§ 71213 - Title 22


Acute Psychiatric Hospital Requirements/Duties

Chapter 2. Acute Psychiatric Hospital


§ 71213. Psychiatric Nursing Service General Requirements.

(a) Written policies and procedures shall be developed and maintained by the director of nursing in consultation with other appropriate health professionals and administration. Policies shall be approved by the governing body. Procedures shall be approved by the administration and medical staff where such is appropriate.

(b) The responsibility and the accountability of the nursing service to the medical staff and hospital administration shall be defined.

(c) There shall be a written organized staff education program which shall include orientation and in–service education and training.

(1) There shall be written objectives, plans for implementation and an evaluation mechanism.

(d) There shall be a written patient care plan developed for each patient in coordination with the total mental health team. This plan shall include goals, problems/needs and approach and shall be available to all members of the mental health team.

(e) There shall be a written nursing audit procedure and evidence that audit procedures are in effect.

(f) There shall be a method for determining staffing requirements based on assessment of patient needs. This assessment shall take into consideration at least the following:

(1) The ability of the patient to care for himself.

(2) His degree of illness.

(3) Requirements for special nursing activities.

(4) Skill level of personnel required in his care.

(5) Placement of the patient in the nursing unit.

(g) There shall be documentation of the methodology used in making staffing determinations. Such documentation shall be part of the records of the nursing service and be available for review.

(h) There shall be a written staffing pattern which shall show:

(1) Total numbers of staff including full–time and full–time equivalents.

(2) The available nursing care hours for each nursing unit.

(3) The categories of staff available for patient care.

(i) There shall be a record retained for six months of the written staffing pattern available for review by the Department at any given time.