R432-300-9. Facility Records

(1) The licensee shall: (a) maintain accurate and complete records that are filed, stored safely, and are easily accessible to staff and the department; (b) ensure records are protected against access by unauthorized individuals; (c) maintain personnel records for each employee that are kept for at least three years after employment termination and include the following content: (i) an employee application; (ii) the date of employment and initial policies and procedures orientation; (iii) the termination date; (iv) the reason for leaving; (v) documentation of CPR, first aid, and emergency procedures training; (vi) a health inventory; (vii) a food handlers permit; (viii) tuberculosis skin test documentation; (ix) documentation of criminal background check; and (x) certifications, registration, and licenses as required. (2) The licensee shall maintain in the facility a separate record for each resident that includes the following: (a) the resident's name, date of birth, and last address; (b) the name, address, and telephone number for: (i) the person who administers and obtains medications, if this is not facility staff; (ii) the individual to be notified in case of accident or death; and (iii) a physician and dentist to be called in an emergency; (c) any known allergies; (d) the admission agreement; (e) a copy of an advanced directive or living will initiated by the resident; (f) a physician's assessment; (g) a resident assessment; (h) a written plan of care; (i) physician orders; (j) daily nursing notes that include: (i) temperature; (ii) pulse; (iii) respirations; (iv) blood pressure; (v) height; and (vi) weight notations when indicated or as needed due to a change in the resident's condition; (k) a record of any resident cash, resources, or valuables entrusted to the facility; and (l) incident and accident reports. (3) The licensee shall retain resident records for at least seven years following discharge.