RELATING TO HEALTHCARE FACILITY NURSE STAFFING.

HB62

HOUSE OF REPRESENTATIVES

H.B. NO.

62

THIRTY-THIRD LEGISLATURE, 2025

STATE OF HAWAII

A BILL FOR AN ACT

RELATING
TO healthcare facility nurse STAFFING
.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

����
SECTION
1.
�
The Hawaii Revised Statutes is
amended by adding a new chapter to be appropriately designated and to read as
follows:

"
Chapter

HEALTHCARE
FACILITY STAFFING

PART I.
�
GENERAL PROVISIONS

����
� -1
�
Definitions.
�

As used in this chapter, unless the context otherwise requires:

����
"Ancillary
staff person" means any person who supports patient care services in a healthcare
facility through regular, delegated tasks performed under the coordination of a
registered nurse for the delivery of safe, therapeutic, and effective patient
care.

����
"Declared
state of emergency" means an emergency declared by the president, the governor,
or a mayor, relating to circumstances that are unpredictable and unavoidable,
affect the delivery of medical care, and require an immediate or exceptional
level of emergency or other medical services at a particular healthcare
facility.
�
"Declared state of
emergency" shall not include an emergency relating to a labor dispute in
the healthcare industry or consistent understaffing in a healthcare facility.

����
"Department"
means the department of health.

����
"Registered
nurse" means a registered nurse licensed under section 457-7 or an
advanced practice registered nurse licensed under section 457-8.5.

����
"Health
care facility" means:

����
(1)
�
A hospital licensed under section 321-14.5;

����
(2)
�
A home care agency licensed under section 321-14.8;

����
(3)
�
An adult residential care home licensed under section
321‑15.6; and

����
(4)
�
An expanded adult residential care home under
section 321-15.62.

����
"Patient
care unit" means any area of a healthcare facility where a patient
receives care.

����
� -2
�
Application and construction.
�
(a)
�

All healthcare facilities shall be subject to the requirements of this
chapter; provided that this chapter shall not be construed to:

����
(1)
�
Change the scope of practice of any registered
nurse; or

����
(2)
�
Provide an exemption from the minimum staffing
requirements established by any other law, rule, or standard.

����
� -3

�
Minimum staffing requirements of registered
nurses.
�
(a)
�
Except as provided in section

-4,
a healthcare facility shall assign at least the number of registered nurses at
all times during every shift consistent with the minimum requirements
established in this section.

����
(b)
�
Each healthcare facility shall assign a registered
nurse to no more than:

����
(1)
�
One patient when:

���������
(A)
�
The patient is receiving critical care or
intensive care; or

���������
(B)
�
The nurse is assigned to a patient care unit,
other than a unit providing emergency services, that receives patients
requiring critical care or intensive care, including a critical care unit, an
intensive care unit, or a patient care unit with neonatal intensive care or
pediatric intensive care patients;

����
(2)
�
One patient when:

���������
(A)
�
The patient is in an operating room; or

���������
(B)
�
The nurse is assigned to an operating room;

���������
provided
that the healthcare facility shall also assign a minimum of one scrub assistant
for each patient in an operating room in addition to the assigned registered
nurse;

����
(3)
�
One patient when the patient is receiving
conscious sedation;

����
(4)
�
One patient when:

���������
(A)
�
The patient is receiving postanesthesia care;
or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients who require post-anesthesia care, including a pediatric
postanesthesia care unit;

����
(5)
�
Three patients when:

���������
(A)
�
The patients are receiving step-down or
intermediate care; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring step-down or intermediate care, including a
step-down or intermediate care unit;

����
(6)
�
Three patients when:

���������
(A)
�
The patients are receiving emergency medical
services and do not require critical care or trauma services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring emergency medical services, including an
emergency department or emergency room;

����
(7)
�
One patient when the patient is receiving
emergency services and requires critical care;

����
(8)
�
One patient when the patient is receiving
emergency services and requires trauma services;

����
(9)
�
Three patients when the patients are
antepartum and not in active labor;

���
(10)
�
Two patients when the patients are antepartum
and require continuous fetal monitoring;

���
(11)
�
One patient when the nurse is assigned to
initiate the patient for epidural anesthesia or the nurse is assigned as the
circulating nurse for cesarean delivery;

���
(12)
�
One patient when the patient is in active
labor;

���
(13)
�
One patient who is giving birth when the nurse
has been assigned only to that patient and one newborn patient when the nurse
has been assigned only to that newborn patient;

���
(14)
�
One newborn patient when the patient is
unstable, as determined by the nurse;

���
(15)
�
One patient couplet of one parent and one
newborn when the parent has given birth within the previous two hours; provided
that in the case of multiple births, one registered nurse shall be assigned for
each additional newborn when the registered nurse has been assigned only to
that newborn;

���
(16)
�
Two patient couplets of one parent and one
newborn when the patients are postpartum;

���
(17)
�
Four patients when the patients are receiving
postpartum or postoperative gynecological care and when the nurse has been
assigned only to patients receiving postpartum or postoperative gynecological
care;

���
(18)
�
Two newborn patients when:

���������
(A)
�
The patients are receiving intermediate care;
or

���������
(B)
�
The nurse has been assigned to a patient care
unit that receives newborn patients requiring intermediate care;

���
(19)
�
Three patients when:

���������
(A)
�
The patients are minors; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients who are minors;

���
(20)
�
Two patients who are minors when:

���������
(A)
�
The patients are receiving bone marrow
transplant services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives bone marrow transplant patients who are minors;

���
(21)
�
One patient when:

���������
(A)
�
The patient is receiving coronary care
services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring coronary care services;

���
(22)
�
One patient when:

���������
(A)
�
The patient requires burn care services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring burn care services;

���
(23)
�
One patient when:

���������
(A)
�
The patient is receiving acute respiratory
care services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring acute respiratory care services;

���
(24)
�
Three patients when:

���������
(A)
�
The patients are receiving telemetry services;
or

���������
(B)
�
The nurse is assigned to a patient care unit that
receives patients requiring telemetry services;

���
(25)
�
Four patients when:

���������
(A)
�
The patients are receiving medical surgical
care services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring medical surgical care services;

���
(26)
�
Three patients when:

���������
(A)
�
The patients are receiving observational care
services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring observational care services;

���
(27)
�
Four patients when:

���������
(A)
�
The patients are receiving acute
rehabilitation services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring acute rehabilitation services;

���
(28)
�
Four patients when:

���������
(A)
�
The patients are receiving specialty care
services; or

���������
(B)
�
The nurse is assigned to a patient care unit
receiving patients requiring specialty care services, including a specialty
care unit, neurological care unit, gastrointestinal unit, orthopedic unit, or
any other unit that is organized, operated, and maintained to provide care for
a specific medical condition or a specific patient population;

���
(29)
�
Four patients when:

���������
(A)
�
The patients are receiving presurgical
admissions services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring presurgical admissions services;

���
(30)
�
Four patients when:

���������
(A)
�
The patients are receiving ambulatory surgical
care services or procedures; or

���������
(B)
�
The nurse is assigned to a patient care unit
that provides ambulatory surgical care services or procedures;

���
(31)
�
Four patients when:

���������
(A)
�
The patients are receiving psychiatric
treatment or services; or

���������
(B)
�
The nurse is assigned to a patient care unit
that receives patients requiring psychiatric treatment or services; and

���
(32)
�
Four patients in any other patient care unit
or for any other patient condition.

����
(c)
�
A healthcare facility may assign a registered
nurse to patients receiving triage services if the nurse is performing only
triage functions and can be immediately available to patients requiring triage
services arriving in a patient care unit that receives patients requiring
emergency medical services.

����
(d)
�
A healthcare facility shall assign registered
nurses in a patient care unit under subsection (a) to meet the highest level of
intensity and type of care provided in the patient care unit.
�
When more than one requirement in subsection (a)
applies to a patient, a healthcare facility shall assign a registered nurse according
to the lowest numerical patient assignment applicable to the patient.

����
(e)
�
If in the professional judgment of the registered
nurse, a patient requires the assignment of more than the number of registered
nurses required under this section, a healthcare facility shall assign
additional registered nurses to the patient consistent with the registered
nurse's professional judgment.

����
� -4
�
Exceptions to staffing requirements.
�
(a)
�

The registered nurse staffing assignments required under section -3
shall not apply during a declared state of emergency.

����
(b)
�
It shall be a defense to a complaint alleging
a violation of section

-3 filed against a healthcare
facility that the healthcare facility demonstrates that it undertook prompt and
diligent efforts to maintain the staffing assignments required under section -3
despite the declared state of emergency.

����
� -5
�
Staffing calculation requirements.
�
(a)
�
A
patient shall be assigned to a registered nurse.
�
A patient shall be considered to be assigned
to a registered nurse if the nurse accepts responsibility for the patient's
care and meets the requirements under section -6.

����
(b)
�
A healthcare facility shall not average the
number of patients or number of registered nurses in a patient care unit for
purposes of this chapter.

����
(c)
�
A healthcare facility shall not include in
the nurse‑to‑patient ratios required under this chapter an
ancillary staff person or a nurse who does not provide direct, in-person, hands‑on
care to a patient, including a nurse administrator, nurse supervisor, nurse
manager, charge nurse, or case manager.
�
A
registered nurse who is also a nurse administrator, nurse supervisor, nurse
manager, charge nurse, case manager, or any other healthcare facility
administrator or supervisor may be included in the calculation of the registered
nurse staffing assignments required under section -3 if
the registered nurse:

����
(1)
�
Has a current and active direct patient care assignment;

����
(2)
�
Provides direct patient care in compliance
with the requirements of this chapter;

����
(3)
�
Has demonstrated current competency in
providing care in the assigned patient care unit and has received orientation
to the unit sufficient to provide competent, safe, therapeutic, and effective
care to patients in the unit;

����
(4)
�
Has the principal responsibility of providing
direct patient care and has no additional job duties when the nurse has a
patient assignment; and

����
(5)
�
Is providing relief for a registered nurse
during breaks, meals, or other routine absences from the unit.

����
(d)
�
A healthcare facility shall not assign an
ancillary staff person to perform tasks that involve professional judgment or
the skill of a registered nurse, including patient assessment, evaluation, and
implementation of a nursing care plan and administration of medications, even
if the provision of care is under the supervision of a registered nurse.

����
(e)
�
A healthcare facility shall not include a registered
nurse in the calculation unless the nurse has the principal responsibility of
providing direct patient care to the assigned patient and has no additional job
duties other than direct patient care, such as a nurse with triage, external
communications, or emergency transport duties.

����
(f)
�
A healthcare facility shall not impose a
mandatory overtime requirement on a registered nurse.

����
(g)
�
A healthcare facility shall not lay off or
otherwise reduce the availability of ancillary staff persons to meet the registered
nurse staffing assignments required under section -3.

����
(h)
�
A healthcare facility shall not use any form
of electronic monitoring, including video monitoring or other remote
monitoring, to fulfill staffing requirements under this chapter.

����
(i)
�
Each healthcare facility shall plan for
routine fluctuations in the number of patients being treated in the facility
resulting from circumstances such as admissions, discharges, and transfers of
patients to maintain staffing ratios under section

-3.

����
� -6

�
Assignment of registered nurses.
�
(a)
�
No less than once each shift, each healthcare
facility shall assign to a patient a registered nurse responsible for the
provision of care to the patient under this section.

����
(b)
�
Each healthcare facility shall not assign a registered
nurse to a patient unless the nurse has demonstrated current competency in
providing care to patients in the patient care unit and has also received
orientation to the unit sufficient to provide care to patients.

����
(c)
�
A healthcare facility may assign a registered
nurse to relieve the originally assigned registered nurse for breaks, meals, and
other routine, expected absence only if the relieving nurse has demonstrated to
the facility competency in providing care to patients in the patient care unit
and received orientation to the unit sufficient to provide care to patients.

����
(d)
�
Each healthcare facility shall include in its
policies and procedures its criteria for making a staffing assignment under
this section.

����
� -7

�
Use of technology.
�
(a)

�
A healthcare facility shall not use electronic
monitoring, including video monitoring or other remote monitoring, to
substitute for the direct observation by a registered nurse or an ancillary
staff person required for patient protection.

����
(b)
�
For purpose of this chapter, a healthcare
facility shall not adopt policies or practices that:

����
(1)
�
Employ:

���������
(A)
�
Health information technology;

���������
(B)
�
Algorithms used to achieve a medical or
nursing care objective,

���������
(C)
�
Systems based on artificial intelligence or
clinical practice guidelines that limit or substitute for the direct care
provided by an assigned registered nurse in the performance of functions that
are part of the nursing process, including the full exercise of independent
professional judgment; or

���������
(D)
�
Systems that limit a registered nurse from
acting as a patient advocate in the exclusive interests of the patient; or

����
(2)
�
Penalize a registered nurse for overriding
technology or guidelines prohibited in paragraph (1) if in the registered
nurse's professional judgment and in accordance with the registered nurse's
scope of practice is in the best interest of the patient to do so.

����
� -8

�
Patient advocacy.
�
(a)
�
A registered nurse shall have the duty and
right to:

����
(1)
�
Act based on the nurse's professional judgment;

����
(2)
�
Provide care in the exclusive interests of the
patient; and

����
(3)
�
Act as the patient's advocate.

����
(b)
�
A registered nurse shall exercise professional
judgment in the performance of the nurse's duties within the nurse's scope of
practice in accordance with chapter 457 in the exclusive interests of the
patient.
�
A registered nurse's actions
under this subsection shall not be considered, relied upon, or represented as a
job function, authority, responsibility, or activity undertaken for the purpose
of serving the business, commercial, operational, or other institutional interests
of the employer.

����
(c)
�
A registered nurse shall provide competent,
safe, therapeutic, and effective nursing care to an assigned patient.
�
Before accepting a patient assignment, a registered
nurse shall:

����
(1)
�
Have the necessary knowledge, judgment, skills,
and ability to provide the required care;

����
(2)
�
Determine using the nurse's professional
judgment whether the nurse is competent to perform the nursing care needed by a
patient who is in a particular patient care unit or who has a particular
diagnosis, condition, prognosis, or other determinative characteristic
affecting nursing care; and

����
(3)
�
Determine using the nurse's professional
judgment whether acceptance of a patient assignment would expose the patient or
registered nurse to the risk of harm.

����
(d)
�
As part of a registered nurse's patient
advocacy, a registered nurse may object to or refuse to accept or participate
in any activity, policy, practice, assignment, or task in a healthcare facility
if the registered nurse:

����
(1)
�
Believes, based on the nurse's professional
judgment, that the activity, policy, practice, assignment, or task would
violate chapter 457 or be outside the nurse's scope of practice;

����
(2)
�
Believes, based on the nurse's professional
judgment, that the activity, policy, practice, assignment, or task would
violate the staffing requirements under section

-3
or would violate any other provision of this chapter; or

����
(3)
�
Believes, based on the nurse's professional
judgment, that the nurse is not prepared by education, training, or experience
to fulfill the assignment without compromising the safety of a patient or
jeopardizing the license of the registered nurse.

����
(e)
�
A healthcare facility, an employee of a healthcare
facility who is primarily responsible for managing the facility, or an employee
of the facility who is primarily responsible for providing patient care
services shall not:

����
(1)
�
Interfere with or prevent a registered nurse
from exercising professional judgment under this section;

����
(2)
�
Limit a registered nurse in performing duties
that are a part of the nursing process, including full exercise of professional
judgment in assessment, planning, implementation, and evaluation of care;

����
(3)
�
Limit a registered nurse in acting as a
patient advocate in the exclusive interests of the patient; or

����
(4)
�
Discharge from duty, threaten, or otherwise
retaliate against a registered nurse who reports an unsafe practice or
violation of policy, federal or state law, federal regulation, or state rule.

����
� -9

�
Record and notice requirements.
�
(a)
�
A healthcare
facility shall maintain and disclose records relating to actual staffing assignments
and any method used to meet the requirements of this chapter under this section
and rules adopted by the department.

����
(b)
�
Records maintained and disclosed under this
section shall include:

����
(1)
�
The number of patients in each patient care
unit during each shift;

����
(2)
�
The identity and duty hours of each registered
nurse assigned to each patient in each patient care unit during each shift;

����
(3)
�
The identity and duty hours of each ancillary
staff person for each patient care unit during each shift;

����
(4)
�
Certification that each registered nurse
received rest and meal breaks and the identity and duty hours of each registered
nurse who provided relief during the breaks; and

����
(5)
�
A copy of each notice required under
subsection (d).

����
(c)
�
Records under this section shall be maintained
for at least three years.

����
(d)
�
Each healthcare facility shall submit all
records under this section to the department.
�
The chief nursing officer shall certify that the
records submitted to the department under this subsection completely and
accurately reflect staffing assignments in each patient care unit.
�
The certification shall be executed under
penalty of perjury and shall contain an express acknowledgment that any false
statement constitutes fraud and is subject to criminal prosecution or civil
penalties.

����
(e)
�
A healthcare facility shall post in each
patient care unit a notice in a form specified by the department that:

����
(1)
�
Explains the requirements of record
maintenance under this section;

����
(2)
�
Includes actual registered nurse staffing
assignments in each patient care unit during each shift;

����
(3)
�
Includes the actual number of ancillary staff
persons and the skill mix of the ancillary staff persons in each patient care
unit during each shift;

����
(4)
�
Identifies the variance between the required
and actual staffing assignments in each patient care unit during each shift;
and

����
(5)
�
Is visible, conspicuous, and accessible to healthcare
facility staff, patients, and the public.

����
(f)
�
Records maintained under this section shall
be available on the healthcare facility's website.

����
� -10

�
Audits.
�

The department shall conduct periodic audits to ensure that a healthcare
facility has implemented the registered nurse staffing requirement under this
chapter.

����
� -11

�
Administrative sanctions; investigation.
�
(a)
�
The department may direct a healthcare
facility to correct any violations under this chapter in a manner and within a
time frame that the department determines appropriate to ensure compliance or protect
public health.

����
(b)
�
A healthcare facility found in violation of:

����
(1)
�
Section

-3,

-5,

-6,

-7,
or

-9, shall be assessed a fine of not more than
$10,000; and

����
(2)
�
Section

-8, shall
be assessed a fine of not more than $25,000.

Each day of violation shall be considered a separate
offense.

����
� -12
�
Complaints.
�

An individual may file a complaint with the department against a healthcare
facility for violations of this chapter.

����
� -13

�
Rulemaking.
�
The department may adopt rules under
chapter 91 for purposes of this chapter."

����
SECTION 2.
�
This Act shall take effect on January 1,
2026.

INTRODUCED BY:

_____________________________

Report Title:

Healthcare
Facilities; Hospitals; Care Homes; Nurses; Ratios

Description:

Implements
various nurse-to-patient ratios at hospitals and care homes.
�
Requires the Department of Health to audit
healthcare facility compliance.

The summary description
of legislation appearing on this page is for informational purposes only and is
not legislation or evidence of legislative intent.