OAR 411-050-0750: Records - Resident

(1) An individual resident record must be developed, kept current, and readily accessible on the premises of the home for each individual admitted to the AFH. The record must be legible and kept in an organized manner so as to be utilized by staff. (2) The record must contain the following information: (a) A complete initial screening assessment and general information form (SDS 902) as described in OAR 411-051-0110. (b) Documentation on form (SDS 913) that the licensee or administrator has informed private-pay residents of the availability of a long-term care assessment. (c) Documentation on form (SDS 0342A) that the licensee or administrator has oriented the resident to emergency evacuation procedures as described in OAR 411-050-0725(1). (d) Documentation that the licensee or administrator has informed all residents of the right to formulate an Advance Directive. (e) FINANCIAL INFORMATION: (A) Detailed records and receipts, if the licensee manages or handles a resident's money. The Resident Account Record (form SDS 713) or other expenditure forms may be used if the licensee manages or handles a resident's money. The record must show amounts and sources of funds received and issued to, or on behalf of, the resident and be initialed by the person making the entry. Receipts must document all deposits and purchases of $5 or more made on behalf of a resident. (B) Residency Agreement signed and dated by the resident or the resident's representative may be kept in a separate file, but must be made available for inspection by the LLA. (f) Medical and legal information, including, but not limited to: (A) Medical history, if available. (B) Current prescribing practitioner orders. (C) Nursing instructions, delegations, and assessments, as applicable. (D) Completed medication administration records retained for at least the last six months or from the date of admission, whichever is less. (Older records may be stored separately). (E) Copies of Guardianship, Conservatorship, Advance Directive for Health Care, Power of Attorney, and Physician's Order for Life Sustaining Treatment (POLST) documents, as applicable. (g) A complete, accurate, and current care plan. (h) Documentation that supports or eliminates any individually-based limitation, as described in OAR 411-051-0115. (i) A copy of the current house policies, as identified in the current Residency Agreement, the current Resident's Bill of Rights, LGBTQIA2S+ Protections, and a copy of the home’s nondiscrimination policy, signed and dated by the resident or the resident's representative. (j) SIGNIFICANT EVENTS AND INCIDENTS. A written report (using form SDS 344 or its equivalent) of all significant incidents relating to the health or safety of the resident, including how and when the incident occurred, who was involved, what action was taken by the licensee and staff, as applicable, and the outcome to the resident. A copy of the report must be sent to the resident’s representative, and case manager, if applicable. (k) NARRATIVE OF RESIDENT'S PROGRESS. Narrative entries describing each resident's progress must be documented at least weekly and maintained in each resident's individual record. All entries must be signed and dated by the person writing them. (l) Non-confidential information or correspondence pertaining to the care needs of the resident. (m) Falsifying records or causing another to do so shall result in issuance of a mandatory civil penalty as described in OAR 411-052-0025(2).