Cal. Code Regs. tit. 9 § 785.12

Current through Register 2024 Notice Reg. No. 25, June 21, 2024

Section 785.12 - Nursing Service-General

(a) Licensed nursing staff shall perform the following nursing services within the scope of their license; services shall include, but not be limited to, the following:

(1) Planning of client care which shall include at least the identification of care needs based upon an initial written and continuing evaluation of the client's needs with input, as necessary, from health professionals involved in the care of the client. Initial evaluation shall commence at the time of admission of the client and be completed within seven (7) days after admission.

(2) Implementing of each client's care plan according to the methods indicated which shall include at a minimum, initial assessment and documentation, ongoing evaluations and documentation, and preparing for and attending client care plan conferences.

(3) Ensuring that clients are served the diets as prescribed by physicians.

(4) Obtaining and documenting physician orders for medical care, appointments and laboratory work-ups or tests, administration of medications including PRN (pro rae natae) and immediately authorized or emergency (STAT) medications.

(5) Monitoring of clients' height and weight, and vital signs.

(6) Implementation and evaluation of quality assurance policies and procedures addressing client care.

(7) Writing, review and sign off of weekly progress notes.

(8) Notifying the physician promptly of:

(A) The admission of a client.

(B) Any sudden marked adverse change in signs, symptoms or behavior exhibited by a client.

(C) An unusual occurrence involving a client, as specified in Section 784.15.

(D) A change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the client's physician.

(E) Any adverse response or reaction by a client to a medication or treatment.

(F) Any error in the administration of a medication or treatment to a client which is life threatening and presents a risk to the client.

(G) The mental health rehabilitation center's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the client.

(H) All attempts to notify physicians shall be noted in the client'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, arrangements for emergency medical care shall be completed.

(b) Unlicensed staff services that can be provided by either rehabilitation or activity program staff as specified in Sections 786.12(c) and 786.19(a) shall be supervised and monitored by licensed nursing staff, and may include the following:

(1) Assisting clients with dressing, grooming, bathing and other personal hygiene related activities.

(2) Taking and recording of clients' height and weight and vital signs.

(3) Assisting clients with getting and eating meals.

(4) Based on established nursing service procedure(s), monitor and report on clients' whereabouts and status when in their room or elsewhere in the mental health rehabilitation center.

Cal. Code Regs. Tit. 9, § 785.12

1. New section filed 8-21-95 as an emergency; operative 8-21-95 (Register 95, No. 34). A Certificate of Compliance must be transmitted to OAL by 2-17-95 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 2-9-96 as an emergency; operative 2-9-96 (Register 96, No. 6). A Certificate of Compliance must be transmitted to OAL by 6-8-96 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 6-10-96 as an emergency; operative 6-10-96 (Register 96, No. 24). A Certificate of Compliance must be transmitted to OAL by 10-8-96 or emergency language will be repealed by operation of law on the following day.
4. New section refiled 10-8-96 as an emergency; operative 10-8-96 (Register 96, No. 41). A Certificate of Compliance must be transmitted to OAL by 2-5-97 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 10-8-96 order transmitted to OAL 2-5-97; disapproved by OAL and order of repeal as to 10-8-96 order filed on 3-21-97 (Register 97, No. 12).
6. New section filed 3-21-97 as an emergency; operative 3-21-97 (Register 97, No. 12). A Certificate of Compliance must be transmitted to OAL by 7-21-97 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 3-21-97 order, including amendment of section, transmitted to OAL 7-21-97 and filed 8-21-97 (Register 97, No. 34).

Note: Authority cited: Sections 5675 and 5768, Welfare and Institutions Code; Section 3 of Chapter 678 of the Statutes of 1994. Reference: Sections 5675 and 5768, Welfare and Institutions Code.