Or. Admin. Code § 411-054-0040 - Change of Condition and Monitoring
(1) CHANGE OF CONDITION. These rules define a
resident's change of condition as either short term or significant with the
following meanings:
(a) Short term change of
condition means a change in the resident's health or functioning that is
expected to resolve or be reversed with minimal intervention or is an
established, predictable, cyclical pattern associated with a previously
diagnosed condition.
(b)
Significant change of condition means a major deviation from the most recent
evaluation that may affect multiple areas of functioning or health that is not
expected to be short term and imposes significant risk to the
resident.
(c) If a resident
experiences a significant change of condition that is a major deviation in the
resident's health or functional abilities, the facility must evaluate the
resident, refer to the facility nurse, document the change, and update the
service plan and the ABST. The staffing plan should also be updated, as
needed.
(d) If a resident
experiences a short-term change of condition that is expected to resolve or
reverse with minimal intervention, the facility must determine and document
what action or intervention is needed for the resident.
(A) The determined action or intervention
must be communicated to staff on each shift.
(B) The documentation of staff instructions
or interventions must be resident specific and made part of the resident record
with weekly progress noted until the condition resolves.
(2) MONITORING. The facility must
have written policies to ensure a resident monitoring and reporting system is
implemented 24-hours a day. The policies must specify staff responsibilities
and identify criteria for notifying the administrator, registered nurse, or
healthcare provider. The facility must:
(a)
Monitor each resident consistent with his or her evaluated needs and service
plan;
(b) Train staff to identify
changes in the resident's physical, emotional and mental functioning and
document and report on the resident's changes of condition;
(c) Have a reporting protocol with access to
a designated staff person, 24-hours a day, seven days a week, who can determine
if a change in the resident's condition requires further action; and
(d) Provide written communication of a
resident's change of condition, and any required interventions, for direct care
staff on each shift.
Notes
Statutory/Other Authority: ORS 410.070 & 443.450
Statutes/Other Implemented: ORS 443.400 - 443.455 & 443.991
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