Florida Senate - 2018                                     SB 638
       
       
        
       By Senator Campbell
       
       
       
       
       
       38-00082-18                                            2018638__
    1                        A bill to be entitled                      
    2         An act relating to delivery of nursing services;
    3         creating the “Florida Hospital Patient Protection
    4         Act”; creating s. 395.1014, F.S.; providing
    5         legislative findings; defining terms; requiring that
    6         each health care facility implement a staffing plan
    7         that provides minimum direct care registered nursing
    8         staffing levels; requiring a direct care registered
    9         nurse to demonstrate competence and to receive
   10         specified orientation before being assigned to a
   11         hospital or clinical unit; prohibiting a health care
   12         facility from imposing mandatory overtime and from
   13         engaging in certain other actions; providing
   14         requirements for the staffing plan; specifying the
   15         required ratios of direct care registered nurses to
   16         patients for each type of care provided; prohibiting a
   17         health care facility from using an acuity adjustable
   18         unit to care for a patient; prohibiting a health care
   19         facility from using video cameras or monitors as
   20         substitutes for the required level of care; providing
   21         an exception during a declared state of emergency;
   22         requiring that the chief nursing officer of a health
   23         care facility, or his or her designee, develop a
   24         staffing plan that meets the required direct care
   25         registered nurse staffing levels; requiring that a
   26         health care facility annually evaluate its actual
   27         direct care registered nurse staffing levels and
   28         update the staffing plan and acuity-based patient
   29         classification system; requiring that certain
   30         documentation be submitted to the Agency for Health
   31         Care Administration and be made available for public
   32         inspection; requiring that the agency approve uniform
   33         standards for use by health care facilities in
   34         establishing nurse staffing requirements by a
   35         specified date; providing requirements for the
   36         committee members who are appointed to develop the
   37         uniform standards; requiring health care facilities to
   38         annually report certain information to the agency and
   39         to post a notice containing such information in each
   40         unit of the facility; providing recordkeeping
   41         requirements; prohibiting a health care facility from
   42         assigning unlicensed personnel to perform functions or
   43         tasks that are performed by a licensed or registered
   44         nurse; specifying those actions that constitute
   45         professional practice by a direct care registered
   46         nurse; requiring that a patient assessment be
   47         performed only by a direct care registered nurse;
   48         authorizing a direct care registered nurse to assign
   49         certain specified activities to other licensed or
   50         unlicensed nursing staff under certain circumstances;
   51         prohibiting a health care facility from deploying
   52         technology that limits certain care provided by a
   53         direct care registered nurse; providing applicability;
   54         providing that it is a duty and right of a direct care
   55         registered nurse to act as the patient’s advocate;
   56         providing certain requirements with respect to such
   57         duty; prohibiting a direct care registered nurse from
   58         accepting an assignment under specified circumstances;
   59         authorizing a direct care registered nurse to refuse
   60         to accept an assignment or to perform a task under
   61         certain circumstances; requiring a direct care
   62         registered nurse to initiate action or to change a
   63         decision or an activity relating to a patient’s health
   64         care under certain circumstances; prohibiting a health
   65         care facility from discharging, or from
   66         discriminating, retaliating, or filing a complaint or
   67         report against, a direct care registered nurse based
   68         on such refusal; providing that a direct care
   69         registered nurse has a right of action against a
   70         health care facility that violates certain provisions;
   71         requiring that the agency establish a toll-free
   72         telephone hotline to provide information and to
   73         receive reports of certain violations; requiring that
   74         certain information be provided to each patient who is
   75         admitted to a health care facility; prohibiting a
   76         health care facility from engaging in certain actions;
   77         prohibiting a health care facility from interfering
   78         with the right of nurses to organize, bargain
   79         collectively, and engage in concerted activity under a
   80         federal act; authorizing the agency to impose fines
   81         for violations; requiring that the agency post on its
   82         website information regarding health care facilities
   83         on which civil penalties have been imposed; providing
   84         an effective date.
   85          
   86  Be It Enacted by the Legislature of the State of Florida:
   87  
   88         Section 1. Short title.—This act may be cited as the
   89  “Florida Hospital Patient Protection Act.”
   90         Section 2. Section 395.1014, Florida Statutes, is created
   91  to read:
   92         395.1014Health care facility patient care standards.—
   93         (1)LEGISLATIVE FINDINGS.—The Legislature finds that:
   94         (a)The state has a substantial interest in ensuring that,
   95  in the delivery of health care services to patients, health care
   96  facilities retain sufficient nursing staff so as to promote
   97  optimal health care outcomes.
   98         (b)Health care services are becoming more complex and it
   99  is increasingly difficult for patients to access integrated
  100  services. Competent, safe, therapeutic, and effective patient
  101  care is jeopardized because of staffing changes implemented in
  102  response to market-driven managed care. In order to ensure
  103  effective protection of patients in acute care settings, it is
  104  essential that qualified direct care registered nurses be
  105  accessible and available to meet the individual needs of the
  106  patient at all times. Also, in order to ensure the health and
  107  welfare of residents and to ensure that hospital nursing care is
  108  provided in the exclusive interests of patients, mandatory
  109  practice standards and professional practice protections for
  110  professional direct care registered nursing staff must be
  111  established. Direct care registered nurses have a duty to care
  112  for assigned patients and a necessary duty of individual and
  113  collective patient advocacy in order to satisfy professional
  114  obligations.
  115         (c)The basic principles of staffing in hospital settings
  116  should be based on the care needs of the individual patient, the
  117  severity of the patient’s condition, the services needed, and
  118  the complexity surrounding those services. Current unsafe
  119  practices by hospital direct care registered nursing staff have
  120  resulted in adverse patient outcomes. Mandating the adoption of
  121  uniform, minimum, numerical, and specific registered nurse-to
  122  patient staffing ratios by licensed hospital facilities is
  123  necessary for competent, safe, therapeutic, and effective
  124  professional nursing care and for the retention and recruitment
  125  of qualified direct care registered nurses.
  126         (d)Direct care registered nurses must be able to advocate
  127  for their patients without fear of retaliation from their
  128  employers. Whistle-blower protections that encourage registered
  129  nurses and patients to notify governmental and private
  130  accreditation entities of suspected unsafe patient conditions,
  131  including protection against retaliation for refusing unsafe
  132  patient care assignments, will greatly enhance the health,
  133  safety, and welfare of patients.
  134         (e)Direct care registered nurses have an irrevocable duty
  135  and right to advocate on behalf of their patients’ interests,
  136  and this duty and right may not be encumbered by cost-saving
  137  practices.
  138         (2)DEFINITIONS.—As used in this section, the term:
  139         (a)“Acuity-based patient classification system” or
  140  “patient classification system” means an established measurement
  141  tool that:
  142         1.Predicts registered nursing care requirements for
  143  individual patients based on the severity of a patient’s
  144  illness; the need for specialized equipment and technology; the
  145  intensity of required nursing interventions; the complexity of
  146  clinical nursing judgment required to design, implement, and
  147  evaluate the patient nursing care plan consistent with
  148  professional standards; the ability for self-care, including
  149  motor, sensory, and cognitive deficits; and the need for
  150  advocacy intervention;
  151         2.Details the amount of nursing care needed and the
  152  additional number of direct care registered nurses and other
  153  licensed and unlicensed nursing staff that the hospital must
  154  assign, based on the independent professional judgment of a
  155  direct care registered nurse, in order to meet the needs of
  156  individual patients at all times; and
  157         3.Can be readily understood and used by direct care
  158  nursing staff.
  159         (b)“Ancillary support staff” means the personnel assigned
  160  to assist in providing nursing services for the delivery of
  161  safe, therapeutic, and effective patient care, including unit or
  162  ward clerks and secretaries, clinical technicians, respiratory
  163  therapists, and radiology, laboratory, housekeeping, and dietary
  164  personnel.
  165         (c)“Clinical supervision” means the assignment and
  166  direction of a patient care task required in the implementation
  167  of nursing care for a patient to other licensed nursing staff or
  168  to unlicensed staff by a direct care registered nurse in the
  169  exclusive interest of the patient.
  170         (d)“Competence” means the ability of a direct care
  171  registered nurse to act and integrate the knowledge, skill,
  172  abilities, and independent professional judgment that underpin
  173  safe, therapeutic, and effective patient care.
  174         (e)“Declared state of emergency” means an officially
  175  designated state of emergency that has been declared by a
  176  federal, state, or local government official who has the
  177  authority to declare the state of emergency. The term does not
  178  include a state of emergency that results from a labor dispute
  179  in the health care industry.
  180         (f)“Direct care registered nurse” means a registered nurse
  181  or licensed practical nurse, as defined in s. 464.003:
  182         1.Who is licensed by the Board of Nursing to engage in the
  183  practice of professional nursing or the practice of practical
  184  nursing, as defined in s. 464.003;
  185         2. Whose competence has been documented; and
  186         3. Who has accepted a direct, hands-on patient care
  187  assignment to implement medical and nursing regimens and provide
  188  related clinical supervision of patient care while exercising
  189  independent professional judgment at all times in the exclusive
  190  interest of the patient.
  191         (g)“Health care facility unit” means an acute care
  192  hospital; an emergency care, ambulatory, or outpatient surgery
  193  facility licensed under this chapter; or a psychiatric facility
  194  licensed under chapter 394.
  195         (h)“Hospital unit” or “clinical unit” means an acuity
  196  adjustable unit, a critical care unit or intensive care unit,
  197  labor and delivery room, antepartum and postpartum unit, newborn
  198  nursery, postanesthesia unit, emergency department, operating
  199  room, pediatric unit, rehabilitation unit, skilled nursing unit,
  200  specialty care unit, step-down unit or intermediate intensive
  201  care unit, surgical unit, telemetry unit, or psychiatric unit.
  202         1.“Acuity adjustable unit” means a unit that adjusts a
  203  room’s technology, monitoring systems, and intensity of nursing
  204  care based on the severity of the patient’s condition.
  205         2.“Critical care unit” or “intensive care unit” means a
  206  nursing unit established to safeguard and protect a patient
  207  whose severity of medical condition requires continuous
  208  monitoring and complex intervention by a direct care registered
  209  nurse and whose restorative measures and level of nursing
  210  intensity require intensive care through direct observation by a
  211  direct care registered nurse and complex monitoring, intensive
  212  intricate assessment, evaluation, specialized rapid
  213  intervention, 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. The term includes a
  216  burn unit, a coronary care unit, or an acute respiratory unit.
  217         3.“Rehabilitation unit” means a functional clinical unit
  218  established to provide rehabilitation services that restore an
  219  ill or injured patient to the highest level of self-sufficiency
  220  or gainful employment of which he or she is capable in the
  221  shortest possible time, compatible with his or her physical,
  222  intellectual, and emotional or psychological capabilities, and
  223  in accordance with planned goals and objectives.
  224         4.“Skilled nursing unit” means a functional clinical unit
  225  established to provide skilled nursing care and supportive care
  226  to patients whose primary need is for skilled nursing care on a
  227  long-term basis and who are admitted after at least a 48-hour
  228  period of continuous inpatient care. The term includes, but is
  229  not limited to, a unit established to provide medical, nursing,
  230  dietary, and pharmaceutical services and activity programs.
  231         5.“Specialty care unit” means a unit established to
  232  safeguard and protect a patient whose severity of illness,
  233  including all co-occurring morbidities, restorative measures,
  234  and level of nursing intensity, requires continuous care through
  235  direct observation by a direct care registered nurse and
  236  monitoring, multiple assessments, specialized interventions,
  237  evaluations, and education or teaching of the patient, the
  238  patient’s family, or other representatives by a competent and
  239  experienced direct care registered nurse. The term includes, but
  240  is not limited to, a unit established to provide the intensity
  241  of care required for a specific medical condition or a specific
  242  patient population or to provide more comprehensive care for a
  243  specific condition or disease than the care required in a
  244  surgical unit.
  245         6.“Step-down unit” or “intermediate intensive care unit”
  246  means a unit established to safeguard and protect a patient
  247  whose severity of illness, including all co-occurring
  248  morbidities, restorative measures, and level of nursing
  249  intensity, requires intermediate intensive care through direct
  250  observation by a direct care registered nurse and monitoring,
  251  multiple assessments, specialized interventions, evaluations,
  252  and education or teaching of the patient, the patient’s family,
  253  or other representatives by a competent and experienced direct
  254  care registered nurse. The term includes units established to
  255  provide care to patients who have moderate or potentially severe
  256  physiological instability requiring technical support, but not
  257  necessarily artificial life support. As used in this
  258  subparagraph, the term:
  259         a.“Artificial life support” means a system that uses
  260  medical technology to aid, support, or replace a vital function
  261  of the body which has been seriously damaged.
  262         b.“Technical support” means the use of specialized
  263  equipment by a direct care registered nurse in providing for
  264  invasive monitoring, telemetry, and mechanical ventilation for
  265  the immediate amelioration or remediation of severe pathology
  266  for a patient requiring less care than intensive care, but more
  267  care than the care provided in a surgical unit.
  268         7.“Surgical unit” means a unit established to safeguard
  269  and protect a patient whose severity of illness, including all
  270  co-occurring morbidities, restorative measures, and level of
  271  nursing intensity, requires continuous care through direct
  272  observation by a direct care registered nurse and monitoring,
  273  multiple assessments, specialized interventions, evaluations,
  274  and education or teaching of the patient, the patient’s family,
  275  or other representatives by a competent and experienced direct
  276  care registered nurse. These units may include patients
  277  requiring less than intensive care or step-down care; patients
  278  receiving 24-hour inpatient general medical care, postsurgical
  279  care, or both general medical and postsurgical care; and mixed
  280  populations of patients of diverse diagnoses and diverse ages,
  281  but excluding pediatric patients.
  282         8.“Telemetry unit” means a unit established to safeguard
  283  and protect a patient whose severity of illness, including all
  284  co-occurring morbidities, restorative measures, and level of
  285  nursing intensity, requires intermediate intensive care through
  286  direct observation by a direct care registered nurse and
  287  monitoring, multiple assessments, specialized interventions,
  288  evaluations, and education or teaching of the patient, the
  289  patient’s family, or other representatives by a competent and
  290  experienced direct care registered nurse. A telemetry unit
  291  includes the equipment used to provide for the electronic
  292  monitoring, recording, retrieval, and display of cardiac
  293  electrical signals.
  294         (i)“Long-term acute care hospital” means a hospital or
  295  health care facility that specializes in providing long-term
  296  acute care to medically complex patients. The term includes a
  297  freestanding and hospital-within-hospital model of a long-term
  298  acute care facility.
  299         (j)“Overtime” means the hours worked in excess of:
  300         1.An agreed-upon, predetermined, regularly scheduled
  301  shift;
  302         2.Twelve hours in a 24-hour period; or
  303         3.Eighty hours in a 14-day period.
  304         (k)“Patient assessment” means the use of critical thinking
  305  by a direct care registered nurse and the intellectually
  306  disciplined process of actively and skillfully interpreting,
  307  applying, analyzing, synthesizing, or evaluating data obtained
  308  through direct observation and communication with others.
  309         (l)“Professional judgment” means the intellectual,
  310  educated, informed, and experienced process that a direct care
  311  registered nurse exercises in forming an opinion and reaching a
  312  clinical decision that is in the patient’s best interest and is
  313  based upon analysis of data, information, and scientific
  314  evidence.
  315         (m)“Skill mix” means the differences in licensing,
  316  specialty, and experience among direct care registered nurses.
  317         (3)MINIMUM DIRECT CARE REGISTERED NURSE STAFFING LEVEL
  318  REQUIREMENTS.—
  319         (a)A health care facility shall implement a staffing plan
  320  that provides for a minimum direct care registered nurse
  321  staffing level in accordance with the general requirements set
  322  forth in this subsection and the directed care registered nurse
  323  staffing levels in a clinical unit as specified in paragraph
  324  (b). Staffing levels for patient care tasks that do not require
  325  a direct care registered nurse are not included within these
  326  ratios and shall be determined pursuant to an acuity-based
  327  patient classification system defined by agency rule.
  328         1.A health care facility may not assign a direct care
  329  registered nurse to a clinical unit unless the health care
  330  facility and the direct care registered nurse determine that the
  331  nurse has demonstrated competence in providing care in the
  332  clinical unit and has also received orientation in the clinical
  333  unit’s area of specialty which is sufficient to provide
  334  competent, safe, therapeutic, and effective care to a patient in
  335  that area. The policies and procedures of the health care
  336  facility must contain the criteria for making this
  337  determination.
  338         2.The direct care registered nurse staffing levels
  339  represent the maximum number of patients that may be assigned to
  340  one direct care registered nurse at any one time.
  341         3.A health care facility:
  342         a.May not average the number of patients and the total
  343  number of direct care registered nurses assigned to patients in
  344  a hospital unit or clinical unit during any period for purposes
  345  of meeting the requirements under this subsection.
  346         b.May not impose mandatory overtime in order to meet the
  347  minimum direct care registered nurse staffing levels in the
  348  hospital unit or clinical unit which are required under this
  349  subsection.
  350         c.Shall ensure that only a direct care registered nurse
  351  may relieve another direct care registered nurse during breaks,
  352  meals, and routine absences from a hospital unit or clinical
  353  unit.
  354         d.May not lay off licensed practical nurses, licensed
  355  psychiatric technicians, certified nursing assistants, or other
  356  ancillary support staff in order to meet the direct care
  357  registered nurse staffing levels required in this subsection for
  358  a hospital unit or clinical unit.
  359         4.Only a direct care registered nurse may be assigned to
  360  an intensive care newborn nursery service unit, which
  361  specifically requires a direct care registered nurse staffing
  362  level of one nurse to two or fewer infants at all times.
  363         5.In the emergency department, only a direct care
  364  registered nurse may be assigned to a triage patient or a
  365  critical care patient.
  366         a.The direct care registered nurse staffing level for
  367  triage patients or critical care patients in the emergency
  368  department must be one nurse to two or fewer patients at all
  369  times.
  370         b.At least two direct care registered nurses must be
  371  physically present in the emergency department when a patient is
  372  present.
  373         c.Triage, radio, specialty, or flight registered nurses do
  374  not count in the calculation of direct care registered nurse
  375  staffing levels. Triage registered nurses may not be assigned
  376  the responsibility of the base radio.
  377         6.Only a direct care registered nurse may be assigned to a
  378  labor and delivery unit.
  379         a.The direct care registered nurse staffing level must be
  380  one nurse to one active labor patient, or one patient having
  381  medical or obstetrical complications, during the initiation of
  382  epidural anesthesia and during circulation for a caesarean
  383  section delivery.
  384         b.The direct care registered nurse staffing level for
  385  antepartum patients who are not in active labor must be one
  386  nurse to three or fewer patients at all times.
  387         c.In the event of a caesarean delivery, the direct care
  388  registered nurse staffing level must be one nurse to four or
  389  fewer mother-plus-infant couplets.
  390         d.In the event of multiple births, the direct care
  391  registered nurse staffing level must be one nurse to six or
  392  fewer mother-plus-infant couplets.
  393         e.The direct care registered nurse staffing level for
  394  postpartum areas in which the direct care registered nurse’s
  395  assignment consists of only mothers must be one nurse to four or
  396  fewer patients at all times.
  397         f.The direct care registered nurse staffing level for
  398  postpartum patients or postsurgical gynecological patients must
  399  be one nurse to four or fewer patients at all times.
  400         g.The direct care registered nurse staffing level for the
  401  well-baby nursery must be one nurse to five or fewer patients at
  402  all times.
  403         h.The direct care registered nurse staffing level for
  404  unstable newborns and newborns in the resuscitation period as
  405  assessed by a direct care registered nurse must be at least one
  406  nurse to one patient at all times.
  407         i.The direct care registered nurse staffing level for
  408  newborns must be one nurse to four or fewer patients at all
  409  times.
  410         7.The direct care registered nurse staffing level for
  411  patients receiving conscious sedation must be at least one nurse
  412  to one patient at all times.
  413         (b)A health care facility’s staffing plan must provide
  414  that, at all times during each shift within a unit of the
  415  facility, a direct care registered nurse is assigned to not more
  416  than:
  417         1.One patient in a trauma emergency unit;
  418         2.One patient in an operating room unit. The operating
  419  room must have at least one direct care registered nurse
  420  assigned to the duties of the circulating registered nurse and a
  421  minimum of one additional person as a scrub assistant for each
  422  patient-occupied operating room;
  423         3.Two patients in a critical care unit, including neonatal
  424  intensive care units; emergency critical care and intensive care
  425  units; labor and delivery units; coronary care units; acute
  426  respiratory care units; postanesthesia units, regardless of the
  427  type of anesthesia received; and postpartum units, so that the
  428  direct care registered nurse staffing level is one nurse to two
  429  or fewer patients at all times;
  430         4.Three patients in an emergency room unit; step-down unit
  431  or intermediate intensive care unit; pediatric unit; telemetry
  432  unit; or combined labor and postpartum unit so that the direct
  433  care registered nurse staffing level is one nurse to three or
  434  fewer patients at all times;
  435         5.Four patients in a surgical unit, antepartum unit,
  436  intermediate care nursery unit, psychiatric unit, or presurgical
  437  or other specialty care unit so that the direct care registered
  438  nurse staffing level is one nurse to four or fewer patients at
  439  all times;
  440         6.Five patients in a rehabilitation unit or skilled
  441  nursing unit so that the direct care registered nurse staffing
  442  level is one nurse to five or fewer patients at all times;
  443         7.Six patients in a well-baby nursery unit so that the
  444  direct care registered nurse staffing level is one nurse to six
  445  or fewer patients at all times; or
  446         8.Three mother-plus-infant couplets in a postpartum unit
  447  so that the direct care registered nurse staffing level is one
  448  nurse to three or fewer mother-plus-infant couplets at all
  449  times.
  450         (c)1.Identifying a hospital unit or clinical unit by a
  451  name or term other than those defined in subsection (2) does not
  452  affect the requirement of direct care registered nurse staffing
  453  levels identified for the level of intensity or type of care
  454  described in paragraphs (a) and (b).
  455         2.Patients shall be cared for only in hospital units or
  456  clinical units in which the level of intensity, type of care,
  457  and direct care registered nurse staffing levels meet the
  458  individual requirements and needs of each patient. A health care
  459  facility may not use an acuity adjustable unit to care for a
  460  patient.
  461         3.A health care facility may not use a video camera or
  462  monitor or any form of electronic visualization of a patient to
  463  substitute for the direct observation required for patient
  464  assessment by the direct care registered nurse and for patient
  465  protection provided by an attendant.
  466         (d)The requirements established under this subsection do
  467  not apply during a declared state of emergency if a health care
  468  facility is requested or expected to provide an exceptional
  469  level of emergency or other medical services.
  470         (e)The chief nursing officer or his or her designee shall
  471  develop a staffing plan for each hospital unit or clinical unit.
  472         1.The staffing plan must be in writing and, based on
  473  individual patient care needs determined by the acuity-based
  474  patient classification system, must specify individual patient
  475  care requirements and the staffing levels for direct care
  476  registered nurses and other licensed and unlicensed personnel.
  477  The direct care registered nurse staffing level on any shift may
  478  not fall below the requirements in paragraphs (a) and (b) at any
  479  time.
  480         2.In addition to the requirements of direct care
  481  registered nurse staffing levels in paragraphs (a) and (b), each
  482  health care facility shall assign additional nursing staff, such
  483  as licensed practical nurses, licensed psychiatric technicians,
  484  and certified nursing assistants, through the implementation of
  485  a valid acuity-based patient classification system for
  486  determining nursing care needs of individual patients which
  487  reflects the assessment of patient nursing care requirements
  488  made by the assigned direct care registered nurse and which
  489  provides for shift-by-shift staffing based on those
  490  requirements. The direct care registered nurse staffing levels
  491  specified in paragraphs (a) and (b) constitute the minimum
  492  number of direct care registered nurses who shall be assigned to
  493  provide direct patient care.
  494         3.In developing the staffing plan, a health care facility
  495  shall provide for direct care registered nurse staffing levels
  496  that are above the minimum levels required in paragraphs (a) and
  497  (b) based upon consideration of the following factors:
  498         a.The number of patients and acuity level of patients as
  499  determined by the application of a patient classification system
  500  on a shift-by-shift basis.
  501         b.The anticipated admissions, discharges, and transfers of
  502  patients during each shift which affect direct patient care.
  503         c.The specialized experience required of direct care
  504  registered nurses on a particular hospital unit or clinical
  505  unit.
  506         d.Staffing levels of other health care personnel who
  507  provide services for direct patient care needs that normally do
  508  not require care by a direct care registered nurse.
  509         e.The level of efficacy of technology that is available
  510  and that affects the delivery of direct patient care.
  511         f.The level of familiarity with hospital practices,
  512  policies, and procedures by a direct care registered nurse from
  513  a temporary agency during a shift.
  514         g.Obstacles to efficiency in the delivery of patient care
  515  caused by the physical layout of the health care facility.
  516         4.A health care facility shall specify the acuity-based
  517  patient classification system used to document actual staffing
  518  in each unit for each shift.
  519         5.A health care facility shall annually evaluate:
  520         a.The reliability of the acuity-based patient
  521  classification system for validating staffing requirements in
  522  order to determine whether the patient classification system
  523  accurately measures individual patient care needs and accurately
  524  predicts the staffing requirements for direct care registered
  525  nurses, licensed practical nurses, licensed psychiatric
  526  technicians, and certified nursing assistants, based exclusively
  527  on individual patient needs.
  528         b.The validity of the patient classification system.
  529         6.A health care facility shall annually update its
  530  staffing plan and acuity-based patient classification system to
  531  the extent appropriate based on the annual evaluation conducted
  532  under subparagraph 5. If the evaluation reveals that adjustments
  533  are necessary in order to ensure accuracy in measuring patient
  534  care needs, such adjustments must be implemented within 30 days
  535  after that determination.
  536         7.Any acuity-based patient classification system adopted
  537  by a health care facility under this subsection must be
  538  transparent in all respects, including disclosure of detailed
  539  documentation of the methodology used to predict nursing
  540  staffing; an identification of each factor, assumption, and
  541  value used in applying such methodology; an explanation of the
  542  scientific and empirical basis for each such assumption and
  543  value; and certification by a knowledgeable and authorized
  544  representative of the health care facility that the disclosures
  545  regarding methods used for testing and validating the accuracy
  546  and reliability of the patient classification system are true
  547  and complete.
  548         a.The documentation required by this subparagraph shall be
  549  submitted in its entirety to the agency as a mandatory condition
  550  of licensure, with a certification by the chief nursing officer
  551  of the health care facility that the documentation completely
  552  and accurately reflects implementation of a valid acuity-based
  553  patient classification system used to determine nursing service
  554  staffing by the facility for each shift on each hospital unit or
  555  clinical unit in which patients receive care. The chief nursing
  556  officer shall execute the certification under penalty of
  557  perjury, and the certification must contain an expressed
  558  acknowledgment that any false statement constitutes fraud and is
  559  subject to criminal and civil prosecution and penalties.
  560         b.Such documentation must be available for public
  561  inspection in its entirety in accordance with procedures
  562  established by administrative rules adopted by the agency,
  563  consistent with the purposes of this section.
  564         8.A staffing plan of a health care facility shall be
  565  developed and evaluated by a committee created by the health
  566  care facility. At least half of the members of the committee
  567  must be unit-specific competent direct care registered nurses.
  568         a.The chief nursing officer at the facility shall appoint
  569  the members who are not direct care registered nurses. The
  570  direct care registered nurses on the committee shall be
  571  appointed by the chief nursing officer if the direct care
  572  registered nurses are not represented by a collective bargaining
  573  agreement or by an authorized collective bargaining agent.
  574         b.In case of a dispute, the direct care registered nurse
  575  assessment shall prevail.
  576         c.This section does not authorize conduct that is
  577  prohibited under the National Labor Relations Act or the Federal
  578  Labor Relations Act of 1978.
  579         9.By July 1, 2019, the agency shall approve uniform
  580  statewide standards for a standardized acuity tool for use in
  581  health care facilities. The standardized acuity tool must
  582  provide a method for establishing nurse staffing requirements
  583  that exceed the required direct care registered nurse staffing
  584  levels in the hospital units or clinical units in paragraphs (a)
  585  and (b).
  586         a.The proposed standards shall be developed by a committee
  587  created by the health care facility consisting of up to 20
  588  members. At least 11 of the committee members must be currently
  589  licensed registered nurses who are employed as direct care
  590  registered nurses, and the remaining members must include a
  591  sufficient number of technical or scientific experts in the
  592  specialized fields who are involved in the design and
  593  development of an acuity-based patient classification system
  594  that meets the requirements of this section.
  595         b.A person who has any employment or any commercial,
  596  proprietary, financial, or other personal interest in the
  597  development, marketing, or use of a private patient
  598  classification system product or related methodology,
  599  technology, or component system is not eligible to serve on the
  600  development committee. A candidate for appointment to the
  601  development committee may not be confirmed as a member until the
  602  candidate files a disclosure-of-interest statement with the
  603  agency, along with a signed certification of full disclosure and
  604  complete accuracy under oath, which provides all necessary
  605  information as determined by the agency to demonstrate the
  606  absence of actual or potential conflict of interest. All such
  607  filings are subject to public inspection.
  608         c.Within 1 year after the official commencement of
  609  committee operations, the development committee shall provide a
  610  written report to the agency which proposes uniform standards
  611  for a valid patient classification system, along with sufficient
  612  explanation and justification to allow for competent review and
  613  determination of sufficiency by the agency. The agency shall
  614  disclose the report to the public upon notice of public hearings
  615  and provide a public comment period for proposed adoption of
  616  uniform standards for a patient classification system by the
  617  agency.
  618         10.A hospital shall adopt and implement the acuity-based
  619  patient classification system and provide staffing based on the
  620  standardized acuity tool. Any additional direct care registered
  621  nurse staffing level that exceeds the direct care registered
  622  nurse staffing levels described in paragraphs (a) and (b) shall
  623  be assigned in a manner determined by such standardized acuity
  624  tool.
  625         11.A health care facility shall submit to the agency its
  626  annually updated staffing plan and acuity-based patient
  627  classification system as required under this paragraph.
  628         (f)1.In each hospital unit or clinical unit, a health care
  629  facility shall post a notice in a form specified by agency rule
  630  which:
  631         a.Explains the requirements imposed under this subsection;
  632         b.Includes actual direct care registered nurse staffing
  633  levels during each shift at the hospital unit or clinical unit;
  634         c.Is visible, conspicuous, and accessible to staff and
  635  patients of the hospital unit or clinical unit and the public;
  636         d.Identifies staffing requirements as determined by the
  637  acuity-based patient classification system for each hospital
  638  unit or clinical unit, documented and posted in the unit for
  639  public view on a day-to-day, shift-by-shift basis;
  640         e.Documents the actual number of staff and the skill mix
  641  at each hospital unit or clinical unit, documented and posted in
  642  the unit for public view on a day-to-day, shift-by-shift basis;
  643  and
  644         f.Reports the variance between the required and actual
  645  staffing patterns at each hospital unit or clinical unit,
  646  documented and posted in the unit for public view on a day-to
  647  day, shift-by-shift basis.
  648         2.a.A long-term acute care hospital shall maintain
  649  accurate records of actual staffing levels in each hospital unit
  650  or clinical unit for each shift for at least 2 years. Such
  651  records must include:
  652         (I)The number of patients in each unit;
  653         (II)The identity and duty hours of each direct care
  654  registered nurse, licensed practical nurse, licensed psychiatric
  655  technician, and certified nursing assistant assigned to each
  656  patient in the hospital unit or clinical unit for each shift;
  657  and
  658         (III)A copy of each posted notice.
  659         b.A health care facility shall make its staffing plan and
  660  acuity-based patient classification system, required under
  661  paragraph (e), and all documentation related to the plan and
  662  patient classification system, available to the agency; to
  663  registered nurses and their collective bargaining
  664  representatives, if any; and to the public under rules adopted
  665  by the agency.
  666         3.The agency shall conduct periodic audits to ensure
  667  implementation of the staffing plan in accordance with this
  668  subsection and to ensure the accuracy of the staffing plan and
  669  patient classification system required under paragraph (e).
  670         (g)A health care facility shall plan for routine
  671  fluctuations such as admissions, discharges, and transfers in
  672  the patient census. If a declared health care emergency causes a
  673  change in the number of patients in a unit, the health care
  674  facility must demonstrate that immediate and diligent efforts
  675  are made to maintain required staffing levels.
  676         (h)The following activities are prohibited:
  677         1.The direct assignment of unlicensed personnel by a
  678  health care facility to perform functions required of a
  679  registered nurse in lieu of care being delivered by a licensed
  680  or registered nurse under the clinical supervision of a direct
  681  care registered nurse.
  682         2.The performance of tasks by unlicensed personnel which
  683  require the clinical assessment, judgment, and skill of a
  684  licensed or registered nurse, including, but not limited to:
  685         a.Nursing activities that require nursing assessment and
  686  judgment during implementation;
  687         b.Physical, psychological, or social assessments that
  688  require nursing judgment, intervention, referral, or followup;
  689  and
  690         c.Formulation of a plan of nursing care and evaluation of
  691  a patient’s response to the care provided, including
  692  administration of medication; venipuncture or intravenous
  693  therapy; parenteral or tube feedings; invasive procedures,
  694  including inserting nasogastric tubes, inserting catheters, or
  695  tracheal suctioning; and educating a patient and the patient’s
  696  family concerning the patient’s health care problems, including
  697  postdischarge care. However, a phlebotomist, an emergency room
  698  technician, or a medical technician may, under the general
  699  supervision of the clinical laboratory director, or his or her
  700  designee, or a physician, perform venipunctures in accordance
  701  with written hospital policies and procedures.
  702         (4)PROFESSIONAL PRACTICE STANDARDS FOR DIRECT CARE
  703  REGISTERED NURSES WORKING IN A HEALTH CARE FACILITY.—
  704         (a)A direct care registered nurse employing scientific
  705  knowledge and experience in the physical, social, and biological
  706  sciences, and exercising independent judgment in applying the
  707  nursing process, shall directly provide:
  708         1.Continuous and ongoing assessments of the patient’s
  709  condition.
  710         2.The planning, clinical supervision, implementation, and
  711  evaluation of the nursing care to each patient.
  712         3.The assessment, planning, implementation, and evaluation
  713  of patient education, including ongoing postdischarge education
  714  of each patient.
  715         4.The delivery of patient care, which must reflect all
  716  elements of the nursing process and must include assessment,
  717  nursing diagnosis, planning, intervention, evaluation, and, as
  718  circumstances require, patient advocacy, and shall be initiated
  719  by a direct care registered nurse at the time of admission.
  720         5.The nursing plan for the patient care, which shall be
  721  discussed with and developed as a result of coordination with
  722  the patient, the patient’s family or other representatives, when
  723  appropriate, and staff of other disciplines involved in the care
  724  of the patient.
  725         6.An evaluation of the effectiveness of the care plan
  726  through assessments based on direct observation of the patient’s
  727  physical condition and behavior, signs and symptoms of illness,
  728  and reactions to treatment and through communication with the
  729  patient and the health care team members, and modification of
  730  the plan as needed.
  731         7.Information related to the initial assessment and
  732  reassessments of the patient, nursing diagnosis, plan,
  733  intervention, evaluation, and patient advocacy, which shall be
  734  permanently recorded in the patient’s medical record as
  735  narrative direct care progress notes. The practice of charting
  736  by exception is prohibited.
  737         (b)1.A patient assessment requires direct observation of
  738  the patient’s signs and symptoms of illness, reaction to
  739  treatment, behavior and physical condition, and interpretation
  740  of information obtained from the patient and others, including
  741  other caregivers on the health care team. A patient assessment
  742  requires data collection by a direct care registered nurse and
  743  the analysis, synthesis, and evaluation of such data.
  744         2.Only a direct care registered nurse may perform a
  745  patient assessment. A licensed practical nurse or licensed
  746  psychiatric technician may assist a direct care registered nurse
  747  in data collection.
  748         (c)1.A direct care registered nurse shall determine the
  749  nursing care needs of individual patients through the process of
  750  ongoing patient assessments, nursing diagnosis, formulation, and
  751  adjustment of nursing care plans.
  752         2.The prediction of individual patient nursing care needs
  753  for prospective assignment of direct care registered nurses
  754  shall be based on individual patient assessments of the direct
  755  care registered nurse assigned to each patient and in accordance
  756  with a documented acuity-based patient classification system as
  757  provided in subsection (3).
  758         (d)Competent performance of the essential functions of a
  759  direct care registered nurse as provided in this section
  760  requires the exercise of independent judgment in the interest of
  761  the patient. A direct care registered nurse’s independent
  762  judgment while performing the functions described in this
  763  section shall be provided in the exclusive interests of the
  764  patient and may not, for any purpose, be considered, relied
  765  upon, or represented as a job function, authority,
  766  responsibility, or activity undertaken in any respect for the
  767  purpose of serving the business, commercial, operational, or
  768  other institutional interests of the health care facility
  769  employer.
  770         (e)1.In addition to the prohibition on assignments of
  771  patient care tasks provided in paragraph (3)(h), a direct care
  772  registered nurse may not assign tasks required to implement
  773  nursing care for a patient to other licensed nursing staff or to
  774  unlicensed staff unless the assigning direct care registered
  775  nurse:
  776         a.Determines that the personnel assigned the tasks possess
  777  the necessary training, experience, and capability to
  778  competently and safely perform the tasks to be assigned; and
  779         b.Effectively supervises the clinical functions and
  780  nursing care tasks performed by the assigned personnel.
  781         2.The exercise of clinical supervision of nursing care
  782  personnel by a direct care registered nurse in the performance
  783  of the functions as provided in this subsection must be in the
  784  exclusive interest of the patient and may not, for any purpose,
  785  be considered, relied upon, or represented as a job function,
  786  authority, responsibility, or activity undertaken in any respect
  787  for the purpose of serving the business, commercial,
  788  operational, or other institutional interests of the health care
  789  facility employer, but constitutes the exercise of professional
  790  nursing authority and duty exclusively in the interest of the
  791  patient.
  792         (f)A health care facility may not deploy technology that
  793  limits the direct care provided by a direct care registered
  794  nurse in the performance of functions that are part of the
  795  nursing process, including the full exercise of independent
  796  professional judgment in the assessment, planning,
  797  implementation, and evaluation of care, or that limits a direct
  798  care registered nurse from acting as a patient advocate in the
  799  exclusive interest of the patient. Technology may not be skill
  800  degrading, interfere with the direct care registered nurse’s
  801  provision of individualized patient care, or override the direct
  802  care registered nurse’s independent professional judgment.
  803         (g)This subsection applies only to direct care registered
  804  nurses employed by or providing care in a health care facility.
  805         (5)DIRECT CARE REGISTERED NURSE’S DUTY AND RIGHT OF
  806  PATIENT ADVOCACY.—
  807         (a)A direct care registered nurse has a duty and right to
  808  act and provide care in the exclusive interest of the patient
  809  and to act as the patient’s advocate.
  810         (b)A direct care registered nurse shall always provide
  811  competent, safe, therapeutic, and effective nursing care to an
  812  assigned patient.
  813         1.Before accepting a patient assignment, a direct care
  814  registered nurse must have the necessary knowledge, judgment,
  815  skills, and ability to provide the required care. It is the
  816  responsibility of the direct care registered nurse to determine
  817  whether he or she is clinically competent to perform the nursing
  818  care required by patients who are in a particular clinical unit
  819  or who have a particular diagnosis, condition, prognosis, or
  820  other determinative characteristic of nursing care, and whether
  821  acceptance of a patient assignment would expose the patient to
  822  the risk of harm.
  823         2.If the direct care registered nurse is not competent to
  824  perform the care required for a patient assigned for nursing
  825  care or if the assignment would expose the patient to risk of
  826  harm, the direct care registered nurse may not accept the
  827  patient care assignment. Such refusal to accept a patient care
  828  assignment is an exercise of the direct care registered nurse’s
  829  duty and right of patient advocacy.
  830         (c)A direct care registered nurse may refuse to accept an
  831  assignment as a nurse in a health care facility if:
  832         1.The assignment would violate a provision of chapter 464
  833  or the rules adopted under that chapter;
  834         2.The assignment would violate subsection (3), subsection
  835  (4), or this subsection; or
  836         3.The direct care registered nurse is not prepared by
  837  education, training, or experience to fulfill the assignment
  838  without compromising the safety of a patient or jeopardizing the
  839  license of the direct care registered nurse.
  840         (d)A direct care registered nurse may refuse to perform an
  841  assigned task as a nurse in a health care facility if:
  842         1.The assigned task would violate a provision of chapter
  843  464 or the rules adopted under that chapter;
  844         2.The assigned task is outside the scope of practice of
  845  the direct care registered nurse; or
  846         3.The direct care registered nurse is not prepared by
  847  education, training, or experience to fulfill the assigned task
  848  without compromising the safety of a patient or jeopardizing the
  849  license of the direct care registered nurse.
  850         (e)In the course of performing the responsibilities and
  851  essential functions described in subsection (4), the direct care
  852  registered nurse assigned to a patient shall receive orders
  853  initiated by physicians and other legally authorized health care
  854  professionals within their scope of licensure regarding patient
  855  care services to be provided to the patient, including, but not
  856  limited to, the administration of medications and therapeutic
  857  agents that are necessary to implement a treatment, a
  858  rehabilitative regimen, or disease prevention.
  859         1.The direct care registered nurse shall assess each such
  860  order before implementation to determine if the order is:
  861         a.In the best interest of the patient;
  862         b.Initiated by a person legally authorized to issue the
  863  order; and
  864         c.Issued in accordance with applicable law and rules
  865  governing nursing care.
  866         2.If the direct care registered nurse determines that the
  867  criteria provided in subparagraph 1. have not been satisfied
  868  with respect to a particular order or if the direct care
  869  registered nurse has some doubt regarding the meaning or
  870  conformance of the order with such criteria, he or she shall
  871  seek clarification from the initiator of the order, the
  872  patient’s physician, or another appropriate medical officer
  873  before implementing the order.
  874         3.If, upon clarification, the direct care registered nurse
  875  determines that the criteria for implementation of an order
  876  provided in subparagraph 1. have not been satisfied, the direct
  877  care registered nurse may refuse implementation on the basis
  878  that the order is not in the best interest of the patient.
  879  Seeking clarification of an order or refusing an order as
  880  described in this subparagraph is an exercise of the direct care
  881  registered nurse’s duty and right of patient advocacy.
  882         (f)A direct care registered nurse shall, as circumstances
  883  require, initiate action to improve the patient’s health care or
  884  to change a decision or activity that, in the professional
  885  judgment of the direct care registered nurse, is against the
  886  interest or desire of the patient or shall give the patient the
  887  opportunity to make informed decisions about the health care
  888  before it is provided.
  889         (6)FREE SPEECH; PATIENT PROTECTION.—
  890         (a)A health care facility may not:
  891         1.Discharge, discriminate against, or retaliate against in
  892  any manner with respect to any aspect of employment, including
  893  discharge, promotion, compensation, or terms, conditions, or
  894  privileges of employment, a direct care registered nurse based
  895  on the direct care registered nurse’s refusal of a work
  896  assignment pursuant to paragraph (5)(c) or an assigned task
  897  pursuant to paragraph (5)(d).
  898         2.File a complaint or a report against a direct care
  899  registered nurse with the Board of Nursing or the agency because
  900  of the direct care registered nurse’s refusal of a work
  901  assignment pursuant to paragraph (5)(c) or an assigned task
  902  pursuant to paragraph (5)(d).
  903         (b)A direct care registered nurse who has been discharged,
  904  discriminated against, or retaliated against in violation of
  905  subparagraph (a)1. or against whom a complaint or a report has
  906  been filed in violation of subparagraph (a)2. may bring a cause
  907  of action in a state court. A direct care registered nurse who
  908  prevails in the cause of action is entitled to one or more of
  909  the following:
  910         1.Reinstatement.
  911         2.Reimbursement of lost wages, compensation, and benefits.
  912         3.Attorney fees.
  913         4.Court costs.
  914         5.Other damages.
  915         (c)A direct care registered nurse, a patient, or any other
  916  individual may file a complaint with the agency against a health
  917  care facility that violates this section. For any complaint
  918  filed, the agency shall:
  919         1.Receive and investigate the complaint;
  920         2.Determine whether a violation of this section as alleged
  921  in the complaint has occurred; and
  922         3.If such a violation has occurred, issue an order
  923  prohibiting the health care facility from subjecting the
  924  complaining direct care registered nurse, the patient, or the
  925  other individual to any retaliation described in paragraph (a).
  926         (d)1.A health care facility may not discriminate or
  927  retaliate in any manner against any patient, employee, or
  928  contract employee of the facility, or any other individual, on
  929  the basis that such individual, in good faith, individually or
  930  in conjunction with another person or persons, has presented a
  931  grievance or complaint; initiated or cooperated in an
  932  investigation or proceeding by a governmental entity, regulatory
  933  agency, or private accreditation body; made a civil claim or
  934  demand; or filed an action relating to the care, services, or
  935  conditions of the health care facility or of any affiliated or
  936  related facilities.
  937         2.For purposes of this paragraph, an individual is deemed
  938  to be acting in good faith if the individual reasonably believes
  939  that the information reported or disclosed is true.
  940         (e)1.A health care facility may not:
  941         a.Interfere with, restrain, or deny the exercise of, or
  942  the attempt to exercise, any right provided or protected under
  943  this section; or
  944         b.Coerce or intimidate any person regarding the exercise
  945  of, or the attempt to exercise, such right.
  946         2.A health care facility may not discriminate or retaliate
  947  against any person for opposing any facility policy, practice,
  948  or action that is alleged to violate, breach, or fail to comply
  949  with any provision of this section.
  950         3.A health care facility, or an individual representing a
  951  health care facility, may not make, adopt, or enforce any rule,
  952  regulation, policy, or practice that in any manner directly or
  953  indirectly prohibits, impedes, or discourages a direct care
  954  registered nurse from engaging in free speech or disclosing
  955  information as provided under this section.
  956         4.A health care facility, or an individual representing a
  957  health care facility, may not in any way interfere with the
  958  rights of nurses to organize, bargain collectively, and engage
  959  in concerted activity under s. 7 of the National Labor Relations
  960  Act.
  961         5.A health care facility shall post in an appropriate
  962  location in each hospital unit or clinical unit a notice in a
  963  form specified by the agency which:
  964         a.Explains the rights of nurses, patients, and other
  965  individuals under this subsection;
  966         b.Includes a statement that a nurse, patient, or other
  967  individual may file a complaint with the agency against a health
  968  care facility that violates this subsection; and
  969         c.Provides instructions on how to file a complaint.
  970         (f)1.The agency shall establish a toll-free telephone
  971  hotline to provide information regarding the requirements of
  972  this section and to receive reports of violations of this
  973  section.
  974         2.A health care facility shall provide each patient
  975  admitted to the facility for inpatient care with the toll-free
  976  telephone hotline described in subparagraph 1. and shall give
  977  notice to each patient that the hotline may be used to report
  978  inadequate staffing or care.
  979         (7)ENFORCEMENT.—
  980         (a)In addition to any other penalty prescribed by law, the
  981  agency may impose civil penalties as follows:
  982         1.Against a health care facility found to have violated a
  983  provision of this section, a civil penalty of up to $25,000 for
  984  each violation, except that the agency shall impose a civil
  985  penalty of at least $25,000 for each violation if the agency
  986  determines that the health care facility has a pattern of
  987  practice of such violation.
  988         2.Against an individual who is employed by a health care
  989  facility and who is found to have violated a provision of this
  990  section, a civil penalty of up to $20,000 for each violation.
  991         (b)The agency shall post on its website the names of
  992  health care facilities against which civil penalties have been
  993  imposed under this subsection and such additional information as
  994  the agency deems necessary.
  995         Section 3. This act shall take effect July 1, 2018.