HOUSE BILL NO. 4550

A bill to amend 1978 PA 368, entitled

"Public health code,"

(MCL 333.1101 to 333.25211) by adding sections 21525 and 21525a.

the people of the state of michigan enact:

Sec. 21525. (1) A hospital shall provide sufficient and qualified registered professional nursing staff at all times to ensure patient safety.

(2) Except as otherwise provided in subsection (15), a hospital shall implement the minimum direct care registered professional nurse-to-patient ratios as provided under this section by not later than 1 year after the effective date of the amendatory act that added this section or by not later than 2 years after the effective date of the amendatory act that added this section if the hospital is located in a rural area.

(3) A hospital shall not assign more patients per direct care registered professional nurse than indicated by the following direct care registered professional nurse-to-patient ratios for each of the corresponding units:

(a) Intensive/critical care, including, but not limited to, coronary care, acute respiratory care, medical, burn, pediatric, or neonatal intensive care patients: 1 r.n. to 1 patient.

(b) Operating room: 1 r.n. to 1 patient, if not less than 1 additional individual serves as a scrub assistant in the unit.

(c) Labor and delivery:

(i) Antepartum: 1 r.n. to 3 pregnant patients or, if continuous fetal monitoring is required, 1 r.n. to 2 pregnant patients.

(ii) Active labor: 1 r.n. to each birthing patient.

(iii) During birth: 1 r.n. to each birthing patient and 1 r.n. to each baby.

(iv) Immediate postpartum: 1 r.n. to each birthing-patient-baby couplet plus 1 r.n. to each additional baby.

(v) Unstable newborn: 1 r.n. to 1 newborn.

(vi) Intermediate care newborn: 1 r.n. to 2 newborns.

(vii) Postpartum/postsurgical birthing-patient-baby couplet: 1 r.n. to 2 couplets.

(viii) Medical/obstetric complications in labor and delivery: 1 r.n. to 1 patient.

(ix) Postpartum birthing patient or well-baby care: 1 r.n. to 4 patients.

(x) Patient receiving conscious sedation: 1 r.n. to 1 patient.

(d) Postanesthesia care unit: 1 r.n. to 1 patient.

(e) Emergency department:

(i) Nontrauma or noncritical care: 1 r.n. to 3 patients, plus 1 r.n. for triage duties.

(ii) Trauma or critical care: 1 r.n. to 1 patient, plus 1 r.n. for triage duties.

(f) Stepdown or intermediate intensive care unit: 1 r.n. to 3 patients.

(g) Telemetry: 1 r.n. to 3 patients.

(h) Medical/surgical: 1 r.n. to 4 patients.

(i) Pediatrics: 1 r.n. to 3 patients.

(j) Behavioral health/psychiatric: 1 r.n. to 4 patients.

(k) Acute rehabilitation: 1 r.n. to 4 patients.

(4) If a unit that is not listed in subsection (3) provides a level of care to patients whose needs are similar to the needs of patients cared for in a unit that is listed in subsection (3), a hospital shall apply the minimum direct care registered professional nurse-to-patient ratio for the unit that is listed in subsection (3) to the unit that is not listed.

(5) The minimum direct care registered professional nurse-to-patient ratios required under this section must be in effect at all times, including during breaks, meals, and other routine, expected absences from a unit.

(6) A hospital shall not do any of the following:

(a) In computing a minimum direct care registered professional nurse-to-patient ratio required under this section, include a registered professional nurse who is not assigned to provide direct patient care in that unit or who is not oriented, qualified, and competent to provide safe patient care in that unit.

(b) Average the number of patients and the total number of direct care registered professional nurses assigned to patients in a unit during a single shift or over a period of time to meet a minimum direct care registered nurse-to-patient ratio required under this section.

(c) Except during a declared state of emergency, impose mandatory overtime to meet a minimum direct care registered professional nurse-to-patient ratio required under this section.

(7) At any time before or during a shift and for any reason, a hospital may increase the number of registered professional nurses above a minimum direct care registered professional nurse-to-patient ratio required under this section.

(8) The minimum direct care registered professional nurse-to-patient ratio established for each unit under this section does not limit, reduce, or otherwise affect the need for other licensed or unlicensed health care professionals, assistants, or support personnel necessary to provide safe patient care within the unit.

(9) A hospital shall post in each unit a notice in a form approved by the department. The notice must be located in a visible and conspicuous location that is accessible to hospital staff, patients, and the public. The notice must contain all of the following information:

(a) The requirements of this section.

(b) An explanation of the rights of direct care registered professional nurses, patients, and other individuals under this section.

(c) A statement that a direct care registered professional nurse, patient, or other individual may file a complaint with the department against a hospital that the direct care registered professional nurse, patient, or other individual believes has violated this section.

(d) Instructions on how to file a complaint with the department for a violation of this section.

(10) The department shall establish and maintain a toll-free telephone number to provide information regarding the minimum direct care registered professional nurse-to-patient ratios under this section and to receive complaints alleging violations of this section. A hospital shall provide the toll-free telephone number to each patient admitted to the hospital for inpatient care and inform each patient that the toll-free telephone number may be used to file a complaint alleging a violation of this section.

(11) A direct care registered professional nurse, a patient, or another individual may file a complaint with the department against a hospital that the direct care registered professional nurse, patient, or other individual believes has violated this section. The department shall investigate each complaint received in the manner provided for investigating written complaints under section 20176.

(12) A hospital that does not comply with a minimum direct care registered professional nurse-to-patient ratio required under this section is in violation of this section. Each shift that does not comply with a minimum direct care registered professional nurse-to-patient ratio for that shift is a separate violation. If the department determines that a hospital has not complied with the minimum direct care registered professional nurse-to-patient ratio required for each unit during each shift under this section, the department shall require the hospital to establish a corrective action plan to prevent the recurrence of the violation. A hospital that violates this section is subject to an administrative fine of not less than $10,000.00 or more than $25,000.00 for each violation or, if the hospital has shown a pattern of violations, not less than $25,000.00 or more than $50,000.00.

(13) The department shall publish on its website the names of the hospitals on which an administrative fine has been imposed under subsection (12), the violation for which the fine was imposed, and any additional information that the department considers appropriate. The department shall consider each violation by a hospital under subsection (12) when making licensure decisions.

(14) The department shall promulgate rules to implement this section.

(15) If a collective bargaining agreement is in effect for employees of a hospital as of the effective date of the amendatory act that added this section and if that collective bargaining agreement prevents compliance with this section, then this section does not apply until after the expiration of that collective bargaining agreement.

(16) As used in this section:

(a) "Declared state of emergency" means an emergency that is declared by a person authorized by the federal government, a local government, or this state and that is related to a circumstance that is unpredictable or unavoidable, affects the delivery of medical care, and requires an immediate or exceptional level of emergency or other medical services at the hospital. Declared state of emergency does not include an emergency that results from a labor dispute in the health care industry or consistent understaffing in the hospital.

(b) "Immediate postpartum" means within 2 hours after birth.

(c) "Mandatory overtime" means a mandated assignment for a direct care registered professional nurse to work more than the direct care registered professional nurse's regularly scheduled hours according to the direct care registered professional nurse's predetermined work schedule.

(d) "Medical/obstetric complications in labor and delivery" includes, but is not limited to, an epidural or a c-section.

(e) "Pattern of violations" means a finding by the department of 2 or more violations in 1 calendar year.

(f) "Registered professional nurse" or "r.n." means that term as defined in section 17201.

(g) "Rural area" means an area that is located outside of a metropolitan statistical area as defined by the United States Office of Management and Budget or that is located in a city, village, or township with a population of no more than 12,000 and in a county with a population of no more than 110,000, according to the most recent federal decennial census.

(h) "Scrub assistant" means an individual functioning in a role that is also known as a surgical technician, operating room technician, surgical tech, first assistant, scrub tech, or scrub. A scrub assistant may be a direct care registered professional nurse.

Sec. 21525a. (1) The nurse-to-patient ratio regulatory fund is created in the state treasury.

(2) The state treasurer shall credit the administrative fines collected under section 21525 to the nurse-to-patient ratio regulatory fund. The state treasurer shall direct the investment of money in the nurse-to-patient ratio regulatory fund and credit interest and earnings from the investments to the nurse-to-patient ratio regulatory fund.

(3) The department is the administrator of the nurse-to-patient ratio regulatory fund for audits of the fund.

(4) The department shall expend money from the nurse-to-patient ratio regulatory fund on appropriation only for the administration of section 21525.

Enacting section 1. This amendatory act takes effect 90 days after the date it is enacted into law.