Nursing Services Requirements for the State of Oregon

411-086-0020 Director of Nursing Services (DNS)

(Effective 10/01/1990)

(1) FULL-TIME. Each facility shall have a director of nursing services who shall be full-time (40-hours per week) in a single nursing facility. Time spent in professional association workshops, seminars and continuing education may be counted in considering whether or not the DNS is full-time.

(2) QUALIFICATIONS. The DNS shall be a registered nurse who has specific knowledge about nursing administration in a nursing facility.

(a) The DNS shall have at least six months experience in a nursing facility, hospital, or inpatient rehabilitation facility;

(b) Within nine months of employment the DNS shall have:

(A) Successfully completed six credit hours in management or supervision, pertinent to long term care, from an accredited college or university; or

(B) A baccalaureate or master's degree in nursing and documentation of course work which includes management or supervision.

(c) The DNS shall successfully complete every two years at least 30 continuing education hours pertinent to nursing administration in a nursing facility.

(3) RESPONSIBILITY.

(a) The DNS shall have written administrative authority, responsibility, and accountability for assuring functions and activities of the nursing services department. The DNS shall participate in the development of any facility policies that affect the nursing services department (OAR 411-085-0210). The DNS shall organize and direct the nursing service department to include as a minimum:

(A) Develop and maintain a nursing service philosophy, objectives, standards of practice, policy and procedure manuals, and job descriptions for each level of nursing service personnel;

(B) Develop and maintain personnel policies of recruitment, orientation, in-service education, supervision, evaluation and termination of nursing service staff;

(C) Develop and maintain policies and procedure for determination of nursing staff's capacity for providing nursing care for any person seeking admission to the facility;

(D) Develop and maintain a quality assurance program for nursing services;

(E) Coordinate nursing service departmental functions and activities with the functions and activities of other departments;

(F) Develop nursing service department budget recommendations and participate with the facility administrator and other department directors in the allocation of funds for the facility;

(G) Participate with the facility administrator and other department directors in development and maintenance of practices and procedures that promote infection control, fire safety, and hazard reduction;

(H) Ensure that all medications and treatments are given promptly as ordered;

(I) Ensure that only licensed nurses or physicians administer injectable medications;

(J) Ensure adequate nursing services staffing (see OAR 411-086-0100), including development of a written staffing plan; and

(K) Ensure that all nursing staff perform their respective duties in a timely, efficient and professional manner;

(b) The DNS shall designate, in writing, a specific registered nurse, licensed to practice in Oregon, to be available immediately in person or by telephone to direct the functions and activities of the nursing services department when the DNS is not available in person or by telephone. This information shall be posted at each nursing station.

(c) The DNS shall be informed regarding residents' conditions, including when a significant change in a resident's condition warrants nursing or medical intervention.

(d) Effective October 1, 1990, or in the event of delay of the actual federal requirement, effective the actual implementation date, the DNS may serve as the charge nurse only if the facility has a licensed bed capacity of 60 or less and does not provide care for residents requiring skilled nursing care.

Stat. Auth: ORS 410 & 441
Stats. Implemented: ORS 441.055 & 441.615

411-086-0030 RN Care Manager

(Effective 10/01/1990)

The RN care manager is a registered nurse who is responsible and accountable for managing the nursing care of his/her assigned residents. Each resident shall have an RN care manager responsible for his/her care.

(1) TRAINING.

(a) Within nine months of hire each RN care manager shall have successfully completed three credit hours from an accredited school, or 30 continuing education hours, pertinent to gerontology, rehabilitation, or long term care;

(b) Within nine months of hire each RN care manager shall have successfully completed three credit hours from an accredited college or university, or 15 continuing education hours, pertinent to management or supervision.

(2) RESPONSIBILITY.

(a) The RN care manager shall be responsible and accountable for managing the nursing care of his/her assigned residents. The RN care manager shall ensure maximum independence and self-direction for residents.

(b) The RN care manager shall coordinate the nursing functions and tasks for those residents with physicians and other health care providers. The responsible RN care manager shall ensure the nursing plan and resident care plan are developed and documented, and that residents' care needs are met.

(c) Delegated authority.

(A) The RN care manager shall delegate to other licensed personnel only those nursing functions and tasks that the licensee is competent and qualified to perform and that are permitted by ORS Chapter 678 and the rules adopted there under.

(B) The RN care manager, or an RN or LPN with delegated authority from the RN care manager, shall ensure that the nursing assistant is assigned and performs only those tasks for which he/she is competent and qualified to perform and that are permitted by ORS Chapter 678 and the rules adopted there under.

(3) DOCUMENTATION. The name of the responsible RN care manager shall be documented in each resident's clinical record.

Stat. Auth: ORS 410 & 441
Stats. Implemented: ORS 441.055 & 441.615

411-086-0100 Nursing Services: Staffing

(Effective 08/01/2004)

(1) STAFFING PLAN.

(a) The facility shall have a written plan which ensures staffing sufficient to meet the needs of each resident and identifies procedures to obtain required staff when absences occur.

(b) The facility shall maintain a written, weekly staffing schedule showing the number and category of staff assigned to each shift and the person(s) to be called in the event of any absence.

(c) Both planned and actual staffing, including number and category of personnel, shall be clearly documented.

(2) MINIMUM STAFFING, GENERALLY. Resident care needs shall be the primary consideration in determining the number and categories of nursing personnel needed. Staffing shall be sufficient in quantity and quality to provide nursing care for each resident as needed, including restorative care that enables each resident to achieve and maintain the highest possible degree of function, self-care and independence, as determined by the resident's care plan. Such staffing shall be provided even though it exceeds other requirements specified by this rule or specified in any waiver.

(3) MINIMUM LICENSED NURSE STAFFING.

(a) Licensed nurse hours shall include no less than one RN hour per resident per week;

(b) When an RN serves in the temporary absence of the administrator, his/her hours shall not be used to meet minimum nursing hours.

(c) In facilities with 41 or more beds the hours of a licensed nurse who serves as facility administrator shall not be included in any licensed nurse coverage required by OAR 411-086-0100.

(d) The facility shall have a licensed charge nurse on each shift, 24-hours per day. The charge nurse must be an RN for no less than eight consecutive hours, between 7 am and 11 pm, seven days a week.

(A) The DNS may serve as charge nurse only when the facility has 60 or fewer residents.

(B) Subsection (3)(d) of this rule may be waived by the Division if the licensee demonstrates that:

(i) It has been unable to recruit appropriate personnel despite diligent effort (including offering wages at the community prevailing rate for nursing facilities);

(ii) The waiver will not endanger the health or safety of residents;

(iii) The request for waiver shall comply with OAR 411-085-0040 and shall be reviewed annually; and

(iv) The request for waiver shall certify that an RN or physician is obligated to immediately respond to telephone calls from the facility.

(4) MINIMUM CERTIFIED NURSING ASSISTANT STAFFING.

(a) Each resident shall have a nursing assistant assigned to his/her care on each shift (nursing assistants may be assigned by room number). The numbers listed in this rule are not intended to indicate sufficient nursing staff; the minimum staff required are the numbers sufficient to meet resident care needs. The number of residents assigned to the nursing assistant shall not exceed the following numbers:

(A) DAY SHIFT (7 am until 3 pm): 10 residents.

(B) SWING SHIFT (3 pm until 11 pm): 15 residents.

(C) NIGHT SHIFT (11 pm until 7 am): 25 residents.

(b) A facility providing an alternate schedule to the Division specifying the maximum numbers of residents assigned to any nursing assistant on each shift may be granted a variance to paragraphs (4)(a)(A), (B) and (C) of this rule. Such requests must comply with OAR 411-085-0040.

(c) This rule does not prohibit nursing assistants from providing care to a resident to whom they are not assigned.

(d) The licensee shall ensure that nursing assistants shall only perform those tasks for which they are competent and qualified to perform and that are permitted by ORS Chapter 678 and the rules adopted thereunder.

(e) Notwithstanding subsection (4)(a) of this rule, the licensee shall ensure that nursing assistants shall not be assigned more residents than the number for which they can meet the individual care needs.

(f) Notwithstanding subsection (4)(a) of this rule, the licensee is required to have a minimum of two nursing care staff on duty at all times.

(g) Notwithstanding subsection (4)(a) of this rule, nursing assistants do not include dining assistants.

(h) A licensee shall not use any individual working in the facility as a nursing assistant for more than four months unless that individual has completed a training and competency evaluation program approved by the Oregon State Board of Nursing (OSBN) or has been deemed competent as a CNA by the OSBN.

(i) No more than 25% of the nursing assistants assigned to residents pursuant to subsection (4)(a) of this rule may be nursing assistants who are not yet certified.

(5) CERTIFIED MEDICATION AIDES. The licensee shall ensure that all nursing assistants administering non-injectable medications are certified as nursing assistants and as medication aides. Documentation of certification shall be maintained in the facility.

Stat. Auth: ORS 410 & 441.055
Stats. Implemented: ORS 441.055, 441.073 & 441.615

411-086-0110 Nursing Services: Resident Care

(Effective 10/01/1990)

(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) and the rules adopted pursuant thereto.

(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.

Stat. Auth: ORS 410 & 441
Stats. Implemented: ORS 441.055 & 441.615

411-086-0120 Nursing Services: Changes of Condition

(Effective 10/01/1990)

(1) CHANGE OF CONDITION (Generally). Nursing staff shall observe, assess, document, and report to the DNS and the resident's physician any significant change in resident condition that warrants medical or nursing intervention, including any significant change in:

(a) Vital signs;

(b) Skin integrity (i.e., decubitus ulcer);

(c) Hydration;

(d) Ability to take or retain food or fluids;

(e) Weight gain/loss;

(f) Bowel or bladder function;

(g) Behavior;

(h) Level of comfort (i.e., pain, injury); or

(i) Level of consciousness.

(2) ACUTE CONDITION CHANGE. The nursing staff shall ensure that any significant and acute condition change is promptly assessed and documented by a registered nurse and that appropriate measures are immediately instituted.

(3) DOCUMENTATION. Documentation shall include assessment, appropriate interventions, monitoring and outcome until point of resolution.

Stat. Auth: ORS 410 & 441

Stats. Implemented: ORS 441.055 & 441.615

411-086-0130 Nursing Services: Notification

(Effective 10/01/1990)

(1) NOTIFICATION OF SIGNIFICANT OTHER(S). The nursing care staff or other designated staff shall notify the resident's significant others as soon as possible whenever:

(a) The resident has had a change of physical, mental or psychosocial status, including death or accident resulting in injury, or change in type of care needed;

(b) The resident has wandered from the facility.

(2) NOTIFICATION OF DIVISION. The nursing care staff shall notify the Division of any situation in which the health or safety of the resident(s) was/is endangered such as:

(a) Suspected abuse;

(b) Fire;

(c) Lost resident;

(d) Accidental or unusual death.

(3) NOTIFICATION OF PHYSICIAN. The nursing care staff shall notify the resident's physician of possible changes in the type of care the resident needs and document such notification in the resident's clinical record. Such notification shall be timely. The physician's determination shall be documented in the resident's clinical record. NOTE: See requirements for physician visits under OAR 411-086-0200.

(4) DOCUMENTATION. The nursing care staff, except as provided by section (3) of this rule, shall document all notification/consultation required by this rule in the resident's clinical record.

Stat. Auth: ORS 410 & 441

Stats. Implemented: ORS 441.055 & 441.615

411-086-0140 Nursing Services: Problem Resolution & Preventive Care

(Effective 10/01/1990)

(1) PROBLEM RESOLUTION and PREVENTION.

(a) Conditions to be Prevented. The licensee shall take all reasonable measures consistent with resident choice to resolve and to prevent undesirable conditions such as:

(A) Decubitus ulcers and other skin breakdowns;

(B) Loss of mobility, or development of contractures or foot drop;

(C) Dehydration;

(D) Impaction;

(E) Infections;

(F) Weight loss/gain;

(G) Loss of range of motion;

(H) Loss of bowel and bladder control; and

(I) Loss of self-esteem or dignity.

(b) Reasonable Measures. Reasonable measures which are required to be taken include, but are not limited to:

(A) Assessment of residents who are at risk;

(B) Implementation of preventive measures; and

(C) Reassessment and modification of treatment program when the program implemented is not effective.

(2) SAFE ENVIRONMENT. The licensee shall ensure the provision of a safe environment to protect residents from injury. Actions taken by the facility staff shall be consistent with each resident's right to fully participate in his or her own care planning and shall not limit any resident's ability to care for herself/himself.

(a) Dangerous Conditions. The licensee shall take all reasonable precautions to protect a resident from possible injury from dangerous conditions.

(b) Falling, Wandering, Negligence. The licensee shall take all reasonable precautions to protect a resident from possible injury from falling, wandering, other resident(s), staff and staff negligence.

(c) Reasonable Precautions. Reasonable precautions include, but are not limited to, provision and documentation of an assessment and evaluation of resident's condition, medications, and treatments, and completion of a care plan, consistent with OAR 411-086-0060; and, when appropriate:

(A) Physician notification;

(B) Provision of additional inservice training; and/or

(C) Evaluation/adjustment of staffing patterns and supervision.

(d) The licensee shall take all reasonable precautions to protect a resident from dangerous conditions relating to remodeling or construction.

(3) The licensee shall ensure that, except when required in an emergency, physical and chemical restraints are only applied in accordance with the resident's care plan. Restraints may be used only to ensure the physical safety of the resident or other residents..

(a) Freedom of Choice. When restraints are considered in the interdisciplinary care planning conference to reduce the risk of injury related to falls, the resident or his/her legal guardian or person acting under the resident's power of attorney for health care must be informed of the potential risks of falling and the risks associated with restraints.

(b) Physician Orders Required. Except as provided in subsection (3)(c) of this rule, physical and chemical restraints may be applied only when a physician orders restraints. An order for restraints must clearly identify the reason for the restraints and the duration and circumstances under which they are to be applied.

(c) Emergencies. In an emergency situation, a registered nurse may use physical restraints without physician orders if necessary to prevent injury to the resident or to other residents and when alternative measures do not work. If restraints are used in an emergency situation, the registered nurse shall document in the resident's clinical record the use of restraints and what alternative measures did not work. A licensed nurse shall contact the physician for restraint orders within 12 hours of application.

(d) Re-evaluation. Whenever restraints are used, circumstances requiring the restraints and the need must be continually re-evaluated and documented in the clinical record.

(e) Staff Convenience/ Discipline. Restraints shall not be used for discipline or staff convenience.

(f) Periodic Release. Residents who are physically restrained must have the restraints released at least every two hours for a minimum of 10 minutes and be repositioned, exercised or provided range of motion during this period.

(g) Toileting. Toileting and incontinence care shall be provided when necessary.

(h) Quick Release. All physical restraints must allow for quick release. Locked restraints may not be used.

(i) Fixed Objects. Residents shall not be physically restrained to a fixed object.

(4) DOCUMENTATION. All preventive measures taken by the facility staff shall be clearly documented. Such documentation shall include assessment of resident(s) at risk, preventive measures taken, results and evaluation of measures taken, and revision of measures as appropriate.

Stat. Auth: ORS 410 & 441.055

Stats. Implemented: ORS 441.055 & 441.615

411-086-0150 Nursing Services: Restorative Care

(Effective 10/01/1990)

(1) RESTORATIVE PROGRAM. Nursing services staff shall provide a restorative program which reestablishes and maintains to the greatest extent practical the functional abilities of residents. Such functional abilities shall include but not be limited by the abilities identified in OAR 411-086-0110(1). The facility shall have written policies governing the provision and documentation of restorative services pursuant to OAR 411-085-0210.

(2) DIRECTOR. The Director of Nursing Services or his/her designee shall ensure the development and implementation of an effective restorative services program.

(3) STAFFING. Restorative services shall be provided by facility nursing staff in accordance with the resident's care plan.

(4) RESTORATIVE PLAN. Each resident shall have a restorative plan based on an assessment of resident's needs and delivered in accordance with the resident care plan.

(a) Restorative services shall be provided to the resident in accordance with the preliminary resident care plan not later than 24 hours after admission.

(b) The restorative services plan shall be reviewed and updated as frequently as the resident's condition changes, but no less often than quarterly.

(5) DOCUMENTATION. All restorative services provided and results of those services shall be clearly documented in the resident's clinical record. Progress notes relevant to the plan shall be documented in the resident's clinical record as frequently as the resident's condition or ability changes, but no less often than quarterly.

Stat. Auth: ORS 410 & 441

Stats. Implemented: ORS 441.055 & 441.615

411-086-0160 Nursing Services: Discharge Summary

(Effective 10/01/1993)

(1) DISCHARGE SUMMARY REQUIRED. A discharge summary shall be completed for each resident before discharge.

(2) CONTENTS. The discharge summary shall include:

(a) A recapitulation of the resident's stay;

(b) A final summary of the resident's status, including the most recent nursing assessment as defined in OAR 411-086-0060; and

(c) A post-discharge plan of care developed in accordance with OAR 411-086-0060 which will assist the resident to adjust to his/her new living environment. A post-discharge plan is not required when the resident is discharged to acute care or to the morgue.

Stat. Auth: ORS 410 & 441.055

Stats. Implemented: ORS 441.055 & 441.615