Florida Senate - 2025 SB 332
By Senator Garcia
36-00867-25 2025332__
1 A bill to be entitled
2 An act relating to patient protection; providing a
3 short title; creating s. 395.1013, F.S.; providing
4 legislative findings; defining terms; requiring health
5 care facilities to implement staffing plans that
6 comply with specified minimum staffing levels for
7 direct care registered nurses; providing construction;
8 prohibiting health care facilities from taking
9 specified actions; requiring such facilities to ensure
10 that certain staffing is maintained; specifying
11 minimum staffing levels for direct care registered
12 nurses based on the hospital or clinical unit setting;
13 requiring that patients be cared for only in hospital
14 or clinical units that meet the specified minimum
15 staffing levels; prohibiting health care facilities
16 from using video cameras or monitors as a substitute
17 for direct observation and assessment by a direct care
18 registered nurse; exempting health care facilities
19 from the minimum staffing level requirements during a
20 declared state of emergency under certain
21 circumstances; providing requirements for any acuity
22 based patient classification system adopted by a
23 health care facility; providing whistle-blower
24 protections; creating a cause of action; providing
25 remedies; providing for complaints to and
26 administrative actions by the Agency for Health Care
27 Administration; prohibiting health care facilities
28 from discriminating or retaliating against persons
29 who, in good faith, initiate, file, or cooperate in an
30 administrative or civil action against the facility;
31 providing construction; providing civil penalties;
32 requiring the agency to post specified information on
33 its website; providing construction with respect to
34 collective bargaining agreements; prohibiting
35 employers from taking specified actions with respect
36 to employment for certain unionized staff; providing
37 an effective date.
38
39 Be It Enacted by the Legislature of the State of Florida:
40
41 Section 1. This act may be cited as the “Florida Patient
42 Protection Act.”
43 Section 2. Section 395.1013, Florida Statutes, is created
44 to read:
45 395.1013 Health care facility patient care standards.—
46 (1) LEGISLATIVE FINDINGS.—The Legislature finds that:
47 (a) The state has a substantial interest in ensuring that,
48 in the delivery of health care services to patients, health care
49 facilities retain sufficient nursing staff to promote optimal
50 health care outcomes.
51 (b) The basic principles of staffing in health care
52 facility settings should be based on the health care needs of
53 the individual patient, the severity of the patient’s condition,
54 the services needed, and the complexity of providing those
55 services.
56 (c) Mandating the adoption of uniform, minimum, numerical,
57 and specific registered nurse-to-patient staffing ratios by
58 health care facilities is necessary for competent, safe,
59 therapeutic, and effective professional nursing care and for the
60 retention and recruitment of qualified direct care registered
61 nurses.
62 (d) Direct care registered nurses must be able to advocate
63 for their patients without fear of retaliation from their
64 employers. Whistle-blower protections that encourage registered
65 nurses and patients to notify governmental and private
66 accreditation entities of suspected unsafe patient conditions,
67 including protection against retaliation for refusing unsafe
68 patient care assignments, will greatly enhance the health,
69 safety, and welfare of patients.
70 (e) Direct care registered nurses have an irrevocable duty
71 and right to advocate on behalf of their patients’ interests,
72 and this duty and right may not be encumbered by cost-saving
73 practices.
74 (2) DEFINITIONS.—As used in this section, the term:
75 (a) “Acuity-based patient classification system” or
76 “patient classification system” means an established measurement
77 tool that:
78 1. Predicts registered nursing care requirements for
79 individual patients based on the severity of a patient’s
80 illness; the need for specialized equipment and technology; the
81 intensity of required nursing interventions; the complexity of
82 clinical nursing judgment required to design, implement, and
83 evaluate the patient nursing care plan consistent with
84 professional standards; the ability for self-care, including
85 motor, sensory, and cognitive deficits; and the need for
86 advocacy intervention;
87 2. Details the amount of nursing care needed and the
88 additional number of direct care registered nurses and other
89 licensed and unlicensed nursing staff that a health care
90 facility must assign, based on the independent professional
91 judgment of a direct care registered nurse, in order to meet the
92 needs of individual patients at all times; and
93 3. Can be readily understood and used by direct care
94 nursing staff.
95 (b) “Ancillary support staff” means the personnel assigned
96 to assist in providing nursing services for the delivery of
97 safe, therapeutic, and effective patient care, including unit or
98 ward clerks and secretaries, clinical technicians, respiratory
99 therapists, and radiology, laboratory, housekeeping, and dietary
100 personnel.
101 (c) “Clinical supervision” means the assignment and
102 direction of a patient care task required in the implementation
103 of nursing care for a patient to other licensed nursing staff or
104 to unlicensed staff by a direct care registered nurse in the
105 exclusive interest of the patient.
106 (d) “Competence” means the ability of a direct care
107 registered nurse to act and integrate the knowledge, skill,
108 abilities, and independent professional judgment that underpin
109 safe, therapeutic, and effective patient care.
110 (e) “Declared state of emergency” means an officially
111 designated state of emergency that has been declared by a
112 federal, state, or local government official who has the
113 authority to declare the state of emergency. The term does not
114 include a state of emergency that results from a labor dispute
115 in the health care industry.
116 (f) “Direct care registered nurse” means a licensed
117 registered nurse whose competence has been documented and who
118 has accepted a direct, hands-on patient care assignment to
119 implement medical and nursing regimens and provide related
120 clinical supervision of patient care while exercising
121 independent professional judgment at all times in the exclusive
122 interest of the patient.
123 (g) “Health care facility” means an acute care hospital,
124 including a long-term acute care hospital, a hospital-based off
125 campus emergency department, an ambulatory surgical center, or a
126 psychiatric facility licensed under chapter 394.
127 (h) “Hospital unit” or “clinical unit” means a critical
128 care unit or intensive care unit, labor and delivery room,
129 antepartum and postpartum unit, newborn nursery, postanesthesia
130 unit, emergency department, operating room, observation unit,
131 pediatric unit, medical-surgical unit, rehabilitation unit,
132 skilled nursing unit, specialty care unit, step-down unit or
133 intermediate intensive care unit, telemetry unit, or psychiatric
134 unit.
135 1. “Critical care unit” or “intensive care unit” means a
136 nursing unit established to safeguard and protect a patient
137 whose severity of medical condition requires continuous
138 monitoring and complex intervention by a direct care registered
139 nurse and whose restorative measures and level of nursing
140 intensity require intensive care through direct observation and
141 complex monitoring, intensive intricate assessment, evaluation,
142 specialized rapid intervention, and education or teaching of the
143 patient, the patient’s family, or other representatives by a
144 direct care registered nurse. The term includes a burn unit, a
145 coronary care unit, an acute respiratory unit, and other
146 critical care settings.
147 2. “Medical-surgical unit” means a unit established to
148 safeguard and protect a patient whose severity of illness,
149 including all co-occurring morbidities, restorative measures,
150 and level of required nursing intensity, requires continuous
151 care through direct observation by a direct care registered
152 nurse and monitoring, multiple assessments, specialized
153 interventions, evaluations, and education or teaching of the
154 patient, the patient’s family, or other representatives by a
155 competent and experienced direct care registered nurse. These
156 units may include patients requiring less than intensive care or
157 step-down care; patients receiving 24-hour inpatient general
158 medical care, postsurgical care, or both general medical and
159 postsurgical care; and mixed populations of patients of diverse
160 diagnoses and diverse age groups, but excluding pediatric
161 patients.
162 3. “Rehabilitation unit” means a functional clinical unit
163 established to provide rehabilitation services that restore an
164 ill or injured patient to the highest level of self-sufficiency
165 or gainful employment of which he or she is capable in the
166 shortest possible time, compatible with his or her physical,
167 intellectual, and emotional or psychological capabilities, and
168 in accordance with planned goals and objectives.
169 4. “Skilled nursing unit” means a functional clinical unit
170 established to provide skilled nursing care and supportive care
171 to patients whose primary need is for skilled nursing care on a
172 long-term basis and who are admitted after at least a 48-hour
173 period of continuous inpatient care. The term includes, but is
174 not limited to, a unit established to provide medical, nursing,
175 dietary, and pharmaceutical services and activity programs.
176 5. “Specialty care unit” means a unit established to
177 safeguard and protect a patient whose severity of illness,
178 including all co-occurring morbidities, restorative measures,
179 and level of required nursing intensity, requires direct
180 observation by a direct care registered nurse and monitoring,
181 multiple assessments, specialized interventions, evaluations,
182 and education or teaching of the patient, the patient’s family,
183 or other representatives by a competent and experienced direct
184 care registered nurse. The term includes, but is not limited to,
185 a unit, such as a transplant unit, established to provide the
186 intensity of care required for a specific medical condition or a
187 specific patient population or to provide more comprehensive
188 care for a specific condition or disease than the care required
189 in a medical-surgical unit.
190 6. “Step-down unit” or “intermediate intensive care unit”
191 means a unit established to safeguard and protect a patient
192 whose severity of illness, including all co-occurring
193 morbidities, restorative measures, and level of required nursing
194 intensity, requires intermediate intensive care through direct
195 observation and monitoring, multiple assessments, specialized
196 interventions, evaluations, and education or teaching of the
197 patient, the patient’s family, or other representatives by a
198 direct care registered nurse. The term includes units
199 established to provide care to patients who have moderate or
200 potentially severe physiological instability requiring technical
201 support, which means the use of specialized equipment by a
202 direct care registered nurse in providing for invasive
203 monitoring, telemetry, and mechanical ventilation for the
204 immediate amelioration or remediation of severe pathology for a
205 patient requiring less care than intensive care but more care
206 than that provided in a medical-surgical unit.
207 7. “Telemetry unit” means a unit established to safeguard
208 and protect a patient whose severity of illness, including all
209 co-occurring morbidities, restorative measures, and level of
210 nursing intensity, requires intermediate intensive care through
211 direct observation by a direct care registered nurse and
212 monitoring, multiple assessments, specialized interventions,
213 evaluations, and education or teaching of the patient, the
214 patient’s family, or other representatives by a competent and
215 experienced direct care registered nurse. A telemetry unit
216 includes the equipment used to provide for the electronic
217 monitoring, recording, retrieval, and display of cardiac
218 electrical signals.
219 (i) “Long-term acute care hospital” means a hospital or
220 health care facility that specializes in providing long-term
221 acute care for medically complex patients. The term includes a
222 freestanding hospital and a hospital-within-hospital model of a
223 long-term acute care facility.
224 (j) “Overtime” means the hours worked in excess of 40 hours
225 per week.
226 (k) “Patient assessment” means the process of actively and
227 skillfully interpreting, applying, analyzing, synthesizing, or
228 evaluating data obtained through direct observation and
229 communication with others.
230 (l) “Professional judgment” means the intellectual,
231 educated, informed, and experienced process that a direct care
232 registered nurse exercises in forming an opinion and reaching a
233 clinical decision that is in the patient’s best interest and is
234 based upon analysis of data, information, and scientific
235 evidence.
236 (3) MINIMUM DIRECT CARE REGISTERED NURSE STAFFING LEVEL
237 REQUIREMENTS.—
238 (a) Each health care facility shall implement a staffing
239 plan that provides for minimum direct care registered nurse
240 staffing levels in accordance with the requirements of this
241 subsection.
242 (b) Staffing levels for patient care tasks that do not
243 require a direct care registered nurse are not included within
244 these ratios and must be determined pursuant to an acuity-based
245 patient classification system defined by agency rule.
246 (c) The direct care registered nurse staffing levels
247 represent the maximum number of patients that may be assigned to
248 one direct care registered nurse at any one time.
249 (d) A health care facility:
250 1. May not average the number of patients and the total
251 number of direct care registered nurses assigned to patients in
252 a hospital unit or clinical unit during any period of time for
253 purposes of meeting the requirements under this subsection.
254 2. May not impose mandatory overtime in order to meet the
255 minimum direct care registered nurse staffing levels in a
256 hospital unit or clinical unit which are required under this
257 subsection.
258 3. May not terminate employment of or refuse to fill
259 vacancies for licensed practical nurses, licensed psychiatric
260 technicians, certified nursing assistants, or other ancillary
261 support staff in order to meet the direct care registered nurse
262 staffing levels in a hospital unit or clinical unit which are
263 required under this subsection.
264 4. Shall ensure that only a direct care registered nurse
265 may relieve another direct care registered nurse during breaks,
266 meals, and routine absences from a hospital unit or clinical
267 unit.
268 (e) Only a direct care registered nurse may be assigned to
269 an intensive care newborn nursery service unit. Such units must
270 have a direct care registered nurse staffing level of one nurse
271 to two or fewer infants at all times.
272 (f) Only a direct care registered nurse may be assigned to
273 a triage patient, and only a direct care registered nurse may be
274 assigned to a critical care patient in the emergency department.
275 1. The direct care registered nurse staffing level for
276 triage patients or critical care patients in the emergency
277 department must be one nurse to two or fewer patients at all
278 times.
279 2. At least two direct care registered nurses must be
280 physically present in the emergency department when a patient is
281 present.
282 3. Registered nurses providing triage, telehealth, private
283 duty, rapid response, or flight services do not count in the
284 calculation of direct care registered nurse staffing levels in
285 the emergency department.
286 4. Triage registered nurses may not be assigned the
287 responsibility of the base radio for the emergency department.
288 (g) Only direct care registered nurses may be assigned to a
289 labor and delivery unit.
290 1. The direct care registered nurse staffing level must be
291 one nurse to one active labor patient or to one patient having
292 medical or obstetrical complications during the initiation of
293 epidural anesthesia and during circulation for a caesarean
294 section delivery.
295 2. The direct care registered nurse staffing level for
296 antepartum patients who are not in active labor must be one
297 nurse to three or fewer patients at all times.
298 3. In the event of a caesarean section delivery, the direct
299 care registered nurse staffing level must be one nurse to two or
300 fewer mother-plus-infant couplets.
301 4. In the event of multiple births, the direct care
302 registered nurse staffing level must be one nurse to three or
303 fewer mother-plus-infant couplets.
304 5. The direct care registered nurse staffing level for
305 postpartum areas in which the direct care registered nurse’s
306 assignment only consists of mothers must be one nurse to four or
307 fewer patients at all times.
308 6. The direct care registered nurse staffing level for
309 postpartum patients or postsurgical gynecological patients must
310 be one nurse to four or fewer patients at all times.
311 7. The direct care registered nurse staffing level for the
312 well-baby nursery must be one nurse to five or fewer patients at
313 all times.
314 8. The direct care registered nurse staffing level for
315 unstable newborns and newborns in the resuscitation period, as
316 assessed by a direct care registered nurse, must be at least one
317 nurse to one patient at all times.
318 9. The direct care registered nurse staffing level for
319 newborn infants not otherwise described in this paragraph must
320 be one nurse to four or fewer patients at all times.
321 (h) The direct care registered nurse staffing level for
322 patients receiving conscious sedation must be at least one nurse
323 to one patient at all times.
324 (i) A health care facility’s staffing plan must provide
325 that, at all times during each shift within a unit of the
326 facility, a direct care registered nurse is assigned to no more
327 than:
328 1. One patient in a trauma emergency unit.
329 2. One patient in an operating room unit. The operating
330 room must have at least one direct care registered nurse
331 assigned to the duties of the circulating registered nurse and a
332 minimum of one additional person as a scrub assistant for each
333 patient-occupied operating room.
334 3. Two patients in a critical care unit, including neonatal
335 intensive care units, emergency critical care units, and
336 intensive care units; labor and delivery units; coronary care
337 units; acute respiratory care units; postanesthesia units,
338 regardless of the type of anesthesia received; and postpartum
339 units, so that the direct care registered nurse staffing level
340 is one nurse to two or fewer patients at all times.
341 4. Four patients in an emergency room unit, pediatrics
342 unit, telemetry unit, oncology unit, or combined labor,
343 delivery, and postpartum unit, so that the direct care
344 registered nurse staffing level is one nurse to four or fewer
345 patients at all times.
346 5. Three patients in a step-down unit or intermediate
347 intensive care unit so that the direct care registered nurse
348 staffing level is one nurse to three or fewer patients at all
349 times.
350 6. Four patients in a medical-surgical unit, antepartum
351 unit, intermediate care nursery unit, psychiatric unit, or
352 presurgical or other specialty care unit, so that the direct
353 care registered nurse staffing level is one nurse to four or
354 fewer patients at all times.
355 7. Five patients in a rehabilitation unit and skilled
356 nursing unit, so that the direct care registered nurse staffing
357 level is one nurse to five or fewer patients at all times.
358 (j) Identifying a hospital unit or clinical unit by a name
359 or term does not affect the requirement of direct care
360 registered nurse staffing level identified for the level of
361 intensity or type of care.
362 (k) Patients must be cared for only in hospital units or
363 clinical units in which the level of nursing intensity, type of
364 care, and direct care registered nurse staffing levels meet the
365 individual requirements and needs of each patient.
366 (l) A health care facility may not use a video camera or
367 monitor or any form of electronic visualization of a patient to
368 substitute for the direct observation required for patient
369 assessment by the direct care registered nurse or for patient
370 protection requiring an in-person attendant.
371 (m) The requirements established under this subsection do
372 not apply during a declared state of emergency if a health care
373 facility is requested or expected to provide an exceptional
374 level of emergency or other medical services.
375 (n) Any acuity-based patient classification system adopted
376 by a health care facility under this subsection must be
377 transparent in all respects, including disclosure of detailed
378 documentation of the methodology used to predict nursing
379 staffing; an identification of each factor, assumption, and
380 value used in applying such methodology; an explanation of the
381 scientific and empirical basis for each such assumption and
382 value; and certification by a knowledgeable and authorized
383 representative of the health care facility that the disclosures
384 regarding methods used for testing and validating the accuracy
385 and reliability of the system are true and complete.
386 (4) WHISTLE-BLOWER PROTECTIONS.—
387 (a) A health care facility may not:
388 1. Discharge, discriminate against, or retaliate against in
389 any manner, with respect to any aspect of employment, including
390 discharge, promotion, compensation, or terms, conditions, or
391 privileges of employment, a direct care registered nurse based
392 on the nurse’s refusal of a work assignment pursuant to this
393 section.
394 2. File a complaint or a report against a direct care
395 registered nurse with the Board of Nursing or the agency because
396 of the nurse’s refusal of a work assignment pursuant to this
397 section.
398 (b) A direct care registered nurse who has been discharged,
399 disciplined, discriminated against, or retaliated against in
400 violation of this section or against whom a complaint or a
401 report has been filed in violation of this section may bring a
402 cause of action in a state court and does not need to exhaust
403 any other cause of action to do so. A direct care registered
404 nurse who prevails in the cause of action is entitled to the
405 following:
406 1. Reinstatement.
407 2. Reimbursement of lost wages, compensation, and benefits.
408 3. Attorney fees.
409 4. Court costs.
410 5. Other damages.
411 (c) A direct care registered nurse, patient, or other
412 individual may file a complaint with the agency against a health
413 care facility that violates this section. For any complaint
414 filed, the agency shall:
415 1. Receive and investigate the complaint;
416 2. Determine whether a violation of this section as alleged
417 in the complaint has occurred; and
418 3. If such a violation has occurred, issue an order that
419 the complaining nurse, patient, or other individual not suffer
420 any retaliation.
421 (d) A health care facility may not discriminate or
422 retaliate in any manner against any patient, employee, or
423 contract employee of the facility, or any other individual, on
424 the basis that such individual, in good faith, individually or
425 in conjunction with another person or persons, has presented a
426 grievance or complaint; initiated or cooperated in an
427 investigation or proceeding by a governmental entity, regulatory
428 agency, or private accreditation body; made a civil claim or
429 demand; or filed an action relating to the care, services, or
430 conditions of the health care facility or of any affiliated or
431 related facilities. For purposes of this paragraph, an
432 individual is deemed to be acting in good faith if the
433 individual reasonably believes the information reported or
434 disclosed is true and that a violation of this section has
435 occurred or may occur.
436 (5) ENFORCEMENT.—
437 (a) In addition to any other penalties prescribed by law,
438 the agency may impose a civil penalty of up to $25,000 for each
439 violation of this section; however, the agency shall impose a
440 civil penalty of at least $25,000 for each such violation if the
441 agency determines that the health care facility has a pattern of
442 practice of such violation.
443 (b) The agency shall post on its website the names of
444 health care facilities against which civil penalties have been
445 imposed under this subsection and any other information the
446 agency deems necessary.
447 (6) COLLECTIVE BARGAINING AGREEMENTS.—If any provision of
448 this section is in conflict with any collective bargaining
449 agreement applying to employees covered by this section, the
450 terms and conditions of that collective bargaining agreement
451 prevail over this section, except when this section provides for
452 a lower ratio of patients to employee staffing. An employer may
453 not impose upon any unionized nursing staff or other unionized
454 staff any changes in wages, hours, or other terms and conditions
455 of employment pursuant to this section.
456 Section 3. This act shall take effect January 1, 2026.