| (4) To assist the committee with the semiannual evaluation,
the LSRH shall report to the committee the variations between the
staffing plan and actual staffing. This report of variations shall
be confidential.
(j) The LSRH shall retain each staffing plan for a
period of two years.
(k) Nonemployee licensed nurses who are working in
the LSRH shall adhere to the LSRH's policies and procedures. The LSRH's
CNO shall provide for the adequate orientation, supervision, and evaluation
of the clinical activities of nonemployee nursing personnel that occur
within the responsibility of the nursing services.
(l) The LSRH shall annually report to the Texas Health
and Human Services Commission on:
(1) whether the LSRH governing body has adopted a nurse
staffing policy;
(2) whether the LSRH has established a nurse staffing
committee that meets the requirements of subsection (e)(4) of this
section;
(3) whether the nurse staffing committee has evaluated
the LSRH official nurse services staffing plan and has reported the
results of the evaluation to the LSRH's governing body; and
(4) the nurse-sensitive outcome measures the committee
adopted for use in evaluating the LSRH official nurse services staffing
plan.
(m) The LSRH shall adopt, implement and enforce policies
on use of mandatory overtime. The policies shall comply with the following
requirements.
(1) As used in this subsection:
(A) "on-call time" means time spent by a nurse who
is not working but who is compensated for availability; and
(B) "mandatory overtime" means a requirement that a
nurse work hours or days that are in addition to the hours or days
scheduled, regardless of the length of a scheduled shift or the number
of scheduled shifts each week. Mandatory overtime does not include
prescheduled on-call time or time immediately before or after a scheduled
shift necessary to document or communicate patient status to ensure
patient safety.
(2) An LSRH may not require a nurse to work mandatory
overtime, and a nurse may refuse to work mandatory overtime.
(3) This subsection does not prohibit a nurse from
volunteering to work overtime.
(4) An LSRH may not use on-call time as a substitute
for mandatory overtime.
(5) The prohibitions on mandatory overtime do not apply
if:
(A) a health care disaster, such as a natural or other
type of disaster that increases the need for health care personnel,
unexpectedly affects the county in which the nurse is employed or
affects a contiguous county;
(B) a federal, state, or county declaration of emergency
is in effect in the county in which the nurse is employed or is in
effect in a contiguous county;
(C) there is an emergency or unforeseen event of a
kind that:
(i) does not regularly occur;
(ii) increases the need for health care personnel at
the LSRH to provide safe patient care; and
(iii) could not prudently be anticipated by the LSRH;
or
(D) the nurse is actively engaged in an ongoing medical
or surgical procedure and the continued presence of the nurse through
the completion of the procedure is necessary to ensure the health
and safety of the patient. The nurse staffing committee shall ensure
that scheduling a nurse for a procedure that could be anticipated
to require the nurse to stay beyond the end of his or her scheduled
shift does not constitute mandatory overtime.
(6) If an LSRH determines that an exception exists
under paragraph (5) of this subsection, the LSRH shall, to the extent
possible, make and document a good faith effort to meet the staffing
need through voluntary overtime, including calling per diems and agency
nurses, assigning floats, or requesting an additional day of work
from off-duty employees.
(7) An LSRH may not suspend, terminate, or otherwise
discipline or discriminate against a nurse who refuses to work mandatory
overtime.
(n) Drugs and biologicals shall be prepared and administered
in accordance with federal and state laws, the orders of the individuals
granted privileges by the medical staff, and accepted standards of
practice.
(o) All drugs and biologicals shall be administered
by, or under supervision of, nursing or other personnel in accordance
with federal and state laws and regulations, including applicable
licensing rules, and in accordance with the approved medical staff
policies and procedures.
(p) All orders for drugs and biologicals shall be in
writing, dated, timed, and signed by the individual responsible for
the care of the patient as specified under §511.46(x) of this
subchapter (relating to Radiologic Services). When telephone or verbal
orders must be used, they shall be:
(1) accepted only by personnel who are authorized to
do so by the medical staff policies and procedures, consistent with
federal and state laws;
(2) dated, timed, and authenticated within 96 hours
by the prescriber or another practitioner who is responsible for the
care of the patient and has been credentialed by the medical staff
and granted privileges that are consistent with the written orders;
and
(3) used infrequently.
(q) There shall be an LSRH procedure for immediately
reporting transfusion reactions, adverse drug reactions, and errors
in administration of drugs to the attending physician and, if appropriate,
to the LSRH-wide quality assessment and performance improvement program.
(r) Blood transfusions shall be prescribed in accordance
with LSRH policy and administered in accordance with a written protocol
for the administration of blood and blood components and the use of
infusion devices and ancillary equipment.
(s) Personnel administering blood transfusions and
intravenous medications shall have special training for this duty
according to written, adopted, implemented, and enforced LSRH policy.
(t) Blood and blood components shall be transfused
through a sterile, pyrogen-free transfusion set that has a filter
designed to retain particles potentially harmful to the recipient.
(u) Nursing staff shall observe and monitor the patient
during blood and blood component transfusions and for an appropriate
time thereafter as required by the LSRH's blood transfusion policy
for suspected adverse reactions.
(v) Pretransfusion and posttransfusion vital signs
shall be recorded.
(w) When warming of blood is indicated, this shall
be accomplished during its passage through the transfusion set. The
warming system shall be equipped with a visible thermometer and may
have an audible warning system. Blood shall not be warmed above 42
degrees Centigrade.
(x) 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:
(1) they have been approved for this use by the U.S.
Food and Drug Administration; or
(2) there is documentation available to show that addition
to the component involved is safe and efficacious.
(y) 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.
(z) Following the transfusion, the blood transfusion
record or a copy shall be made a part of the patient's medical record.
(aa) An LSRH shall adopt, implement, and enforce a
policy to ensure the LSRH complies with Texas Occupations Code Chapter
301, Subchapter I (relating to Reporting Violations and Patient Care
Concerns), and Chapter 303 (relating to Nursing Peer Review), and
with the rules adopted by the Texas Board of Nursing in Texas Administrative
Code Title 22 §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).
(bb) The LSRH shall adopt, implement, and enforce policies
and procedures related to the work environment for nurses which:
(1) improve workplace safety and reduce the risk of
injury, occupational illness, and violence; and
Cont'd... |
