Florida Senate - 2014                                    SB 1026
       
       
        
       By Senator Braynon
       
       
       
       
       
       36-00481-14                                           20141026__
    1                        A bill to be entitled                      
    2         An act relating to health care; creating the “Florida
    3         Hospital Patient Protection Act”; creating s.
    4         395.1014, F.S.; providing legislative findings;
    5         defining terms; requiring minimum staffing levels of
    6         direct care registered nurses in a health care
    7         facility; requiring that each health care facility
    8         implement a staffing plan; prohibiting a health care
    9         facility from imposing mandatory overtime and certain
   10         other actions; specifying the required ratios of
   11         direct care registered nurses to patients for each
   12         type of care provided; prohibiting a health care
   13         facility from using an acuity-adjustable unit to care
   14         for a patient; prohibiting a health care facility from
   15         using video cameras or monitors as substitutes for the
   16         required level of care; providing an exception during
   17         a declared state of emergency; requiring that the
   18         chief nursing officer of a health care facility
   19         prepare a written staffing plan that meets the direct
   20         care registered nurse staffing levels required by the
   21         act; requiring that a health care facility annually
   22         evaluate its actual direct care registered nurse
   23         staffing levels and update the staffing plan based on
   24         the evaluation; requiring that certain documentation
   25         be submitted to the Agency for Health Care
   26         Administration and be made available for public
   27         inspection; requiring that the agency develop uniform
   28         standards for use by health care facilities in
   29         establishing nurse staffing requirements; providing
   30         requirements for the committee members who are
   31         appointed to develop the uniform standards; requiring
   32         health care facilities to annually report certain
   33         information to the agency and post a notice containing
   34         such information in each unit of the facility;
   35         prohibiting a health care facility from assigning
   36         unlicensed personnel to perform functions or tasks
   37         that are performed by a licensed or registered nurse;
   38         specifying those actions that constitute professional
   39         practice by a direct care registered nurse; requiring
   40         that patient assessment be performed only by a direct
   41         care registered nurse; authorizing a direct care
   42         registered nurse to assign certain specified
   43         activities to other licensed or unlicensed nursing
   44         staff; prohibiting a health care facility from
   45         deploying technology that limits certain care provided
   46         by a direct care registered nurse; providing that it
   47         is a duty and right of a direct care registered nurse
   48         to act as the patient’s advocate; providing certain
   49         requirements with respect to such duty; authorizing a
   50         direct care registered nurse to refuse to perform
   51         certain activities if she or he determines that it is
   52         not in the best interest of the patient; authorizing a
   53         direct care registered nurse to refuse an assignment
   54         under certain circumstances; prohibiting a health care
   55         facility from discharging, discriminating, or
   56         retaliating against a nurse based on such refusal;
   57         providing that a direct care registered nurse has a
   58         right of action against a health care facility that
   59         violates certain provisions of the act; requiring that
   60         the agency establish a toll-free telephone hotline to
   61         provide information and to receive reports of
   62         violations of the act; requiring that certain
   63         information be provided to each patient who is
   64         admitted to a health care facility; prohibiting a
   65         health care facility from interfering with the right
   66         of nurses to organize or bargain collectively;
   67         authorizing the agency to impose fines for violations
   68         of the act; requiring that the agency post on its
   69         website information regarding health care facilities
   70         that have violated the act; providing an effective
   71         date.
   72          
   73  Be It Enacted by the Legislature of the State of Florida:
   74  
   75         Section 1. Short title.—This act may be cited as the
   76  “Florida Hospital Patient Protection Act.”
   77         Section 2. Section 395.1014, Florida Statutes, is created
   78  to read:
   79         395.1014Health care facility patient care standards.—
   80         (1)LEGISLATIVE FINDINGS.—The Legislature finds that:
   81         (a) The state has a substantial interest in ensuring that,
   82  in the delivery of health care services to patients, health care
   83  facilities retain sufficient nursing staff so as to promote
   84  optimal health care outcomes.
   85         (b) Health care services are becoming more complex and it
   86  is increasingly difficult for patients to access integrated
   87  services. Competent, safe, therapeutic, and effective patient
   88  care is jeopardized because of staffing changes implemented in
   89  response to market-driven managed care. In order to ensure
   90  effective protection of patients in acute care settings, it is
   91  essential that qualified direct care registered nurses be
   92  accessible and available to meet the individual needs of the
   93  patient at all times. Also, in order to ensure the health and
   94  welfare of residents and to ensure that hospital nursing care is
   95  provided in the exclusive interests of patients, mandatory
   96  practice standards and professional practice protections for
   97  professional direct care registered nursing staff must be
   98  established. Direct care registered nurses have a duty to care
   99  for assigned patients and a necessary duty of individual and
  100  collective patient advocacy in order to satisfy professional
  101  obligations.
  102         (c) The basic principles of staffing in hospital settings
  103  should be based on the care needs of the individual patient, the
  104  severity of the patient’s condition, the services needed, and
  105  the complexity surrounding those services. Current unsafe
  106  practices by hospital direct care registered nursing staff have
  107  resulted in adverse patient outcomes. Mandating the adoption of
  108  uniform, minimum, numerical, and specific registered nurse-to
  109  patient staffing ratios by licensed hospital facilities is
  110  necessary for competent, safe, therapeutic, and effective
  111  professional nursing care and for the retention and recruitment
  112  of qualified direct care registered nurses.
  113         (d) Direct care registered nurses must be able to advocate
  114  for their patients without fear of retaliation from their
  115  employers. Whistle-blower protections that encourage registered
  116  nurses and patients to notify governmental and private
  117  accreditation entities of suspected unsafe patient conditions,
  118  including protection against retaliation for refusing unsafe
  119  patient care assignments, will greatly enhance the health,
  120  safety, and welfare of patients.
  121         (e) Direct care registered nurses have an irrevocable duty
  122  and right to advocate on behalf of their patients’ interests and
  123  this duty and right may not be encumbered by cost-saving
  124  practices.
  125         (2)DEFINITIONS.—As used in this section, the term:
  126         (a) “Acuity-based patient classification system,” “acuity
  127  system,” or “patient classification system” means an established
  128  measurement tool that:
  129         1. Predicts registered nursing care requirements for
  130  individual patients based on the severity of a patient’s
  131  illness; the need for specialized equipment and technology; the
  132  intensity of required nursing interventions; the complexity of
  133  clinical nursing judgment required to design, implement, and
  134  evaluate the patient nursing care plan consistent with
  135  professional standards; the ability for self-care, including
  136  motor, sensory, and cognitive deficits; and the need for
  137  advocacy intervention;
  138         2. Details the amount of nursing care needed and the
  139  additional number of direct care registered nurses and other
  140  licensed and unlicensed nursing staff that the hospital must
  141  assign, based on the independent professional judgment of a
  142  direct care registered nurse, in order to meet the needs of
  143  individual patients at all times; and
  144         3. Can be readily understood and used by direct care
  145  nursing staff.
  146         (b) “Ancillary support staff” means the personnel assigned
  147  to assist in providing nursing services in the delivery of safe,
  148  therapeutic, and effective patient care, including unit or ward
  149  clerks and secretaries, clinical technicians, respiratory
  150  therapists, and radiology, laboratory, housekeeping, and dietary
  151  personnel.
  152         (c) “Clinical supervision” means the assignment and
  153  direction of a patient care task required in the implementation
  154  of nursing care for a patient to other licensed nursing staff or
  155  to unlicensed staff by a direct care registered nurse in the
  156  exclusive interest of the patient.
  157         (d) “Competence” means the ability of a direct care
  158  registered nurse to act and integrate the knowledge, skill,
  159  abilities, and independent professional judgment that underpin
  160  safe, therapeutic, and effective patient care.
  161         (e) “Declared state of emergency” means an officially
  162  designated state of emergency which has been declared by a
  163  federal, state, or local government official who has the
  164  authority to declare the state of emergency. The term does not
  165  include a state of emergency which results from a labor dispute
  166  in the health care industry.
  167         (f) “Direct care registered nurse” means a licensed
  168  registered nurse whose competence has been documented and who
  169  has accepted a direct, hands-on patient care assignment to
  170  implement medical and nursing regimens and provide related
  171  clinical supervision of patient care while exercising
  172  independent professional judgment at all times in the exclusive
  173  interest of the patient.
  174         (g) “Health care facility” means an acute care hospital; an
  175  emergency care, ambulatory, or outpatient surgery facility
  176  licensed under this chapter; or a psychiatric facility licensed
  177  under chapter 394.
  178         (h) “Hospital unit” or “clinical unit” means a critical
  179  care or intensive care unit, labor and delivery room, antepartum
  180  and postpartum unit, newborn nursery, postanesthesia unit,
  181  emergency department, operating room, pediatric unit, surgical
  182  unit, rehabilitation unit, skilled nursing unit, specialty care
  183  unit, step-down unit or intermediate intensive care unit,
  184  telemetry unit, or psychiatric unit.
  185         1. “Acuity adjustable unit” means a unit that adjusts a
  186  room’s technology, monitoring systems, and intensity of nursing
  187  care based on the severity of the patient’s condition.
  188         2. “Critical care unit” or “intensive care unit” means a
  189  nursing unit established to safeguard and protect a patient
  190  whose severity of medical condition requires continuous
  191  monitoring and complex intervention by a direct care registered
  192  nurse and whose restorative measures and level of nursing
  193  intensity require intensive care through direct observation by a
  194  direct care registered nurse and complex monitoring, intensive
  195  intricate assessment, evaluation, specialized rapid
  196  intervention, and education or teaching of the patient, the
  197  patient’s family, or other representatives by a competent and
  198  experienced direct care registered nurse. The term includes a
  199  burn unit, a coronary care unit, or an acute respiratory unit.
  200         3. “Rehabilitation unit” means a functional clinical unit
  201  established to provide rehabilitation services that restore an
  202  ill or injured patient to the highest level of self-sufficiency
  203  or gainful employment of which he or she is capable in the
  204  shortest possible time, compatible with his or her physical,
  205  intellectual, and emotional or psychological capabilities, and
  206  in accordance with planned goals and objectives.
  207         4. “Skilled nursing unit” means a functional clinical unit
  208  established to provide skilled nursing care and supportive care
  209  to patients whose primary need is for skilled nursing care on a
  210  long-term basis and who are admitted after at least a 48-hour
  211  period of continuous inpatient care. The term includes, but is
  212  not limited to, a unit established to provide medical, nursing,
  213  dietary, and pharmaceutical services and activity programs.
  214         5. “Specialty care unit” means a unit established to
  215  safeguard and protect a patient whose severity of illness,
  216  including all co-occurring morbidities, restorative measures,
  217  and level of nursing intensity, requires continuous care through
  218  direct observation by a direct care registered nurse and
  219  monitoring, multiple assessments, specialized interventions,
  220  evaluations, and education or teaching of the patient, the
  221  patient’s family, or other representatives by a competent and
  222  experienced direct care registered nurse. The term includes, but
  223  is not limited to, a unit established to provide the intensity
  224  of care required for a specific medical condition or a specific
  225  patient population or to provide more comprehensive care for a
  226  specific condition or disease than the care required in a
  227  surgical unit.
  228         6. “Step-down unit” or “intermediate intensive care unit”
  229  means a unit established to safeguard and protect a patient
  230  whose severity of illness, including all co-occurring
  231  morbidities, restorative measures, and level of nursing
  232  intensity, requires intermediate intensive care through direct
  233  observation by a direct care registered nurse and monitoring,
  234  multiple assessments, specialized interventions, evaluations,
  235  and education or teaching of the patient, the patient’s family,
  236  or other representatives by a competent and experienced direct
  237  care registered nurse. The term includes units established to
  238  provide care to patients who have moderate or potentially severe
  239  physiologic instability requiring technical support, but not
  240  necessarily artificial life support. As used in this
  241  subparagraph, the term:
  242         a. “Artificial life support” means a system that uses
  243  medical technology to aid, support, or replace a vital function
  244  of the body which has been seriously damaged.
  245         b. “Technical support” means the use of specialized
  246  equipment by a direct care registered nurse in providing for
  247  invasive monitoring, telemetry, and mechanical ventilation for
  248  the immediate amelioration or remediation of severe pathology
  249  for a patient requiring less care than intensive care, but more
  250  care than the care provided in a surgical unit.
  251         7. “Surgical unit” means a unit established to safeguard
  252  and protect a patient whose severity of illness, including all
  253  co-occurring morbidities, restorative measures, and level of
  254  nursing intensity requires continuous care through direct
  255  observation by a direct care registered nurse and monitoring,
  256  multiple assessments, specialized interventions, evaluations,
  257  and education or teaching of the patient, the patient’s family,
  258  or other representatives by a competent and experienced direct
  259  care registered nurse. These units may include patients
  260  requiring less than intensive care or step-down care; patients
  261  receiving 24-hour inpatient general medical care, postsurgical
  262  care, or both general medical and postsurgical care; and mixed
  263  populations of patients of diverse diagnoses and diverse age
  264  groups, but excluding pediatric patients.
  265         8. “Telemetry unit” means a unit established to safeguard
  266  and protect a patient whose severity of illness, including all
  267  co-occurring morbidities, restorative measures, and level of
  268  nursing intensity, requires intermediate intensive care through
  269  direct observation by a direct care registered nurse and
  270  monitoring, multiple assessments, specialized interventions,
  271  evaluations, and education or teaching of the patient, the
  272  patient’s family, or other representatives by a competent and
  273  experienced direct care registered nurse. A telemetry unit
  274  includes the equipment used to provide for the electronic
  275  monitoring, recording, retrieval, and display of cardiac
  276  electrical signals.
  277         (i) “Licensed nurse” means a registered nurse or a licensed
  278  practical nurse, as defined in s. 464.003, who is licensed by
  279  the Board of Nursing to engage in the practice of professional
  280  nursing or the practice of practical nursing, as defined in s.
  281  464.003.
  282         (j) “Long-term acute care hospital” means a hospital or
  283  health care facility that specializes in providing long-term
  284  acute care to medically complex patients. The term includes a
  285  freestanding and hospital-within-hospital model of a long-term
  286  acute care facility.
  287         (k) “Overtime” means the hours worked in excess of:
  288         1. An agreed-upon, predetermined, regularly scheduled
  289  shift;
  290         2. Twelve hours in a 24-hour period; or
  291         3. Eighty hours in a 14-day period.
  292         (l) “Patient assessment” means the use of critical thinking
  293  by a direct care licensed nurse and is the intellectually
  294  disciplined process of actively and skillfully interpreting,
  295  applying, analyzing, synthesizing, or evaluating data obtained
  296  through direct observation and communication with others.
  297         (m) “Professional judgment” means the intellectual,
  298  educated, informed, and experienced process that a direct care
  299  registered nurse exercises in forming an opinion and reaching a
  300  clinical decision that is in the patient’s best interest and is
  301  based upon analysis of data, information, and scientific
  302  evidence.
  303         (n) “Skill mix” means the differences in licensing,
  304  specialty, and experience among direct care registered nurses.
  305         (3)MINIMUM DIRECT CARE REGISTERED NURSE STAFFING LEVEL
  306  REQUIREMENTS.—
  307         (a) Each health care facility shall implement a staffing
  308  plan that provides for a minimum direct care registered nurse
  309  staffing level in accordance with the general requirements set
  310  forth in this subsection and the directed care registered nurse
  311  staffing levels in a clinical unit as specified in paragraph
  312  (b). Staffing levels for patient care tasks that do not require
  313  a direct care registered nurse are not included within these
  314  ratios and shall be determined pursuant to an acuity-based
  315  patient classification system defined by agency rule.
  316         1. A health care facility may not assign a direct care
  317  registered nurse to a clinical unit unless the health care
  318  facility and the direct care registered nurse determine that she
  319  or he has demonstrated and validated current competence in
  320  providing care in that clinical unit and has also received
  321  orientation to that area which is sufficient to provide
  322  competent, safe, therapeutic, and effective care to a patient in
  323  that area. The policies and procedures of the health care
  324  facility must contain the criteria for making this
  325  determination.
  326         2. The direct care registered nurse staffing levels
  327  represent the maximum number of patients that may be assigned to
  328  one direct care registered nurse at any time.
  329         3. A health care facility:
  330         a. May not average the number of patients and the total
  331  number of direct care registered nurses assigned to patients in
  332  a hospital unit or clinical unit during any period of time for
  333  purposes of meeting the requirements under this section.
  334         b. May not impose mandatory overtime in order to meet the
  335  minimum direct care registered nurse staffing levels in the
  336  hospital unit or clinical unit which are required under this
  337  subsection.
  338         c. Shall ensure that only a direct care registered nurse
  339  may relieve another direct care registered nurse during breaks,
  340  meals, and routine absences from a hospital unit or clinical
  341  unit.
  342         d. May not lay off licensed practical nurses, licensed
  343  psychiatric technicians, certified nursing assistants, or other
  344  ancillary support staff in order to meet the directed care
  345  registered nurse staffing levels in a hospital unit or clinical
  346  unit, as required in this subsection.
  347         4. Only a direct care registered nurse may be assigned to
  348  an intensive care newborn nursery service unit, which
  349  specifically requires a direct care registered nurse staffing
  350  level of one nurse to two or fewer infants at all times.
  351         5. Only a direct care registered nurse may be assigned to a
  352  triage patient, and only a direct care registered nurse may be
  353  assigned to a critical care patient in the emergency department.
  354         a. The direct care registered nurse staffing level for
  355  triage patients or critical care patients in the emergency
  356  department must be one nurse to two or fewer patients at all
  357  times.
  358         b. At least two direct care registered nurses must be
  359  physically present in the emergency department when a patient is
  360  present.
  361         c. Triage-, radio-, specialty-, or flight-registered nurses
  362  do not count in the calculation of direct care registered nurse
  363  staffing levels.
  364         d. Triage-registered nurses may not be assigned the
  365  responsibility of the base radio.
  366         6. Only a direct care registered nurse may be assigned to a
  367  labor and delivery unit.
  368         a. The direct care registered nurse staffing level must be
  369  one nurse to one active labor patient, or one patient having
  370  medical or obstetrical complications, during the initiation of
  371  epidural anesthesia and during circulation for a caesarean
  372  delivery.
  373         b. The direct care registered nurse staffing level for
  374  antepartum patients who are not in active labor must be one
  375  nurse to three or fewer patients at all times.
  376         c. In the event of a caesarean delivery, the total number
  377  of mothers plus infants assigned to a single direct care
  378  registered nurse may not exceed four.
  379         d. In the event of multiple births, the total number of
  380  mothers plus infants assigned to a single direct care registered
  381  nurse may not exceed six.
  382         e. The direct care registered nurse staffing level for
  383  postpartum areas in which the direct care registered nurse’s
  384  assignment consists of only mothers must be one nurse to four or
  385  fewer patients at all times.
  386         f. The direct care registered nurse staffing level for only
  387  postpartum women or postsurgical gynecological patients must be
  388  one nurse to four or fewer patients at all times.
  389         g. The direct care registered nurse staffing level for the
  390  well-baby nursery must be one nurse to five or fewer patients at
  391  all times.
  392         h. The direct care registered nurse staffing level for
  393  unstable newborns and those in the resuscitation period as
  394  assessed by a direct care registered nurse must be at least one
  395  nurse to one patient at all times.
  396         i. The direct care registered nurse staffing level for
  397  recently born infants must be one nurse to four or fewer
  398  patients at all times.
  399         7. The direct care registered nurse staffing level for
  400  patients receiving conscious sedation must be at least one nurse
  401  to one patient at all times.
  402         (b) A health care facility’s staffing plan must provide
  403  that, at all times during each shift within a unit of the
  404  facility, a direct care registered nurse is assigned to not more
  405  than:
  406         1. One patient in a trauma emergency unit;
  407         2. One patient in an operating room unit. The operating
  408  room must have at least one direct care registered nurse
  409  assigned to the duties of the circulating registered nurse and a
  410  minimum of one additional person as a scrub assistant for each
  411  patient-occupied operating room;
  412         3. Two patients in a critical care unit, including neonatal
  413  intensive care units, emergency critical care and intensive care
  414  units, labor and delivery units, coronary care units, acute
  415  respiratory care units, postanesthesia units regardless of the
  416  type of anesthesia received, and postpartum units, so that the
  417  direct care registered nurse staffing level is one nurse to two
  418  or fewer patients at all times;
  419         4. Three patients in an emergency room unit, step-down unit
  420  or intermediate intensive care unit, pediatrics unit, telemetry
  421  unit, or combined labor, delivery, and postpartum unit, so that
  422  the direct care registered nurse staffing level is one nurse to
  423  three or fewer patients at all times;
  424         5. Four patients in a surgical unit, antepartum unit,
  425  intermediate care nursery unit, psychiatric unit, or presurgical
  426  or other specialty care unit so that the direct care registered
  427  nurse staffing level is one nurse to four or fewer patients at
  428  all times;
  429         6. Five patients in a rehabilitation unit and skilled
  430  nursing unit, so that the direct care registered nurse staffing
  431  level is one nurse to five or fewer patients at all times;
  432         7. Six patients in a well-baby nursery unit so that the
  433  direct care registered nurse staffing level is one nurse to six
  434  or fewer patients at all times; or
  435         8. Three mother plus infant couplets in a postpartum unit
  436  so that the direct care registered nurse staffing level is one
  437  nurse to three or fewer mother plus infant couplets at all
  438  times.
  439         (c)1. Identifying a hospital unit or clinical unit by a
  440  name or term other than those defined in subsection (2) does not
  441  affect the requirement of direct care registered nurse staffing
  442  level identified for the level of intensity or type of care
  443  described in paragraphs (a) and (b).
  444         2. Patients shall be cared for only in hospital units or
  445  clinical units in which the level of intensity, type of care,
  446  and direct care registered nurse staffing levels meet the
  447  individual requirements and needs of each patient. A health care
  448  facility may not use an acuity-adjustable unit to care for a
  449  patient.
  450         3. A health care facility may not use a video camera or
  451  monitor or any form of electronic visualization of a patient to
  452  substitute for the direct observation required for patient
  453  assessment by the direct care registered nurse and for patient
  454  protection required by an attendant.
  455         (d) The requirements established under this subsection do
  456  not apply during a declared state of emergency if a health care
  457  facility is requested or expected to provide an exceptional
  458  level of emergency or other medical services.
  459         (e)The chief nursing officer or his or her designee shall
  460  develop a staffing plan for each hospital unit or clinical unit.
  461         1. The staffing plan must be in writing and, based on
  462  individual patient care needs determined by the patient
  463  classification system, must specify individual patient care
  464  requirements and the staffing levels for direct care registered
  465  nurses and other licensed and unlicensed personnel. The direct
  466  care registered nurse staffing level on any shift may not at any
  467  time fall below the requirements of paragraphs (a) and (b).
  468         2. In addition to the requirements of direct care
  469  registered nurse staffing levels of paragraphs (a) and (b), each
  470  health care facility shall assign additional nursing staff, such
  471  as licensed practical nurses, licensed psychiatric technicians,
  472  and certified nursing assistants, through the implementation of
  473  a valid patient classification system for determining nursing
  474  care needs of individual patients which reflects the assessment
  475  of patient nursing care requirements made by the assigned direct
  476  care registered nurse and which provides for shift-by-shift
  477  staffing based on those requirements. The direct care registered
  478  nurse staffing levels specified in paragraphs (a) and (b)
  479  constitute the minimum number of registered nurses who shall be
  480  assigned to provide direct patient care.
  481         3. In developing the staffing plan, a health care facility
  482  shall provide for direct care registered nurse staffing levels
  483  that are above the minimum levels required under paragraphs (a)
  484  and (b) based upon consideration of the following factors:
  485         a. The number of patients and acuity level of patients as
  486  determined by the application of an acuity system on a shift-by
  487  shift basis.
  488         b. The anticipated admissions, discharges, and transfers of
  489  patients during each shift which affect direct patient care.
  490         c. The specialized experience required of direct care
  491  registered nurses on a particular hospital unit or clinical
  492  unit.
  493         d. Staffing levels of other health care personnel who
  494  provide services for direct patient care needs which normally do
  495  not require care by a direct care registered nurse.
  496         e. The level of efficacy of technology that is available
  497  and that affects the delivery of direct patient care.
  498         f. The level of familiarity with hospital practices,
  499  policies, and procedures by a direct care registered nurse from
  500  a temporary agency during a shift.
  501         g. Obstacles to efficiency in the delivery of patient care
  502  caused by the physical layout of the health care facility.
  503         4. A health care facility shall specify the system used to
  504  document actual staffing in each unit for each shift.
  505         5. A health care facility shall annually evaluate:
  506         a. The reliability of the patient classification system for
  507  validating staffing requirements in order to determine whether
  508  the system accurately measures individual patient care needs and
  509  accurately predicts the staffing requirements for direct care
  510  registered nurses, licensed practical nurses, licensed
  511  psychiatric technicians, and certified nursing assistants, based
  512  exclusively on individual patient needs.
  513         b. The validity of the acuity-based patient classification
  514  system.
  515         6. A health care facility shall update its staffing plan
  516  and acuity system to the extent appropriate based on the annual
  517  evaluation. If the evaluation reveals that adjustments are
  518  necessary in order to ensure accuracy in measuring patient care
  519  needs, such adjustments must be implemented within 30 days after
  520  that determination.
  521         7. Any acuity-based patient classification system adopted
  522  by a health care facility under this subsection must be
  523  transparent in all respects, including disclosure of detailed
  524  documentation of the methodology used to predict nursing
  525  staffing; an identification of each factor, assumption, and
  526  value used in applying such methodology; an explanation of the
  527  scientific and empirical basis for each such assumption and
  528  value; and certification by a knowledgeable and authorized
  529  representative of the health care facility that the disclosures
  530  regarding methods used for testing and validating the accuracy
  531  and reliability of the system are true and complete.
  532         a. The documentation required by this subparagraph shall be
  533  submitted in its entirety to the agency as a mandatory condition
  534  of licensure, with a certification by the chief nursing officer
  535  for the health care facility that the documentation completely
  536  and accurately reflects implementation of a valid acuity-based
  537  patient classification system used to determine nursing service
  538  staffing by the facility for each shift on each hospital unit or
  539  clinical unit in which patients receive care. The chief nursing
  540  officer shall execute the certification under penalty of
  541  perjury, and the certification must contain an expressed
  542  acknowledgment that any false statement constitutes fraud and is
  543  subject to criminal and civil prosecution and penalties.
  544         b. Such documentation must be available for public
  545  inspection in its entirety in accordance with procedures
  546  established by administrative rules adopted by the agency,
  547  consistent with the purposes of this act.
  548         8. A staffing plan of a health care facility shall be
  549  developed and evaluated by a committee created by the health
  550  care facility. At least half of the members of the committee
  551  must be unit-specific competent direct care registered nurses.
  552         a. The chief nursing officer at the facility shall appoint
  553  the members who are not direct care registered nurses. The
  554  direct care registered nurses on the committee shall be
  555  appointed by the chief nursing officer, if the direct care
  556  registered nurses are not represented by a collective bargaining
  557  agreement; or an authorized collective bargaining agent.
  558         b. In case of a dispute, the direct care registered nurse
  559  assessment shall prevail.
  560         c. This act does not authorize conduct that is prohibited
  561  under the National Labor Relations Act or under the Federal
  562  Labor Relations Act.
  563         9. By July 1, 2015, the agency shall approve uniform
  564  statewide standards for a standardized acuity tool for use in
  565  health care facilities. The standardized acuity tool will
  566  provide a method for establishing nurse staffing requirements
  567  that exceed the required direct care registered nurse staffing
  568  levels in the hospital units or clinical units under paragraphs
  569  (a) and (b).
  570         a. The proposed standards shall be developed by a committee
  571  created by the health care facility consisting of up to 20
  572  members. At least 11 of the committee members must be currently
  573  licensed registered nurses who are employed as direct care
  574  registered nurses, and the remaining members must include a
  575  sufficient number of technical or scientific experts in the
  576  specialized fields who are involved in the design and
  577  development of a patient classification system that meets the
  578  requirements of this act.
  579         b. A person who has any employment or any commercial,
  580  proprietary, financial, or other personal interest in the
  581  development, marketing, or use of a private patient
  582  classification system product or related methodology,
  583  technology, or component system is not eligible to serve on the
  584  development committee. A candidate for appointment to the
  585  development committee may not be confirmed as a member until the
  586  candidate files a disclosure-of-interest statement with the
  587  agency, along with a signed certification of full disclosure and
  588  complete accuracy under oath, which provides all necessary
  589  information as determined by the agency to demonstrate the
  590  absence of actual or potential conflict of interest. All such
  591  filings are subject to public inspection.
  592         c. Within 1 year after the official commencement of
  593  committee operations, the development committee shall provide a
  594  written report to the agency which proposes uniform standards
  595  for a valid patient classification system, along with sufficient
  596  explanation and justification to allow for competent review and
  597  determination of sufficiency by the agency. The agency shall
  598  disclose the report to the public upon notice of public hearings
  599  and provide a public comment period for proposed adoption of
  600  uniform standards for a patient classification system by the
  601  agency.
  602         10. Each hospital shall adopt and implement the patient
  603  classification system and provide staffing based on the
  604  standardized acuity tool. Any additional direct care registered
  605  nurse staffing levels that exceed the direct care registered
  606  nurse staffing levels described in paragraphs (a) and (b) shall
  607  be assigned in a manner determined by such standardized acuity
  608  tool.
  609         11. A health care facility shall submit to the agency its
  610  staffing plan and annual update required under paragraph (e).
  611         (f)1. In each hospital unit or clinical unit, a health care
  612  facility shall post a uniform notice in a form specified by
  613  agency rule which:
  614         a. Explains the requirements imposed under this subsection;
  615         b. Includes actual direct care registered nurse staffing
  616  levels during each shift;
  617         c. Is visible, conspicuous, and accessible to staff,
  618  patients, and the public;
  619         d. Identifies staffing requirements as determined by the
  620  patient classification system for each hospital unit or clinical
  621  unit, documented and posted on the unit for public view on a
  622  day-to-day, shift-by-shift basis;
  623         e. Documents the actual number of staff and the skill mix,
  624  documented and posted on the hospital unit or clinical unit for
  625  public view on a day-to-day, shift-by-shift basis; and
  626         f. Reports the variance between the required and actual
  627  staffing patterns, documented and posted on the hospital unit or
  628  clinical unit for public view on a day-to-day, shift-by-shift
  629  basis.
  630         2.a. Each long-term acute care hospital shall maintain
  631  accurate records of actual staffing levels in each hospital unit
  632  or clinical unit for each shift for at least 2 years. Such
  633  records must include:
  634         (I) The number of patients in each unit;
  635         (II) The identity and duty hours of each direct care
  636  registered nurse, licensed practical nurse, licensed psychiatric
  637  technician, and certified nursing assistant assigned to each
  638  patient in each hospital unit or clinical unit in each shift;
  639  and
  640         (III) A copy of each posted notice.
  641         b. Each health care facility shall make its records
  642  maintained under paragraph (e) available to the agency; to
  643  registered nurses and their collective bargaining
  644  representatives, if any; and to the public under rules adopted
  645  by the agency.
  646         3. The agency shall conduct periodic audits to ensure
  647  implementation of the staffing plan in accordance with this
  648  section and to ensure accuracy in records maintained under
  649  paragraph (e).
  650         (g) Health 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 facility must
  654  demonstrate that immediate and diligent efforts are made to
  655  maintain required staffing levels.
  656         (h) The following activities are prohibited:
  657         1. The direct assignment of unlicensed personnel by a
  658  health care facility to perform functions required of a
  659  registered nurse in lieu of care being delivered by a licensed
  660  or registered nurse under the clinical supervision of a direct
  661  care registered nurse.
  662         2. The performance of tasks by unlicensed personnel which
  663  require the clinical assessment, judgment, and skill of a
  664  licensed registered nurse, including, but not limited to:
  665         a. Nursing activities that require nursing assessment and
  666  judgment during implementation;
  667         b. Physical, psychological, or social assessments that
  668  require nursing judgment, intervention, referral, or followup;
  669  and
  670         c. Formulation of a plan of nursing care and evaluation of
  671  a patient’s response to the care provided, including
  672  administration of medication; venipuncture or intravenous
  673  therapy; parenteral or tube feedings; invasive procedures,
  674  including inserting nasogastric tubes, inserting catheters, or
  675  tracheal suctioning; and educating patients and their families
  676  concerning the patient’s health care problems, including
  677  postdischarge care. However, a phlebotomist, an emergency room
  678  technician, or a medical technician may, under the general
  679  supervision of the clinical laboratory director or designee or a
  680  physician, perform venipunctures in accordance with written
  681  hospital policies and procedures.
  682         (4)PROFESSIONAL PRACTICE STANDARDS FOR DIRECT CARE
  683  REGISTERED NURSES WORKING IN A HEALTH CARE FACILITY.—
  684         (a) A direct care registered nurse employing scientific
  685  knowledge and experience in the physical, social, and biological
  686  sciences and exercising independent judgment in applying the
  687  nursing process, shall directly provide:
  688         1. Continuous and ongoing assessments of the patient’s
  689  condition.
  690         2. The planning, clinical supervision, implementation, and
  691  evaluation of the nursing care to each patient.
  692         3. The assessment, planning, implementation, and evaluation
  693  of patient education, including ongoing postdischarge education
  694  of each patient.
  695         4. The delivery of patient care, which must reflect all
  696  elements of the nursing process and must include assessment,
  697  nursing diagnosis, planning, intervention, evaluation, and, as
  698  circumstances require, patient advocacy and shall be initiated
  699  by a direct care registered nurse at the time of admission.
  700         5. The nursing plan for the patient care, which shall be
  701  discussed with and developed as a result of coordination with
  702  the patient, the patient’s family or other representatives, when
  703  appropriate, and staff of other disciplines involved in the care
  704  of the patient.
  705         6. An evaluation of the effectiveness of the care plan
  706  through assessments based on direct observation of the patient’s
  707  physical condition and behavior, signs and symptoms of illness,
  708  and reactions to treatment and through communication with the
  709  patient and the health care team members and shall modify the
  710  plan as needed.
  711         7. Information related to the initial assessment and
  712  reassessments of the patient, nursing diagnosis, plan,
  713  intervention, evaluation, and patient advocacy, which shall be
  714  permanently recorded in the patient’s medical record as
  715  narrative direct care progress notes. The practice of charting
  716  by exception is expressly prohibited.
  717         (b)1. A patient assessment requires direct observation of
  718  the patient’s signs and symptoms of illness, reaction to
  719  treatment, behavior and physical condition, and interpretation
  720  of information obtained from the patient and others, including
  721  other caregivers on the health care team. A patient assessment
  722  requires data collection by a direct care registered nurse and
  723  the analysis, synthesis, and evaluation of such data.
  724         2. Only a direct care registered nurse may perform a
  725  patient assessment. A licensed practical nurse or licensed
  726  psychiatric technician may assist a direct care registered nurse
  727  in data collection.
  728         (c)1. A direct care registered nurse shall determine the
  729  nursing care needs of individual patients through the process of
  730  ongoing patient assessments, nursing diagnosis, formulation, and
  731  adjustment of nursing care plans.
  732         2. The prediction of individual patient nursing care needs
  733  for prospective assignment of direct care registered nurses
  734  shall be based on individual patient assessments of the direct
  735  care registered nurse assigned to each patient and in accordance
  736  with a documented patient classification system as provided in
  737  subsection (3).
  738         (d) Competent performance of the essential functions of a
  739  direct care registered nurse as provided in this section
  740  requires the exercise of independent judgment in the interests
  741  of the patient. The exercise of such independent judgment,
  742  unencumbered by the commercial or revenue-generation priorities
  743  of a health care facility or employing entity of the direct care
  744  registered nurse, is essential to safe nursing care.
  745         1. Current documented, demonstrated, and validated
  746  competency is required for each direct care registered nurse and
  747  must be determined based on the satisfactory performance of:
  748         a. The statutorily recognized duties and responsibilities
  749  of a registered nurse as set forth in chapter 464 and under
  750  rules adopted under that chapter; and
  751         b. The standards required under subsections (3) and (4),
  752  which are specific to each hospital unit or clinical unit.
  753         2. A direct care registered nurse’s independent judgment
  754  while performing the functions described in this section shall
  755  be provided in the exclusive interests of the patient and may
  756  not, for any purpose, be considered, relied upon, or represented
  757  as a job function, authority, responsibility, or activity
  758  undertaken in any respect for the purpose of serving the
  759  business, commercial, operational, or other institutional
  760  interests of the health care facility employer.
  761         (e)1. In addition to the prohibition on assignments of
  762  patient care tasks provided in paragraph (3)(h), a direct care
  763  registered nurse may assign tasks required in the implementation
  764  of nursing care for a patient to other licensed nursing staff or
  765  to unlicensed staff only if the assigning direct care registered
  766  nurse:
  767         a. Determines that the personnel assigned the tasks possess
  768  the necessary training, experience, and capability to
  769  competently and safely perform the tasks to be assigned; and
  770         b. Effectively supervises the clinical functions and
  771  nursing care tasks performed by the assigned personnel.
  772         2. The exercise of clinical supervision of nursing care
  773  personnel by a direct care registered nurse in the performance
  774  of the functions as provided in this subsection must be in the
  775  exclusive interests of the patient and may not, for any purpose,
  776  be considered, relied upon, or represented as a job function,
  777  authority, responsibility, or activity undertaken in any respect
  778  for the purpose of serving the business, commercial,
  779  operational, or other institutional interests of the health care
  780  facility employer, but constitutes the exercise of professional
  781  nursing authority and duty exclusively in the interests of the
  782  patient.
  783         (f) A health care facility may not deploy technology that
  784  limits the direct care provided by a direct care registered
  785  nurse in the performance of functions that are part of the
  786  nursing process, including the full exercise of independent
  787  professional judgment in the assessment, planning,
  788  implementation, and evaluation of care, or that limits a direct
  789  care registered nurse from acting as a patient advocate in the
  790  exclusive interest of the patient. Technology may not be skill
  791  degrading, interfere with the direct care registered nurse’s
  792  provision of individualized patient care, override the direct
  793  care registered nurse’s independent professional judgment, or
  794  interfere with the direct care registered nurse’s right to
  795  advocate in the exclusive interest of the patient.
  796         (g) This subsection applies only to nurses employed by or
  797  providing care in a health care facility.
  798         (5)DIRECT CARE REGISTERED NURSE’S DUTY AND RIGHT OF
  799  PATIENT ADVOCACY.—
  800         (a) A direct care registered nurse has a duty and right to
  801  act and provide care in the exclusive interest of the patient
  802  and to act as the patient’s advocate.
  803         (b) A direct care registered nurse shall always provide
  804  competent, safe, therapeutic, and effective nursing care to an
  805  assigned patient.
  806         1. Before accepting a patient assignment, a direct care
  807  registered nurse must have the necessary knowledge, judgment,
  808  skills, and ability to provide the required care. It is the
  809  responsibility of the direct care registered nurse to determine
  810  whether the nurse is clinically competent to perform the nursing
  811  care required by patients in a particular clinical unit or who
  812  have a particular diagnosis, condition, prognosis, or other
  813  determinative characteristic of nursing care, and whether
  814  acceptance of a patient assignment would expose the patient to
  815  the risk of harm.
  816         2. If the direct care registered nurse is not competent to
  817  perform the care required for a patient assigned for nursing
  818  care or if the assignment would expose the patient to risk of
  819  harm, the direct care registered nurse may not accept the
  820  patient care assignment. Such refusal to accept a patient care
  821  assignment is an exercise of the direct care registered nurse’s
  822  duty and right of patient advocacy.
  823         (c) A direct care registered nurse may refuse to accept an
  824  assignment as a nurse in a health care facility if:
  825         1. The assignment would violate a provision of chapter 464
  826  or the rules adopted under that chapter;
  827         2. The assignment would violate subsection (3), subsection
  828  (4), or this subsection; or
  829         3. The direct care registered nurse is not prepared by
  830  education, training, or experience to fulfill the assignment
  831  without compromising the safety of a patient or jeopardizing the
  832  license of the direct care registered nurse.
  833         (d) A direct care registered nurse may refuse to perform an
  834  assigned task as a nurse in a health care facility if:
  835         1. The assigned task would violate a provision of chapter
  836  464 or the rules adopted under that chapter;
  837         2. The assigned task is outside the scope of practice of
  838  the direct care registered nurse; or
  839         3. The direct care registered nurse is not prepared by
  840  education, training, or experience to fulfill the assigned task
  841  without compromising the safety of a patient or jeopardizing the
  842  license of the direct care registered nurse.
  843         (e) In the course of performing the responsibilities and
  844  essential functions described in subsection (4), the direct care
  845  registered nurse assigned to a patient receives orders initiated
  846  by physicians and other legally authorized health care
  847  professionals within their scope of licensure regarding patient
  848  care services to be provided to the patient, including, but not
  849  limited to, the administration of medications and therapeutic
  850  agents that are necessary to implement a treatment, disease
  851  prevention, or rehabilitative regimen.
  852         1. The direct care registered nurse shall assess each such
  853  order before implementation to determine if the order is:
  854         a. In the best interest of the patient;
  855         b. Initiated by a person legally authorized to issue the
  856  order; or
  857         c. Issued in accordance with applicable law and rules
  858  governing nursing care.
  859         2. If the direct care registered nurse determines that
  860  these criteria have not been satisfied with respect to a
  861  particular order or if the nurse has some doubt regarding the
  862  meaning or conformance of the order with these criteria, he or
  863  she shall seek clarification from the initiator of the order,
  864  the patient’s physician, or another appropriate medical officer
  865  before implementing the order.
  866         3. If, upon clarification, the direct care registered nurse
  867  determines that the criteria for implementation of an order have
  868  not been satisfied, the nurse may refuse implementation on the
  869  basis that the order is not in the best interest of the patient.
  870  Seeking clarification of an order or refusing an order as
  871  described in this section is an exercise of the direct care
  872  registered nurse’s duty and right of patient advocacy.
  873         (f) A direct care registered nurse shall, as circumstances
  874  require, initiate action to improve the patient health care or
  875  to change decisions or activities that, in the professional
  876  judgment of the direct care registered nurse, are against the
  877  interests or wishes of the patient, or shall give the patient
  878  the opportunity to make informed decisions about the health care
  879  before it is provided.
  880         (6)FREE SPEECH; PATIENT PROTECTION.—
  881         (a) A health care facility may not:
  882         1. Discharge, discriminate, or retaliate in any manner with
  883  respect to any aspect of employment, including discharge,
  884  promotion, compensation, or terms, conditions, or privileges of
  885  employment, against a direct care registered nurse based on the
  886  nurse’s refusal of a work assignment or assigned task pursuant
  887  to paragraph (5)(c).
  888         2. File a complaint or a report against a direct care
  889  registered nurse with the Board of Nursing or the agency because
  890  of the nurse’s refusal of a work assignment or assigned task
  891  pursuant to paragraph (5)(c).
  892         (b) A direct care registered nurse who has been discharged,
  893  discriminated against, or retaliated against in violation of
  894  this section or against whom a complaint or a report has been
  895  filed in violation of subparagraph (a)2. may bring a cause of
  896  action in a state court. A direct care registered nurse who
  897  prevails on the cause of action is entitled to one or more of
  898  the following:
  899         1. Reinstatement.
  900         2. Reimbursement of lost wages, compensation, and benefits.
  901         3. Attorney fees.
  902         4. Court costs.
  903         5. Other damages.
  904         (c) A direct care registered nurse, patient, or other
  905  individual may file a complaint with the agency against a health
  906  care facility that violates this act. For any complaint filed,
  907  the agency shall:
  908         1. Receive and investigate the complaint;
  909         2. Determine whether a violation of this act as alleged in
  910  the complaint has occurred; and
  911         3. If such a violation has occurred, issue an order that
  912  the complaining nurse or individual not suffer any retaliation
  913  described paragraph (a).
  914         (d)1. The agency shall provide for the establishment of a
  915  toll-free telephone hotline to provide information regarding the
  916  requirements of this section and to receive reports of
  917  violations of this subsection.
  918         2. A health care facility shall provide each patient
  919  admitted to the facility for inpatient care with the toll-free
  920  telephone hotline described in subparagraph 1. and shall give
  921  notice to each patient that the hotline may be used to report
  922  inadequate staffing or care.
  923         (e)1. A health care facility may not discriminate or
  924  retaliate in any manner against any patient, employee, or
  925  contract employee of the facility, or any other individual, on
  926  the basis that such individual, in good faith, individually or
  927  in conjunction with another person or persons, has presented a
  928  grievance or complaint; initiated or cooperated in an
  929  investigation or proceeding by a governmental entity, regulatory
  930  agency, or private accreditation body; made a civil claim or
  931  demand; or filed an action relating to the care, services, or
  932  conditions of the health care facility or of any affiliated or
  933  related facilities.
  934         2. For purposes of this paragraph, an individual is deemed
  935  to be acting in good faith if the individual reasonably
  936  believes:
  937         a. The information reported or disclosed is true; and
  938         b. A violation of this act has occurred or may occur.
  939         (f)1. A health care facility may not:
  940         a. Interfere with, restrain, or deny the exercise of, or
  941  the attempt to exercise, any right provided or protected under
  942  this act; or
  943         b. Coerce or intimidate any person regarding the exercise
  944  of, or the attempt to exercise, such right.
  945         2. A health care facility may not discriminate or retaliate
  946  against any person for opposing any facility policy, practice,
  947  or actions that are alleged to violate, breach, or fail to
  948  comply with any provision of this act.
  949         3. A health care facility, or an individual representing a
  950  health care facility, may not make, adopt, or enforce any rule,
  951  regulation, policy, or practice that in any manner directly or
  952  indirectly prohibits, impedes, or discourages a direct care
  953  registered nurse from engaging in free speech activities or
  954  disclosing information as provided under this act.
  955         4. A health care facility, or an individual representing a
  956  health care facility, may not in any way interfere with the
  957  rights of nurses to organize, bargain collectively, and engage
  958  in concerted activity under chapter 7 of the National Labor
  959  Relations Act, 29 U.S.C. s. 157.
  960         5. A health care facility shall post in an appropriate
  961  location in each hospital unit or clinical unit a conspicuous
  962  notice in a form specified by the agency which:
  963         a. Explains the rights of nurses, patients, and other
  964  individuals under this subsection;
  965         b. Includes a statement that a nurse, patient, or other
  966  individual may file a complaint with the agency against a health
  967  care facility that violates this act; and
  968         c. Provides instructions on how to file a complaint.
  969         (7)ENFORCEMENT.—
  970         (a) In addition to any other penalties prescribed by law,
  971  the agency may impose civil penalties as follows:
  972         1. Against a health care facility found to have violated a
  973  provision of this act, a civil penalty of up to $25,000 for each
  974  violation, except that the agency shall impose a civil penalty
  975  of at least $25,000 for each violation if the agency determines
  976  that the health care facility has a pattern of practice of such
  977  violation.
  978         2. Against an individual who is employed by a health care
  979  facility and who is found to have violated a provision of this
  980  act, a civil penalty of up to $20,000 for each violation.
  981         (b) The agency shall post on its website the names of
  982  health care facilities against which civil penalties have been
  983  imposed under this act and such additional information as the
  984  agency deems necessary.
  985         Section 3. This act shall take effect July 1, 2014.