Nursing Services Requirements for the State of Rhode Island

PART III RESIDENT CARE SERVICES Section 19.0 Resident Care Policies

19.1 Each facility shall have written resident care policies to govern the continuing nursing care and related medical or other services provided.

19.2 Resident care policies and procedures shall be developed and reviewed annually, and revised as necessary, in all facilities by a group of professional personnel including one or more physicians, a registered nurse, and other professional personnel as deemed necessary (e.g., social workers, physical therapists,
etc.). Documentation of this annual review shall be made available to the licensing agency upon request.

19.3 Resident care policies shall be available for review by all residents, physicians, community agencies, relatives and personnel and shall include provisions for at least the following:

a) meeting the total medical and psychosocial needs of residents;

b) the establishment of written plans of care for each resident for medical, nursing and other related services provided;

c) the range of services available and provided to residents and constraints imposed by limitations of services, physicians, facilities, staff coverage, payment mechanism or other;

d) the frequency of physician visits shall be at a minimum of 90 days;

e) the protection of residents' personal and property rights;

f) types of clinical conditions acceptable for admission to specific levels of care and appropriate services;

g) emergency admissions or discharges and emergency care of residents;

h) requirements for informed consent by resident, parent, guardian or legal representative for treatment;

i) notification of next of kin, attending physician or responsible agency of any transfer or discharge;

j) notification of next of kin, attending physician or responsible agency of any change of condition;

k) transfer of medical information in accordance with reference 17;

l) discharge and termination of services; and

m) provision for continuity of resident care as related to discharge planning, which shall include a mechanism for recording, transmitting and receiving information essential to the continuity of resident care.

Such information shall contain no less than the following:

i. resident identification data; such as name, address, age, gender, name of next of kin, health insurance coverage, etc.;

ii. diagnosis and prognosis, medical status of resident, brief description of current illness, medical and nursing plans of care including such information as medications, treatments, dietary needs, baseline laboratory data;

iii. functional status;

iv. special services such as physical therapy, occupational therapy, speech therapy and such other;

v. psychosocial needs;

vi. bed-hold policy and readmission in accordance with section 18.18.1 c) herein; and

vii. such other information pertinent to ensure continuity of resident care.

19.4 There shall be documented evidence of the designation of responsibility to a physician, or to a nurse or to the medical staff for the execution and implementation of resident care policies.

a) When a nurse is designated as the responsible agent for a day-to-day execution of resident care policies, a physician shall be available to provide necessary medical guidance.

Section 22.0 Nursing Service

22.1 Each facility shall have a formally organized nursing service with an organization chart reflecting the lines of communication. The authority, responsibilities and duties for each nursing service position and/or category shall be clearly delineated in writing through job descriptions.

22.2 The nursing service shall be under the direction of a Director of Nurses who shall be a registered nurse employed full-time. A relief registered nurse shall be employed to insure full-time coverage in the absence (including vacation, sick time, days off, or other) of the designated registered nurse.

a) The Director of Nurses employed full-time in accordance with section 22.2 above shall not be the administrator nor the assistant administrator and shall:

(1) have at least two years experience in nursing supervision or, by training and experience, shall have demonstrated competency in nursing service management;

(2) be employed by only one facility in said capacity; and

(3) be responsible for the total nursing service which shall include no less than:

i. development, maintenance and evaluation of standards of nursing practice;

ii. development and periodic revision of nursing policies and procedure manuals;

iii. recommendation to the facility's administration of the number and categories of nursing personnel required to provide resident care;

iv. training, assignment, supervision and evaluation of personnel;

v. coordination of nursing care services with other services, e.g., medical,
nutrition, etc.; and

vi. all other functions and activities related to nursing service management.

22.3 Each facility shall have a registered nurse on the premises twenty-four (24) hours a day. In addition, the necessary nursing service personnel (licensed and non-licensed) shall be in sufficient numbers on a 24 hour basis, to assess the needs of resident, to develop and implement resident care plans, to provide direct resident care services, and to perform other related activities to maintain the health, safety and welfare of residents.

a) There shall be a master plan of the staffing pattern for providing 24 hour nursing service; for the distribution of nursing personnel for each floor and/or nursing unit; for the replacement of nursing personnel; and for forecasting future needs. The staffing pattern shall include provisions for nurses, aides, orderlies and other personnel as required.

b) The number and type of nursing personnel shall be based on resident care needs and classifications as determined for each nursing unit. Each nursing facility shall be responsible to have sufficient qualified staff to meet the needs of the residents.

c) At least one individual who is certified in Basic Life Support must be available twenty-four hours a day (24 hrs./day) within the facility.

22.4 The Director of Nurses may act as a charge nurse only when the facility is licensed for 30 beds or less.

22.5 Whenever the licensing agency determines, in the course of inspecting a facility, that additional staffing is necessary on any nursing unit to provide adequate nursing care and treatment or to ensure the safety of residents, the licensing agency may require the facility to provide such additional staffing and any or all of the following actions shall be taken to enforce compliance with the determination of the licensing agency.

a) The facility shall be cited for a deficiency and shall be required to augment its staff within 10 days in accordance with the determination of the licensing agency.

b) If failure to augment staffing is cited, the facility shall be required to curtail admission to the facility.

c) If a continued failure to augment staffing is cited, the facility shall be subjected to an immediate compliance order to increase the staffing, in accordance with section 23-1-21 of the General Laws of Rhode Island of as amended.

d) The sequence and inclusion or non-inclusion of the specific sanctions enumerated in sections above may be modified in accordance with the severity of the deficiency in terms of its impact on the quality of resident care.

22.6 No nursing staff of any facility shall be regularly scheduled for double shifts.

Section 23.0 Selected Nursing Care Procedures

23.1 Written resident care plans, including problems, measurable goals, interventions, and time frames, shall be developed and maintained for each resident consonant with the attending physician's plan of medical care.

a) Resident care plans shall be reviewed, evaluated and revised by professional staff no less than every three months, or when there is a significant change in the resident's health status.

23.2 The personal hygiene of each resident shall be attended to. All residents shall receive care including care of skin, shampooing and grooming of hair, oral hygiene, shaving, cleaning and cutting of fingernails and toenails. Residents shall be kept free of offensive odors.

23.3 Residents shall be encouraged and/or assisted to function at their highest level of self-care and independence. Every effort shall be made to keep residents active and out of bed for reasonable periods of time except when contraindicated by physician orders.

23.4 Every facility shall have an active program for rehabilitative nursing care.

23.5 Such supportive and restorative nursing care needed to maintain maximum functioning of the resident shall be provided.

23.6 Each resident shall be given care to prevent pressure ulcers, contractures and deformities, including: a) preventive skin care as appropriate; b) changing the position of bedfast and chair-fed residents; c) maintaining proper body alignment and joint movement to prevent contractures and deformities; and d) encouraging, assisting and training residents in self-care and activities of daily living.

23.7 Measures shall be taken to prevent and reduce incontinence for each resident which shall include no less than:

a) written assessment by a registered nurse, within two (2) weeks of admission, of each incontinent resident's ability to participate in a bowel and/or bladder training program;

b) an individualized plan of care for each resident selected for training to be included in the resident's nursing care plan to restore as much normal bladder function as possible.

Administration of Drugs

23.8 Drugs shall be administered in accordance with written orders of the attending physician and procedures established in accordance with sections 26.1 and 26.2 herein. Such procedures shall include measures to assure: (1) that drugs are checked against physicians' orders; (2) that the resident is identified prior to administration of a drug; (3) that each resident has an individual medication record; and (4) that the dose of drug administered to each resident is properly recorded therein by the person administering the drug.

a) Drugs not specifically limited as to time or number of doses when ordered shall be controlled by automatic stop orders or other methods in accordance with written policies.

b) Physicians' verbal orders for drugs and biologicals shall be given only to a licensed nurse, a registered pharmacist or to a physician and shall be immediately recorded and signed by the person receiving the order. Such orders shall be countersigned by the attending physician within fifteen (15) days.

Administration of Drugs by Non-Licensed Personnel

23.9 Selected non-licensed personnel who have satisfactorily completed a State Approved Course in Drug Administration and have demonstrated competency in accordance with the state-approved protocol in drug administration may administer oral or topical drugs, with the exception of all Schedule II drugs, with supervision in accordance with the state-approved protocol in drug administration. If such unlicensed personnel are from temporary employment agencies, the facility shall have onsite evidence of supervision in accordance with the state-approved protocol in drug administration.