Section 340.1300 Facility Policies

Section 340

Section 340.1300  Facility

Policies

a)         The facility shall have written policies and procedures

governing all services provided by the facility.  The written policies and

procedures shall be formulated with the involvement of the administrator.  The

policies shall comply with the Act and this Part.  The written policies shall

be followed in operating the facility and shall be reviewed at least annually

by the facility's advising physician or the medical advisory committee, as

evidenced by a dated signature.

b)         An advisory physician, or a medical advisory committee

composed of physicians, shall be responsible for advising the administrator on

the overall medical management of the residents and the staff of the facility.

c)         All of the information contained in the policies shall be

available to the public, staff and residents, and for review by the Department.

d)         The written policies shall include, at a minimum, the

following provisions:

1)         Admission, transfer, and discharge of residents, including the

types of services offered by the facility that would cause residents to be

admitted, transferred or discharged, and transfers within the facility from one

room to another;

2)         Resident care services, including physician services,

emergency services, personal care and nursing services, restorative services,

activity services, pharmaceutical services, dietary services, social services,

clinical records, dental services, and diagnostic services (including

laboratory and x-ray);

3)         A policy prohibiting blood transfusions, unless the facility

is hospital based and appropriate services are available in case of an adverse

reaction to the transfusions; and

4)

A

policy to identify, assess, and develop strategies to control risk of injury to

residents and nurses and other health care workers associated with the lifting,

transferring, repositioning, or movement of a resident

A policy prohibiting blood transfusions, unless the facility

is hospital based and appropriate services are available in case of an adverse

reaction to the transfusions; and

4)

A

policy to identify, assess, and develop strategies to control risk of injury to

residents and nurses and other health care workers associated with the lifting,

transferring, repositioning, or movement of a resident.  The policy shall

establish a process that, at a minimum, includes all of the following:

A)

Analysis

of the risk of injury to residents and nurses and other health care workers

taking into account the resident handling needs of the resident populations

served by the facility and the physical environment in which the resident

handling and movement occurs.

B)

Education

of nurses in the identification, assessment, and control of risks of injury to

residents and nurses and other health care workers during resident handling.

C)

Evaluation

of alternative ways to reduce risks associated with resident handling,

including evaluation of equipment and the environment.

D)

Restriction,

to the extent feasible with existing equipment and aids, of manual resident

handling or movement of all or most of a resident's weight, except for

emergency, life-threatening, or otherwise exceptional circumstances.

E)

Procedures

for a nurse to refuse to perform or be involved in resident handling or

movement that the nurse, in good faith, believes will expose a resident or

nurse or other health care worker to an unacceptable risk of injury.

F)

Development

of strategies to control risk of injury to residents and nurses and other

health care workers associated with the lifting, transferring, repositioning,

or movement of a resident

o refuse to perform or be involved in resident handling or

movement that the nurse, in good faith, believes will expose a resident or

nurse or other health care worker to an unacceptable risk of injury.

F)

Development

of strategies to control risk of injury to residents and nurses and other

health care workers associated with the lifting, transferring, repositioning,

or movement of a resident.

G)

Consideration

of the feasibility of incorporating resident handling equipment or the physical

space and construction design needed to incorporate that equipment when

developing architectural plans for construction or remodeling of a facility or

unit of a facility in which resident handling and movement occurs.

(Section

3-206.05 of the Act)

e)         For the purposes of

subsection (d)(4):

1)         "

Health

care worker" means an individual providing direct resident care services

who may be required to lift, transfer, reposition, or move a resident.

2)

"Nurse"

means an advanced practice nurse, a registered nurse, or a licensed practical

nurse licensed under the Nurse Practice Act.

(Section 3-206.05 of the Act)

f)         The facility shall have a written agreement with one or more

hospitals to provide diagnostic, emergency and routine acute care hospital

services.  The Department will waive this requirement if the facility can

document  that it is unable to meet the requirement because of its remote

location or refusal of local hospitals to enter an agreement.

g)         The advisory physician or medical advisory committee shall

develop policies and procedures to be followed during the various medical

emergencies that may occur from time to time in a facility

epartment will waive this requirement if the facility can

document  that it is unable to meet the requirement because of its remote

location or refusal of local hospitals to enter an agreement.

g)         The advisory physician or medical advisory committee shall

develop policies and procedures to be followed during the various medical

emergencies that may occur from time to time in a facility. These medical

emergencies include, but are not limited to:

1)         Pulmonary emergencies (for example, airway obstruction,

foreign body aspiration, and acute respiratory distress, failure or arrest);

2)         Cardiac emergencies (for example, ischemic pain, cardiac

failure or cardiac arrest);

3)         Traumatic injuries (for example, fractures, burns or

lacerations);

4)         Toxicologic emergencies (for example, untoward drug reactions

or overdoses); and

5)         Other medical emergencies (for example, convulsions or shock).

h)         The facility shall maintain in a suitable location the

equipment to be used during the emergencies detailed in subsection (g) of this

Section. This equipment shall include, at a minimum, a portable oxygen kit,

including a face mask or cannula, an airway, and a bag-valve-mask manual

ventilating device.