510 NURSING
511 PROFESSIONAL NURSE SUPERVISION
511.1 A licensed registered nurse shall
be employed full-time as the Director of Nursing Services
and normally work on the day shift. In skilled nursing
facilities registered nurse relief shall be provided for the
off days of the Director of Nursing Services. If the
Director of Nursing Services has other institutional
responsibilities in addition to written job description, a licensed registered
nurse shall serve as assistant so that there is the
equivalent of a full-time Director of Nursing Services on
duty.
511.2 In Intermediate Care Facilities
the registered nurse must work forty (40) hours per week,
normally on the day shift. An LPN may serve as relief on the
Director of Nursing Services' days off.
511.3 The Director of Nursing Services
shall be responsible for the development and maintenance of
nursing service objectives, standards of nursing practice,
nursing policy and procedures manuals, written job
descriptions for each level of nursing personnel, scheduling
of daily rounds to see all patients, methods for
coordination of nursing service with other patient services,
for recommending the number and levels of nursing personnel
to be employed to meet the needs of the patients, nursing
staff development, and supervision of nursing documentation.
511.4 The Director of Nursing Services
can serve as Director of Nursing Services in only one
facility.
512 CHARGE NURSE
512.1 In Skilled nursing Facilities,
the Director of Nursing Services shall designate as charge
nurse for each shift a registered nurse, a licensed
practical nurse, or a licensed psychiatric technician nurse.
Responsibilities of the charge nurse shall include
supervision of the total nursing activities in the facility
during his/her assigned tour of duty.
512.2 In Intermediate Care Facilities,
the Director of Nursing Services shall designate as charge
nurse for each shift a registered nurse, a licensed
practical nurse, or a licensed psychiatric technician nurse.
In facilities admitting or retaining patients requiring
medications or treatments on the night shift, the charge
nurse designated on the night shift must be a licensed
nurse.
512.3 The charge nurse's duties shall
include as a minimum:
Responsibility for observation of
work performance of aides in delivery of direct care.
Administration of medication if there
is no assigned medication nurse.
Ordering medications from the
pharmacy.
All direct observations of patients
to observe and evaluate physical and emotional status.
Delegate responsibility for the
direct care of specific patients to the nursing staff based
on the need of the patients.
Taking phone orders from physicians
or dentists.
Giving shift report to the next
shift.
Shift count of control drugs.
Dietary observations.
512.4 The Director of Nursing Services
shall not serve as charge nurse in a Skilled Nursing
Facility with an average daily total occupancy of
seventy-one (71) or more patients. Waivered Licensed
Practical Nurses shall not serve as charge nurse unless they
have passed the State Pool Examination or Public Health
Proficiency Examination.
513 NURSING STAFF
513.1 All registered nurses, licensed
practical nurses, and licensed psychiatric technicians employed in the nursing
home shall be currently licensed in the State of Arkansas.
513.2 The licensed nursing staff
required shall be computed in accordance with Section 520.
513.3 The nursing aide requirement
shall be computed in accordance with Section 520.
513.4 In nursing homes with more than
one classification of license, each distinct part shall be
staffed according to the requirements for each
classification.
514 PERSONNEL ASSIGNMENTS
514.1 The nursing staff shall be
engaged in the direct care and treatment of the patients.
514.2 No aide shall be permitted to
combine the duties of housekeeping, laundry, or kitchen
duties with nursing because of the danger of cross infection
to the patient.
514.3 In multi-story homes, each floor
should be staffed as an individual unit.
516 NURSING CARE REQUIREMENTS
516.1 Charting
a. Summary charting should address the
resident's problems/needs, interventions to resolve those
needs, and the progress made toward achieving the resident
goals as listed on the care plan.
b. All disciplines (nursing, dietary,
therapies, social, etc.) may document their progress notes on the same chart to
promote continuity of care.
c. All charting notations made on the
nurses progress notes or flow sheets shall be entered by
time and date, and shall be signed or initialed. d. Minimum
requirements for summary charting based on the resident's
Level of Care are as follows:
Skilled Every two (2) weeks
Intermediate I Every two (2) weeks
Intermediate II Monthly
Intermediate III Monthly
e. The following observations must be
charted upon occurrence*:
* If a flow sheet is utilized for
documentation of the following, it is only necessary to
document a summarization on the nurse's progress notes based
on the time frequencies in item (d) above.
1. Accidents/Incidents (charting will
be done every shift for at least 48 hours or until the resident returns to
pre-accident status or stable condition, which ever is longer);
2. Significant changes in the residents
physical, mental, or psychosocial status (i.e., a
deterioration in health, mental, or psychosocial status in
either life-threatening conditions or clinical
complications). Charting will be required on every shift
until the resident's condition becomes stable; 3. Any need
to alter treatment significantly (i.e., a need to
discontinue an existing form of treatment. due to adverse
consequences, or to commence a new form of treatment);
4. Use of physical restraints to
include the type applied, time of application, checks, releases and exercise of
resident. (Flow sheet may be used.);
5. Bedtime snacks for therapeutic diets
and physician ordered supplemental feedings to include the
type, amount served and amount consumed. (Flow sheet may be
used.);
6. Meal consumption for residents at
nutritional risk to include percentage of meal consumed.
(Flow sheet may be used.);
7. PRN medications to include name,
amount, route of administration, time, reason given and
response. PRN "controlled" drugs must also be charted in the
nurse's notes, which must also contain the condition of the
patient before and after administration.
8. Foley catheters to include
documentation of insertion, reinsertion, removal and
catheter irrigations. The total amount of urinary output
must be documented, at a minimum, every eight (8) hours.
(Flow sheet may be used.);
9. Nasogastric or gastrostomy tubes to
include documentation of insertion, reinsertion, removal,
placement checks, care of site, type of formula, amount of
formula, rate of feeding, and flushes. Total fluid intake
must be documented, at a minimum, every eight (8) hours to
include formula and flushes. (Flow sheet may be used.);
10. Problem skin conditions to include
date of onset and weekly progress notes. Documentation must
identify the skin problem, stage, size, color, odor and
drainage, if any. The chart shall also document the date and
time of treatments and dressings. (Flow sheet may be used.);
11. Physician visits to include date of
visit;
12. Any contacts with the physician
(date and time) regarding the resident's condition and the
physician's response/instructions;
13. Residents condition on discharge
or transfer;
14. Disposition of personal belongings
and medications upon discharge;
15. Time of death of a resident, the
name of person pronouncing death and disposition of the
body.
f. Vital signs must be charted weekly
and weights monthly unless ordered more frequently. (Flow
sheet: may be used.)
516.2 Routine Care and Services
Each patient in the home shall receive
the type of nursing care including restorative nursing as
required by his/her condition. Patients shall be encouraged
to be active, to develop techniques for self-help, and be
stimulated to develop hobbies and interests. Criteria for
determining adequate and proper care includes:
516.2.1 Kind and considerate care and
treatment at all times.
516.2.2 A minimum of a complete bath
twice a week for all ambulatory patients with adequate
assistance or supervision as needed. Patients who are
incontinent or are confined to bed shall have a complete
bath daily and partial baths each time the bed or clothing
is wet or soiled. All soiled linen and clothing shall be
replaced with clean dry ones.
516.2.3 A minimum of one shampoo every
week and assistance with daily hair grooming. Patients shall
not be required to pay for routine hair grooming provided by
facility staff.
516.2.4 Assistance with or supervision
of shaving of men patients at least every other day except when
contraindicated or refused by the patient. Patients shall
not be required to pay for routine shaving.
516.2.5 Oral care shall be provided at
least twice a day.
516.2.6 Hands and feet shall have
proper care and attention. Nails shall be kept clean and
trimmed. Additional lotion shall be applied to hands and
feet when indicated. Precautions shall be taken to prevent
foot drop in bed patients.
516.2.7 Bed linens shall be changed
weekly or more often as needed and adjusted at least daily.
516.2.8 Patients shall have clean and
seasonal clothing as needed to present a neat and clean
appearance, to be free of odors, and to be comfortable.
516.2.9 Measures shall be taken toward
the prevention of pressure sores, and if they exist,
treatment shall be given on written medical order. The
position of bed patients shall be changed every two (2)
hours during the day and night.
516.2.10 Each mattress and pillow shall
be moisture proof or must have a moisture proof cover.
Rubber or plastic sheets shall be cleaned often to prevent
accumulation of odors. Clean cloth draw sheets shall be used
over the rubber or plastic sheet.
516.2.11 Assistance with the use of
commode, bedpan, or toilet, and keeping the commode, bedpan,
and urinal clean and free of odors. Bedpans, urinals, and
wash basins shall be name-labeled, cleaned after each use,
properly stored in the patient's bedside cabinet, and
sanitized at least weekly. Any of these utensils not
name-labeled and stored in individual bedside cabinets must
be sterilized after each use.
516.2.12 Each patient shall be up and
out of bed for at least a brief period everyday unless the
physician has written an order for him/her to remain in bed.
516.2.13 Fluids shall be offered at
frequent intervals when the patient is unable to obtain
them. Water pitchers shall be refilled at least once each
shift and should be kept in reach of patients. Clean
drinking glasses shall be kept with each water pitcher.
516.2.14 Physical findings
(temperature, pulse, respiration, and blood pressure) shall
be taken and recorded as ordered by the physician, but not
less than one (1) time a week. All residents with indwelling
catheters should have urine output recorded each shift.
516.2.15 Administration of oxygen.
516.2.16 Documentation that a
continuous program of bowel or bladder training is provided
when appropriate.
516.2.17 Proper bed and chair
positioning.
516.2.18 Nursing equipment is in
sufficient supply, in good condition, is properly cleaned
and cared for, well organized, and readily available.
516.2.19 Precautions to assure the
safety of patients are continuously in effect. (See, also,
Section 309 regarding restraints.)
516.2.20 Bedside nursing care.
516.2.21 Administration of hypodermic
medications as prescribed.
516.2.22 Rehabilitation programs such
as physical therapy, occupational therapy, speech therapy, etc., as
required by written physician orders. Such therapies must be
administered by qualified persons.
516. 3 Skilled Nursing Facilities:
In addition, the following services
will be required in Skilled Nursing Facilities:
Intravenous feedings
Complex dressings
Skilled nursing care
Tube feedings
There will be no administration of
blood in the nursing home unless the nursing home is
physically connected to a hospital. In any nursing home
administering blood, a registered nurse must be on duty
throughout the entire administration.
520.2
RATIO OF DIRECT-CARE STAFF TO RESIDENTS COMPUTATION
520.2.1
Minimum staffing computations shall be performed using the
following method:
Step 1
Determine the midnight census for the date the shift begins.
Step 2
Divide the census by the ratio of direct-care staff required
for the shift being computed. The result will be the total
number of direct-care staff required for the shift.
Step 3
Divide the census by the required ratio of licensed
personnel for the shift being computed. The result will be
the total number of licensed direct-care staff required for
the shift.
Step 4
Subtract the results of Step 3 from the results of Step 2.
The result will be the total number of remaining direct-care
staff required for the shift.
520.2.2
All computations shall be carried to the hundredth place. If
the computations result in other than a whole number of
direct-care staff for a shift, the number shall be rounded
up to the next whole number when the computation, carried to
the hundredth place, is fifty-one hundredths (.51) or
higher.
520.2.3
Facilities shall have no less than one (1) licensed
personnel per shift for direct-care staff as of July 1,
2001.
520.3
MINIMUM DIRECT-CARE STAFF RATIOS
520.3.1
Beginning October 1, 2003, facilities shall maintain the
following direct-care staff to resident ratios:
520.3.1.1
Day Shift: One (1) direct-care staff to every six (6)
residents; of which there shall be one (1) licensed nurse to
every forty (40) residents.
520.3.1.2
Evening Shift: One (1) direct-care staff to every nine (9)
residents; of which there shall be one (1) licensed nurse to
every forty (40) residents.
520.3.1.3
Night Shift: One (1) direct-care staff to every fourteen
(14) residents; of which there shall be one (1) licensed
nurse to every eighty (80) residents.
Beginning
October 1, 2003
Example
The facility has a census of eighty-two (82) residents as of
midnight on December 10, 2003, and is computing the required
direct-care staff for the day shift of December 11, 2003.
The day shift has a direct-care-staff to resident ratio of
one (1) direct-care staff to every six (6) residents, of
which there shall be one (1) licensed staff member to every
forty (40) residents.
Step 1:
Census of 82
Step 2: 82
/6 = 13.67 [Round to 14; total number of direct-care staff
required]
Step 3: 82
/40 = 2.05 [Round to 2; number of licensed direct-care
staff required]
Step 4: 14
2 = 12 [Number of remaining direct-care staff required]
Total
number of direct-care staff for the day shift: 14
Total
number of licensed direct-care staff for the day shift: 2
Total
number of remaining direct care staff for the day shift: 12
Example
The facility has a census of ninety-seven (97) residents as
of midnight on January 3, 2004, and is computing the
required direct care staff for the evening shift. The
evening shift has a direct-care staff to resident ratio of
one (1) direct-care staff to every nine (9) residents, of
which there shall be one (1) licensed staff member to every
forty (40) residents.
Step 1
Census of 97
Step 2
97 /9 = 10.77 [Round to 11; total number of direct-care
staff required]
Step 3
97 /40 = 2.42 [Round to 2;
number of licensed direct-care staff required]
Step 4 11
2 = 9 [Number of remaining direct-care staff required]
Total
number of direct-care staff for the evening shift: 11
Total
number of licensed direct-care staff for the evening shift:
2
Total
number of remaining direct care staff for the evening shift:
9
Example
The facility has a census of one hundred forty-two (142)
residents as of midnight on December 7, 2003, and is
computing the required direct-care staff for the night
shift. The night shift has a direct-care-staff to resident
ratio of one (1) direct-care staff to every fourteen (14)
residents, of which there shall be one (1) licensed staff
member to every eighty (80) residents.
Step 1
Census of 142
Step 2
142 /14 = 10.14 [Round to 10; total number of direct-care
staff]
Step 3
142 /80 = 1.77 [Round to 2; number of licensed direct-care
staff]
Step 4 10
2 = 8 [Number of remaining direct-care staff]
Total
number of direct-care staff for the night shift: 10
Total
number of licensed direct-care staff for the night shift: 2
Total
number of remaining direct care staff for the night shift: 8
520.4
EXCEPTIONS TO MINIMUM STAFFING RATIOS
520.4.1
Upon an increase in a facilitys resident census, the
facility shall be exempt from any corresponding increase in
staffing ratios for a period of nine (9) consecutive shifts
beginning with the first shift following the midnight census
for the date of the expansion of the resident census.
520.4.2
When residents are relocated or transferred from facilities
due to natural disaster, emergency or as a result of state
or federal action, the Department of Human Services may
waive, for a period of no more than three (3) months from
the date of transfer, some or all of any required increase
in direct-care staff for the facility or facilities to whom
the residents are relocated or transferred. Waivers will
only be granted for good cause shown, and upon telephone,
facsimile or written request. A grant of a waiver is within
the sole discretion of the Office of Long Term Care.
Facilities may apply for a waiver by writing the Director of
the Office of Long Term Care. The written request should
state, at a minimum:
a. The
date of the transfer for each resident;
b. The
number of residents transferred for each date in which
residents were received from another facility;
c. The
anticipated date by which the facility will be able to meet
the increased number of minimum staff for the total number
of residents of the entire facility, including all residents
received in transfer;
d. The
name of the facility from which the residents were
transferred; and,
e. A brief
explanation as to why the facilitys staffing cannot be
increased prior to the anticipated increase date set out in
c, above.
520.5
STAFFING REPORTS
520.5.1 By
the fifth (5th) day of
each month, each nursing facility or nursing home shall
submit a written report of all shifts for the preceding
month to the Office of Long Term Care, utilizing form
DMS-718.
520.5.2 In
addition, each report shall designate the shifts in which
minimum staffing standards were not met, as set forth in
form DMS-718.
520.6 FLEX
STAFFING
520.6.1
Flex staffing permits facilities to vary the beginning and
ending hours for shifts, so that facilities may maximize
staff time to the benefit of residents. Regardless whether a
facility employs shifts of greater duration than specified
in these regulations such as ten (10) or twelve (12) hour
shifts for purposes of computing minimum staffing ratios
the facility
shall base their computations on three shifts of equal length.
Facilities can, however, designate that their shifts will begin
earlier or later than specified in Sections 520.1.3
through 520.1.5.
520.6.2 When
facilities utilize flex staffing, the shifts must meet the
staffing requirements set forth herein for the entire period of
the shift. As way of example only, if a facility begins a shift
at 5:30 a.m., the minimum staffing requirements for that shift,
which would end at 1:30, would be minimum staffing requirements
for the Day Shift as set forth in Sections 520.1.3 through
520.1.5, and those minimums must be maintained throughout the
entire shift.
520.6.3 The
Office of Long Term Care shall be notified in writing when a
facility implements a flex-staffing schedule. The written notice
shall state the beginning and ending hours of each shift under
the flex staffing.
520.7
PENALTIES
Violations of
these regulations shall be punishable in accordance with Ark.
Code Ann. § 20-10-1407 and 20-10-1408.
Date __________
DAILY STAFFING LOG
_________________________________________________________________
__________________________________________________________________
Facility Hall, Wing or Corridor
SHIFT SIGN-IN SHEET
Staff Day Shift sign name below Evening Shift sign
name below Night Shift sign name below
Time In Signature Time Out
Time In Signature Time Out Time In Signature Time Out
RNs
LPNs
CNAs
RNA
NUMBER OF RESIDENTS ON HALL, WING OR CORRIDOR AS OF MIDNIGHT CENSUS:
DMS-7780 (11/99)
Comments:
_____________________________________________________________
________________________________________________________________________
________________________________________________________________________
_____________________________________________________________________________________
Reviewed: Admin/DON/Designee
Date
Instructions for Completing Form DMS-7780
As
required by Ark. Code Ann. § 20-10-1401 et seq., a copy
of the Form DMS-7780 is to be
completed and posted daily as specified in these
instructions and LTC Section 520.9.
Start a new Log with each Day Shift.
1.
Date Enter the current date.
2.
Facility Enter facility name.
3.
Hall, Wing or Corridor Specify the hall, corridor, or
wing that the Log covers. See
Section 520.9.1.
4.
Shift Sign-In Sheet Staff will sign in at the
beginning of each shift and sign out at the
end of each shift on the Shift Sign-In Sheet in the
section designated for their licensure or
certification status. On the log, each person will:
specify his/her time in
sign name
specify time out
RNs, LPNs and RNAs working as CNAs will sign in under
the section for their licensure,
but the facility shall denote on the form that they are
working as CNAs for that shift by
placing "(CNA)" after their name. Likewise, RNs working
as LPNs will sign in under the RN
section, but the facility shall denote on the form that
they are working as LPNs by
placing "(LPN)" after their name.
5
Today's Residents on Unit At the beginning of each
shift, the Charge Nurse or
designee will enter the number of residents on that unit
as of 12:01 a.m. of the date of the
report. See Section 520.9.1 for the definition of
shifts.
6.
Comments The Administrator or designee may enter
comments explaining any
discrepancies between required and actual staffing.
7.
Post the log - See Sections 520.9.1(a), (b), (c), (e),
and (i), and 520.9.3.
8.
Review The Administrator, DON or Designee will sign
and date each staffing log prior to
filing.
9.
Save and file the logs for audit by OLTC - See Section
520.9.4.
