Nursing Services Requirements for the State of New Jersey

SUBCHAPTER 25. MANDATORY NURSE STAFFING

8:39-25.1 Mandatory policies and procedures for nurse staffing

(a) There shall be a full-time director of nursing or nursing administrator who is a registered professional nurse licensed in the State of New Jersey, who has at least two years of supervisory experience in providing care to long-term care residents, and who supervises all nursing personnel.

(b) During a temporary absence of the director of nursing, there shall be a registered professional nurse on duty who shall be designated in writing as an alternate to the director of nursing. The alternate shall be temporarily responsible for supervising all nursing personnel.

8:39-25.2 Mandatory nurse staffing amounts and availability

(a) The facility shall provide nursing services and licensed nursing and ancillary personnel at all times. In accordance with N.J.A.C. 13:37-6.2, the registered professional nurse may delegate selected nursing tasks in the implementation of the nursing regimen to licensed practical nurses and ancillary nursing personnel.

(b) The facility shall provide nursing services by registered professional nurses, licensed practical nurses, and nurse aides (the hours of the director of nursing are not included in this computation, except for the direct care hours of the director of nursing in facilities where the director of nursing provides more than the minimum hours required at N.J.A.C. 8:39-25.1(a) above) on the basis of:

1. Total number of residents multiplied by 2.5 hours/day; plus

2. Total number of residents receiving each service listed below, multiplied by the corresponding number of hours per day:

Wound care 0.75 hour/day

Nasogastric tube feedings and/or gastrostomy1.00 hour/day

Oxygen therapy 0.75 hour/day

Tracheostomy 1.25 hours/day

Intravenous therapy 1.50 hours/day

Use of respirator 1.25 hours/day

Head trauma stimulation/advanced neuromuscular/ 1.50 hours/day

orthopedic care

(c) The following definitions shall be used for nursing services set forth in (b)2 above:

1. Wound care includes, but is not limited to, ulcers, burns, pressure sores, open surgical sites, fistulas, tube sites and tumor erosion sites. In this category are Stage II pressure sores encompassing two or more distinct lesions on separate anatomical sites, and Stage III and Stage IV pressure sores.

i. Tube site and surrounding skin related to ostomy feeding is not to be counted as wound care unless there are complicating factors, such as: exudative, suppurative or ulcerative inflammation which require specific physician or advanced practice nurse prescribed intervention provided by the licensed nurse beyond routine cleansing and dressing.

ii. Stage III and Stage IV are defined as follows:

(1) Stage III. The wound extends through the epidermis and dermis into the subcutaneous fat and is a full thickness wound. There may be inflammation, necrotic tissue, infection and drainage and undermining sinus tract formation. The drainage can be serosanguinous or purulent. The area is painful.

(2) Stage IV. The pressure wound extends through the epidermis, dermis, and subcutaneous fat into fascia, muscle and/or bone. Eschar, undermining odor and profuse drainage may exist.

(3) Other wounds which may be categorized under wound care as defined in (c)1 above include:

(A) Open wounds which are draining purulent or colored exudate or which have a foul odor present and/or for which the individual is receiving antibiotic therapy;

(B) Wounds with a drain or T-tube;

(C) Wounds which require irrigation or instillation of a sterile cleansing or medicated solution and/or packing with sterile gauze;

(D) Recently debrided ulcers;

(E) Wounds with exposed internal vessels or a mass that may have a proclivity for hemorrhage when dressing is changed (for example, post radical neck surgery, cancer of the vulva);

(F) Open wounds, widespread skin disease or complications following radiation therapy, or which result from immune deficiencies or vascular insufficiencies;

(G) Complicated post-operative wounds that exhibit signs of infection, allergic reactions or an underlying medical condition that affects healing.

2. Tube feedings, which include Nasogastric tube and percutaneous feedings, provide the individual with more than 26% of his or her calories and at least 501 milliliters of hydration daily and are required to treat the individual’s condition after all non-invasive avenues to improve the nutritional status have been exhausted with no improvement. The clinical record shall document the non-invasive measures provided and the individual’s poor response. The record shall also indicate the medical condition for which the feedings are ordered. Included in this service is the routine care of the tube site and surrounding skin of the surgical gastrostomy.

i. Feeding tubes that are routinely clamped off and are no longer the primary source of dietary administration and nutritional support are covered under the basic 2.5 hours/day of nursing service and shall not be counted as an additional nursing service.

3. Oxygen therapy includes complex provision of oxygen/respiratory therapies due to the nature of the individual’s condition, the type or multiplicity of procedures required and the need for therapies for which the individual is dependent upon administration by licensed staff, such as positive pressure breathing therapy, nasal BiPAP and aerosol therapy.

4. Tracheostomy includes new tracheostomy sites and complicated cases involving symptomatic infections and unstable respiratory functioning.

5. Intravenous therapy includes clinically indicated therapies ordered by the physician, such as central venous lines, Hickman/Broviac catheters, heparin locks, total parenteral nutrition, clysis, hyperalimentation and peritoneal dialysis. When clinically indicated, intravenous medications should be appropriately and safely administered within prevailing medical protocols. If intravenous therapy is for the purpose of hydration, the clinical record shall document any preventive measures and attempts to improve hydration orally, and the individual’s inadequate response.

6. Respirator use includes care for individuals who are stable and no longer require acute or specialized respirator programs and who require mechanical ventilation to oxygenate their blood. Ongoing assessment, intervention, and evaluation by a registered professional nurse are needed. The individual’s treatment plan should include protocols for weaning the individual from assisted respiration and/or self care when clinically indicated and ordered by the physician or advanced practice nurse.

7. Head trauma stimulation/advanced neuromuscular/orthopedic care:

i. Care of head trauma is directed toward individuals who are stable (have plateau) and can no longer benefit from a rehabilitative unit or unit for specialized care of the injured head. Individuals shall have access to and periodic reviews by such specialists as a neurologist, neurophysiologist, psychiatrist and vocational rehabilitation specialist, in accordance with their clinical needs. There shall also be contact with appropriate therapies, such as physical therapy, speech-language pathology services and occupational therapy. The distinguishing characteristic for add-on hours for head trauma is the necessity for ongoing assessment and evaluation by a registered professional nurse focusing on early identification of complications, and implementation of appropriate nursing interventions. Nursing protocols may be initiated which are specifically designed to meet individual needs of head injured individuals. The nurse may also supervise a coma stimulation program, when this need is identified by the interdisciplinary team.

ii. Advanced neuromuscular care needs shall be identified by the physician for individuals during an unstable episode or where there is advanced and progressive deterioration in which the individual requires observation for neurological complications, monitoring, and administration of medications or nursing interventions to stabilize the condition and prevent unnecessary regression.

iii. Advanced orthopedic care is the care of plastered body parts with a pre-existing peripheral vascular or circulatory condition requiring observations for complications and monitoring and administration of medication to control pain and/or infection. Such care also involves additional measures to maintain mobility; care of post-operative fracture and joint arthroplasty, during the immediate sub acute post-operative period involving proper alignment; teaching and counseling and follow-up to therapeutic exercise and activity regimens. Individuals in this group shall be identified by the physician as needing advanced orthopedic care. If the requirement for advanced orthopedic care exceeds 30 days, clinical need must be demonstrated and clearly documented by the interdisciplinary team.

(d) In facilities with 150 licensed beds or more, there shall be an assistant director of nursing who is a registered professional nurse.

(e) A registered professional nurse shall be on duty at all times in facilities with more than 150 licensed beds.

(f) At least 20 percent of the hours of care required by (b) above shall be provided by individuals who are either registered professional nurses or licensed practical nurses.

(g) The nurse aide component of the facility's total hourly nurse staffing requirement, as specified in (b) above, shall be met by nurse aides who have completed a nurse aide training course approved by the New Jersey State Department of Health and Senior Services and have passed the New Jersey Nurse Aide Certification Examination, in accordance with N.J.A.C. 8:39-43 and/or by newly hired individuals who have worked in the facility for less than four months and who are enrolled in a nurse aide training program.

(h) There shall be at least one registered professional nurse on duty in the facility during all day shifts. (During a temporary absence, not to exceed 72 hours, the registered professional nurse may be on duty during the evening or night shift).

(i) There shall be at least one registered professional nurse on duty or on call during all evening and night shifts.

SUBCHAPTER 26. ADVISORY NURSE STAFFING

8:39-26.1 Advisory structural organization for nurse staffing

Facilities with more than 200 licensed beds employ at least one full-time equivalent staff educator; facilities with between 100 and 200 licensed beds employ at least a half-time staff educator; or facilities with fewer than 100 licensed beds employ a staff educator at least one-fifth time.

8:39-26.2 Advisory policies and procedures for nurse staffing

(a) The facility establishes and implements a system for assigning nursing personnel on the basis of a classification system involving resident acuity.

(b) The facility uses a primary system in which nurse aides are assigned on a regular basis to specific residents to provide continuity of care.

8:39-26.3 Advisory nurse staffing amounts and availability

(a) A registered professional nurse is on duty at all times in facilities with fewer than 100 licensed beds, two registered professional nurses are on duty at all times in facilities with 100 to 200 licensed beds, and three registered nurses are on duty at all times in facilities with more than 300 beds.

(b) The facility provides direct nursing services pursuant to N.J.A.C. 8:39-25.2(b) which are increased by at least ten percent.

(c) At least 50 minutes per resident per day of resident care is provided by licensed nurses, that is, registered professional nurses and licensed practical nurses. (This is an average. It is equal to one full-time equivalent nurse for every ten residents.)

(d) All nurse aides working in the facility have completed a training and orientation program to all services of at least two weeks full-time duration within the facility prior to their permanent assignment in the facility.

(e) Each resident care unit in the facility meets the nurse staffing requirements mandated in N.J.A.C. 8:39-25.2(b).

8:39-26.4 Advisory qualifications for nurse staffing

(a) The director of nursing has a baccalaureate or master's degree in nursing or a health-related field.

(b) An advanced practice nurse who is Board certified in family, adult, or geriatric practice is available on staff or under contract with the facility to perform assessments and to provide consultation to other staff members.

(c) The facility employs an advanced practice nurse certified in gerontology or psychiatric nursing on at least a half time basis.

(d) A nurse who holds certification in gerontological nursing, rehabilitation nursing, or a related field of nursing from the American Nurses Credentialing Center of the American Nurses Association, is available on staff or under contract with the facility.