Ordinarily, the planning and management of a treatment plan which does not involve the furnishing of skilled services requires the skills of a nurse only where the facts of the case establish that the aggregate of such unskilled services, when considered in light of the patient's condition, necessitates the regular daily involvement of a licensed nurse to ensure the patient's recovery and/or medical safety.

For example, an aged patient with a history of diabetes mellitus and angina pectoris is recovering from an open reduction of a fracture of the neck of the femur. They require, among other services, careful skin care, appropriate oral medication, a diabetic diet, a therapeutic exercise program to preserve muscle tone and body condition, and observation to notice signs of deterioration in their condition or complications resulting from their restricted mobility. Although any one of the required services could be performed by a properly instructed unskilled person, such a person would not have the capability of understanding the relationship among the services and their effect on each other. Since the nature of the patient's condition, their age, and their immobility create a high potential for serious complications, such an understanding is essential to assure the patient's recovery and safety.

Under these circumstances, the management of such a plan requires the skills of a nurse, even though each individual service it involves is normally unskilled.

Observation is a skilled nursing service when the unstabilized condition of the patient requires the skills of a licensed nurse to detect and evaluate the patient's need for possible modification of treatment or institution of medical procedures. For example, pending stabilization of the condition, a patient suffering from arteriosclerotic heart disease may require close observation by skilled nurses for signs of decompensation and loss of fluid balance in order to determine whether the digitalis dosage should be changed or other therapeutic measures should be taken.

Similarly, in some cases, surgical patients (including postoperative cataract patients) are transferred from a hospital to an SNF while still in the immediate unstabilized postoperative period during which the possibility of adverse reaction to anesthesia and other aspects of the operative procedure necessitates close skilled monitoring.

The classification of a particular service as skilled is based on the technical or professional health training required to effectively perform or supervise the service. In many instances a service may be classified as a skilled service on the basis of the complexity alone, e.g., intravenous and intramuscular injections or insertion of catheters. On the other hand, a patient following instructions can normally take a daily vitamin pill. Consequently, the act of giving the vitamin pill to a patient who is too senile to take it himself is not a skilled service. Similarly, State law may require that all institutional patients receive medication only from a licensed nurse. This fact does not make administration of a medication a skilled nursing service if such medication can be prescribed for administration at home without the presence of a licensed nurse.

Any generally nonskilled service could, because of special medical complications, require skilled performance, supervision, or observation. In such cases, the complications and special services involved must be documented by physician orders and/or nursing notes. For example, the existence of a plaster cast on an extremity would not generally indicate a need for skilled care. However, a preexisting acute skin problem and a need for special traction of the injured extremity might require the presence of professional health personnel in order to properly observe for complications and adjust traction accordingly. Such procedures should be undertaken only on specific physician orders and should be documented in the patient's clinical record. The possibility of adverse effects from the improper performance of an otherwise unskilled service does not make it a skilled service unless there is documentation.