OAR 333-071-0480: Nursing Care Management

(1) The nursing care of each patient in a health care facility shall be the responsibility of a registered nurse (RN). (2) The RN will only provide services to the patients for which she or he is educationally and experientially prepared and for which competency has been maintained. (3) The RN shall be responsible and accountable for managing the nursing care of her or his assigned patients. She or he shall only assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. The responsible RN shall ensure that the following activities are completed: (a) Document the admission assessment of the patient within four hours following admission and initiate a written plan of care. This shall be reviewed and updated whenever the patient’s status changes. (b) Develop and document, within eight hours following admission, a plan of care for nursing services for the patient, based on the patient assessment and realistic, understandable, achievable patient goals consistent with the applicable rules in OAR chapter 851, division 45. (c) Observe and report to the nurse manager and the patient's physician or other health care provider authorized by law, when appropriate, any significant changes in the patient's condition that warrant interventions that have not been previously prescribed or planned for. (d) When the RN questions the efficacy, need or safety of continuation of medications being administered to a patient, the RN shall report that question to the physician or other responsible health care provider authorized by law authorizing the medication and shall seek further instructions concerning the continuation of the medication. (4)(a) An SICF shall maintain documentation of certification of certified nursing assistants (CNA's), which shall be available on request to Authority personnel. (b) A nursing assistant who works in an SICF must be certified prior to assuming nursing assistant duties in accordance with OAR chapter 851, division 62. (c) An SICF shall maintain documentation that CNAs, whose function includes administration of non-injectable medications, are qualified.