Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2019

II 116TH CONGRESS 1ST SESSION S. 1357 To amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio requirements in hospitals, and for other purposes. IN THE SENATE OF THE UNITED STATES MAY 8, 2019 Mr. BROWN (for himself, Ms. BALDWIN, Ms. HARRIS, Mr. SANDERS, and Ms. WARREN) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions A BILL To amend the Public Health Service Act to establish direct care registered nurse-to-patient staffing ratio require- ments in hospitals, and for other purposes. Be it enacted by the Senate and House of Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE; TABLE OF CONTENTS; FINDINGS. 3 (a) SHORT TITLE.—This Act may be cited as the 4 ‘‘Nurse Staffing Standards for Hospital Patient Safety 5 and Quality Care Act of 2019’’. 6 (b) TABLE OF CONTENTS.—The table of contents for 7 this Act is as follows: 8 Sec. 1. Short title; table of contents; findings. VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6211 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 2 •S 1357 IS Sec. 2. Minimum direct care registered nurse staffing requirement. Sec. 3. Enforcement of requirements through Federal programs. Sec. 4. Nurse workforce initiative. (c) FINDINGS.—Congress finds the following: 1 (1) The Federal Government has a substantial 2 interest in promoting quality care and improving the 3 delivery of health care services to patients in health 4 care facilities in the United States. 5 (2) Recent changes in health care delivery sys- 6 tems that have resulted in higher acuity levels 7 among patients in health care facilities increase the 8 need for improved quality measures in order to pro- 9 tect patient care and reduce the incidence of medical 10 errors. 11 (3) Inadequate and poorly monitored registered 12 nurse staffing practices that result in too few reg- 13 istered nurses providing direct care jeopardize the 14 delivery of quality health care services. 15 (4) Numerous studies have shown that patient 16 outcomes are directly correlated to direct care reg- 17 istered nurse staffing levels, including a 2010 18 Health Services Research study that concluded that 19 implementation of minimum nurse-to-patient staff- 20 ing ratios in California has led to improved patient 21 outcomes and nurse retention and a 2014 Agency 22 for Healthcare Research and Quality study that con- 23 cluded increases in nurse staffing and skill mix lead 24 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 3 •S 1357 IS to improved quality and reduced length of stay at no 1 additional cost. 2 (5) Requirements for direct care registered 3 nurse staffing ratios will help address the registered 4 nurse shortage in the United States by aiding in re- 5 cruitment of new registered nurses and improving 6 retention of registered nurses who are considering 7 leaving direct patient care because of demands cre- 8 ated by inadequate staffing. 9 (6) Establishing adequate minimum direct care 10 registered nurse-to-patient ratios that take into ac- 11 count patient acuity measures will improve the deliv- 12 ery of quality health care services and guarantee pa- 13 tient safety. 14 (7) Establishing safe staffing standards for di- 15 rect care registered nurses is a critical component of 16 assuring that there is adequate hospital staffing at 17 all levels to improve the delivery of quality care and 18 protect patient safety. 19 SEC. 2. MINIMUM DIRECT CARE REGISTERED NURSE 20 STAFFING REQUIREMENT. 21 (a) MINIMUM DIRECT CARE REGISTERED NURSE 22 STAFFING REQUIREMENTS.—The Public Health Service 23 Act (42 U.S.C. 201 et seq.) is amended by adding at the 24 end the following new title: 25 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 4 •S 1357 IS ‘‘TITLE XXXIV—MINIMUM DI- 1 RECT CARE REGISTERED 2 NURSE STAFFING REQUIRE- 3 MENT 4 ‘‘SEC. 3401. MINIMUM NURSE STAFFING REQUIREMENT. 5 ‘‘(a) STAFFING PLAN.— 6 ‘‘(1) IN GENERAL.—A hospital shall implement 7 a staffing plan that— 8 ‘‘(A) provides adequate, appropriate, and 9 quality delivery of health care services and pro- 10 tects patient safety; and 11 ‘‘(B) is consistent with the requirements of 12 this title. 13 ‘‘(2) EFFECTIVE DATES.— 14 ‘‘(A) IMPLEMENTATION OF STAFFING 15 PLAN.—Subject to subparagraph (B), the re- 16 quirements under paragraph (1) shall take ef- 17 fect on a date to be determined by the Sec- 18 retary, but not later than 1 year after the date 19 of the enactment of this title. 20 ‘‘(B) APPLICATION OF MINIMUM DIRECT 21 CARE REGISTERED NURSE-TO-PATIENT RA- 22 TIOS.—The requirements under subsection (b) 23 shall take effect as soon as practicable, as de- 24 termined by the Secretary, but not later than— 25 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 5 •S 1357 IS ‘‘(i) 2 years after the date of enact- 1 ment of this title; and 2 ‘‘(ii) in the case of a hospital in a 3 rural area (as defined in section 4 1886(d)(2)(D) of the Social Security Act), 5 4 years after the date of enactment of this 6 title. 7 ‘‘(b) MINIMUM DIRECT CARE REGISTERED NURSE- 8 TO-PATIENT RATIOS.— 9 ‘‘(1) IN GENERAL.—Except as provided in para- 10 graph (4) and other provisions of this section, a hos- 11 pital’s staffing plan shall provide that, at all times 12 during each shift within a unit of the hospital, and 13 with a full complement of ancillary and support 14 staff, a direct care registered nurse may be assigned 15 to not more than the following number of patients 16 in that unit: 17 ‘‘(A) One patient in trauma emergency 18 units. 19 ‘‘(B) One patient in operating room units, 20 provided that a minimum of 1 additional person 21 serves as a scrub assistant in such unit. 22 ‘‘(C) Two patients in critical care units, in- 23 cluding neonatal intensive care units, emer- 24 gency critical care and intensive care units, 25 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 6 •S 1357 IS labor and delivery units, coronary care units, 1 acute respiratory care units, postanesthesia 2 units, and burn units. 3 ‘‘(D) Three patients in emergency room 4 units, pediatrics units, stepdown units, telem- 5 etry units, antepartum units, and combined 6 labor, deliver, and postpartum units. 7 ‘‘(E) Four patients in medical-surgical 8 units, intermediate care nursery units, acute 9 care psychiatric units, and other specialty care 10 units. 11 ‘‘(F) Five patients in rehabilitation units 12 and skilled nursing units. 13 ‘‘(G) Six patients in postpartum (3 cou- 14 plets) units and well-baby nursery units. 15 ‘‘(2) SIMILAR UNITS WITH DIFFERENT 16 NAMES.—The Secretary may apply minimum direct 17 care registered nurse-to-patient ratios established in 18 paragraph (1) for a hospital unit referred to in such 19 paragraph to a type of hospital unit not referred to 20 in such paragraph if such type of hospital unit pro- 21 vides a level of care to patients whose needs are 22 similar to the needs of patients cared for in the hos- 23 pital unit referred to in such paragraph. 24 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 7 •S 1357 IS ‘‘(3) APPLICATION OF RATIOS TO HOSPITAL 1 NURSING PRACTICE STANDARDS.— 2 ‘‘(A) IN GENERAL.—A patient assignment 3 may be included in the calculation of the direct 4 care registered nurse-to-patient ratios required 5 in this subsection only if care is provided by a 6 direct care registered nurse and the provision of 7 care to the particular patient is within that di- 8 rect care registered nurse’s competence. 9 ‘‘(B) DEMONSTRATION OF UNIT-SPECIFIC 10 COMPETENCE.—A hospital shall not assign a di- 11 rect care registered nurse to a hospital unit un- 12 less that hospital determines that the direct 13 care registered nurse has demonstrated current 14 competence in providing care in that unit, and 15 has also received orientation to that hospital’s 16 unit sufficient to provide competent care to pa- 17 tients in that unit. 18 ‘‘(C) DUTIES OF THE ASSIGNED DIRECT 19 CARE REGISTERED NURSE.—Each patient shall 20 be assigned to a direct care registered nurse 21 who shall directly provide the assessment, plan- 22 ning, supervision, implementation, and evalua- 23 tion of the nursing care provided to the patient 24 at least every shift and has the responsibility 25 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 8 •S 1357 IS for the provision of care to a particular patient 1 within his or her scope of practice. 2 ‘‘(D) NURSE ADMINISTRATORS AND SU- 3 PERVISORS.—A registered nurse who is a nurse 4 administrator, nurse supervisor, nurse manager, 5 charge nurse, case manager, or any other hos- 6 pital administrator or supervisor, shall not be 7 included in the calculation of the direct care 8 registered nurse-to-patient ratio unless that 9 nurse has a current and active direct patient 10 care assignment and provides direct patient 11 care in compliance with the requirements of this 12 section, including competency requirements. 13 The exemption in this subsection shall apply 14 only during the hours in which the individual 15 registered nurse has the principal responsibility 16 of providing direct patient care and has no ad- 17 ditional job duties as would a direct care reg- 18 istered nurse. 19 ‘‘(E) OTHER PERSONNEL.—Other per- 20 sonnel may perform patient care tasks based on 21 their training and demonstrated skill but may 22 not perform or assist in direct care registered 23 nurse functions unless authorized to do in ac- 24 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 9 •S 1357 IS cordance with State scope of practice laws and 1 regulations. 2 ‘‘(F) TEMPORARY NURSING PERSONNEL.— 3 A hospital shall not assign any nursing per- 4 sonnel from temporary nursing agencies patient 5 care to any hospital unit without such personnel 6 having demonstrated competence on the as- 7 signed unit and received orientation to that hos- 8 pital’s unit sufficient to provide competent care 9 to patients in that unit. 10 ‘‘(G) ANCILLARY AND ADDITIONAL STAFF- 11 ING.—The need for additional staffing of direct 12 care registered nurses, licensed vocational or 13 practical nurses, licensed psychiatric techni- 14 cians, certified nursing or patient care assist- 15 ants, or other licensed or unlicensed ancillary 16 staff above the minimum registered nurse-to-pa- 17 tient ratios shall be based on the assessment of 18 the individual patient’s nursing care require- 19 ment, the individual patient’s nursing care plan, 20 and acuity level. 21 ‘‘(4) RESTRICTIONS.— 22 ‘‘(A) PROHIBITION AGAINST AVERAGING.— 23 A hospital shall not average the number of pa- 24 tients and the total number of direct care reg- 25 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 10 •S 1357 IS istered nurses assigned to patients in a hospital 1 unit during any 1 shift or over any period of 2 time for purposes of meeting the requirements 3 under this subsection. 4 ‘‘(B) PROHIBITION AGAINST IMPOSITION 5 OF MANDATORY OVERTIME REQUIREMENTS.—A 6 hospital shall not impose mandatory overtime 7 requirements to meet the hospital unit direct 8 care registered nurse-to-patient ratios required 9 under this subsection. 10 ‘‘(C) RELIEF DURING ROUTINE AB- 11 SENCES.—A hospital shall ensure that only a 12 direct care registered nurse who has dem- 13 onstrated current competence to the hospital in 14 providing care on a particular unit and has also 15 received orientation to that hospital’s unit suffi- 16 cient to provide competent care to patients in 17 that unit may relieve another direct care reg- 18 istered nurse during breaks, meals, and other 19 routine, expected absences from a hospital unit. 20 ‘‘(D) APPLICATION OF DIRECT CARE REG- 21 ISTERED NURSE-TO-PATIENT RATIOS IN PA- 22 TIENT-ACUITY ADJUSTABLE UNITS.—Patients 23 shall be cared for only on units or patient care 24 areas where the direct care registered nurse-to- 25 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 11 •S 1357 IS patient ratios meet the level of intensity, type 1 of care, and the individual requirements and 2 needs of each patient. Notwithstanding para- 3 graph (2), hospitals that provide patient care in 4 units or patient care areas that are acuity 5 adaptable or acuity adjustable shall apply the 6 direct care registered nurse-to-patient ratio re- 7 quired in this section for the highest patient 8 acuity level or level of care in that unit or pa- 9 tient care area, and shall comply with all other 10 requirements of this section. 11 ‘‘(E) USE OF VIDEO MONITORS.—A hos- 12 pital shall not employ video monitors or any 13 form of electronic visualization of a patient as 14 a substitute for the direct observation required 15 for patient assessment by the direct care reg- 16 istered nurse or required for patient protection. 17 Video monitors or any form of electronic visual- 18 ization of a patient shall not be included in the 19 calculation of the direct care registered nurse- 20 to-patient ratio required in this subsection and 21 shall not replace the requirement of paragraph 22 (3)(D) that each patient shall be assigned to a 23 direct care registered nurse who shall directly 24 provide the assessment, planning, supervision, 25 VerDate Sep 11 2014 00:54 May 16, 2019 Jkt 089200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S1357.IS S1357 kjohnson on DSK79L0C42 with BILLS 12 •S 1357 IS implementation, and evaluation of the nursing 1 care provided to the patient at least every shift 2 and have the responsibility for the provision of 3 care to a particular patient within his or her 4 scope of practice. 5 ‘‘(F) USE OF OTHER TECHNOLOGY.—A 6 hospital shall not employ technology that sub- 7 stitutes for the assigned registered nurse’s pro- 8 fessional judgment in assessment, planning, im- 9 plementation, and evaluation of care. 10 ‘‘(5) ADJUSTMENT OF RATIOS.— 11 ‘‘(A) IN GENERAL.—If necessary to protect 12 patient safety, the S [Text truncated for display. 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