77 Ill. Adm. Code 380.620
Health/Nursing Services
Section 380.620Â Health/Nursing Services
a)Â Â Â Â Â Â Â Â The
licensee shall ensure sufficient nursing services to meet the needs of all
consumers being served by the facility. Licensed nursing staff shall perform
nursing services within the scope of their licenses, and the nursing services
shall be consistent with the care requirements for each respective level of
service, including time frames, as described in Subpart B. Services shall
include, but not be limited to, the following:
1)Â Â Â Â Â Â Â Â Nursing
participation in the formulation of an interdisciplinary treatment plan, which
shall include identification of nursing care needs based upon an initial
written nursing evaluation of the consumer's needs with input, as necessary,
from health professionals involved in the care of the consumer. The initial
nursing care needs, including the physical evaluation required in Section
380.610(b)(1), shall commence at the time of admission of the consumer and be
completed within seven days after admission;
2)Â Â Â Â Â Â Â Â The
implementation of each consumer's treatment plan according to the methods
indicated, with ongoing monitoring and documentation of the effectiveness of
the plan, and participation in consumer treatment plan conferences for review
and modification of each consumer's treatment plans;
3)Â Â Â Â Â Â Â Â Ensuring
that the dietary department receives dietary orders that are prescribed by
physicians or dieticians;
4)Â Â Â Â Â Â Â Â Obtaining
and documenting physician orders for medical care, appointments and laboratory
workups and tests, administration of medications, including pro re nata (PRN)
and immediately authorized or emergency (STAT) medications;
5)Â Â Â Â Â Â Â Â Implementation
and evaluation of quality improvement policies and procedures;
6)Â Â Â Â Â Â Â Â The
writing, review and signoff of progress notes and notes regarding any change in
a consumer's condition; and
7)Â Â Â Â Â Â Â Â Notifying
the physician promptly of:
A)Â Â Â Â Â Â Â The
admission of a consumer;
B)Â Â Â Â Â Â Â Any
sudden, marked or adverse change in signs, symptoms or behavior exhibited by a
consumer;
C)Â Â Â Â Â Â Â An
unusual incident involving a consumer, as specified in Section 380.530;
D)Â Â Â Â Â Â Â Any
adverse response or reaction by a consumer to a medication or treatment;
E)Â Â Â Â Â Â Â Any
error in the administration of a medication or treatment to a consumer that is
life threatening or that presents a risk to a consumer; and
F)Â Â Â Â Â Â Â Â The
facility's inability to obtain or administer, on a prompt and timely basis,
drugs, equipment, supplies or services as prescribed.
b)Â Â Â Â Â Â Â Â All
attempts to notify physicians shall be noted in the consumer's record,
including the time and method of communication and the name of the person
acknowledging contact, if any. If the physician is not readily available,
emergency medical care shall be arranged immediately.
c)
If
a facility orders transportation of a consumer of the facility by ambulance,
then the facility must maintain a written record that shows the name of the
person who placed the order for that transportation and the medical reason for
that transportation.
(Section 3-212 of the Act)
d)Â Â Â Â Â Â Â Â Under
the supervision of licensed nursing staff, an RSA shall monitor the following:
1)Â Â Â Â Â Â Â Â Assisting
consumers with dressing, grooming, bathing and personal hygiene related
activities, as needed; and
2)Â Â Â Â Â Â Â Â Measuring
and recording a consumer's height, weight and vital signs, including
temperature, blood pressure and pulse, on admission. At a minimum, vital signs
and weight shall be taken weekly for four weeks and then monthly. Weights and
vital signs shall be charted in a format that allows for trending and
patterning over time. Any clinically significant worsening shall be reported
to the physician to assess the need for increased monitoring.