Nursing Services Requirements for the State of California

§ 72309. Nursing Service.

Nursing service means a service staffed, organized and equipped to provide skilled nursing care to patients on a continuous basis.

Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code.

§ 72311. Nursing Service -General

(a) Nursing service shall include, but not be limited to, the following:

(1) Planning of patient care, which shall include at least the following:

(A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.

(B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited.

(C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition.

(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.

(3) Notifying the attending physician promptly of:

(A) The admission of a patient.

(B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient.

(C) An unusual occurrence involving a patient, as defined in Section 72541.

(D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient's physician.

(E) Any untoward response or reaction by a patient to a medication or treatment.

(F) Any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient.

(G) The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient.

(b) All attempts to notify physicians shall be noted in the patient's health record including the time and method of communication and the name of the person acknowledging contact, if any. If the attending physician or his designee is not readily available, emergency medical care shall be provided as outlined in Section 72301(g).

(c) Licensed nursing personnel shall ensure that patients are served the diets as prescribed by attending physicians.

Note: Authority cited: Section 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code.

§ 72315. Nursing Service -Patient Care.

(a) No patient shall be admitted or accepted for care by a skilled nursing facility except on the order of a physician.

(b) Each patient shall be treated as individual with dignity and respect and shall not be subjected to verbal or physical abuse of any kind.

(c) Each patient, upon admission, shall be given orientation to the skilled nursing facility and the facility's services and staff.

(d) Each patient shall be provided care which shows evidence of good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning and cutting of fingernails and toenails. The patient shall be free of offensive odors.

(e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by physician's orders.

(f) Each patient shall be given care to prevent formation and progression of decubiti, contractures and deformities. Such care shall include:

(1) Changing position of bedfast and chairfast patients with preventive skin care in accordance with the needs of the patient.

(2) Encouraging, assisting and training in self-care and activities of daily living.

(3) Maintaining proper body alignment and joint movement to prevent contractures and deformities.

(4) Using pressure-reducing devices where indicated.

(5) Providing care to maintain clean, dry skin free from feces and urine.

(6) Changing of linens and other items in contact with the patient, as necessary, to maintain a clean, dry skin free from feces and urine.

(7) Carrying out of physician's orders for treatment of decubitus ulcers. The facility shall notify the physician, when a decubitus ulcer first occurs, as well as when treatment is not effective, and shall document such notification as required in Section 72311(b).

(g) Each patient requiring help in eating shall be provided with assistance when served, and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating.

(h) Each patient shall be provided with good nutrition and with necessary fluids for hydration.

(i) Measures shall be implemented to prevent and reduce incontinence for each patient and shall include:

(1) Written assessment by a licensed nurse to determine the patient's ability to participate in a bowel and/or bladder management program. This is to be initiated within two weeks after admission of an incontinent patient.

(2) An individualized plan, in addition to the patient care plan, for each patient in a bowel and/or bladder management program.

(3) A weekly written evaluation in the progress notes by a licensed nurse of the patient's performance in the bowel and/or bladder management program.

(j) Fluid intake and output shall be recorded for each patient as follows:

(1) If ordered by the physician.

(2) For each patient with an indwelling catheter:

(A) Intake and output records shall be evaluated at least weekly and each evaluation shall be included in the licensed nurses' progress notes.

(B ) After 30 days the patient shall be reevaluated by the licensed nurse to determine further need for the recording of intake and output.

(k) The weight and length of each patient shall be taken and recorded in the patient's health record upon admission, and the weight shall be taken and recorded once a month thereafter.

(l) Each patient shall be provided visual privacy during treatments and personal care.

(m) Patient call signals shall be answered promptly.

Note: Authority cited: Sections 208(a) and 1275, Health and Safety Code. Reference; Section 1275, Health and Safety Code.

§ 72327. Nursing Service -Director of Nursing Service.

(a) The director of nursing service shall be a registered nurse and shall be employed eight hours a day, on the day shift five days a week.

(b) The director of nursing service shall have at least one year of experience in nursing supervision within the last five years.

(c) The director of nursing service shall have, in writing, administrative authority, responsibility and accountability for the nursing services within the facility and serve only one facility in this capacity at any one time.

Note: Authority cite: Sections 208(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code.

§72329. Nursing Service -Staff.

(a) Nursing service personnel shall be employed and on duty in at least the number and with the qualifications determined by the Department to provide the necessary nursing services for patients admitted for care. The Department may require a facility to provide additional staff as set forth in Section 72501(g).

(b) Facilities licensed for 59 or fewer beds shall have at least one registered nurse or a licensed vocational nurse, awake and on duty, in the facility at all times, day and night.

(c) Facilities licensed for 60 to 99 beds shall have at least one registered nurse or licensed vocational nurse, awake and on duty, in the facility at all times, day and night, in addition to the director of nursing services. The director of nursing service shall not have charge nurse responsibilities.

(d) Facilities licensed for 100 or more beds shall have at least one registered nurse, awake and on duty, in the facility at all times, day and night, in addition to the director of nursing service. The director of nursing service shall not have charge nurse responsibilities.

(e) Nursing stations shall be staffed with nursing personnel when patients are housed in the nursing unit.

(f) Each facility shall employ sufficient nursing staff to provide a minimum daily average of 3.0 nursing hours per patient day.

(1) Facilities which provide care for mentally disordered patients and in which licensed psychiatric technicians provide patient care shall meet the following standards:

(A) If patients are not certified for special treatment programs, facilities shall employ sufficient staff to provide a minimum daily average of 3.0 nursing hours per patient day.

(B) For patients certified for special treatment programs, facilities shall employ sufficient staff to provide a minimum daily average of 2.3 nursing hours per patient day for each patient certified to the special treatment program, exclusive of additional staff required to meet the staffing standards of the special treatment program.

(g) Staffing for a distinct part intermediate care unit in a skilled nursing facility:

(1) Units of less than 50 intermediate care beds shall not be required to provide licensed personnel in addition to those provided in the skilled nursing facility unless the Department determines through a written evaluation that additional licensed personnel are necessary to protect the health and safety of patients.

(2) Units of 50 or more intermediate care beds shall provide a registered nurse or licensed vocational nurse employed 8 hours on the day shift, 7 days per week in the unit.

(3) For purposes of this section intermediate care beds that are licensed as such by the Department shall not be included for establishing licensed nurse staffing as required in Section 72329(f)(1) if the unit is used exclusively for intermediate care patients.

Note: Authority cited: Sections 208(a), 1275 and 1276.5, Health and Safety Code. Reference: Sections 1276 and 1276.5, Health and Safety Code; and Section 14110.7(c), Welfare and Institutions Code.