Section 390.1040  Nursing Services


a)         The facility shall have a written program of Nursing Services, providing for a planned medical program, encompassing nursing treatments, rehabilitation and habilitation nursing, skilled observations, and ongoing  evaluation and coordination of the resident's individual habilitation plan.


b)         There shall be a sufficient number of nursing and auxiliary personnel on duty 24 hours each day to provide adequate and properly supervised nursing services to meet the nursing needs of the residents.  There shall be at least one registered nurse seven days a week, for 8 consecutive hours.  There shall be at least one registered nurse or licensed practical nurse on duty at all times and on each floor housing residents.  Nursing staff personnel shall include registered professional nurses, licensed practical nurses, and auxiliary personnel as defined in Section 390.330 of this Part.


c)         There shall be a director of nursing who shall be a registered nurse.


d)         The director of nursing shall have knowledge and training in nursing service administration, restorative and habilitative nursing.


e)         The director of nursing shall be a full-time employee who is on duty a minimum of 36 hours, four days per week.  At least 50 percent of this person's hours shall be regularly scheduled  some time between 7 A.M. and 7 P.M.


1)         A facility may, with written approval from the Department, have two registered nurses share the duties of this position if it is unable to obtain a full-time person.  Such an arrangement will be granted approval only through written documentation that the facility was unable to obtain the full-time services of a qualified individual to fill this position.  Such documentation shall include, but not be limited to:  an advertisement that has appeared in a newspaper of general circulation in the area for at least three weeks; the names, addresses and phone numbers of all persons who applied for the position and the reasons why they were not acceptable or would not work full-time; and information about the number and availability of registered nurses in the area. The Department will grant approval only when such documentation indicates that there were no qualified applicants who were willing to accept the job on a full-time basis, and the pool of registered nurses available in the area cannot be expected to produce, in the near future, a qualified person who is willing to work full-time.  If two persons are to share the position,  one shall be designated the Director of Nursing Services and the other shall be designated the Assistant Director of Nursing Services.  Both of these persons shall be R.N.s.


2)         In facilities with a capacity of less than 50 beds, this person (or these persons), may also provide direct patient care, and this person's time may be included in meeting the staff/resident ratio requirements.


f)         In facilities of 100 occupied beds or more, there shall be an assistant director of nursing who is a registered nurse licensed to practice in Illinois. The assistant must meet the qualifications specified in subsection (d) of this Section.


g)         The assistant director of nursing shall be a full-time employee who is on duty a minimum of 36 hours, four days per week.  The assistant need not work on the day shift but may be assigned to any shift.


h)         The assistant director of nursing shall assist the director in carrying out her responsibilities.


i)          The responsibilities of the director of nursing shall include, at a minimum, the following:


1)         Assigning and directing the activities of nursing and auxiliary service personnel.


2)         Planning an up-to-date resident care plan for each resident in cooperation with the interdisciplinary team based on individual needs and goals to be accomplished, physician's orders, and personal care and nursing needs. Services such as nursing, developmental, activities, dietary, and such other modalities as are ordered by the physician, shall be reflected in the preparation of the resident care plan.  The plan shall be in writing and shall be reviewed and modified in keeping with the care needed as indicated by the resident's condition.  The plan shall be reviewed every three months.


3)         Recommending to the administrator the number and levels of nursing personnel to be employed, participating in their recruitment and selection and recommending termination of employment when necessary.


4)         Participating in planning and budgeting for nursing services including purchasing of necessary equipment and supplies.


5)         Developing and maintaining nursing service objectives, standards of nursing practice, written policies and procedures, and written job descriptions for each level of nursing and auxiliary personnel.


6)         Coordinating health services and nursing services with other resident care services such as medical, pharmaceutical, dietary activities, and any other restorative and habilitative services offered.


7)         Planning of inservice education, embracing orientation, skill training, and ongoing education for all nursing personnel covering all aspects of resident care and programming.  The educational program shall include training and practice in activities and restorative and habilitative nursing techniques through out-of-facility or in-facility training programs.  The director of nursing may conduct these programs personally or see to it that they are carried out.


8)         Participating in the development and implementation of resident care policies and bringing resident care problems, requiring changes in policy, to the attention of the facility's policy development group.  (See Section 390.610(a).)


9)         Participating in the screening of prospective residents and their placement in terms of services they need and nursing competencies available.


j)          Nursing care (including personal, habilitative and rehabilitative care measures) shall be practiced on a 24 hour, seven day a week basis in the care of residents.  Those procedures requiring medical approval shall be ordered by the attending physician.


k)         Nursing care shall include at a minimum the following:


1)         All medications including oral, rectal, hypodermic, and intra-muscular shall be properly administered.


2)         All treatment such as:  enemas, irrigations, catherizations, applications of dressing or bandages, supervision of special diets, restorative and habilitative measures in Section 390.1620(a)(11) and other treatments involving a like level of skill, shall be properly administered.


3)         All objective observations of changes in a resident's condition, including mental and emotional changes, as a means for analyzing and determining care required and the need for further medical, nursing or  psychosocial evaluation and treatment shall be provided.


l)          Each resident shall have his temperature taken daily unless otherwise ordered by the physician.  If the temperature varies two degrees from the normal for the resident, the physician shall be notified.


m)        Skin care shall be given to prevent pressure sores, heat rashes or other skin breakdown.  Each resident with pressure sores, heat  rashes or other skin breakdown shall be  checked at least every two hours and given care as needed including clothing and  diaper change.  Skin care shall be given with each diaper change.


n)         Skin care should be provided as follows:


1)         Bathing, clean linens, diapers, and clothing each time the bed or clothing is soiled.  Rubber, plastic, or other types of linen protectors (newspapers not acceptable)  shall be properly cleaned and completely covered to prevent direct contact with the resident.  If rubber, plastic, or other type of waterproof materials are used for protective pants, they shall not come in  direct contact with the resident.  Special attention shall be given to the skin to  prevent irritations, skin rashes, or ulcerations.


2)         Assistance in being up and out of bed as much as the condition of the resident permits.  The resident may be denied this assistance only upon the written order of his physician.  If the resident cannot move himself, he shall have his position changed every two hours or more as necessary.


o)         All necessary precautions shall be taken to assure the safety of residents at all times, such as:  nonslip wax on floors; equipment, adaptive equipment and assistive devices properly maintained; and proper use of side rails on beds and restraints.  (See Section 390.2020(a)(2).)


p)         Each resident shall perform all of the following personal care functions independently if possible.  If unable to do so, assistance shall be provided by staff.


1)         Each resident shall bathe as often as necessary, but at least daily.


2)         Each resident shall change clothing as often as necessary, but at least daily.


3)         Each resident shall shampoo as often as necessary, but at least weekly.


4)         Each resident shall clean and trim fingernails and toenails as often as necessary but at least weekly.


5)         Each resident shall perform oral hygiene as often as necessary, but at least daily.


6)         Each female resident shall be provided with commercial sanitary napkins during menses.  Frequent cleansing of the perineal area shall be performed.


q)         Haircuts shall be provided as needed.  Socially acceptable hair styles and the wishes of the resident must be taken into consideration.


r)          Each resident shall dress in street clothing and be out of bed at all times other than regularly scheduled sleeping or napping hours, unless contraindicated.


s)         Each resident shall be weighed upon admission and at least once a week thereafter unless otherwise ordered in writing by the physician.  Any significant change shall be reported to the attending physician and dietitian.


t)          Each resident shall be encouraged and, if necessary, assisted in maintaining good body alignment while lying in bed, sitting or standing, through proper positioning and turning.


u)         Each resident shall be assisted in maintaining maximum joint range of motion, and active range of motion through proper exercises.


v)         Each resident shall be trained and encouraged to adopt food habits as near as possible to normal.  Residents shall receive solids, unless otherwise ordered in writing  by the physician.  Each resident shall eat in as upright a position as possible and out of bed unless contraindicated.


w)        Each incontinent resident shall be assisted in regaining bowel and bladder patterns through proper bowel and bladder training or retraining. The use of indwelling catheters shall be discouraged.


x)         All residents shall be encouraged and, when necessary, taught to function at their maximum level in all activities of daily living for as long as and to the degree that they are able.


y)         All residents shall be assisted and encouraged with daily ambulation unless otherwise ordered by the physician.


z)         All residents shall be taught and assisted with safe transfer activities in an effort to help them retain, regain, or gain their maximum level of independence.


aa)       Staffing shall be based on the needs of the residents, and shall be determined by figuring the number of hours of personal and habilitative time each resident needs on each shift of the day.  This determination  shall be made separately for both licensed nursing personnel and other personal and habilitative care personnel.  Personal and habilitative personnel may include, in addition to licensed nurses, such persons as aides, orderlies, therapists, teachers, and any other person providing direct habilitative care to residents.


1)         In a facility whose residents participate in regularly scheduled therapeutic programs outside the facility, such as school or sheltered workshops, the minimum hours of care that must be provided are reduced proportionately.


2)         It is the responsibility of each facility to determine the staffing needed to meet the needs of its residents.  It is the responsibility of the Department to verify that the staffing provided by the facility is sufficient to meet the needs of the residents.


3)         The following figures apply to hours of care actually provided and not to hours of care scheduled to be provided.


4)         Each resident shall be provided with a minimum of four hours of personal and habilitative care each day.  The director of nursing shall not be included in hours of personal and habilitative care provided.


5)         The facility shall schedule personnel in such a manner that the needs of all residents are met.  At least 30 percent of the minimum required hours shall be on the day shift, at least 30 percent of the minimum required hours shall be on the evening shift, and at least ten percent of the minimum required hours shall be on the night shift.  The total percentage must add up to 100 percent each day.  At least 12.5 percent of the hours of care provided on  each shift must be by licensed nursing  personnel.  Licensed nursing personnel may be used to replace other personal and habilitative care staff if the needs of the residents are met by such  staffing.


6)         Staffing Calculations


A)        When computing the number of staff hours needed per shift, any figure less than .25 will be dropped from the computation and any  figure of .75 or higher will go to the next higher number.  Figures in between .25 and  .75 will require at least the amount of coverage indicated:  .25 will require two hours of coverage; .3 will require two and one half hours of coverage; .5 will require four hours of coverage; .6 will require five hours of coverage; .74 will require six hours of coverage; .75 or higher will require eight hours of coverage.


B)        These hours may be provided by:  a part-time person working those hours only on that shift each day; a full-time person working a shift that spans two regular shifts (such as from 12 noon to 8 P.M.); or by an additional full-time person on the shift.  However, these figures are minimal staffing requirements, and it is recommended that a full-time person be provided.


bb)       In addition to the other requirements of this Section, the following also apply:


1)         There shall be a licensed nurse designated as being in charge of nursing services on all shifts when neither the director of nursing nor assistant director of nursing are on duty.  If registered nurses and licensed practical nurses are on duty on the same shift, this person shall be a registered nurse. This person may be a charge nurse on one of the nursing units.


2)         There shall be at least one person awake, dressed and on duty at all times in each separate nursing unit.


3)         There shall be at least one registered nurse on duty seven days per week, 8 consecutive hours.


4)         There shall be at least one registered nurse or licensed practical nurse on duty at all times.


5)         There shall be at least one registered nurse or licensed practical nurse on duty on each floor housing residents.


6)         The need for licensed nurses on each nursing unit will be determined on an individual case basis, dependent upon the individual situation.  If such additional staffing is required, the Department will inform the facility in writing of the kind and amount of additional staff time required, and the reason why it is needed.


7)         The need for an additional licensed nurse to serve as a "house supervisor" will be determined on an individual case basis.  If the Department determines that there is a need for a registered nurse on certain shifts whose sole duties will consist of supervising the nursing services of the facility, the Department shall notify the facility in writing when and why such a person is needed.  This person shall not perform the duties of a charge nurse while serving as the "house supervisor".


(Source:  Amended at 20 Ill. Reg. 12101, effective September 10, 1996)