Is there any CA State Law that protects the nurses?

**NickiLaughs, ADN, BSN, RN** · May 6, 2010

I think at a hospital that does "team nursing" that is legal. Because the 8 patients can technically be divided between the RN and LVN. I know some hospitals do this practice. I have coworkers who worked at a hospital like that and left because it was more overwhelming. They are not required to change the ratio because of the team nursing. If it is too much, I would seek out a job at a hospital that does the typical ratio law required in California.

However, there is often not LVN's, and sometimes no CNA's depending.

In California the ratio law is as follows:

Med Surg: 1: 5

Telemetry: 1:4

DOU 1:3

ICU 1:2

ER 1:4, ICU patients in ER is 1:2

Keep in mind that there is often a lack of ancillary staff. we end up doing baths sometimes,(CNA's are iffy and we don't have them in ICU), we will give all our own meds (no LVN) and often do not have a secretary so we are putting in all our own orders.

Chico David, BSN, RN · May 6, 2010

If existing California ratio law were properly enforced, the kind of team nursing approach you describe would be illegal, since only the RN can legally be assigned patients. The other staff are there to assist, but every patient must legally be assigned to an RN. Of course, long standing practice has been to effectively assign patients to an LVN and have an RN "cover" those patients. In actual law, the concept of "covering" does not exist - the RN is responsible for all of those patients.

But the enforcing of laws, like the making of them, is a political process. At the present time, the governor of California does not believe in the ratio law, so we can't count on the government to enforce the law. In unionized hospitals where the nurses are willing to take a stand, there has been quite a bit of success - though admittedly uneven - with enforcing the law through contractual mechanisms or through direct action by nurses. Maybe - if people pay attention - we can succeed in electing a governor this year who will actually enforce the law.

Peds_Nurse · May 6, 2010

I understand the question deals with hospital care, but what about us in long term? I'm an LVN and I have anywhere from 20-25 patients to care for with only 2 CNAs to answer call lights, etc. I do my own med pass and charting. We have 1 RN per shift and he/she has her own 20-25 patients to care for. Is there a ratio in long term care? any laws in CA to protect us?

Chico David, BSN, RN · May 6, 2010

I understand the question deals with hospital care, but what about us in long term? I'm an LVN and I have anywhere from 20-25 patients to care for with only 2 CNAs to answer call lights, etc. I do my own med pass and charting. We have 1 RN per shift and he/she has her own 20-25 patients to care for. Is there a ratio in long term care? any laws in CA to protect us?

Long term care is a whole different game, about which I know little. I do know that the ratio law that covers acute care does not cover long term care, and I also know that patients in long term care settings are more acute and getting more sophisticated care than they used to and that levels of reimbursement have not gone up to match - but nobody needs to tell you that, I'm sure. The California Nurses Association, which pushed through the ratio law, only represents RNs and so has no members in long term care.

classicdame, MSN, EdD · May 6, 2010

every employer has to follow dept of labor laws. The state may have occupational codes pertaining to nursing. Best to look at the nurse practice act first.

redrose4u · May 6, 2010

Thanks for all the replies...Its really hard when they demand quality care but the load is just much...the California Board of Nursing should also look into this matter. They should investigate also that at this time of recession some facilities or hospitals are taking advantage of the staff, threatening to fire anyone they see who does not follow their rule. The truth of the matter is that when some neglect happens , its not because of the nurses only, they should blame the hospital administration as well for the load of work they give to the nurses. Worse some hospitals don't want to give overtime because of the low census season at this time so the tendency is to just work and do what one can,forget the quality care when our bodies cannot do everything they are demanding us....I guess the only thing for now is that all nurses should unite in all hospitals/facilities and voice out their concerns so some State Law may exist soon for the nurse employees...thanks again for the replies :cool:

elkpark · May 6, 2010

Thanks for all the replies...Its really hard when they demand quality care but the load is just much...the California Board of Nursing should also look into this matter. They should investigate also that at this time of recession some facilities or hospitals are taking advantage of the staff, threatening to fire anyone they see who does not follow their rule. The truth of the matter is that when some neglect happens , its not because of the nurses only, they should blame the hospital administration as well for the load of work they give to the nurses. Worse some hospitals don't want to give overtime because of the low census season at this time so the tendency is to just work and do what one can,forget the quality care when our bodies cannot do everything they are demanding us....I guess the only thing for now is that all nurses should unite in all hospitals/facilities and voice out their concerns so some State Law may exist soon for the nurse employees...thanks again for the replies

I'm not sure what it is you're looking for -- CA is already the only state in the US that has a state law mandating a maximum nurse/patient ratio. You are already better off, and better protected in that regard, than nurses in any other US state. That's not good enough?

Weebee, LVN · Mar 20, 2011

If existing California ratio law were properly enforced, the kind of team nursing approach you describe would be illegal, since only the RN can legally be assigned patients. The other staff are there to assist, but every patient must legally be assigned to an RN. Of course, long standing practice has been to effectively assign patients to an LVN and have an RN "cover" those patients. In actual law, the concept of "covering" does not exist - the RN is responsible for all of those patients.
But the enforcing of laws, like the making of them, is a political process. At the present time, the governor of California does not believe in the ratio law, so we can't count on the government to enforce the law. In unionized hospitals where the nurses are willing to take a stand, there has been quite a bit of success - though admittedly uneven - with enforcing the law through contractual mechanisms or through direct action by nurses. Maybe - if people pay attention - we can succeed in electing a governor this year who will actually enforce the law.

Anyone know where to find this "law" showing it illegal for a RN to "Team" with a LVN as the RN will be responsible for more than the number of patients assigned to each floor... example Med/Surg 1 nurse to 5 patients.

NurseCubanitaRN2b, BSN, RN · Mar 21, 2011

Team nursing is NOT illegal.

allnurses Guide · Mar 21, 2011

it is illegal but is not simple. unless the registered nurse who assessed the patients determined that in his or her professional judgment assignment of the team is in the best interest of the patients it is in violation of the law.

in an acute care hospital an lvn may only practice nursing under the clinical supervision of a registered nurse. effective supervision requires that the rn be both present and available to the patient and the lvn at all times.

licensed vocational nurses work under the supervision of registered nurses (rn) or licensed physicians. lvns' skills are developed in medical-surgical, maternity and pediatric nursing. - http://www.bvnpt.ca.gov/general_information/health_care.shtml

title 22 of the california code of regulations contains requirements for hospital licensure.

title 22 section 70215 describes the nursing process and makes it absolutely clear that each patient must be assigned to a registered nurse. (read it below)

team nursing is not forbidden. title 22 section 70217 states:

licensed vocational nurses may constitute up to 50 percent of the licensed nurses assigned to patient care on any unit, except where registered nurses are required pursuant to the patient classification system or this section. only registered nurses shall be assigned to intensive care newborn nursery service units, which specifically require one registered nurse to two or fewer infants. in the emergency department, only registered nurses shall be assigned to triage patients and only registered nurses shall be assigned to critical trauma patients.

the section regarding the patient classification (acuity) system states that in addition to the requirements of the nurse to patient ratios the hospital must implement a patient classification system for determining nursing care needs of individual patients that reflects the assessment, made by a registered nurse of patient requirements and provides for shift-by-shift staffing based on those requirements.

additional staff in excess of these prescribed ratios, including non-licensed staff, shall be assigned in accordance with the hospital's documented patient classification system for determining nursing care requirements, considering factors that include the severity of the illness, the need for specialized equipment and technology, the complexity of clinical judgment needed to design, implement, and evaluate the patient care plan, the ability for self-care, and the licensure of the personnel required for care.

the way hospitals violate the law is that administration mandates 50% lvn staff so that on a med-surg unit an lvn is illegally assigned to 5 patients and the supervising rn is responsible for ten. no rn assessed the safety of this. remember "if it wasn't charted it wasn't done."?

the acuity of patients admitted to acute care hospitals is too high for one rn to be assigned responsibility for so many patients. ideally a hospital would fill the requirement to add staff by assigning an lvn to work with one or two rn whose assignment included high acuity patients. the alternative would be to add an rn.

title 22 section 70217 - regulations effective january 1, 2004

section 70215 is quoted below:

70215. planning and implementing patient care.
(a) a registered nurse shall directly provide:
(1) ongoing patient assessments as defined in the business and professions code, section 2725(d). such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area.
(2) the planning, supervision, implementation, and evaluation of the nursing care provided to each patient. the implementation of nursing care may be delegated by the registered nurse responsible for the patient to other licensed nursing staff, or may be assigned to unlicensed staff, subject to any limitations of their licensure, certification, level of validated competency, and/or regulation.
(3) the assessment, planning, implementation, and evaluation of patient education, including ongoing discharge teaching of each patient. any assignment of specific patient education tasks to patient care personnel shall be made by the registered nurse responsible for the patient.
(b) the planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission.
© the nursing plan for the patient's care shall be discussed with and developed as a result of coordination with the patient, the patient's family, or other representatives, when appropriate, and staff of other disciplines involved in the care of the patient.
(d) information related to the patient's initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient's medical record.

to find title 22 section 70215 and other hospital regulations:

1. first go to - [color=#3754d4]california code of regulations (all titles, 1 through 28)

2. next click title 22. social security

3. next click division 5. licensing and certification of health facilities chapter 1. general acute care hospitals

4. then click article 3. basic services

5. lastly click 70215. planning and implementing patient care.

allnurses Guide · Mar 21, 2011

the department of public health (licensing and certification division) is the agency that determines the compliance of health facilities with state and federal laws, rules, and regulations.

reports on the result of each inspection of a hospital along with the plan of action and hospital comments are kept on file in the department. all inspection records, lists of deficiencies, and plans of correction are open to public inspection.

nursing staff, patient, family member, and others can file a complaint.

the whistle blower protection laws in long term and acute facilities provide protection against retaliation but not if you complain anonymously.

it is best to file a written complaint. include the name and address of the facility.

it is important to include the date, time, and location (unit or room numbers).

name(s) or medical record numbers of patient(s) involved may be provided to this agency. it is not a hipaa violation. include the names of involved staff and staffing assignment sheets if available.

describe why the patient did not have a low acuity. if the hospital just staffs by the census with no variation write that with a couple weeks census and staffing as an example.

remember in california a competent nurse must provide relief for meals and breaks.

describe the incident with a quote from title 22 and include the number of the section violated. include medications or treatments missed or late, adverse events such a fall, a patient not assessed frequently enough who had to go to icu or who coded, a fall, or other event. these events can make the hospital pay a fine.

if the nurses prevented adverse events (as we always try to do) then even if the hospital is in violation they only have to write their plan not to do it again.

california department of public health offices - http://www.cdph.ca.gov/certlic/facilities/pages/lcdistrictoffices.aspx#riverside

public records page - http://www.cdph.ca.gov/pages/publicrecords.aspx

scroll down this page for more information in the nursing practice & patient advocacy alerts - http://www.nationalnursesunited.org/pages/nursing-practice