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: 79 395.1014 Health 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.