H.F. 2193 DIVISION I 1 NURSE STAFFING AND COLLABORATIVE NURSE STAFFING COMMITTEES 2 Section 1. NEW SECTION . 135P.1 Definitions. 3 1. “Acuity” means the measure of a patient’s severity of 4 illness or medical condition including but not limited to the 5 stability of physiological and psychological parameters and the 6 dependency needs of the patient and the patient’s family. 7 2. “Department” means the department of inspections and 8 appeals. 9 3. “Hospital” means the same as defined in section 135B.1. 10 5. “Mental health institute” means a mental health institute 11 as described in chapter 226. 12 4. “Mental illness” means a substantial disorder of thought 13 or mood which significantly impairs judgment, behavior, or the 14 capacity to recognize reality or the ability to cope with the 15 ordinary demands of life. 16 6. “Nursing care” means those services which can be provided 17 only under the direction of a registered nurse or a licensed 18 practical nurse. 19 7. “Nursing facility” means the same as defined in section 20 135C.1. 21 8. “Rehabilitative services” means services to encourage and 22 assist restoration of optimum mental and physical capabilities 23 of the individual resident of a health care facility. 24 9. “Resident” means an individual admitted to a health care 25 facility in the manner prescribed by section 135C.23. 26 10. “School nurse” means a person who holds an endorsement 27 or a statement of professional recognition for school nurses 28 issued by the board of educational examiners. 29 11. “Supervision” means oversight and inspection of the act 30 of accomplishing a function or activity. 31 Sec. 2. NEW SECTION . 135P.2 Hospital nurse staffing plan 32 and standards. 33 1. A hospital shall approve, implement, and comply with a 34 direct care registered nurse staffing plan developed by the 35 -1- LSB 5200YH (18) 84 ad/nh 1/ 19

H.F. 2193 hospital’s collaborative nurse staffing committee established 1 pursuant to section 135P.4. The plan shall provide for the 2 adequate, appropriate, and quality delivery of health care 3 services and protect patient safety. 4 2. Except as otherwise provided in this section, a 5 hospital’s staffing plan shall provide that, at all times 6 during each shift within a unit of the hospital, a direct care 7 registered nurse may be assigned to not more than the following 8 number of patients in the specified unit: 9 a. One patient in a trauma emergency unit. 10 b. One patient in an operating room unit, provided that at 11 least one additional person serves as a scrub assistant in such 12 unit. 13 c. Two patients in a critical care unit, including neonatal 14 intensive care units, emergency critical care and intensive 15 care units, labor and delivery units, coronary care units, 16 acute respiratory care units, postanesthesia units, and burn 17 units. 18 d. Three patients in an emergency room unit, pediatrics 19 unit, stepdown unit, or combined labor, deliver, and postpartum 20 unit. 21 e. Four patients in a medical-surgical unit, intermediate 22 care nursery unit, acute care psychiatric unit, or other 23 specialty care unit. 24 f. Five patients in a rehabilitation unit or skilled nursing 25 unit. 26 g. Six patients in a postpartum unit or well-baby nursery 27 unit. 28 3. The department may apply minimum direct care registered 29 nurse-to-patient ratios established in subsection 2 for a 30 hospital unit referred to in that subsection to a type of 31 hospital unit not referred to in that subsection if the 32 hospital unit provides a level of care to patients whose needs 33 are similar to the needs of patients cared for in the hospital 34 unit referred to in that subsection. 35 -2- LSB 5200YH (18) 84 ad/nh 2/ 19

H.F. 2193 4. In developing the staffing plan, the collaborative nurse 1 staffing committee shall provide for direct care registered 2 nurse-to-patient ratios above the minimum ratios provided in 3 subsection 2, if appropriate, based upon consideration of the 4 following factors: 5 a. The number of patients and acuity level of patients 6 as determined by the application of an acuity system, on a 7 shift-by-shift basis. 8 b. The anticipated admissions, discharges, and transfers of 9 patients during each shift that impact direct patient care. 10 c. Specialized experience required of direct care registered 11 nurses on a particular unit. 12 d. Staffing levels and services provided by licensed 13 vocational or practical nurses, licensed psychiatric 14 technicians, certified nurse assistants, or other ancillary 15 staff in meeting direct patient care needs not required by a 16 direct care registered nurse. 17 e. The level of technology available that affects the 18 delivery of direct patient care. 19 f. The level of familiarity with hospital practices, 20 policies, and procedures by temporary agency direct care 21 registered nurses used during a shift. 22 g. Obstacles to efficiency in the delivery of patient care 23 presented by physical layout. 24 h. Other information relevant to patient care. 25 5. This section shall not be construed as a prohibition 26 on a hospital’s ability to set standards that are at least 27 equivalent to the requirements under this section. 28 6. a. A hospital shall not average the number of patients 29 and the total number of direct care registered nurses assigned 30 to patients in a hospital unit during any one shift or over any 31 period of time for purposes of meeting the requirements under 32 this section. 33 b. A hospital shall not impose mandatory overtime 34 requirements to meet the hospital unit direct care registered 35 -3- LSB 5200YH (18) 84 ad/nh 3/ 19

H.F. 2193 nurse-to-patient ratios required under this section. 1 c. A hospital shall ensure that only a direct care 2 registered nurse may relieve another direct care registered 3 nurse during breaks, meals, and other routine, expected 4 absences from a hospital unit. 5 d. A hospital shall not encroach on the scope of practice of 6 a direct care registered nurse. A hospital shall not require a 7 direct care registered nurse to train a replacement if doing so 8 would compromise patient safety. 9 e. A hospital shall establish a system to document actual 10 staffing in each unit for each shift. 11 f. To the extent appropriate based on the staffing plan in 12 each unit in relation to actual patient care requirements and 13 the accuracy of the acuity system, a hospital shall annually 14 approve updates to the nurse staffing plan developed by the 15 collaborative nurse staffing committee. 16 g. Once developed, a hospital shall conspicuously post 17 the required staffing levels for each unit in the unit and in 18 waiting areas. The postings must be visible to hospital staff, 19 patients, and the public. 20 7. A hospital shall not discipline a direct care registered 21 nurse for refusing to accept an assignment if, in good faith 22 and in the nurse’s professional judgment, the nurse determines 23 that the assignment is unsafe for patients due to patient 24 acuity and nursing intensity. 25 8. The requirements established in this section shall not 26 apply during a state of emergency if a hospital is requested or 27 expected to provide an exceptional level of emergency or other 28 medical services. 29 9. The requirements established in subsections 2, 3, 30 and 6 do not apply to entities designated as critical access 31 hospitals pursuant to 42 U.S.C. § 1395i-4. The nurse staffing 32 plan at a critical access hospital shall follow the standards 33 set in subsections 2, 3, and 6 as is reasonable based on the 34 hospital’s needs and capabilities. 35 -4- LSB 5200YH (18) 84 ad/nh 4/ 19

H.F. 2193 10. The department may sanction a hospital for failure to 1 comply with this section, including failure to staff patient 2 care units at levels required in its staffing plan. 3 11. The department may adopt rules to enforce this section. 4 Sec. 3. NEW SECTION . 135P.3 Nursing facility and mental 5 health institute nurse staffing plan and standards. 6 1. A nursing facility or mental health institute shall 7 approve, implement, and comply with a direct care registered 8 nurse staffing plan developed by the facility’s or institute’s 9 collaborative nurse staffing committee established pursuant 10 to section 135P.4. The plan shall provide for the adequate, 11 appropriate, and quality delivery of health care services and 12 protect patient safety. 13 2. In developing the staffing plan, the collaborative nurse 14 staffing committee shall provide for direct care registered 15 nurse-to-patient ratios based upon consideration of the 16 following factors: 17 a. The number of patients and acuity level of patients 18 as determined by the application of an acuity system, on a 19 shift-by-shift basis. 20 b. The anticipated admissions, discharges, and transfers of 21 patients during each shift that impact direct patient care. 22 c. Specialized experience required of direct care registered 23 nurses on a particular unit. 24 d. Staffing levels and services provided by licensed 25 vocational or practical nurses, licensed psychiatric 26 technicians, certified nurse assistants, or other ancillary 27 staff in meeting direct patient care needs not required by a 28 direct care registered nurse. 29 e. The level of technology available that affects the 30 delivery of direct patient care. 31 f. The level of familiarity with the nursing facility’s or 32 mental health institute’s practices, policies, and procedures 33 by temporary agency direct care registered nurses used during a 34 shift. 35 -5- LSB 5200YH (18) 84 ad/nh 5/ 19

H.F. 2193 g. Obstacles to efficiency in the delivery of patient care 1 presented by physical layout. 2 h. Other information relevant to patient care. 3 3. a. A nursing facility or mental health institute 4 shall not average the number of patients and the total number 5 of direct care registered nurses assigned to patients in a 6 nursing facility or mental health institute unit during any one 7 shift or over any period of time for purposes of meeting the 8 requirements of a direct care registered nurse staffing plan 9 developed pursuant to this section. 10 b. A nursing facility or mental health institute shall not 11 impose mandatory overtime requirements to meet the nursing 12 facility or mental health institute unit direct care registered 13 nurse-to-patient ratios required by a direct care registered 14 nurse staffing plan developed pursuant to this section. 15 c. A nursing facility or mental health institute shall 16 ensure that only a direct care registered nurse may relieve 17 another direct care registered nurse during breaks, meals, and 18 other routine, expected absences from a nursing facility or 19 mental health institute unit. 20 d. A nursing facility or mental health institute shall not 21 encroach on the scope of practice of a direct care registered 22 nurse. A nursing facility or mental health institute shall not 23 require a direct care registered nurse to train a replacement 24 if doing so would compromise patient safety. 25 e. A nursing facility or mental health institute shall 26 establish a system to document actual staffing in each unit for 27 each shift. 28 f. To the extent appropriate based on the staffing plan in 29 each unit in relation to actual patient care requirements and 30 the accuracy of the acuity system, a nursing facility or mental 31 health institute shall annually approve updates to the nurse 32 staffing plan developed by the collaborative nurse staffing 33 committee. 34 g. Once developed, a nursing facility or mental health 35 -6- LSB 5200YH (18) 84 ad/nh 6/ 19

H.F. 2193 institute shall conspicuously post the required staffing levels 1 for each unit in the unit and in waiting areas. The postings 2 must be visible to nursing facility or mental health institute 3 staff, patients, and the public. 4 4. A nursing facility or mental health institute shall 5 not discipline a direct care registered nurse for refusing 6 to accept an assignment if, in good faith and in the nurse’s 7 professional judgment, the nurse determines that the assignment 8 is unsafe for patients due to patient acuity and nursing 9 intensity. 10 5. The requirements established in this section shall not 11 apply during a state of emergency if a nursing facility or 12 mental health institute is requested or expected to provide an 13 exceptional level of emergency or other medical services. 14 6. The department may sanction a nursing facility for 15 failure to comply with the provisions of this section, 16 including failure to staff patient care units at levels 17 required in its staffing plan. 18 7. The department may adopt rules to enforce this section. 19 Sec. 4. NEW SECTION . 135P.4 Collaborative nurse staffing 20 committee. 21 1. A hospital, nursing facility, or mental health institute 22 shall establish a collaborative nurse staffing committee 23 comprised of nonsupervisory staff nurses. The membership of 24 the committee shall be apportioned among registered nurses, 25 licensed practical nurses, and advanced practice registered 26 nurses based upon the proportion of each type of nonsupervisory 27 nurse licensee to the total of all nonsupervisory nurses 28 employed by the hospital, nursing facility, or mental health 29 institute. Each member of the committee shall be appointed 30 respectively by other nonsupervisory nurses who hold the same 31 license. The committee shall include at least six members, and 32 shall meet at least annually. The hospital, nursing facility, 33 or mental health institute shall compensate the nurses who 34 are employed by the hospital, nursing facility, or mental 35 -7- LSB 5200YH (18) 84 ad/nh 7/ 19

H.F. 2193 health institute and serve on the collaborative nurse staffing 1 committee for time spent on committee business. 2 2. By majority vote, the committee may establish its own 3 rules and procedures, and shall set the term of membership. 4 3. a. The committee shall recommend a nurse staffing plan 5 to the hospital, nursing facility, or mental health institute 6 as provided under sections 135P.2 and 135P.3. If the hospital, 7 nursing facility, or mental health institute does not approve 8 the plan, the hospital, nursing facility, or mental health 9 institute shall provide a written response to the committee, 10 indicating the reasons for not approving the recommended nurse 11 staffing plan. 12 b. The committee shall annually evaluate its staffing 13 plan for each type of unit in relation to actual patient care 14 requirements and the accuracy of its acuity system. The 15 committee shall recommend updates to the nurse staffing plan 16 annually based on the evaluation. If the hospital, nursing 17 facility, or mental health institute does not approve the 18 updates, the hospital, nursing facility, or mental health 19 institute shall provide a written response to the committee, 20 indicating the reasons for not approving the recommended 21 updates to the nurse staffing plan. 22 c. The committee shall recommend a reporting system 23 for a nurse staffing violation that allows a person with 24 knowledge of the violation, including but not limited to 25 health care practitioners, hospital, nursing facility, or 26 mental health institute employees, patients, and visitors, 27 to make a report of the violation to the department. If the 28 committee makes a recommendation to the hospital, nursing 29 facility, or mental health institute and the hospital, nursing 30 facility, or mental health institute does not approve the 31 committee’s recommendation, the hospital, nursing facility, 32 or mental health institute shall provide a written response 33 to the committee indicating the reasons for not approving the 34 recommendation. 35 -8- LSB 5200YH (18) 84 ad/nh 8/ 19

H.F. 2193 4. The committee may make other recommendations related 1 to providing direct care to patients. If the committee 2 makes a recommendation to the hospital, nursing facility, or 3 mental health institute and the hospital, nursing facility, 4 or mental health institute does not approve the committee’s 5 recommendation, the hospital, nursing facility, or mental 6 health institute shall provide a written response to the 7 committee, indicating the reasons for not approving the 8 recommendation of the committee. 9 Sec. 5. NEW SECTION . 135P.5 School nurse staffing. 10 1. A school district shall approve, implement, and comply 11 with a school nurse staffing plan developed by the school 12 nurses in the district. The plan shall provide for the 13 adequate, appropriate, and quality delivery of health care 14 services. 15 2. In developing the school nurse staffing plan, the school 16 nurses shall consider the following factors: 17 a. The number of enrolled students in the school district. 18 b. The anticipated need for direct health care services at 19 each school in the district. 20 c. Staffing levels and services provided by licensed 21 vocational or practical nurses, licensed psychiatric 22 technicians, certified nurse assistants, or other ancillary 23 staff in meeting direct student health care needs not required 24 by a direct care registered nurse. 25 d. The level of technology available that affects the 26 delivery of direct student health care. 27 e. Obstacles to efficiency in the delivery of student health 28 care including the location of schools in the district. 29 f. Other information relevant to student health care. 30 3. The school nurse staffing plan shall include but is not 31 limited to: 32 a. The delivery of services that must be administered by a 33 school nurse. 34 b. The delivery of services that require direct supervision 35 -9- LSB 5200YH (18) 84 ad/nh 9/ 19

H.F. 2193 of a school nurse. 1 c. The delivery of services that require indirect 2 supervision of a school nurse. 3 4. If the school district does not approve the school 4 nurse staffing plan, it shall provide a written response to 5 the school nurses, indicating the reason for not following the 6 recommended school nurse staffing plan. 7 5. The school nurses shall annually evaluate the nurse 8 staffing plan and meet with the school board of the school 9 district for which the nurses are employed to recommend updates 10 to the school nurse staffing plan. If the school district does 11 not approve the updates it shall provide a written response to 12 the school nurses, indicating the reason for not following the 13 recommended updates to the nurse staffing plan. 14 6. The requirements established in this section shall 15 not apply during a state of emergency if a school district 16 is requested or expected to provide an exceptional level of 17 emergency or other medical services. 18 7. The school district must compensate school nurses 19 for time spent on developing and evaluating the school nurse 20 staffing plan. 21 8. The school nurses may make other recommendations related 22 to providing direct care to students in the school district. 23 If the school nurses make a recommendation to the school 24 district and the school district does not follow the school 25 nurses’ recommendation, it shall provide a written response to 26 the school nurses, indicating the reason for not following the 27 recommendation. 28 Sec. 6. NEW SECTION . 152.13 Scope of practice. 29 The scope of practice of a direct care registered nurse shall 30 not be encroached by any person. 31 Sec. 7. Section 256.11, subsection 9B, Code 2011, is amended 32 to read as follows: 33 9B. Beginning July 1, 2007, each school district shall have 34 a school nurse to provide health services to its students. 35 -10- LSB 5200YH (18) 84 ad/nh 10/ 19

H.F. 2193 Each Beginning July 1, 2015, each school district shall work 1 toward the goal of having have at least one full-time school 2 nurse for every seven six hundred fifty students when more than 3 two hundred students are enrolled in the school district. Each 4 school district shall approve, implement, and comply with a 5 nurse staffing plan pursuant to section 135P.5. For purposes 6 of this subsection , “school nurse” means a person who holds 7 an endorsement or a statement of professional recognition for 8 school nurses issued by the board of educational examiners 9 under chapter 272 . 10 Sec. 8. EFFECTIVE DATE. 11 1. Except as otherwise provided by this Act, this division 12 of this Act takes effect July 1, 2013. 13 2. The minimum direct care registered nurse-to-patient 14 ratios established in sections 135P.2 and 135P.3, as enacted in 15 this division of this Act, and the school nurse staffing plan 16 established in section 135P.5, as enacted in this Act, shall 17 take effect not later than July 1, 2014, or in the case of a 18 critical access hospital as defined in 42 U.S.C. § 1395i-4, not 19 later than July 1, 2016. 20 DIVISION II 21 PATIENT SAFETY PLAN 22 Sec. 9. NEW SECTION . 135P.6 Patient safety plan. 23 1. A hospital, nursing facility, or mental health institute 24 shall develop, implement, and comply with a patient safety 25 plan for the purpose of improving the health and safety of 26 patients and reducing preventable patient safety events. The 27 patient safety plan shall be developed by the hospital, nursing 28 facility, or mental health institute in coordination with the 29 entity’s health care professionals. 30 2. The patient safety plan shall, at a minimum, provide for 31 the establishment of all of the following: 32 a. A patient safety committee or a committee equivalent in 33 composition and function. The committee shall be comprised of 34 various health care professionals employed by the hospital, 35 -11- LSB 5200YH (18) 84 ad/nh 11/ 19

H.F. 2193 nursing facility, or mental health institute, at least half 1 of whom shall be direct care nurses. A hospital, nursing 2 facility, or mental health institute shall compensate the 3 health care professionals who are employed by the hospital, 4 nursing facility, or mental health institute and serve on the 5 patient safety committee or equivalent committee for time spent 6 on committee business. 7 b. The committee shall do all of the following: 8 (1) Review and approve the patient safety plan. 9 (2) Receive and review reports of patient safety events as 10 defined in subsection 3. 11 (3) Monitor implementation of corrective actions for 12 patient safety events. 13 (4) Make recommendations to eliminate future patient safety 14 events. 15 (5) Review and revise the patient safety plan at least 16 annually to evaluate and update the plan and to incorporate 17 advancements in patient safety practices. 18 c. A reporting system for patient safety events that allows 19 a person with knowledge of a patient safety event, including 20 but not limited to health care practitioners and hospital, 21 nursing facility, or mental health institute employees, 22 patients, and visitors, to make a report of a patient safety 23 event to the hospital, nursing facility, or mental health 24 institute. A reporting system shall support and encourage a 25 culture of safety and the reporting of patient safety events. 26 d. A process for a team of hospital, nursing facility, or 27 mental health institute staff to conduct analyses, including 28 but not limited to root cause analyses of patient safety 29 events. The team shall be composed of the entity’s various 30 categories of health care professionals with the appropriate 31 competencies to conduct the required analyses. 32 e. A process for providing ongoing patient safety training 33 for hospital, nursing facility, or mental health institute 34 personnel and health care practitioners. 35 -12- LSB 5200YH (18) 84 ad/nh 12/ 19

H.F. 2193 3. For the purposes of this section, patient safety events 1 shall be defined by the patient safety plan and shall include 2 but are not limited to health-care-associated infections, 3 as defined in the federal centers for disease control and 4 prevention’s national healthcare safety network, or its 5 successor, unless the department accepts the recommendation of 6 the healthcare-associated infection advisory committee, or its 7 successor, that are determined to be preventable. 8 Sec. 10. EFFECTIVE DATE. 9 1. Except as otherwise provided by this Act, this division 10 of this Act takes effect July 1, 2013. 11 2. The implementation of a hospital, nursing facility, 12 or mental health institute patient safety plan pursuant to 13 section 135P.6, as enacted in this Act, shall take effect not 14 later than July 1, 2014, or, in the case of a critical access 15 hospital as defined in 42 U.S.C. § 1395i-4, not later than July 16 1, 2016. 17 DIVISION III 18 PATIENT PROTECTION 19 Sec. 11. NEW SECTION . 135P.7 Retaliation prohibited —— 20 remedies. 21 1. a. A hospital, nursing facility, mental heath institute, 22 or school district shall not take retaliatory action against a 23 nurse as a reprisal when the nurse reports an action or event 24 to the hospital, nursing facility, mental heath institute, 25 or school district or to the department or other applicable 26 entity, and the nurse reasonably believes, based on the nurse’s 27 professional standards of care, professional code of ethics, or 28 other established guidelines for direct care workers including 29 but not limited to a patient safety plan or a nurse staffing 30 plan, that the action or event the nurse has observed occurring 31 at the hospital, nursing facility, mental heath institute, or 32 school district is a material violation of health and safety 33 laws or a breach of public safety that has caused serious harm 34 to or creates a significant probability of serious harm to 35 -13- LSB 5200YH (18) 84 ad/nh 13/ 19

H.F. 2193 patients or health care recipients. 1 b. For purposes of this section, “retaliatory action” 2 includes but is not limited to an action by a hospital, nursing 3 facility, mental health institute, or school district to 4 discharge a nurse or to take or fail to take action regarding 5 a nurse’s appointment or proposed appointment to, take or 6 fail to take action regarding a nurse’s promotion or proposed 7 promotion to, or fail to provide an advantage in a position in 8 employment. 9 c. Paragraph “a ” does not apply if the disclosure of the 10 information is prohibited by statute. 11 2. Subsection 1 may be enforced through a civil action. 12 a. A person who violates subsection 1 is liable to an 13 aggrieved nurse for affirmative relief including reinstatement, 14 with or without back pay, or any other equitable relief the 15 court deems appropriate, including attorney fees and costs. 16 b. When a person commits, is committing, or proposes to 17 commit an act in violation of subsection 1, an injunction may 18 be granted through an action in district court to prohibit the 19 person from continuing such acts. The action for injunctive 20 relief may be brought by the aggrieved nurse. 21 EXPLANATION 22 This bill relates to patient safety through nurse staffing. 23 The bill creates new Code chapter 135P to establish nurse 24 staffing plans, collaborative nurse staffing committees, and 25 patient safety plans. The bill also prohibits retaliatory 26 action against nurses. 27 Division I of the bill relates to nurse staffing plans. 28 The bill requires a hospital to approve, implement, and 29 comply with a nurse staffing plan developed by the hospital’s 30 collaborative nurse staffing committee required by the bill. 31 The nurse staffing plan must provide for adequate, appropriate, 32 and quality delivery of services to patients. The bill sets 33 required registered nurse staffing levels that the staffing 34 plan must include. The bill provides that the department of 35 -14- LSB 5200YH (18) 84 ad/nh 14/ 19

H.F. 2193 inspections and appeals (DIA) may apply the minimum direct care 1 registered nurse-to-patient ratios to other hospital units if 2 the unit provides a level of care to patients whose needs are 3 similar to that listed. The bill also provides factors for the 4 collaborative nurse staffing committee to consider when setting 5 nurse-to-patient ratios above what is listed in the bill. The 6 bill provides that the nurse staffing plan provisions should 7 not be construed as a prohibition on the hospital’s ability to 8 set standards that are equivalent to or higher than set under 9 the bill. 10 The bill specifies a hospital’s obligations regarding a 11 staffing plan. The bill prohibits a hospital from averaging 12 the number of patients and total number of direct care 13 registered nurses assigned to a unit during any one shift or 14 over a period of a time in order to meet the requirements of 15 the nurse staffing plan. A hospital cannot impose mandatory 16 overtime requirements to meet the ratios required. Only direct 17 care registered nurses can relieve other direct care registered 18 nurses. A hospital cannot encroach on a direct care registered 19 nurse’s scope of practice or require a direct care registered 20 nurse to train a replacement if doing so would jeopardize 21 patient safety. A hospital must establish a system to document 22 staffing in each unit for each shift. A hospital shall 23 approve updates to the nurse staffing plan as is appropriate 24 in relation to patient care requirements and the accuracy of 25 the acuity system. A hospital must conspicuously post staffing 26 levels for each unit in the unit and in waiting areas. A 27 hospital may not discipline a direct care registered nurse for 28 refusing to accept an assignment, if the nurse believes in good 29 faith and within the nurse’s judgment that the assignment is 30 unsafe for patients. The bill provides that the requirements 31 established do not apply during a state of emergency. The bill 32 provides an exception from the staffing requirements and the 33 hospital obligations for critical access hospitals. The bill 34 also provides for the DIA to sanction a hospital for failing 35 -15- LSB 5200YH (18) 84 ad/nh 15/ 19

H.F. 2193 to comply with the bill and allows the DIA to enact rules to 1 enforce the bill. 2 The bill imposes similar requirements on nursing facilities 3 and mental health institutes, providing factors the facility’s 4 or mental health institute’s collaborative nurse staffing 5 committee must consider when developing a staffing plan, but 6 the bill does not require specific staffing ratios for nursing 7 facilities or mental health institutes. 8 The bill provides that hospitals, nursing facilities, 9 and mental health institutes shall establish collaborative 10 nurse staffing committees comprised of nonsupervisory staff 11 nurses. The membership of a committee shall be apportioned 12 among registered nurses, licensed practical nurses, and 13 advanced practice registered nurses based upon the proportion 14 of each type of nonsupervisory nurse licensees to the total 15 of nonsupervisory nurses employed by the hospital, facility, 16 or institute. The members of the committee will be appointed 17 by other nonsupervisory nurses with the same license. The 18 committee must have six members and must meet at least 19 annually. The hospital, nursing facility, or mental health 20 institute must compensate the employed nurses for time spent 21 on committee business. The committee may establish its own 22 rules and procedures by majority vote. The committee shall 23 recommend a nurse staffing plan to the hospital, facility, or 24 institute. The hospital, facility, or institute must provide 25 a written response indicating the reasons for not approving 26 the plan if it does not approve the plan. The committee must 27 annually evaluate the staffing plan and recommend updates to 28 the hospital, nursing facility, or mental health institute 29 respectively. If the hospital, nursing facility, or mental 30 health institute does not approve the updates, it shall provide 31 a written response indicating the reasons. The committee 32 must also recommend a reporting system for a nurse staffing 33 violation that allows a person with knowledge of the violation 34 to make a report to the DIA. The committee may make other 35 -16- LSB 5200YH (18) 84 ad/nh 16/ 19

H.F. 2193 recommendations related to providing direct care to patients 1 to the hospital, nursing facility, or mental health institute, 2 respectively. If the hospital, nursing facility, or mental 3 health institute does not approve the recommendation, it shall 4 provide written notice indicating the reason. 5 The bill also requires a school district to approve, 6 implement, and comply with a school nurse staffing plan 7 developed by the district’s school nurses. The bill requires 8 the district’s school nurses to consider, the number of 9 enrolled students, the need for direct health care services at 10 each school, the staffing levels and services provided by other 11 ancillary staff, the technology available that affects delivery 12 of care, obstacles to efficiency including the location of 13 schools in the district, and other relevant information. The 14 school nursing staffing plan must include at least the delivery 15 of services required to be administered by a school nurse, the 16 delivery of services that require the direct supervision of the 17 school nurse, and the delivery of services that require the 18 indirect supervision of a school nurse. The bill states that 19 a school district that does not approve a nurse staffing plan 20 must provide a written response indicating the reason for not 21 following the plan. 22 The bill also requires school nurses to annually evaluate 23 the nurse staffing plan and meet with the school board to 24 recommend updates to the plan. The school nurses also may make 25 other recommendations to the school district. If the school 26 district does not approve the updates or other recommendations, 27 it must provide a written response indicating the reason for 28 not adopting the recommended updates. 29 The bill requires a school district to compensate a school 30 nurse for time spent developing and evaluating the school nurse 31 staffing plan. 32 The bill also amends Code section 256.11 regarding the 33 school nurse requirements for a school district. The bill 34 requires a school district which has more than 200 students 35 -17- LSB 5200YH (18) 84 ad/nh 17/ 19

H.F. 2193 enrolled to have at least one full-time school nurse for every 1 600 students beginning in 2015. 2 The division takes effect July 1, 2013. The direct care 3 registered nurse-to-patient ratios and school nurse staffing 4 plans take effect not later than July 1, 2014, or July 1, 2016, 5 for a critical access hospital. 6 Division II of the bill relates to patient safety plans. 7 The bill provides that a hospital, nursing facility, or 8 mental health institute must develop, implement, and comply 9 with a patient safety plan. The patient safety plan must 10 include and establish a patient safety committee or equivalent 11 committee. The committee shall be comprised of the entity’s 12 various health care professionals, but at least half of the 13 committee shall be comprised of direct care nurses. The 14 health care professionals employed by the entity who serve 15 on the committee must be compensated for the time spent on 16 committee business. The patient safety committee must review 17 and approve the patient safety plan, receive and review reports 18 of patient safety events, monitor implementation of corrective 19 actions, make recommendations to eliminate future patient 20 safety events, review and revise the patient safety plan at 21 least annually, and update the plan. The bill provides that a 22 patient safety plan must include a reporting system for patient 23 safety events, a process for a team of the entity’s staff to 24 conduct analyses of patient safety events, and a process for 25 providing ongoing patient safety training. The bill states 26 that a “patient safety event”, as used in the bill, shall be 27 defined by the patient safety plan. This division of the bill 28 related to patient safety plans takes effect July 1, 2013. 29 The implementation of a patient safety plan shall take effect 30 by July 1, 2014, except that a critical access hospital must 31 implement a patient safety plan by July 1, 2016. 32 Division III of the bill relates to nurses reporting 33 violations that affect patient safety. The bill provides 34 that a hospital, nursing facility, mental health institute, 35 -18- LSB 5200YH (18) 84 ad/nh 18/ 19

H.F. 2193 or school district shall not discharge or otherwise retaliate 1 against a nurse employed by the entity as a reprisal when the 2 nurse reports an action or event to the entity, DIA, or other 3 applicable state agency and the nurse reasonably believes the 4 action or event is a material violation of health and safety 5 laws or is a breach of public safety that has caused serious 6 harm to or creates a significant probability of serious harm 7 to patients or health care recipients. The division does not 8 apply if the disclosure is prohibited by statute. A person 9 who violates the division is liable to an aggrieved nurse for 10 affirmative relief including reinstatement with or without back 11 pay or any other equitable relief the court deems appropriate. 12 The bill also provides for an injunction when a person is 13 committing or proposes to commit an act in violation of the 14 division. 15 -19- LSB 5200YH (18) 84 ad/nh 19/ 19