Nursing Services Upgraded to Prevent Deficiencies

October 11th, 2016

The April 7, 2015, CAH manual includes rewrites of all the nursing interpretive guidelines, starting at tag 294. Nursing services must be organized to meet the needs of the patients. The hospital must have a chief nursing officer who is an RN responsible for the development of the nursing policies and procedures. Nursing staff should always be aware of the hospital’s policy. Be warned: Surveyors will hold staff accountable.

There must also be a nursing care plan as part of the permanent medical record. Nursing can do it as part of the interdisciplinary plan of care.

Any agency nurses must be oriented and supervised. Hospitals have flexibility on this. Some have computerized educational programs, others information on a CD, and others have a self-assessment learning packet. The surveyor may interview nurses to determine how all the staff, including agency nurses, is oriented. The surveyor may look at staffing plans.

There is a separate section on drugs and biologicals, but the nursing section contains interpretive guidelines on drugs and IVs. CMS requires an order for drugs and biologicals that is not only signed but dated and timed. Orders must be written and drugs administered should be consistent with the acceptable standard of care. CMS specifically mentions organizations such as the Institute for Healthcare Improvement, the CDC, the Institute for Safe Medication Practices, U.S. Pharmacopeia, Infusion Nurses Society, and the National Coordinating Council for Medication Error Reporting and Prevention.

The guidelines must ensure compliance with standards for self-administered medications, staff training, basic safe practices, timing of medication, standards for IV medication, documentation, and assessment of patients receiving medications. Appendix A defines many of these areas in detail and includes a section for ensuring safe opioid use. Staff should be familiar with the opioid policy, how to monitor patients safely on opioids, and how frequently to monitor, including vital signs, pulse oximetry, sedation scale evaluation, and end tidal CO2. There is also a detailed section on safe administration of IVs and blood.

Staff must be trained on the policy and it must be approved by the Medical Executive Committee. Staff should also ensure all IVs and other lines are going at the correct amount including IV pumps. Patients must be told to notify a nurse immediately if they have any trouble breathing or if they think they may be having an adverse reaction to the medication. Hospitals may want to consider using a special assessment sheet when opioids are prescribed.

This section also includes requirements for verbal and standing orders, a longtime area of deficiencies. Staff should not take a verbal order unless necessary. Verbal orders should be documented in the medical record by the person taking the order, then signed and dated. The practitioner giving the order must sign the order off promptly.

The hospital is required to have a policy for verbal and standing orders.

Hospitals should also review the Final National Action Plan for ADR Prevention, which includes a section on safe opioid use.