Bill Amendment: IL SB1908 | 2019-2020 | 101st General Assembly

NOTE: For additional amemendments please see the Bill Drafting List

---

Bill Title: SAFE PATIENT LIMITS

Status: 2021-01-13 - Session Sine Die [SB1908 Detail]

Download: Illinois-2019-SB1908-Senate_Amendment_001.html

---

Sen. Cristina Castro

Filed: 3/21/2019

10100SB1908sam001 LRB101 08484 CPF 58244 a
AMENDMENT TO SENATE BILL 1908
AMENDMENT NO. ______. Amend Senate Bill 1908 by replacing
everything after the enacting clause with the following:
"Section 1. Short title. This Act may be cited as the Safe
Patient Limits Act.
Section 5. Definitions. In this Act:
"Couplet" means one mother and one baby.
"Critical trauma patient" means a patient who has an injury
to an anatomic area that (i) requires life-saving
interventions, or (ii) in conjunction with unstable vital
signs, poses an immediate threat to life or limb.
"Department" means the Department of Public Health.
"Facility" means a hospital licensed under the Hospital
Licensing Act or organized under the University of Illinois
Hospital Act, a private or State-owned and State-operated
general acute care hospital, an LTAC hospital as defined in

10100SB1908sam001 - 2 - LRB101 08484 CPF 58244 a
Section 10 of the Long Term Acute Care Hospital Quality
Improvement Transfer Program Act, an acute psychiatric
hospital, an acute care specialty hospital, an ambulatory
surgical treatment center as defined in Section 3 of the
Ambulatory Surgical Treatment Center Act, or an acute care unit
within a health care facility.
"Health care workforce" means personnel employed by or
contracted to work at a facility that have an effect upon the
delivery of quality care to patients, including, but not
limited to, registered nurses, licensed practical nurses,
unlicensed assistive personnel, service, maintenance,
clerical, professional, and technical workers, and other
health care workers.
"Immediate postpartum patients" means those patients who
have given birth within the previous 2 hours.
"Nursing care" means care that falls within the scope of
practice as defined in the Nurse Practice Act or is otherwise
encompassed within recognized standards of nursing practice,
including assessment, nursing diagnosis, planning,
intervention, evaluation, and patient advocacy.
"Registered nurse" means a competent registered nurse who
has accepted a direct, hands-on patient care assignment to
implement the nursing care plan for that patient and the
nursing process while, at all times, exercising independent
professional judgment in the exclusive interest of the patient.
"Specialty care unit" means a unit which is organized,

10100SB1908sam001 - 3 - LRB101 08484 CPF 58244 a
operated, and maintained to provide care for a specific medical
condition or a specific patient population.
For the purposes of this Act, a patient is considered
assigned to a registered nurse if the registered nurse accepts
responsibility for the patient's nursing care.
Section 10. Maximum patient assignments for registered
nurses.
(a) The maximum number of patients assigned to a registered
nurse in a facility shall not exceed the limits provided in
this Section. However, nothing shall preclude a facility from
assigning fewer patients to a registered nurse than the limits
provided in this Section. The requirements provided in this
Section shall apply at all times during each shift and within
each clinical unit and patient care area.
(b) In all units with critical care or intensive care
patients, including, but not limited to, coronary care, acute
respiratory, burn, or neonatal intensive care patients, the
maximum patient assignment of critical care patients to a
registered nurse is 2.
(c) In all units with step-down or intermediate care
patients, the maximum patient assignment of step-down or
intermediate care patients to a registered nurse is 3.
(d) In all units with postanesthesia care patients, the
maximum patient assignment of postanesthesia care patients
under the age of 18 to a registered nurse is one. The maximum

10100SB1908sam001 - 4 - LRB101 08484 CPF 58244 a
patient assignment of postanesthesia care patients 18 years of
age or older to a registered nurse is 2.
(e) In all units with operating room patients, the maximum
patient assignment of operating room patients to a registered
nurse is one, provided that a minimum of one additional person
serves as a scrub assistant for each patient.
(f) In the emergency department:
(1) In a unit providing basic emergency medical
services or comprehensive emergency medical services, the
maximum patient assignment at any time to a registered
nurse is 3.
(2) The maximum assignment of critical care emergency
patients to a registered nurse is 2. A patient in the
emergency department shall be considered a critical care
patient when the patient meets the criteria for admission
to a critical care service area within the hospital.
(3) The maximum assignment of critical trauma patients
in an emergency unit to a registered nurse is one.
(4) At least one direct care registered professional
nurse shall be assigned to triage patients. The direct care
registered professional nurse assigned to triage patients
shall be immediately available at all times to triage
patients when they arrive in the emergency department. The
direct care registered professional nurse assigned to
triage patients shall perform triage functions only.
(g) In all units with maternal child care patients:

10100SB1908sam001 - 5 - LRB101 08484 CPF 58244 a
(1) The maximum patient assignment to a registered
nurse of antepartum patients requiring continuous fetal
monitoring is 2.
(2) The maximum patient assignment of other antepartum
patients to a registered nurse is 3.
(3) The maximum patient assignment of active labor
patients to a registered nurse is one.
(4) The maximum patient assignment during birth is one
registered nurse responsible for the mother and, for each
baby born, one registered nurse whose sole responsibility
is that baby.
(5) The maximum patient assignment of immediate
postpartum patients is one couplet, and in the case of
multiple births, one nurse for each additional baby.
(6) The maximum patient assignment of postpartum
patients to a registered nurse is 6 patients or 3 couplets.
(h) In all units with pediatric patients, the maximum
patient assignment of pediatric patients to a registered nurse
is 3.
(i) In all units with psychiatric patients, the maximum
patient assignment of psychiatric patients to a registered
nurse is 4.
(j) In all units with medical and surgical patients, the
maximum patient assignment of medical or surgical patients to a
registered nurse is 4.
(k) In all units with telemetry patients, the maximum

10100SB1908sam001 - 6 - LRB101 08484 CPF 58244 a
patient assignment of telemetry patients to a registered nurse
is 3.
(l) In all units with observational patients, the maximum
patient assignment of observational patients to a registered
nurse is 3.
(m) In all units with acute rehabilitation patients, the
maximum patient assignment of acute rehabilitation patients to
a registered nurse is 4.
(n) In all specialty care units, the maximum patient
assignment to a registered nurse is 4.
(o) In all units with conscious sedation patients, the
maximum patient assignment of conscious sedation patients to a
registered nurse is one.
(p) In any unit not otherwise listed in this Section, the
maximum patient assignment to a registered nurse is 4.
Section 15. Use of rapid response teams as first responders
prohibited. A rapid response team nurse shall not be given
direct care patient assignments while assigned as a nurse
responsible for responding to a rapid response team request.
Section 20. Implementation by a facility.
(a) A facility shall implement the patient limits
established by Section 10 without diminishing the staffing
levels of the facility's health care workforce.
(b) There shall be no averaging of the number of patients

10100SB1908sam001 - 7 - LRB101 08484 CPF 58244 a
and the total number of registered nurses in each clinical unit
or patient care area in order to meet the limits established
under this Act.
(c) Only registered nurses providing direct patient care
shall be included in complying with the patient limits under
Section 10. Nurse administrators, nurse supervisors, nurse
managers, charge nurses, case managers, ancillary staff,
unlicensed personnel, or any other hospital administrator or
supervisor shall not be included in complying with the patient
limits under Section 10.
(d) Identifying a clinical unit or patient care area by a
name or term other than those listed in this Act does not
affect a facility's requirement to staff the unit consistent
with the patient limits identified for the level of intensity
or type of care described in this Act.
(e) A registered nurse providing direct care to a patient
has the authority to determine if a change in the patient's
status places the patient in a different category requiring a
different patient limit under Section 10.
(f) A registered nurse may determine that additional
ancillary staff, such as licensed practical nurses, certified
nursing assistants, or other ancillary staff, excluding
medical assistants, are needed in order to provide safe care.
(g) A facility shall not employ video monitors or any form
of electronic visualization of a patient as a substitute for
the direct observation required for patient assessment by the

10100SB1908sam001 - 8 - LRB101 08484 CPF 58244 a
registered nurse or for patient protection. Video monitors or
any form of electronic visualization of a patient shall not
constitute compliance with the patient limits under Section 10.
Section 25. Changes in patient census.
(a) A facility shall plan for routine fluctuations in its
patient census, including, but not limited to, admissions,
discharges, and transfers.
(b) If a health care emergency causes a change in the
number of patients in a clinical care unit or patient care
area, a facility must be able to demonstrate that immediate and
diligent efforts were made to maintain required staffing levels
under this Act. For purposes of this subsection, "health care
emergency" means an emergency declared by the federal
government or the head of a State or local governmental entity.
Section 30. Record of staff assignments. A facility shall
keep a record of the actual direct care registered professional
nurse, licensed practical nurse, certified nursing assistant,
and other ancillary staff assignments to individual patients
documented on a day-to-day, shift-by-shift basis and shall keep
copies of its staff assignments on file for a period of 7
years.
Section 35. Implementation by the Department. The
Department shall adopt rules governing the implementation and

10100SB1908sam001 - 9 - LRB101 08484 CPF 58244 a
operation of this Act.
Section 40. Patient acuity systems. Nothing in this Act
precludes the use of patient acuity systems consistent with
Section 10.10 of the Hospital Licensing Act. However, the
maximum patient assignments in Section 10 shall not be exceeded
regardless of the use and application of any patient acuity
system.
Any method, software, or tool used to create or evaluate a
staffing plan adopted by a facility shall be established in
coordination with direct care registered professional nurses
and shall be transparent in all respects, including disclosure
of detailed documentation of the methodology used to determine
nurse staffing and identifying each factor, assumption, and
value used in applying the methodology. The Department shall
establish procedures to ensure that the documentation
submitted under this Section is available for public inspection
in its entirety.
Section 45. Training. All facilities shall adopt written
policies and procedures for the training and orientation of
nursing staff. No registered nurse shall be assigned to a
nursing unit or clinical area unless that nurse has first
received training and orientation in that clinical area that is
sufficient to provide competent care to patients in that area
and has demonstrated competence in providing care in that area.

10100SB1908sam001 - 10 - LRB101 08484 CPF 58244 a
The written policies and procedures for that training and
orientation of nursing staff shall require that all temporary
personnel receive the same amount and type of training and
orientation that is required for permanent staff. Coverage
during breaks, meals, and other routine, expected absences from
the clinical or patient care area must comply with this
Section.
Section 50. Enforcement. A facility's failure to adhere to
the limits set by Section 10 shall be reported by the
Department to the Attorney General for enforcement, for which
the Attorney General may bring action in a court of competent
jurisdiction seeking injunctive relief and civil penalties. A
separate and distinct violation, for which the facility shall
be subject to a civil penalty of up to $25,000, shall be deemed
to have been committed on each day during which any violation
continues after receipt of written notice of the violation from
the Department by the facility. The requirements of this Act,
and its enforcement, shall be suspended during a public health
emergency declared by the State or federal government.
Section 55. Whistleblower protection.
(a) A registered professional nurse may object to or refuse
to participate in any activity, practice, assignment, or task
if:
(1) in good faith, the nurse reasonably believes it to

10100SB1908sam001 - 11 - LRB101 08484 CPF 58244 a
be a violation of the direct care registered professional
nurse-to-patient ratios established under this Act; or
(2) the nurse is not prepared by education, training,
or experience to fulfill the assignment without
compromising the safety of any patient or jeopardizing the
license of the nurse.
(b) A facility shall not retaliate, discriminate, or
otherwise take adverse action in any manner with respect to any
aspect of a nurse's employment, including discharge,
promotion, compensation, or terms, conditions, or privileges
of employment, based on the nurse's refusal to complete an
assignment under subsection (a).
(c) A facility shall not file a complaint against a
registered professional nurse with the Board of Nursing based
on the nurse's refusal to complete an assignment under
subsection (a).
(d) A facility shall not retaliate, discriminate, or
otherwise take adverse action in any manner against any person
or with respect to any aspect of a nurse's employment,
including discharge, promotion, compensation, or terms,
conditions, or privileges of employment, based on that nurse's
or that person's opposition to any hospital policy, practice,
or action that the nurse in good faith believes violates this
Act.
(e) A facility shall not retaliate, discriminate, or
otherwise take adverse action against any patient or employee

10100SB1908sam001 - 12 - LRB101 08484 CPF 58244 a
of the facility or any other individual on the basis that the
patient, employee, or individual, in good faith, individually
or in conjunction with another person or persons, has presented
a grievance or complaint, or has initiated or cooperated in any
investigation or proceeding of any governmental entity,
regulatory agency, or private accreditation body, made a civil
claim or demand, or filed an action relating to the care,
services, or conditions of the facility or of any affiliated or
related facilities.
(f) A facility shall not do either of the following:
(1) Interfere with, restrain, or deny the exercise of,
or attempt to deny the exercise of, a right conferred under
this Act.
(2) Coerce or intimidate any individual regarding the
exercise of, or an attempt to exercise, a right conferred
by this Act.
Section 60. Severability. The provisions of this Act are
severable, and if any clause, sentence, paragraph, subsection,
or Section of this law or any application thereof shall be
adjudged by any court of competent jurisdiction to be invalid,
such judgment shall not affect, impair, or invalidate the
remainder thereof but shall be confined in its operation to the
clause, sentence, paragraph, subsection, Section, or
application adjudged invalid and such clause, sentence,
paragraph, subsection, Section, or application shall be

10100SB1908sam001 - 13 - LRB101 08484 CPF 58244 a
reformed and construed so that it would be valid to the maximum
extent permitted.
Section 85. The Hospital Licensing Act is amended by
changing Section 10.10 as follows:
(210 ILCS 85/10.10)
Sec. 10.10. Nurse Staffing by Patient Acuity.
(a) Findings. The Legislature finds and declares all of the
following:
(1) The State of Illinois has a substantial interest in
promoting quality care and improving the delivery of health
care services.
(2) Evidence-based studies have shown that the basic
principles of staffing in the acute care setting should be
based on the complexity of patients' care needs aligned
with available nursing skills to promote quality patient
care consistent with professional nursing standards.
(3) Compliance with this Section promotes an
organizational climate that values registered nurses'
input in meeting the health care needs of hospital
patients.
(b) Definitions. As used in this Section:
"Acuity model" means an assessment tool selected and
implemented by a hospital, as recommended by a nursing care
committee, that assesses the complexity of patient care needs

10100SB1908sam001 - 14 - LRB101 08484 CPF 58244 a
requiring professional nursing care and skills and aligns
patient care needs and nursing skills consistent with
professional nursing standards.
"Department" means the Department of Public Health.
"Direct patient care" means care provided by a registered
professional nurse with direct responsibility to oversee or
carry out medical regimens or nursing care for one or more
patients.
"Nursing care committee" means an existing or newly created
hospital-wide committee or committees of nurses whose
functions, in part or in whole, contribute to the development,
recommendation, and review of the hospital's nurse staffing
plan established pursuant to subsection (d).
"Registered professional nurse" means a person licensed as
a Registered Nurse under the Nurse Practice Act.
"Written staffing plan for nursing care services" means a
written plan for guiding the assignment of patient care nursing
staff based on multiple nurse and patient considerations that
yield minimum staffing levels for inpatient care units and the
adopted acuity model aligning patient care needs with nursing
skills required for quality patient care consistent with
professional nursing standards.
(c) Written staffing plan.
(1) Every hospital shall implement a written
hospital-wide staffing plan, recommended by a nursing care
committee or committees, that provides for minimum direct

10100SB1908sam001 - 15 - LRB101 08484 CPF 58244 a
care professional registered nurse-to-patient staffing
needs for each inpatient care unit. The written
hospital-wide staffing plan shall include, but need not be
limited to, the following considerations:
(A) The complexity of complete care, assessment on
patient admission, volume of patient admissions,
discharges and transfers, evaluation of the progress
of a patient's problems, ongoing physical assessments,
planning for a patient's discharge, assessment after a
change in patient condition, and assessment of the need
for patient referrals.
(B) The complexity of clinical professional
nursing judgment needed to design and implement a
patient's nursing care plan, the need for specialized
equipment and technology, the skill mix of other
personnel providing or supporting direct patient care,
and involvement in quality improvement activities,
professional preparation, and experience.
(C) Patient acuity and the number of patients for
whom care is being provided.
(D) The ongoing assessments of a unit's patient
acuity levels and nursing staff needed shall be
routinely made by the unit nurse manager or his or her
designee.
(E) The identification of additional registered
nurses available for direct patient care when

10100SB1908sam001 - 16 - LRB101 08484 CPF 58244 a
patients' unexpected needs exceed the planned workload
for direct care staff.
(2) In order to provide staffing flexibility to meet
patient needs, every hospital shall identify an acuity
model for adjusting the staffing plan for each inpatient
care unit.
(3) The written staffing plan shall be posted in a
conspicuous and accessible location for both patients and
direct care staff, as required under the Hospital Report
Card Act. A copy of the written staffing plan shall be
provided to any member of the general public upon request.
(d) Nursing care committee.
(1) Every hospital shall have a nursing care committee.
A hospital shall appoint members of a committee whereby at
least 50% of the members are registered professional nurses
providing direct patient care.
(2) A nursing care committee's recommendations must be
given significant regard and weight in the hospital's
adoption and implementation of a written staffing plan.
(3) A nursing care committee or committees shall
recommend a written staffing plan for the hospital based on
the principles from the staffing components set forth in
subsection (c). In particular, a committee or committees
shall provide input and feedback on the following:
(A) Selection, implementation, and evaluation of
minimum staffing levels for inpatient care units.

10100SB1908sam001 - 17 - LRB101 08484 CPF 58244 a
(B) Selection, implementation, and evaluation of
an acuity model to provide staffing flexibility that
aligns changing patient acuity with nursing skills
required.
(C) Selection, implementation, and evaluation of a
written staffing plan incorporating the items
described in subdivisions (c)(1) and (c)(2) of this
Section.
(D) Review the following: nurse-to-patient
staffing guidelines for all inpatient areas; and
current acuity tools and measures in use.
(4) A nursing care committee must address the items
described in subparagraphs (A) through (D) of paragraph (3)
semi-annually.
(e) Nothing in this Section 10.10 shall be construed to
limit, alter, or modify any of the terms, conditions, or
provisions of a collective bargaining agreement entered into by
the hospital.
(f) A hospital shall not directly assign any unlicensed
personnel to perform registered professional nurse functions
in lieu of care delivered by a registered professional nurse
and shall not assign unlicensed personnel to perform registered
professional nurse functions under the supervision of a direct
care registered professional nurse.
(g) Unlicensed personnel shall not be required to perform
tasks that require the clinical assessment, professional

10100SB1908sam001 - 18 - LRB101 08484 CPF 58244 a
judgment, and skill of a licensed registered professional
nurse, including, but not limited to, the following: activities
that require a nursing assessment or nursing judgment during
implementation; physical, psychological, and social
assessments that require nursing judgment, intervention,
referral, or follow-up; formulation of a plan of nursing care
and evaluation of a patient's response to the care provided;
and administration of medications.
(Source: P.A. 96-328, eff. 8-11-09; 97-423, eff. 1-1-12;
97-813, eff. 7-13-12.)
Section 90. The Nurse Practice Act is amended by adding
Sections 50-15.1, 50-15.5, 50-15.10, and 50-15.15 as follows:
(225 ILCS 65/50-15.1 new)
Sec. 50-15.1. Functions generally.
(a) A direct care registered professional nurse, holding a
valid license to practice as a registered professional nurse,
employing scientific knowledge and experience in the physical,
social, and biological sciences, and exercising independent
professional judgment in applying the nursing process in the
exclusive interests of a patient, shall directly perform the
following essential functions:
(1) Continuous and ongoing comprehensive nursing
assessments of a patient's condition based upon the
independent professional judgment of the direct care

10100SB1908sam001 - 19 - LRB101 08484 CPF 58244 a
registered professional nurse.
(2) Planning, implementation, and evaluation of the
nursing care provided to each patient. The implementation
of nursing care may be assigned by the direct care
registered professional nurse responsible for the patient
to other licensed nursing staff or to unlicensed staff,
subject to any limitations of the licensure,
certification, level of validated competency, or
applicable law concerning such staff. In any case, however:
(A) The direct care registered professional nurse
assigned to a patient must determine in her or his
professional judgment that nursing personnel to be
assigned patient care tasks possess the necessary
preparation and capability to competently perform the
assigned tasks.
(B) The direct care registered professional nurse
may assign the implementation of nursing care only when
the registered professional nurse is physically
present and available.
(3) Assessment, planning, implementation, and
evaluation of patient education, including ongoing
discharge education of each patient.
(b) The planning and delivery of patient care shall: (i)
reflect all elements of the nursing process, including
comprehensive nursing assessment, nursing diagnosis, planning,
intervention, evaluation, and, as circumstances require,

10100SB1908sam001 - 20 - LRB101 08484 CPF 58244 a
patient advocacy; and (ii) be initiated by a direct care
registered professional nurse at the time of a patient's
admission to the hospital.
(c) A nursing plan for a patient's care shall be discussed
with and developed as a result of coordination with the
patient, the patient's family, or other representatives of the
patient, when appropriate, and staff of other disciplines
involved in the care of the patient.
(d) A direct care registered professional nurse shall
evaluate the effectiveness of the care plan through: (i)
comprehensive nursing assessments based on direct observation
of the patient's physical condition and behavior, signs and
symptoms of illness, and reactions to treatment; and (ii)
communication with the patient and other caregivers as
applicable. The direct care registered professional nurse
shall modify the plan as needed.
(e) Information related to the patient's initial
comprehensive nursing assessment and reassessments, nursing
diagnosis, plan, intervention, evaluation, and patient
advocacy shall be permanently recorded, as narrative
registered professional nurse progress notes, in the patient's
medical record. The practice of "charting by exception" is
expressly prohibited.
(225 ILCS 65/50-15.5 new)
Sec. 50-15.5. Patient assessment.

10100SB1908sam001 - 21 - LRB101 08484 CPF 58244 a
(a) Patient assessment requires: (i) direct observation of
the patient's signs and symptoms of illness, reaction to
treatment, behavior and physical condition; and (ii)
interpretation of information obtained from the patient and
others, including other caregivers, as applicable.
(b) Only a direct care registered professional nurse who is
physically present with the patient is authorized to perform
patient assessments. A licensed practical nurse may assist a
direct care registered professional nurse in data collection.
(225 ILCS 65/50-15.10 new)
Sec. 50-15.10. Determining nursing care needs of patients.
(a) The nursing care needs of each individual patient shall
be determined by a direct care registered professional nurse
through the process of ongoing comprehensive nursing
assessments, nursing diagnosis, and formulation and adjustment
of nursing care plans.
(b) The prediction of individual patient nursing care needs
for prospective assignment of direct care registered
professional nurses shall be based on individual comprehensive
nursing assessments by the direct care registered professional
nurse assigned to each patient.
(225 ILCS 65/50-15.15 new)
Sec. 50-15.15. Independent professional judgment.
(a) Competent performance of the essential functions of a

10100SB1908sam001 - 22 - LRB101 08484 CPF 58244 a
direct care registered professional nurse requires the
exercise of independent professional judgment in the exclusive
interests of the patient. The exercise of such independent
professional judgment, unencumbered by the commercial or
revenue-generation priorities of a hospital, long term acute
care hospital, or ambulatory surgical treatment center or other
employing entity of a direct care registered professional
nurse, is necessary to ensure safe, therapeutic, effective, and
competent treatment of hospital patients and is essential to
protect the health and safety of the people of Illinois.
(b) The exercise of independent professional judgment by a
direct care registered professional nurse in the performance of
the essential functions, as described in paragraphs (1), (2),
and (3) of subsection (a) of Section 15-1, shall be provided in
the exclusive interests of the patient and shall not, for any
purpose, be considered, relied upon, or represented as a job
function, authority, responsibility, or activity undertaken in
any respect for the purpose of serving the business,
commercial, operational, or other institutional interests of
the hospital.
(c) No hospital, long term acute care hospital, ambulatory
surgical treatment center, or other health care institution
shall utilize technology that:
(1) limits a direct care registered professional nurse
in performing functions that are part of the nursing
process, including full exercise of independent

10100SB1908sam001 - 23 - LRB101 08484 CPF 58244 a
professional judgment in assessment, planning,
implementation and evaluation of care; or
(2) limits a direct care registered professional nurse
in acting as a patient advocate in the exclusive interests
of the patient.
Technology shall not be skill-degrading, interfere with a
direct care registered professional nurse's provision of
individualized patient care, or override a direct care
registered professional nurse's independent professional
judgment.".