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RULE §511.61Nursing Services

(a) A limited services rural hospital (LSRH) shall have a well-organized nursing service with a plan of administrative authority and delineation of responsibilities for patient care and provides 24-hour nursing services as needed.

(b) An LSRH shall provide nursing services in accordance with current recognized standards or recommended practices.

(c) Nursing services shall be under the administrative authority of a chief nursing officer (CNO) who is a registered nurse (RN).

  (1) The CNO shall be responsible for the operation of nursing services, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the LSRH.

  (2) The CNO shall report directly to the individual who has authority to represent the LSRH and who is responsible for the operation of the LSRH according to the policies and procedures of the LSRH's governing board.

  (3) The CNO shall participate with the governing body, medical staff, and clinical areas, in planning, promoting and conducting performance improvement activities.

(d) An LSRH shall adopt, implement and enforce a procedure to verify nursing personnel for whom licensure is required have valid and current licensure.

(e) An LSRH shall comply with the following nursing staff requirements.

  (1) The LSRH shall have adequate numbers of RNs, licensed vocational nurses (LVNs), and other personnel to provide nursing care to all patients as needed in accordance with subsection (f) of this section.

  (2) The LSRH shall have an adequate number of RNs on duty to meet the LSRH's minimum staff requirements in accordance with subsection (f)(2) of this section to include supervisory and staff RNs to ensure the immediate availability of an RN for emergency care or for any patient when needed.

  (3) The nursing staff shall develop and keep current a nursing plan of care for each patient which addresses the patient's needs.

  (4) The LSRH shall establish a nurse staffing committee as a standing committee of the LSRH. The committee shall be established in accordance with Texas Health and Safety Code (HSC) Chapter 161, Subchapter D (relating to Medical Committees, Medical Peer Review Committees, and Compliance Officers), to be responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan. As used in this section, "committee" or "staffing committee" means a nurse staffing committee established under this paragraph.

(f) An LSRH shall adopt, implement, and enforce a written official nurse services staffing plan. As used in this subsection, "patient care unit" means a unit or area of an LSRH in which registered nurses provide patient care.

  (1) The official nurse services staffing plan and policies shall:

    (A) require significant consideration to be given to the nurse staffing plan recommended by the LSRH's nurse staffing committee and the committee's evaluation of any existing plan;

    (B) be based on the needs of each patient care unit and shift and on evidence relating to patient care needs;

    (C) require use of the official nurse services staffing plan as a component in setting the nurse staffing budget;

    (D) encourage nurses to provide input to the nurse staffing committee relating to nurse staffing concerns;

    (E) protect from retaliation nurses who provide input to the nurse staffing committee;

    (F) reflect current standards established by private accreditation organizations, governmental entities, national nursing professional associations, and other health professional organizations and should be developed based upon a review of the codes of ethics developed by the nursing profession through national nursing organizations; and

    (G) comply with this section.

  (2) The plan shall set minimum staffing levels for patient care units that are:

    (A) based on multiple nurse and patient considerations including:

      (i) patient characteristics and number of patients for whom care is being provided, including number of admissions, discharges, and transfers on a unit;

      (ii) intensity of patient care being provided and variability of patient care across a nursing unit;

      (iii) scope of services provided;

      (iv) context within which care is provided, including architecture and geography of the environment, and the availability of technology; and

      (v) nursing staff characteristics, including staff consistency and tenure, preparation and experience, and the number and competencies of clinical and non-clinical support staff the nurse must collaborate with or supervise;

    (B) determined by the nursing assessment and in accordance with evidence-based safe nursing standards; and

    (C) recalculated at least annually, or as necessary.

  (3) The plan shall include:

    (A) a method for adjusting the staffing plan shift to shift for each patient care unit based on factors, such as, the intensity of patient care to provide staffing flexibility to meet patient needs;

    (B) a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources;

    (C) how on-call time will be used;

    (D) a mechanism for evaluating the effectiveness of the official nurse services staffing plan based on patient needs, nursing sensitive quality indicators, nurse satisfaction measures collected by the LSRH, and evidence-based nurse staffing standards, which must include at least one from each of the following three types of outcomes shall be correlated to the adequacy of staffing:

      (i) nurse-sensitive patient outcomes selected by the nurse staffing committee, such as, patient falls, adverse drug events, injuries to patients, skin breakdown, pneumonia, infection rates, upper gastrointestinal bleeding, shock, cardiac arrest, length of stay, or patient readmissions;

      (ii) operational outcomes, such as, work-related injury or illness, vacancy and turnover rates, nursing care hours per patient day, on-call use, or overtime rates; and

      (iii) substantiated patient complaints related to staffing levels;

    (E) a process that facilitates the timely and effective identification of concerns about the adequacy of the staffing plan by the nurse staffing committee, which includes:

      (i) a prohibition on retaliation for reporting concerns;

      (ii) a requirement that nurses report concerns timely through appropriate channels within the LSRH;

      (iii) orientation of nurses on how to report concerns and to whom;

      (iv) encouraging nurses to provide input to the committee relating to nurse staffing concerns;

      (v) review, assessment, and response by the committee to staffing concerns expressed to the committee;

      (vi) a process for providing feedback during the committee meeting on how concerns are addressed by the committee; and

      (vii) use of the nurse safe harbor peer review process pursuant to Texas Occupations Code §303.005 (relating to Request for Peer Review Committee Determination); and

    (F) policies and procedures that require:

      (i) orientation of nurses and other personnel who provide nursing care to all patient care units to which they are assigned on either a temporary or permanent basis;

      (ii) the orientation of nurses and other personnel and the competency to perform nursing services is documented in accordance with LSRH policy; and

      (iii) nursing assignments be congruent with documented competency.

(g) The LSRH shall use the staffing plan required under subsection (f) of this section as a component in setting the nurse staffing budget and guiding the LSRH in assigning nurses LSRH wide.

(h) The LSRH shall make readily available to nurses on each patient care unit at the beginning of each shift the official nurse services staffing plan levels and current staffing levels for that unit and that shift.

(i) There shall be a semiannual evaluation by the staffing committee of the effectiveness of the official nurse services staffing plan and variations between the staffing plan and actual staffing.

  (1) The evaluation shall consider the outcomes and nursing-sensitive indicators as set out in subsection (f)(3)(D)(i) of this section, patient needs, nurse satisfaction measures collected by the LSRH, and evidence-based nurse staffing standards.

  (2) The evaluation shall be documented in the minutes of the committee and presented to the LSRH governing body.

  (3) The LSRH may determine whether the evaluation is done on a unit or facility level basis.


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