(a)
Hospitals shall provide staffing by licensed nurses, within the scope of their
licensure in accordance with the following nurse-to-patient ratios. Licensed
nurse means a registered nurse, licensed vocational nurse and, in psychiatric
units only, a psychiatric technician. Staffing for care not requiring a
licensed nurse is not included within these ratios and shall be determined
pursuant to the patient classification system.
No hospital shall assign a licensed nurse to a nursing unit
or clinical area unless that hospital determines that the licensed nurse has
demonstrated current competence in providing care in that area, and has also
received orientation to that hospital's clinical area sufficient to provide
competent care to patients in that area. The policies and procedures of the
hospital shall contain the hospital's criteria for making this
determination.
Licensed nurse-to-patient ratios represent the maximum
number of patients that shall be assigned to one licensed nurse at any one
time. "Assigned" means the licensed nurse has responsibility for the provision
of care to a particular patient within his/her scope of practice. There shall
be no averaging of the number of patients and the total number of licensed
nurses on the unit during any one shift nor over any period of time. Only
licensed nurses providing direct patient care shall be included in the
ratios.
Nurse Administrators, Nurse Supervisors, Nurse Managers,
and Charge Nurses, and other licensed nurses shall be included in the
calculation of the licensed nurse-to-patient ratio only when those licensed
nurses are engaged in providing direct patient care. When a Nurse
Administrator, Nurse Supervisor, Nurse Manager, Charge Nurse or other licensed
nurse is engaged in activities other than direct patient care, that nurse shall
not be included in the ratio. Nurse Administrators, Nurse Supervisors, Nurse
Managers, and Charge Nurses who have demonstrated current competence to the
hospital in providing care on a particular unit may relieve licensed nurses
during breaks, meals, and other routine, expected absences from the
unit.
Licensed vocational nurses may constitute up to 50 percent
of the licensed nurses assigned to patient care on any unit, except where
registered nurses are required pursuant to the patient classification system or
this section. Only registered nurses shall be assigned to Intensive Care
Newborn Nursery Service Units, which specifically require one registered nurse
to two or fewer infants. In the Emergency Department, only registered nurses
shall be assigned to triage patients and only registered nurses shall be
assigned to critical trauma patients.
Nothing in this section shall prohibit a licensed nurse
from assisting with specific tasks within the scope of his or her practice for
a patient assigned to another nurse. "Assist" means that licensed nurses may
provide patient care beyond their patient assignments if the tasks performed
are specific and time-limited.
(1) The
licensed nurse-to-patient ratio in a critical care unit shall be 1:2 or fewer
at all times. "Critical care unit" means a nursing unit of a general acute care
hospital which provides one of the following services: an intensive care
service, a burn center, a coronary care service, an acute respiratory service,
or an intensive care newborn nursery service. In the intensive care newborn
nursery service, the ratio shall be 1 registered nurse:2 or fewer patients at
all times.
(2) The surgical service
operating room shall have at least one registered nurse assigned to the duties
of the circulating nurse and a minimum of one additional person serving as
scrub assistant for each patient-occupied operating room. The scrub assistant
may be a licensed nurse, an operating room technician, or other person who has
demonstrated current competence to the hospital as a scrub assistant, but shall
not be a physician or other licensed health professional who is assisting in
the performance of surgery.
(3) The
licensed nurse-to-patient ratio in a labor and delivery suite of the perinatal
service shall be 1:2 or fewer active labor patients at all times. When a
licensed nurse is caring for antepartum patients who are not in active labor,
the licensed nurse-to-patient ratio shall be 1:4 or fewer at all
times.
(4) The licensed
nurse-to-patient ratio in a postpartum area of the perinatal service shall be
1:4 mother-baby couplets or fewer at all times. In the event of multiple
births, the total number of mothers plus infants assigned to a single licensed
nurse shall never exceed eight. For postpartum areas in which the licensed
nurse's assignment consists of mothers only, the licensed nurse-to-patient
ratio shall be 1:6 or fewer at all times.
(5) The licensed nurse-to-patient ratio in a
combined Labor/Delivery/Postpartum area of the perinatal service shall be 1:3
or fewer at all times the licensed nurse is caring for a patient combination of
one woman in active labor and a postpartum mother and infant The licensed
nurse-to-patient ratio for nurses caring for women in active labor only,
antepartum patients who are not in active labor only, postpartum women only, or
mother-baby couplets only, shall be the same ratios as stated in subsections
(3) and (4) above for those categories of patients.
(6) The licensed nurse-to-patient ratio in a
pediatric service unit shall be 1:4 or fewer at all times.
(7) The licensed nurse-to-patient ratio in a
postanesthesia recovery unit of the anesthesia service shall be 1:2 or fewer at
all times, regardless of the type of anesthesia the patient received.
(8) In a hospital providing basic emergency
medical services or comprehensive emergency medical services, the licensed
nurse-to-patient ratio in an emergency department shall be 1:4 or fewer at all
times that patients are receiving treatment. There shall be no fewer than two
licensed nurses physically present in the emergency department when a patient
is present.
At least one of the licensed nurses shall be a registered
nurse assigned to triage patients. The registered nurse assigned to triage
patients shall be immediately available at all times to triage patients when
they arrive in the emergency department. When there are no patients needing
triage, the registered nurse may assist by performing other nursing tasks. The
registered nurse assigned to triage patients shall not be counted in the
licensed nurse-to-patient ratio.
Hospitals designated by the Local Emergency Medical
Services (LEMS) Agency as a "base hospital," as defined in section 1797.58 of
the Health and Safety Code, shall have either a licensed physician or a
registered nurse on duty to respond to the base radio 24 hours each day. When
the duty of base radio responder is assigned to a registered nurse, that
registered nurse may assist by performing other nursing tasks when not
responding to radio calls, but shall be immediately available to respond to
requests for medical direction on the base radio. The registered nurse assigned
as base radio responder shall not be counted in the licensed nurse-to-patient
ratios.
When licensed nursing staff are attending critical care
patients in the emergency department, the licensed nurse-to-patient ratio shall
be 1:2 or fewer critical care patients at all times. 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.
Only registered nurses shall be assigned to critical trauma
patients in the emergency department, and a minimum registered
nurse-to-critical trauma patient ratio of 1:1 shall be maintained at all times.
A critical trauma patient is a patient who has injuries to an anatomic area
that :
(1) require life saving
interventions, or
(2) in
conjunction with unstable vital signs, pose an immediate threat to life or
limb.
(9) The licensed
nurse-to-patient ratio in a step-down unit shall be 1:4 or fewer at all times.
Commencing January 1, 2008, the licensed nurse-to-patient ratio in a step-down
unit shall be 1:3 or fewer at all times. A "step down unit" is defined as a
unit which is organized, operated, and maintained to provide for the monitoring
and care of patients with moderate or potentially severe physiologic
instability requiring technical support but not necessarily artificial life
support. Step-down patients are those patients who require less care than
intensive care, but more than that which is available from medical/surgical
care. "Artificial life support" is defined as a system that uses medical
technology to aid, support, or replace a vital function of the body that has
been seriously damaged. "Technical support" is defined as specialized equipment
and/or personnel providing for invasive monitoring, telemetry, or mechanical
ventilation, for the immediate amelioration or remediation of severe
pathology.
(10) The licensed
nurse-to-patient ratio in a telemetry unit shall be 1:5 or fewer at all times.
Commencing January 1, 2008, the licensed nurse-to-patient ratio in a telemetry
unit shall be 1:4 or fewer at all times. "Telemetry unit" is defined as a unit
organized, operated, and maintained to provide care for and continuous cardiac
monitoring of patients in a stable condition, having or suspected of having a
cardiac condition or a disease requiring the electronic monitoring, recording,
retrieval, and display of cardiac electrical signals. "Telemetry unit" as
defined in these regulations does not include fetal monitoring nor fetal
surveillance.
(11) The licensed
nurse-to-patient ratio in medical/surgical care units shall be 1:6 or fewer at
all times. Commencing January 1, 2005, the licensed nurse-to-patient ratio in
medical/surgical care units shall be 1:5 or fewer at all times. A
medical/surgical unit is a unit with beds classified as medical/surgical in
which patients, who require less care than that which is available in intensive
care units, step-down units, or specialty care units receive 24 hour inpatient
general medical services, post-surgical services, or both general medical and
post-surgical services. These units may include mixed patient populations of
diverse diagnoses and diverse age groups who require care appropriate to a
medical/surgical unit.
(12) The
licensed nurse-to-patient ratio in a specialty care unit shall be 1:5 or fewer
at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio
in a specialty care unit shall be 1:4 or fewer at all times. A specialty care
unit is defined as a unit which is organized, operated, and maintained to
provide care for a specific medical condition or a specific patient population.
Services provided in these units are more specialized to meet the needs of
patients with the specific condition or disease process than that which is
required on medical/surgical units, and is not otherwise covered by subdivision
(a).
(13) The licensed
nurse-to-patient ratio in a psychiatric unit shall be 1:6 or fewer at all
times. For purposes of psychiatric units only, "licensed nurses" also includes
psychiatric technicians in addition to licensed vocational nurses and
registered nurses. Licensed vocational nurses, psychiatric technicians, or a
combination of both, shall not exceed 50 percent of the licensed nurses on the
unit.
(14) Identifying a unit by a
name or term other than those used in this subsection does not affect the
requirement to staff at the ratios identified for the level or type of care
described in this subsection.
(b) In addition to the requirements of
subsection (a), the hospital shall implement a patient classification system as
defined in Section
70053.2 above for determining
nursing care needs of individual patients that reflects the assessment, made by
a registered nurse as specified at subsection
70215(a)(1), of
patient requirements and provides for shift-by-shift staffing based on those
requirements. The ratios specified in subsection (a) shall constitute the
minimum number of registered nurses, licensed vocational nurses, and in the
case of psychiatric units, psychiatric technicians, who shall be assigned to
direct patient care. Additional staff in excess of these prescribed ratios,
including non-licensed staff, shall be assigned in accordance with the
hospital's documented patient classification system for determining nursing
care requirements, considering factors that include the severity of the
illness, the need for specialized equipment and technology, the complexity of
clinical judgment needed to design, implement, and evaluate the patient care
plan, the ability for self-care, and the licensure of the personnel required
for care. The system developed by the hospital shall include, but not be
limited to, the following elements:
(1)
Individual patient care requirements.
(2) The patient care delivery
system.
(3) Generally accepted
standards of nursing practice, as well as elements reflective of the unique
nature of the hospital's patient population.
(c) A written staffing plan shall be
developed by the administrator of nursing service or a designee, based on
patient care needs determined by the patient classification system. The
staffing plan shall be developed and implemented for each patient care unit and
shall specify patient care requirements and the staffing levels for registered
nurses and other licensed and unlicensed personnel. In no case shall the
staffing level for licensed nurses fall below the requirements of subsection
(a). The plan shall include the following:
(1)
Staffing requirements as determined by the patient classification system for
each unit, documented on a day-to-day, shift-by-shift basis.
(2) The actual staff and staff mix provided,
documented on a day-to-day, shift-by-shift basis.
(3) The variance between required and actual
staffing patterns, documented on a day-to-day, shift-by-shift
basis.
(d) In addition to
the documentation required in subsections (c)(1) through (3) above, the
hospital shall keep a record of the actual registered nurse, licensed
vocational nurse and psychiatric technician assignments to individual patients
by licensure category, documented on a day-to-day, shift-by-shift basis. The
hospital shall retain:
(1) The staffing plan
required in subsections (c)(1) through (3) for the time period between
licensing surveys, which includes the Consolidated Accreditation and Licensing
Survey process, and
(2) The record
of the actual registered nurse, licensed vocational nurse and psychiatric
technician assignments by licensure category for a minimum of one
year.
(e) The reliability
of the patient classification system for validating staffing requirements shall
be reviewed at least annually by a committee appointed by the nursing
administrator to determine whether or not the system accurately measures
patient care needs.
(f) At least
half of the members of the review committee shall be registered nurses who
provide direct patient care.
(g) If
the review reveals that adjustments are necessary in the patient classification
system in order to assure accuracy in measuring patient care needs, such
adjustments must be implemented within thirty (30) days of that
determination.
(h) Hospitals shall
develop and document a process by which all interested staff may provide input
about the patient classification system, the system's required revisions, and
the overall staffing plan.
(i) The
administrator of nursing services shall not be designated to serve as a charge
nurse or to have direct patient care responsibility, except as described in
subsection (a) above.
(j)
Registered nursing personnel shall:
(1)
Assist the administrator of nursing service so that supervision of nursing care
occurs on a 24-hour basis.
(2)
Provide direct patient care.
(3)
Provide clinical supervision and coordination of the care given by licensed
vocational nurses and unlicensed nursing personnel.
(k) Each patient care unit shall have a
registered nurse assigned, present and responsible for the patient care in the
unit on each shift.
(l) A rural
General Acute Care Hospital as defined in Health and Safety Code Section
1250(a), may apply for and be granted program flexibility for the requirements
of subsection
70217(i) and for
the personnel requirements of subsection (j)(1) above.
(m) Unlicensed personnel may be utilized as
needed to assist with simple nursing procedures, subject to the requirements of
competency validation. Hospital policies and procedures shall describe the
responsibility of unlicensed personnel and limit their duties to tasks that do
not require licensure as a registered or vocational nurse.
(n) Nursing personnel from temporary nursing
agencies shall not be responsible for a patient care unit without having
demonstrated clinical and supervisory competence as defined by the hospital's
standards of staff performance pursuant to the requirements of subsection
70213(c)
above.
(o) Hospitals which utilize
temporary nursing agencies shall have and adhere to a written procedure to
orient and evaluate personnel from these sources. Such procedures shall require
that personnel from temporary nursing agencies be evaluated as often, or more
often, than staff employed directly by the hospital.
(p) All registered and licensed vocational
nurses utilized in the hospital shall have current licenses. A method to
document current licensure shall be established.
(q) The hospital shall plan for routine
fluctuations in patient census. If a healthcare emergency causes a change in
the number of patients on a unit, the hospital must demonstrate that prompt
efforts were made to maintain required staffing levels. A healthcare emergency
is defined for this purpose as an unpredictable or unavoidable occurrence at
unscheduled or unpredictable intervals relating to healthcare delivery
requiring immediate medical interventions and care.
