Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 250 - HOSPITAL LICENSING REQUIREMENTS › Subpart I - NURSING SERVICE AND ADMINISTRATION › Section 250.1030 - Policies and Procedures

Current through Register Vol. 48, No. 28, July 12, 2024
a) For the
				purposes of this Section:
"Health care worker" means an individual providing
				  direct patient care services who may be required to lift, transfer, reposition,
				  or move a patient.
A direct patient care provider is the same as a
				  health care worker.
"Safe lifting equipment and accessories" means
				  mechanical equipment designed to lift, move, reposition, and transfer patients,
				  including, but not limited to, fixed and portable ceiling lifts, sit-to-stand
				  lifts, slide sheets and boards, slings, and repositioning and turning
				  sheets.
"Safe lifting team" means at least 2 individuals who
				  are trained in the use of both safe lifting techniques and safe lifting
				  equipment and accessories, including the responsibility for knowing the
				  location and condition of such equipment and accessories.
(Section
				  6.25 of the Act)
b) 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.
c) The nursing policies and procedures shall
				be dated to indicate the time of the most recent review or revision.
d) 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, and 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 and training of nurses and other direct patient care
				providers in the identification, assessment, and control of risks of injury to
				patients and nurses and other health care workers during patient handling and
				on safe lifting policies and techniques and current lifting
				equipment;
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;
H)
In developing architectural plans
				for construction or remodeling of a hospital or unit of a hospital in which
				patient handling and movement occurs, consideration of the feasibility of
				incorporating patient handling equipment or the physical space and construction
				design needed to incorporate that equipment;
I)
Fostering and maintaining patient
				safety, dignity, self-determination, and choice, including the following
				policies, strategies, and procedures
:
i)
The existence and availability of
				a trained safe lifting team
;
ii)
A policy of advising patients of
				a range of transfer and lift options, including adjustable diagnostic and
				treatment equipment, mechanical lifts, and provision of a trained safe lifting
				team;
iii)
The
				right of a competent patient, or guardian of a patient adjudicated incompetent,
				to choose among the range of transfer and lift options, subject to the
				provisions of
subsection (d)(7)(I)(v)
;
iv)
Procedures for documenting, upon
				admission and as status changes, a mobility assessment and plan for lifting,
				transferring, repositioning, or movement of a patient, including the choice of
				the patient or patient's guardian among the range of transfer and lift options;
				and
v)
Incorporation of such safe lifting procedures, techniques, and
				equipment as are consistent with applicable federal law;
(Section
				6.25(b) of the Act)
8) Nursing role in other hospital services,
				including but not limited to services such as dietary, pharmacy, and
				housekeeping; and
9) Emotional and
				attitudinal support. (Refer to Section
				250.260(b)(1).)