Section 250.1030  Policies and Procedures

a)         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.

b)         The nursing policies and procedures shall be dated to indicate the time of the most recent review or revision.

c)         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.  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 of nurses in the identification, assessment, and control of risks of injury to patients and nurses and other health care workers during patient handling;

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; and

H)        Consideration of the feasibility of incorporating patient handling equipment or the physical space and construction design needed to incorporate that equipment when developing architectural plans for construction or remodeling of a hospital or unit of a hospital in which patient handling and movement occurs. (Section 6.25 of the Act)

8)         Nursing role in other hospital services, including but not limited to such services as dietary, pharmacy and housekeeping.

9)         Emotional and attitudinal support. (Refer to Section 250.260(b)(1).)

d)         A nursing procedure manual shall be developed and copies 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.

e)         The procedure manual shall provide a ready reference on nursing procedures and a basis for standardization of procedures and equipment in the hospital.

(Source:  Amended at 35 Ill. Reg. 4556, effective March 4, 2011)