HB 1283

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

CODING: Words stricken are deletions; words underlined are additions.