6 Colo. Code Regs. § 1011-1-5-9

Current through Register Vol. 47, No. 11, June 10, 2024

Section 6 CCR 1011-1-5-9 - NURSING SERVICES

9.1 ORGANIZATION

The facility shall have a department of nursing services that is formally organized to provide complete, effective care to each resident. The facility shall clearly define qualifications, authority and responsibility of nursing personnel in written job descriptions.

9.2 DIRECTOR OF NURSING

Except as provided in section 9.5 , the nursing care facility shall employ a full-time (40 hours/week) director of nursing who is a registered nurse, qualified by education and experience to direct facility nursing care.

9.3 24-HOUR NURSING COVERAGE

The facility shall be staffed with qualified nursing personnel, awake and on duty, who are familiar with the residents and their needs in a number sufficient to meet resident functional dependency, medical and nursing needs.

A) Staff shall be sufficient in number to provide prompt assistance to persons needing or potentially needing assistance, considering individual needs such as the risk of accidents, hazards or other untoward events.

B) Except as provided in section 9.5 , a nursing care facility shall be staffed at all times with at least one registered nurse who is on duty on the premises. Each resident care unit shall be staffed with at least one licensed nurse.

C) A nursing care facility shall provide nurse staffing sufficient to meet the needs of residents, but no less than two hours of nursing time per resident per day. In facilities of 60 residents or more, the time of the director of nursing and other supervisory personnel who are not providing direct resident care shall not be used in computing this ratio.

D) Nursing personnel shall be trained in nursing procedures and responsibilities and shall be familiar with any equipment necessary for care on the unit.

E) All certified nursing assistants shall function under the direction of a licensed nurse.

F) If a nursing care facility operates out of more than one building, it shall have staff on duty 24 hours per day in each building in a number sufficient to meet resident care needs.

9.4 WRITTEN PROCEDURES

The facility shall have written nursing procedures establishing the standards of performance for safe, effective nursing care of residents and shall assure that they are followed by all nursing staff.

A) Procedures shall include the requirement that medications be administered in compliance with applicable Colorado law.

B) The nursing procedures shall be evaluated and revised as necessary, but no less often than annually.

9.5 EXCEPTIONS

Nothing contained in this section 9 shall require any rural nursing care facility that is a skilled nursing care facility to employ nursing staff beyond current federal certification requirements. Since federal standards require that nurse staffing be sufficient to meet the total nursing needs of all residents, resident conditions will determine the specific numbers and qualifications of staff that each facility must provide.

A) A rural facility is one that is located in:

1) A county with a population of fewer than 15,000; or

2) A municipality with a population of fewer than 15,000 that is located ten miles or more from a municipality with a population of 15,000 or more; or

3) The unincorporated part of a county ten miles or more from a municipality with a population of 15,000 or more.

B) To the extent that these regulations require any facility to employ a registered nurse more than 40 hours per week, the Department may waive such requirements for such periods as it deems appropriate if, based on findings consistent with 6 CCR 1011-1, Chapter 2, Part 5, it determines that:

1) The facility is located in a rural area as defined in section 9.5(A);

2) The facility has at least one full-time registered nurse who is regularly on duty 40 hours per week;

3) The facility has only residents whose attending physicians have indicated in orders or admission notes that each resident does not require the services of a registered nurse for a 48-hour period or the facility has made arrangements for a registered nurse, consulting registered nurse or physician to spend such time at the facility as is determined necessary by the resident's attending physician to provide necessary skilled nursing services on days when the regular full-time registered nurse is not on duty; and

4) The facility has made and continues to make a good faith effort to comply with the more than 40-hour registered nurse requirement, but registered nurses are unavailable in the area.

9.6 SUPPLIES AND EQUIPMENT

The facility shall provide the supplies and equipment necessary to conduct a preventive, therapeutic and rehabilitative nursing program. Equipment includes devices to assist residents to perform activities of daily living.

A) Equipment shall be maintained in clean and proper functioning condition.

B) The facility shall provide or assist residents to obtain walkers, crutches, canes and wheelchairs with appropriate padding, all of which shall fit residents properly.

C) Nursing staff shall be trained in rehabilitative nursing procedures, including preventive nursing care measures, and in the proper use of prosthetic devices and equipment.

9.7 CARE POLICIES

The facility shall have written resident care policies approved by the governing body, which staff shall follow.

9.8 MEDICATION ADMINISTRATION

Medications shall be identified as specified in sections 19.3 . Staff shall verify identification of the medication when the medication is prepared as well as when it is administered.

A) Medications and treatments shall be given only as ordered by a practitioner. Medications shall be administered by medication certified or licensed nursing personnel as allowed within the individual's license or certification scope of practice.

B) Medication shall be administered in a form that can be most easily tolerated by the resident. Staff shall not mask the medication or alter its form through crushing, dissolving or other means, if to do so would be hazardous and not without first informing the resident or resident representative.

C) Medications that are prepared but unused shall be disposed of in accordance with state law and the facility's written procedures.

D) All administered medications shall be recorded in the resident's health information record, indicating the name, reason, strength, dosage and mode of administration; the date and time of administration; the signature of the person administering the medication and effectiveness of "as needed" medications.

E) To encourage independence and prepare residents for discharge, the facility shall permit self-administration of medications in appropriate cases upon the order of the attending practitioner and under the guidance of a licensed nurse.

F) If facility policy permits medications to be kept at the bedside, the interdisciplinary team shall approve such types of medications. The facility shall ensure that each such medication ordered by a practitioner to be kept at the bedside is used properly, its use is documented and it is stored in a secure manner that protects all residents.

G) Drug reactions and significant medication errors shall be reported within 30 minutes to the resident's practitioner. A call to the practitioner's office or answering service does not meet the facility's responsibility to provide emergency care. The resident's condition shall be monitored for 72 hours and observations documented in the health information record.

H) If a resident is administered psychoactive medications, he or she shall be evaluated for medication effectiveness at least every three months. The resident shall be assessed every six months for adverse effects including, but not limited to, extrapyramidal syndrome and neuroleptic malignant syndrome.

9.9 RESTRAINTS

Facilities shall comply with the Protection of Persons from Restraint Act at Section 26-20-101, et seq., C.R.S., in addition to the requirements of this section 9.9.

A) Restraint means any method or device used to involuntarily limit freedom of movement,

including but not limited to bodily physical force, mechanical devices or chemicals.

1) Chemical restraint involves giving an individual medication involuntarily for the purpose of restraining that individual, but does not include medication administered for voluntary or life-saving medical procedures.

2) Physical restraint involves the use of bodily, physical force to involuntarily limit an individual's freedom of movement.

3) Mechanical restraint involves the use of a physical device to involuntarily restrict the movement of an individual or the movement or normal function of a portion of the individual's body.

B) Restraint does NOT include:

1) The use of protective devices or adaptive devices for providing physical support, prevention of injury, voluntary or life-saving medical procedures,

2) The holding of a resident for less than five minutes by a staff person for the protection of the resident or other persons,

3) Placement of a resident in his or her room for the night, or

4) The use of a time-out as defined in writing by the facility.

C) The facility shall establish written policies and procedures governing the use of restraints. The facility shall ensure and document that reasonable efforts are attempted to obtain consent from the resident and/or resident representative for the use of restraints. The facility shall inform the resident and/or resident representative regarding the potential risks and benefits of restraints prior to their use.

D) Medical conditions that warrant the use of restraint shall be documented in the resident's health information record and include an order from a physician or advanced practice nurse, ongoing assessments and care plans. An order alone is not sufficient to warrant the use of the restraint.

E) The facility shall document oversight, assessment of the restraint during use, substantiation of the medical condition requiring the restraint and the expected length of time for the restraint to be used. The facility shall also document the frequency and duration of safety checks during restraint use.

F) Residents in mechanical restraints shall be observed at least every 15 minutes to ensure that the resident is properly positioned and the resident's physical needs are being met. Each observation shall be documented in writing.

G) At least every two hours during waking hours, residents shall have the physical restraint removed and shall have the opportunity to drink fluids; be toileted; and be exercised, moved or repositioned; which activity shall be documented in the resident's health information record.

9.10 SAFETY DEVICES

A safety device such as an alarm, helmet or pillow is used to protect the resident from injury to self, maintain body alignment or facilitate comfort. Prior to using any safety device, the facility shall assess the resident to properly identify the resident's needs and medical symptoms that the safety device is being employed to address. The facility shall also ensure that any safety device being used is not a mechanical restraint.

A) Safety devices shall only be used for appropriate clinical conditions.

B) The facility shall establish written policies and procedures governing the use of safety devices.

C) If a safety device meets the definition of a restraint, then all requirements in section 9.9 apply. A registered nurse may order a safety device after assessing and determining the need exists. Through the nursing assessment, if the need is ongoing, a comprehensive, documented physical and functional assessment shall be completed no less often than after the first 24 hours and quarterly thereafter.

D) At least every two hours residents with safety devices shall be observed and such observation shall be documented.

E) Residents with safety devices shall have either a call signal switch or similar device within reach or some other appropriate means of communication provided.

9.11 PRACTITIONER NOTIFICATION

Facility staff shall promptly notify the attending practitioner regarding unexpected deterioration in a resident's physical or mental condition and any incident or accident involving the resident.

6 CCR 1011-1-5-9