Title: Section 405.5 - Nursing services

405.5 Nursing services. The governing body shall ensure that the hospital has an organized nursing service that provides 24-hour services and that meets the care needs of all patients in accordance with established standards of nursing practice. The nursing services for all patients shall be provided or supervised by a registered professional nurse who is on duty and available at all times.

(a) Organization and staffing. (1) The hospital shall have a written nursing service plan of administrative authority and delineation of responsibilities. The director of the nursing service shall be a licensed registered professional nurse who is qualified by training and experience for such position. The director of the nursing service shall be responsible for the operation of the service, including developing such nursing service plan to be approved by the hospital for determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital in accordance with the hospital’s clinical staffing plan as provided in paragraph (8) of this subdivision.

(2) The hospital shall employ licensed and currently registered professional nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. The hospital shall provide supervisory and staff personnel for each department or nursing unit to ensure, when needed in accordance with generally accepted standards of nursing practice, the immediate availability of a registered professional nurse for bedside care of any patient.

(3) Job descriptions for each position classification of registered professional nurses and ancillary nursing personnel shall specify standards of performance and delineate the functions, responsibilities, and specific qualifications of each classification.

(4) A written evaluation of the performance, credentials, and competence of registered professional nurses and ancillary nursing personnel shall be conducted on at least a biennial basis.

(5) When nursing services are provided by nursing students, nurses with limited permits, or by personnel from outside sources, the hospital shall retain full responsibility for the quality of nursing care rendered in the hospital.

(i) Nursing students, nurses with limited permits, and registered professional nurses from outside sources who are working in the hospital shall adhere to the policies and procedures of the hospital.

(ii) The director of nursing services shall provide for the supervision and evaluation of the clinical activities of all nursing personnel.

(6) All nursing services personnel, including nursing students and nonemployee licensed nurses who are working in the hospital, shall receive a basic orientation to prepare them for their specific duties and responsibilities prior to performing any nursing functions within a patient care area. For employee nurses and nursing students, the hospital shall provide or arrange for the provision of training programs to augment their knowledge of pertinent new developments in patient care. The hospital shall also require that nonemployee licensed nurses obtain education and training pertinent to the clinical duties to which they are assigned.

(7) Nursing services personnel employed in specialty areas, including, but not limited to, emergency services, must complete training and education specific to the specialty area.  Nursing services personnel must be periodically reevaluated for competency and ongoing education and training provided to maintain competency in the specialty area.

(8) Hospitals must establish and maintain a clinical staffing committee as provided in section 2805‑t of the Public Health Law. The clinical staffing committee shall develop and oversee the implementation of an annual clinical staffing plan. The clinical staffing plan shall delineate intensive care and critical care units of the hospital. The clinical staffing plan shall include specific staffing for each patient care unit and work shift and shall be based on the needs of patients. Staffing plans shall include specific guidelines or ratios, matrices, or grids indicating how many patients are assigned to each registered nurse and the number of nurses and ancillary nursing personnel to be present on each unit and shift. Ancillary nursing personnel includes, but is not limited to, certified nurse assistants, patient care technicians, and other non-licensed members of the frontline team assisting with nursing tasks. Each hospital shall adopt and submit its first clinical staffing plan under this paragraph no later than July 1, 2022, and annually thereafter. Beginning January 1, 2023, and annually thereafter, each hospital shall implement the clinical staffing plan adopted by July 1 of the prior calendar year, and any subsequent amendments, and assign personnel to each patient care unit in accordance with the plan. Factors to be considered and incorporated in the development of the clinical staffing plan shall include, but are not limited to:

(i) census, including total numbers of patients on the unit on each shift and activity such as patient discharges, admissions, and transfers;

(ii) measures of acuity and intensity of all patients and nature of the care to be delivered on each unit and shift;

(iii) skill mix;

(iv) the availability, level of experience, and specialty certification or training of nursing personnel providing patient care, including charge nurses, on each unit and shift;

(v) the need for specialized or intensive equipment;

(vi) the architecture and geography of the patient care unit, including but not limited to placement of patient rooms, treatment areas, nursing stations, medication preparation areas, and equipment;

(vii) mechanisms and procedures to provide for one-to-one patient observation, when needed, for patients on psychiatric or other units as appropriate;

(viii) other special characteristics of the unit or community patient population, including age, cultural and linguistic diversity and needs, functional ability, communication skills, and other relevant social or socio-economic factors;

(ix) measures to increase worker and patient safety, which could include measures to improve patient throughput;

(x) staffing guidelines adopted or published by other states or local jurisdictions, national nursing professional associations, specialty nursing organizations, and other health professional organizations;

(xi) availability of other personnel supporting nursing services on the unit;

(xii) waiver of plan requirements in the case of unforeseeable emergency circumstances as defined in subdivision fourteen of section 2805‑t of the Public Health Law;

(xiii) coverage to enable registered nurses, licensed practical nurses, and ancillary staff to take meal and rest breaks, planned time off, and unplanned absences that are reasonably foreseeable as required by law or the terms of an applicable collective bargaining agreement, if any, between the general hospital and a representative of the nursing or ancillary staff;

(xiv) the nursing quality indicators required under section 400.25 of this Title;

(xv) general hospital finances and resources; and

(xvi) provisions for limited short-term adjustments made by appropriate general hospital personnel overseeing patient care operations to the staffing levels required by the plan, necessary to account for unexpected changes in circumstances that are to be of limited duration.

(b) Delivery of services. (1) There shall be working relationships among medical staff, nursing staff and staff of other departments or services to assure that all patient care needs are met.

(i) Nursing services personnel shall execute the orders of physicians and other practitioners, authorized by the governing body to order such services.

(ii) Registered professional nurses shall confer with the responsible practitioner relative to patient care on an ongoing basis and relative to significant changes in the patient's condition as necessary.

(iii) The hospital shall develop and implement policies and procedures for prompt review and correction, as necessary, of health care practitioner orders which have, or have the likely potential for having, negative impact on patient care and safety and which should not be carried out.

(2) There shall be continuous review and evaluation of the adequacy and appropriateness of nursing care provided for patients.

(i) Nursing care policies and procedures shall be written and consistent with generally accepted standards of nursing practice.

(ii) A registered professional nurse shall plan, supervise, and evaluate the nursing care for each patient. A registered professional nurse shall assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the preparation and competence of such other nursing personnel.

(3) Written nursing care plans shall be kept current. Such plans shall indicate what nursing care is needed, how it is to be provided, and the methods, approaches and mechanisms for ongoing modifications necessary to ensure the most effective and beneficial results for the patient. Patient education and patient/family knowledge of care requirements shall be included in the nursing plan.  The nursing care plan may be integrated into the overall interdisciplinary plan of care.

(4) Nursing documentation shall describe the nursing care given and include information and observations of significance so that they contribute to the continuity of patient care. Nursing interventions and patient responses shall be documented.

(c) Administration of drugs. All drugs and biologicals shall be administered in accordance with the orders of the practitioner or practitioners responsible for the patient's care as specified under section 405.2 of this Part, and generally accepted standards of practice. They shall be administered by a licensed physician or a registered professional nurse, or other personnel in accordance with applicable licensing requirements of title 8 of the New York State Education Law, except for the self-administration of medications as set forth in paragraphs (4) and (5) of this subdivision, and in accordance with hospital policies and procedures.  For purposes of this subdivision, “self-administration” means administration by the patient or the patient’s caregiver, including but not limited to a caregiver pursuant to section 2994-ii(3) of the Public Health Law, or a designated caregiver pursuant to section 3360(5) of the Public Health Law.

(1) All orders for drugs and biologicals shall be authenticated by the practitioner or practitioners responsible for the care of the patient as specified under section 405.2 of this Part.

(2) Blood transfusions and intravenous medications shall be administered in accordance with approved medical staff and nursing service policies and procedures. If blood transfusions and intravenous medications are administered by personnel other than physicians, such personnel shall have completed specific training to prepare them for this duty.

(3) There shall be a hospital procedure and nursing policies and procedures for the reporting and review of transfusion reactions, adverse drug reactions, and errors in administration of drugs.

(4) Hospitals, in accordance with hospital policies and procedures, may authorize hospital-issued prescription and non-prescription medications to be self-administered, provided that:

(i) a practitioner responsible for the care of the patient in the hospital has issued an order permitting self-administration;

(ii) the capacity of the patient or the patient’s caregiver to administer the medication has been assessed;

(iii) the patient or the patient’s caregiver has been given instructions for the safe and accurate administration of the medication;

(iv) the security of the medication is addressed; and

(v) documentation is made of the administration of each medication in the patient’s record, as reported by the patient or the patient’s caregiver.

(5) Hospitals, in accordance with hospital policies and procedures, may authorize a patient to bring in his or her own medications, including prescription medications, non-prescription medications and medical marihuana as defined in section 3360(8) of the Public Health Law, and self-administer such medications, provided that:

(i) a practitioner responsible for the care of the patient in the hospital has issued an order permitting self-administration of the medication the patient brought into the hospital, and in the case of medical marihuana, upon presentation of the patient or designated caregiver’s registry identification card issued pursuant to section 3363 of the Public Health Law;

(ii) the capacity of the patient or the patient’s caregiver to administer the medication has been assessed;

(iii) a determination is made concerning whether the patient or the patient’s caregiver needs instruction on the safe and accurate administration of the medication;

(iv) the medication is identified and visually evaluated for integrity;

(v) the security of the medication is addressed;

(vi) documentation is made of the administration of each medication in the patient’s record, as reported by the patient or the patient’s caregiver; and

(vii) if a patient dies in the hospital, any unused prescription medication shall be destroyed or disposed of in accordance with all applicable state and federal laws and regulations. Such prescription medications may not be turned over to the patient’s caregiver.  In the case of medical marihuana, it may be turned over to the deceased patient’s designated caregiver or to appropriate law enforcement for destruction or disposal.

(d) Nasogastric tube feedings. Following consideration of possible alternatives for short term nutritional therapy, nasogastric tubes and feeding formulations may be used for feeding purposes when determined clinically appropriate by the attending practitioner. Nasogastric tube feedings shall be used to promote a therapeutic program to maintain adequate nutrition and hydration and include a plan to help the patient develop or regain eating skills.

(1) Nasogastric tube feeding formulations shall be given in accordance with the manufacturer's instructions or at a rate appropriate to the physical size of the resident and the amount of fluid and nutrients necessary to meet the assessed caloric and fluid needs of the patient.

(2) To minimize patient discomfort, nasogastric tubes used for patient feeding purposes shall:

(i) be the smallest gauge appropriate for the patient and shall not exceed 3.96 millimeters (#12 French) in outside diameter unless medically indicated;

(ii) be made of a soft, flexible material such as medical grade polyurethane or silicone; and

(iii) be specifically manufactured for nasogastric feeding purposes.

(3) Patients receiving nasogastric tube feedings shall be periodically evaluated for the ability to return to normal feeding function. If nasogastric feedings are to be continued longer than three months, permanent enteral feeding procedures such as surgical gastrostomy or jejunostomy shall be considered. If the nasogastric feeding is continued, the reasons for continuation shall be documented in the patient's medical record.

(4) The facility shall develop and implement policies and procedures for inpatient nasogastric tube feedings which are written in accordance with prevailing standards of professional practice and in consultation with the medical, nursing, dietary and pharmacy services of the facility. Medical practitioners shall be informed of such policies and procedures governing the use of nasogastric tubes for patient feeding. The policies and procedures shall address as a minimum:

(i) types and sizes of nasogastric tubes and the various types of feeding formulations available at the facility;

(ii) the need to assess each patient's clinical and nutritional status to determine the size of the nasogastric tube and type of feeding appropriate for that individual;

(iii) standard techniques for inserting a nasogastric tube and confirming the correct placement of the tube;

(iv) procedures for administering nasogastric feedings including positioning the patient and the need for patient observation and monitoring before, during and following the feeding; and

(v) infection control practices related to tube feedings.

(e) Quality assurance. The nursing service shall monitor and evaluate the quality and appropriateness of patient care and the resolution of identified problems. This process shall be integrated with the quality assurance committee in accordance with hospital policies and procedures.

(1) Nursing service personnel shall meet as often as necessary to identify and resolve problems and potential problems in the provision of nursing care, taking into consideration the findings from relevant nursing care monitoring and evaluation activities.

(2) Documentation of such reviews shall include findings, conclusions, recommendations and actions taken in conjunction with the hospital-wide quality assurance program and shall be maintained for review and analysis.