Rep. Fred Crespo

Filed: 3/26/2019





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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    "Direct care registered professional nurse" means a
14registered professional nurse whose primary role is to provide
15direct hands-on patient care.
16    "Facility" means a hospital licensed under the Hospital



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1Licensing Act or organized under the University of Illinois
2Hospital Act, a private or State-owned and State-operated
3general acute care hospital, an LTAC hospital as defined in
4Section 10 of the Long Term Acute Care Hospital Quality
5Improvement Transfer Program Act, an ambulatory surgical
6treatment center as defined in Section 3 of the Ambulatory
7Surgical Treatment Center Act, an acute psychiatric hospital,
8an acute care specialty hospital, or an acute care unit within
9a health care facility. "Facility" does not include: (1) the
10Alton Mental Health Center, at Alton; (2) the Chicago-Read
11Mental Health Center, at Chicago; (3) the Clyde L. Choate
12Mental Health and Developmental Center, at Anna; (4) the Elgin
13Mental Health Center, at Elgin; (5) the John J. Madden Mental
14Health Center, at Chicago; (6) the Andrew McFarland Mental
15Health Center, at Springfield; and (7) the Chester Mental
16Health Center, at Chester.
17    "Health care workforce" means personnel employed by or
18contracted to work at a facility that have an effect upon the
19delivery of quality care to patients, including, but not
20limited to, registered nurses, licensed practical nurses,
21unlicensed assistive personnel, service, maintenance,
22clerical, professional, and technical workers, and other
23health care workers.
24    "Immediate postpartum patients" means those patients who
25have given birth within the previous 2 hours.
26    "Nursing care" means care that falls within the scope of



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1practice as described in Section 55-30 or 60-35 of the Nurse
2Practice Act or is otherwise encompassed within recognized
3standards of nursing practice.
4    "Rapid response team" means a team of health care providers
5that provide care to hospitalized patients with early signs of
6deterioration to prevent respiratory or cardiac arrest.
7    "Registered nurse" or "registered professional nurse"
8means a person who is licensed as a registered professional
9nurse under the Nurse Practice Act and practices nursing as
10described in Section 60-35 of the Nurse Practice Act.
11    "Specialty care unit" means a unit which is organized,
12operated, and maintained to provide care for a specific medical
13condition or a specific patient population.
14    For the purposes of this Act, a patient is considered
15assigned to a registered nurse if the registered nurse accepts
16responsibility for the patient's nursing care.
17    Section 10. Maximum patient assignments for registered
19    (a) The maximum number of patients assigned to a registered
20nurse in a facility shall not exceed the limits provided in
21this Section. However, nothing shall preclude a facility from
22assigning fewer patients to a registered nurse than the limits
23provided in this Section. The requirements of this Section
24apply at all times during each shift within each clinical unit
25and each patient care area.



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1    The requirements of this Section do not apply to: (1) the
2Alton Mental Health Center, at Alton; (2) the Chicago-Read
3Mental Health Center, at Chicago; (3) the Clyde L. Choate
4Mental Health and Developmental Center, at Anna; (4) the Elgin
5Mental Health Center, at Elgin; (5) the John J. Madden Mental
6Health Center, at Chicago; (6) the Andrew McFarland Mental
7Health Center, at Springfield; and (7) the Chester Mental
8Health Center, at Chester
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.
26    (f) In the emergency department:



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



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



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1a registered nurse is 4.
2    (n) In all specialty care units, the maximum patient
3assignment to a registered nurse is 4.
4    (o) In all units with conscious sedation patients, the
5maximum patient assignment of conscious sedation patients to a
6registered nurse is one.
7    (p) In any unit not otherwise listed in this Section, the
8maximum patient assignment to a registered nurse is 4.
9    Section 15. Use of rapid response teams as first responders
10prohibited. A rapid response team nurse shall not be given
11direct care patient assignments while assigned as a nurse
12responsible for responding to a rapid response team request.
13    Section 20. Implementation by a facility.
14    (a) A facility shall implement the patient limits
15established by Section 10 without diminishing the staffing
16levels of the facility's health care workforce, as defined in
17Section 5.
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
23shall count toward 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
3count toward 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.
19    Section 50. Enforcement. A facility's failure to adhere to
20the limits set by Section 10 shall be reported by the
21Department to the Attorney General for enforcement, for which
22the Attorney General may bring action in a court of competent
23jurisdiction seeking injunctive relief and civil penalties. A
24separate and distinct violation, for which the facility shall



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



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1on the nurse's refusal to complete an assignment under
2subsection (a).
3    (d) A facility shall not retaliate, discriminate, or
4otherwise take adverse action in any manner against any person
5or with respect to any aspect of a nurse's employment,
6including discharge, promotion, compensation, or terms,
7conditions, or privileges of employment, based on that nurse's
8or that person's opposition to any hospital policy, practice,
9or action that the nurse in good faith believes violates this
11    (e) A facility shall not retaliate, discriminate, or
12otherwise take adverse action against any patient or employee
13of the facility or any other individual on the basis that the
14patient, employee, or individual, in good faith, individually
15or in conjunction with another person or persons, has presented
16a grievance or complaint, or has initiated or cooperated in any
17investigation or proceeding of any governmental entity,
18regulatory agency, or private accreditation body, made a civil
19claim or demand, or filed an action relating to the care,
20services, or conditions of the facility or of any affiliated or
21related facilities.
22    (f) A facility shall not do either of the following:
23        (1) Interfere with, restrain, or deny the exercise of,
24    or attempt to deny the exercise of, a right conferred under
25    this Act.
26        (2) Coerce or intimidate any individual regarding the



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1    exercise of, or an attempt to exercise, a right conferred
2    by this Act.
3    Section 60. Severability. The provisions of this Act are
4severable, and if any clause, sentence, paragraph, subsection,
5or Section of this law or any application thereof shall be
6adjudged by any court of competent jurisdiction to be invalid,
7such judgment shall not affect, impair, or invalidate the
8remainder thereof but shall be confined in its operation to the
9clause, sentence, paragraph, subsection, Section, or
10application adjudged invalid and such clause, sentence,
11paragraph, subsection, Section, or application shall be
12reformed and construed so that it would be valid to the maximum
13extent permitted.
14    Section 85. The Hospital Licensing Act is amended by
15changing Section 10.10 as follows:
16    (210 ILCS 85/10.10)
17    Sec. 10.10. Nurse Staffing by Patient Acuity.
18    (a) Findings. The Legislature finds and declares all of the
20        (1) The State of Illinois has a substantial interest in
21    promoting quality care and improving the delivery of health
22    care services.
23        (2) Evidence-based studies have shown that the basic



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1    principles of staffing in the acute care setting should be
2    based on the complexity of patients' care needs aligned
3    with available nursing skills to promote quality patient
4    care consistent with professional nursing standards.
5        (3) Compliance with this Section promotes an
6    organizational climate that values registered nurses'
7    input in meeting the health care needs of hospital
8    patients.
9    (b) Definitions. As used in this Section:
10    "Acuity model" means an assessment tool selected and
11implemented by a hospital, as recommended by a nursing care
12committee, that assesses the complexity of patient care needs
13requiring professional nursing care and skills and aligns
14patient care needs and nursing skills consistent with
15professional nursing standards.
16    "Department" means the Department of Public Health.
17    "Direct patient care" means care provided by a registered
18professional nurse with direct responsibility to oversee or
19carry out medical regimens or nursing care for one or more
21    "Nursing care committee" means an existing or newly created
22hospital-wide committee or committees of nurses whose
23functions, in part or in whole, contribute to the development,
24recommendation, and review of the hospital's nurse staffing
25plan established pursuant to subsection (d).
26    "Registered professional nurse" means a person licensed as



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



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



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



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1    (e) Nothing in this Section 10.10 shall be construed to
2limit, alter, or modify any of the terms, conditions, or
3provisions of a collective bargaining agreement entered into by
4the hospital.
5    (f) Delegation of nursing interventions by a registered
6professional nurse must be in accordance with Section 50-75 of
7the Nurse Practice Act.
8    (g) A hospital shall not mandate that a registered
9professional nurse delegate a nursing intervention, including,
10but not limited to, medication administration, nursing
11judgment, comprehensive patient assessment, development of the
12plan of care, or evaluation of care. A delegation of a nursing
13intervention granted by a registered professional nurse shall
14not be re-delegated to another.
15(Source: P.A. 96-328, eff. 8-11-09; 97-423, eff. 1-1-12;
1697-813, eff. 7-13-12.)
17    Section 90. The Nurse Practice Act is amended by adding
18Section 50-15.15 as follows:
19    (225 ILCS 65/50-15.15 new)
20    Sec. 50-15.15. Clinical professional judgment.
21    (a) Performance of the scope of practice of a direct care
22registered professional nurse requires the exercise of
23professional judgment in the exclusive interests of the
24patient. The exercise of such professional judgment,



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1unencumbered by the commercial or revenue-generation
2priorities of a hospital, long term acute care hospital, or
3ambulatory surgical treatment center or other employing entity
4of a direct care registered professional nurse, is necessary to
5ensure safe, therapeutic, effective, and competent treatment
6of patients and is essential to protect the health and safety
7of the people of Illinois.
8    (b) The exercise of professional judgment by a direct care
9registered professional nurse in the performance of the scope
10of practice of the registered professional nurse under Section
1160-35 or the scope of practice of the advanced practice
12registered nurse under Section 65-30 shall be provided in the
13exclusive interests of the patient and shall not, for any
14purpose, be considered, relied upon, or represented as a job
15function, authority, responsibility, or activity undertaken in
16any respect for the purpose of serving the business,
17commercial, operational, or other institutional interests of
18the employer.
19    (c) No hospital, long term acute care hospital, ambulatory
20surgical treatment center, or other health care institution
21shall adopt policies that:
22        (1) limit a direct care registered professional nurse
23    in performing duties that are part of the nursing process,
24    including full exercise of professional judgment in
25    assessment, planning, implementation and evaluation of
26    care; or



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1        (2) limit a direct care registered professional nurse
2    in acting as a patient advocate in the exclusive interests
3    of the patient.".