Nurse Ratio Checks Rarely Done

As state officials move to relax some of the nurse-to-patient ratios imposed earlier this year, only a fraction of California’s hospitals have been inspected to determine whether they are complying with the law.

The state Department of Health Services, which licenses the state’s 451 acute-care hospitals covered by the law, has completed investigations of just 28 facilities, according to state data.

The department does not do random inspections to determine whether the ratios are being followed, relying instead on complaints from the public and self-reporting by hospitals that they are at times out of compliance. Since the law took effect in January, 78 complaints have been filed.

Officials said they don’t have the power to fine or close facilities that don’t meet the ratios. The state has found staffing deficiencies at 15 hospitals, and in all cases has demanded a plan of correction from administrators. In four cases, the inspections led the state to cite the hospitals for other deficiencies not related to nurse staffing.

“We consistently enforce all of the regulations that have to do with patient safety,” said Sandra Shewry, the state’s health director. “Any time there’s an allegation and that allegation could place a patient in immediate jeopardy of health or safety, we assign a nurse or regulator to visit the facility within 48 hours.”

Other staffing complaints that do not indicate immediate patient harm will be investigated at the regular hospital inspection, which happens every three years, state officials said.

As a result, it remains unclear how many hospitals are complying with the ratios.

A hospitals association, which opposes the ratios, says its survey found 85% of hospitals out of compliance. A survey by a nurses union, which supports the ratios, found 42% of hospitals out of compliance.

The confusion comes from a law passed by the Legislature in 1999, the first in the country to set standards for the maximum number of patients that each nurse is allowed to handle at all times. Those numbers are based on the severity of the patients’ illnesses. In the operating room, for example, each patient should have nurse. In a medical-surgical ward, one nurse may take care of six patients.

Gov. Arnold Schwarzenegger’s administration Thursday proposed scaling back some of the ratios. The request included allowing more flexibility in the emergency department during unexpected surges and delaying implementation of a second phase of the law, which requires that the nurse-to-patient ratio in medical-surgical wards drop from 1 to 6 to 1 to 5 next year.

The proposed changes, which officials said were prompted in part by the financial burden the ratios were placing on hospitals, must be approved by the state Office of Administrative Law.

The ratios have been the subject of debate since their passage, upheld most recently by a Sacramento County Superior Court judge in May after a challenge from a hospital organization. Hospital administrators have complained about the cost of complying with the law and the impracticality of meeting the ratios “at all times.” Nursing unions strongly support the law and believe the ratios are improving patient care.

Some union officials believe the state should do more to enforce the rules.

“Our feeling is ... the department should be more assertive,” said Jill Furillo, the Southern California director of the California Nurses Assn., who lobbied for the ratios in 1999.

Part of the problem, she said, is that the state health department lacks both the money to go after every offender immediately and the power to punish. The state can require a plan of correction and can tell the federal government that the hospital does not comply with all state laws, possibly threatening that hospital’s Medicare and Medicaid funding.

Furillo said that during the 2003 legislative session, her group pushed for “three strikes” legislation for hospitals to give the department “some authority with teeth.” That law would have fined a hospital for violating the staffing law within a six-month period, Furillo said. It was not moving very quickly through the Legislature and so the union put it aside for study, she said.

Hospital officials say they are struggling to find enough nurses to meet the ratios -- and to find the money to pay for them.

Jan Emerson, a spokeswoman for the California Healthcare Assn., agreed that the Schwarzenegger administration has “not aggressively enforced the ratios.”

She praised the state for not cracking down on hospitals that fail to meet what some administrators consider an impossible goal but said the ratio law presented another headache.

“The problem is, that doesn’t alleviate a hospital’s legal liability,” she said, adding that patients could potentially use a hospital’s failure to meet the ratios as a cause for legal damages. “We are frankly surprised that hasn’t happened yet -- tort cases, liability cases that trial lawyers make.”

Emerson said the Schwarzenegger administration’s proposed changes to the ratio rules would be “extremely helpful,” and rejected an assertion by union officials that the proposal would jeopardize the health of patients.

“Hospitals were not unsafe on Dec. 31 and suddenly safe on Jan. 1,” when the law went into effect, she said. “We’re not saying the ratios should let one nurse care for 20 patients.”

State officials said they were trying to be sensible about the numbers.

Brenda Klutz, deputy director of licensing and certification for the state Health Services Department, said if the department hears a complaint that a hospital unit was out of compliance for 15 minutes on a p.m. shift, “we will follow up and investigate. It doesn’t mean rolling out immediately.”

Klutz said she believes it is “really bureaucratic of us” to consider such a short time period to be a violation.

In addition, not all of the state’s numbers for ratios are backed by conclusive scientific evidence, she said. The state took the maximum ratio of four patients per nurse in the pediatric ward from the American Academy of Pediatrics’ recommendation, but “for units such as medical-surgical wards, there was no recommendation from groups like the American Academy of Pediatrics,” she said.

For this reason, and to learn more about the effects on finances and recruiting, the department hopes to move up a planned study of the law, Klutz said.

Although the Legislature heard hours of testimony during hearings throughout the state before passing the law, California is still the first state to try this experiment, officials said.

“What we want to do is be informed really by solid data we can verify. How has this affected patient care? Has it improved patient outcomes?” Klutz said.

“We really have an obligation, before we make further changes to the law, to get those answers.”