| (G) Drugs or medications, including those intended
for intravenous use, shall not be added to blood or blood components.
A 0.9% sodium chloride injection, United States Pharmacopeia, may
be added to blood or blood components. Other solutions intended for
intravenous use may be used in an administration set or added to blood
or blood components under either of the following conditions:
(i) they have been approved for this use by the Federal
Drug Administration; or
(ii) there is documentation available to show that
addition to the component involved is safe and efficacious.
(H) There shall be a system for detection, reporting
and evaluation of suspected complications of transfusion. Any adverse
event experienced by a patient in association with a transfusion is
to be regarded as a suspected transfusion complication. In the event
of a suspected transfusion complication, the personnel attending the
patient shall notify immediately a responsible physician and the transfusion
service and document the complication in the patient's medical record.
All suspected transfusion complications shall be evaluated promptly
according to an established procedure.
(I) Following the transfusion, the blood transfusion
record or a copy shall be made a part of the patient's medical record.
(6) Reporting and peer review of a vocational or registered
nurse. A hospital shall adopt, implement, and enforce a policy to
ensure that the hospital complies with the Occupations Code §§301.401
- 301.403, 301.405 and Chapter 303 (relating to Grounds for Reporting
Nurse, Duty of Nurse to Report, Duty of Peer Review Committee to Report,
Duty of Person Employing Nurse to Report, and Nursing Peer Review
respectively), and with the rules adopted by the Board of Nurse Examiners
in 22 TAC §217.16 (relating to Minor Incidents), §217.19
(relating to Incident-Based Nursing Peer Review and Whistleblower
Protections), and §217.20 (relating to Safe Harbor Peer Review
for Nurses and Whistleblower Protections).
(7) Policies and procedures related to workplace safety.
(A) The hospital shall adopt, implement and enforce
policies and procedures related to the work environment for nurses
which:
(i) improve workplace safety and reduce the risk of
injury, occupational illness, and violence; and
(ii) increase the use of ergonomic principles and ergonomically
designed devices to reduce injury and fatigue.
(B) The policies and procedures adopted under subparagraph
(A) of this paragraph, at a minimum, must include:
(i) evaluating new products and technology that incorporate
ergonomic principles;
(ii) educating nurses in the application of ergonomic
practices;
(iii) conducting workplace audits to identify areas
of risk of injury, occupational illness, or violence and recommending
ways to reduce those risks;
(iv) controlling access to those areas identified as
having a high risk of violence; and
(v) promptly reporting crimes committed against nurses
to appropriate law enforcement agencies.
(8) Safe patient handling and movement practices.
(A) The hospital shall adopt, implement and enforce
policies and procedures to identify, assess, and develop strategies
to control risk of injury to patients and nurses associated with the
lifting, transferring, repositioning, or movement of a patient.
(B) The policies and procedures shall establish a process
that, at a minimum, includes the following:
(i) analysis of the risk of injury to both patients
and nurses posed by the patient handling needs of the patient populations
served by the hospital and the physical environment in which patient
handling and movement occurs;
(ii) education of nurses in the identification, assessment,
and control of risks of injury to patients and nurses during patient
handling;
(iii) evaluation of alternative ways to reduce risks
associated with patient handling, including evaluation of equipment
and the environment;
(iv) restriction, to the extent feasible with existing
equipment and aids, of manual patient handling or movement of all
or most of a patient's weight to emergency, life-threatening, or otherwise
exceptional circumstances;
(v) collaboration with and annual report to the nurse
staffing committee;
(vi) procedures for nurses to refuse to perform or
be involved in patient handling or movement that the nurse believes
in good faith will expose a patient or a nurse to an unacceptable
risk of injury;
(vii) submission of an annual report to the governing
body on activities related to the identification, assessment, and
development of strategies to control risk of injury to patients and
nurses associated with the lifting, transferring, repositioning, or
movement of a patient; and
(viii) development of architectural plans for constructing
or remodeling a hospital or a unit of a hospital in which patient
handling and movement occurs, with consideration of the feasibility
of incorporating patient handling equipment or the physical space
and construction design needed to incorporate that equipment at a
later date.
(p) Outpatient services. If the hospital provides outpatient
services, the services shall meet the needs of the patients in accordance
with acceptable standards of practice.
(1) Organization. Outpatient services shall be appropriately
organized and integrated with inpatient services.
(2) Personnel.
(A) The hospital shall assign an individual to be responsible
for outpatient services.
(B) The hospital shall have appropriate physicians
on staff and other professional and nonprofessional personnel available.
(q) Pharmacy services. The hospital shall provide pharmaceutical
services that meet the needs of the patients.
(1) Compliance. The hospital shall provide a pharmacy
which is licensed, as required, by the Texas State Board of Pharmacy.
Pharmacy services shall comply with all applicable statutes and rules.
(2) Organization. The hospital shall have a pharmacy
directed by a licensed pharmacist.
(3) Medical staff. The medical staff shall be responsible
for developing policies and procedures that minimize drug errors.
This function may be delegated to the hospital's organized pharmaceutical
services.
(4) Pharmacy management and administration. The pharmacy
or drug storage area shall be administered in accordance with accepted
professional principles.
(A) Standards of practice as defined by state law shall
be followed regarding the provision of pharmacy services.
(B) The pharmaceutical services shall have an adequate
number of personnel to ensure quality pharmaceutical services including
emergency services.
(i) The staff shall be sufficient in number and training
to respond to the pharmaceutical needs of the patient population being
served. There shall be an arrangement for emergency services.
(ii) Employees shall provide pharmaceutical services
within the scope of their license and education.
(C) Drugs and biologicals shall be properly stored
to ensure ventilation, light, security, and temperature controls.
(D) Records shall have sufficient detail to follow
the flow of drugs from entry through dispensation.
(E) There shall be adequate controls over all drugs
and medications including the floor stock. Drug storage areas shall
be approved by the pharmacist, and floor stock lists shall be established.
(F) Inspections of drug storage areas shall be conducted
throughout the hospital under pharmacist supervision.
(G) There shall be a drug recall procedure.
(H) A full-time, part-time, or consulting pharmacist
shall be responsible for developing, supervising, and coordinating
all the activities of the pharmacy services.
(i) Direction of pharmaceutical services may not require
on-premises supervision but may be accomplished through regularly
scheduled visits in accordance with state law.
(ii) A job description or other written agreement shall
clearly define the responsibilities of the pharmacist.
(I) Current and accurate records shall be kept of the
receipt and disposition of all scheduled drugs.
(i) There shall be a record system in place that provides
the information on controlled substances in a readily retrievable
manner which is separate from the patient record.
(ii) Records shall trace the movement of scheduled
drugs throughout the services, documenting utilization or wastage.
Cont'd... |
