La. Admin. Code tit. 50 § II-10121

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10121 - Nursing Services

A. The facility shall provide an organized nursing service with a sufficient number of licensed and unlicensed qualified nursing personnel to meet the total nursing needs of all residents in accordance with the resident care policies of the facility on a 24 hour basis.

1. The facility shall provide:

a. policies that are designed to ensure that each resident:

i. receives treatments, medications, diets as prescribed, rehabilitative nursing care as needed;

ii. receives care to prevent pressure sores and deformities;

iii. is kept comfortable, clean, and well-groomed;

iv. is protected from accident, injury, and infection; and

v. is encouraged, assisted, and trained in self-care and group activities.

b. Assurance that all nursing personnel are assigned duties consistent with their education and experience and based on the characteristics of the resident load; and

c. Weekly time schedules which indicate the number and classification of nursing personnel, including relief personnel who worked in each unit for each tour of duty.

B. Director of Nursing Services. all nursing facilities shall have a director of nursing (DON) who is a qualified registered nurse employed full-time and regularly assigned to the day shift.

1. The director of nursing must have, in writing, administrative authority, responsibility and accountability for the functions, activities, and training of the nursing services staff.

2. The director of nursing may serve only one facility in the capacity of director of nursing.

3. If a change occurs in the individual who is the director of nursing, notice shall be provided by the facility administrator (or governing body in absence of administrator) to BHSF/HSS at the time the change occurs. Notice shall include the identity of all individuals involved and the specific changes which have occurred. Failure to provide written notice by certified mail within 30 calendar days from the date a change occurs, will result in a Class C civil money penalty. (Refer to Subchapter L Sanctions.)

4. The Bureau shall allow long term care facilities 30 days from the date of change in the position of director of nursing to fill a resulting vacancy. In the interim, an RN must be assigned the responsibility of the DON position. Waiver of the 30 day time limit may be granted by the Bureau if:

a. The facility demonstrates to the satisfaction of the bureau that the facility has been unable, despite diligent efforts (including offering wages at the community prevailing rate for nursing facilities) to recruit a director of nursing.

b. The Bureau determines that a waiver of the director of nursing will not endanger the health and safety of individuals staying in the facility.

5. Failure to fill a vacancy or to notify the Bureau in writing that the director of nursing position (where no waiver has been granted) has been filled by the thirty-first day of vacancy (or expiration of any waiver granted) shall result in a class C civil money penalty. (Refer to Sanctions.)

6. The bureau shall retain the right to apply any other applicable remedies.

C. Assistant Director of Nursing. If the director of nursing has administrative responsibilities or the nursing facility has a licensed bed capacity of 101 or more, the facility shall have a full-time assistant director of nursing (ADON).

D. RN Coverage. A nursing facility shall use the services of an RN for at least 8 consecutive hours a day, seven days a week. When seven-day RN coverage cannot be provided, the facility must notify Health Standards Section following guidelines outlined for the separation of the director of nursing.

E. Waiver. If a facility is unable to obtain the seven-day RN coverage the facility may request a waiver. To obtain a waiver for the seven-day RN coverage, the facility shall submit a written request to the regional office which includes:

1. proof that diligent efforts have been made to recruit appropriate personnel. Newspaper invoices with the ad attached shall be submitted and the hourly salary offered and any other benefits offered;

2. names and phone numbers of RN's interviewed for the job.

a. Upon receipt of this information, the regional office will review the level of care of the residents in the facility and make a determination that approval of the waiver would/would not endanger the health or safety of the residents staying in the facility. The regional office will make a recommendation to the state office to approve/deny the waiver.

b. The facility will be notified, in writing, as to the approval/denial of the waiver by state office. Although a facility is granted a waiver, the facility shall continue to recruit for an RN on a continuous basis to fill the position.

c. A waiver approval will expire after one year or upon the next standard survey.

d. The nursing facility that is granted such a waiver by the state notifies residents of the facility (or where appropriate, the guardians or legal representatives of such residents) and members of their immediate families of the waiver.

e. When a waiver for seven-day RN coverage has been granted, the facility cannot train nursing assistants.

F. Waiver in a Skilled Nursing Facility or Dually Certified SNF/NF. The secretary of DHHS may waive the requirement that a SNF provide the services of a registered nurse for more than 40 hours a week, including a director of nursing if the secretary finds that the facility:

1. is located in a rural area and the supply of SNF services in the area is not sufficient to meet the needs of individuals residing in the area;

2. has one full-time registered nurse who is regularly on duty at the facility 40 hours a week; and

3. has only residents whose physicians have indicated through written orders that they do not require the services of a registered nurse or physician for a 48 hour period, or has made arrangements for a registered nurse or physician to spend time at the facility to provide necessary skilled nursing services on days when the regular full-time registered nurse is not on duty.

a. To apply for a waiver of registered nurse coverage in a skilled nursing facility, the provider should send a written request to: Health Care Financing Administration, Regional Office VI, 1200 Main Tower Building, Dallas, Texas 75202, attn: Mr. Mitchell Chunn.

b. Facilities providing the following levels of care may not request a waiver for seven-day RN coverage:

i. skilled - NRTP;

ii. skilled - ID; or

iii. skilled - TDC.

G. Charge Nurse. A registered nurse, or a qualified licensed practical (vocational) nurse shall be designated as charge nurse by the DON for each tour of duty and is responsible for supervision of the total nursing activities in the facility during each tour of duty.

1. A director of nursing may not serve as charge nurse in a facility with an average daily total occupancy of 60 or more residents.

2. The charge nurse delegates responsibility to nursing personnel for the direct nursing care of specific residents during each tour of duty on the basis of staff qualifications, size/physical layout of the facility, characteristics of resident load, and emotional, social, and nursing care needs of the residents.

H. Certified Nursing Assistants (CNA). A nursing facility shall not use any individual who is not a certified nursing assistant in the facility on or after October 1, 1990 for more than four months unless the individual has completed a training and competency evaluation program or competency evaluation program approved by the state agency. For additional information, refer to the Chapter on nurse aide training.

I. Clerical Staff. Effective September, 1991 all facilities shall employ two full-time clerical employees.

J. Other Nursing Services. Nursing services shall be provided to the resident to ensure that the needs of the resident are met. These services include the following:

1. Drug Administration. Medications shall be administered only by a licensed physician, licensed/applicant nurse, or the resident (with the approval of the ID team as documented in the comprehensive care plan.)

2. The facility should be cognizant of the mental status of the resident's roommate(s) or other potential problems which could result in abuses with drugs used for self-administration.

3. Medications shall be administered in accordance with the facility's established written procedures and the written policies of the pharmaceutical services committee to ensure the following criteria are met:

a. Drugs to be administered are checked against physician's orders.

b. The resident is identified before administering the drug.

c. All medications/treatments are administered and properly charted in accordance with nursing practice standards. The reason for each medication omission shall be recorded in the resident's active medical record.

i. The drug dosage shall be prepared, administered, and recorded by the same person.

ii. Medications prescribed for one resident shall not be administered to any other person.

iii. Medication errors and adverse drug reactions shall be immediately reported to the attending physician and recorded in the medical record.

iv. Current medication reference texts or sources shall be kept in all facilities.

4. Automatic Stop Orders. Medications 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. The attending physician must be notified of an automatic stop order prior to the last dose so that (s)he may decide if the administration of the drug or biological is to be continued or altered.

5. Self Administration. Self administration of medication is allowed only in accordance with orders of resident's attending physician, in conjunction with the ID team, when documented in the comprehensive care plan.

6. Drug Orders. Medications shall be ordered by the attending physician verbally or in writing.

a. Verbal medication orders shall be:

i. given only to a licensed/applicant nurse, pharmacist, physician's assistant, nurse practitioner, clinical nurse specialist or another physician;

ii. immediately recorded, fully dated, and signed by the individual receiving the order;

iii. fully dated and signed by the physician within seven days; and

iv. Category II controlled substances must be confirmed in writing within 72 hours and may be given only in an emergency (controlled substance as of 1970).

7. Standing orders, if used, shall be placed in each resident's record and shall be signed by the resident's attending physician and fully dated. These orders shall be reviewed, signed, and fully dated at least annually.

8. Activities of Daily Living (ADL). Based on the comprehensive assessment of a resident, the facility shall ensure that:

a. a resident's abilities in activities of daily living (ADLs) do not diminish unless circumstances of the individual's clinical condition demonstrate that diminution was unavoidable;

b. activities of daily living (ADLs) include the ability to do the following:

i. bathe, dress and groom;

ii. transfer and ambulate;

iii. toilet;

iv. eat; and

v. to use speech, language or other functional communication system.

c. A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming and personal/oral hygiene.

d. A resident is to be given the appropriate treatment and services to maintain or improve his/her functional status and abilities to perform their ADLs.

9. Vision and Hearing. The residents shall receive proper treatment and assistive devices to maintain vision and hearing abilities. The facility shall assist the resident in making appointments and arranging for transportation to and from appointments and in locating assistance from community and charitable organizations when payment is not available through Medicaid, Medicare, or private insurance.

10. Pressure Sores. A resident who enters a facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they are unavoidable. A resident having pressure sores shall receive necessary treatment and services to promote healing, prevent infection, and prevent sores from developing unless the individual's clinical condition demonstrates that they were unavoidable.

11. Urinary Incontinence. A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible and prevent skin breakdown.

12. Restorative Nursing Care. Nursing services shall be provided in accordance with the needs of the residents and restorative nursing care is provided to each resident to achieve and maintain the highest possible degree of function, self-care, and independence. Restorative nursing care services must be performed daily for those residents who require such service.

13. Range of Motion. A resident who enters the facility with full range of motion (ROM) should not experience reduction in ROM unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable. A resident with limited ROM must receive appropriate treatment and services to increase/maintain or prevent further decrease in range of motion.

14. Psychological Functioning. A resident who displays psychosocial adjustment difficulty shall receive appropriate treatment and services to achieve as much remotivation and reorientation as possible. A resident whose assessment did not reveal a psychosocial adjustment difficulty should not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behavior unless the resident's clinical condition demonstrates that such a pattern was unavoidable.

15. Naso-Gastric-Gastrostomy Tubes. A resident who has been able to eat an adequate diet with assistance should not be fed by naso-gastric (NG) tube unless the resident's clinical condition demonstrates that the use of NG tube was unavoidable.

a. A resident who is fed by NG or gastrostomy tubes shall receive the appropriate treatment and services to prevent:

i. aspiration pneumonia;

ii. diarrhea and vomiting;

iii. dehydration and metabolic abnormalities;

iv. nasal pharyngeal ulcers.

b. Feedings shall be provided to restore normal feeding function if possible.

16. Accidents. The resident's environment shall remain as free of accident hazards as possible. Each resident shall receive adequate supervision and assistive devices to prevent accidents.

17. Nutrition. Each resident shall be maintained within acceptable parameters of nutritional states such as body weight and protein levels unless the resident's clinical condition demonstrates that this is not possible. In instances where a nutritional problem has been identified, the resident shall be assessed for the need of a therapeutic diet. A therapeutic diet must be prescribed by the attending physician.

18. Hydration. Each resident must receive sufficient fluid intake to maintain proper hydration and health.

19. Special Needs. Residents must receive proper treatment and care for the following:

a. injections;

b. parenteral and enteral fluids;

c. colostomy, ureterostomy, or ileostomy care;

d. tracheostomy care;

e. tracheal suctioning;

f. respiratory care;

g. podiatric care; and

h. prosthesis.

NOTE: Resident's rights and/or advance directives may supersede the above standards.

K. Release of a Body by a Registered Nurse. In the absence of a physician in a setting other than an acute care facility, when an anticipated death has apparently occurred, registered nurses may have the decedent removed to the designated funeral home in accordance with the standing order of a medical director/consultant setting forth basic written criteria for a reasonable determination of death. This is not applicable in cases where the death was unexpected.

La. Admin. Code tit. 50, § II-10121

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996), amended LR 23:970 (August 1997).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.