HB62

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).

(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:	_____________________________

HOUSE OF REPRESENTATIVES	H.B. NO.	62
THIRTY-THIRD LEGISLATURE, 2025
STATE OF HAWAII