An Act To Increase the Safety of Hospital Patients
Maine Legislature, Session 123, LD 1538
Committee: Health and Human Services
Sponsors: FAIRCLOTH, PERRY, CONNOR, CUMMINGS, DRISCOLL, PENDLETON, PINGREE, STRIMLING
Amends: 22 MRSA §1832

Legislative Document 
No. 1538 
H.P.1063 
House of Representatives, March 20, 2007 
An Act To Increase the Safety of Hospital Patients 
Reference to the Committee on Health and Human Services suggested and ordered printed. 
Presented by Representative FAIRCLOTH of Bangor. 
Cosponsored by Senator PERRY of Penobscot and 
'I'J1~ /J7.1iItlC~ 
MllLICENT M. MacFARLAND 
Clerk 
Representatives: CONNOR of Kennebunk, Speaker CUMMINGS of Portland, DRISCOLL of 
Westbrook, PENDLETON of Scarborough, PERRY of Calais, PINGREE of North Haven, 
Senator: STRIMLING of Cumberland. 
Printed on recYf;)ed paper 
Be it enacted by the People of the State of Maine as follows: 
Sec. 1. 22 MRSA §1832 is enacted to read: 
§1832. Hospital staffing 
Staffing in all hospitals licensed under this chapter is subject to the provisions of this 
section. 
1. Definitions. As used in this section, unless the context otherwise indicates, the 
following terms have the following meanings. 
A. "Acuity" means the severity of patient illness, the need for specialized equipment 
and technology, the intensity of required nursing interventions and the complexity of 
clinical nursing judgment required to design, implement and evaluate the patient's 
nursing care plan consistent with professional standards. 
B. "Patient classification system" or "system" means a standardized set of criteria 
based on scientific data that acts as a measurement instrument used to predict 
registered nursing care requirements for each patient based on the acuity of the 
patient. The system determines the additional number of direct-care registered nurses 
and other licensed and unlicensed nursing staff the hospital must assign to meet the 
individual patient needs at all times. 
C. "Assigned" means that a direct-care registered nurse has responsibility for the 
provision of care to a particular patient within a nurse's validated competency. 
D. 
"Clinical judgment" means the application of a direct-care registered nurse's 
knowledge, skill and expertise and experience in making independent decisions about 
patient care. 
E. "Competence" means the ability of a direct-care registered nurse to integrate and 
act upon the knowledge, skills, abilities and independent professional judgment that 
ensure safe and therapeutic patient care. 
F. "Critical access hospital" means a facility designated pursuant to a Medicare rural 
hospital flexibility program established by the State and as defined in 42 United 
States Code, section 1395x(mm). 
G. "Direct-care registered nurse" means a registered nurse who has accepted the 
direct, hands-on patient care assignment to implement medical and nursing regimens 
while exercising independent professional judgment at all times in the interest of the 
patient. 
H. "Hospital" means a hospital licensed under chapter 405. 
I. "Hospital unit" or "clinical unit" means an intensive care unit, critical care unit, 
bum unit, labor and delivery room, antepartum and postpartum unit, newborn 
nursery, post-anesthesia service area, emergency department, operating room, 
pediatric unit, transitional or intermediate care unit, specialty care unit, monitoring 
unit. general medical care unit. medical surgical unit, psychiatric unit. rehabilitation 
unit or skilled nursing facility unit. 
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J. "Patient assessment" means the use 'if criti~ilihink'~lg to interpret, apply, analyze, 
synthesize and evaluate data obtained through a direct-care registered 
nurse'~ 
observation and communication with others. 
K. 
"Professional judgment" means the intellectual process that a direct·care 
registered nurse exercises in forming an opinion and reaching a clinical decision that 
is in the patient's best interest, based upon the analysis of data, informationmci 
scientific evidence. 
2. 
Minimum, specific and numeric direct-care re2istered nurse-to-patient 
staffin&:: ratios by hospital unit. The minimum staffing ratios for general, acute and 
specialty hospitals for nurse-to-patient care are established in this subsection for direct-
care registered nurses as follows. 
A. The direct-care registered nurse-to-patient ratio in an intensive care unit is 1:2 or 
fewer at all times. 
B. The direct-care registered nurse-to-patient ratio for a critical care unit is 1:2 or 
fewer at all times. 
C. The direct-care registered nurse-to-patient ratio for a neonatal intensive care unit 
is 1:2 or fewer at all times. 
D. The direct-care registered nurse-to-patient ratio for a bum unit is 1:2 or fewer at 
all times. 
E. 
The direct-care registered nurse-to-patient ratio for a transitional, intermediate 
care unit is 1:3 or fewer at all times. 
F. An operating room must have at least one direct-care registered nurse assigned to 
the duties of the circulating registered nurse and a minimum of one additional person 
as a scrub assistant for each patient-occupied operating room at all times. 
G. The direct-care registered nurse-to-patient ratio in a post-anesthesia recovery unit 
is 1:2 or fewer at all times, regardless of the type of anesthesia the patient received. 
H. The direct-care registered nurse-to-patient ratio for a patient receiving conscious 
sedation is 1: I at all times. 
\. The direct-care registered nurse-to-patient ratio for an emergency department is 
1:4 or fewer at all times. The direct-care registered nurse-to-patient ratio for critical 
care patients in the emergency department is 1:2 or fewer at all times. Only direct-
care registered nurses may be assigned to critical trauma patients in the emergency 
department, and a minimum direct-care registered nurse-to-critical trauma patient 
ratio of 1: 1 must be maintained at all times. In an emergency department, triage, 
radio, specialty and flight registered nurses do not count in the calculation of a direct-
care registered nurse-to-patient ratio . 
J. The direct-care registered nurse-to-patient ratio in the labor and delivery suite of 
prenatal services is I: I at all times for active labor patients and patients with medical 
or obstetrical complications. The direct-care registered nurse-to-patient ratio is I: 1 at 
all times for initiating epidural anesthesia and circulation for cesarean delivery. The 
direct-care registered nurse-to-patient ratio for a patient in immediate postpartum is 
1:2 or fewer at all times. 
K. The direct-care registered nurse-to-patient ratio for an antepartum patient who is 
not in active labor is 1:3 or fewer at all times. The direct-care registered nurse-to-
patient ratio for a patient in a postpartum area of the prenatal services is 1:3 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 direct-care registered nurse may not exceed 
6. For a postpartum ar.ea in which the direct-care registered nurse's assignment 
consists of mothers only, the direct-care registered nurse-to-patient ratio is 1:4 or 
fewer at all times. The direct-care registered nurse-to-patient ratio for a postpartum 
woman or postoperative gynecological patient only is 1:4 or fewer at all times. The 
well baby nursery direct-care registered nurse ratio is 1 :5. The direct-care registered 
nurse-to-patient ratio for unstable newborns and those in the resuscitation period as 
assessed by the direct-care registered nurse is 1: 1 at all times. The direct-care 
registered nurse-to-patient ratio for recently born infants is 1:4 or fewer at all times. 
L. The direct-care registered nurse-to-patient ratio for pediatrics is 1:3 or fewer at all 
times. 
M. The direct-care registered nurse-to-patient ratio in the monitoring unit is 1:3 or 
fewer at all times. 
N. The direct-care registered nurse-to-patient ratio in a medical surgical unit is 1:4 or 
fewer at all times. The direct-care registered nurse-to-patient ratio for a presurgical 
admissions unit or ambulatory surgical unit is 1:4 or fewer at all times. 
O. The direct-care registered nurse-to-patient ratio in a specialty unit is 1:4 or fewer 
at all times. 
P. 
The direct-care registered nurse-to-patient ratio in a psychiatric unit is 1:4 or 
fewer at all times. 
Q. The direct-care registered nurse-to-patient ratio in a rehabilitation unit or a skilled 
nursing facility is 1:5 or fewer at all times. 
3. Hospital unit staffing plans based on individual patient needs as determined 
by valid patient classification system and direct-care professional nurse patient 
assessments. In addition to the direct-care registered nurse-to-patient ratio requirements 
in subsection 2, each hospital shall assign additional direct-care registered nurses and 
other licensed or unlicensed staff by using a patient classification system for determining 
patient care needs of individual patients that reflects the assessment of patient nursing 
care requirements made by the assigned direct-care registered nurse and shall provide for 
shift-by-shift staffing based on those requirements. 
4. General Requirements. Each hospital must provide minimum staffing by direct-
care registered nurses in accordance with the general requirements of this section and the 
clinical unit direct-care registered nurse-to-patient ratios specified in subsection 2. 
Staffing for patient care tasks not requiring a direct-care registered nurse is not included 
within these ratios and must be determined p-ursuant to the patient classification system 
described in subsection 3. 
A. 
A hospital may not assign a direct-care registered nurse to a nursing unit or 
clinical area unless that hospital and the direct-care registered nurse determine that 
the nurse has demonstrated current competence in providing care in that area and has 
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also received orientation to that hospital's clinical area sufficient to provide safe, 
therapeutic and competent care to patients in that areuhe policies ~ndJllilcedures of 
the hospital must contain the hospital's criteria for making this determination. 
B. Direct-care registered nurse-to-patient ratios represent the maximum number of 
patients that.may be assigned to one direct-care registered nurse at all times. 
C. There may be no averaging of the number of patients or the total number of 
direct-care registered nurses on a unit during anyone shift or over any period of time. 
D. Only direct-care registered nurses providing direct patient care may be included 
in the ratios. Nurse administrators, nurse supervisors, nurse managers, charge nurses 
and case managers may not be included in the calculation of the direct-care registered 
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nurse-to-patient ratio. Only direct-care registered nurses may relieve other direct-care 
registered nurses during breaks, meals and other routine, expected absences from a 
unit. 
5. Additional Conditions. Identifying a unit by a name or term other than those 
used in subsection 2 does not affect the requirement to staff at the direct-care registered 
nurse-to-patient ratio identified for the level of intensity or type of care described in this 
subsection. Patients may be cared for only in units where the level of intensity, type of 
care and the direct-care registered nurse-to-patient ratio meet the needs of each patient. 
6. Restriction. The following activities are prohibited. 
A. A hospital may not directly assign any unlicensed personnel to perform functions 
of a direct-care registered nurse in lieu of care delivered by a licensed registered 
nurse and may not assign unlicensed personnel to perform functions of a direct-care 
registered nurse under the supervision of a direct-care registered nurse. 
B. Unlicensed personnel may not perform tasks that require the clinical assessment, 
judgment and skill of a licensed direct-care registered nurse, including, without 
limitation, nursing activities that require nursing assessment and judgment during 
implementation; physical, psychological and social assessment that require nursing 
judgment, intervention, referral or follow-up; formulation of a plan of nursing care 
and evaluation of a patient's response to the care provided; and administration of 
medications. 
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C. A hospital may not impose mandatory overtime requirements to meet the staffing 
ratios imposed in subsection 2. 
7. Hospital nursing practice standard; direct-care registered nurse professional 
obligations. A direct-care registered nurse employed in a hospital has a professional 
obligation to: 
A. Provide safe, therapeutic and competent nursing care to assigned patients. Before 
accepting a patient assignment, a direct-care registered nurse must have the necessary 
knowledge, judgment, skills and ability to provide the required care. 
It is the 
responsibility of the direct-care registered nurse to determine whether the nurse is 
clinically competent to perform the nursing care required by patients in a particular 
clinical unit or with a particular diagnosis, condition, prognosis and other aspects of 
nursing care. 
If the direct-care registered nurse is not clinically competent to 
perfonn the care required for a patient to be assigned for nursing care, the nurse 
should not accept the patient care assignment. Such a refusal to accept a patient care 
assignment is an exercise of the direct-care registered nurse's duty and the right of 
patient advocacy; 
B. Assess each medical order and, prior to acting on the order, detennine whether the 
order is in the best interest of the patient and was initiated by a person legally 
authorized to initiate such an order; 
C. Advocate in the exclusive interest of a patient or patients at the hospital. The 
direct-care registered nurse has the professional obligation and therefore the right to 
act as the patient's advocate, as circumstances require, bv initiating action to improve 
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health care or to change decisions or activities that in the professional judgment of 
the registered nurse are against the interests or wishes of the patient or bv giving the 
patient the opportunity to make infonned decisions about health care before it is 
provided: 
D. Perfonn continuous and ongoing patient assessments based upon the independent 
professional judgment of the direct-care registered nurse. Patient assessment requires 
direct observation of the patient's signs and svmptoms of ilIness, reaction to 
treatment, behavior and physical condition, interpretation of infonnation obtained 
from the patient and others, including other caregivers on the health team. 
Assessment requires data colIection by the direct-care registered nurse and the 
analysis, synthesis and evaluation of such data. Only direct-care registered nurses are 
authorized to perfonn patient assessments. Licensed vocational nurses may assist 
direct-care registered nurses in data collection; and 
E. 
Plan, implement and evaluate the nursing care provided to each patient. The 
planning and delivery of patient care must reflect alI elements of the nursing process: 
assessment, 
nursing 
diagnosis, 
planning. 
intervention, 
evaluation 
and, 
as 
circumstances require, patient advocacy and must be initiated by the direct-care 
registered nurse at the time of admission. 
8. Protection of patients and direct-care registered nurses. A hospital may not 
discharge from duty or otherwise retaliate against a direct-care registered nurse with 
responsibility for patient care who reports unsafe practices or violations of policy, 
regulation, rule or law. 
A direct-care registered nurse responsible for patient care in a hospital has the right of 
free speech and is protected in the exercise of that right during working hours and during 
off-duty hours. The right of free speech protected by this section is a necessary incident 
of the professional nurse's duty and the right of patient advocacy, is essential to protecting 
the health and safety of hospital patients and is presumed to be in the public interest. 
A. 
Protected speech under this subsection includes the reporting intemaIly, 
extemalIy or publicly of actions, conduct, events, practices or other matters that are 
believed by the nurse to constitute: 
(I) A violation of federal, state or local laws or regulations; 
(2) 
A breach of applicable codes of professional ethics, including the 
professional and ethical obligations of direct-care registered nurses; 
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(3) A serious concern of the reporting direct-care registered nurse that the nurse 
believes is appropriate or required for disclosure in furth~ran~.~_l!!.l.~LillPQ.Qr.t~f th~ 
nurse's exercise of patient advocacy duties to: 
(a) 
Improve health care or change decisions or activities that, in the 
professional judgment of the direct-care registered nurse, are against the 
interests or wishes of the patient; or 
(b) 
Ensure that the patient is afforded meaningful opportunity to make 
informed decisions about health care before it is provided; or 
( 4) A concern reported under this paragraph that is intended to aid and support 
the exercise of patient advocacy duties by a direct-care registered nurse 
colleague. 
B. 
Nothing in this paragraph is intended to authorize disclosure of private and 
confidential patient information, except when such a disclosure is required by law, 
compelled by proper legal process, consented to by the patient or provided in 
confidence to regulatory or accreditation agencies or other government entities for 
investigatory purposes or pursuant to formal or informal complaints of unlawful or 
improper practices for purposes of achieving corrective and remedial action. 
9. Consumer protection. A hospital shall daily post in a conspicuous place visible 
to the public the ratio of direct-care registered nursing staff to patients in each unit and 
give each patient admitted to the hospital for inpatient care the toll-free telephone number 
for the Division of Licensing and Regulatory Services within the department to report 
inadequate staffing or care. 
10. Enforcement against a hospital. A hospital that violates the provisions of this 
section is subject to enforcement action by the department, including suspension or 
revocation of license to operate as follows: 
A. For a violation of the minimum staffing ratios, a fine not to exceed $25,000 per 
violation plus $10,000 per nursing unit shift until the violation is corrected; and 
B. For a violation of or interference with the rights provided under subsection 8, a 
civil penalty of not more than $25,000 for each such violation or occurrence of 
prohibited conduct 
11. Enforcement against others. Any hospital management, nursing service or 
medical personnel found to have violated or interfered 
with any of the rights or 
protections provided and guaranteed under this section is subject to a civil penalty of not 
more than $25,000 for each violation or occurrence of prohibited conduct 
12. Waiver. The department shall grant to a critical access hospital a waiver of the 
requirements of subsections 2 to 5 for one year after the effective date of this Act for the 
purpose of preparing for compliance with these provisions. Thereafter, the department 
may grant waivers, after public notice and reasonable opportunity for public comment, 
based upon express findings supported by a written record that the requested waiver does 
not jeopardize the health, safety and well-being of patients affected and is needed for 
increased operational efficiency. 
SUMMARY 
This bill imposes minimum staffing requirements for direct-care registered nurse-to-
patient staffing on all hospitals with an increase of direct-care registered nurses and other 
licensed and unlicensed nursing staff required based on the individual acuity of the 
patients. The bill articulates professional responsibilities for direct-care registered nurses 
and protections for certain functions and activities. The bill requires daily posting of 
staffing ratios, requires that patients be given the toll-free telephone number of the 
Division of Licensing and Regulatory Services within the Department of Health and 
Human Services and punishes violations of the provisions of this bill by a fine of up to 
$25,000 per violation and additional fines until the violation is corrected. Any hospital 
management, nursing service or medical personnel found to have violated or interfered 
with these protected rights is subject to penalties. 
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