| (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.
Cont'd... |
