Oversight of resident care by a registered nurse

Due to the increasing needs of the seniors, we care for in the assisted living setting it is imperative for a registered nurse to be involved with the clinical oversight of the community. In the state of West Virginia, you may either employee a RN within the facility staff or contract with a nurse to work as needed. Having a nurse on-site will allow your community to have superior clinical care and ultimately ensure compliance with the following regulation provided by OHFLAC:

6.6.  Limited and Intermittent Nursing Care.

 

6.6.1.  The licensee shall arrange for a registered professional nurse to assume responsibility for the oversight of nursing care and services.  Arrangements for nursing services may be made by contract with a registered nurse or a nursing service with a management entity, or the licensee may employ a registered nurse.  Arrangements with a home care agency will satisfy the requirement for nursing oversight if they meet all the requirements of this section.  (Class I)

 

6.6.2.  The licensee shall ensure that the registered nurse is notified immediately when a resident with nursing care needs is admitted or readmitted, and immediately when a nursing care need for a current resident is identified. Documentation of the notification shall be in the resident’s record.  (Class I)

 

6.6.3.  The licensee shall implement the recommendations of the registered nurse regarding care, services, and staff training.  (Class I)

 

6.6.4.  Unless the licensee employs a full-time registered nurse, he or she shall ensure that the registered nurse maintains a record with an entry for each visit which shall include at least the date, time in, and time out; a list of duties performed during each visit; a brief statement regarding identified concerns and recommended actions taken to resolve them; and a complete signature.  (Class III)

 

6.6.5.  The licensee shall develop a plan that provides for 24-hour accessibility between the residence, the registered nurse, and other emergency personnel.  (Class I)

 

6.6.6.  A registered nurse shall perform and document a nursing assessment for each resident with nursing needs within 24 hours following admission and update the assessment at the time of any significant, temporary, or permanent change in the resident’s condition.  (Class I)

 

6.6.7.  A registered nurse shall develop and document a service plan to meet any identified nursing and medical needs of the resident within seven days after admission and shall update the plan at the time of a significant temporary or permanent change in condition.  (Class I)

 

6.6.8.  A registered nurse shall see the resident weekly, if the resident has nursing care needs, and more often if indicated by the needs of the resident, and document a progress note in the resident’s record reflecting the status of the resident and any changes in his or her condition.  (Class II)

 

6.6.9.  A registered nurse shall provide needed training or recommend to the licensee appropriate training for staff, including when to contact the registered nurse regarding changes in a resident’s condition.  (Class II)

 

6.6.10.  A registered nurse shall participate in the decision to admit or discharge a resident with nursing care needs.  (Class II)

Top Takeaways:

  • 6.6. A registered nurse shall perform and document a nursing assessment for each resident with nursing needs within 24 hours following admission and update the assessment at the time of any significant, temporary, or permanent change in the resident’s condition.  (Class I)

Every resident who is deemed to require nursing care shall be assessed by the community nurse within 24 hours following admission along with a reassessment during any change in medical condition. Without a doubt, OHFLAC inspectors will review the medical records of any resident who is receiving nursing services. Your team must review these files on a consistent basis to ensure you are in compliance.

  • 6.7. A registered nurse shall develop and document a service plan to meet any identified nursing and medical needs of the resident within seven days after admission and shall update the plan at the time of a significant temporary or permanent change in condition.  (Class I)

In the same token as subsection 6.6.6 a service plan shall be developed for every resident admitted into the facility. This service plan is built to identify all the care needs a resident will require from your team while living in the facility. Again, this service plan must be updated with every change in resident condition.

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