(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 Section70053.2 above for determining nursing care needs of
individual patients that reflects the assessment, made by a registered nurse as
specified at subsection70215(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.
