Current through Reg. 49, No. 38; September 20, 2024
(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.
(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
(2) increase the use of ergonomic principles
and ergonomically designed devices to reduce injury and fatigue.
(cc) The policies and procedures
adopted under subsection (bb) of this section must address at least the
following:
(1) evaluating new products and
technology that incorporate ergonomic principles;
(2) educating nurses in the application of
ergonomic practices;
(3) conducting
workplace audits to identify areas of risk of injury, occupational illness, or
violence and recommending ways to reduce those risks;
(4) controlling access to those areas
identified as having a high risk of violence; and
(5) promptly reporting crimes committed
against nurses to appropriate law enforcement agencies.
(dd) The LSRH 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. The policies and
procedures shall establish a process that includes at least the following:
(1) analysis of the risk of injury to both
patients and nurses posed by the patient handling needs of the patient
populations served by the LSRH and the physical environment in which patient
handling and movement occurs;
(2)
education of nurses in the identification, assessment, and control of risks of
injury to patients and nurses during patient handling;
(3) evaluation of alternative ways to reduce
risks associated with patient handling, including evaluation of equipment and
the environment;
(4) 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;
(5) collaboration with and annual report to
the nurse staffing committee;
(6)
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;
(7) 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
(8) development of
architectural plans for constructing or remodeling a LSRH or a unit of an LSRH
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.
