H. B. 2949
(By Delegates Hatfield, Brown, Guthrie, Klempa, Mahan,
Marshall, Martin, Moye, Paxton, Rodighiero and Wells)
[Introduced March 4, 2009; referred to the
Committee on Health and Human Resources then the Judiciary.]
A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new article, designated §16-43-1 and
§16-43-2, 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.
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 and §16-43-2, 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 RN's 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 section, the following words, shall,
unless the context clearly requires otherwise, have the following
meanings:
(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) "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;
(6) "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;
(7) "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
(8) "Ratio," means the actual number of patients to be
assigned to each direct-care registered nurse.
(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) "CRRT" means continuous renal replacement therapy.
(b) Each facility, as defined in subsection (a) of this
section, is to develop within one year of passage of this article,
a standardized acuity-based patient classification system as
defined in subsection (a) of this section to be utilized 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) Burn Unit 1:2;
(5) Step-down/Intermediate Care 1:3;
(6) Operating Room:
(A) RN as Circulator 1:1; and
(B) RN as monitor in moderate sedation cases 2:1;
(7) Post Anesthesia Care Unit:
(A) Under Anesthesia 1:1; and
(B) Post Anesthesia 1:2;
(8) Emergency Department 1:3:
(A) Emergency Critical Care 1:2; and
(B) Emergency Trauma 1:1;
(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.)
(9) 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;
(10) Pediatrics 1:4;
(11) Psychiatric 1:4;
(12) Medical and Surgical 1:4;
(13) Telemetry 1:4;
(14) Observational/Outpatient Treatment 1:4;
(15) Transitional Care 1:5;
(16) Rehabilitation Unit 1:5; and
(17) Specialty Care Unit 1:4.
Any unit not otherwise 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 herein may be construed to preclude
any facility from increasing the number of direct-care registered
nurses, nor shall the requirements set forth be deemed to supersede
or replace any requirements otherwise mandated by law, regulation
or collective bargaining contract so 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 deemed 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 clauses (1) to (5) of
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 and/or 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. Such complaint shall cause an investigation by the
office to determine whether any violation of law or rule by the
facility has occurred.
(f) No facility may 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. Such 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) Such 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) Such 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) Such 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 shall
be 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 shall 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.
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."
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.