Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-510-0045
Nurse Staffing Posting and Record Requirements


(1)

On each hospital unit, a hospital shall post a complaint notice that:

(a)

Summarizes the provisions of ORS 441.152 (Nurse Staffing Advisory Board) to 441.177 (Posting of audit reports and civil penalties);

(b)

Is clearly visible to the public; and

(c)

Includes the Authority’s complaint reporting phone number, electronic mail address and website address.

(2)

A hospital shall also post an anti-retaliation notice on the premises that:

(a)

Summarizes the provisions of ORS 441.181 (Retaliation prohibited), 441.183 (Remedies for retaliation), 441.184 (Unlawful employment practices) and 441.192 (Notice of employment outside of hospital);

(b)

Is clearly visible; and

(c)

Is posted where notices to employees and applicants for employment are customarily displayed.

(3)

A hospital shall keep and maintain all records necessary to demonstrate compliance with ORS 441.152 (Nurse Staffing Advisory Board) to 441.177 (Posting of audit reports and civil penalties). These records shall:

(a)

Be maintained for no fewer than three years;

(b)

Be promptly provided to the Authority upon request; and

(c)

Include, at minimum:

(A)

The staffing plan;

(B)

The hospital nurse staffing committee charter;

(C)

Staffing committee meeting minutes;

(D)

Documentation showing how all members of the staffing committee were selected;

(E)

All complaints filed with the staffing committee;

(F)

Personnel files for all nursing staff positions that include, at minimum, job descriptions, required licensure and specialized qualifications and competencies required for the individual’s assigned nurse specialty or unit;

(G)

Documentation showing work schedules for nursing staff in each hospital nurse specialty or unit;

(H)

Documentation showing actual hours worked by all nursing staff;

(I)

Documentation showing all work schedule variances that resulted in the use of replacement nursing staff;

(J)

Documentation showing how many on-call hours, if any, required nursing staff to be on the hospital premises;

(K)

Documentation showing how many required meeting, education and training hours, if any, were required of nursing staff;

(L)

The hospital’s mandatory overtime policy and procedure;

(M)

Documentation showing how many, if any, overtime hours were worked by nursing staff;

(N)

Documentation of all waiver requests, if any, submitted to the Authority;

(O)

Documentation showing how many, if any, additional hours were worked due to emergency circumstances and the nature of those circumstances;

(P)

The list of on-call nursing staff used to obtain replacement nursing staff;

(Q)

Documentation showing how and when the hospital updates its list of on-call staff used to obtain replacement nursing staff and how the hospital determines eligibility to remain on the list;

(R)

Documentation showing the hospital’s procedures for obtaining replacement nursing staff, including efforts made to obtain replacement staff;

(S)

Documentation showing the hospital’s actual efforts to seek replacement staff when needed;

(T)

Documentation showing each actual instance in which the hospital implemented the policy described in OAR 333-510-0110 (Nurse Staffing Plan Requirements)(2)(g) to initiate limitations on admission or diversion of patients to another hospital; and

(U)

All staffing committee reports filed with the hospital administration following a review of the staffing plan.
Source

Last accessed
Jun. 8, 2021