Written policies and procedures for
patient care shall be developed, maintained and implemented by the nursing
(1) Policies and procedures which
involve the medical staff shall be reviewed and approved by the medical staff
prior to implementation.
Policies and procedures of other departments which contain requirements for the
nursing service shall be reviewed and approved by the nursing service prior to
(3) The nursing
service shall review and revise policies and procedures every three years, or
more often if necessary.
hospital administration and the governing body shall review and approve all
policies and procedures that relate to the nursing service every three years or
more often, if necessary.
(b) Policies and procedures shall be based on
current standards of nursing practice and shall be consistent with the nursing
process which includes: assessment, nursing diagnosis, planning, intervention,
evaluation, and, as circumstances require, patient advocacy.
(c) Policies and procedures which contain
competency standards for staff performance in the delivery of patient care
shall be established, implemented, and updated as needed for each nursing unit,
including standards for the application of restraints. Standards shall include
the elements of competency validation for patient care personnel other than
registered nurses as set forth in Section 70016, and the elements of competency
validation for registered nurses as set forth in Section 70016.1. At least
annually, patient care personnel shall receive a written performance
evaluation. The evaluation shall include, but is not limited to, measuring
individual performance against established competency standards.
(d) Policies and procedures that require
consistency and continuity in patient care, incorporating the nursing process
and the medical treatment plan, shall be developed and implemented in
cooperation with the medical staff.
(e) Policies and procedures shall be
developed and implemented which establish mechanisms for rapid deployment of
personnel when any labor intensive event occurs which prevents nursing staff
from providing attention to all assigned patients, such as multiple admissions
or discharges, or an emergency health crisis.