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 SENIOR SERVICES

services offered and the range of nursing care activities.

1. (4) Nursing policies and standards of practice describing patient care shall be in writing and be kept current and readily available to staff.
2. (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.
3. (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.
4. (7) Policies shall make provision for nursing personnel to be participants of hospital committees concerned with patient care activities.

5. (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 and a reasonable effort has been made to secure safe staffing. Reasonable efforts undertaken shall be documented 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) 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;
2. (C) Other than overtime permitted under subsections (8)(A) and (B), the facility is prohibited from requiring a nurse to work additional consecutive hours beyond the nurse’s predetermined schedule of hours when doing so may, in the nurse’s judgment, jeopardize patient safety 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;
3. (D) Nurses required to work more than twelve (12) consecutive hours under subsections (8)(A) or (B) shall be provided the option to have at least ten (10) consecutive hours of uninterrupted off-duty time immediately following the worked time; and
4. (E) The nursing service shall maintain and make available upon request to the department a list of qualified nurses, nurse registries, and per diem nurses that may be called upon to provide replacement staff in the event of sickness, vacations, vacancies, disasters, and other absences of direct care nursing staff.

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 appropriate meetings of the medical staff and governing board of the hospital.
6. (14) The nursing service administrator shall be accountable for the selection, promotion, and termination of all nursing personnel under the authority of nursing service.
7. (15) A qualified registered professional nurse shall be designated and authorized to act in the absence of the nursing service administrator.
8. (16) Nursing personnel shall hold a valid and current license in accordance with sections 335.011–335.096, RSMo.
9. (17) 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 per hospital policy and revised as necessary to reflect current job requirements.
10. (18) There shall be scheduled annual evaluations of job performance for all classifications of nursing personnel.
11. (19) All nursing personnel shall be oriented to the hospital, nursing services, their position classification, the use of overtime, and the nursing service regulation 19 CSR 30- 20.096. The orientation shall be of sufficient length and content to prepare nursing personnel for their specified duties and responsibilities. Competency shall be validated and documented prior to assuming independent performance in actual patient situations.
12. (20) 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.
13. (21) By January 15 of each year, every hospital shall develop, implement, and submit to the Department of Health and Senior Services, a written or electronic copy of the hospital-wide staffing plan for nursing services. Every hospital shall have a policy that requires the input on the staffing plan from direct care nursing staff from within the hospital.

14. (22) The hospital-wide staffing plan for nursing services shall:

    1. (A) Include the number, skill mix, and qualifications of direct care nursing staff needed for each unit of the hospital;
    2. (B) Be based on the expected nursing care required by the unit population and individual needs of each patient. The expected unit population and individual nursing care needs of each patient shall be the major consideration in determining the number and skill mix of direct care nursing staff needed;
    3. (C) Identify relevant factors in each hospital unit including, but not limited to, the number of patients in a unit; intensity of care required; skill and experience of care givers including registered nurses, licensed practical nurses, ancillary personnel, and other members of the patient care team consistent with the level of authority and responsibility delegated under state licensure; admission, discharge, and transfers; nonpatient care duties; geography of a unit; and the availability of technological support;
    4. (D) Provide for documentation of the actual staffing plan; and
    5. (E) Nurses included in the staffing plan count shall spend a minimum of seventy-five percent (75%) of their time providing direct patient care.

15. (23) Every hospital shall establish nursing sensitive indicators and monitor outcomes of these indicators to evaluate the adequacy of the hospital-wide staffing plan for nursing services. At least one (1) of each of the following three (3) types of outcomes shall be used to evaluate the adequacy of the staffing plan:

    1. (A) Patient outcomes such as patient falls, adverse drug events, injuries to patients, skin breakdown, infection rates, length of stay, or patient readmissions;
    2. (B) Operational outcomes such as workrelated injury or illness, vacancy and turnover rates, nursing care hours per patient day, oncall use, or overtime rates; and
    3. (C) Validated patient complaints related to staffing levels.
16. (24) The hospital shall, in consultation with its direct care nursing staff, monitor and evaluate the hospital-wide staffing plan and nursing sensitive outcomes for effectiveness on a continual basis and revise the plan annually and as necessary.
17. (25) Each facility shall develop and utilize a methodology which ensures it is staffed with sufficient numbers and skill mix of appropriately qualified direct care nursing staff in each unit to meet the unit population and individualized care needs of the patients. Each unit shall document actual staffing and patient census during every shift.
18. (26) At a minimum, there shall be a sufficient number of registered professional nurses on duty at all times to provide patient care requiring the judgment and skills of a registered professional nurse and to supervise the activities of all nursing personnel.
19. (27) 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.
20. (28) Each nursing unit shall post in a visible location on the nursing unit or make available to the patient(s) or patient’s authorized representative a copy of the unit’s hospital-wide staffing plan for nursing services and documentation of actual daily staffing levels.
21. (29) Patient care assignments shall be consistent with the qualifications of the nursing personnel and the identified patient needs.
22. (30) 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.
23. (31) Evidence of planning the patient’s care, education, and discharge needs shall be addressed, kept current, and appropriately documented in the medical records.
24. (32) 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: section 192.006, RSMo 2000, and sections 197.080 and 197.154, RSMo Supp. 2013.* This rule previously filed as 19 CSR 30-20.021(3)(E). Original rule filed June 27, 2007, effective Feb. 29, 2008. Amended: Filed Oct. 22, 2008, effective June 30, 2009. Amended: Filed Dec. 31, 2013, effective Aug. 30, 2014.

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