Bill Text: FL H0305 | 2011 | Regular Session | Introduced

Bill Title: Health Care

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced - Dead) 2011-05-07 - Indefinitely postponed and withdrawn from consideration [H0305 Detail]

Download: Florida-2011-H0305-Introduced.html
HB 305

A bill to be entitled
2An act relating to health care; creating the "Florida
3Hospital Patient Protection Act"; providing legislative
4findings; providing definitions; providing minimum
5staffing level requirements for the ratio of direct care
6registered nurses to patients in a health care facility;
7requiring that each health care facility implement a
8staffing plan; prohibiting the imposition of mandatory
9overtime and certain other actions by a health care
10facility; specifying the required nurse-to-patient ratios
11for each type of care provided; prohibiting the use of
12video cameras or monitors by a health care facility as a
13substitute for the required level of care; requiring that
14the chief nursing officer of a health care facility
15prepare a written staffing plan that meets the staffing
16levels required by the act; requiring that a health care
17facility annually evaluate its actual staffing levels and
18update the staffing plan based on the evaluation;
19requiring that certain documentation be submitted to the
20Agency for Health Care Administration and made available
21for public inspection; requiring that the agency develop
22uniform standards for use by health care facilities in
23establishing nurse staffing requirements; providing
24requirements for the committee members who are appointed
25to develop the uniform standards; requiring health care
26facilities to annually report certain information to the
27agency and post a notice containing such information in
28each unit of the facility; prohibiting a health care
29facility from assigning unlicensed personnel to perform
30functions or tasks that are performed by a licensed or
31registered nurse; specifying those actions that constitute
32professional practice by a direct care registered nurse;
33requiring that patient assessment be performed only by a
34direct care registered nurse; authorizing a direct care
35registered nurse to assign certain specified activities to
36other licensed or unlicensed nursing staff; prohibiting a
37health care facility from deploying technology that limits
38certain care provided by a direct care registered nurse;
39providing that it is a duty and right of a direct care
40registered nurse to act as the patient's advocate;
41providing certain requirements with respect to such duty;
42authorizing a direct care registered nurse to refuse to
43perform certain activities if he or she determines that it
44is not in the best interests of the patient; providing
45that a direct care registered nurse may refuse to accept
46an assignment under certain circumstances; prohibiting a
47health care facility from discharging, discriminating, or
48retaliating against a nurse based on such refusal;
49providing that a direct care registered nurse has a right
50of action against a health care facility that violates
51certain provisions of the act; requiring that the Agency
52for Health Care Administration establish a toll-free
53telephone hotline to provide information and to receive
54reports of violations of the act; requiring that certain
55information be provided to each patient who is admitted to
56a health care facility; prohibiting a health care facility
57from interfering with the right of nurses to organize or
58bargain collectively; authorizing the agency to impose
59fines for violations of the act; requiring that the agency
60post in its website information regarding health care
61facilities that have violated the act; providing an
62effective date.
64Be It Enacted by the Legislature of the State of Florida:
66     Section 1.  Short title.-Sections 1 through 8 of this act
67may be cited as the "Florida Hospital Patient Protection Act."
68     Section 2.  Legislative findings.-The Legislature finds
70     (1)  The state has a substantial interest in ensuring that,
71in the delivery of health care services to patients, health care
72facilities retain sufficient nursing staff so as to promote
73optimal health care outcomes.
74     (2)  Health care services are becoming more complex and it
75is increasingly difficult for patients to access integrated
76services. Competent, safe, therapeutic, and effective patient
77care is jeopardized because of staffing changes implemented in
78response to market-driven managed care. To ensure effective
79protection of patients in acute care settings, it is essential
80that qualified direct care registered nurses be accessible and
81available to meet the individual needs of the patient at all
82times. In order to ensure the health and welfare of state
83residents and to ensure that hospital nursing care is provided
84in the exclusive interests of patients, mandatory practice
85standards and professional practice protections for professional
86direct care registered nursing staff must be established. Direct
87care registered nurses have a fiduciary duty to care for
88assigned patients and a necessary duty of individual and
89collective patient advocacy in order to satisfy professional
90fiduciary obligations.
91     (3)  The basic principles of staffing in hospital settings
92should be based on the care needs of the individual patient, the
93severity of the patient's condition, the services needed, and
94the complexity surrounding those services. Current unsafe
95practices by hospital direct care registered nursing staff have
96resulted in adverse patient outcomes. Mandating the adoption of
97uniform, minimum, numerical, and specific registered nurse-to-
98patient staffing ratios by licensed hospital facilities is
99necessary for competent, safe, therapeutic, and effective
100professional nursing care and for the retention and recruitment
101of qualified direct care registered nurses.
102     (4)  Direct care registered nurses must be able to advocate
103for their patients without fear of retaliation from their
104employer. Whistle-blower protections that encourage registered
105nurses and patients to notify governmental and private
106accreditation entities of suspected unsafe patient conditions,
107including protection against retaliation for refusing unsafe
108patient care assignments, will greatly enhance the health,
109welfare, and safety of patients.
110     (5)  Direct care registered nurses have an irrevocable duty
111and right to advocate on behalf of their patients' interests,
112and this duty and right may not be encumbered by cost-saving
114     Section 3.  Definitions.-As used in sections 1 through 8 of
115this act, the term:
116     (1)  "Acuity-based patient classification system," "acuity
117system," or "patient classification system" means an established
118measurement tool that:
119     (a)  Predicts registered nursing care requirements for
120individual patients based on the severity of patient illness,
121the need for specialized equipment and technology, the intensity
122of required nursing interventions, and the complexity of
123clinical nursing judgment required to design, implement, and
124evaluate the patient's nursing care plan consistent with
125professional standards, the ability for self-care, including
126motor, sensory, and cognitive deficits, and the need for
127advocacy intervention;
128     (b)  Details the amount of nursing care needed and the
129additional number of direct care registered nurses and other
130licensed and unlicensed nursing staff that the hospital must
131assign, based on the independent professional judgment of the
132direct care registered nurse, in order to meet the individual
133patient needs at all times; and
134     (c)  Is stated in terms that can be readily used and
135understood by direct care nursing staff.
136     (2)  "Agency" means the Agency for Health Care
138     (3)  "Ancillary support staff" means the personnel assigned
139to assist in providing nursing services in the delivery of safe,
140therapeutic, and effective patient care, including unit or ward
141clerks and secretaries, clinical technicians, respiratory
142therapists, and radiology, laboratory, housekeeping, and dietary
144     (4)  "Clinical judgment" means the application of the
145direct care registered nurse's knowledge, skill, expertise, and
146experience in making independent decisions about patient care.
147     (5)  "Clinical supervision" means the assignment and
148direction of patient care tasks required in the implementation
149of nursing care for patients to other licensed nursing staff or
150to unlicensed staff by a direct care registered nurse in the
151exclusive interests of the patients.
152     (6)  "Competence" means the ability of the direct care
153registered nurse to act and integrate the knowledge, skills,
154abilities, and independent professional judgment that underpin
155safe, therapeutic, and effective patient care. Current
156documented, demonstrated, and validated competency is required
157for all direct care registered nurses and must be determined
158based on the satisfactory performance of:
159     (a)  The statutorily recognized duties and responsibilities
160of the registered nurses, as set forth in chapter 464, Florida
161Statutes, and rules adopted thereunder; and
162     (b)  The standards required under sections 4 and 5 of this
163act, which are specific to each hospital unit.
164     (7)  "Declared state of emergency" means an officially
165designated state of emergency that has been declared by a
166federal, state, or local government official who has the
167authority to declare the state of emergency. The term does not
168include a state of emergency that results from a labor dispute
169in the health care industry.
170     (8)  "Direct care registered nurse" means a licensed nurse
171who has documented clinical competence and who has accepted a
172direct, hands-on patient care assignment to implement medical
173and nursing regimens and provide related clinical supervision of
174patient care while exercising independent professional judgment
175at all times in the exclusive interest of the patient.
176     (9)  "Health care facility" means an acute care hospital;
177an emergency care, ambulatory, or outpatient surgery facility
178licensed under chapter 395, Florida Statutes; or a psychiatric
179facility licensed under chapter 394, Florida Statutes, including
180a critical access and long-term acute care hospital.
181     (10)  "Hospital unit" or "clinical patient care area" means
182an intensive care or critical care unit, burn unit, labor and
183delivery room, antepartum and postpartum unit, newborn nursery,
184postanesthesia service area, emergency department, operating
185room, pediatric unit, step-down or intermediate care unit,
186specialty care unit, telemetry unit, general medical or surgical
187care unit, psychiatric unit, rehabilitation unit, or skilled
188nursing facility unit, and as further defined in this
190     (a)  "Critical care unit" or "intensive care unit" means a
191nursing unit of an acute care hospital which is established to
192safeguard and protect patients whose severity of medical
193conditions require continuous monitoring and complex
194interventions by direct care registered nurses and whose
195restorative measures and level of nursing intensity requires
196intensive care through direct observation by the direct care
197registered nurse, complex monitoring, intensive intricate
198assessment, evaluation, specialized rapid intervention, and
199education or teaching of the patient, the patient's family, or
200other representatives by a competent and experienced direct care
201registered nurse. The term includes an intensive care unit, a
202burn center, a coronary care unit, or an acute respiratory unit.
203     (b)  "Step-down unit" or "intermediate intensive care unit"
204means a unit established to safeguard and protect patients whose
205severity of illness, including all co-occurring morbidities,
206restorative measures, and level of nursing intensity, requires
207intermediate intensive care through direct observation by the
208direct care registered nurse, monitoring, multiple assessments,
209specialized interventions, evaluations, and education or
210teaching of the patient's family or other representatives by a
211competent and experienced direct care registered nurse. The term
212includes units established to provide care to patients who have
213moderate or potentially severe physiologic instability requiring
214technical support but not necessarily artificial life support.
215"Artificial life support" means a system that uses medical
216technology to aid, support, or replace a vital function of the
217body that has been seriously damaged. "Technical support" means
218the use of specialized equipment by direct care registered
219nurses in providing for invasive monitoring, telemetry, and
220mechanical ventilation for the immediate amelioration or
221remediation of severe pathology for those patients requiring
222less care than intensive care, but more than that which is
223required from medical or surgical care.
224     (c)  "Medical or surgical unit" means a unit established to
225safeguard and protect patients whose severity of illness,
226including all co-occurring morbidities, restorative measures,
227and level of nursing intensity requires continuous care through
228direct observation by the direct care registered nurse,
229monitoring, multiple assessments, specialized interventions,
230evaluations, and education or teaching of the patient's family
231or other representatives by a competent and experienced direct
232care registered nurse. These units may include patients
233requiring less than intensive care or step-down care; patients
234receiving 24-hour inpatient general medical care, post-surgical
235care, or both general medical and post-surgical care; and mixed
236patient populations of diverse diagnoses and diverse age groups,
237but excluding pediatric patients.
238     (d)  "Telemetry unit" means a unit that is established to
239safeguard and protect patients whose severity of illness,
240including all co-occurring morbidities, restorative measures,
241and level of nursing intensity, requires intermediate intensive
242care through direct observation by the direct care registered
243nurse, monitoring, multiple assessments, specialized
244interventions, evaluations, and education or teaching of the
245patient's family or other representatives by a competent and
246experienced direct care registered nurse. A telemetry unit
247includes the equipment used to provide for the electronic
248monitoring, recording, retrieval, and display of cardiac
249electrical signals.
250     (e)  "Specialty care unit" means a unit that is established
251to safeguard and protect patients whose severity of illness,
252including all co-occurring morbidities, restorative measures,
253and level of nursing intensity, requires continuous care through
254direct observation by the direct care registered nurse,
255monitoring, multiple assessments, specialized interventions,
256evaluations, and education or teaching of the patient's family
257or other representatives by a competent and experienced direct
258care registered nurse. The term includes a unit established to
259provide the intensity of care required for a specific medical
260condition or a specific patient population or to provide more
261comprehensive care for a specific condition or disease process
262than that which is required on medical or surgical units, and
263includes those units not otherwise covered by the definitions in
264this section.
265     (f)  "Rehabilitation unit" means a functional clinical unit
266for the provision of those rehabilitation services that restore
267an ill or injured patient to the highest level of self-
268sufficiency or gainful employment of which he or she is capable
269in the shortest possible time, compatible with the patient's
270physical, intellectual, and emotional or psychological
271capabilities, and in accord with planned goals and objectives.
272     (g)  "Skilled nursing facility" means a functional clinical
273unit for the provision of skilled nursing care and supportive
274care to patients whose primary need is for the availability of
275skilled nursing care on a long-term basis and who are admitted
276after at least a 48-hour period of continuous inpatient care.
277The term includes, but need not be limited to, medical, nursing,
278dietary, and pharmaceutical services and activity programs.
279     (11)  "Licensed nurse" means a registered nurse or a
280licensed practical nurse, as defined in s. 464.003, Florida
281Statutes, who is licensed by the Board of Nursing to engage in
282the practice of professional nursing or the practice of
283practical nursing, as defined in s. 464.003, Florida Statutes.
284     (12)  "Long-term acute care hospital" means any hospital or
285health care facility that specializes in providing long-term
286acute care to medically complex patients. The term includes
287freestanding and hospital-within-hospital models of long-term
288acute care facilities.
289     (13)  "Overtime" means the hours worked in excess of:
290     (a)  An agreed-upon, predetermined, regularly scheduled
292     (b)  Twelve hours in a 24-hour period; or
293     (c)  Eighty hours in a consecutive 14-day period.
294     (14)  "Patient assessment" means the use of critical
295thinking by a direct care licensed nurse and is the
296intellectually disciplined process of actively and skillfully
297interpreting, applying, analyzing, synthesizing, or evaluating
298data obtained through the direct observation and communication
299with others.
300     (15)  "Professional judgment" means the intellectual,
301educated, informed, and experienced process that the direct care
302registered nurse exercises in forming an opinion and reaching a
303clinical decision that is in the patient's best interest and is
304based upon analysis of data, information, and scientific
306     (16)  "Skill mix" means the differences in licensing,
307specialty, and experience among direct care registered nurses.
308     (17)  "Staffing level" means the actual numerical
309registered nurse-to-patient ratio within a nursing department,
310unit, or clinical patient care area.
311     Section 4.  Minimum direct care registered nurse-to-patient
312staffing requirements.-
313     (1)  Each health care facility shall implement a staffing
314plan that provides for minimum staffing by direct care
315registered nurses in accordance with the general requirements
316set forth in this section and the clinical unit direct care
317registered nurse-to-patient ratios specified in subsection (2).
318Staffing for patient care tasks not requiring a direct care
319registered nurse is not included within these ratios and shall
320be determined pursuant to an acuity-based patient classification
321system defined by agency rule.
322     (a)  A health care facility may not assign a direct care
323registered nurse to a nursing unit or clinical area unless that
324health care facility and the direct care registered nurse
325determine that she or he has demonstrated and validated current
326competence in providing care in that area and has also received
327orientation to that clinical area which is sufficient to provide
328competent, safe, therapeutic, and effective care to patients in
329that area. The policies and procedures of the health care
330facility must contain the criteria for making this
332     (b)  Direct care registered nurse-to-patient ratios
333represent the maximum number of patients that shall be assigned
334to one direct care registered nurse at all times.
335     (c)  "Assigned" means the direct care registered nurse has
336responsibility for the provision of care to a particular patient
337within her or his validated competency.
338     (d)1.  A health care facility may not average the number of
339patients and the total number of direct care registered nurses
340assigned to patients in a clinical unit during any one shift or
341over any period of time for purposes of meeting the requirements
342under this section.
343     2.  A health care facility may not impose mandatory
344overtime requirements in order to meet the hospital unit direct
345care registered nurse-to-patient ratios required under this
347     3.  A health care facility shall ensure that only a direct
348care registered nurse may relieve another direct care registered
349nurse during breaks, meals, and routine absences from a clinical
351     4.  A health care facility may not impose layoffs of
352licensed practical nurses, licensed psychiatric technicians,
353certified nursing assistants, or other ancillary support staff
354in order to meet the clinical unit direct care registered nurse-
355to-patient ratios required in this section.
356     (e)  Only direct care registered nurses shall be assigned
357to intensive care newborn nursery service units, which
358specifically require one direct care registered nurse to two or
359fewer infants at all times.
360     (f)  Only direct care registered nurses shall be assigned
361to triage patients and only direct care registered nurses shall
362be assigned to critical trauma patients.
363     1.  The direct care registered nurse-to-patient ratio for
364critical care patients in the emergency department shall be 1 to
3652 or fewer at all times.
366     2.  No fewer than two direct care registered nurses must be
367physically present in the emergency department when a patient is
369     3.  Triage, radio, specialty, or flight-registered nurses
370do not count in the calculation of direct care registered nurse-
371to-patient ratios.
372     4.  Triage-registered nurses may not be assigned the
373responsibility of the base radio.
374     (g)  In the labor and delivery unit, the direct care
375registered nurse-to-patient ratio shall be 1 to 1 for active
376labor patients and patients having medical or obstetrical
377complications, during the initiation of epidural anesthesia, and
378during circulation for cesarean delivery.
379     1.  The direct care registered nurse-to-patient ratio for
380antepartum patients who are not in active labor shall be 1 to 3
381or fewer at all times.
382     2.  In the event of cesarean delivery, the total number of
383mothers plus infants assigned to a single direct care registered
384nurse may not exceed four.
385     3.  In the event of multiple births, the total number of
386mothers plus infants assigned to a single direct care registered
387nurse may not exceed six.
388     4.  For postpartum areas in which the direct care
389registered nurse's assignment consists of mothers only, the
390direct care registered nurse-to-patient ratio shall be 1 to 4 or
391fewer at all times.
392     5.  The direct care registered nurse-to-patient ratio for
393postpartum women or postsurgical gynecological patients only
394shall be 1 to 4 or fewer at all times.
395     6.  The direct care registered nurse-to-patient ratio for
396the well-baby nursery shall be 1 to 5 at all times.
397     7.  The direct care registered nurse-to-patient ratio for
398unstable newborns and those in the resuscitation period as
399assessed by the direct care registered nurse shall be 1 to 1 at
400all times.
401     8.  The direct care registered nurse-to-patient ratio for
402recently born infants shall be 1 to 4 or fewer at all times.
403     (h)  The direct care registered nurse-to-patient ratio for
404patients receiving conscious sedation shall be 1 to 1 or fewer
405at all times.
406     (2)  A health care facility's staffing plan shall provide
407that, at all times during each shift within a unit of the
408facility, a direct care registered nurse is assigned to not more
409than the following number of patients in that unit:
410     (a)  One patient in trauma emergency units.
411     (b)  One patient in operating room units. The operating
412room shall have at least one direct care registered nurse
413assigned to the duties of the circulating registered nurse and a
414minimum of one additional person as a scrub assistant for each
415patient-occupied operating room.
416     (c)  Two patients in critical care units, including
417neonatal intensive care units, emergency critical care and
418intensive care units, labor and delivery units, coronary care
419units, acute respiratory care units, postanesthesia units
420regardless of the type of anesthesia received, burn units, and
421immediate postpartum patients, so that the direct-care
422registered nurse-to-patient ratio is 1 to 2 at all times.
423     (d)  Three patients in the emergency room units, step-down
424or intermediate intensive care units, pediatrics units,
425telemetry units, and combined labor, delivery, and postpartum
426units, so that the direct care registered nurse-to-patient
427ratios is 1 to 3 or fewer at all times.
428     (e)  Four patients in medical-surgical units, antepartum
429units, intermediate care nursery units, psychiatric units, and
430presurgical and other specialty care units, so that the direct
431care registered nurse-to-patient ratio is 1 to 4 or fewer at all
433     (f)  Five patients in rehabilitation units and skilled
434nursing units, so that the direct care registered nurse-to-
435patient ratio is 1 to 5 or fewer at all times.
436     (g)  Six patients in well-baby nursery units, so that the
437direct care registered nurse-to-patient ratio is 1 to 6 or fewer
438at all times.
439     (h)  Three couplets in postpartum units, so that the direct
440care registered nurse-to-patient ratio is 1 to 3 couplets or
441fewer at all times.
442     (3)(a)  Identifying a unit or clinical patient care area by
443a name or term other than those defined in section 3 of this act
444does not affect the requirement to provide for staff at the
445direct care registered nurse-to-patient ratios identified for
446the level of intensity or type of care described in subsections
447(1) and (2).
448     (b)  Patients shall be cared for only on units or clinical
449patient care areas where the level of intensity, type of care,
450and direct care registered nurse-to-patients ratios meet the
451individual requirements and needs of each patient. The use of
452patient acuity-adjustable units is strictly prohibited.
453     (c)  Video cameras or monitors or any form of electronic
454visualization of a patient may not be substituted for the direct
455observation required for patient assessment by the direct care
456registered nurse and for patient protection required by an
458     (4)  The requirements established under this section do not
459apply during a declared state of emergency if a health care
460facility is requested or expected to provide an exceptional
461level of emergency or other medical services.
462     (5)(a)  A written staffing plan shall be developed by the
463chief nursing officer or a designee, based on individual patient
464care needs determined by the patient classification system. The
465staffing plan shall be developed and implemented for each
466patient care unit and must specify individual patient care
467requirements and the staffing levels for direct care registered
468nurses and other licensed and unlicensed personnel. In no case
469shall the staffing level for direct care registered nurses on
470any shifts fall below the requirements of subsections (1) and
472     (b)  In addition to the direct care registered nurse-ratio
473requirements of subsections (1) and (2), each health care
474facility shall assign additional nursing staff, such as licensed
475practical nurses, licensed psychiatric technicians, and
476certified nursing assistants, through the implementation of a
477valid patient classification system for determining nursing care
478needs of individual patients which reflects the assessment made
479by the assigned direct care registered nurse of patient nursing
480care requirements and which provides for shift-by-shift staffing
481based on those requirements. The ratios specified in subsections
482(1) and (2) constitute the minimum number of registered nurses
483who shall be assigned to provide direct patient care.
484     (c)  In developing the staffing plan, a health care
485facility shall provide for direct care registered nurse-to-
486patient ratios above the minimum ratios required under
487subsections (1) and (2) based upon consideration of the
488following factors:
489     1.  The number of patients and acuity level of patients as
490determined by the application of an acuity system on a shift-by-
491shift basis.
492     2.  The anticipated admissions, discharges, and transfers
493of patients during each shift which affect direct patient care.
494     3.  Specialized experience required of direct care
495registered nurses on a particular unit.
496     4.  Staffing levels and services provided by other health
497care personnel in meeting direct patient care needs that do not
498require care by a direct care registered nurse.
499     5.  The efficacy of technology that is available and that
500affects the delivery of direct patient care.
501     6.  The level of familiarity with hospital practices,
502policies, and procedures by temporary agency direct care
503registered nurses who are assigned during a shift.
504     7.  Obstacles to efficiency in the delivery of patient care
505which is caused by the physical layout of the health care
507     (d)  A health care facility shall specify the system used
508to document actual staffing in each unit for each shift.
509     (e)  A health care facility shall annually evaluate:
510     1.  The reliability of the patient classification system
511for validating staffing requirements in order to determine
512whether the system accurately measures individual patient care
513needs and accurately predicts the staffing requirements for
514direct care registered nurses, licensed practical nurses,
515licensed psychiatric technicians, and certified nursing
516assistants, based exclusively on individual patient needs.
517     2.  The validity of the acuity-based patient classification
519     (f)  A health care facility shall update its staffing plan
520and acuity system to the extent appropriate based on the annual
521evaluation. If the review reveals that adjustments are necessary
522in order to ensure accuracy in measuring patient care needs,
523such adjustments must be implemented within 30 days after that
525     (g)1.  Any acuity-based patient classification system
526adopted by a health care facility under this section shall be
527transparent in all respects, including disclosure of detailed
528documentation of the methodology used to predict nursing
529staffing; an identification of each factor, assumption, and
530value used in applying such methodology; an explanation of the
531scientific and empirical basis for each such assumption and
532value; and certification by a knowledgeable and authorized
533representative of the health care facility that the disclosures
534regarding methods used for testing and validating the accuracy
535and reliability of the system are true and complete.
536     2.  The documentation required by this section shall be
537submitted in its entirety to the Agency of Health Care
538Administration as a mandatory condition of licensure, with a
539certification by the chief nurse officer for the health care
540facility that it completely and accurately reflects
541implementation of a valid acuity-based patient classification
542system used to determine nursing service staffing by the
543facility for every shift on every clinical unit in which
544patients reside and receive care. The certification shall be
545executed by the chief nurse officer under penalty of perjury and
546must contain an expressed acknowledgement that any false
547statement in the certification constitutes fraud and is subject
548to criminal and civil prosecution and penalties.
549     3.  Such documentation shall be available for public
550inspection in its entirety in accordance with procedures
551established by appropriate administrative rules adopted by the
552Agency for Health Care Administration, consistent with the
553purposes of this act.
554     (h)1.  A staffing plan of a health care facility shall be
555developed and evaluated by a committee. At least one-half of the
556members of the committee shall be unit-specific competent direct
557care registered nurses who provide direct patient care.
558     2.  The members of the committee shall be appointed by the
559chief nurse officer, except at a facility where direct care
560registered nurses are represented for collective bargaining
561purposes, all direct care registered nurses on the committee
562shall be appointed by the authorized collective bargaining
563agent. In case of a dispute, the direct care registered nurse
564assessment shall prevail. This act does not authorize conduct
565that is prohibited under the National Labor Relations Act or
566under the Federal Labor Relations Act.
567     (i)1.  By July 1, 2012, the Agency for Health Care
568Administration shall develop uniform statewide standards for a
569standardized acuity tool for use in health care facilities which
570provides a method for establishing nurse staffing requirements
571that exceed the hospital unit or clinical patient care area
572direct care registered nurse-to-patient ratios required under
573subsections (1) and (2).
574     2.  Proposed standards shall be developed by a committee
575composed of not more than 20 individuals, at least 11 of whom
576must be currently licensed registered nurses who are employed as
577direct care registered nurses, and the remaining 9 must include
578a sufficient number of technical or scientific experts in the
579specialized fields involved in the design and development of a
580patient classification system that meets the requirements of
581this act.
582     3.  A person who has any employment, commercial,
583proprietary, financial, or other personal interest in the
584development, marketing, or utilization of any private patient
585classification system product or related methodology,
586technology, or component system is not eligible to serve on the
587development committee. A candidate for appointment to the
588development committee may not be confirmed as a member until the
589individual files a disclosure-of-interest statement with the
590agency, along with a signed certification of full disclosure and
591complete accuracy under oath, which provides all necessary
592information as determined by the agency to demonstrate the
593absence of actual or potential conflict of interest. All such
594filings are subject to public inspection.
595     4.  Within 1 year after the official commencement of
596committee operations, the development committee shall provide a
597written report to the agency which proposes uniform standards
598for a valid patient classification system, along with sufficient
599explanation and justification to allow for competent review and
600determination of sufficiency by the agency. The report shall be
601disclosed to the public upon notice of public hearings and a
602public comment period for proposed adoption of uniform standards
603for a patient classification system by the agency.
604     (j)  Each hospital shall adopt and implement the patient
605classification system and provide staffing based on such tool.
606Any additional direct care registered nursing staffing levels
607that exceed the direct care registered nurse-to-patient ratios
608described in subsections (1) and (2) shall be assigned in a
609manner determined by such statewide tool.
610     (k)  A health care facility shall submit to the agency its
611staffing plan and annual update required under this section.
612     (6)(a)  In each unit, a health care facility shall post a
613uniform notice in a form specified by the agency by rule which:
614     1.  Explains the requirements imposed under this section;
615     2.  Includes actual direct care registered nurse-to-patient
616ratios during each shift;
617     3.  Is visible, conspicuous, and accessible to staff,
618patients, and the public;
619     4.  Identifies staffing requirements as determined by the
620patient classification system for each unit, documented and
621posted on the unit for public view on a day-to-day, shift-by-
622shift basis;
623     5.  Reports the actual number of staff and the staff mix,
624documented and posted on the unit for public view on a day-to-
625day, shift-by-shift basis; and
626     6.  Reports the variance between the required and actual
627staffing patterns, documented and posted on the unit for public
628view on a day-to-day, shift-by-shift basis.
629     (b)1.  Each acute care facility shall maintain accurate
630records of actual direct care registered nurse-to-patient ratios
631in each unit for each shift for at least 2 years. Such records
632shall include:
633     a.  The number of patients in each unit;
634     b.  The identity and duty hours of each direct care
635registered nurse, licensed practical nurse, licensed psychiatric
636technician, and certified nursing assistant assigned to each
637patient in each unit in each shift. The hospital shall retain
638the record for 2 years; and
639     c.  A copy of each posted notice.
640     2.  Each hospital shall make its records maintained under
641the requirements of this section available to:
642     a.  The agency;
643     b.  Registered nurses and their collective bargaining
644representatives, if any; and
645     c.  The public under rules adopted by the agency.
646     (c)  The agency shall conduct periodic audits to ensure:
647     1.  Implementation of the staffing plan in accordance with
648this section; and
649     2.  Accuracy in records maintained under this section.
650     (7)  Acute care facilities shall plan for routine
651fluctuations such as admissions, discharges, and transfers in
652the patient census. If a declared health care emergency causes a
653change in the number of patients on a unit, the hospital must
654demonstrate that immediate and diligent efforts were made to
655maintain required staffing levels.
656     (8)  The following activities are prohibited:
657     (a)  A health care facility may not directly assign any
658unlicensed personnel to perform registered-nurse functions in
659lieu of care being delivered by a licensed or registered nurse,
660and may not assign unlicensed personnel to perform registered-
661nurse functions under the clinical supervision of a direct care
662registered nurse.
663     (b)  Unlicensed personnel may not perform tasks that
664require the clinical assessment, judgment, and skill of a
665licensed registered nurse, including, without limitation,
666nursing activities that require nursing assessment and judgment
667during implementation; physical, psychological, or social
668assessments that require nursing judgment, intervention,
669referral, or followup; formulation of a plan of nursing care and
670a evaluation of a patient's response to the care provided,
671including administration of medication, venipuncture or
672intravenous therapy, parenteral or tube feedings, invasive
673procedures, including inserting nasogastric tubes, inserting
674catheters, or tracheal suctioning, educating patients and their
675families concerning the patient's health care problems,
676including postdischarge care, with the exception that only
677phlebotomists, emergency room technicians, and medical
678technicians, under the general supervision of the clinical
679laboratory director or designee or a physician, may perform
680venipunctures in accordance with written hospital policies and
682     Section 5.  Professional practice standards for direct care
683registered nurses working in a health care facility.-
684     (1)  A direct care registered nurse, currently licensed to
685practice as a registered nurse, employing scientific knowledge
686and experience in the physical, social, and biological sciences,
687and exercising independent judgment in applying the nursing
688process, shall directly provide:
689     (a)  Continuous and ongoing assessments of the patient's
690condition based upon the independent professional judgment of
691the direct care registered nurse.
692     (b)  The planning, clinical supervision, implementation,
693and evaluation of the nursing care provided to each patient.
694     (c)  The assessment, planning, implementation, and
695evaluation of patient education, including ongoing discharge
696teaching of each patient.
697     (d)  The planning and delivery of patient care, which shall
698reflect all elements of the nursing process and shall include
699assessment, nursing diagnosis, planning, intervention,
700evaluation, and, as circumstances require, patient advocacy, and
701shall be initiated by a direct care registered nurse at the time
702of admission.
703     (e)  The nursing plan for the patient's care, which shall
704be discussed with and developed as a result of coordination with
705the patient, the patient's family, or other representatives,
706when appropriate, and staff of other disciplines involved in the
707care of the patient.
708     (f)  An evaluation of the effectiveness of the care plan
709through assessments based on direct observation of the patient's
710physical condition and behavior, signs and symptoms of illness,
711and reactions to treatment and through communication with the
712patient and the health care team members, and shall modify the
713plan as needed.
714     (g)  Information related to the patient's initial
715assessment and reassessments, nursing diagnosis, plan,
716intervention, evaluation, and patient advocacy, which shall be
717permanently recorded in the patient's medical record as
718narrative direct care progress notes. The practice of charting
719by exception is expressly prohibited.
720     (2)(a)  Patient assessment requires direct observation of
721the patient's signs and symptoms of illness, reaction to
722treatment, behavior and physical condition, and interpretation
723of information obtained from the patient and others, including
724other caregivers on the health team. Assessment requires data
725collection by the direct care registered nurse and the analysis,
726synthesis, and evaluation of such data.
727     (b)  Only direct care registered nurses are authorized to
728perform patient assessments. A licensed practical nurse or
729licensed psychiatric technician may assist direct care
730registered nurses in data collection.
731     (3)(a)  The nursing care needs of individual patients shall
732be determined by a direct care registered nurse through the
733process of ongoing patient assessments, nursing diagnosis,
734formulation, and adjustment of nursing care plans.
735     (b)  The prediction of individual patient nursing care
736needs for prospective assignment of direct care registered
737nurses shall be based on individual patient assessments of the
738direct care registered nurse assigned to each patient and in
739accordance with a documented patient classification system as
740provided in subsections (1) and (2) of section 4 of this act.
741     (4)(a)  Competent performance of the essential functions of
742a direct care registered nurse as provided in this section
743requires the exercise of independent judgment in the interests
744of the patient. The exercise of such independent judgment,
745unencumbered by the commercial or revenue-generation priorities
746of a hospital or employing entity of a direct care registered
747nurse, is essential to safe nursing care.
748     (b)  The exercise of independent judgment by a direct care
749registered nurse in the performance of the functions described
750in this section shall be provided in the exclusive interests of
751the patient and may not, for any purpose, be considered, relied
752upon, or represented as a job function, authority,
753responsibility, or activity undertaken in any respect for the
754purpose of serving the business, commercial, operational, or
755other institutional interests of the hospital employer.
756     (5)(a)  In addition to the limitations on assignments of
757patient care tasks provided in subsection (8) of section 4 of
758this act, a direct care registered nurse who is responsible for
759a patient may assign tasks required in the implementation of
760nursing care for that patient to other licensed nursing staff or
761to unlicensed staff only if the assigning direct care registered
763     1.  Determines that the personnel assigned the tasks
764possess the necessary training, experience, and capability to
765competently and safely perform the tasks to be assigned; and
766     2.  Effectively supervises the clinical functions and
767nursing care tasks performed by the assigned personnel.
768     (b)  The exercise of clinical supervision of nursing care
769personnel by a direct care registered nurse in the performance
770of the functions as provided in this section shall be in the
771exclusive interests of the patient and may not, for any purpose
772whatsoever, be considered, relied upon, or represented as a job
773function, authority, responsibility, or activity undertaken in
774any respect for the purpose of serving the business, commercial,
775operational, or other institutional interests of the hospital
776employer, but constitutes the exercise of professional nursing
777authority and duty exclusively in the interests of the patient.
778     (6)  A health care facility may not engage in the
779deployment of technology that limits the direct care provided by
780a direct care registered nurse in the performance of functions
781that are part of the nursing process, including the full
782exercise of independent clinical judgment in the assessment,
783planning, implementation, and evaluation of care, or that limits
784a direct registered nurse from acting as a patient advocate in
785the exclusive interest of the patient. Technology may not be
786skill degrading, interfere with the direct care registered
787nurse's provision of individualized patient care, override the
788direct care registered nurse's independent professional
789judgment, or interfere with the registered nurse's right to
790advocate in the exclusive interest of the patient.
791     (7)  This section applies only to nurses employed by or
792providing care in a health care facility.
793     Section 6.  Direct care registered nurse's duty and right
794of patient advocacy.-
795     (1)  By virtue of their professional license and ethical
796obligations, all direct care registered nurses have a duty and
797right to act and provide care in the exclusive interests of the
798patients and to act as the patient's advocate, as circumstances
799require, in accordance with this section.
800     (2)  The direct care registered nurse is always responsible
801for providing competent, safe, therapeutic, and effective
802nursing care to assigned patients.
803     (a)  Before accepting a patient assignment, a direct care
804registered nurse must have the necessary knowledge, judgment,
805skills, and ability to provide the required care. It is the
806responsibility of the direct care registered nurse to determine
807whether she or he is clinically competent to perform the nursing
808care required by patients in a particular clinical unit or who
809have a particular diagnosis, condition, prognosis, or other
810determinative characteristic of nursing care, and whether
811acceptance of a patient assignment would expose the patient to
812the risk of harm.
813     (b)  If the direct care registered nurse is not clinically
814competent to perform the care required for a patient assigned
815for nursing care, or if the assignment would expose the patient
816to risk of harm, the direct care registered nurse may not accept
817the patient care assignment. Such refusal to accept a patient
818care assignment is an exercise of the direct care registered
819nurse's duty and right of patient advocacy.
820     (3)  In the course of performing the responsibilities and
821essential functions described in section 5 of this act and this
822section, the direct care registered nurse assigned to a patient
823receives orders initiated by physicians and other legally
824authorized health care professionals within their scope of
825licensure regarding patient care services to be provided to the
826patient, including, without limitation, the administration of
827medications and therapeutic agents that are necessary to
828implement a treatment, disease prevention, or rehabilitative
830     (a)  The direct care registered nurse shall assess each
831such order before implementation in order to determine if the
832order is:
833     1.  In the best interests of the patient;
834     2.  Initiated by a person legally authorized to issue the
835order; and
836     3.  Issued in accordance with applicable law and rules
837governing nursing care.
838     (b)  If the direct care registered nurse determines these
839criteria have not been satisfied with respect to a particular
840order, or has some doubt regarding the meaning or conformance of
841the order with these criteria, she or he shall seek
842clarification from the initiator of the order, the patient's
843physician, or other appropriate medical officer. Clarification
844must be obtained prior to implementation.
845     (c)  If, upon clarification, the direct care registered
846nurse determines that the criteria for implementation of an
847order have not been satisfied, she or he may refuse
848implementation on the basis that the order is not in the best
849interests of the patient. Seeking clarification of an order or
850refusing an order as described in this section constitutes an
851exercise of the direct care registered nurse's duty and right of
852patient advocacy.
853     (4)  A direct care registered nurse has the professional
854obligation and therefore the right to act as the patient's
855advocate, as circumstances require, by initiating action to
856improve health care or to change decisions or activities that,
857in the professional judgment of the direct care registered
858nurse, are against the interests or wishes of the patient, or by
859giving the patient the opportunity to make informed decisions
860about health care before it is provided.
861     Section 7.  Free speech; patient protection.-
862     (1)  A direct care registered nurse has the right to act as
863the patient's advocate, as circumstances require, by:
864     (a)  Initiating action to improve health care or to change
865decisions or activities that, in the professional judgment of
866the nurse, are against the interests and wishes of the patient;
868     (b)  Giving the patient an opportunity to make informed
869decisions about health care before it is provided.
870     (2)  A direct care registered nurse may refuse to accept an
871assignment as a nurse in a health care facility if:
872     (a)  The assignment would violate any provision of chapter
873464, Florida Statutes, or the rules adopted thereunder;
874     (b)  The assignment would violate sections 3 through 6 of
875this act; or
876     (c)  The direct care registered nurse is not prepared by
877education, training, or experience to fulfill the assignment
878without compromising the safety of any patient or jeopardizing
879the license of the registered nurse.
880     (3)  A direct care registered nurse may refuse to perform
881any assigned tasks as a nurse in a health care facility if:
882     (a)  The assigned task would violate any provision of
883chapter 464, Florida Statutes, or the rules adopted thereunder;
884     (b)  The assigned task is outside the scope of practice of
885the direct care registered nurse; or
886     (c)  The direct care registered nurse is not prepared by
887education, training, or experience to fulfill the assigned task
888without compromising the safety of any patient or jeopardizing
889the license of the direct care registered nurse.
890     (4)(a)  A health care facility may not discharge,
891discriminate, or retaliate in any manner with respect to any
892aspect of employment, including discharge, promotion,
893compensation, or terms, conditions, or privileges of employment,
894against a direct care registered nurse based on the nurse's
895refusal of a work assignment or assigned task as provided in
896this section.
897     (b)  A health care facility may not file a complaint or a
898report against a direct care registered nurse with the Board of
899Nursing or the Agency for Health Care Administration because of
900the nurse's refusal of a work assignment or assigned task
901described in this section.
902     (5)  Any direct care registered nurse who has been
903discharged, discriminated against, or retaliated against in
904violation of this section or against whom a complaint has been
905filed in violation of paragraph (4)(b) may bring a cause of
906action in a state court. A direct care registered nurse who
907prevails on the cause of action is entitled to one or more of
908the following:
909     (a)  Reinstatement.
910     (b)  Reimbursement of lost wages, compensation, and
912     (c)  Attorney's fees.
913     (d)  Court costs.
914     (e)  Other damages.
915     (6)  A direct care registered nurse, patient, or other
916individual may file a complaint with the agency against a health
917care facility that violates the provisions of this act. For any
918complaint filed, the agency shall:
919     (a)  Receive and investigate the complaint;
920     (b)  Determine whether a violation of this act as alleged
921in the complaint has occurred; and
922     (c)  If such a violation has occurred, issue an order that
923the complaining nurse or individual not suffer any retaliation
924described in this section.
925     (7)(a)  The agency shall provide for the establishment of a
926toll-free telephone hotline to provide information regarding the
927requirements of this section and to receive reports of
928violations of such section.
929     (b)  A health care facility shall provide each patient
930admitted to the facility for inpatient care with the hotline
931described in paragraph (a), and shall give notice to each
932patient that such hotline may be used to report inadequate
933staffing or care.
934     (8)(a)  A health care facility may not discriminate or
935retaliate in any manner against any patient, employee, or
936contract employee of the facility, or any other individual, on
937the basis that such individual, in good faith, individually or
938in conjunction with another person or persons, has presented a
939grievance or complaint, or has initiated or cooperated in any
940investigation or proceeding of any governmental entity,
941regulatory agency, or private accreditation body, made a civil
942claim or demand, or filed an action relating to the care,
943services, or conditions of the health care facility or of any
944affiliated or related facilities.
945     (b)  For purposes of this subsection, an individual shall
946be deemed to be acting in good faith if the individual
947reasonably believes:
948     1.  The information reported or disclosed is true; and
949     2.  A violation of this act has occurred or may occur.
950     (9)(a)  A health care facility may not:
951     1.  Interfere with, restrain, or deny the exercise, or
952attempt to exercise, by any person of any right provided or
953protected under this act; or
954     2.  Coerce or intimidate any person regarding the exercise
955or attempt to exercise such right.
956     (b)  A health care facility may not discriminate or
957retaliate against any person for opposing any facility policy,
958practice, or actions that are alleged to violate, breach, or
959fail to comply with any provision of this act.
960     (c)  A health care facility, or an individual representing
961a health care facility, may not make, adopt, or enforce any
962rule, regulation, policy, or practice that in any manner
963directly or indirectly prohibits, impedes, or discourages a
964direct care registered nurse from, or intimidates, coerces, or
965induces a direct care registered nurse regarding, engaging in
966free speech activities or disclosing information as provided
967under this act.
968     (d)  A health care facility, or an individual representing
969a health care facility, may not in any way interfere with the
970rights of nurses to organize, bargain collectively, and engage
971in concerted activity under chapter 7 of the National Labor
972Relations Act, 29 U.S.C. s. 157.
973     (e)  A health care facility shall post in an appropriate
974location in each unit a conspicuous notice in a form specified
975by the agency which:
976     1.  Explains the rights of nurses, patients, and other
977individuals under this section;
978     2.  Includes a statement that a nurse, patient, or other
979individual may file a complaint with the agency against a health
980care facility that violates the provisions of this act; and
981     3.  Provides instructions on how to file a complaint.
982     Section 8.  Enforcement.-
983     (1)  In addition to any other penalties prescribed by law,
984the agency may impose civil penalties as follows:
985     (a)  The agency may impose against a health care facility
986found to be in violation of any provision of this act a civil
987penalty of not more than $25,000 for each such violation, except
988that the agency shall impose a civil penalty of more than
989$25,000 for each violation in the case of a health care facility
990that the agency determines has a pattern of practice of such
992     (b)  The agency may impose against an individual who is
993employed by a health care facility and who is found by the
994agency to have violated a requirement of this act a civil
995penalty of not more than $20,000 for each such violation.
996     (2)  The agency shall post on its Internet website the
997names of health care facilities against which civil penalties
998have been imposed under this act, and such additional
999information as the agency deemed necessary.
1000     Section 9.  This act shall take effect July 1, 2011.

CODING: Words stricken are deletions; words underlined are additions.