California Code of Regulations › Title 22 - Social Security › Division 5 - Licensing and Certification of Health Facilities, Home Health Agencies, Clinics, and Referral Agencies › Chapter 1 - General Acute Care Hospitals › Article 3 - Basic Services › Section 70217 - Nursing Service Staff

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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.