Title: Section 400.25 - Disclosure of nursing quality indicators

Effective Date

01/07/2015

Section 400.25 Disclosure of nursing quality indicators.

(a) Definitions. For purposes of this section, the following terms shall have the following meanings:

(1) Acuity means the nursing care requirements of patients or residents.

(2) Case mix means the differences in patients or residents within a population in terms of their physical and mental conditions, and the resources that are used in their care.

(3) Fall means:

(i) For general hospitals, an unplanned descent to the floor with or without injury to the patient including unassisted and assisted descents whether they result from physiological or environmental reasons.

(ii) For nursing homes, an unintentional change in position coming to rest on the ground, floor or onto the next lower surface with or without injury to the resident including intercepted falls.

(4) Fall injury level means:

(i) For general hospitals, the degree of injury resulting from a fall and designated as moderate, major or fatal. For purposes of this subparagraph: moderate injuries involve suturing, application of steri-strips/skin glue, splinting or muscle/joint strain; major injuries involve surgery, casting or traction, or require consultation to rule out neurological or internal injury or patients with coagulopathy that receive blood products as a result of the fall; and fatal falls involve injuries that cause the patient’s death but do not include falls caused by physiologic events.

(ii) For nursing homes, the degree of injury resulting from a fall designated as major involves bone fractures, joint dislocations, closed head injuries with altered consciousness or subdural hematoma.

(5) Healthcare setting associated infection means any localized or systemic patient condition that:

(i) resulted from the presence of an infectious agent or its toxin(s) as determined by clinical examination or by laboratory testing; and

(ii) was not found to be present or incubating at the time of admission unless the infection was related to a previous admission to the same setting.

(6) Licensed Practical Nurse means a person who is licensed and currently registered as a Licensed Practical Nurse pursuant to Article 139 of the New York State Education Law.

(7) Patient includes a resident of a nursing home.

(8) Patient care staff means unit-based Registered Nurses, Licensed Practical Nurses and unlicensed personnel providing direct patient care greater than 50% of their shift.

(9) Patient day is the average number of patients a unit has per shift during a 24 hour period.

(10) Pressure ulcer means a localized injury to the skin and/or underlying tissue as a result of pressure or pressure in combination with shear acquired after admission to a healthcare facility.

(11) Registered Nurse means a person who is licensed and currently registered as a Registered Professional Nurse pursuant to Article 139 of the New York State Education Law.

(12) Shift means a 24 hour period of time as a whole or divided into parts as appropriate to the reporting facility.

(13) Unit means a distinct location providing patient care in a general hospital or nursing home distinguished from other distinct locations by name, number or other patient-specific factors.

(14) Unlicensed personnel means individuals trained to function in an assistive role to nurses in the provision of patient care, as assigned by and under the supervision of the Registered Nurse.

(b) Nurse Staffing Indicators are:

(1) The total number of productive hours of care provided by patient care staff per patient day for each unit, and the number and percentage of productive hours of care provided by Registered Nurses, Licensed Practical Nurses and unlicensed personnel each; and

(2) the average Registered Nurse and Licensed Practical Nurse to patient ratio for each unit and on each shift.

(c) Nurse-sensitive patient outcome indicators for general hospitals are:

(1) Falls with injury rate as indicated by the frequency in which falls result in a fall injury level of moderate, major or fatal per applicable unit calculated no less often than quarterly.

(2) Health care acquired pressure ulcers as indicated by the percentage of patients with facility-acquired pressure ulcer(s) of the skin that are determined to be stages II, III, IV, unstageable and suspected deep tissue injury per applicable unit calculated no less often than quarterly.

(3) Healthcare setting associated infection rates per applicable unit calculated no less often than quarterly for the following:

(i) Central line associated blood stream infection;

(ii) Catheter associated urinary tract infection; and

(iii) Ventilator associated (pneumonia) event.

(d) Nurse-sensitive patient outcome indicators for nursing homes are:

(1) Percent of long-stay residents who experienced one or more falls with major injury.

(2) Percentage of short-stay residents who have medical conditions that predispose them to developing a facility-acquired pressure ulcer with new or worsening pressure ulcers Stage II-IV.

(3) Percentage of long-stay residents with urinary tract health care setting associated infections.

(e) Within 30 days of a written request, general hospitals and nursing homes shall provide to the requester in hard copy or an electronic copy such as a portable document format (pdf) file, the following information for a three to twelve month period of time that is not more than one year prior to the date of the request:

(1) nurse staffing indicators and nurse-sensitive patient outcome indicators specified in this section;

(2) the procedures and processes used for determining and adjusting staffing levels based on patient case mix and acuity;

(3) the final conclusions of any complaint investigations filed with any state or federal regulatory agency or accrediting agency and any citations resulting from surveys; and

(4) the sources and dates for data disclosed.

(f) Facilities shall have policies and procedures for documentation and management of requests and responses to requests under this section. Documentation of requests and responses to requests under this section shall be kept for a period of no less than two years from the date the request for information was received.

Volume

VOLUME C (Title 10)

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