WEST virginia Legislature
2017 regular session
By
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to the Committee on Health and Human Resources then Government Organizations.
A BILL to amend the Code
of West Virginia, 1931, as amended, by adding thereto a new article, designated
§16-43-1, §16-43-2 and §16-43-3, all relating to ensuring patient safety;
defining terms; creating an "acuity-based patient classification
system;" directing hospitals to establish an acuity standard; establishing
minimum direct-care registered nurse to patient ratios; providing additional
conditions for licensing; prohibiting assignment of unlicensed personnel to
perform licensed nurse functions; requiring a full-time registered nurse
executive leader; providing for quality assurance; requiring appropriate
orientation and competence in clinical area of assignment with documentation
thereof to be maintained in personnel files; and exempting critical access
hospitals.
Be it enacted by the
Legislature of West Virginia:
That the Code of West
Virginia, 1931, as amended, be amended by adding thereto a new article,
designated §16-43-1, §16-43-2 and §16-43-3,
all to read as follows:
ARTICLE 43. ENSURING PATIENT SAFETY ACT.
§16-43-1. Legislative findings.
Health care services are becoming more complex and it is
increasingly difficult for patients to access integrated services. Competent,
safe, therapeutic and effective patient care is jeopardized because of staffing
changes implemented in response to market-driven managed care. To ensure effective protection of patients in
acute care settings, it is essential that qualified direct care registered
professional nurses be accessible and available to meet the individual needs of
the patient at all times. To ensure the health and welfare of West Virginia
citizens, mandatory hospital direct care professional nursing practice
standards and professional practice protections must be established to assure
that hospital nursing care is provided in the exclusive interests of patients
§16-43-2. Ensuring Patient Safety Act.
(a) As used in this article:
(1) "Acuity-based patient classification system"
means a standardized set of criteria based on scientific data that acts as a
measurement instrument which predicts registered nursing care requirements for
individual patients based on severity of patient illness, need for specialized
equipment and technology, intensity of nursing interventions required and the
complexity of clinical nursing judgment needed to design, implement and
evaluate the patient’s nursing care plan consistent with professional standards
of care, details the amount of registered nursing care needed, both in number of
direct-care registered nurses and skill mix of nursing personnel required on a
daily basis for each patient in a nursing department or unit and is stated in
terms that readily can be used and understood by direct-care registered nurses.
The acuity system criteria shall take into consideration the patient care
services provided not only by registered nurses but also by licensed practical
nurses and other health care personnel;
(2) "Assessment tool" means a measurement system
which compares the registered nurse staffing level in each nursing department
or unit against actual patient nursing care requirements in order to review the
accuracy of an acuity system;
(3) "Board" means the Board of Examiners for
Registered Professional Nursing;
(4) "Charge nurse" means a registered nurse who is
assigned to manage the operations of the patient care area for a shift, and the
coordination of activities in the patient care area;
(5) "CRRT" means continuous renal replacement
therapy.
(6) "Direct-care registered nurse" means a
registered nurse who has accepted direct responsibility and accountability to
carry out medical regimens, nursing or other bedside care for patients;
(7) "Facility" means a hospital, the teaching
hospital of a medical school, any licensed private or state-owned and operated
general acute-care hospital, an acute psychiatric hospital, a specialty
hospital or any acute-care unit within a state operated facility, but does not
include critical access hospitals.
(8) "Nursing care" means care which falls within
the scope of practice as prescribed by state law or otherwise encompassed
within recognized professional standards of nursing practice, including
assessment, nursing diagnosis, planning, intervention, evaluation and patient
advocacy; and
(9) "Patient assessment" means the utilization of critical
thinking which is the intellectually disciplined process of actively and
skillfully interpreting, applying, analyzing and evaluating data obtained
through direct observation and communication with others.
(10) "Ratio" means the actual number of patients to
be assigned to each direct-care registered nurse.
(b) Each facility, as defined in subsection (a) of this
section, is to develop within one year of the effective date of this article, a
standardized acuity-based patient classification system as defined in
subsection (a) of this section to be used to establish the number of direct
care registered nurses needed to meet patient needs. Each of these facilities
shall designate a charge nurse to conduct a patient assessment in order to
assign direct-care registered nurses based on acuity level.
(c) Each facility shall also incorporate and maintain the
following minimum direct-care registered nurse-to-patient ratios:
(1) Intensive Care Unit: 1:2;
(2) Critical Care Unit 1:2 unless Balloon Pump or CRRT 1:1;
(3) Neo-natal Intensive Care 1:2 unless Balloon Pump or CRRT
1:1;
(4) New Born Nursery/Neo Natal Unit 1:4;
(5) Burn Unit 1:2;
(6) Step-down/Intermediate Care 1:3;
(7) Operating Room:
(A) RN as Circulator 1:1; and
(B) RN as monitor in moderate sedation cases 2:1;
(8) Post Anesthesia Care Unit:
(A) Under Anesthesia 1:1; and
(B) Post Anesthesia 1:2;
(9) Emergency Department 1:3:
(A) Emergency Critical Care 1:2; and
(B) Emergency Trauma 1:1;
(C) The triage, radio, or other specialty registered nurse
shall not be counted as part of the number in clause (A) or (B) of this
paragraph;
(10) Labor and Delivery:
(A) Active Labor 1:1;
(B) Immediate Postpartum 1:2 (one couplet);
(C) Postpartum 1:6 (three couplets);
(D) Intermediate Care Nursery 1:4; and
(E) Well-Baby Nursery 1:6;
(11) Pediatrics 1:4;
(12) Psychiatric 1:4;
(13) Medical and Surgical 1:4;
(14) Telemetry 1:4;
(15) Observational/Outpatient Treatment 1:4;
(16) Transitional Care 1:5;
(17) Rehabilitation Unit 1:5; and
(18) Specialty Care Unit 1:4.
Any unit not listed above shall be considered a specialty
care unit.
These ratios constitute the minimum number of direct-care
registered nurses. Additional direct-care
registered nurses shall be added and the ratio adjusted to ensure direct-care
registered nurse staffing in accordance with an approved acuity-based patient
classification system. Nothing in this
article precludes any facility from increasing the number of direct-care
registered nurses, nor do the requirements of this article supersede or replace
any requirements otherwise mandated by law, rule or collective bargaining
contract as long as the facility meets the minimum requirements outlined.
(d) Each facility shall annually submit to the Office of
Health Facility Licensure and Certification a prospective staffing plan, as
considered appropriate by each charge nurse, together with a written
certification that the staffing plan is sufficient to provide adequate and
appropriate delivery of health care services to patients for the ensuing year
and does all of the following:
(1) Meets the minimum direct-care registered nurse-to-patient
ratio requirements of subsection (c) of this section;
(2) Employs the acuity-based patient classification system
for addressing fluctuations in patient acuity levels requiring increased
registered nurse staffing levels above the minimums set forth in subsection (c)
of this section;
(3) Provides for orientation of registered nursing staff to
assigned clinical practice areas, including temporary assignments;
(4) Includes other unit or department activity such as
discharges, transfers and admissions, administrative and support tasks that are
expected to be done by direct-care registered nurses in addition to direct
nursing care; and
(5) Submits the assessment tool used to validate the acuity
system relied upon in the plan. As a
condition of licensing, each facility annually shall submit to the department
an audit of the preceding year’s staffing plan as dictated in this
subsection. The audit shall compare the
staffing plan with measurements of actual staffing as well as measurements of
actual acuity for all units within the facility.
(e) As a condition of licensing, a facility required to have
a staffing plan under this section shall:
(1) Prominently post on each unit the daily written nurse
staffing plan to reflect the registered nurse-to-patient ratio as a means of
providing information and protection; and
(2) Provide each patient or family member, or both patient
and family member, with a toll-free hotline number for the Office of Health
Facility Licensure and Certification, which may be used to report inadequate
registered nurse staffing. A complaint
shall cause an investigation by the office to determine whether any violation
of law or rule by the facility has occurred.
(f) A facility may not directly assign any unlicensed
personnel to perform nondelegable licensed nurse functions in-lieu of care
delivered by a licensed registered nurse.
Additionally, unlicensed personnel are prohibited from performing tasks
which require the clinical assessment, judgment and skill of a licensed
registered nurse. These functions shall
include, but are not limited to:
(1) Nursing activities which require nursing assessment and
judgment during implementation;
(2) Physical, psychological and social assessment which
requires nursing judgment, intervention, referral or follow-up;
(3) Formulation of the plan of nursing care and evaluation of
the patient's/client's response to the care provided; and
(4) Administration of medication.
(g) The rules shall require that a full-time registered nurse
executive leader be employed by each facility to be responsible for the overall
execution of resources to ensure sufficient registered nurse staffing is
provided by the facility.
(h) The rules shall require that a full-time registered nurse
be designated by the facility to be responsible for the overall quality
assurance of nursing care as provided by the facility.
(i) The rules shall require that a full-time registered nurse
be designated by each facility to ensure the overall occupational health and
safety of nursing staff employed by the facility.
(j) For purposes of compliance with this section no
registered nurse may be assigned to a unit or a clinical area within a health
facility unless that registered nurse has an appropriate orientation in that
clinical area sufficient to provide competent nursing care to the patients in
that area, and has demonstrated current competence in providing care in that
area. There shall be a written,
organized education plan for providing orientation and competency validation
for all patient care personnel:
(1) All patient care personnel shall complete orientation to
the hospital and their assigned patients and patient care unit or units before receiving
patient care assignments;
(2) All patient care personnel shall be subject to the
process of competency validation for their assigned patients and patient care
unit or units;
(3) Prior to the completion of validation of the competency
standards for the patient care unit, patient care assignments are subject to
the following restrictions:
(A) Assignments shall include only those duties and
responsibilities for which competency has been validated;
(B) A registered nurse who has demonstrated competency for
the patient care unit shall be responsible for the nursing care, and shall be
assigned as a resource nurse for those registered nurses who have not completed
validation for that unit; and
(C) Registered nurses may not be assigned total patient responsibility
for patient care until all the standards of competency for that unit have been
validated;
(4) Orientation and competency validation shall be documented
in the employee’s file and shall be retained for the duration of the
individual’s employment; and
(5) The staff education and training program shall be based
on current standards of nursing practice, established standards of staff
performance, individual staff needs and needs identified in the quality
assurance process.
(k) The setting of staffing standards for registered nurses
is not to be interpreted as justifying the understaffing of other critical
health care workers, including licensed practical nurses and unlicensed
assistive personnel. The availability of
these other health care workers enables registered nurses to focus on the
nursing care functions that only registered nurses, by law, are permitted to
perform and thereby helps to ensure adequate staffing levels.
§16-43-3. Exemption.
Critical access hospitals are exempt from the provisions of
this article.
NOTE: The purpose of this bill is to ensure patient
safety by establishing minimum direct-care registered nurse to patient
ratios. It provides for creating an
"acuity-based patient classification system" and exempts critical
access hospitals from its provisions. The bill defines terms and directs
hospitals to establish an acuity standard. The bill establishes minimum direct-care
registered nurse to patient ratios.
Strike-throughs indicate language
that would be stricken from a heading or the present law and underscoring
indicates new language that would be added.