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Politico Pro: "Unions push lawmakers for strict enforcement of nurse-patient ratios"

April 11, 2019

By Angela Hart

04/11/2019 03:34 PM EDT

SACRAMENTO — California hospitals are fighting a renewed effort by organized labor to step up enforcement of nurse staffing ratios, saying it's nearly impossible to meet requirements that minimum ratios be met "at all times."

Sen. Connie Leyva (D-Chino) this year reintroduced a bill that would increase enforcement — and fines — for hospitals that aren't meeting ratio requirements, following a veto last year by former Gov. Jerry Brown of a similar proposal.

CA SB227 (19R) would require the California Department of Public Health to increase unannounced inspections and impose new fines for each violation — $30,000 for the first infraction and $60,000 for subsequent violations. The state's nurse-to-patient ratio law was enacted in 1999.

"I wouldn't be here again if there wasn't a compliance problem," Leyva said as her bill cleared the Senate Health Committee this week. "Hospitals have had 20 years to get it right and they have not."

The difficulty, said Debby Rogers, a lobbyist with the California Hospital Association, is in requiring that minimum staffing levels be met "every minute, every second, every day." It would put hospitals at risk of violations and penalties if they fall out of compliance for "even a moment," she said.

"Hospitals are complicated environments," Rogers said. "When we think about those employees driving the freeway to get to work, if there's a car accident or a sick child that needs to be dropped off at grandma's house instead of school and that nurse is five minutes late, that's a penalty under this bill.

"The strict liability standard that appears in the bill today will increase fines incredibly," she said.

Hospitals argue that the state Department of Public Health already has adequate enforcement authority. California — the only state in the nation with minimum nurse staffing requirements — is required to inspect hospitals at least once every three years. Public health inspectors can also issue financial penalties, ranging from $75,000 to $125,000, for widespread, severe violations that risk patient safety or death, if the department sees fit. They can also assess lower penalties for less serious or isolated infractions.

The department issued 634 nursing staff violations from 2008 to 2017, according to the Senate Health Committee analysis on the bill, including 88 in 2017. But the department hasn't been aggressive enough in imposing fines, lawmakers and nurses said, and that is putting patient safety at risk.

"California leads the nation on nurse-to-patient ratios. The problem is there's no enforcement of those regulations unless there's a death," said Kathy Montanino, a Riverside registered nurse and member of the Service Employees International Union Local 121RN, chief sponsor of the Leyva bill.

She argued that hospitals are understaffing to "pad their bottom line" and the tactics are putting "patients at risk of injury or death." Hospitals are required to have nurse-patient ratios of 1-to-1 in operating rooms, 1-to-2 in intensive care units and 1-to-5 in medical-surgical units. Though the law has been in place for two decades, it did not take effect until 2004.

The fight over staffing is a longstanding battle in the Capitol between unions and hospitals. Backers emphasize patient safety concerns, but the bill is also a helpful organizing tool for unions seeking to increase membership and build the ranks of California nurses.

Leyva, a former union organizer and president of the California Labor Federation, said Wednesday that the bill could help unions, if successful.

"If they hire more nurses, wonderful — all the better for patient safety," she told POLITICO.

Assemblyman Rob Bonta (D-Alameda), a co-author, characterized the bill as a move to help patients, but also to protect unionized workers.

"It's about ... providing true access to high-quality affordable health care, and it's also about workers' rights," he said. "The nurse-to-patient ratio is so critical to make sure to provide adequate patient care, and it's absolutely critical to make sure our workers are treated fairly ...and are not overworked."

In his veto message last year, Brown said California law already provides the state with adequate authority to enforce nurse-patient ratios.

"California hospitals are regularly inspected to assure patient safety and quality of care," Brown wrote. "When violations are found, penalties are imposed based on an overall assessment of the severity and duration of the violations, including for any failure to meet the required staffing ratio.

"Hospitals...are best evaluated in a comprehensive manner and I am reluctant to start singling out specific violations for a separate penalty," Brown said.

Leyva said she hopes things will be different under Gov. Gavin Newsom, who heavily courted union support during his run for office.

"We have a new governor and he's a little more out front on things than our last governor," Leyva said. Should the bill reach his desk, she said, "We'll have some hard conversations with him."