PURPOSE: This rule establishes the requirements for nursing services in a hospital.

1. (1) The nursing service shall be integrated and identified within the total hospital organizational structure.
2. (2) The nursing service shall have a written organizational structure that indicates lines of authority, accountability and communication.
3. (3) The organization of the nursing service shall conform with the variety of patient care services offered and the range of nursing care activities.
4. (4) Nursing policies and standards of practice describing patient care shall be in writing and be kept current.
5. (5) Policies shall provide for the collaboration of nursing personnel with members of the medical staff and other health care disciplines regarding patient care issues.
6. (6) Nursing service policies shall establish an appropriate committee structure to oversee and assist in the provision of quality nursing care. The purpose and function of each committee shall be defined and a record of its activities shall be maintained.
7. (7) Policies shall make provision for nursing personnel to be participants of hospital committees concerned with patient care activities.

8. (8) Policies shall be developed regarding the use of overtime. The policies shall be based on the following standards:

   1. (A) Overtime shall not be mandated for any licensed nursing personnel except when an unexpected nurse staffing shortage arises that involves a substantial risk to patient safety, in which case a reasonable effort must be applied to secure safe staffing before requiring the on-duty licensed nursing personnel to work overtime. Reasonable efforts undertaken shall be verified by the hospital. Reasonable efforts shall include pursuing all of the following:

      1. 1. Reassigning on-duty staff;
      2. 2. Seeking volunteers to work extra time

from all available qualified nursing staff who are presently working;

1. 3. Contacting qualified off-duty employ-

ees who have made themselves available to work extra time, per diem staff, float pool and flex team nurses; and

1. 4. Seeking personnel from a contracted

temporary agency or agencies when such staffing is permitted by law or an applicable collective bargaining agreement and when the employer regularly uses the contracted temporary agency or agencies;

1. (B) In the absence of nurse volunteers, float pool nurses, flex team nurses or contracted temporary agency staff secured by the reasonable efforts as described in subsection (8)(A) and if qualified reassignments cannot be made, the hospital may require the nurse currently providing the patient care to fulfill his or her obligations based on the Missouri Nurse Practice Act by performing the patient care which is required;
2. (C) The prohibition of mandatory overtime does not apply to overtime work that occurs because of an unforeseeable emergency or when a hospital and a subsection of nurses commit, in writing, to a set, predetermined staffing schedule or prescheduled on-call time. An unforeseeable emergency is defined as a period of unusual, unpredictable or unforeseeable circumstances such as, but not limited to, an act of terrorism, a disease outbreak, adverse weather conditions, or natural disasters which impact patient care and which prevent replacement staff from reporting for duty;
3. (D) The facility is prohibited from requiring a nurse to work additional consecutive hours and from taking action against a nurse on the grounds that a nurse failed to work the additional hours or when a nurse declines to work additional consecutive hours beyond the nurse’s predetermined schedule of hours because doing so may, in the nurse’s judgement, jeopardize patient safety;
4. (E) Subsection (8)(D) is not applicable if overtime is permitted under subsections (8)(A), (B), and (C).
5. (F) Nurses required to work more than twelve (12) consecutive hours under subsections (8)(A), (B), or (C) shall be provided the option to have at least ten (10) consecutive hours of uninterrupted off-duty time immediately following the worked time.

1. (9) The nursing service shall be administered and directed by a qualified registered professional nurse with appropriate education, experience and demonstrated ability in nursing practice and management.
2. (10) The nursing service administrator shall be responsible to the chief executive officer or chief operating officer.
3. (11) The nursing service administrator shall be a full-time employee and shall have the authority and be accountable for assuring the provision of quality nursing care for those patient areas delineated in the organizational structure.
4. (12) The nursing service administrator shall participate in the formulation of hospital policies and the development of long-range plans relating to patient care.
5. (13) The nursing service administrator, or designee, shall represent nursing at all appro- 19 CSR 30-20

priate meetings of the medical staff and governing board of the hospital.

1. (14) The nursing service administrator shall be accountable for the selection, promotion and termination of all nursing personnel under the authority of nursing service.
2. (15) The nursing service administrator shall have sufficient time to perform the necessary managerial duties and functions of the position.
3. (16) A qualified registered professional nurse shall be designated and authorized to act in the absence of the nursing service administrator.
4. (17) Nursing personnel shall hold a valid and current license in accordance with sections 335.011–335.096, RSMo.
5. (18) There shall be a job description for each classification of nursing personnel which delineates the specific qualifications, licensure, certification, authority, responsibilities, functions and performance standards for that classification. Job descriptions shall be reviewed annually and revised as necessary to reflect current job requirements.
6. (19) There shall be scheduled annual evaluations of job performance for all classifications of nursing personnel.
7. (20) All nursing personnel shall be oriented to the hospital, nursing services, their position classification and the use of overtime. The orientation shall be of sufficient length and content to prepare nursing personnel for their specified duties and responsibilities. Competency shall be validated prior to assuming independent performance in actual patient situation.
8. (21) For specialized nursing units and those units providing specific clinical services, written policies and procedures, including standards of practice, shall be available and current.
9. (22) Nursing personnel meetings shall be conducted at intervals necessary for leadership and to communicate management information. Separate meetings for the various job classifications of personnel may be conducted. Minutes of all meetings shall be maintained and reflect attendance, scope of discussion and action(s) taken. The minutes shall be filed according to hospital policy. SENIOR SERVICES
10. (23) Each facility shall develop and utilize a methodology which ensures adequate nurse staffing that will meet the needs of the patients. At a minimum, on duty at all times there shall be a sufficient number of registered professional nurses to provide patient care requiring the judgment and skills of a registered professional nurse and to supervise the activities of all nursing personnel.
11. (24) There shall be sufficient licensed and ancillary nursing personnel on duty on each nursing unit to meet the needs of each patient in accordance with accepted standards of nursing practice.
12. (25) Patient care assignments shall be consistent with the qualifications of the nursing personnel and the identified patient needs.
13. (26) Documentation in the patient’s medical record shall reflect use of the nursing process in the delivery of care throughout the patient’s hospitalization.
14. (27) A registered professional nurse shall assess the patient’s needs for nursing care in all settings where nursing care is provided. A nursing assessment shall be completed within twenty-four (24) hours of admission as an inpatient. The registered professional nurse may be assisted in the process by other qualified nursing staff members.
15. (28) Patient education and discharge needs shall be addressed and appropriately documented in the medical records.
16. (29) The necessary types and quantities of supplies and equipment shall be available to meet the current needs of each patient. Reference materials pertinent to patient care shall be readily accessible.

AUTHORITY: sections 192.006 and 197.080, RSMo 2000 and 197.154, RSMo Supp. 2007.* This rule previously filed as 19 CSR 30-20.021(3)(E). Original rule filed June 27, 2007, effective Feb. 29, 2008.

*Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004.