Section 390.1040 Nursing Services

Section 390

Section 390.1040  Nursing

Services

a)         The facility shall have a written program of Nursing Services,

providing for a planned medical program, encompassing nursing treatments,

rehabilitation and habilitation nursing, skilled observations, and ongoing

evaluation and coordination of the resident's individual habilitation plan.

b)         There shall be a sufficient number of nursing and auxiliary

personnel on duty 24 hours each day to provide adequate and properly supervised

nursing services to meet the nursing needs of the residents.  There shall be at

least one registered professional nurse on duty seven days a week, for 8

consecutive hours.  There shall be at least one registered professional nurse

or licensed practical nurse on duty at all times and on each floor housing

residents.  Nursing staff personnel shall include registered professional

nurses, licensed practical nurses, and auxiliary personnel as defined in

Section 390.330.

c)         There shall be a director of nursing who shall be a registered

professional nurse.

d)         The director of nursing shall have knowledge and training in

nursing service administration, restorative and habilitative nursing.

e)         The director of nursing shall be a full-time employee who is

on duty a minimum of 36 hours, four days per week.  At least 50 percent of this

person's hours shall be regularly scheduled between 7 A.M. and 7 P.M.

1)         A facility may, with written approval from the Department,

have two registered professional nurses share the duties of this position if it

is unable to obtain a full-time person.  Such an arrangement will be granted

approval only through written documentation that the facility was unable to

obtain the full-time services of a qualified individual to fill this position

A.M. and 7 P.M.

1)         A facility may, with written approval from the Department,

have two registered professional nurses share the duties of this position if it

is unable to obtain a full-time person.  Such an arrangement will be granted

approval only through written documentation that the facility was unable to

obtain the full-time services of a qualified individual to fill this position.

Documentation shall include, but not be limited to: an advertisement that has

appeared in a newspaper of general circulation in the area for at least three

weeks; the names, addresses and phone numbers of all persons who applied for

the position and the reasons why they were not acceptable or would not work

full-time; and information about the number and availability of registered professional

nurses in the area. The Department will grant approval only when such

documentation indicates that there were no qualified applicants who were

willing to accept the job on a full-time basis, and the pool of registered professional

nurses available in the area cannot be expected to produce, in the near future,

a qualified person who is willing to work full-time.  If two persons are to

share the position, one shall be designated the Director of Nursing Services

and the other shall be designated the Assistant Director of Nursing Services.

Both of these persons shall be registered professional nurses.

2)         In facilities with a capacity of less than 50 beds, this

person (or these persons), may also provide direct patient care, and this

person's time may be included in meeting the staff-to-resident ratio

requirements.

f)         In facilities with 100 occupied beds or more, there shall be

an assistant director of nursing who is a registered professional nurse

licensed to practice in Illinois. The assistant must meet the qualifications

specified in subsection (d).

g)         The assistant director of nursing shall be a full-time

employee who is on duty a minimum of 36 hours, four days per week

requirements.

f)         In facilities with 100 occupied beds or more, there shall be

an assistant director of nursing who is a registered professional nurse

licensed to practice in Illinois. The assistant must meet the qualifications

specified in subsection (d).

g)         The assistant director of nursing shall be a full-time

employee who is on duty a minimum of 36 hours, four days per week.  The

assistant director of nursing is not required to work on the day shift but may

be assigned to any shift.

h)         The assistant director of nursing shall assist the director of

nursing in carrying out the director's responsibilities.

i)          The responsibilities of the director of nursing shall

include, at a minimum, the following:

1)         Assigning and directing the activities of nursing and

auxiliary service personnel.

2)         Planning an up-to-date resident care plan for each resident in

cooperation with the interdisciplinary team based on individual needs and goals

to be accomplished, physician's orders, and personal care and nursing needs.

Services such as nursing, developmental, activities, dietary, and such other

modalities as are ordered by the physician, shall be reflected in the

preparation of the resident care plan.  The plan shall be in writing and shall

be reviewed and modified in keeping with the care needed as indicated by the

resident's condition.  The plan shall be reviewed every three months.

3)         Recommending to the administrator the number and levels of

nursing personnel to be employed, participating in their recruitment and

selection and recommending termination of employment when necessary.

4)         Participating in planning and budgeting for nursing services

including purchasing of necessary equipment and supplies.

5)         Developing and maintaining nursing service objectives,

standards of nursing practice, written policies and procedures, and written job

descriptions for each level of nursing and auxiliary personnel

and recommending termination of employment when necessary.

4)         Participating in planning and budgeting for nursing services

including purchasing of necessary equipment and supplies.

5)         Developing and maintaining nursing service objectives,

standards of nursing practice, written policies and procedures, and written job

descriptions for each level of nursing and auxiliary personnel.

6)         Coordinating health services and nursing services with other

resident care services such as medical, pharmaceutical, dietary activities, and

any other restorative and habilitative services offered.

7)         Planning and implementation of in-service education, embracing

orientation, skill training, and ongoing education for all nursing personnel

covering all aspects of resident care and programming.  The educational program

shall include training and practice in activities and restorative and

habilitative nursing techniques through out-of-facility or in-facility training

programs.  The director of nursing may conduct these programs personally or see

to it that they are carried out.

8)         Participating in the development and implementation of

resident care policies and bringing resident care problems, requiring changes

in policy, to the attention of the facility's policy development group.  (See

Section 390.610(a).)

9)         Participating in the screening of prospective residents and

their placement in terms of services they need and nursing competencies

available.

j)          Nursing care (including personal, habilitative and

rehabilitative care measures) shall be practiced on a 24 hour, seven day a week

basis in the care of residents.  Those procedures requiring medical approval

shall be ordered by the attending physician.

k)         Nursing care shall include at a minimum the following:

1)         Proper administration of all medications including oral,

rectal, hypodermic, and intra-muscular

nal, habilitative and

rehabilitative care measures) shall be practiced on a 24 hour, seven day a week

basis in the care of residents.  Those procedures requiring medical approval

shall be ordered by the attending physician.

k)         Nursing care shall include at a minimum the following:

1)         Proper administration of all medications including oral,

rectal, hypodermic, and intra-muscular.

2)         Proper administration of all treatments, including:  enemas,

irrigations, catheterizations, applications of dressing or bandages,

supervision of special diets, restorative and habilitative measures, and other

treatments involving a like-level of skill.

3)         Proper documentation of all objective observations of changes

in a resident's condition, including mental and emotional changes, as a means

for analyzing and determining care required and the need for further medical,

nursing or psychosocial evaluation and treatment shall be provided.

l)          Each resident shall have their temperature taken daily unless

otherwise ordered by the physician.  If the temperature varies two degrees from

the normal for the resident, the physician shall be notified.

m)        Skin care shall be given to prevent pressure sores, heat rashes

or other skin breakdown.  Each resident with pressure sores, heat rashes or

other skin breakdown shall be checked at least every two hours and given care

as needed including clothing and diaper changes.  Skin care shall be given with

each diaper change.

n)         Skin care should be provided as follows:

1)         Bathing, clean linens, diapers, and clothing each time the bed

or clothing is soiled.  Rubber, plastic, or other types of linen protectors

(newspapers not acceptable) shall be properly cleaned and completely covered to

prevent direct contact with the resident.  If rubber, plastic, or other type of

waterproof materials are used for protective pants, they shall not come in

direct contact with the resident

ean linens, diapers, and clothing each time the bed

or clothing is soiled.  Rubber, plastic, or other types of linen protectors

(newspapers not acceptable) shall be properly cleaned and completely covered to

prevent direct contact with the resident.  If rubber, plastic, or other type of

waterproof materials are used for protective pants, they shall not come in

direct contact with the resident.  Special attention shall be given to the skin

to prevent irritations, skin rashes, or ulcerations.

2)         Assistance in being up and out of bed as much as the condition

of the resident permits.  The resident may be denied this assistance only upon

the written order of the resident's physician.  If the resident is unable to

change position, the resident's position shall be changed every two hours or

more as necessary.

o)         All necessary precautions shall be taken to ensure the safety

of residents at all times, including, but not limited to use of  nonslip wax on

floors; proper maintenance for all equipment, adaptive equipment and assistive

devices; and proper use of side rails on beds and restraints.

p)         Each resident shall perform all of the following personal care

functions independently if possible.  If unable to do so, assistance shall be

provided by staff.

1)         Bathe as often as necessary, but at least daily.

2)         Change clothing as often as necessary, but at least daily.

3)         Shampoo hair as often as necessary, but at least weekly.

4)         Clean and trim fingernails and toenails as often as necessary

but at least weekly.

5)         Perform oral hygiene as often as necessary, but at least

daily.

6)         Provide commercial sanitary napkins to each female resident during

menses.  Frequent cleansing of the perineal area shall be performed.

q)         Haircuts shall be provided as needed.  Socially acceptable

hair styles and the wishes of the resident must be taken into consideration

cessary

but at least weekly.

5)         Perform oral hygiene as often as necessary, but at least

daily.

6)         Provide commercial sanitary napkins to each female resident during

menses.  Frequent cleansing of the perineal area shall be performed.

q)         Haircuts shall be provided as needed.  Socially acceptable

hair styles and the wishes of the resident must be taken into consideration.

r)          Each resident shall dress in street clothing and be out of

bed at all times other than regularly scheduled sleeping or napping hours,

unless contraindicated.

s)         Each resident shall be weighed upon admission and at least

once a week thereafter unless otherwise ordered in writing by the physician.

Any significant change shall be reported to the attending physician and

dietitian.

t)          Each resident shall be encouraged and, if necessary, assisted

in maintaining good body alignment while lying in bed, sitting or standing,

through proper positioning and turning.

u)         Each resident shall be assisted in maintaining maximum joint

range of motion, and active range of motion through proper exercises.

v)         Each resident shall be trained and encouraged to adopt food

habits as near as possible to normal.  Residents shall receive solids, unless

otherwise ordered in writing by the physician.  Each resident shall eat in as

upright a position as possible and out of bed unless contraindicated.

w)        Each incontinent resident shall be assisted in regaining bowel

and bladder patterns through proper bowel and bladder training or retraining.

The use of indwelling catheters shall be discouraged.

x)         All residents shall be encouraged and, when necessary, taught

to function at their maximum level in all activities of daily living for as

long as and to the degree that they are able.

y)         All residents shall be assisted and encouraged with daily

ambulation unless otherwise ordered by the physician

r training or retraining.

The use of indwelling catheters shall be discouraged.

x)         All residents shall be encouraged and, when necessary, taught

to function at their maximum level in all activities of daily living for as

long as and to the degree that they are able.

y)         All residents shall be assisted and encouraged with daily

ambulation unless otherwise ordered by the physician.

z)         All residents shall be taught and assisted with safe transfer

activities in an effort to help them retain, regain, or gain their maximum

level of independence.

aa)

Facility staffing shall be based on all the needs of the

residents and comply with

the requirements of this Section.

Facilities

shall provide each resident, regardless of age, no less than 4.0 hours of

nursing and personal care time each day.

(Section 2-218 of the Act)

1)         In a facility whose residents participate in regularly

scheduled therapeutic programs outside the facility, such as school or

sheltered workshops, the minimum hours of care that must be provided are

reduced proportionately.

2)         It is the responsibility of each facility to determine the

staffing needed to meet the needs of its residents.

A facility's failure to

comply with

Section 2-218 of the Act,

shall constitute a Type "B"

violation.

(Section 2-218 of the Act)

3)         The director of nursing shall not be included in hours of

personal and habilitative care provided.

4)         The facility shall schedule personnel in such a manner that

the needs of all residents are met.  At least 30 percent of the minimum

required hours shall be on the day shift, at least 30 percent of the minimum

required hours shall be on the evening shift, and at least ten percent of the

minimum required hours shall be on the night shift.  The total percentage must

add up to 100 percent each day.  At least 12.5 percent of the hours of care

provided on each shift must be by licensed nursing personnel

0 percent of the minimum

required hours shall be on the day shift, at least 30 percent of the minimum

required hours shall be on the evening shift, and at least ten percent of the

minimum required hours shall be on the night shift.  The total percentage must

add up to 100 percent each day.  At least 12.5 percent of the hours of care

provided on each shift must be by licensed nursing personnel.  Licensed nursing

personnel may be used to replace other personal and habilitative care staff if

the needs of the residents are met. Personal and habilitative care staff may

include, in addition to licensed nurses, DSPs, aides, orderlies, therapists,

teachers, and any other person providing direct habilitative care to residents.

5)         Staffing Calculations

A)        When computing the number of staff hours needed per shift, any

figure less than .25 will be dropped from the computation and any figure of .75

or higher will be rounded to the next higher number.  Figures that fall between

.25 and .75 will require at least the amount of coverage indicated:  .25 will

require two hours of coverage; .3 will require two and one half hours of

coverage; .5 will require four hours of coverage; .6 will require five hours of

coverage; .74 will require six hours of coverage; .75 or higher will require

eight hours of coverage.

B)        These hours may be provided by:  a part-time person working

those hours only on that shift each day; a full-time person working a shift

that spans two regular shifts (such as from 12 noon to 8 P.M.); or by an

additional full-time person on the shift.  However, these figures represent

minimum staffing requirements, and it is recommended that a full-time person be

provided.

bb)       In addition to the other requirements of this Section, the

following also apply:

1)         There shall be a licensed nurse designated as being in charge

of nursing services on all shifts when neither the director of nursing nor

assistant director of nursing are on duty

these figures represent

minimum staffing requirements, and it is recommended that a full-time person be

provided.

bb)       In addition to the other requirements of this Section, the

following also apply:

1)         There shall be a licensed nurse designated as being in charge

of nursing services on all shifts when neither the director of nursing nor

assistant director of nursing are on duty.  If registered professional nurses

and licensed practical nurses are on duty on the same shift, this person shall

be a registered professional nurse. This person may be a charge nurse on one of

the nursing units.

2)         There shall be at least one person awake, dressed and on duty

at all times in each separate nursing unit.

3)         There shall be at least one registered professional nurse on

duty seven days per week, 8 consecutive hours per day.

4)         There shall be at least one registered professional nurse or

licensed practical nurse on duty at all times.

5)         There shall be at least one registered professional nurse or

licensed practical nurse on duty on each floor housing residents.

6)         The need for licensed nurses on each nursing unit will be

determined on an individual case basis, dependent upon the individual

situation.  If such additional staffing is required, the Department will inform

the facility in writing of the kind and amount of additional staff time

required, and the reason why it is needed.

7)         The need for an additional licensed nurse to serve as a

"house supervisor" will be determined on an individual case basis.

If the Department determines that there is a need for a registered professional

nurse on certain shifts whose sole duties will consist of supervising the

nursing services of the facility, the Department shall notify the facility in

writing regarding this determination.  This person shall not perform the duties

of a charge nurse while serving as the "house supervisor".