Section 518.1700  Nursing Services


The FEC shall provide an organized nursing service and shall maintain a staff of nursing personnel organized to provide the nursing care for its patients commensurate with size, scope and nature of services.


a)         Director of Nursing Administration or Nursing Service Manager


1)         The nursing service shall be under the direction of a registered professional nurse who has qualifications in nursing administration and/or nursing management and who has the ability to organize, coordinate, and evaluate the service.


2)         The nursing administrator (director of nursing) shall hold a degree in nursing or have documented experience and relevant continuing education. He/she shall be employed full-time within the FEC as director of the nursing administration or nursing service manager.


3)         The nursing administrator shall be accountable to the chief executive officer or designee for developing and implementing policies and procedures of the service and for the nursing practice.


4)         The nursing administrator shall have authority over the selection, promotion and retention of nursing personnel based on established job descriptions.


5)         A qualified registered nurse shall be designated and authorized to act in the absence of the nursing administrator on a 24-hour basis.


b)         Nursing Staff


1)         A sufficient number of registered professional nurses shall be on duty at all times to assess, plan, assign, supervise, and evaluate nursing care and provide patients nursing care for which the judgment and specialized skills of a registered nurse are required.


2)         Licensed practical nurses and other nursing personnel shall be qualified through training, education, and experience, and shall have demonstrated abilities to give nursing care that does not require the skill and judgment of a registered professional nurse.  Auxiliary nursing personnel shall be assigned and supervised by a registered professional nurse and shall be given only those duties for which they are trained.


3)         The number of registered professional nurses, licensed practical nurses and other nursing personnel assigned shall be consistent with the types of nursing care needed by the patients and the capabilities of the staff. Patients shall be evaluated near the end of each change of shift by criteria developed by the nursing service.


c)         Staffing Standards


1)         Staffing schedules shall reflect actual nursing personnel required for the FEC.  Staffing patterns shall reflect consideration of nursing goals, standards of nursing practice, and the needs of the patients.


2)         Staffing schedules shall accomplish the following:


A)        Identification of the nurse in charge.


B)        Assignment of personnel in a manner that gives consideration to patient care and minimizes the risk of cross-infections.


C)        Projection of future time schedules indicating assignment of personnel by name, status, date and duty tour.


D)        Time schedules shall be kept in detail, indicating the assignment of nursing personnel by name, status, date, and patient care assignment.  Actual time reports shall be kept verifying personnel attendance by name, date, patient care assignment, and time of actual attendance.


d)         Planning, decision making, and formulation of policies that affect the operation of the nursing service, the care of patients, or the environment of patients shall include nursing service representatives, and their recommendations shall be considered.


e)         Job descriptions shall be written for each position classification in the nursing service and shall delineate the functions, responsibilities, and qualifications for each classification.  Copies of job descriptions shall be available to nursing personnel.


f)         Procedures shall be maintained to ensure that nursing personnel for whom licensure is required have valid and current licenses in the State of Illinois and to verify licensure status.


g)         The current license and credentials of private duty and agency nurses shall be verified prior to assignment.  The nursing service shall maintain adequate supervision of private duty and agency nurses and shall require that they abide by the appropriate policies and procedures and maintain the standards of the FEC and the nursing service.


h)         Nursing policies and procedures shall be developed, reviewed periodically 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 FEC services or departments.  The policies and procedures shall be dated to indicate the time of the most recent review or revision.


i)          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 an order 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.


7)         Patient safety.


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


9)         Emotional and attitudinal support.


j)          A nursing procedure manual shall be developed, and copies shall be available to the nursing staff and to other services and departments, including members of the medical staff and students.


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


(Source:  Amended at 33 Ill. Reg. 8317, effective June 4, 2009)