Idaho Admin. Code r. 16.03.14.310

Current through September 2, 2024

Section 16.03.14.310 - NURSING SERVICE

There shall be an organized nursing department with a plan that delineates authority, responsibility and duties of each category of nursing personnel, and a functional structure for cooperative planning and cooperation. An organizational chart shall be in the nursing service office and in all policy manuals. Job descriptions shall be available and in use that delineate responsibilities, functions or duties, and qualifications for each category of nursing positions.

01.Director of Nursing Services. The nursing service shall be under the overall direction of a qualified licensed registered nurse with education and experience commensurate with size and complexity of the hospital whose duties are as follows:

a. To organize, coordinate, and evaluate nursing service functions and staff; and

b. To be responsible for development and implementation of policies and procedures as they relate to care of patients; and

c. To select, promote, and terminate nursing staff; and

d. To establish a procedure to insure staff licenses are valid and current.

02.Records. Nurses shall maintain records that document patient status, progress and care given using descriptive measurable data. This documentation shall include but not be limited to:

a. Admission note; and

b. Vital signs; and

c. Medication record; and

d. Rationale for and results of PRN drug administration; and

e. Patient teaching; and

f. Adverse drug or blood reaction; and

g. Discharge note.

03.Patient Care Plans. Individual patient care plans shall be developed, implemented and kept current for each inpatient. Each patient care plan shall include but is not limited to:

a. Nursing care treatments required by the patient; and

b. Medical treatment ordered for the patient; and

c. A plan devised to include both short-term and long-term goals; and

d. Patient and family teaching plan both for hospital stay and discharge; and

e. A description of socio-psychological needs of the patient and a plan to meet those needs.

04.Nursing Department Meetings. The nursing service department or appropriate committee shall meet monthly to review and evaluate the activities and programs of the nursing service and related departments. All meetings shall be documented to include:

a. Subject matter; and

b. Who and how presented; and

c. A record of attendance.

05.New Employee Orientation. An orientation shall be given to all new employees of the nursing service.

06.Inservice/Continuing Education. An ongoing educational program shall be developed, implemented and evaluated for nursing service.

07.Policies and Procedures. Written policies supported by written procedures shall be available for all nursing staff that includes all areas for delivery of nursing services and shall be consistent with generally accepted nursing practice. The following shall be included with all other policies and procedures for nursing services:

a. There shall be a written procedure for reporting and processing incidents/accidents to patients; and

b. There shall be a written procedure for reporting and processing medication errors.

08.Staffing. The following rules apply to the nursing staff:

a. There shall be adequate nursing personnel to plan, administer, and evaluate individual bedside nursing care; and

b. A licensed registered nurse shall be on duty on the premises twenty-four (24) hours a day.

09.Monthly Staffing Patterns. Monthly staffing patterns indicating daily staff, staff titles, and patient census shall be kept.

10.Staff Assignments. Licensed registered nurses shall make assignments for nursing care.

a. In the absence of the Director of Nursing Services, an RN shall be designated to assume the director's duties.

b. There shall be a licensed registered nurse on duty at all times.

c. There shall be twenty-four (24) hour licensed registered nurse coverage in critical care areas in accordance with Subsection 420.02.d. Exception: small hospitals may have an available licensed registered nurse on call to the critical care unit, when there are no patients in the critical care unit.

d. No person will be assigned nursing duties (aides and orderlies included) who has been on duty in the facility during the preceding twelve (12) hours, except in an emergency.

e. There shall be sufficient numbers of nursing personnel in all categories to ensure quality of patient care.

f. Personnel who have a communicable disease, infectious wound or other transmittable conditions and who provide care or services to patients shall be required to implement protective infection control techniques approved by administration; or be required not to work until the infectious stage is corrected; or be reassigned to a work area where contact with others is not expected and likelihood of transmission of infection is absent; or seek other remedy to avoid spreading the employees infection.

g. A licensed registered nurse shall make assignments of nursing care to nursing assistants.

h. Private duty nurses shall be currently licensed in Idaho and shall comply with all hospital rules and regulations, and be under the general direction of the appropriate DNS.

i. Private duty nurses shall not be assigned to critical care areas unless properly oriented and fully trained to the policies and procedures of the hospital.

Idaho Admin. Code r. 16.03.14.310

Effective March 17, 2022