10.07.02.12

.12 Nursing Services.

A. Organization, Policies, and Procedures. Nursing service shall provide the care appropriate to the patients' needs with the organizational plan, authority, functions, and duties clearly defined. Nurses and supportive personnel shall be chosen for their training, experience, and ability. Policies and procedures shall be adopted and made available to all nursing personnel.

B. Director of Nursing. The facility shall provide for an organized nursing service, under the direction of a full-time registered nurse except that a licensed practical nurse serving as director of nursing as of the effective date of these regulations may continue to serve as director of nursing in the comprehensive care facility in which employed. Upon departure of the licensed practical nurse, the successor shall be a registered nurse. If the director of nursing is a licensed practical nurse, there shall be sufficient hours of consultation with the licensed practical nurse from a registered nurse to assess and plan the patient care, to evaluate the outcomes of the services provided, and to initiate reassessment and replanning.

C. Signed Agreement.

(1) A signed copy of the agreement between the administrator and the director of nursing, showing the license number, shall be filed with the Department upon:

(a) Application for an initial license; and

(b) A change of director of nursing.

(2) The agreement shall specify the duties of the director of nursing.

D. Termination of Services of Director of Nursing. If the director of nursing terminates his services, the administrator immediately shall notify the Department of the termination. The name of the replacement and registration number shall be supplied to the Department as soon as the employment is effected. A copy of the agreement between the administrator and the replacement shall be sent to the Department.

E. Director of Nursing's Vacancy Exceeding 30 Days. If the position of director of nursing remains vacant for a period of 30 days, the license may be revoked unless the administrator and the governing body are able to demonstrate that they have made every effort to obtain a replacement.

F. Relief for Director of Nursing. When the director of nursing is absent, he shall designate an experienced, qualified registered nurse to direct the nursing service. In facilities in which the director of nursing serves as relief for the administrator, the director of nursing shall designate a specific registered nurse who shall be in charge of the nursing service. See Regulation .07C, of this regulation.

G. Responsibilities of the Director of Nursing. The responsibilities of the director of nursing shall include:

(1) Assisting in the development and updating of statements of nursing philosophy and objectives, defining the type of nursing care the facility shall provide;

(2) Preparation of written job descriptions for nursing personnel;

(3) Planning for the total nursing needs of patients to be met and recommending the assignment of a sufficient number of supervisory and supportive personnel for each tour of duty;

(4) Development and maintenance of nursing service policies and procedures to implement the program of care;

(5) Participation in the coordination of patient services through appropriate staff committee meetings (pharmacy, infection control, patient care policies, and utilization review) and departmental meetings;

(6) Cooperation with administration in planning the orientation program and the staff development program to upgrade the competency of the personnel;

(7) Ensurance that the philosophy and objectives are understood and practiced by nursing personnel;

(8) Participation in planning and budgeting for nursing services;

(9) Establishment of a procedure to ensure that nursing personnel, including private duty nurses, have valid and current Maryland licenses;

(10) Execution of patient care policies (unless delegated to principal physician, medical director);

(11) Participation in the selection of prospective admissions to ensure that facility's staff is capable of meeting the needs of all patients admitted;

(12) Coordination of the interdisciplinary patient care management efforts;

(13) Supervision of medicine aides to ensure that there is no deviation from the limitations and restrictions placed upon them.

H. Delegation of Responsibilities. If any of the above responsibilities are delegated to others, there shall be a clear delegation of authority.

I. Supervisory Personnel—Comprehensive Care Facilities.

(1) Comprehensive care facilities shall provide at least the following supervisory personnel:

Patients Registered Nurses
(a) 2—99 One—full-time
(b) 100—199 Two—full-time
(c) 200—299 Three—full-time
(d) 300—399 Four—full-time

(2) The director of nursing is included in the above requirements.

J. Hours of Bedside Care—Comprehensive Care Facility. Comprehensive care facilities shall employ supervisory personnel and a sufficient number of supportive personnel, trained and experienced, or both, to provide a minimum of 2 hours of bedside care per licensed bed per day, 7 days per week. Bedside hours include the care provided by registered nurses, licensed practical nurses, and supportive personnel except that ward clerks' time shall be computed at 50 percent of the time provided in the nursing unit. Only those hours which the director of nursing spends in bedside care may be counted in the 2-hour minimal requirement. The director of nursing's time counted in bedside care shall be documented.

K. Exception for Facilities Which Do Not Participate in a Federal Program. Facilities with 40 or fewer beds which do not participate in a federal program may request the Department for an exception to the above staffing pattern. If in the public interest and there is no hazard to the patients, the Department may grant an exception based on information which includes the:

(1) Size of the facility;

(2) Geographic location of the facility;

(3) Admission policies of the facility;

(4) Existing staffing pattern of the facility;

(5) Number of volunteers in the activity program.

L. Staffing in Extended Care Facility. Extended care facilities shall be staffed with a registered nurse, 24 hours per day, 7 days per week. Additional registered nurses, licensed practical nurses, and supportive personnel shall be employed to meet the needs of all the patients admitted. The facility shall be staffed in accordance with guidelines established by the Department.

M. Staffing in Distinct Part Extended Care Facility. In multi-level facilities the director of nursing shall be in charge of the entire facility. A registered nurse at all times shall be in charge of a distinct part extended care facility. Additional registered nurses, licensed practical nurses, and supportive personnel shall be employed to meet the needs of all the patients admitted. The distinct part shall be staffed in accordance with guidelines established by the Department.

N. Nursing Service Personnel on Duty. The ratio of nursing service personnel on duty to patients may not at any time be less than one to 25, of fraction thereof.

O. Nursing Care—24 Hours a Day. There shall be sufficient licensed and supportive nursing service personnel on duty 24 hours a day to provide appropriate bedside care to assure that each patient:

(1) Receives treatments, medications, and diet as prescribed;

(2) Receives rehabilitative nursing care as needed;

(3) Receives proper care to prevent decubitus ulcers and deformities;

(4) Is kept comfortable, clean, and well-groomed;

(5) Is protected from accident, injury, and infection;

(6) Is encouraged, assisted, and trained in self-care and group activities.

P. Daily Rounds—Director of Nursing. Although daily rounds are primarily the responsibility of the charge nurse or nurses, the director or assistant director of nursing should make clinical rounds to nursing units, randomly reviewing clinical records, medication orders, patient care plans, staff assignments, and visiting patients. If indicated, the director or assistant director of nursing should accompany physicians visiting patients.

Q. Charge Nurse. At least one licensed nurse shall be on duty at all times and shall be designated by the director of nursing to be in charge of the nursing activities during each tour of duty. The charge nurse or nurses shall have the ability to recognize significant changes in the condition of patients and to take necessary action.

R. Charge Nurses' Daily Rounds. The charge nurse or nurses shall make daily rounds to all nursing units for which responsible, performing such functions as:

(1) Visiting each patient;

(2) Reviewing clinical records, medication orders, patient care plans, and staff assignments;

(3) To the degree possible, accompanying physicians when visiting patients.

S. Program of Restorative Nursing Care. There shall be an active program of restorative nursing care aimed at assisting each patient to achieve and maintain his highest level of independent function including activities of daily living. This program shall include:

(1) Ambulation and range of motion;

(2) Maintaining good body alignment and proper positioning of bedfast patients;

(3) Encouraging and assisting patients to change positions at least every 2 hours to stimulate circulation and prevent decubiti and deformities;

(4) Encouraging and assisting patients to keep active and out of bed for reasonable periods of time, within the limitations permitted by physicians' orders, and encouraging patients to achieve independence in activities; and

(5) Assisting patients to adjust to their disabilities, to use their prosthetic and assistive devices, and to redirect their interests, if necessary.

T. Coordination of Nursing and Dietetic Services. Nursing and dietetic services shall establish an effective policy to assure that:

(1) Nursing personnel are aware of the nutritional needs and food and fluid intake of patients and ensure that special feedings and nourishment are provided when required;

(2) Nursing personnel assist promptly when necessary in the feeding of patients;

(3) The dietetic service is informed of physicians' diet orders and of patients' problems;

(4) Food and fluid intake of patients is observed, and deviations from normal are recorded and reported to the:

(a) Charge nurse,

(b) Physician, and

(c) Dietetic service.

U. Inservice Educational Program. There shall be a continuing inservice educational program in effect for all nursing personnel in addition to a thorough job orientation for new personnel. There shall be documentation of content of programs and names and titles of participants. The program which shall be the responsibility of the director of nursing shall be approved by the Department.

V. Director of Nursing's Continuing Education. The director of nursing shall assume responsibility for maintaining his own professional competence through participation in programs of continuing education.

W. Responsibility to Report Care Which is Considered Questionable. If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, the nurse shall call this to the attention of the supervisor who, in turn, shall, if indicated, refer the matter to the director of nursing services. If warranted, the director of nursing shall bring the matter to the attention of the principal physician or medical director, as applicable.