Florida Senate - 2017 SB 1754 By Senator Campbell 38-01417-17 20171754__ 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 6 minimum direct care registered nurse staffing levels 7 in a health care facility; requiring that each health 8 care facility implement a staffing plan; prohibiting a 9 health care facility from imposing mandatory overtime 10 and certain other actions; specifying the required 11 ratios of direct care registered nurses to patients 12 for each type of care provided; prohibiting a health 13 care facility from using an acuity adjustable unit to 14 care for a patient; prohibiting a health care facility 15 from using video cameras or monitors as substitutes 16 for the required level of care; providing an exception 17 during a declared state of emergency; requiring that 18 the chief nursing officer of a health care facility, 19 or his or her designee, prepare a written staffing 20 plan that meets the direct care registered nurse 21 staffing levels required by the act; requiring that a 22 health care facility annually evaluate its actual 23 direct care registered nurse staffing levels and 24 update the staffing plan based on the evaluation; 25 requiring that certain documentation be submitted to 26 the Agency for Health Care Administration and be made 27 available for public inspection; requiring that the 28 agency develop uniform standards for use by health 29 care facilities in establishing nurse staffing 30 requirements; providing requirements for the committee 31 members who are appointed to develop the uniform 32 standards; requiring health care facilities to 33 annually report certain information to the agency and 34 post a notice containing such information in each unit 35 of the facility; prohibiting a health care facility 36 from assigning unlicensed personnel to perform 37 functions or tasks that are performed by a licensed or 38 registered nurse; specifying those actions that 39 constitute professional practice by a direct care 40 registered nurse; requiring that a patient assessment 41 be performed only by a direct care registered nurse; 42 authorizing a direct care registered nurse to assign 43 certain specified activities to other licensed or 44 unlicensed nursing staff; prohibiting a health care 45 facility from deploying technology that limits certain 46 care provided by a direct care registered nurse; 47 providing that it is a duty and right of a direct care 48 registered nurse to act as the patient’s advocate; 49 providing certain requirements with respect to such 50 duty; authorizing a direct care registered nurse to 51 refuse to perform certain activities if he or she 52 determines that it is not in the best interest of the 53 patient; authorizing a direct care registered nurse to 54 refuse an assignment under certain circumstances; 55 prohibiting a health care facility from discharging, 56 discriminating against, or retaliating against a nurse 57 based on such refusal; providing that a direct care 58 registered nurse has a right of action against a 59 health care facility that violates certain provisions 60 of the act; requiring that the agency establish a 61 toll-free telephone hotline to provide information and 62 to receive reports of violations of the act; requiring 63 that certain information be provided to each patient 64 who is admitted to a health care facility; prohibiting 65 a 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, 123 and 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 for the delivery of 148 safe, therapeutic, and effective patient care, including unit or 149 ward 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 that 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 that 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) “Unit” means an acute care hospital; an emergency care, 175 ambulatory, or outpatient surgery facility licensed under this 176 chapter; or a psychiatric facility licensed under chapter 394. 177 (h) “Hospital unit” or “clinical unit” means a critical 178 care or intensive care unit, labor and delivery room, antepartum 179 and postpartum unit, newborn nursery, postanesthesia unit, 180 emergency department, operating room, pediatric unit, surgical 181 unit, rehabilitation unit, skilled nursing unit, specialty care 182 unit, step-down unit or intermediate intensive care unit, 183 telemetry unit, or psychiatric unit. 184 1. “Acuity adjustable unit” means a unit that adjusts a 185 room’s technology, monitoring systems, and intensity of nursing 186 care based on the severity of the patient’s condition. 187 2. “Critical care unit” or “intensive care unit” means a 188 nursing unit established to safeguard and protect a patient 189 whose severity of medical condition requires continuous 190 monitoring and complex intervention by a direct care registered 191 nurse and whose restorative measures and level of nursing 192 intensity require intensive care through direct observation by a 193 direct care registered nurse and complex monitoring, intensive 194 intricate assessment, evaluation, specialized rapid 195 intervention, and education or teaching of the patient, the 196 patient’s family, or other representatives by a competent and 197 experienced direct care registered nurse. The term includes a 198 burn unit, a coronary care unit, or an acute respiratory unit. 199 3. “Rehabilitation unit” means a functional clinical unit 200 established to provide rehabilitation services that restore an 201 ill or injured patient to the highest level of self-sufficiency 202 or gainful employment of which he or she is capable in the 203 shortest possible time, compatible with his or her physical, 204 intellectual, and emotional or psychological capabilities, and 205 in accordance with planned goals and objectives. 206 4. “Skilled nursing unit” means a functional clinical unit 207 established to provide skilled nursing care and supportive care 208 to patients whose primary need is for skilled nursing care on a 209 long-term basis and who are admitted after at least a 48-hour 210 period of continuous inpatient care. The term includes, but is 211 not limited to, a unit established to provide medical, nursing, 212 dietary, and pharmaceutical services and activity programs. 213 5. “Specialty care unit” means a unit established to 214 safeguard and protect a patient whose severity of illness, 215 including all co-occurring morbidities, restorative measures, 216 and level of nursing intensity, requires continuous care through 217 direct observation by a direct care registered nurse and 218 monitoring, multiple assessments, specialized interventions, 219 evaluations, and education or teaching of the patient, the 220 patient’s family, or other representatives by a competent and 221 experienced direct care registered nurse. The term includes, but 222 is not limited to, a unit established to provide the intensity 223 of care required for a specific medical condition or a specific 224 patient population or to provide more comprehensive care for a 225 specific condition or disease than the care required in a 226 surgical unit. 227 6. “Step-down unit” or “intermediate intensive care unit” 228 means a unit established to safeguard and protect a patient 229 whose severity of illness, including all co-occurring 230 morbidities, restorative measures, and level of nursing 231 intensity, requires intermediate intensive care through direct 232 observation by a direct care registered nurse and monitoring, 233 multiple assessments, specialized interventions, evaluations, 234 and education or teaching of the patient, the patient’s family, 235 or other representatives by a competent and experienced direct 236 care registered nurse. The term includes units established to 237 provide care to patients who have moderate or potentially severe 238 physiological instability requiring technical support, but not 239 necessarily artificial life support. As used in this 240 subparagraph, the term: 241 a. “Artificial life support” means a system that uses 242 medical technology to aid, support, or replace a vital function 243 of the body which has been seriously damaged. 244 b. “Technical support” means the use of specialized 245 equipment by a direct care registered nurse in providing for 246 invasive monitoring, telemetry, and mechanical ventilation for 247 the immediate amelioration or remediation of severe pathology 248 for a patient requiring less care than intensive care, but more 249 care than the care provided in a surgical unit. 250 7. “Surgical unit” means a unit established to safeguard 251 and protect a patient whose severity of illness, including all 252 co-occurring morbidities, restorative measures, and level of 253 nursing intensity, requires continuous care through direct 254 observation by a direct care registered nurse and monitoring, 255 multiple assessments, specialized interventions, evaluations, 256 and education or teaching of the patient, the patient’s family, 257 or other representatives by a competent and experienced direct 258 care registered nurse. These units may include patients 259 requiring less than intensive care or step-down care; patients 260 receiving 24-hour inpatient general medical care, postsurgical 261 care, or both general medical and postsurgical care; and mixed 262 populations of patients of diverse diagnoses and diverse age 263 groups, but excluding pediatric patients. 264 8. “Telemetry unit” means a unit established to safeguard 265 and protect a patient whose severity of illness, including all 266 co-occurring morbidities, restorative measures, and level of 267 nursing intensity, requires intermediate intensive care through 268 direct observation by a direct care registered nurse and 269 monitoring, multiple assessments, specialized interventions, 270 evaluations, and education or teaching of the patient, the 271 patient’s family, or other representatives by a competent and 272 experienced direct care registered nurse. A telemetry unit 273 includes the equipment used to provide for the electronic 274 monitoring, recording, retrieval, and display of cardiac 275 electrical signals. 276 (i) “Licensed nurse” means a registered nurse or a licensed 277 practical nurse, as defined in s. 464.003, who is licensed by 278 the Board of Nursing to engage in the practice of professional 279 nursing or the practice of practical nursing, as defined in s. 280 464.003. 281 (j) “Long-term acute care hospital” means a hospital or 282 health care facility that specializes in providing long-term 283 acute care to medically complex patients. The term includes a 284 freestanding and hospital-within-hospital model of a long-term 285 acute care facility. 286 (k) “Overtime” means the hours worked in excess of: 287 1. An agreed-upon, predetermined, regularly scheduled 288 shift; 289 2. Twelve hours in a 24-hour period; or 290 3. Eighty hours in a 14-day period. 291 (l) “Patient assessment” means the use of critical thinking 292 by a direct care licensed nurse and the intellectually 293 disciplined process of actively and skillfully interpreting, 294 applying, analyzing, synthesizing, or evaluating data obtained 295 through direct observation and communication with others. 296 (m) “Professional judgment” means the intellectual, 297 educated, informed, and experienced process that a direct care 298 registered nurse exercises in forming an opinion and reaching a 299 clinical decision that is in the patient’s best interest and is 300 based upon analysis of data, information, and scientific 301 evidence. 302 (n) “Skill mix” means the differences in licensing, 303 specialty, and experience among direct care registered nurses. 304 (3) MINIMUM DIRECT CARE REGISTERED NURSE STAFFING LEVEL 305 REQUIREMENTS.— 306 (a) Each health care facility shall implement a staffing 307 plan that provides for a minimum direct care registered nurse 308 staffing level in accordance with the general requirements set 309 forth in this subsection and the directed care registered nurse 310 staffing levels in a clinical unit as specified in paragraph 311 (b). Staffing levels for patient care tasks that do not require 312 a direct care registered nurse are not included within these 313 ratios and shall be determined pursuant to an acuity-based 314 patient classification system defined by agency rule. 315 1. A health care facility may not assign a direct care 316 registered nurse to a clinical unit unless the health care 317 facility and the direct care registered nurse determine that the 318 nurse has demonstrated and validated current competence in 319 providing care in that clinical unit and has also received 320 orientation in that area which is sufficient to provide 321 competent, safe, therapeutic, and effective care to a patient in 322 that area. The policies and procedures of the health care 323 facility must contain the criteria for making this 324 determination. 325 2. The direct care registered nurse staffing levels 326 represent the maximum number of patients that may be assigned to 327 one direct care registered nurse at any one time. 328 3. A health care facility: 329 a. May not average the number of patients and the total 330 number of direct care registered nurses assigned to patients in 331 a hospital unit or clinical unit during any period of time for 332 purposes of meeting the requirements under this subsection. 333 b. May not impose mandatory overtime in order to meet the 334 minimum direct care registered nurse staffing levels in the 335 hospital unit or clinical unit which are required under this 336 subsection. 337 c. Shall ensure that only a direct care registered nurse 338 may relieve another direct care registered nurse during breaks, 339 meals, and routine absences from a hospital unit or clinical 340 unit. 341 d. May not lay off licensed practical nurses, licensed 342 psychiatric technicians, certified nursing assistants, or other 343 ancillary support staff in order to meet the direct care 344 registered nurse staffing levels in a hospital unit or clinical 345 unit, as required in this subsection. 346 4. Only a direct care registered nurse may be assigned to 347 an intensive care newborn nursery service unit, which 348 specifically requires a direct care registered nurse staffing 349 level of one nurse to two or fewer infants at all times. 350 5. Only a direct care registered nurse may be assigned to a 351 triage patient, and only a direct care registered nurse may be 352 assigned to a critical care patient in the emergency department. 353 a. The direct care registered nurse staffing level for 354 triage patients or critical care patients in the emergency 355 department must be one nurse to two or fewer patients at all 356 times. 357 b. At least two direct care registered nurses must be 358 physically present in the emergency department when a patient is 359 present. 360 c. Triage, radio, specialty, or flight registered nurses do 361 not count in the calculation of direct care registered nurse 362 staffing levels. 363 d. Triage registered nurses may not be assigned the 364 responsibility of the base radio. 365 6. Only a direct care registered nurse may be assigned to a 366 labor and delivery unit. 367 a. The direct care registered nurse staffing level must be 368 one nurse to one active labor patient, or one patient having 369 medical or obstetrical complications, during the initiation of 370 epidural anesthesia and during circulation for a caesarean 371 section delivery. 372 b. The direct care registered nurse staffing level for 373 antepartum patients who are not in active labor must be one 374 nurse to three or fewer patients at all times. 375 c. In the event of a caesarean delivery, the direct care 376 registered nurse staffing level must be one nurse to four or 377 fewer mother-plus-infant couplets. 378 d. In the event of multiple births, the direct care 379 registered nurse staffing level must be one nurse to six or 380 fewer mother-plus-infant couplets. 381 e. The direct care registered nurse staffing level for 382 postpartum areas in which the direct care registered nurse’s 383 assignment consists of only mothers must be one nurse to four or 384 fewer patients at all times. 385 f. The direct care registered nurse staffing level for 386 postpartum patients or postsurgical gynecological patients must 387 be one nurse to four or fewer patients at all times. 388 g. The direct care registered nurse staffing level for the 389 well-baby nursery must be one nurse to five or fewer patients at 390 all times. 391 h. The direct care registered nurse staffing level for 392 unstable newborns and newborns in the resuscitation period as 393 assessed by a direct care registered nurse must be at least one 394 nurse to one patient at all times. 395 i. The direct care registered nurse staffing level for 396 newborn infants must be one nurse to four or fewer patients at 397 all times. 398 7. The direct care registered nurse staffing level for 399 patients receiving conscious sedation must be at least one nurse 400 to one patient at all times. 401 (b) A health care facility’s staffing plan must provide 402 that, at all times during each shift within a unit of the 403 facility, a direct care registered nurse is assigned to not more 404 than: 405 1. One patient in a trauma emergency unit; 406 2. One patient in an operating room unit. The operating 407 room must have at least one direct care registered nurse 408 assigned to the duties of the circulating registered nurse and a 409 minimum of one additional person as a scrub assistant for each 410 patient-occupied operating room; 411 3. Two patients in a critical care unit, including neonatal 412 intensive care units; emergency critical care and intensive care 413 units; labor and delivery units; coronary care units; acute 414 respiratory care units; postanesthesia units, regardless of the 415 type of anesthesia received; and postpartum units so that the 416 direct care registered nurse staffing level is one nurse to two 417 or fewer patients at all times; 418 4. Three patients in an emergency room unit; step-down unit 419 or intermediate intensive care unit; pediatrics unit; telemetry 420 unit; or combined labor, delivery, and postpartum unit so that 421 the direct care registered nurse staffing level is one nurse to 422 three or fewer patients at all times; 423 5. Four patients in a surgical unit, antepartum unit, 424 intermediate care nursery unit, psychiatric unit, or presurgical 425 or other specialty care unit so that the direct care registered 426 nurse staffing level is one nurse to four or fewer patients at 427 all times; 428 6. Five patients in a rehabilitation unit and skilled 429 nursing unit so that the direct care registered nurse staffing 430 level is one nurse to five or fewer patients at all times; 431 7. Six patients in a well-baby nursery unit so that the 432 direct care registered nurse staffing level is one nurse to six 433 or fewer patients at all times; or 434 8. Three mother-plus-infant couplets in a postpartum unit 435 so that the direct care registered nurse staffing level is one 436 nurse to three or fewer mother-plus-infant couplets at all 437 times. 438 (c)1. Identifying a hospital unit or clinical unit by a 439 name or term other than those defined in subsection (2) does not 440 affect the requirement of direct care registered nurse staffing 441 levels identified for the level of intensity or type of care 442 described in paragraphs (a) and (b). 443 2. Patients shall be cared for only in hospital units or 444 clinical units in which the level of intensity, type of care, 445 and direct care registered nurse staffing levels meet the 446 individual requirements and needs of each patient. A health care 447 facility may not use an acuity adjustable unit to care for a 448 patient. 449 3. A health care facility may not use a video camera or 450 monitor or any form of electronic visualization of a patient to 451 substitute for the direct observation required for patient 452 assessment by the direct care registered nurse and for patient 453 protection required by an attendant. 454 (d) The requirements established under this subsection do 455 not apply during a declared state of emergency if a health care 456 facility is requested or expected to provide an exceptional 457 level of emergency or other medical services. 458 (e) The chief nursing officer or his or her designee shall 459 develop a staffing plan for each hospital unit or clinical unit. 460 1. The staffing plan must be in writing and, based on 461 individual patient care needs determined by the patient 462 classification system, must specify individual patient care 463 requirements and the staffing levels for direct care registered 464 nurses and other licensed and unlicensed personnel. The direct 465 care registered nurse staffing level on any shift may not fall 466 below the requirements in paragraphs (a) and (b) at any time. 467 2. In addition to the requirements of direct care 468 registered nurse staffing levels in paragraphs (a) and (b), each 469 health care facility shall assign additional nursing staff, such 470 as licensed practical nurses, licensed psychiatric technicians, 471 and certified nursing assistants, through the implementation of 472 a valid patient classification system for determining nursing 473 care needs of individual patients which reflects the assessment 474 of patient nursing care requirements made by the assigned direct 475 care registered nurse and which provides for shift-by-shift 476 staffing based on those requirements. The direct care registered 477 nurse staffing levels specified in paragraphs (a) and (b) 478 constitute the minimum number of registered nurses who shall be 479 assigned to provide direct patient care. 480 3. In developing the staffing plan, a health care facility 481 shall provide for direct care registered nurse staffing levels 482 that are above the minimum levels required in paragraphs (a) and 483 (b) based upon consideration of the following factors: 484 a. The number of patients and acuity level of patients as 485 determined by the application of an acuity system on a shift-by 486 shift basis. 487 b. The anticipated admissions, discharges, and transfers of 488 patients during each shift which affect direct patient care. 489 c. The specialized experience required of direct care 490 registered nurses on a particular hospital unit or clinical 491 unit. 492 d. Staffing levels of other health care personnel who 493 provide services for direct patient care needs that normally do 494 not require care by a direct care registered nurse. 495 e. The level of efficacy of technology that is available 496 and that affects the delivery of direct patient care. 497 f. The level of familiarity with hospital practices, 498 policies, and procedures by a direct care registered nurse from 499 a temporary agency during a shift. 500 g. Obstacles to efficiency in the delivery of patient care 501 caused by the physical layout of the health care facility. 502 4. A health care facility shall specify the system used to 503 document actual staffing in each unit for each shift. 504 5. A health care facility shall annually evaluate: 505 a. The reliability of the patient classification system for 506 validating staffing requirements in order to determine whether 507 the system accurately measures individual patient care needs and 508 accurately predicts the staffing requirements for direct care 509 registered nurses, licensed practical nurses, licensed 510 psychiatric technicians, and certified nursing assistants, based 511 exclusively on individual patient needs. 512 b. The validity of the acuity-based patient classification 513 system. 514 6. A health care facility shall annually update its 515 staffing plan and acuity system to the extent appropriate based 516 on the annual evaluation conducted under subparagraph 5. If the 517 evaluation reveals that adjustments are necessary in order to 518 ensure accuracy in measuring patient care needs, such 519 adjustments must be implemented within 30 days after that 520 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 of 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 section. 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 by an authorized collective bargaining agent. 558 b. In case of a dispute, the direct care registered nurse 559 assessment shall prevail. 560 c. This section does not authorize conduct that is 561 prohibited under the National Labor Relations Act or the Federal 562 Labor Relations Act. 563 9. By July 1, 2018, the agency shall approve uniform 564 statewide standards for a standardized acuity tool for use in 565 health care facilities. The standardized acuity tool shall 566 provide a method for establishing nurse staffing requirements 567 which exceed the required direct care registered nurse staffing 568 levels in the hospital units or clinical units in paragraphs (a) 569 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 section. 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 annually updated staffing plan and acuity system as required 611 under this paragraph. 612 (f)1. In each hospital unit or clinical unit, a health care 613 facility shall post a uniform notice in a form specified by 614 agency rule which: 615 a. Explains the requirements imposed under this subsection; 616 b. Includes actual direct care registered nurse staffing 617 levels during each shift at the hospital unit or clinical unit; 618 c. Is visible, conspicuous, and accessible to staff and 619 patients of the hospital unit or clinical unit and the public; 620 d. Identifies staffing requirements as determined by the 621 patient classification system for each hospital unit or clinical 622 unit, documented and posted in the unit for public view on a 623 day-to-day, shift-by-shift basis; 624 e. Documents the actual number of staff and the skill mix 625 at each hospital unit or clinical unit, documented and posted in 626 the unit for public view on a day-to-day, shift-by-shift basis; 627 and 628 f. Reports the variance between the required and actual 629 staffing patterns at each hospital unit or clinical unit, 630 documented and posted in the unit for public view on a day-to 631 day, shift-by-shift basis. 632 2.a. Each long-term acute care hospital shall maintain 633 accurate records of actual staffing levels in each hospital unit 634 or clinical unit for each shift for at least 2 years. Such 635 records must include: 636 (I) The number of patients in each unit; 637 (II) The identity and duty hours of each direct care 638 registered nurse, licensed practical nurse, licensed psychiatric 639 technician, and certified nursing assistant assigned to each 640 patient in the hospital unit or clinical unit for each shift; 641 and 642 (III) A copy of each posted notice. 643 b. Each health care facility shall make its records 644 maintained under paragraph (e) available to the agency; to 645 registered nurses and their collective bargaining 646 representatives, if any; and to the public under rules adopted 647 by the agency. 648 3. The agency shall conduct periodic audits to ensure 649 implementation of the staffing plan in accordance with this 650 subsection and to ensure the accuracy of records maintained 651 under paragraph (e). 652 (g) Health care facilities shall plan for routine 653 fluctuations such as admissions, discharges, and transfers in 654 the patient census. If a declared health care emergency causes a 655 change in the number of patients in a unit, the facility must 656 demonstrate that immediate and diligent efforts are made to 657 maintain required staffing levels. 658 (h) The following activities are prohibited: 659 1. The direct assignment of unlicensed personnel by a 660 health care facility to perform functions required of a 661 registered nurse in lieu of care being delivered by a licensed 662 or registered nurse under the clinical supervision of a direct 663 care registered nurse. 664 2. The performance of tasks by unlicensed personnel which 665 require the clinical assessment, judgment, and skill of a 666 licensed registered nurse, including, but not limited to: 667 a. Nursing activities that require nursing assessment and 668 judgment during implementation; 669 b. Physical, psychological, or social assessments that 670 require nursing judgment, intervention, referral, or followup; 671 and 672 c. Formulation of a plan of nursing care and evaluation of 673 a patient’s response to the care provided, including 674 administration of medication; venipuncture or intravenous 675 therapy; parenteral or tube feedings; invasive procedures, 676 including inserting nasogastric tubes, inserting catheters, or 677 tracheal suctioning; and educating patients and their families 678 concerning the patient’s health care problems, including 679 postdischarge care. However, a phlebotomist, an emergency room 680 technician, or a medical technician may, under the general 681 supervision of the clinical laboratory director, or his or her 682 designee, or a physician, perform venipunctures in accordance 683 with written hospital policies and procedures. 684 (4) PROFESSIONAL PRACTICE STANDARDS FOR DIRECT CARE 685 REGISTERED NURSES WORKING IN A HEALTH CARE FACILITY.— 686 (a) A direct care registered nurse employing scientific 687 knowledge and experience in the physical, social, and biological 688 sciences, and exercising independent judgment in applying the 689 nursing process, shall directly provide: 690 1. Continuous and ongoing assessments of the patient’s 691 condition. 692 2. The planning, clinical supervision, implementation, and 693 evaluation of the nursing care to each patient. 694 3. The assessment, planning, implementation, and evaluation 695 of patient education, including ongoing postdischarge education 696 of each patient. 697 4. The delivery of patient care, which must reflect all 698 elements of the nursing process and must include assessment, 699 nursing diagnosis, planning, intervention, evaluation, and, as 700 circumstances require, patient advocacy, and shall be initiated 701 by a direct care registered nurse at the time of admission. 702 5. The nursing plan for the patient care, which shall be 703 discussed with and developed as a result of coordination with 704 the patient, the patient’s family or other representatives, when 705 appropriate, and staff of other disciplines involved in the care 706 of the patient. 707 6. An evaluation of the effectiveness of the care plan 708 through assessments based on direct observation of the patient’s 709 physical condition and behavior, signs and symptoms of illness, 710 and reactions to treatment and through communication with the 711 patient and the health care team members, and modification of 712 the plan as needed. 713 7. Information related to the initial assessment and 714 reassessments of the patient, nursing diagnosis, plan, 715 intervention, evaluation, and patient advocacy, which shall be 716 permanently recorded in the patient’s medical record as 717 narrative direct care progress notes. The practice of charting 718 by exception is expressly prohibited. 719 (b)1. A patient assessment requires direct observation of 720 the patient’s signs and symptoms of illness, reaction to 721 treatment, behavior and physical condition, and interpretation 722 of information obtained from the patient and others, including 723 other caregivers on the health care team. A patient assessment 724 requires data collection by a direct care registered nurse and 725 the analysis, synthesis, and evaluation of such data. 726 2. Only a direct care registered nurse may perform a 727 patient assessment. A licensed practical nurse or licensed 728 psychiatric technician may assist a direct care registered nurse 729 in data collection. 730 (c)1. A direct care registered nurse shall determine the 731 nursing care needs of individual patients through the process of 732 ongoing patient assessments, nursing diagnosis, formulation, and 733 adjustment of nursing care plans. 734 2. The prediction of individual patient nursing care needs 735 for prospective assignment of direct care registered nurses 736 shall be based on individual patient assessments of the direct 737 care registered nurse assigned to each patient and in accordance 738 with a documented patient classification system as provided in 739 subsection (3). 740 (d) Competent performance of the essential functions of a 741 direct care registered nurse as provided in this section 742 requires the exercise of independent judgment in the interest of 743 the patient. The exercise of such independent judgment, 744 unencumbered by the commercial or revenue-generation priorities 745 of a health care facility or employing entity of the direct care 746 registered nurse, is essential to safe nursing care. 747 1. Current documented, demonstrated, and validated 748 competency is required for each direct care registered nurse and 749 must be determined based on the satisfactory performance of: 750 a. The statutorily recognized duties and responsibilities 751 of a registered nurse as set forth in chapter 464 and under 752 rules adopted under that chapter; and 753 b. The standards required under subsection (3) and this 754 subsection that are specific to each hospital unit or clinical 755 unit. 756 2. A direct care registered nurse’s independent judgment 757 while performing the functions described in this section shall 758 be provided in the exclusive interests of the patient and may 759 not, for any purpose, be considered, relied upon, or represented 760 as a job function, authority, responsibility, or activity 761 undertaken in any respect for the purpose of serving the 762 business, commercial, operational, or other institutional 763 interests of the health care facility employer. 764 (e)1. In addition to the prohibition on assignments of 765 patient care tasks provided in paragraph (3)(h), a direct care 766 registered nurse may assign tasks required to implement nursing 767 care for a patient to other licensed nursing staff or to 768 unlicensed staff only if the assigning direct care registered 769 nurse: 770 a. Determines that the personnel assigned the tasks possess 771 the necessary training, experience, and capability to 772 competently and safely perform the tasks to be assigned; and 773 b. Effectively supervises the clinical functions and 774 nursing care tasks performed by the assigned personnel. 775 2. The exercise of clinical supervision of nursing care 776 personnel by a direct care registered nurse in the performance 777 of the functions as provided in this subsection must be in the 778 exclusive interest of the patient and may not, for any purpose, 779 be considered, relied upon, or represented as a job function, 780 authority, responsibility, or activity undertaken in any respect 781 for the purpose of serving the business, commercial, 782 operational, or other institutional interests of the health care 783 facility employer, but constitutes the exercise of professional 784 nursing authority and duty exclusively in the interest of the 785 patient. 786 (f) A health care facility may not deploy technology that 787 limits the direct care provided by a direct care registered 788 nurse in the performance of functions that are part of the 789 nursing process, including the full exercise of independent 790 professional judgment in the assessment, planning, 791 implementation, and evaluation of care, or that limits a direct 792 care registered nurse from acting as a patient advocate in the 793 exclusive interest of the patient. Technology may not be skill 794 degrading, interfere with the direct care registered nurse’s 795 provision of individualized patient care, override the direct 796 care registered nurse’s independent professional judgment, or 797 interfere with the direct care registered nurse’s right to 798 advocate in the exclusive interest of the patient. 799 (g) This subsection applies only to nurses employed by or 800 providing care in a health care facility. 801 (5) DIRECT CARE REGISTERED NURSE’S DUTY AND RIGHT OF 802 PATIENT ADVOCACY.— 803 (a) A direct care registered nurse has a duty and right to 804 act and provide care in the exclusive interest of the patient 805 and to act as the patient’s advocate. 806 (b) A direct care registered nurse shall always provide 807 competent, safe, therapeutic, and effective nursing care to an 808 assigned patient. 809 1. Before accepting a patient assignment, a direct care 810 registered nurse must have the necessary knowledge, judgment, 811 skills, and ability to provide the required care. It is the 812 responsibility of the direct care registered nurse to determine 813 whether the nurse is clinically competent to perform the nursing 814 care required by patients in a particular clinical unit or who 815 have a particular diagnosis, condition, prognosis, or other 816 determinative characteristic of nursing care, and whether 817 acceptance of a patient assignment would expose the patient to 818 the risk of harm. 819 2. If the direct care registered nurse is not competent to 820 perform the care required for a patient assigned for nursing 821 care or if the assignment would expose the patient to risk of 822 harm, the direct care registered nurse may not accept the 823 patient care assignment. Such refusal to accept a patient care 824 assignment is an exercise of the direct care registered nurse’s 825 duty and right of patient advocacy. 826 (c) A direct care registered nurse may refuse to accept an 827 assignment as a nurse in a health care facility if: 828 1. The assignment would violate a provision of chapter 464 829 or the rules adopted under that chapter; 830 2. The assignment would violate subsection (3), subsection 831 (4), or this subsection; or 832 3. The direct care registered nurse is not prepared by 833 education, training, or experience to fulfill the assignment 834 without compromising the safety of a patient or jeopardizing the 835 license of the direct care registered nurse. 836 (d) A direct care registered nurse may refuse to perform an 837 assigned task as a nurse in a health care facility if: 838 1. The assigned task would violate a provision of chapter 839 464 or the rules adopted under that chapter; 840 2. The assigned task is outside the scope of practice of 841 the direct care registered nurse; or 842 3. The direct care registered nurse is not prepared by 843 education, training, or experience to fulfill the assigned task 844 without compromising the safety of a patient or jeopardizing the 845 license of the direct care registered nurse. 846 (e) In the course of performing the responsibilities and 847 essential functions described in subsection (4), the direct care 848 registered nurse assigned to a patient shall receive orders 849 initiated by physicians and other legally authorized health care 850 professionals within their scope of licensure regarding patient 851 care services to be provided to the patient, including, but not 852 limited to, the administration of medications and therapeutic 853 agents that are necessary to implement a treatment, a 854 rehabilitative regime, or disease prevention. 855 1. The direct care registered nurse shall assess each such 856 order before implementation to determine if the order is: 857 a. In the best interest of the patient; 858 b. Initiated by a person legally authorized to issue the 859 order; and 860 c. Issued in accordance with applicable law and rules 861 governing nursing care. 862 2. If the direct care registered nurse determines that the 863 criteria provided in subparagraph 1. have not been satisfied 864 with respect to a particular order or if the nurse has some 865 doubt regarding the meaning or conformance of the order with 866 such criteria, he or she shall seek clarification from the 867 initiator of the order, the patient’s physician, or another 868 appropriate medical officer before implementing the order. 869 3. If, upon clarification, the direct care registered nurse 870 determines that the criteria for implementation of an order 871 provided in subparagraph 1. have not been satisfied, the nurse 872 may refuse implementation on the basis that the order is not in 873 the best interest of the patient. Seeking clarification of an 874 order or refusing an order as described in this subparagraph is 875 an exercise of the direct care registered nurse’s duty and right 876 of patient advocacy. 877 (f) A direct care registered nurse shall, as circumstances 878 require, initiate action to improve the patient health care or 879 to change decisions or activities that, in the professional 880 judgment of the direct care registered nurse, are against the 881 interests or wishes of the patient, or shall give the patient 882 the opportunity to make informed decisions about the health care 883 before it is provided. 884 (6) FREE SPEECH; PATIENT PROTECTION.— 885 (a) A health care facility may not: 886 1. Discharge, discriminate against, or retaliate against in 887 any manner with respect to any aspect of employment, including 888 discharge, promotion, compensation, or terms, conditions, or 889 privileges of employment, a direct care registered nurse based 890 on the nurse’s refusal of a work assignment pursuant to 891 paragraph (5)(c) or an assigned task pursuant to paragraph 892 (5)(d). 893 2. File a complaint or a report against a direct care 894 registered nurse with the Board of Nursing or the agency because 895 of the nurse’s refusal of a work assignment pursuant to 896 paragraph (5)(c) or an assigned task pursuant to paragraph 897 (5)(d). 898 (b) A direct care registered nurse who has been discharged, 899 discriminated against, or retaliated against in violation of 900 this section or against whom a complaint or a report has been 901 filed in violation of subparagraph (a)2. may bring a cause of 902 action in a state court. A direct care registered nurse who 903 prevails in the cause of action is entitled to one or more of 904 the following: 905 1. Reinstatement. 906 2. Reimbursement of lost wages, compensation, and benefits. 907 3. Attorney fees. 908 4. Court costs. 909 5. Other damages. 910 (c) A direct care registered nurse, patient, or other 911 individual may file a complaint with the agency against a health 912 care facility that violates this section. For any complaint 913 filed, the agency shall: 914 1. Receive and investigate the complaint; 915 2. Determine whether a violation of this section as alleged 916 in the complaint has occurred; and 917 3. If such a violation has occurred, issue an order that 918 the complaining nurse, patient, or other individual not suffer 919 any retaliation described in paragraph (a). 920 (d)1. The agency shall provide for the establishment of a 921 toll-free telephone hotline to provide information regarding the 922 requirements of this subsection and to receive reports of 923 violations of this subsection. 924 2. A health care facility shall provide each patient 925 admitted to the facility for inpatient care with the toll-free 926 telephone hotline described in subparagraph 1. and shall give 927 notice to each patient that the hotline may be used to report 928 inadequate staffing or care. 929 (e)1. A health care facility may not discriminate or 930 retaliate in any manner against any patient, employee, or 931 contract employee of the facility, or any other individual, on 932 the basis that such individual, in good faith, individually or 933 in conjunction with another person or persons, has presented a 934 grievance or complaint; initiated or cooperated in an 935 investigation or proceeding by a governmental entity, regulatory 936 agency, or private accreditation body; made a civil claim or 937 demand; or filed an action relating to the care, services, or 938 conditions of the health care facility or of any affiliated or 939 related facilities. 940 2. For purposes of this paragraph, an individual is deemed 941 to be acting in good faith if the individual reasonably 942 believes: 943 a. The information reported or disclosed is true; and 944 b. A violation of this section has occurred or may occur. 945 (f)1. A health care facility may not: 946 a. Interfere with, restrain, or deny the exercise of, or 947 the attempt to exercise, any right provided or protected under 948 this section; or 949 b. Coerce or intimidate any person regarding the exercise 950 of, or the attempt to exercise, such right. 951 2. A health care facility may not discriminate or retaliate 952 against any person for opposing any facility policy, practice, 953 or action that is alleged to violate, breach, or fail to comply 954 with any provision of this section. 955 3. A health care facility, or an individual representing a 956 health care facility, may not make, adopt, or enforce any rule, 957 regulation, policy, or practice that in any manner directly or 958 indirectly prohibits, impedes, or discourages a direct care 959 registered nurse from engaging in free speech or disclosing 960 information as provided under this subsection. 961 4. A health care facility, or an individual representing a 962 health care facility, may not in any way interfere with the 963 rights of nurses to organize, bargain collectively, and engage 964 in concerted activity under chapter 7 of the National Labor 965 Relations Act, 29 U.S.C. s. 157. 966 5. A health care facility shall post in an appropriate 967 location in each hospital unit or clinical unit a conspicuous 968 notice in a form specified by the agency which: 969 a. Explains the rights of nurses, patients, and other 970 individuals under this subsection; 971 b. Includes a statement that a nurse, patient, or other 972 individual may file a complaint with the agency against a health 973 care facility that violates this subsection; and 974 c. Provides instructions on how to file a complaint. 975 (7) ENFORCEMENT.— 976 (a) In addition to any other penalties prescribed by law, 977 the agency may impose civil penalties as follows: 978 1. Against a health care facility found to have violated a 979 provision of this section, a civil penalty of up to $25,000 for 980 each violation, except that the agency shall impose a civil 981 penalty of at least $25,000 for each violation if the agency 982 determines that the health care facility has a pattern of 983 practice of such violation. 984 2. Against an individual who is employed by a health care 985 facility and who is found to have violated a provision of this 986 section, a civil penalty of up to $20,000 for each violation. 987 (b) The agency shall post on its website the names of 988 health care facilities against which civil penalties have been 989 imposed under this subsection and such additional information as 990 the agency deems necessary. 991 Section 3. This act shall take effect July 1, 2017.