The nurse executive directs the implementation of a nurse staffing plan(s).

(1)

The nurse executive, who is a licensed registered nurse, is responsible for the operation of nursing services, including determining the following: - Nursing policies and procedures - Types and numbers of nursing and other staff necessary to provide nursing care for all areas of the hospital

(2)

The nurse executive assumes an active leadership role with the hospital’s governing body, senior leadership, medical staff, management, and other clinical leaders in the hospital’s decision-making structure and process. Note 1: The nurse executive possesses a postgraduate degree in nursing or a related field, the knowledge and skills associated with an advanced degree, or a written plan to obtain these qualifications. Note 2: A related field may include health care administration or business administration.

(4)

A registered nurse directly provides or supervises the nursing services provided by other staff to patients 24 hours a day, 7 days a week. The hospital has a licensed practical nurse or registered nurse on duty at all times. Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: A registered nurse is immediately available for the provision of care of any patient. Note 2: For hospitals that use Joint Commission accreditation for deemed-status purposes: Rural hospitals with a 24-hour nursing waiver granted under 42 CFR 488.54(c) are not required to have 24-hour nursing services.

(5)

There must be an adequate number of licensed registered nurses, licensed practical (vocational) nurses, and other staff to provide nursing care to all patients, as needed. Note: There are supervisors and staff for each department or nursing unit to make certain a registered nurse is immediately available for the care of any patient.

(7)

The hospital has policies and procedures that establish which outpatient departments, if any, are not required to have a registered nurse present. The policies and procedures meet the following requirements: - Establish criteria that such outpatient departments need to meet, taking into account the types of services delivered, the general level of acuity of patients served by the department, and established standards of practice for the services delivered - Describe alternative staffing plans - Are approved by the director of nursing - Are reviewed at least once every three years