1. NORTH AMERICAN HEALTHCARE UPDATE OF NURSING SERVICES

2. POLICY  Facility through nursing & other services ensures that resident reaches his/her highest level of functioning.  Goals Recognize the limits of the disease Recognize the limits of the disease Normal aging process Normal aging process Resident’s right to treatment/refusal of: Resident’s right to treatment/refusal of: TreatmentTreatment Resident safetyResident safety

3.  Skilled care and rehabilitation/restorative services are provided based on: Strength & needs; Strength & needs; Has a treatment plan directed to increasing resident’s improvement Has a treatment plan directed to increasing resident’s improvement Prevention of accidents and maintenance of a safe environment Prevention of accidents and maintenance of a safe environment

4. COMPREHENSIVE FUNCTIONAL ASSESSMENT (MDS)  Facility shall complete a MDS which describes: Capability to perform daily life functions; Capability to perform daily life functions; Significant impairments in functional capacity; Significant impairments in functional capacity; Ongoing assessment of resident’s health and psychosocial status and changes in condition; Ongoing assessment of resident’s health and psychosocial status and changes in condition; Safety. Safety.

5. CARE PLAN  Shall be based on: Initial comprehensive assessment; Initial comprehensive assessment; Interdisciplinary Team’s decision; Interdisciplinary Team’s decision; Interim conditions that require care and treatment services and unrelated risks. Interim conditions that require care and treatment services and unrelated risks.

6. IN-SERVICE EDUCATION  Continuing in-service education program: Conducted for all nursing personnel Conducted for all nursing personnel Thorough job orientation for new personnel Thorough job orientation for new personnel Skill training for non-professional personnel shall begin at the time of orientation Skill training for non-professional personnel shall begin at the time of orientation Also, refer to Nursing Assistant Program Also, refer to Nursing Assistant Program

7. IN-SERVICE EDUCATION -2  Planned in-service programs: Conducted regularly; Conducted regularly; Documented in writing (content, instructor, teaching aides employed, attendance) Documented in writing (content, instructor, teaching aides employed, attendance) Include: Include: Demonstration;Demonstration; Practice;Practice; Supervision.Supervision.

8. IN-SERVICE EDUCATION -3  Orientation shall include but shall not be limited to: Emergency procedures; Emergency procedures; Residents’ rights; Residents’ rights; Skills required; Skills required; Protection of health information (HIPAA); Protection of health information (HIPAA); Abuse prevention/reporting; Abuse prevention/reporting; Sanction policies/procedures (HIPAA); Sanction policies/procedures (HIPAA); Physician reporting and Resident Safety Plan. Physician reporting and Resident Safety Plan.

9. UNUSUAL OCCURRENCE(S) - REPORTING  Nursing to notify the attending physician of unusual occurrences that affect or potentially affect the care and services to residents. Changes in condition; Changes in condition; Safety reportable events; Safety reportable events; Medication errors; Medication errors; Need to alter treatment significantly; Need to alter treatment significantly; Other significant resident events; Other significant resident events; Any epidemic outbreaks; Any epidemic outbreaks; And others (see Admin #7005). And others (see Admin #7005).

10. RESIDENT SAFETY (See Safety Plan)  During care and services, all staffs shall follow the infection control system policies & procedures Use proper hand hygiene programs; Use proper hand hygiene programs; Reduce suffering from preventable events; Reduce suffering from preventable events; Report events to the Quality Assurance Committee via Infection Control / Resident Safety Review. Report events to the Quality Assurance Committee via Infection Control / Resident Safety Review.

11. RESIDENT SAFETY (See Safety Plan) -2  Resident Safety Program Foremost Foremost Staffs are trained report & monitor unsafe conditions; Staffs are trained report & monitor unsafe conditions; Resident events that might affect resident safety Resident events that might affect resident safety Observing urine outputObserving urine output Site of tubes such as G-tubes;Site of tubes such as G-tubes; Patient safety of peripheral devicesPatient safety of peripheral devices Wheelchairs and any other patient related equipmentWheelchairs and any other patient related equipment Pumps;Pumps; Appropriate positioning of healthcare tubesAppropriate positioning of healthcare tubes

12. RESIDENT SAFETY (See Safety Plan) -3  Resident Safety Program Resident events that might affect resident safety (cont.) Resident events that might affect resident safety (cont.) Resident protectionsResident protections Care management environmental and criminal eventsCare management environmental and criminal events

13. ASSESSMENT AT DISCHARGE  Discharge information: Completed in conjunction with ancillary services such as social services and activities Completed in conjunction with ancillary services such as social services and activities Provide sufficient information to ensure continuity of care Provide sufficient information to ensure continuity of care  POLST form: Completed: Completed: At admissionAt admission During stayDuring stay At dischargeAt discharge Original form shall be sent with the resident. Original form shall be sent with the resident.

14. ASSESSMENT ON TRANSFER TO ACUTE HOSPITAL  Resident is sent to an acute hospital: Final nursing note shall include clinical documentation that describes: Final nursing note shall include clinical documentation that describes: AssessmentAssessment Care and services providedCare and services provided Relevant dates and timesRelevant dates and times Interfacility Transfer Record Interfacility Transfer Record Notations of any copies from the health record that were sent with the residentNotations of any copies from the health record that were sent with the resident POLST form shall be sent with the resident if one is in effectPOLST form shall be sent with the resident if one is in effect