California Nurse-to-Patient Ratios: Facility Guide
As a facility leader, it’s crucial to stay informed about laws that influence nurse staffing ratios. Each state regulates its own policies, with California being the first state to enact mandatory staffing minimums. Over the past two decades, this California nurse-to-patient ratio law has helped improve care quality and increase nurse retention.
So, you may be wondering, what is the nurse-to-patient ratio in California? To help you stay compliant with staffing laws, we’ll outline all relevant guidelines and nurse-to-patient ratios for registered nurses (RNs), licensed vocational nurses (LVNs), and certified nursing assistants (CNAs) in the state.
California Nurse-to Patient Ratio: Acute Care
The California nurse-patient ratio law (A.B. 394) was passed in 1999, making California the first state in the country to enforce mandatory nurse-to-patient ratios for hospitals. These ratios went into effect in 2004, establishing the maximum number of patients that could be assigned to one licensed nurse during each shift. Exact ratios vary by specialty and are further broken down in the table below.
| Specialty Type |
|
|---|---|
| Operating Room |
1:1 |
| Trauma Patients in the ER |
1:1 |
| ICU Patients in the ER |
1:2 |
| Intensive/Critical Care |
1:2 |
| Labor and Delivery |
1:2 |
| Neonatal Intensive Care |
1:2 |
| Post-Anesthesia Recovery |
1:2 |
|
Step Down |
1:3 |
| Antepartum |
1:4 |
| Emergency Room |
1:4 |
| Other Specialty Care |
1:4 |
| Pediatrics |
1:4 |
| Postpartum Couplets |
1:4 |
| Telemetry |
1:4 |
| Medical/Surgical |
1:5 |
| Postpartum Women Only |
1:6 |
| Psychiatric |
1:6 |
California Nurse-to-Patient Ratio: Post-Acute Care
While California requires minimum nurse-to-patient ratios for acute care settings, there are no specified ratios for skilled nursing facilities (SNFs) and nursing homes. These facilities are more generally required to deliver at least 3.5 hours of nursing care per patient each day (including RNs, LVNs, and CNAs), with CNAs performing at least 2.4 hours of care each day.
The table below outlines more specific supervision requirements based on the number of beds a SNF or nursing home has filled.
| Number of Beds | Minimum Supervision Requirements |
|---|---|
| <60 Beds | RN or LVN awake and on duty at all times |
| 60-99 Beds | RN or LVN awake and on duty at all times, plus Director of Nursing on site |
| 100+ Beds | RN awake and on duty at all times, plus Director of Nursing on site |
How Nurse-to-Patient Ratios Apply to RNs vs. LVNs
When it comes to fulfilling California’s nurse-to-patient ratios for acute care, LVNs can account for 50% of the licensed nurses assigned to deliver care on any unit — unless an RN is required based on patient needs and scope of practice considerations. Additionally, only RNs can be assigned to:
- Intensive Care Newborn Nursery Service Units, which require 1 RN for every 2 infants.
- Emergency Departments, which require RNs to be assigned to triage and critical trauma patients.
How Nurse-to-Patient Ratios Apply to CNAs
You may also be wondering, What is the legal CNA-to-patient ratio in California? Aside from the minimum 2.4 daily contact hours required of CNAs working in SNFs, California doesn’t mandate any specific ratios for nursing assistants and assistive personnel.
However, there are provisions in A.B. 394 that regulate how unlicensed assistive personnel can be used. Hospitals can’t assign unlicensed assistive personnel to perform any nursing or RN functions under the supervision of an RN, which include, but are not limited to:
- Administration of medication
- Venipuncture
- Invasive procedures
Additional Staffing Guidelines for Facilities
To effectively implement these staffing requirements, there are additional provisions outlined in California’s Code of Regulations that facility leaders should know. Below, we’ll summarize key aspects of these provisions and how they impact nurse staffing.
Patient Classification System and Nursing Staff
Beyond the minimum nurse-to-patient ratio, California nurse staffing law requires additional licensed nurses to be added to units based on a documented patient classification system. This classification is based on several factors including illness severity, the complexity of clinical judgment, and the need for any specialized technology.
Restrictions on Unsafe Floating
Facilities must also provide proper orientation and necessary training to nurses who are floating to a different clinical unit. Any temporary staff must receive the same orientation and meet the same competencies that are expected of regular staff.
Ratios Apply at all Times
The nurse-to-patient ratios in acute care settings apply at all times. This includes during any meals and breaks. Additionally, facilities are expected to find proper replacements to fulfill these ratios when nursing staff call off of their shifts.
Prohibitions on Averaging and Ancillary Staff Cuts
Facilities can’t average the total number of patients and nursing staff to meet staffing requirements. To prevent hospitals from cutting back on LVNs and unlicensed nursing personnel, California law also supports existing staffing models utilizing a mix of RNs, LVNs, and unlicensed assistive personnel.
Are You Equipped to Maintain Adequate Staffing Levels?
Staffing can undoubtedly be a challenge, and you may be seeking ways to hire and retain more nurses to meet the California nurse-to-patient ratio. Need additional insights? IntelyCare offers dozens of useful tips to help you foster a stronger, healthier, and happier workforce.