Bill Text: FL S2316 | 2010 | Regular Session | Introduced
Bill Title: Florida Hospital Patient Protection Act [SPSC]
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Failed) 2010-04-30 - Died in Committee on Health Regulation [S2316 Detail]
Download: Florida-2010-S2316-Introduced.html
Florida Senate - 2010 (Corrected Copy) SB 2316 By Senator Hill 1-01695A-10 20102316__ 1 A bill to be entitled 2 An act relating to health care; creating the “Florida 3 Hospital Patient Protection Act”; providing 4 legislative findings; providing definitions; providing 5 minimum staffing level requirements for the ratio of 6 direct care registered nurses to patients in a health 7 care facility; requiring that each health care 8 facility implement a staffing plan; prohibiting the 9 imposition of mandatory overtime and certain other 10 actions by a health care facility; specifying the 11 required nurse-to-patient ratios for each type of care 12 provided; prohibiting the use of video cameras or 13 monitors by a health care facility as a substitute for 14 the required level of care; requiring that the chief 15 nursing officer of a health care facility prepare a 16 written staffing plan that meets the staffing levels 17 required by the act; requiring that a health care 18 facility annually evaluate its actual staffing levels 19 and update the staffing plan based on the evaluation; 20 requiring that certain documentation be submitted to 21 the Agency for Health Care Administration and made 22 available for public inspection; requiring that the 23 agency develop uniform standards for use by health 24 care facilities in establishing nurse staffing 25 requirements; providing requirements for the committee 26 members who are appointed to develop the uniform 27 standards; requiring health care facilities to 28 annually report certain information to the agency and 29 post a notice containing such information in each unit 30 of the facility; prohibiting a health care facility 31 from assigning unlicensed personnel to perform 32 functions or tasks that are performed by a licensed or 33 registered nurse; specifying those actions that 34 constitute professional practice by a direct care 35 registered nurse; requiring that patient assessment be 36 performed only by a direct care registered nurse; 37 authorizing a direct care registered nurse to assign 38 certain specified activities to other licensed or 39 unlicensed nursing staff; prohibiting a health care 40 facility from deploying technology that limits certain 41 care provided by a direct care registered nurse; 42 providing that it is a duty and right of a direct care 43 registered nurse to act as the patient’s advocate; 44 providing certain requirements with respect to such 45 duty; authorizing a direct care registered nurse to 46 refuse to perform certain activities if he or she 47 determines that it is not in the best interests of the 48 patient; providing that a direct care registered nurse 49 may refuse to accept an assignment under certain 50 circumstances; prohibiting a health care facility from 51 discharging, discriminating, or retaliating against a 52 nurse based on such refusal; providing that a direct 53 care registered nurse has a right of action against a 54 health care facility that violates certain provisions 55 of the act; requiring that the Agency for Health Care 56 Administration establish a toll-free telephone hotline 57 to provide information and to receive reports of 58 violations of the act; requiring that certain 59 information be provided to each patient who is 60 admitted to a health care facility; prohibiting a 61 health care facility from interfering with the right 62 of nurses to organize or bargain collectively; 63 authorizing the agency to impose fines for violations 64 of the act; requiring that the agency post in its 65 website information regarding health care facilities 66 that have violated the act; providing an effective 67 date. 68 69 Be It Enacted by the Legislature of the State of Florida: 70 71 Section 1. Short title.—Sections 1 through 8 of this act 72 may be cited as the “Florida Hospital Patient Protection Act.” 73 Section 2. Legislative findings.—The Legislature finds 74 that: 75 (1) The state has a substantial interest in ensuring that, 76 in the delivery of health care services to patients, health care 77 facilities retain sufficient nursing staff so as to promote 78 optimal health care outcomes. 79 (2) Health care services are becoming more complex and it 80 is increasingly difficult for patients to access integrated 81 services. Competent, safe, therapeutic, and effective patient 82 care is jeopardized because of staffing changes implemented in 83 response to market-driven managed care. To ensure effective 84 protection of patients in acute care settings, it is essential 85 that qualified direct care registered nurses be accessible and 86 available to meet the individual needs of the patient at all 87 times. In order to ensure the health and welfare of state 88 residents and to ensure that hospital nursing care is provided 89 in the exclusive interests of patients, mandatory practice 90 standards and professional practice protections for professional 91 direct care registered nursing staff must be established. Direct 92 care registered nurses have a fiduciary duty to care for 93 assigned patients and a necessary duty of individual and 94 collective patient advocacy in order to satisfy professional 95 fiduciary obligations. 96 (3) The basic principles of staffing in hospital settings 97 should be based on the care needs of the individual patient, the 98 severity of the patient’s condition, the services needed, and 99 the complexity surrounding those services. Current unsafe 100 practices by hospital direct care registered nursing staff have 101 resulted in adverse patient outcome. Mandating the adoption of 102 uniform, minimum, numerical, and specific registered nurse-to 103 patient staffing ratios by licensed hospital facilities is 104 necessary for competent, safe, therapeutic, and effective 105 professional nursing care and for the retention and recruitment 106 of qualified direct care registered nurses. 107 (4) Direct care registered nurses must be able to advocate 108 for their patients without fear of retaliation from their 109 employer. Whistle-blower protections that encourage registered 110 nurses and patients to notify governmental and private 111 accreditation entities of suspected unsafe patient conditions, 112 including protection against retaliation for refusing unsafe 113 patient care assignments, will greatly enhance the health, 114 welfare, and safety of patients. 115 (5) Direct care registered nurses have an irrevocable duty 116 and right to advocate on behalf of their patients’ interests, 117 and this duty and right may not be encumbered by cost-saving 118 schemes. 119 Section 3. Definitions.—As used in sections 1 through 8 of 120 this act, the term: 121 (1) “Acuity-based patient classification system,” “acuity 122 system,” or “patient classification system” means an established 123 measurement tool that: 124 (a) Predicts registered nursing care requirements for 125 individual patients based on the severity of patient illness, 126 the need for specialized equipment and technology, the intensity 127 of required nursing interventions, and the complexity of 128 clinical nursing judgment required to design, implement, and 129 evaluate the patient’s nursing care plan consistent with 130 professional standards, the ability for self-care, including 131 motor, sensory, and cognitive deficits, and the need for 132 advocacy intervention; 133 (b) Details the amount of nursing care needed and the 134 additional number of direct care registered nurses and other 135 licensed and unlicensed nursing staff that the hospital must 136 assign, based on the independent professional judgment of the 137 direct care registered nurse, in order to meet the individual 138 patient needs at all times; and 139 (c) Is stated in terms that can be readily used and 140 understood by direct care nursing staff. 141 (2) “Agency” means the Agency for Health Care 142 Administration. 143 (3) “Ancillary support staff” means the personnel assigned 144 to assist in providing nursing services in the delivery of safe, 145 therapeutic, and effective patient care, including unit or ward 146 clerks and secretaries, clinical technicians, respiratory 147 therapists, and radiology, laboratory, housekeeping, and dietary 148 personnel. 149 (4) “Clinical judgment” means the application of the direct 150 care registered nurse’s knowledge, skill, expertise, and 151 experience in making independent decisions about patient care. 152 (5) “Clinical supervision” means the assignment and 153 direction of patient care tasks required in the implementation 154 of nursing care for patients to other licensed nursing staff or 155 to unlicensed staff by a direct care registered nurse in the 156 exclusive interests of the patients. 157 (6) “Competence” means the ability of the direct care 158 registered nurse to act and integrate the knowledge, skills, 159 abilities, and independent professional judgment that underpin 160 safe, therapeutic, and effective patient care. Current 161 documented, demonstrated, and validated competency is required 162 for all direct care registered nurses and must be determined 163 based on the satisfactory performance of: 164 (a) The statutorily recognized duties and responsibilities 165 of the registered nurses, as set forth in chapter 464, Florida 166 Statutes, and rules adopted thereunder; and 167 (b) The standards required under sections 4 and 5 of this 168 act, which are specific to each hospital unit. 169 (7) “Declared state of emergency” means an officially 170 designated state of emergency that has been declared by a 171 federal, state, or local government official who has the 172 authority to declare the state of emergency. The term does not 173 include a state of emergency that results from a labor dispute 174 in the health care industry. 175 (8) “Direct care registered nurse” means a licensed nurse 176 who has documented clinical competence and who has accepted a 177 direct, hands-on patient care assignment to implement medical 178 and nursing regimens and provide related clinical supervision of 179 patient care while exercising independent professional judgment 180 at all times in the exclusive interest of the patient. 181 (9) “Health care facility” means an acute care hospital; an 182 emergency care, ambulatory, or outpatient surgery facility 183 licensed under chapter 395, Florida Statutes; or a psychiatric 184 facility licensed under chapter 394, Florida Statutes, including 185 a critical access and long-term acute care hospital. 186 (10) “Hospital unit” or “clinical patient care area” means 187 an intensive care or critical care unit, burn unit, labor and 188 delivery room, antepartum and postpartum unit, newborn nursery, 189 postanesthesia service area, emergency department, operating 190 room, pediatric unit, step-down or intermediate care unit, 191 specialty care unit, telemetry unit, general medical or surgical 192 care unit, psychiatric unit, rehabilitation unit, or skilled 193 nursing facility unit, and as further defined in this 194 subsection. 195 (a) “Critical care unit” or “intensive care unit” means a 196 nursing unit of an acute care hospital which is established to 197 safeguard and protect patients whose severity of medical 198 conditions require continuous monitoring and complex 199 interventions by direct care registered nurses and whose 200 restorative measures and level of nursing intensity requires 201 intensive care through direct observation by the direct care 202 registered nurse, complex monitoring, intensive intricate 203 assessment, evaluation, specialized rapid intervention, and 204 education or teaching of the patient, the patient’s family, or 205 other representatives by a competent and experienced direct care 206 registered nurse. The term includes an intensive care unit, a 207 burn center, a coronary care unit, or an acute respiratory unit. 208 (b) “Step-down unit” or “intermediate intensive care unit” 209 means a unit established to safeguard and protect patients whose 210 severity of illness, including all co-occurring morbidities, 211 restorative measures, and level of nursing intensity, requires 212 intermediate intensive care through direct observation by the 213 direct care registered nurse, monitoring, multiple assessments, 214 specialized interventions, evaluations, and education or 215 teaching of the patient’s family or other representatives by a 216 competent and experienced direct care registered nurse. The term 217 includes units established to provide care to patients who have 218 moderate or potentially severe physiologic instability requiring 219 technical support but not necessarily artificial life support. 220 “Artificial life support” means a system that uses medical 221 technology to aid, support, or replace a vital function of the 222 body that has been seriously damaged. “Technical support” means 223 the use of specialized equipment by direct care registered 224 nurses in providing for invasive monitoring, telemetry, and 225 mechanical ventilation for the immediate amelioration or 226 remediation of severe pathology for those patients requiring 227 less care than intensive care, but more than that which is 228 required from medical or surgical care. 229 (c) “Medical or surgical unit” means a unit established to 230 safeguard and protect patients whose severity of illness, 231 including all co-occurring morbidities, restorative measures, 232 and level of nursing intensity requires continuous care through 233 direct observation by the direct care registered nurse, 234 monitoring, multiple assessments, specialized interventions, 235 evaluations, and education or teaching of the patient’s family 236 or other representatives by a competent and experienced direct 237 care registered nurse. These units may include patients 238 requiring less than intensive care or step-down care; patients 239 receiving 24-hour inpatient general medical care, post-surgical 240 care, or both general medical and post-surgical care; and mixed 241 patient populations of diverse diagnoses and diverse age groups, 242 but excluding pediatric patients. 243 (d) “Telemetry unit” means a unit that is established to 244 safeguard and protect patients whose severity of illness, 245 including all co-occurring morbidities, restorative measures, 246 and level of nursing intensity requires intermediate intensive 247 care through direct observation by the direct registered nurse, 248 monitoring, multiple assessments, specialized interventions, 249 evaluations, and education or teaching of the patient’s family 250 or other representatives by a competent and experienced direct 251 care registered nurse. A telemetry unit includes the equipment 252 used to provide for the electronic monitoring, recording, 253 retrieval, and display of cardiac electrical signals. 254 (e) “Specialty care unit” means a unit that is established 255 to safeguard and protect patients whose severity of illness, 256 including all co-occurring morbidities, restorative measures, 257 and level of nursing intensity requires continuous care through 258 direct observation by the direct care registered nurse, 259 monitoring, multiple assessments, specialized interventions, 260 evaluations, and education or teaching of the patient’s family 261 or other representatives by a competent and experienced direct 262 care registered nurse. The term includes a unit established to 263 provide the intensity of care required for a specific medical 264 condition or a specific patient population or to provide more 265 comprehensive care for a specific condition or disease process 266 than that which is required on medical or surgical units, and 267 includes those units not otherwise covered by the definitions in 268 this section. 269 (f) “Rehabilitation unit” means a functional clinical unit 270 for the provision of those rehabilitation services that restore 271 an ill or injured patient to the highest level of self 272 sufficiency or gainful employment of which he or she is capable 273 in the shortest possible time, compatible with the patient’s 274 physical, intellectual, and emotional or psychological 275 capabilities, and in accord with planned goals and objectives. 276 (g) “Skilled nursing facility” means a functional clinical 277 unit for the provision of skilled nursing care and supportive 278 care to patients whose primary need is for the availability of 279 skilled nursing care on a long-term basis and who are admitted 280 after at least a 48-hour period of continuous inpatient care. 281 The term includes, but need not be limited to, medical, nursing, 282 dietary, and pharmaceutical services and activity programs. 283 (11) “Licensed nurse” means a registered nurse or a 284 licensed practical nurse, as defined in s. 464.003, Florida 285 Statutes, who is licensed by the Board of Nursing to engage in 286 the practice of professional nursing or the practice of 287 practical nursing, as defined in s. 464.003, Florida Statutes. 288 (12) “Long-term acute care hospital” means any hospital or 289 health care facility that specializes in providing long-term 290 acute care to medically complex patients. The term includes 291 freestanding and hospital-within-hospital models of long-term 292 acute care facilities. 293 (13) “Overtime” means the hours worked in excess of: 294 (a) An agreed-upon, predetermined, regularly scheduled 295 shift; 296 (b) Twelve hours in a 24-hour period; or 297 (c) Eighty hours in a consecutive 14-day period. 298 (14) “Patient assessment” means the use of critical 299 thinking by a direct care licensed nurse and is the 300 intellectually disciplined process of actively and skillfully 301 interpreting, applying, analyzing, synthesizing, or evaluating 302 data obtained through the direct observation and communication 303 with others. 304 (15) “Professional judgment” means the intellectual, 305 educated, informed, and experienced process that the direct care 306 registered nurse exercises in forming an opinion and reaching a 307 clinical decision that is in the patient’s best interest and is 308 based upon analysis of data, information, and scientific 309 evidence. 310 (16) “Skill mix” means the differences in licensing, 311 specialty, and experience among direct care registered nurses. 312 (17) “Staffing level” means the actual numerical registered 313 nurse-to-patient ratio within a nursing department, unit, or 314 clinical patient care area. 315 Section 4. Minimum direct care registered nurse-to-patient 316 staffing requirements.— 317 (1) Each health care facility shall implement a staffing 318 plan that provides for minimum staffing by direct care 319 registered nurses in accordance with the general requirements 320 set forth in this section and the clinical unit direct care 321 registered nurse-to-patient ratios specified in subsection (2). 322 Staffing for patient care tasks not requiring a direct care 323 registered nurse is not included within these ratios and shall 324 be determined pursuant to an acuity-based patient classification 325 system defined by agency rule. 326 (a) A health care facility may not assign a direct care 327 registered nurse to a nursing unit or clinical area unless that 328 health care facility and the direct care registered nurse 329 determine that she or he has demonstrated and validated current 330 competence in providing care in that area and has also received 331 orientation to that clinical area which is sufficient to provide 332 competent, safe, therapeutic, and effective care to patients in 333 that area. The policies and procedures of the health care 334 facility must contain the criteria for making this 335 determination. 336 (b) Direct care registered nurse-to-patient ratios 337 represent the maximum number of patients that shall be assigned 338 to one direct care registered nurse at all times. 339 (c) “Assigned” means the direct care registered nurse has 340 responsibility for the provision of care to a particular patient 341 within her or his validated competency. 342 (d)1. A health care facility may not average the number of 343 patients and the total number of direct care registered nurses 344 assigned to patients in a clinical unit during any one shift or 345 over any period of time for purposes of meeting the requirements 346 under this section. 347 2. A health care facility may not impose mandatory overtime 348 requirements in order to meet the hospital unit direct care 349 registered nurse-to-patient ratios required under this section. 350 3. A health care facility shall ensure that only a direct 351 care registered nurse may relieve another direct care registered 352 nurse during breaks, meals, and routine absences from a clinical 353 unit. 354 4. A health care facility may not impose layoffs of 355 licensed practical nurses, licensed psychiatric technicians, 356 certified nursing assistants, or other ancillary support staff 357 in order to meet the clinical unit direct care registered nurse 358 to-patient ratios required in this section. 359 (e) Only direct care registered nurses shall be assigned to 360 intensive care newborn nursery service units, which specifically 361 require one direct care registered nurse to two or fewer infants 362 at all times. 363 (f) Only direct care registered nurses shall be assigned to 364 triage patients and only direct care registered nurses shall be 365 assigned to critical trauma patients. 366 1. The direct care registered nurse-to-patient ratio for 367 critical care patients in the emergency department shall be 1 to 368 2 or fewer at all times. 369 2. No fewer than two direct care registered nurses must be 370 physically present in the emergency department when a patient is 371 present. 372 3. Triage, radio, specialty, or flight-registered nurses do 373 not count in the calculation of direct care registered nurse-to 374 patient ratio. 375 4. Triage-registered nurses may not be assigned the 376 responsibility of the base radio. 377 (g) In the labor and delivery unit, the direct care 378 registered nurse-to-patient ratio shall be 1 to 1 for active 379 labor patients and patients having medical or obstetrical 380 complications, during the initiation of epidural anesthesia, and 381 during circulation for cesarean delivery. 382 1. The direct care registered nurse-to-patient ratio for 383 antepartum patients who are not in active labor shall be 1 to 3 384 or fewer at all times. 385 2. In the event of cesarean delivery, the total number of 386 mothers plus infants assigned to a single direct care registered 387 nurse may not exceed four. 388 3. In the event of multiple births, the total number of 389 mothers plus infants assigned to a single direct care registered 390 nurse may not exceed six. 391 4. For postpartum areas in which the direct care registered 392 nurse’s assignment consists of mothers only, the direct care 393 registered nurse-to-patient ratio shall be 1 to 4 or fewer at 394 all times. 395 5. The direct care registered nurse-to-patient ratio for 396 postpartum women or postsurgical gynecological patients only 397 shall be 1 to 4 or fewer at all times. 398 6. The direct care registered nurse-to-patient ratio for 399 the well-baby nursery shall be 1 to 5 at all times. 400 7. The direct care registered nurse-to-patient ratio for 401 unstable newborns and those in the resuscitation period as 402 assessed by the direct care registered nurse shall be 1 to 1 at 403 all times. 404 8. The direct care registered nurse-to-patient ratio for 405 recently born infants shall be 1 to 4 or fewer at all times. 406 (h) The direct care registered nurse-to-patient ratio for 407 patients receiving conscious sedation shall be 1 to 1 or fewer 408 at all times. 409 (2) A health care facility’s staffing plan shall provide 410 that, at all times during each shift within a unit of the 411 facility, a direct care registered nurse is assigned to not more 412 than the following number of patients in that unit: 413 (a) One patient in trauma emergency units. 414 (b) One patient in operating room units. The operating room 415 shall have at least one direct care registered nurse assigned to 416 the duties of the circulating registered nurse and a minimum of 417 one additional person as a scrub assistant for each patient 418 occupied operating room. 419 (c) Two patients in critical care units, including neonatal 420 intensive care units, emergency critical care and intensive care 421 units, labor and delivery units, coronary care units, acute 422 respiratory care units, postanesthesia units regardless of the 423 type of anesthesia received, burn units, and immediate 424 postpartum patients, so that the direct-care registered nurse 425 to-patient ratio is 1 to 2 at all times. 426 (d) Three patients in the emergency room units, step-down 427 or intermediate intensive care units, pediatrics units, 428 telemetry units, and combined labor, delivery, and postpartum 429 units, so that the direct care registered nurse-to-patient 430 ratios is 1 to 3 or fewer at all times. 431 (e) Four patients in medical-surgical units, antepartum 432 units, intermediate care nursery units, psychiatric units, and 433 presurgical and other specialty care units, so that the direct 434 care registered nurse-to-patient ratio is 1 to 4 or fewer at all 435 times. 436 (f) Five patients in rehabilitation units and skilled 437 nursing units, so that the direct care registered nurse-to 438 patient ratio is 1 to 5 or fewer at all times. 439 (g) Six patients in well-baby nursery units, so that the 440 direct care registered nurse-to-patient ratio is 1 to 6 or fewer 441 at all times. 442 (h) Three couplets in postpartum units, so that the direct 443 care registered nurse-to-patient ratio is 1 to 3 couplets or 444 fewer at all times. 445 (3)(a) Identifying a unit or clinical patient care area by 446 a name or term other than those defined in section 3 of this act 447 does not affect the requirement to provide for staff at the 448 direct care registered nurse-to-patient ratios identified for 449 the level of intensity or type of care described in subsections 450 (1) and (2). 451 (b) Patients shall be cared for only on units or clinical 452 patient care areas where the level of intensity, type of care, 453 and direct care registered nurse-to-patients ratios meet the 454 individual requirements and needs of each patient. The use of 455 patient acuity-adjustable units is strictly prohibited. 456 (c) Video cameras or monitors or any form of electronic 457 visualization of a patient may not be substituted for the direct 458 observation required for patient assessment by the direct care 459 registered nurse and for patient protection required by an 460 attendant. 461 (4) The requirements established under this section do not 462 apply during a declared state of emergency if a health care 463 facility is requested or expected to provide an exceptional 464 level of emergency or other medical services. 465 (5)(a) A written staffing plan shall be developed by the 466 chief nursing officer or a designee, based on individual patient 467 care needs determined by the patient classification system. The 468 staffing plan shall be developed and implemented for each 469 patient care unit and must specify individual patient care 470 requirements and the staffing levels for direct care registered 471 nurses and other licensed and unlicensed personnel. In no case 472 shall the staffing level for direct care registered nurses on 473 any shifts fall below the requirements of subsections (1) and 474 (2). 475 (b) In addition to the direct care registered nurse-ratio 476 requirements of subsections (1) and (2), each health care 477 facility shall assign additional nursing staff, such as licensed 478 practical nurses, licensed psychiatric technicians, and 479 certified nursing assistants, through the implementation of a 480 valid patient classification system for determining nursing care 481 needs of individual patients which reflects the assessment made 482 by the assigned direct care registered nurse of patient nursing 483 care requirements and which provides for shift-by-shift staffing 484 based on those requirements. The ratios specified in subsections 485 (1) and (2) constitute the minimum number of registered nurses 486 who shall be assigned to provide direct patient care. 487 (c) In developing the staffing plan, a health care facility 488 shall provide for direct care registered nurse-to-patient ratios 489 above the minimum ratios required under subsections (1) and (2) 490 based upon consideration of the following factors: 491 1. The number of patients and acuity level of patients as 492 determined by the application of an acuity system on a shift-by 493 shift basis. 494 2. The anticipated admissions, discharges, and transfers of 495 patients during each shift which effect direct patient care. 496 3. Specialized experience required of direct care 497 registered nurses on a particular unit. 498 4. Staffing levels and services provided by other health 499 care personnel in meeting direct patient care needs that do not 500 require care by a direct care registered nurse. 501 5. The efficacy of technology that is available and that 502 affects the delivery of direct patient care. 503 6. The level of familiarity with hospital practices, 504 policies, and procedures by temporary agency direct care 505 registered nurses who are assigned during a shift. 506 7. Obstacles to efficiency in the delivery of patient care 507 which is caused by the physical layout of the health care 508 facility. 509 (d) A health care facility shall specify the system used to 510 document actual staffing in each unit for each shift. 511 (e) A health care facility shall annually evaluate: 512 1. The reliability of the patient classification system for 513 validating staffing requirements in order to determine whether 514 the system accurately measures individual patient care needs and 515 accurately predicts the staffing requirements for direct care 516 registered nurses, licensed practical nurses, licensed 517 psychiatric technicians, and certified nursing assistants, based 518 exclusively on individual patient needs. 519 2. The validity of the acuity-based patient classification 520 system. 521 (f) A health care facility shall update its staffing plan 522 and acuity system to the extent appropriate based on the annual 523 evaluation. If the review reveals that adjustments are necessary 524 in order to ensure accuracy in measuring patient care needs, 525 such adjustments must be implemented within 30 days after that 526 determination. 527 (g)1. Any acuity-based patient classification system 528 adopted by a health care facility under this section shall be 529 transparent in all respects, including disclosure of detailed 530 documentation of the methodology used to predict nursing 531 staffing; an identification of each factor, assumption, and 532 value used in applying such methodology; an explanation of the 533 scientific and empirical basis for each such assumption and 534 value; and certification by a knowledgeable and authorized 535 representative of the health care facility that the disclosures 536 regarding methods used for testing and validating the accuracy 537 and reliability of the system are true and complete. 538 2. The documentation required by this section shall be 539 submitted in its entirety to the Agency of Health Care 540 Administration as a mandatory condition of licensure, with a 541 certification by the chief nurse officer for the health care 542 facility that it completely and accurately reflects 543 implementation of a valid acuity-based patient classification 544 system used to determine nursing service staffing by the 545 facility for every shift on every clinical unit in which 546 patients reside and receive care. The certification shall be 547 executed by the chief nurse officer under penalty of perjury and 548 must contain an expressed acknowledgement that any false 549 statement in the certification constitutes fraud and is subject 550 to criminal and civil prosecution and penalties. 551 3. Such documentation shall be available for public 552 inspection in its entirety in accordance with procedures 553 established by appropriate administrative rules adopted by the 554 Agency for Health Care Administration, consistent with the 555 purposes of this act. 556 (h)1. A staffing plan of a health care facility shall be 557 developed and evaluated by a committee. At least one-half of the 558 members of the committee shall be unit-specific competent direct 559 care registered nurses who provide direct patient care. 560 2. The members of the committee shall be appointed by the 561 chief nurse officer, except at a facility where direct care 562 registered nurses are represented for collective bargaining 563 purposes, all direct care registered nurses on the committee 564 shall be appointed by the authorized collective bargaining 565 agent. In case of a dispute, the direct care registered nurse 566 assessment shall prevail. This act does not authorize conduct 567 that is prohibited under the National Labor Relations Act or 568 under the Federal Labor Relations Act. 569 (i)1. By July 1, 2011, the Agency for Health Care 570 Administration shall develop uniform statewide standards for a 571 standardized acuity tool for use in health care facilities which 572 provides a method for establishing nurse staffing requirements 573 which exceed the hospital unit or clinical patient care area 574 direct care registered nurse-to-patient ratios required under 575 subsections (1) and (2). 576 2. Proposed standards shall be developed by a committee 577 composed of no more than 20 individuals, at least 11 of whom 578 must be currently licensed registered nurses who are employed as 579 direct care registered nurses, and the remaining 9 shall include 580 a sufficient number of technical or scientific experts in the 581 specialized fields involved in the design and development of a 582 patient classification system that meets the requirements of 583 this act. 584 3. A person who has any employment, commercial, 585 proprietary, financial, or other personal interest in the 586 development, marketing, or utilization of any private patient 587 classification system product or related methodology, 588 technology, or component system is not eligible to serve on the 589 development committee. A candidate for appointment to the 590 development committee may not be confirmed as a member until the 591 individual files a disclosure-of-interest statement with the 592 agency, with signed certification of full disclosure and 593 complete accuracy under oath, which provides all necessary 594 information as determined by the agency to demonstrate the 595 absence of actual or potential conflict of interest. All such 596 filings are subject to public inspection. 597 4. Within 1 year after the official commencement of 598 committee operations, the development committee shall provide a 599 written report to the agency which proposes uniform standards 600 for a valid patient classification system, along with sufficient 601 explanation and justification to allow for competent review and 602 determination by the agency. The report shall be disclosed to 603 the public upon notice of public hearings and a public comment 604 period for proposed adoption of uniform standards for a patient 605 classification system by the agency. 606 (j) Each hospital shall adopt and implement the patient 607 classification system and provide staffing based on such tool. 608 Any additional direct care registered nursing staffing levels 609 that exceed the direct care registered nurse-to-patient ratios 610 described in subsections (1) and (2) shall be assigned in a 611 manner determined by such statewide tool. 612 (k) A health care facility shall submit to the agency its 613 staffing plan and annual update required under this section. 614 (6)(a) In each unit, a health care facility shall post a 615 uniform notice in a form specified by the agency by rule which: 616 1. Explains the requirements imposed under this section; 617 2. Includes actual direct care registered nurse-to-patient 618 ratios during each shift; 619 3. Is visible, conspicuous, and accessible to staff, 620 patients, and the public; 621 4. Identifies staffing requirements as determined by the 622 patient classification system for each unit, documented and 623 posted on the unit for public view on a day-to-day, shift-by 624 shift basis; 625 5. Reports the actual number of staff and the staff mix, 626 documented and posted on the unit for public view on a day-to 627 day, shift-by-shift basis; and 628 6. Reports the variance between the required and actual 629 staffing patterns, documented and posted on the unit for public 630 view on a day-to-day, shift-by-shift basis. 631 (b)1. Each acute care facility shall maintain accurate 632 records of actual direct care registered nurse-to-patient ratios 633 in each unit for each shift for at least 2 years. Such records 634 shall include: 635 a. The number of patients in each unit; 636 b. The identity and duty hours of each direct care 637 registered nurse, licensed practical nurse, licensed psychiatric 638 technician, and certified nursing assistant assigned to each 639 patient in each unit in each shift. The hospital shall retain 640 the record for 2 years; and 641 c. A copy of each posted notice. 642 2. Each hospital shall make its records maintained under 643 the requirements of this section available to: 644 a. The agency; 645 b. Registered nurses and their collective bargaining 646 representatives, if any; and 647 c. The public under rules adopted by the agency. 648 (c) The agency shall conduct periodic audits to ensure: 649 1. Implementation of the staffing plan in accordance with 650 this section; and 651 2. Accuracy in records maintained under this section. 652 (7) Acute care facilities shall plan for routine 653 fluctuations such as admissions, discharges, and transfers in 654 the patient census. If a declared health care emergency causes a 655 change in the number of patients on a unit, the hospital must 656 demonstrate that immediate and diligent efforts were made to 657 maintain required staffing levels. 658 (8) The following activities are prohibited: 659 (a) A health care facility may not directly assign any 660 unlicensed personnel to perform registered-nurse functions in 661 lieu of care being delivered by a licensed or registered nurse, 662 and may not assign unlicensed personnel to perform registered 663 nurse functions under the clinical supervision of a direct care 664 registered nurse. 665 (b) Unlicensed personnel may not perform tasks that require 666 the clinical assessment, judgment, and skill of a licensed 667 registered nurse, including, without limitation, nursing 668 activities that require nursing assessment and judgment during 669 implementation; physical, psychological, or social assessments 670 that require nursing judgment, intervention, referral, or 671 followup; formulation of a plan of nursing care and a evaluation 672 of a patient’s response to the care provided, including 673 administration of medication, venipuncture or intravenous 674 therapy, parenteral or tube feedings, invasive procedures, 675 including inserting nasogastric tubes, inserting catheters, or 676 tracheal suctioning, educating patients and their families 677 concerning the patient’s health care problems, including 678 postdischarge care, with the exception that only phlebotomists, 679 emergency room technicians, and medical technicians, under the 680 general supervision of the clinical laboratory director or 681 designee or a physician, may perform venipunctures in accordance 682 with written hospital policies and procedures. 683 Section 5. Professional practice standards for direct care 684 registered nurses working in a health care facility.— 685 (1) A direct care registered nurse, currently licensed to 686 practice as a registered nurse, employing scientific knowledge 687 and experience in the physical, social, and biological sciences, 688 and exercising independent judgment in applying the nursing 689 process, shall directly provide: 690 (a) Continuous and ongoing assessments of the patient’s 691 condition based upon the independent professional judgment of 692 the direct care registered nurse. 693 (b) The planning, clinical supervision, implementation, and 694 evaluation of the nursing care provided to each patient. 695 (c) The assessment, planning, implementation, and 696 evaluation of patient education, including ongoing discharge 697 teaching of each patient. 698 (d) The planning and delivery of patient care, which shall 699 reflect all elements of the nursing process and shall include 700 assessment, nursing diagnosis, planning, intervention, 701 evaluation, and, as circumstances require, patient advocacy, and 702 shall be initiated by a direct care registered nurse at the time 703 of admission. 704 (e) The nursing plan for the patient’s care, which shall be 705 discussed with and developed as a result of coordination with 706 the patient, the patient’s family, or other representatives, 707 when appropriate, and staff of other disciplines involved in the 708 care of the patient. 709 (f) An evaluation of the effectiveness of the care plan 710 through assessments based on direct observation of the patient’s 711 physical condition and behavior, signs and symptoms of illness, 712 and reactions to treatment and through communication with the 713 patient and the health care team members, and shall modify the 714 plan as needed. 715 (g) Information related to the patient’s initial assessment 716 and reassessments, nursing diagnosis, plan, intervention, 717 evaluation, and patient advocacy, which shall be permanently 718 recorded in the patient’s medical record as narrative direct 719 care progress notes. The practice of charting by exception is 720 expressly prohibited. 721 (2)(a) Patient assessment requires direct observation of 722 the patient’s signs and symptoms of illness, reaction to 723 treatment, behavior and physical condition, and interpretation 724 of information obtained from the patient and others, including 725 other caregivers on the health team. Assessment requires data 726 collection by the direct care registered nurse and the analysis, 727 synthesis, and evaluation of such data. 728 (b) Only direct care registered nurses are authorized to 729 perform patient assessments. A licensed practical nurse or 730 licensed psychiatric technician may assist direct care 731 registered nurses in data collection. 732 (3)(a) The nursing care needs of individual patients shall 733 be determined by a direct care registered nurse through the 734 process of ongoing patient assessments, nursing diagnosis, 735 formulation, and adjustment of nursing care plans. 736 (b) The prediction of individual patient nursing care needs 737 for prospective assignment of direct care registered nurses 738 shall be based on individual patient assessments of the direct 739 care registered nurse assigned to each patient and in accordance 740 with a documented patient classification system as provided in 741 subsections (1) and (2) of section 4 of this act. 742 (4)(a) Competent performance of the essential functions of 743 a direct care registered nurse as provided in this section 744 requires the exercise of independent judgment in the interests 745 of the patient. The exercise of such independent judgment, 746 unencumbered by the commercial or revenue-generation priorities 747 of a hospital or employing entity of a direct care registered 748 nurse, is essential to safe nursing care. 749 (b) The exercise of independent judgment by a direct care 750 registered nurse in the performance of the functions described 751 in this section shall be provided in the exclusive interests of 752 the patient and may not, for any purpose, be considered, relied 753 upon, or represented as a job function, authority, 754 responsibility, or activity undertaken in any respect for the 755 purpose of serving the business, commercial, operational, or 756 other institutional interests of the hospital employer. 757 (5)(a) In addition to the limitations on assignments of 758 patient care tasks provided in subsection (8) of section 4 of 759 this act, a direct care registered nurse who is responsible for 760 a patient may assign tasks required in the implementation of 761 nursing care for that patient to other licensed nursing staff or 762 to unlicensed staff only if she or he: 763 1. Determines that the personnel assigned the tasks possess 764 the necessary training, experience, and capability to 765 competently and safely perform the tasks to be assigned; and 766 2. The assigning direct care registered nurse effectively 767 supervises the clinical functions and nursing care tasks 768 performed by the assigned personnel. 769 (b) The exercise of clinical supervision of nursing care 770 personnel by a direct care registered nurse in the performance 771 of the functions as provided in this section shall be in the 772 exclusive interests of the patient and may not, for any purpose 773 whatsoever, be considered, relied upon, or represented as a job 774 function, authority, responsibility, or activity undertaken in 775 any respect for the purpose of serving the business, commercial, 776 operational, or other institutional interests of the hospital 777 employer, but constitutes the exercise of professional nursing 778 authority and duty exclusively in the interests of the patient. 779 (6) A health care facility may not engage in the deployment 780 of technology that limits the direct care provided by a direct 781 care registered nurse in the performance of functions that are 782 part of the nursing process, including the full exercise of 783 independent clinical judgment in assessment, planning, 784 implementation, and evaluation of care, or that limits a direct 785 registered nurse from acting as a patient advocate in the 786 exclusive interest of the patient. Technology may not be skill 787 degrading, interfere with the direct care registered nurse’s 788 provision of individualized patient care, override the direct 789 care registered nurse’s independent professional judgment or 790 interfere with the registered nurse’s right to advocate in the 791 exclusive interest of the patient. 792 (7) This section applies only to nurses employed by or 793 providing care in a health care facility. 794 Section 6. Direct care registered nurse’s duty and right of 795 patient advocacy.— 796 (1) By virtue of their professional license and ethical 797 obligations, all direct care registered nurses have a duty and 798 right to act and provide care in the exclusive interests of the 799 patients and to act as the patient’s advocate, as circumstances 800 require, in accordance with this section. 801 (2) The direct care registered nurse is always responsible 802 for providing competent, safe, therapeutic, and effective 803 nursing care to assigned patients. 804 (a) Before accepting a patient assignment, a direct care 805 registered nurse must have the necessary knowledge, judgment, 806 skills, and ability to provide the required care. It is the 807 responsibility of the direct care registered nurse to determine 808 whether she or he is clinically competent to perform the nursing 809 care required by patients in a particular clinical unit or who 810 have a particular diagnosis, condition, prognosis, or other 811 determinative characteristics of nursing care, and whether 812 acceptance of a patient assignment would expose the patient to 813 the risk of harm. 814 (b) If the direct care registered nurse is not clinically 815 competent to perform the care required for a patient assigned 816 for nursing care, or if the assignment would expose the patient 817 to risk of harm, the direct care registered nurse shall not 818 accept the patient care assignment. Such refusal to accept a 819 patient care assignment is an exercise of the direct care 820 registered nurse’s duty and right of patient advocacy. 821 (3) In the course of performing the responsibilities and 822 essential functions described in section 5 of this act and this 823 section, the direct care registered nurse assigned to a patient 824 receives orders initiated by physicians and other legally 825 authorized health care professionals within their scope of 826 licensure regarding patient care services to be provided to the 827 patient, including, without limitation, the administration of 828 medications and therapeutic agents that are necessary to 829 implement a treatment, disease prevention, or rehabilitative 830 regimen. 831 (a) The direct care registered nurse shall assess each such 832 order before implementation in order to determine if the order 833 is: 834 1. In the best interests of the patient; 835 2. Initiated by a person legally authorized to issue the 836 order; and 837 3. Issued in accordance with applicable law and rules 838 governing nursing care. 839 (b) If the direct care registered nurse determines these 840 criteria have not been satisfied with respect to a particular 841 order, or has some doubt regarding the meaning or conformance of 842 the order with these criteria, she or he shall seek 843 clarification from the initiator of the order, the patient’s 844 physician, or other appropriate medical officer. Clarification 845 must be obtained prior to implementation. 846 (c) If, upon clarification, the direct care registered 847 nurse determines that the criteria for implementation of an 848 order have not been satisfied, she or he may refuse 849 implementation on the basis that the order is not in the best 850 interests of the patient. Seeking clarification of an order or 851 refusing an order as described in this section constitutes an 852 exercise of the direct care registered nurse’s duty and right of 853 patient advocacy. 854 (4) A direct care registered nurse has the professional 855 obligation and therefore the right to act as the patient’s 856 advocate, as circumstances require, by initiating action to 857 improve health care or to change decisions or activities that, 858 in the professional judgment of the direct care registered 859 nurse, are against the interests or wishes of the patient, or by 860 giving the patient the opportunity to make informed decisions 861 about health care before it is provided. 862 Section 7. Free speech; patient protection.— 863 (1) A direct care registered nurse has the right to act as 864 the patient’s advocate, as circumstances require, by: 865 (a) Initiating action to improve health care or to change 866 decisions or activities that, in the professional judgment of 867 the nurse, are against the interests and wishes of the patient; 868 and 869 (b) Giving the patient an opportunity to make informed 870 decisions about health care before it is provided. 871 (2) A direct care registered nurse may refuse to accept an 872 assignment as a nurse in a health care facility if: 873 (a) The assignment would violate any provision of chapter 874 464, Florida Statutes, or the rules adopted thereunder; 875 (b) The assignment would violate sections 3 through 6 of 876 this act; or 877 (c) The direct care registered nurse is not prepared by 878 education, training, or experience to fulfill the assignment 879 without compromising the safety of any patient or jeopardizing 880 the license of the registered nurse. 881 (3) A direct care registered nurse may refuse to perform 882 any assigned tasks as a nurse in a health care facility if: 883 (a) The assigned task would violate any provision of 884 chapter 464, Florida Statutes, or the rules adopter thereunder; 885 (b) The assigned task is outside the scope of practice of 886 the direct care registered nurse; or 887 (c) The direct care registered nurse is not prepared by 888 education, training, or experience to fulfill the assigned task 889 without compromising the safety of any patient or jeopardizing 890 the license of the direct care registered nurse. 891 (4)(a) A health care facility may not discharge, 892 discriminate, or retaliate in any manner with respect to any 893 aspect of employment, including discharge, promotion, 894 compensation, or terms, conditions, or privileges of employment 895 against a direct care registered nurse based on the nurse’s 896 refusal of a work assignment or assigned task as provided in 897 this section. 898 (b) A health care facility may not file a complaint or a 899 report against a direct care registered nurse with the Board of 900 Nursing or the Agency for Health Care Administration because of 901 the nurse’s refusal of a work assignment or assigned task 902 described in this section. 903 (5) Any direct care registered nurse who has been 904 discharged, discriminated against, or retaliated against in 905 violation of this section or against whom a complaint has been 906 filed in violation of paragraph (4)(b) may bring a cause of 907 action in a state court. A direct care registered nurse who 908 prevails on the cause of action is entitled to one or more of 909 the following: 910 (a) Reinstatement. 911 (b) Reimbursement of lost wages, compensation, and 912 benefits. 913 (c) Attorneys’ fees. 914 (d) Court costs. 915 (e) Other damages. 916 (6) A direct care registered nurse, patient, or other 917 individual may file a complaint with the agency against a health 918 care facility that violates the provisions of this act. For any 919 complaint filed, the agency shall: 920 (a) Receive and investigate the complaint; 921 (b) Determine whether a violation of this act as alleged in 922 the complaint has occurred; and 923 (c) If such a violation has occurred, issue an order that 924 the complaining nurse or individual shall not suffer any 925 retaliation described in this section. 926 (7)(a) The agency shall provide for the establishment of a 927 toll-free telephone hotline to provide information regarding the 928 requirements of this section and to receive reports of 929 violations of such section. 930 (b) A health care facility shall provide each patient 931 admitted to the facility for in-patient care with the hotline 932 described in paragraph (a), and shall give notice to each 933 patient that such hotline may be used to report inadequate 934 staffing or care. 935 (8)(a) A health care facility may not discriminate or 936 retaliate in any manner against any patient, employee, or 937 contract employee of the facility, or any other individual, on 938 the basis that such individual, in good faith, individually or 939 in conjunction with another person or persons, has presented a 940 grievance or complaint, or has initiated or cooperated in any 941 investigation or proceeding of any governmental entity, 942 regulatory agency, or private accreditation body, made a civil 943 claim or demand, or filed an action relating to the care, 944 services, or conditions of the health care facility or of any 945 affiliated or related facilities. 946 (b) For purposes of this subsection, an individual shall be 947 deemed to be acting in good faith if the individual reasonably 948 believes: 949 1. The information reported or disclosed is true; and 950 2. A violation of this act has occurred or may occur. 951 (9)(a) A health care facility may not: 952 1. Interfere with, restrain, or deny the exercise, or 953 attempt to exercise, by any person of any right provided or 954 protected under this act; or 955 2. Coerce or intimidate any person regarding the exercise 956 or attempt to exercise such right. 957 (b) A health care facility may not discriminate or 958 retaliate against any person for opposing any facility policy, 959 practice, or actions that are alleged to violate, breach, or 960 fail to comply with any provision of this act. 961 (c) A health care facility, or an individual representing a 962 health care facility, may not make, adopt, or enforce any rule, 963 regulation, policy, or practice that in any manner directly or 964 indirectly prohibits, impedes, or discourages a direct care 965 registered nurse from, or intimidates, coerces, or induces a 966 direct care registered nurse regarding, engaging in free speech 967 activities or disclosing information as provided under this act. 968 (d) A health care facility, or an individual representing a 969 health care facility, may not in any way interfere with the 970 rights of nurses to organize, bargain collectively, and engage 971 in concerted activity under s. 7 of the National Labor Relations 972 Act, 29 U.S.C. s. 157. 973 (e) A health care facility shall post in an appropriate 974 location in each unit a conspicuous notice in a form specified 975 by the agency which: 976 1. Explains the rights of nurses, patients, and other 977 individuals under this section; 978 2. Includes a statement that a nurse, patient, or other 979 individual may file a complaint with the agency against a health 980 care facility that violates the provisions of this act; and 981 3. Provides instructions on how to file a complaint. 982 Section 8. Enforcement.— 983 (1) In addition to any other penalties prescribed by law, 984 the agency may impose civil penalties as follows: 985 (a) The agency may impose against a health care facility 986 found to be in violation of any provision of this act a civil 987 penalty of not more than $25,000 for each such violation, except 988 that the agency shall impose a civil penalty of more than 989 $25,000 for each violation in the case of a health care facility 990 that the agency determines has a pattern of practice of such 991 violation. 992 (b) The agency may impose against an individual who is 993 employed by a health care facility and who is found by the 994 agency to have violated a requirement of this act a civil 995 penalty of not more than $20,000 for each such violation. 996 (2) The agency shall post on its Internet website the names 997 of health care facilities against which civil penalties have 998 been imposed under this act, and such additional information as 999 the agency deemed necessary. 1000 Section 9. This act shall take effect July 1, 2010.
