6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 14

Current through Register Vol. 47, No. 20, October 25, 2024

Part 14 - NURSING SERVICES

14.1 There shall be a nursing department formally organized to provide complete, effective care to each patient.

14.2 Nursing services shall be directed by a registered nurse qualified by education, training, competencies, and experience to direct effective nursing care. For purposes of this chapter, this individual is referred to as the Senior Nurse Executive.

14.3 The Senior Nurse Executive shall be responsible for ensuring that all nursing staff have the qualifications, competencies, and experience necessary to deliver the care assigned in accordance with professional standards of practice and hospital policy and procedure.

14.4 Nursing Services Policies and Procedures

(A) The service shall develop and implement policies and procedures that establish the standards for performance of safe nursing care.

(B) The policies and procedures shall be based on nationally-recognized practice guidelines and data-driven measures.

(C) The policies and procedures shall be reviewed periodically and revised as necessary, no less than every three (3) years.

14.5 Nursing staff shall conduct initial and ongoing assessments and screenings of the patient's physical, cognitive, behavioral, emotional, and psychosocial status in sufficient scope and detail to meet the needs of the patient, according to hospital policy and professional standards of practice.

14.6 Nurse Staffing Committee

(A) Each hospital shall establish a nurse staffing committee, either by creating a new committee or assigning the nurse staffing functions to an existing hospital staffing committee.

(B) The nurse staffing committee shall:

(1) Develop and implement the process for addressing any concerns or complaints brought forth by staff;

(2) Annually develop and oversee a master nurse staffing plan for the hospital;

(3) Have at least 60% or greater participation by clinical staff nurses, in addition to auxiliary personnel and nurse management;

(4) Include a designated leader of workplace violence prevention and reduction efforts;

(5) Describe in writing the process for receiving, tracking, and resolving complaints and receiving feedback on the master nurse staffing plan from clinical staff nurses and other staff; and

(6) Make the complaint and feedback process available to all providers, including clinical staff nurses, nurse aides, and EMS providers.

(C) The hospital and nurse staffing committee shall develop, document, and implement a charter or guideline.

(D) The nurse staffing committee documentation shall be made available to hospital nursing staff.

(E) If the results of the review and the nurse staffing plan indicate that the current master nurse staffing plan has not resulted in adequate staffing, and/or the healthcare needs of the patients are not met, the nurse staffing plan shall be modified through the nurse staffing committee.

(F) Report Requirements

(1) The nurse staffing plan shall be made available to the hospital's governing body, which maintains the responsibility to protect the health, safety, and welfare of patients, commensurate with the scope and types of services provided at the hospital, either directly or through the Senior Nurse Executive.

(2) The purpose of the nurse staffing plan is to ensure the hospital is adequately staffed, and the healthcare, safety, and welfare needs of patients and staff are met. The following factors, at a minimum, shall be addressed in the nurse staffing plan:

(a) Current best practices, taking into consideration community standards, and benchmarking or evidence-based metrics, as applicable;

(b) Patient census;

(c) Patient acuity or workload;

(d) Churn (admissions/discharges/transfers);

(e) Skill mix;

(f) RN education;

(g) Patient outcomes; and

(h) Workforce metrics and staff feedback.

(3) The nurse staffing plan shall be issued to the governing body for approval following each review of the staffing plan.

(G) The nurse staffing committee may publish a report that is responsive to the changes made to the recommended master nurse staffing plan at Part 14.7(A)(5).

14.7 Nurse Staffing Plans

(A) Master Nurse Staffing Plan

(1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that:

(a) Provides for continuous registered nurse coverage, for distribution of nursing and auxiliary personnel, and for forecasting future needs;

(b) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines;

(c) Includes strategies that promote the health, safety, and welfare of the hospitals' employees and patients;

(d) Includes guidance and a process for reducing nurse-to-patient assignments to align with the demand based on patient acuity;

(e) Is voted on and recommended by at least sixty (60) percent of the nurse staffing committee; and

(f) May include innovative staffing models.

(2) The master nurse staffing plan must be based on the different types of patients cared for on each inpatient care unit and in the emergency department, the skill mix, specialized qualifications, and level of competency necessary for nursing staff to ensure that the hospital is staffed to meet the safety and healthcare needs of patients.

(3) The master nurse staffing plan shall specify how each patient is provided access to care from a registered nurse, when applicable.

(4) Once the master nurse staffing plan has been initiated, ongoing staffing effectiveness shall be reviewed and documented through the nurse staffing committee.

(5) The nurse staffing committee shall submit the recommended master nurse staffing plan to the hospital's senior nurse executive and the hospital's governing body for approval.

(A) If the final staffing plan approved by the hospital changes materially from the recommendations put forth by the nurse staffing committee, the senior nurse executive shall provide the nurse staffing committee with a written explanation for the changes.

(1) If, after receiving the explanation referenced above, the nurse staffing committee believes the final staffing plan does not meet the nurse staffing standards established in this Part 14, the staffing committee, with a vote of sixty (60) percent or more of the members, may request the Department review the final adopted staffing plan to ensure compliance with these rules.

(6) The hospital shall evaluate the master nurse staffing plan and prepare a report for internal review by the nurse staffing committee on a quarterly basis.

(7) The hospital shall prepare and submit the following to the Department on an annual basis:

(a) The final approved master nurse staffing plan, and

(b) An annual report containing the details of the quarterly evaluation, in the form and manner determined by the Department.

(B) Inpatient Care Unit and Emergency Department Plans

(1) Each open inpatient care unit and emergency department within the hospital shall have a twenty-four (24) hour nurse staffing plan.

(C) The master nurse staffing plan, inpatient care unit plans, and emergency department plans shall be made available to and reviewed with each individual member of the nursing staff annually. The hospital shall maintain documentation of the annual plan reviews.

(1) The hospital shall provide the relevant unit-based staffing plan to:

(a) each applicant for a nursing position on a given unit upon an offer of employment, and

(b) a patient upon request.

(D) When updates are made to the master nurse staffing plan, inpatient care unit plan, or emergency department plan, the updates shall be made available to each member of the nursing staff.

14.8 The authority and responsibility of each nurse and auxiliary personnel shall be clearly defined in written policies. Auxiliary personnel shall only be assigned duties for which they are qualified, and shall be under the supervision of a registered nurse.

14.9 At least one (1) registered nurse and one (1) auxiliary personnel shall be on duty at all times in each open inpatient unit and in the emergency department. Additional staffing needs shall be determined by the hospital's master nurse staffing plan.

14.10 One (1) registered nurse qualified by education, training, competencies, and experience, shall be designated in charge of each open inpatient care unit and the emergency department, and that individual shall be delegated the authority and responsibility for the nursing services on that unit. Additional registered nurses or other auxiliary personnel shall be available.

6 CCR 1011-1 Chapter 04, pt. 14