1. (a) Charting.

   1. (1) Summary charting should address:

      1. (A) The resident's problems/needs;
      2. (B) Interventions to resolve those needs; and
      3. (C) The progress made toward achieving the resident goals as listed on the care plan.
   2. (2) All disciplines (nursing, dietary, therapies, social, etc.) may document their progress notes on the same chart to promote continuity of care.

   3. (3) All charting notations made on the nurse’s progress notes or flow sheets shall be:

      1. (A) Entered by time and date; and
      2. (B) Signed or initialed.

   4. (4) Minimum requirements for summary charting based on the resident's level of care are as follows:

      1. (A) Skilled, every two (2) weeks;
      2. (B) Intermediate I, every two (2) weeks;
      3. (C) Intermediate II, monthly; and
      4. (D) Intermediate III, monthly.

   5. (5)

      1. (A) The following observations must be charted upon occurrence:
2. (i)
3. (a) (a) Accidents/incidents.

4. (b) (b) Charting will be done every shift for at least forty-eight (48) hours or until the resident returns to preaccident status or stable condition, whichever is longer;

   1. (ii)
5. (a) (a) Significant changes in the resident’s physical, mental, or psychosocial status, i.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.

6. (b) (b) Charting will be required on every shift until the resident's condition becomes stable;

   1. (iii) 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);

      1. (iv)
7. (a) (a) Use of physical restraints to include the type applied, time of application, checks, releases, and exercise of resident.

8. (b) (b) Flow sheet may be used;

   1. (v)

9. (a) (a) Bedtime snacks for therapeutic diets and physician ordered supplemental feedings to include:

   1. (1) (1) The type;
   2. (2) (2) Amount served; and
   3. (3) (3) Amount consumed.

10. (b) (b) Flow sheet may be used;

    1. (vi)
11. (a) (a) Meal consumption for residents at nutritional risk to include percentage of meal consumed.

12. (b) (b) Flow sheet may be used;

    1. (vii)

13. (a) (a) PRN medications to include:

    1. (1) (1) Name;
    2. (2) (2) Amount;
    3. (3) (3) Route of administration;
    4. (4) (4) Time;
    5. (5) (5) Reason given; and
    6. (6) (6) Response.

14. (b) (b) 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;

    1. (viii)

15. (a) (a) Foley catheters to include documentation of:

    1. (1) (1) Insertion;
    2. (2) (2) Reinsertion;
    3. (3) (3) Removal; and
    4. (4) (4) Catheter irrigations.

16. (b) (b) The total amount of urinary output must be documented, at a minimum, every eight (8) hours.

    1. (c) (c) Flow sheet may be used;

       1. (ix)

17. (a) (a) Nasogastric or gastrostomy tubes to include documentation of:

    1. (1) (1) Insertion;
    2. (2) (2) Reinsertion;
    3. (3) (3) Removal;
    4. (4) (4) Placement checks;
    5. (5) (5) Care of site;
    6. (6) (6) Type of formula;
    7. (7) (7) Amount of formula;
    8. (8) (8) Rate of feeding; and
    9. (9) (9) Flushes.

18. (b) (b) Total fluid intake must be documented, at a minimum, every eight (8) hours to include formula and flushes.

    1. (c) (c) Flow sheet may be used;

       1. (x)
19. (a) (a) Problem skin conditions to include date of onset and weekly progress notes.

20. (b) (b) Documentation must identify the skin problem, stage, size, color, odor, and drainage, if any.

    1. (c) (c) The chart shall also document the date and time of treatments and dressings.

       1. (d) (d) Flow sheet may be used;

          1. (xi) Physician visits to include date of visit;
          2. (xii) Any contacts with the physician (date and time) regarding the resident's condition and the physician's response/instructions;
          3. (xiii) Resident’s condition on discharge or transfer;
          4. (xiv) Disposition of personal belongings and medications upon discharge; and
          5. (xv) Time of death of a resident, the name of person pronouncing death, and disposition of the body.
       2. (B) If a flow sheet is utilized for documentation under subdivision (e)(1) of this section, it is only necessary to document a summarization on the nurse's progress notes based on the time frequencies in subdivision (a)(4) of this section.
    2. (6) Vital signs must be charted weekly and weights monthly unless ordered more frequently (flow sheet may be used).

21. (b) Routine care and services.

    1. (1) Each patient in the home shall receive the type of nursing care, including restorative nursing, as required by his or her condition.

    2. (2) Patients shall be encouraged to:

       1. (A) Be active;
       2. (B) Develop techniques for self-help; and
       3. (C) Be stimulated to develop hobbies and interests.

    3. (3) Criteria for determining adequate and proper care includes:

       1. (A) Kind and considerate care and treatment at all times;

       2. (B)

          1. (i) A minimum of a complete bath twice a week for all ambulatory patients with adequate assistance or supervision as needed.
          2. (ii) 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.
          3. (iii) All soiled linen or clothing shall be replaced with clean, dry linen or clothing;

       3. (C)

          1. (i) A minimum of one (1) shampoo every week and assistance with daily hair grooming.
          2. (ii) Patients shall not be required to pay for routine hair grooming provided by facility staff;

       4. (D)

          1. (i) Assistance with or supervision of shaving of men patients at least every other day except when contraindicated or refused by the patient.
          2. (ii) Patients shall not be required to pay for routine shaving;
       5. (E) Oral care shall be provided at least twice a day;

       6. (F)

          1. (i) Hands and feet shall have proper care and attention.
          2. (ii) Nails shall be kept clean and trimmed.
          3. (iii) Additional lotion shall be applied to hands and feet when indicated.
          4. (iv) Precautions shall be taken to prevent foot drop in bed patients;

       7. (G) Bed linens shall be:

          1. (i) Changed weekly or more often as needed; and
          2. (ii) Adjusted at least daily;

       8. (H) Patients shall have clean and seasonal clothing as needed to:

          1. (i) Present a neat and clean appearance;
          2. (ii) Be free of odors; and
          3. (iii) Be comfortable;

       9. (I)

          1. (i) Measures shall be taken toward the prevention of pressure sores, and if they exist, treatment shall be given on written medical order.
          2. (ii) The position of bed patients shall be changed every two (2) hours during the day and night;

       10. (J)

           1. (i) Each mattress and pillow shall be moisture proof or must have a moisture proof cover.
           2. (ii) Rubber or plastic sheets shall be cleaned often to prevent accumulation of odors.
           3. (iii) Clean cloth draw sheets shall be used over the rubber or plastic sheet;

       11. (K)

           1. (i) Assistance with the use of commode, bedpan, or toilet, and keeping the commode, bedpan, and urinal clean and free of odors.
           2. (ii) Bedpans, urinals, and wash basins shall be:
22. (a) (a) Name-labeled;

23. (b) (b) Cleaned after each use;

    1. (c) (c) Properly stored in the patient's bedside cabinet; and

       1. (d) (d) Sanitized at least weekly.

          1. (iii) Any of these utensils not name-labeled and stored in individual bedside cabinets must be sterilized after each use;
       2. (L) 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 or her to remain in bed;

       3. (M)

          1. (i) Fluids shall be offered at frequent intervals when the patient is unable to obtain them.
          2. (ii)
24. (a) (a) Water pitchers shall be refilled at least once each shift and should be kept in reach of patients.

25. (b) (b) Clean drinking glasses shall be kept with each water pitcher;

    1. (N)

       1. (i) Physical findings (temperature, pulse, respiration, and blood pressure) shall be taken and recorded as ordered by the physician, but not less frequently than one (1) time a week.

          1. (ii) All residents with indwelling catheters should have urine output recorded each shift;
       2. (O) Administration of oxygen;
       3. (P) Documentation that a continuous program of bowel or bladder training is provided when appropriate;
       4. (Q) Proper bed and chair positioning;

       5. (R) Nursing equipment is:

          1. (i) In sufficient supply;
          2. (ii) In good condition;
          3. (iii) Properly cleaned and cared for;
          4. (iv) Well organized; and
          5. (v) Readily available;

       6. (S)

          1. (i) Precautions to ensure the safety of patients are continuously in effect.
          2. (ii) See also 20 CAR § 400-402 regarding restraints;
       7. (T) Bedside nursing care;
       8. (U) Administration of hypodermic medications as prescribed; and

       9. (V)

          1. (i) Rehabilitation programs such as physical therapy, occupational therapy, speech therapy, etc., as required by written physician orders.
          2. (ii) Such therapies must be administered by qualified persons.
          3. (c) Skilled nursing facilities.

    2. (1) In addition, the following services will be required in skilled nursing facilities:

       1. (A) Intravenous feedings;
       2. (B) Complex dressings;
       3. (C) Skilled nursing care; and
       4. (D) Tube feedings.
    3. (2) There will be no administration of blood in the nursing home unless the nursing home is physically connected to a hospital.
    4. (3) In any nursing home administering blood, a registered nurse must be on duty throughout the entire administration.

Codification Notes: “PRN” means pro re nata, a Latin phrase meaning “as necessary” or “as needed”.