Cal. Code Regs. Tit. 22, § 72311 - Nursing Service-General
(a) Nursing service shall include, but not be
limited to, the following:
(1) Planning of
patient care, which shall include at least the following:
(A) Identification of care needs based upon
an initial written and continuing assessment of the patient's needs with input,
as necessary, from health professionals involved in the care of the patient.
Initial assessments shall commence at the time of admission of the patient and
be completed within seven days after admission.
(B) Development of an individual, written
patient care plan which indicates the care to be given, the objectives to be
accomplished and the professional discipline responsible for each element of
care. Objectives shall be measurable and time-limited.
(C) Reviewing, evaluating and updating of the
patient care plan as necessary by the nursing staff and other professional
personnel involved in the care of the patient at least quarterly, and more
often if there is a change in the patient's condition.
(2) Implementing of each patient's care plan
according to the methods indicated. Each patient's care shall be based on this
plan.
(3) Notifying the attending
licensed healthcare practitioner acting within the scope of his or her
professional licensure promptly of:
(A) The
admission of a patient.
(B) Any
sudden and/or marked adverse change in signs, symptoms or behavior exhibited by
a patient.
(C) An unusual
occurrence, as provided in Section
72541, involving a
patient.
(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 patient's licensed healthcare practitioner acting
within the scope of his or her professional licensure.
(E) Any untoward response or reaction by a
patient to a medication or treatment.
(F) Any error in the administration of a
medication or treatment to a patient which is life threatening and presents a
risk to the patient.
(G) The
facility'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
patient.
(b)
All attempts to notify licensed healthcare practitioners acting within the
scope of his or her professional licensure shall be noted in the patient's
health record including the time and method of communication and the name of
the person acknowledging contact, if any. If the attending licensed healthcare
practitioner acting within the scope of his or her professional licensure or
his or her designee is not readily available, emergency medical care shall be
provided as outlined in Section
72301(g).
(c) Licensed nursing personnel shall ensure
that patients are served the diets as ordered by the attending licensed
healthcare practitioner acting within the scope of his or her professional
licensure.
Notes
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
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