OAR 411-086-0120: Nursing Services: Changes of Condition

(1) Change of Condition (Generally). Nursing staff shall observe, assess, document, and report to the DNS and the resident’s physician any significant change in resident condition that warrants medical or nursing intervention, including any significant change in: (a) Vital signs; (b) Skin integrity (i.e., decubitus ulcer); (c) Hydration; (d) Ability to take or retain food or fluids; (e) Weight gain/loss; (f) Bowel or bladder function; (g) Behavior; (h) Level of comfort (i.e., pain, injury); or (i) Level of consciousness. (2) Acute Condition Change. The nursing staff shall ensure that any significant and acute condition change is promptly assessed and documented by a registered nurse and that appropriate measures are immediately instituted. (3) Documentation. Documentation shall include assessment, appropriate interventions, monitoring and outcome until point of resolution.