1. (a) The facility in conjunction with the medical and nursing staff shall develop written policies and procedures which guide the provision of care in a special care unit. These policies and procedures shall be approved by the medical staff and include:

   1. (1) patient admission and discharge criteria;
   2. (2) notification of appropriate medical staff for changes in the condition of the patient;
   3. (3) use of standing orders and emergency protocols;
   4. (4) designation of staff members authorized to perform special procedures and special circumstances requiring such authorization;
   5. (5) patient care procedures, including medication administration;
   6. (6) infection control;
   7. (7) pertinent safety practices;
   8. (8) use of equipment and procedures to be followed in the event of equipment failure;
   9. (9) regulations governing visitors and traffic control; and
   10. (10) role of special care unit in internal and external disaster plans.
2. (b) The governing body shall review, update and approve regularly, but at least every three years, its policies and procedures.

History Note: Authority G.S. 131E-79;
Eff. January 1, 1996;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.