(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.