Rep. Fred Crespo

Filed: 3/19/2019





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2    AMENDMENT NO. ______. Amend House Bill 2604 by replacing
3everything after the enacting clause with the following:
4    "Section 1. Short title. This Act may be cited as the Safe
5Patient Limits Act.
6    Section 5. Definitions. In this Act:
7    "Couplet" means one mother and one baby.
8    "Critical trauma patient" means a patient who has an injury
9to an anatomic area that (i) requires life-saving
10interventions, or (ii) in conjunction with unstable vital
11signs, poses an immediate threat to life or limb.
12    "Department" means the Department of Public Health.
13    "Facility" means a hospital licensed under the Hospital
14Licensing Act or organized under the University of Illinois
15Hospital Act, a private or State-owned and State-operated
16general acute care hospital, an acute psychiatric hospital, an



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1acute care specialty hospital, or an acute care unit within a
2health care facility.
3    "Health care workforce" means personnel employed by or
4contracted to work at a facility that have an effect upon the
5delivery of quality care to patients, including, but not
6limited to, registered nurses, licensed practical nurses,
7unlicensed assistive personnel, service, maintenance,
8clerical, professional, and technical workers, and other
9health care workers.
10    "Immediate postpartum patients" means those patients who
11have given birth within the previous 2 hours.
12    "Nursing care" means care that falls within the scope of
13practice as defined in the Nurse Practice Act or is otherwise
14encompassed within recognized standards of nursing practice,
15including assessment, nursing diagnosis, planning,
16intervention, evaluation, and patient advocacy.
17    "Registered nurse" means a competent registered nurse who
18has accepted a direct, hands-on patient care assignment to
19implement the nursing care plan for that patient and the
20nursing process while, at all times, exercising independent
21professional judgment in the exclusive interest of the patient.
22    "Specialty care unit" means a unit which is organized,
23operated, and maintained to provide care for a specific medical
24condition or a specific patient population.
25    For the purposes of this Act, a patient is considered
26assigned to a registered nurse if the registered nurse accepts



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1responsibility for the patient's nursing care.
2    Section 10. Maximum patient assignments for registered
4    (a) The maximum number of patients assigned to a registered
5nurse in a facility shall not exceed the limits provided in
6this Section. However, nothing shall preclude a facility from
7assigning fewer patients to a registered nurse than the limits
8provided in this Section.
9    (b) In all units with critical care or intensive care
10patients, including, but not limited to, coronary care, acute
11respiratory, burn, or neonatal intensive care patients, the
12maximum patient assignment of critical care patients to a
13registered nurse is 2.
14    (c) In all units with step-down or intermediate care
15patients, the maximum patient assignment of step-down or
16intermediate care patients to a registered nurse is 3.
17    (d) In all units with postanesthesia care patients, the
18maximum patient assignment of postanesthesia care patients
19under the age of 18 to a registered nurse is one. The maximum
20patient assignment of postanesthesia care patients 18 years of
21age or older to a registered nurse is 2.
22    (e) In all units with operating room patients, the maximum
23patient assignment of operating room patients to a registered
24nurse is one, provided that a minimum of one additional person
25serves as a scrub assistant for each patient.



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1    (f) In the emergency department:
2        (1) In a unit providing basic emergency medical
3    services or comprehensive emergency medical services, the
4    maximum patient assignment at any time to a registered
5    nurse is 3.
6        (2) The maximum assignment of critical care emergency
7    patients to a registered nurse is 2. A patient in the
8    emergency department shall be considered a critical care
9    patient when the patient meets the criteria for admission
10    to a critical care service area within the hospital.
11        (3) The maximum assignment of critical trauma patients
12    in an emergency unit to a registered nurse is one.
13        (4) At least one direct care registered professional
14    nurse shall be assigned to triage patients. The direct care
15    registered professional nurse assigned to triage patients
16    shall be immediately available at all times to triage
17    patients when they arrive in the emergency department. The
18    direct care registered professional nurse assigned to
19    triage patients shall perform triage functions only.
20    (g) In all units with maternal child care patients:
21        (1) The maximum patient assignment to a registered
22    nurse of antepartum patients requiring continuous fetal
23    monitoring is 2.
24        (2) The maximum patient assignment of other antepartum
25    patients to a registered nurse is 3.
26        (3) The maximum patient assignment of active labor



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1    patients to a registered nurse is one.
2        (4) The maximum patient assignment during birth is one
3    registered nurse responsible for the mother and, for each
4    baby born, one registered nurse whose sole responsibility
5    is that baby.
6        (5) The maximum patient assignment of immediate
7    postpartum patients is one couplet, and in the case of
8    multiple births, one nurse for each additional baby.
9        (6) The maximum patient assignment of postpartum
10    patients to a registered nurse is 6 patients or 3 couplets.
11    (h) In all units with pediatric patients, the maximum
12patient assignment of pediatric patients to a registered nurse
13is 4.
14    (i) In all units with psychiatric patients, the maximum
15patient assignment of psychiatric patients to a registered
16nurse is 4.
17    (j) In all units with medical and surgical patients, the
18maximum patient assignment of medical or surgical patients to a
19registered nurse is 4.
20    (k) In all units with telemetry patients, the maximum
21patient assignment of telemetry patients to a registered nurse
22is 3.
23    (l) In all units with observational patients, the maximum
24patient assignment of observational patients to a registered
25nurse is 4.
26    (m) In all units with acute rehabilitation patients, the



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1maximum patient assignment of acute rehabilitation patients to
2a registered nurse is 4.
3    (n) In all specialty care units, the maximum patient
4assignment to a registered nurse is 4.
5    (o) In all units with conscious sedation patients, the
6maximum patient assignment of conscious sedation patients to a
7registered nurse is one.
8    (p) In any unit not otherwise listed in this Section, the
9maximum patient assignment to a registered nurse is 4.
10    Section 15. Use of rapid response teams as first responders
11prohibited. A rapid response team nurse shall not be given
12direct care patient assignments while assigned as a nurse
13responsible for responding to a rapid response team request.
14    Section 20. Implementation by a facility.
15    (a) A facility shall implement the patient limits
16established by Section 10 without diminishing the staffing
17levels of the facility's health care workforce.
18    (b) There shall be no averaging of the number of patients
19and the total number of registered nurses in each clinical unit
20or patient care area in order to meet the limits established
21under this Act.
22    (c) Only registered nurses providing direct patient care
23must comply with the patient limits under Section 10. Nurse
24administrators, nurse supervisors, nurse managers, charge



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1nurses, case managers, ancillary staff, unlicensed personnel,
2or any other hospital administrator or supervisor shall not be
3required to comply with the patient limits under Section 10.
4    (d) Identifying a clinical unit or patient care area by a
5name or term other than those listed in this Act does not
6affect a facility's requirement to staff the unit consistent
7with the patient limits identified for the level of intensity
8or type of care described in this Act.
9    (e) A registered nurse providing direct care to a patient
10has the authority to determine if a change in the patient's
11status places the patient in a different category requiring a
12different patient limit under Section 10.
13    (f) A registered nurse may determine that additional
14ancillary staff, such as licensed practical nurses, certified
15nursing assistants, or other ancillary staff, excluding
16medical assistants, are needed in order to provide safe care.
17    (g) A facility shall not employ video monitors or any form
18of electronic visualization of a patient as a substitute for
19the direct observation required for patient assessment by the
20registered nurse or for patient protection. Video monitors or
21any form of electronic visualization of a patient shall not
22constitute compliance with the patient limits under Section 10.
23    Section 25. Changes in patient census.
24    (a) A facility shall plan for routine fluctuations in its
25patient census, including, but not limited to, admissions,



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1discharges, and transfers.
2    (b) If a health care emergency causes a change in the
3number of patients in a clinical care unit or patient care
4area, a facility must be able to demonstrate that immediate and
5diligent efforts were made to maintain required staffing levels
6under this Act. For purposes of this subsection, "health care
7emergency" means an emergency declared by the federal
8government or the head of a State or local governmental entity.
9    Section 30. Record of staff assignments. A facility shall
10keep a record of the actual direct care registered professional
11nurse, licensed practical nurse, certified nursing assistant,
12and other ancillary staff assignments to individual patients
13documented on a day-to-day, shift-by-shift basis and shall keep
14copies of its staff assignments on file for a period of 7
16    Section 35. Implementation by the Department. The
17Department shall adopt rules governing the implementation and
18operation of this Act.
19    Section 40. Patient acuity systems. Nothing in this Act
20precludes the use of patient acuity systems consistent with
21Section 10.10 of the Hospital Licensing Act. However, the
22maximum patient assignments in Section 10 shall not be exceeded
23regardless of the use and application of any patient acuity



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2    Any method, software, or tool used to create or evaluate a
3staffing plan adopted by a facility shall be established in
4coordination with direct care registered professional nurses
5and shall be transparent in all respects, including disclosure
6of detailed documentation of the methodology used to determine
7nurse staffing and identifying each factor, assumption, and
8value used in applying the methodology. The Department shall
9establish procedures to ensure that the documentation
10submitted under this Section is available for public inspection
11in its entirety.
12    Section 45. Training. All facilities shall adopt written
13policies and procedures for the training and orientation of
14nursing staff. No registered nurse shall be assigned to a
15nursing unit or clinical area unless that nurse has first
16received training and orientation in that clinical area that is
17sufficient to provide competent care to patients in that area
18and has demonstrated competence in providing care in that area.
19The written policies and procedures for that training and
20orientation of nursing staff shall require that all temporary
21personnel receive the same amount and type of training and
22orientation that is required for permanent staff.
23    Section 50. Enforcement. A facility's failure to adhere to
24the limits set by Section 10 shall be reported by the



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1Department to the Attorney General for enforcement, for which
2the Attorney General may bring action in a court of competent
3jurisdiction seeking injunctive relief and civil penalties. A
4separate and distinct violation, for which the facility shall
5be subject to a civil penalty of up to $25,000, shall be deemed
6to have been committed on each day during which any violation
7continues after receipt of written notice of the violation from
8the Department by the facility. The requirements of this Act,
9and its enforcement, shall be suspended during a public health
10emergency declared by the State or federal government.
11    Section 55. Whistleblower protection.
12    (a) A registered professional nurse may object to or refuse
13to participate in any activity, practice, assignment, or task
15        (1) in good faith, the nurse reasonably believes it to
16    be a violation of the direct care registered professional
17    nurse-to-patient ratios established under this Act; or
18        (2) the nurse is not prepared by education, training,
19    or experience to fulfill the assignment without
20    compromising the safety of any patient or jeopardizing the
21    license of the nurse.
22    (b) A facility shall not retaliate, discriminate, or
23otherwise take adverse action in any manner with respect to any
24aspect of a nurse's employment, including discharge,
25promotion, compensation, or terms, conditions, or privileges



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1of employment, based on the nurse's refusal to complete an
2assignment under subsection (a).
3    (c) A facility shall not file a complaint against a
4registered professional nurse with the Board of Nursing based
5on the nurse's refusal to complete an assignment under
6subsection (a).
7    (d) A facility shall not retaliate, discriminate, or
8otherwise take adverse action in any manner against any person
9or with respect to any aspect of a nurse's employment,
10including discharge, promotion, compensation, or terms,
11conditions, or privileges of employment, based on that nurse's
12or that person's opposition to any hospital policy, practice,
13or action that the nurse in good faith believes violates this
15    (e) A facility shall not retaliate, discriminate, or
16otherwise take adverse action against any patient or employee
17of the facility or any other individual on the basis that the
18patient, employee, or individual, in good faith, individually
19or in conjunction with another person or persons, has presented
20a grievance or complaint, or has initiated or cooperated in any
21investigation or proceeding of any governmental entity,
22regulatory agency, or private accreditation body, made a civil
23claim or demand, or filed an action relating to the care,
24services, or conditions of the facility or of any affiliated or
25related facilities.
26    (f) A facility shall not do either of the following:



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1        (1) Interfere with, restrain, or deny the exercise of,
2    or attempt to deny the exercise of, a right conferred under
3    this Act.
4        (2) Coerce or intimidate any individual regarding the
5    exercise of, or an attempt to exercise, a right conferred
6    by this Act.
7    Section 60. Severability. The provisions of this Act are
8severable, and if any clause, sentence, paragraph, subsection,
9or Section of this law or any application thereof shall be
10adjudged by any court of competent jurisdiction to be invalid,
11such judgment shall not affect, impair, or invalidate the
12remainder thereof but shall be confined in its operation to the
13clause, sentence, paragraph, subsection, Section, or
14application adjudged invalid and such clause, sentence,
15paragraph, subsection, Section, or application shall be
16reformed and construed so that it would be valid to the maximum
17extent permitted.
18    Section 85. The Hospital Licensing Act is amended by
19changing Section 10.10 as follows:
20    (210 ILCS 85/10.10)
21    Sec. 10.10. Nurse Staffing by Patient Acuity.
22    (a) Findings. The Legislature finds and declares all of the



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1        (1) The State of Illinois has a substantial interest in
2    promoting quality care and improving the delivery of health
3    care services.
4        (2) Evidence-based studies have shown that the basic
5    principles of staffing in the acute care setting should be
6    based on the complexity of patients' care needs aligned
7    with available nursing skills to promote quality patient
8    care consistent with professional nursing standards.
9        (3) Compliance with this Section promotes an
10    organizational climate that values registered nurses'
11    input in meeting the health care needs of hospital
12    patients.
13    (b) Definitions. As used in this Section:
14    "Acuity model" means an assessment tool selected and
15implemented by a hospital, as recommended by a nursing care
16committee, that assesses the complexity of patient care needs
17requiring professional nursing care and skills and aligns
18patient care needs and nursing skills consistent with
19professional nursing standards.
20    "Department" means the Department of Public Health.
21    "Direct patient care" means care provided by a registered
22professional nurse with direct responsibility to oversee or
23carry out medical regimens or nursing care for one or more
25    "Nursing care committee" means an existing or newly created
26hospital-wide committee or committees of nurses whose



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1functions, in part or in whole, contribute to the development,
2recommendation, and review of the hospital's nurse staffing
3plan established pursuant to subsection (d).
4    "Registered professional nurse" means a person licensed as
5a Registered Nurse under the Nurse Practice Act.
6    "Written staffing plan for nursing care services" means a
7written plan for guiding the assignment of patient care nursing
8staff based on multiple nurse and patient considerations that
9yield minimum staffing levels for inpatient care units and the
10adopted acuity model aligning patient care needs with nursing
11skills required for quality patient care consistent with
12professional nursing standards.
13    (c) Written staffing plan.
14        (1) Every hospital shall implement a written
15    hospital-wide staffing plan, recommended by a nursing care
16    committee or committees, that provides for minimum direct
17    care professional registered nurse-to-patient staffing
18    needs for each inpatient care unit. The written
19    hospital-wide staffing plan shall include, but need not be
20    limited to, the following considerations:
21            (A) The complexity of complete care, assessment on
22        patient admission, volume of patient admissions,
23        discharges and transfers, evaluation of the progress
24        of a patient's problems, ongoing physical assessments,
25        planning for a patient's discharge, assessment after a
26        change in patient condition, and assessment of the need



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1        for patient referrals.
2            (B) The complexity of clinical professional
3        nursing judgment needed to design and implement a
4        patient's nursing care plan, the need for specialized
5        equipment and technology, the skill mix of other
6        personnel providing or supporting direct patient care,
7        and involvement in quality improvement activities,
8        professional preparation, and experience.
9            (C) Patient acuity and the number of patients for
10        whom care is being provided.
11            (D) The ongoing assessments of a unit's patient
12        acuity levels and nursing staff needed shall be
13        routinely made by the unit nurse manager or his or her
14        designee.
15            (E) The identification of additional registered
16        nurses available for direct patient care when
17        patients' unexpected needs exceed the planned workload
18        for direct care staff.
19        (2) In order to provide staffing flexibility to meet
20    patient needs, every hospital shall identify an acuity
21    model for adjusting the staffing plan for each inpatient
22    care unit.
23        (3) The written staffing plan shall be posted in a
24    conspicuous and accessible location for both patients and
25    direct care staff, as required under the Hospital Report
26    Card Act. A copy of the written staffing plan shall be



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1    provided to any member of the general public upon request.
2    (d) Nursing care committee.
3        (1) Every hospital shall have a nursing care committee.
4    A hospital shall appoint members of a committee whereby at
5    least 50% of the members are registered professional nurses
6    providing direct patient care.
7        (2) A nursing care committee's recommendations must be
8    given significant regard and weight in the hospital's
9    adoption and implementation of a written staffing plan.
10        (3) A nursing care committee or committees shall
11    recommend a written staffing plan for the hospital based on
12    the principles from the staffing components set forth in
13    subsection (c). In particular, a committee or committees
14    shall provide input and feedback on the following:
15            (A) Selection, implementation, and evaluation of
16        minimum staffing levels for inpatient care units.
17            (B) Selection, implementation, and evaluation of
18        an acuity model to provide staffing flexibility that
19        aligns changing patient acuity with nursing skills
20        required.
21            (C) Selection, implementation, and evaluation of a
22        written staffing plan incorporating the items
23        described in subdivisions (c)(1) and (c)(2) of this
24        Section.
25            (D) Review the following: nurse-to-patient
26        staffing guidelines for all inpatient areas; and



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1        current acuity tools and measures in use.
2        (4) A nursing care committee must address the items
3    described in subparagraphs (A) through (D) of paragraph (3)
4    semi-annually.
5    (e) Nothing in this Section 10.10 shall be construed to
6limit, alter, or modify any of the terms, conditions, or
7provisions of a collective bargaining agreement entered into by
8the hospital.
9    (f) A hospital shall not directly assign any unlicensed
10personnel to perform registered professional nurse functions
11in lieu of care delivered by a registered professional nurse
12and shall not assign unlicensed personnel to perform registered
13professional nurse functions under the supervision of a direct
14care registered professional nurse.
15    (g) Unlicensed personnel shall not be required to perform
16tasks that require the clinical assessment, professional
17judgment, and skill of a licensed registered professional
18nurse, including, but not limited to, the following: activities
19that require a nursing assessment or nursing judgment during
20implementation; physical, psychological, and social
21assessments that require nursing judgment, intervention,
22referral, or follow-up; formulation of a plan of nursing care
23and evaluation of a patient's response to the care provided;
24and administration of medications.
25(Source: P.A. 96-328, eff. 8-11-09; 97-423, eff. 1-1-12;
2697-813, eff. 7-13-12.)



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1    Section 90. The Nurse Practice Act is amended by adding
2Sections 50-15.1, 50-15.5, 50-15.10, and 50-15.15 as follows:
3    (225 ILCS 65/50-15.1 new)
4    Sec. 50-15.1. Functions generally.
5    (a) A direct care registered professional nurse, holding a
6valid license to practice as a registered professional nurse,
7employing scientific knowledge and experience in the physical,
8social, and biological sciences, and exercising independent
9professional judgment in applying the nursing process in the
10exclusive interests of a patient, shall directly perform the
11following essential functions:
12        (1) Continuous and ongoing comprehensive nursing
13    assessments of a patient's condition based upon the
14    independent professional judgment of the direct care
15    registered professional nurse.
16        (2) Planning, implementation, and evaluation of the
17    nursing care provided to each patient. The implementation
18    of nursing care may be assigned by the direct care
19    registered professional nurse responsible for the patient
20    to other licensed nursing staff or to unlicensed staff,
21    subject to any limitations of the licensure,
22    certification, level of validated competency, or
23    applicable law concerning such staff. In any case, however:
24            (A) The direct care registered professional nurse



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1        assigned to a patient must determine in her or his
2        professional judgment that nursing personnel to be
3        assigned patient care tasks possess the necessary
4        preparation and capability to competently perform the
5        assigned tasks.
6            (B) The direct care registered professional nurse
7        may assign the implementation of nursing care only when
8        the registered professional nurse is physically
9        present and available.
10        (3) Assessment, planning, implementation, and
11    evaluation of patient education, including ongoing
12    discharge education of each patient.
13    (b) The planning and delivery of patient care shall: (i)
14reflect all elements of the nursing process, including
15comprehensive nursing assessment, nursing diagnosis, planning,
16intervention, evaluation, and, as circumstances require,
17patient advocacy; and (ii) be initiated by a direct care
18registered professional nurse at the time of a patient's
19admission to the hospital.
20    (c) A nursing plan for a patient's care shall be discussed
21with and developed as a result of coordination with the
22patient, the patient's family, or other representatives of the
23patient, when appropriate, and staff of other disciplines
24involved in the care of the patient.
25    (d) A direct care registered professional nurse shall
26evaluate the effectiveness of the care plan through: (i)



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1comprehensive nursing assessments based on direct observation
2of the patient's physical condition and behavior, signs and
3symptoms of illness, and reactions to treatment; and (ii)
4communication with the patient and other caregivers as
5applicable. The direct care registered professional nurse
6shall modify the plan as needed.
7    (e) Information related to the patient's initial
8comprehensive nursing assessment and reassessments, nursing
9diagnosis, plan, intervention, evaluation, and patient
10advocacy shall be permanently recorded, as narrative
11registered professional nurse progress notes, in the patient's
12medical record. The practice of "charting by exception" is
13expressly prohibited.
14    (225 ILCS 65/50-15.5 new)
15    Sec. 50-15.5. Patient assessment.
16    (a) Patient assessment requires: (i) direct observation of
17the patient's signs and symptoms of illness, reaction to
18treatment, behavior and physical condition; and (ii)
19interpretation of information obtained from the patient and
20others, including other caregivers, as applicable.
21    (b) Only a direct care registered professional nurse who is
22physically present with the patient is authorized to perform
23patient assessments. A licensed practical nurse may assist a
24direct care registered professional nurse in data collection.



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1    (225 ILCS 65/50-15.10 new)
2    Sec. 50-15.10. Determining nursing care needs of patients.
3    (a) The nursing care needs of each individual patient shall
4be determined by a direct care registered professional nurse
5through the process of ongoing comprehensive nursing
6assessments, nursing diagnosis, and formulation and adjustment
7of nursing care plans.
8    (b) The prediction of individual patient nursing care needs
9for prospective assignment of direct care registered
10professional nurses shall be based on individual comprehensive
11nursing assessments by the direct care registered professional
12nurse assigned to each patient.
13    (225 ILCS 65/50-15.15 new)
14    Sec. 50-15.15. Independent professional judgment.
15    (a) Competent performance of the essential functions of a
16direct care registered professional nurse requires the
17exercise of independent professional judgment in the exclusive
18interests of the patient. The exercise of such independent
19professional judgment, unencumbered by the commercial or
20revenue-generation priorities of a hospital, long term acute
21care hospital, or ambulatory surgical treatment center or other
22employing entity of a direct care registered professional
23nurse, is necessary to ensure safe, therapeutic, effective, and
24competent treatment of hospital patients and is essential to
25protect the health and safety of the people of Illinois.



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1    (b) The exercise of independent professional judgment by a
2direct care registered professional nurse in the performance of
3the essential functions, as described in paragraphs (1), (2),
4and (3) of subsection (a) of Section 15-1, shall be provided in
5the exclusive interests of the patient and shall not, for any
6purpose, be considered, relied upon, or represented as a job
7function, authority, responsibility, or activity undertaken in
8any respect for the purpose of serving the business,
9commercial, operational, or other institutional interests of
10the hospital.
11    (c) No hospital, long term acute care hospital, ambulatory
12surgical treatment center, or other health care institution
13shall utilize technology that:
14        (1) limits a direct care registered professional nurse
15    in performing functions that are part of the nursing
16    process, including full exercise of independent
17    professional judgment in assessment, planning,
18    implementation and evaluation of care; or
19        (2) limits a direct care registered professional nurse
20    in acting as a patient advocate in the exclusive interests
21    of the patient.
22    Technology shall not be skill-degrading, interfere with a
23direct care registered professional nurse's provision of
24individualized patient care, or override a direct care
25registered professional nurse's independent professional