigh each resident on admission and quarterly thereafter or more often if resident's condition warrants it.

(d) Adequate sleep and rest;

(e) Oral hygiene;

(f) Bowel and bladder evacuation and continence;

(g) Optimal freedom from pain; and

(h) Resident ability to:

(A) Dress, bathe and groom;

(B) Transfer and ambulate;

(C) Appropriately interact with others; and

(D) Effective October 1, 1990, or in the event of delay of the federal requirement, effective the actual federal implementation date, self-medicate based on nursing and physician assessment and provision of instruction to the resident if necessary.

(2) Coordination of Services. The DNS and RN care manager shall coordinate the provision of nursing services for the resident with other disciplines and providers. The DNS and RN care manager shall ensure provision and documentation of resident care interventions prescribed by other health care professionals, including timely medications and treatments ordered by the resident's physician.

(3) Questionable Care. When any RN questions the efficacy, need or safety of medications or treatments, the RN shall report that question to the attending physician or nurse practitioner. The RN shall seek and document instructions received and all actions taken to ensure problem resolution.

(4) Standards of Practice. Nursing care staff shall provide nursing services in accordance with the Oregon Nurse Practice Act (ORS Chapter 678).

(5) Documentation. Licensed nursing staff shall evaluate and accurately document in the clinical record the effectiveness of services provided to the resident, including required preventive care, at least quarterly.

Notes

Or. Admin. R. 411-086-0110

SSD 19-1990, f. 8-29-90, cert. ef. 10-1-90

Stat. Auth.: ORS 410.070, 410.090 & 441.055

Stats. Implemented: ORS 441.055 & 441.615