W. Va. Code R. § 64-12-12

Current through Register Vol. XLI, No. 36, September 6, 2024

Section 64-12-12 - Nursing Service

12.1. The hospital shall organize the nursing services to provide comprehensive, effective nursing care to each patient under the direction of a registered professional nurse currently licensed in West Virginia and with the education and experience to demonstrate his or her ability to properly execute his or her functions and responsibilities.

12.2. The Director of Nursing shall ensure that there are policy and procedure manuals developed for each different type of patient care unit and that the specific manuals are available on each specific unit.

12.3. The hospital shall maintain a written nursing service plan of administrative authority with delineation of responsibilities and duties of each category of nursing personnel, which shall include at least:

12.3.1. A statement of the policy, mission, and objectives of the nursing service; and

12.3.2. Current job descriptions, qualifications, and specifications for each category of nursing personnel of which there is documented annual review.

12.4. The following records shall be available at the hospital:

12.4.1. Documentation that lists and verifies that all licensed nursing personnel, including private duty and per diem nurses, are currently licensed to practice nursing in West Virginia and that those licenses are in good standing; and

12.4.2. A confidential personnel record for each employee containing information to support the employee's assignment.

12.5. The record shall contain at least the following information:

12.5.1. A dated application for employment verified by references which includes the applicant's training and experience;

12.5.2. Current licensure, registration, or certification status;

12.5.3. Evaluations of work performance signed by the employee and his or her supervisor;

12.5.4. Subsequent change of status forms including change of address, salary adjustments, merit increases, and promotions; and

12.5.5. A record of each employee's participation in continuing education.

12.6. The hospital shall maintain a job description for each job category, including the following:

12.6.1. The job title and qualifications, including educational and skill requirements;

12.6.2. A general description of the employee's duties and responsibilities including limitations, if applicable; and

12.6.3. Supervision to be given and received.

12.7. The hospital shall make available to all nursing employees and provide explanation of the written personnel policies, procedures, and organizational charts.

12.8. The following records shall be available in the nursing department:

12.8.1. Current nursing care policy and procedure manuals;

12.8.2. Minutes and records of attendance at all meetings;

12.8.3. A list of nursing service committees and other committees on which nursing is represented; and

12.8.4. A master staffing plan for the current year.

12.9. The hospital shall provide an adequate number of registered professional nurses and other nursing personnel to meet the following minimum staff requirements:

12.9.1. To provide administrative assistance and supervision during the absence of the Director of Nursing;

12.9.2. To provide supervisory personnel qualified by experience, education, and ability for each specialty area of the nursing department;

12.9.3. To provide a registered professional nurse on duty and immediately available for bedside care of any patient when needed on each shift, 24 hours per day, seven days a week; and

12.9.4. To provide the availability of licensed practical nurses, health care personnel, both to supplement registered professional nurses according to patient acuity.

12.10. If it is hospital policy to use nursing assistants interchangeably between acute patient care units and an extended care unit, the hospital shall maintain documented evidence of nurse assistant training certification for personnel used in this manner.

12.11. The hospital shall provide additional personnel, as needed, to provide clerical procedures.

12.12. The registered professional nurse shall plan, supervise, and evaluate the nursing care for each patient, according to the needs of the patient.

12.13. The hospital shall establish and maintain a current individualized patient care plan for each patient.

12.14. The hospital shall maintain documented nursing notes for each patient.

12.15. Nursing representatives shall be members of committees concerned with interdepartmental policies affecting nursing services and nursing care.

12.16. Planned meetings shall be held by the nursing department according to hospital policy to discuss patient care, nursing service problems, and administrative policies and to analyze the quality of nursing care rendered to patients.

12.17. The hospital shall provide documented, continuing education activities for all nursing personnel. These activities shall include, but not be limited to, on the job training and development programs. Records of these program activities shall be maintained, including methods used and an evaluation of their effectiveness.

W. Va. Code R. § 64-12-12