Or. Admin. Code § 411-050-0750 - Records - Resident
(1) An
individual resident record must be developed, kept current, and readily
accessible on the premises of the home for each individual admitted to the AFH.
The record must be legible and kept in an organized manner so as to be utilized
by staff.
(2) The record must
contain the following information:
(a) A
complete initial screening assessment and general information form (SDS 902) as
described in OAR 411-051-0110.
(b) Documentation on form (SDS 913) that the
licensee or administrator has informed private-pay residents of the
availability of a long-term care assessment.
(c) Documentation on form (SDS 0342A) that
the licensee or administrator has oriented the resident to emergency evacuation
procedures as described in OAR
411-050-0725(1).
(d) Documentation that the licensee or
administrator has informed all residents of the right to formulate an Advance
Directive.
(e) FINANCIAL
INFORMATION:
(A) Detailed records and
receipts, if the licensee manages or handles a resident 's money. The Resident
Account Record (form SDS 713) or other expenditure forms may be used if the
licensee manages or handles a resident 's money. The record must show amounts
and sources of funds received and issued to, or on behalf of, the resident and
be initialed by the person making the entry. Receipts must document all
deposits and purchases of $5 or more made on behalf of a resident .
(B) Residency Agreement signed and dated by
the resident or the resident 's representative may be kept in a separate file,
but must be made available for inspection by the LLA.
(f) Medical and legal information, including,
but not limited to:
(A) Medical history, if
available.
(B) Current prescribing
practitioner orders.
(C) Nursing
instructions, delegations, and assessments, as applicable.
(D) Completed medication administration
records retained for at least the last six months or from the date of
admission, whichever is less. (Older records may be stored
separately).
(E) Copies of
Guardianship, Conservatorship, Advance Directive for Health Care, Power of
Attorney, and Physician's Order for Life Sustaining Treatment (POLST)
documents, as applicable.
(g) A complete, accurate, and current care
plan.
(h) Documentation that
supports or eliminates any individually-based limitation, as described in OAR
411-051-0115.
(i) A copy of the current house policies, as
identified in the current Residency Agreement , the current Resident 's Bill of
Rights, LGBTQIA2S+ Protections, and a copy of the home 's nondiscrimination
policy, signed and dated by the resident or the resident 's
representative.
(j) SIGNIFICANT
EVENTS AND INCIDENTS. A written report (using form SDS 344 or its equivalent)
of all significant incidents relating to the health or safety of the resident ,
including how and when the incident occurred, who was involved, what action was
taken by the licensee and staff, as applicable, and the outcome to the
resident . A copy of the report must be sent to the resident 's representative,
and case manager , if applicable.
(k) NARRATIVE OF RESIDENT 'S PROGRESS.
Narrative entries describing each resident 's progress must be documented at
least weekly and maintained in each resident 's individual record. All entries
must be signed and dated by the person writing them.
(l) Non-confidential information or
correspondence pertaining to the care needs of the resident .
(m) Falsifying records or causing another to
do so shall result in issuance of a mandatory civil penalty as described in OAR
411-052-0025(2).
Notes
Statutory/Other Authority: ORS 409.050, 410.070, 413.085, 441.122, 443.001, 443.004, 443.725, 443.730, 443.735, 443.738, 443.742, 443.760, 443.767, 443.775, 443.790 & 443.880
Statutes/Other Implemented: ORS 197.660 - 197.670, 409.050, 410.070, 413.085, 441.112, 441.114, 441.373, 443.001 - 443.004, 443.705 - 443.825, 443.875 & 443.991
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