Policies and Procedures

Section 250 Section 250.1030  Policies and Procedures a)         For the purposes of this Section: "Health care worker" means an individual providing direct patient care services who may be required to lift, transfer, reposition, or move a patient. A direct patient care provider is the same as a health care worker. "Safe lifting equipment and accessories" means mechanical equipment designed to lift, move, reposition, and transfer patients, including, but not limited to, fixed and portable ceiling lifts, sit-to-stand lifts, slide sheets and boards, slings, and repositioning and turning sheets. "Safe lifting team" means at least 2 individuals who are trained in the use of both safe lifting techniques and safe lifting equipment and accessories, including the responsibility for knowing the location and condition of such equipment and accessories. (Section 6.25 of the Act) b)         Nursing policies and procedures shall be developed, reviewed periodically but at least once a year, and revised as necessary by nursing representatives in cooperation with appropriate representatives from administration, the medical staff, and other concerned hospital services or departments. c)         The nursing policies and procedures shall be dated to indicate the time of the most recent review or revision. d)         Written policies shall include, but not be limited to, the following: 1)         Criteria pertaining to the performance of special procedures and the circumstances and supervision under which these may be performed by nursing personnel; 2)         Communication and implementation of diagnostic and therapeutic orders, including verbal orders, and the responsibility and mechanism for nursing service to obtain clarification of orders when indicated; 3)         Administration of medication; 4)         Assignments for providing nursing care to patients; 5)         Documentation in patients' records by nursing personnel; 6)         Infection control, pursuant to Section 250.1100; 7) A policy to identify, assess, and develop strategies to control risk of injury to patients and nurses and other health care workers, associated with the lifting, transferring, repositioning, or movement of a patient. The policy shall establish a process that, at a minimum, includes all of the following: A) Analysis of the risk of injury to patients and nurses and other health care workers posted by the patient handling needs of the patient populations served by the hospital and the physical environment in which the patient handling and movement occurs; B) Education and training of nurses and other direct patient care providers in the identification, assessment, and control of risks of injury to patients and nurses and other health care workers during patient handling and on safe lifting policies and techniques and current lifting equipment; C) Evaluation of alternative ways to reduce risks associated with patient handling, including evaluation of equipment and the environment; D) Restriction, to the extent feasible with existing equipment and aids, of manual patient handling or movement of all or most of a patient's weight except for emergency, life-threatening, or otherwise exceptional circumstances; E) Collaboration with, and an annual report to, the nurse staffing committee; F) Procedures for a nurse to refuse to perform or be involved in patient handling or movement that the nurse in good faith believes will expose a patient or nurse or other health care worker to an unacceptable risk of injury; G) Submission of an annual report to the hospital's governing body or quality assurance committee on activities related to the identification, assessment, and development of strategies to control risk of injury to patients and nurses and other health care workers associated with the lifting, transferring, repositioning, or movement of a patient; H) In developing architectural plans for construction or remodeling of a hospital or unit of a hospital in which patient handling and movement occurs, consideration of the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment; I) Fostering and maintaining patient safety, dignity, self-determination, and choice, including the following policies, strategies, and procedures : i) The existence and availability of a trained safe lifting team ; ii) A policy of advising patients of a range of transfer and lift options, including adjustable diagnostic and treatment equipment, mechanical lifts, and provision of a trained safe lifting team; iii) The right of a competent patient, or guardian of a patient adjudicated incompetent, to choose among the range of transfer and lift options, subject to the provisions of subsection (d)(7)(I)(v) ; iv) Procedures for documenting, upon admission and as status changes, a mobility assessment and plan for lifting, transferring, repositioning, or movement of a patient, including the choice of the patient or patient's guardian among the range of transfer and lift options; and v) Incorporation of such safe lifting procedures, techniques, and equipment as are consistent with applicable federal law; (Section 6.25(b) of the Act) 8)         Nursing role in other hospital services, including but not limited to services such as dietary, pharmacy, and housekeeping; and 9)         Emotional and attitudinal support. (Refer to Section 250.260(b)(1).) e)         A nursing procedure manual shall be developed to provide a ready reference on nursing procedures and a basis for standardization of procedures and equipment in the hospital. f)         Copies of the nursing procedure manual shall be available on the patient care units, to the nursing staff, and to other services and departments of the hospital, including members of the medical staff and students. g) The use of latex gloves by hospital staff is prohibited.  If a crisis exists that interrupts a hospital's ability to reliably source nonlatex gloves, hospital staff may use latex gloves upon a patient.  However, during the crisis, hospital staff shall prioritize, to the extent feasible, using nonlatex gloves for the treatment of any patient with self-identified allergy to latex; and any patient upon whom the latex gloves are to be used who is unconscious or otherwise physically unable to communicate and whose medical history lacks sufficient information to indicate whether or not the patient has a latex allergy. (Sections 10(c) and 15 of the Latex Glove Ban Act)