Via electronic mail to CHCQRegulations@cdph.ca.gov. 

May 20, 2025​

Mandi Posner, Deputy Director
Center for Health Care Quality
California Department of Public Health
1615 Capitol Avenue, Sacramento, CA 95899-7377

RE: Comments on Questions for Stakeholder Meeting – Acute Psychiatric Hospital Regulations AFL-25-16

Dear Deputy Director Posner:

California Nurses Association/National Nurses United (CNA), representing more than 100,000 registered nurses (RNs) who provide direct patient care in California including nurses who work in acute psychiatric hospitals (APHs), writes to you in response to questions posed at the May 13, 2025, Stakeholder Meeting on Acute Psychiatric Hospital Regulations held by the California Department of Public Health (CDPH). By fully implementing safe registered nurse-to-patient ratios throughout acute psychiatric care facilities in California, CDPH can ensure all Californians can access high-quality behavioral health care services. To this end and to protect behavioral health patients, RNs, and other health care workers in our acute psychiatric care facilities, CNA urges that CDPH issue emergency regulations mandating unit-specific minimum numerical registered nurse-to-patient ratios in acute psychiatric facilities throughout the state.

On April 15, 2025, CNA sent a letter to Governor Gavin Newsom urging the issuance of CDPH emergency regulations establishing mandatory minimum registered nurse-to-patient staffing ratios for APHs. We reiterate this request that CDPH issue emergency regulations on APH registered nursing staffing ratios, and CNA urges CDPH to implement the proposed regulations that we attached to our letter to Governor Newsom. CNA's proposed regulatory language for emergency rulemaking on APH minimum safe nu​rse staffing standards is attached to these comments as Attachment 1, and CNA's April 15, 2025, letter to Governor Newsom is attached to these comments to as Attachment 2. RN staffing ratios in California acute psychiatric facilities must be implemented without delay to prevent further patient harm and preserve thousands of lives.

As registered nurses, CNA members know that one of the most effective ways to protect patients is through safe and effective staffing. Staffing levels of RNs that facilitate safe,  competent, therapeutic, and effective care are vital to the safety of patients in our hospitals. For decades, research has demonstrated that safe RN-to-patient staffing ratios are associated with lower mortality, lower nurse burnout, and better nurse retention.[1] The only way to ensure that all hospitals—including APHs—have safe staffing levels that are consistently adhered to is through legally mandated minimum RN-to-patient ratios. California's legislature recognized this in 1999 when it passed Assembly Bill No. 394 (A.B. 394) (Kuehl) and mandated that California's health services agency promulgate regulations on mandatory minimum numerical nurse staffing ratios for all hospitals in the state, including general acute care hospitals (GACHs) and APHs.

Although state regulators should have issued APH nurse staffing ratios promptly after A.B. 394 went into effect over two decades ago, the recently exposed dire state of patient care in APHs emphatically demonstrates the urgent need to issue these regulations. For these reasons, the reasons set forth in CNA's April 15, 2025, letter to Governor Newsom, and the reasons below, CNA urges CDPH to promptly issue emergency regulations establishing APH minimum numerical registered nurse-to-patient staffing ratios.

1. What is the method used by acute psychiatric hospitals to determine real-time staffing needs?

To determine real-time staffing needs, CDPH should require that APHs start with minimum RN-to-patient ratios and staff additional RNs based on patient need as assessed by the direct care registered nurse. This said, given the differences in staffing among APHs, there currently does not appear to be a consistent method to ensure a safe staffing baseline in APHs. Indeed, research has shown that despite concerns about workplace violence, staffing levels, and use of seclusion and restraint, increases in RN staffing in acute psychiatric settings have not kept pace with increases in general acute care settings.[2] In Attachment 2 to these comments, CDPH will find a complete list of research literature specifically supporting safe staffing levels for inpatient psychiatric patients, which CNA sent to Governor Newsom on April 15, 2025.[3]

Recent news reports of serious patient harm, including death and sexual assault, demonstrate that some for-profit APHs are severely understaffed, confirming research that shows RN staffing levels are lower in for‐profit facilities.[4]​ In contrast, CDPH regulations mandating RN-to-patient ratios would establish a minimum staffing standard that would apply to all APHs. 

Critically, a registered nurse's patient assessment should be the basis for the final decision making on staffing needs, which should be reflected in CDPH's regulation on APH registered nurse staffing standards. While some APHs may use a patient classification system (PCS), these systems alone cannot determine staffing needs. PCSs are a method for establishing staffing requirements by unit, patient, and shift, as defined by section 70053.2 of title 22 of the California Code of Regulations. Notably, however, in general acute care hospitals (GACHs), the PCSs are often adjusted to conform to a budget rather than to patient acuity and patient treatment needs.[5] Because even the best PCS cannot capture all relevant issues to real time staffing needs, CDPH should ensure in its APH nurse staffing regulation that an RN must directly assess each patient to determine their needs. 

CDPH should adopt, as has been required under the Health and Safety Code section 1276.4 for over twenty years, RN-to-patient ratios in APHs that set a minimum standard to protect patients and staff in the inpatient APH setting. In its regulation, CDPH should require that APHs assign additional staff based on patient needs as determined by the assessment of the assigned RN. These minimum protective standards “level the playing field” to ensure a safe staffing baseline for every patient in every APH regardless of ownership type. 

2. What is the minimum nurse to patient ratio needed for a unit that cares for adults? Is the minimum staffing the same for every shift? How should other mental health workers be included in the nursing ratio? Please explain.

• CDPH Should Require a Minimum 1:6 Staffing Ratio—Which Must be a Registered Nurse-to-Patient Ratio—For Acute Adult Psychiatric Patients to Ensure That APH Patients Receive Competent, Therapeutic Care in a Safe Environment.

As the sponsor of the 1999 enabling legislation requiring the establishment of both GACH and APH minimum RN-to-patient ratios, CNA urges CPDH to adopt a minimum RN-to-adult psychiatric patient ratio of 1:6 or fewer at all times. To ensure that acute psychiatric patients in APHs have the same standard of care as acute psychiatric patient in GACHs, CDPH must adopt, at a minimum, a registered nurse staffing ratio of 1:6.[6] In other words, CPDH should adopt a minimum nurse staffing standard that requires the following: Every psychiatric patient admitted to an APH must be assigned to a registered nurse who has responsibility for all professional nursing care duties for no more than 6 patients.

CDPH should further limit the number of patients that are assigned to the RN in units in which patients have higher acuity or are at risk of harm to themselves or others. Examples of such units include units for patients who are at risk of harm to themselves or others, dual diagnosis units for patients with substance use disorder and another psychiatric diagnosis, geriatric units, and units for patients with both medical and psychiatric needs. For example, for patients at risk of harm to themselves or others, the GACH ratio of 1:1 registered nurse-to-patient ratio for critical trauma patients should be adopted. Patients in the APH setting are entitled to staffing protections that, at the very least, mirror those in GACHs. To the greatest extent possible, CDPHs APH staffing requirements should mirror the unit-specific numerical ratios and other implementation standards for GACHs found in California Code of Regulations, title 22, section 70217. CNA's proposed regulatory language for APH staffing standards, which is attached here as Attachment 1, has been adopted from the GACH rulemaking, adapted to reflect the inpatient psychiatric units and unit types found in APHs.

CDPH has been statutorily required to adopt APH nurse staffing ratios for over 25 years. CDPH is required by Health and Safety Code section 1276.4, subdivision (a) to adopt regulations that “establish minimum, specific, and numerical licensed nurse-to-patient ratios by licensed nurse classification and by hospital unit” for all GACHs, APHs, and special hospitals. Section 1276.4, subdivision (b) of the Health and Safety Code further clarifies that, “These ratios shall constitute the minimum number of registered and licensed nurses that shall be allocated.”

Importantly, as enumerated in statute, these nurse staffing ratios must be adopted in accordance with hospital licensing and certification requirements as well as registered nursing practice standards, including regulations on the registered nurse nursing process and registered nurse competency. These regulations include California Code of Regulations, title 22, sections 70053.2, 70215, and 70217 and title 16, section 1443.5 as they were in effect when A.B. 394 was signed into law on October 10, 1999. Specifically, as enumerated in Health and Safety Code section 1276.4, subdivision (a), CDPH must adopt registered nurse to patient ratios in accordance with each of the following:

• California Code of Regulations, title 22, section 70053.2, describing the hospital licensing and certification requirements around the use of a PCS. Section 70053.2 defines the PCS, in part, as a method for establishing staffing requirements by unit, patient, and shift based upon the requirements of individual patients.
• California Code of Regulations, title 22, section 70215, establishing the role of the RN in the planning and implementing of patient care through the nursing process.
• California Code of Regulations, title 22, section 70217, further describing the PCS and the duties of the assigned RN.[7]
• California Code of Regulations, title 16, section 1443.5, establishing registered nurse standards of competency.
  

As described in more detail below, the above statutory references to regulations on hospital licensing and registered nurse scope of practice, in effect, establish the registered nurse as responsible for the ongoing assessment of each and every patient admitted to an APH and responsible for all the specific RN roles in determining appropriate nursing care plans and staffing needs of patients.

• Because the Nurse Staffing Ratio Statute Requires the Assessment of an RN to Determine the Nursing Care Needs of Individual Patients, APH Nurse Staffing Ratios Must be Registered Nurse-to-Patient Staffing Ratios.

In accordance with the statutory mandate to implement staffing standards that meet the individualized care needs of patients, the APH nurse staffing ratios must be registered nurse-to-patient ratios. Taken together, the expressly stated standards in the nurse staffing ratios enabling legislation, A.B. 394 (1999), require that a registered nurse, consistent with their scope of practice, exercise their independent professional judgment to provide an ongoing assessment of the individual care needs of each patient and to ensure that the delivery of care reflects the nursing process.[8]

First, the APH nurse staffing ratios enabling legislation expressly identifies its legislative purpose of meeting individualized care needs of patients. Section 1 of A.B. 394 enumerates the statutory purpose of Health and Safety Code section 1276.4, expressly stating that staffing in acute care settings must be “based on the patient's care needs, the severity of condition, services needed, and the complexity surrounding those services[.]”[9]

Second, A.B. 394 goes on in section 2 to recognize that individualized patient care needs can only be determined through the ongoing assessment of the assigned registered nurse and in accordance with nursing scope of practice.[10] Specifically, A.B. 394, as codified in Health and Safety Code section 1276.4, subdivision (a), requires that CDPH “shall adopt” the nurse staffing ratio regulations “in accordance with” several expressly listed hospital licensing and certification requirements and registered nurse competency requirements, including the following requirements:

• Pursuant to California Code of Regulations, title 22, section 70215, subdivision (a)(1) (as it was in effect in Oct. 1999), the nurse staffing ratios must be based on a determination of nursing care needs of individual patients that reflects the registered nurse's ongoing assessment of each patient's care requirements and that provides for shift-by-shift staffing based on those requirements.[11] Section 70215, subdivision (a) expressly states that “[a] registered nurse shall directly provide” the ongoing patient assessment.
• Pursuant to California Code of Regulations, title 22, section 70215, subdivision (b), the nurse staffing ratios “shall” provide sufficient nurse staffing to ensure that the planning and delivery of patient care “reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission." In accordance with nursing scope of practice, the demonstrated ability to apply the nursing process determines the competency of registered nurses and the nursing process is a duty and function that can only be applied by a competent registered nurse.[12]
• Pursuant to California Code of Regulations, title 22, section 70217, subdivision (a) (as it was in effect in Oct. 1999), the nurse staffing ratios must be determined in accordance with individual patient care requirements and generally accepted standards of nursing practice, and must be reflective of unique patient populations.[13]
• Pursuant to California Code of Regulations, title 16, section 1443.5, the nurse staffing ratios must be consistent with the standards of competency of registered nurses.
  

Taken as a whole, in order for CDPH to adopt nurse staffing ratios in accordance with California Code of Regulations, title 22, sections 70053.2, 70215, and 70217 and title 16, section 1443.5, the nurse staffing ratio must be a registered nurse staffing ratio that ensures that the registered nurse can directly provide an ongoing patient assessment of their individual care needs while meeting registered nurse competency standards and applying the nursing process.

Importantly, considering that the nursing process and ongoing patient assessment can only be provided by a registered nurse, the nurse staffing ratios must be registered nurse staffing ratios to ensure that staffing standards do not result in a conflict with nursing scope of practice. Indeed, Health and Safety Code section 1276.4, subdivision (h) directs CDPH, in its adoption of the nurse staffing ratios, to ensure that scope of nursing practice controls if there is a conflict between statute and any provision or regulation defining the scope of nursing practice.

Finally, litigation over nurse-to-patient ratio regulations for GACHs confirmed the role of RNs in the nurse staffing ratio. The California Superior Court summarized the role of RNs in the licensed nurse ratios statute under Health and Safety Code, section 1276.4 in its final decision in California Nurses Association v. Schwarzenegger et al., which was the litigation regarding the implementation of GACH nurse-to-patient ratios regulation. Judge Judy Holzer Hersher's final decision in the case confirms that RN scope of practice controls where there may be a conflict between the nursing ratios statute and any nursing scope of practice regulation.

These sections [of the California Code of Regulations referenced in Health and Safety Code section 1276.4(a)] describe or explain the professional obligations of registered nurses in the provision of health care. For example, section 70053.2 describes the Patient Classification System. Section 70215 provides that an [sic] nurse must provide, among other things, ongoing patient assessments as defined in the Nursing Practice Act, and the planning, supervision, implementation, and evaluation of nursing care to each patient in accordance with the elements of the nursing process. Section 70217(j) likewise provides that nursing personnel shall assist the administrator of nursing services, provide direct patient care, and provide clinical supervision and coordination of care given by licensed vocational nurses and unlicensed nursing personnel. And, as discussed above, section 1443.5 of Title 16 describes the applicable nursing “Standards of Competent Performance.” The statute [Health & Safety Code section 1276.4, subdivision (h)] provides that “in case of conflict between this section and any provision or regulation defining the scope of nursing practice, the scope of practice provisions shall control.”[14]

• CDPH Must Not Adopt, in the APH Nurse Staffing Ratio, Dangerous Status Quo APH Staffing Mixes That Do Not Require Minimum RN Staffing and RN Patient Assignment.

In adopting minimum nurse staffing ratios for APHs, CDPH should not merely codify the demonstrably dangerous status quo staffing mix at APHs that largely relies on licensed vocational nurses and psychiatric technicians without appropriate minimum RN staffing and RN assignment to each patient. The current staffing mix in APHs has resulted in a failure to protect patients, which has prompted the current discussion regarding APH staffing ratios and the May 13, 2025, CDPH stakeholder meeting. The suggestion by hospital representatives during the May 13 stakeholder meeting that the APH staffing ratio should be composed of 50 percent RNs and licensed vocational nurses (LVNs) and 50 percent psychiatric technicians (PTs) and unlicensed mental health workers would dangerously codify the current failing staffing mix at APHs.

The status quo staffing mix has led to unnecessary patient deaths, sexual assaults, other negative patient outcomes, and unsafe working conditions for nurses and other mental health workers in APHs, and it is clearly failing patients. This is evidenced by the San Francisco Chronicle's series of investigative articles and the Los Angeles Times' database documenting patient deaths, sexual assaults, and other incidents resulting from inadequate staffing.[15] Moreover, research has shown that staffing standards that allow substitution of non-RNs are insufficient and produce worse outcomes for patient care, including in APH settings.[16]

Currently, California has a minimum acute psychiatric staffing standard of 1:6 nurse-to patients in GACH psychiatric units, which as discussed throughout these comments must be implemented as a registered nurse-to-patient staffing ratio. There is no reason to deviate from this ratio to provide a lower standard of care in APHs. Moreover, similar to GACHs, CDPH should adopt minimum RN-to-patient ratios that further limit the number of patients that are assigned to the registered nurse for patients in higher acuity units. For example, for patients at risk of harm to self or others, the GACH ratio of 1:1 registered nurse-to-patient ratio for critical trauma patients should be adopted. Again, CNA has included additional unit-specific ratios in proposed regulatory language in Amendment 1.

• While Other Mental Health Workers Play Important Supplemental Care Roles in APHs, it is Inappropriate for CDPH to Include Them in the Nurse Staffing Ratio.

For the purposes of the nurse staffing ratio, it is inappropriate to include other mental health workers. First, because only registered nurses can be assigned patients, any nurse staffing ratio functions to establish a registered nurse-to-patient staffing ratio. Although other mental health workers, including LVNs, PTs, and unlicensed mental health workers, may supplement psychiatric patient care, every psychiatric patient admitted to an APH must be assigned to a registered nurse who has responsibility for all of the professional duties required for nursing care. The implementation of GACHs nurse staffing ratios makes clear that “[a] patient is counted in the nurse-to-patient ratios when the patient is assigned to a licensed nurse for care.”[17]

Because each patient must be assigned to an RN and because an RN must perform the ongoing patient assessment, the APH staffing ratio, as implemented, must be an RN-to-patient ratio. As discussed further below, the scope and duty of RNs require ongoing assessment and observation by an RN that cannot be delegated to other mental health workers, particularly given the high acuity and complexity of care required for acute psychiatric patients. Under the Nurse Practice Act, the RN has a statutory duty of care to perform ongoing patient assessment. This RN duty is clearly defined in section 2725, subdivision (b)(4) of the Business and Professions Code and in California Code of Regulations, title 22, section 70215. The RN must be face-to-face with the patient to perform assessments, observe the signs and symptoms of psychiatric illness, and evaluate the reactions to treatments, such as medication that has been administered for exacerbations (i.e., worsening or intensification) of acute psychiatric illness.

• The High Acuity and Complex Care Needs of APH Patients Require Registered Nurses with the Appropriate Competency, Education, and Scope of Practice.

Because patients in acute inpatient settings, including APH patients, have high acuity and complexity of care that require an RN's scientific knowledge and scope of practice, CDPH must ensure that minimum nurse staffing ratios are minimum registered nurse staffing ratios.[18] The need for RN staffing for APH patients is demonstrated both by Medi-Cal's inpatient psychiatric patient medical necessity criteria[19] and registered nurses' “Standards of Competent Performance” in carrying out the nursing process.[20] CDPH must ensure that no more than 6 patients can be assigned to a registered nurse to ensure that they are able to provide the required care and oversight required by statute and regulation. Moreover, CDPH, in the APH nurse staffing ratios regulation, should further limit the number of patients assigned to a registered nurse for patients with high acuity. CNA has included additional unit-specific ratios in proposed regulatory language attached in Attachment 1.

First, Medi-Cal's medical necessity criteria for reimbursement for psychiatric inpatient hospital services demonstrate APH patients' high acuity and complexity of care and the need for RN staffing.[21] Medi-Cal's medical necessity criteria for APHs begins by requiring that a patient have a specific psychiatric diagnosis.[22] Medi-Cal specifies eighteen psychiatric diagnoses that include disruptive behavior and attention deficit disorders; feeding and eating disorders of infancy or early childhood; substance induced disorders, only with psychotic, mood, or anxiety disorder; and schizophrenia and other psychotic disorders.[23] Many of these psychiatric diagnoses also have significant physical health impacts, which demonstrates the high diagnostic and treatment complexity of APH patient care.

Under Medi-Cal's medical necessity criteria, patients can only be admitted to APHs if they cannot be safely treated at a lower level of care, demonstrating a higher level of acuity compared to patients in non-acute settings and the need for RN care.[24] Patients admitted to APH settings under Medi-Cal's criteria also require psychiatric inpatient hospital services for reasons that include that they “[r]epresent a current danger to self or others, or significant property destruction;” “[p]resent a severe risk to [their] physical health” or that they require admission for “[f]urther psychiatric evaluation," “[m]edication treatment,” or other treatment that requires inpatient hospitalization.[25]​ For continued inpatient psychiatric hospitalization, Medi-Cal requires that the patient continues to meet the medical necessity criteria, has a serious adverse reaction to medication or other treatment, develops new indications that meet the medical necessity criteria, or needs continued medical evaluation or treatment that require inpatient hospitalization.[26] Patients admitted under these criteria are clearly high acuity and require complex and multi-dimensional care that requires the scope of practice of an RN.

Second, the APH staffing ratio must be an RN staffing standard, because the high acuity and complexity of patients in any inpatient acute care setting requires the care of an RN who has the appropriate education, competency, and scope of practice. With respect to RN competency standards, only an RN has the scientific knowledge to perform the nursing process required for the high acuity and complex patients in any inpatient hospital setting. The RN competency standard requires that the RN have “the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process[,]”[27] which is crucial for the care of APH patients who, based on admission criteria, have complex needs and high acuity. All of the diagnoses included in the medical necessity criteria have social aspects and many—such as eating disorders and substance induced disorders combined with a psychotic, mood, or anxiety order—include biological and physical aspects.[28] In some cases, it may be unclear whether a patient with an altered mental status has a behavioral, substance-based, or physical issue or some combination of the three. Only an RN has the educational background to apply social, biological, and physical sciences, through the nursing process, to high acuity and complex APH patients.

• The Nursing Process Requires that the Registered Nurse-to-Patient Ratio be 1:6 or Fewer Patients at All Times.

In adopting nurse staffing ratios for APHs, CDPH must ensure that RNs are staffed at sufficient levels to meet the nursing care needs of APH patients due to their high acuity as well as diagnostic and treatment complexity. The ratio must provide sufficient RN staffing to ensure that the planning and delivery of patient care reflects all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy.[29] We describe each of the steps in the nursing process here, which underscores the need for the assignment and sufficient staffing of registered nurses to meet the care needs of patients.

Only RNs must be counted towards the APH nurse staffing ratios because patient care in the inpatient acute care setting requires the ongoing application of the nursing process, which can only be performed by the RN. The registered nurse initiates the nursing process at the time of admission, yet providing patient care requires ongoing use of the nursing process throughout the patient's stay.[30] In addition to a thorough assessment, formulation of a nursing diagnosis, and creating a nursing plan at admission, RN statutory and regulatory duties include conducting ongoing assessments, implementing the care plan through specific nursing interventions, evaluating the effects of the nursing interventions, and modifying the nursing care plan as needed.[31]

Enumerating the steps in the nursing process demonstrates the breadth and depth of the RN's responsibilities and underscores why the APH staffing ratio must be an RN-to-patient ratio.[32] First, the RN performs the nursing assessment.[33] Second, the RN formulates a nursing diagnosis based on this assessment, which includes observation of their physical condition and behavior, as well as interpretation of information obtained from the patient and others, including the health team.[34]​ Third, the RN collaborates with the patient, the patient's family or other representative (when appropriate), and other staff involved in the patient's care such as psychiatrists, psychologists, and social workers.[35] Fourth, the RN implements the plan by performing the nursing interventions described in the care plan, including explaining the health treatment to the patient and family and performing other nursing interventions such as administering medication.[36] Fifth, the RN evaluates the effect of the interventions on the patient and modifies the care plan, if needed.[37] The nursing process requires the RN to perform ongoing assessments to evaluate any modifications and to ensure that the care plan continues to meet the patient's needs.[38] Finally, the RN must document all of this information in the patient's medical record.[39]

The RN's duty of patient advocacy also demonstrates why the APH ratio must be an RN-to-patient ratio. In addition to carrying out the nursing process, the RN may need to advocate for their patients.[40] RN patient advocacy includes acting on the patient's behalf “to improve health care or to change decisions or activities which are against the interests or wishes of the [patient], and by giving the [patient] the opportunity to make informed decisions about health care before it is provided.”[41] Finally, when it is time for the patient to be discharged, the RN teaches the patient, and their family or representative when appropriate, how to care for the patient's health needs.[42]

As discussed above, the nursing process is both complex and comprehensive. The nursing process in units with patients who have higher acuity will require more attention from the registered nurse. High-acuity patients require a more intensive care plan, more frequent assessments and evaluations, and greater collaboration with health care professionals. For these reasons, CDPH should adjust the minimum registered nurse ratio to further limit the number of patients that are assigned to the RN in units with higher acuity patients; CNA has included additional unit-specific ratios in proposed regulatory language attached in Attachment 1.

The Ability of a Registered Nurse to Delegate Does Not Support Assigning Patients Above the Minimum 1:6 Registered Nurse-to-Patient Ratio and Does Not Support the Inclusion of Non-RNs in the 1:6 Ratio.

While RNs may delegate nursing care tasks, the limitations of the scope of practice of other mental health workers obviate both assigning more patients to the RN and including non-RNs in the nurse staffing ratio. Although some nursing interventions may be delegated to other staff in implementing the nursing care plan, this delegation is subject to limitations based on non-RN staff's “licensure, certification, level of validated competency, and/or regulation.”[43] Licensure as an LVN or PT does not require the educational background in social, biological, and physical sciences that is required for licensure as an RN. Thus, LVNs and PTs are not authorized to formulate a nursing diagnosis, develop a care plan, evaluate its effectiveness in patients, or many of the other things an RN does in applying scientific knowledge to provide patient care as required by the RN competency standards.

Moreover, there are explicit statutory limits on what an RN can delegate to unlicensed personnel, which makes it inappropriate to include non-RNs in the nurse staffing ratio. Specifically, the Business and Professions Code prohibits an APH from “assign[ing] unlicensed personnel to perform nursing functions in lieu of a registered nurse and may not allow unlicensed personnel to perform functions under the direct clinical supervision of a registered nurse that require a substantial amount of scientific knowledge and technical skills […].”[44] Among the list of “functions” that must be performed by an RN are administering medication, assessing a patient's condition, and educating patients and their families about a patient's health care issues and post-discharge care.[45]

Significantly, delegation may do little to reduce an RN's workload because the assigned RN is still responsible for the delegated nursing interventions and must oversee the delegation to the non-RN. Specifically, the RN must oversee all delegatees performing nursing interventions[46] and assess the patient and evaluate the effectiveness of the delegated nursing interventions while continuing to perform all aspects of the nursing process that cannot be delegated. Finally, RNs will be able to delegate fewer nursing interventions in units in which patients have higher acuity or are at risk of harm to themselves or others. Thus, the minimum registered nurse ratio should further limit the number of patients that are assigned to the RN in higher acuity units.

In sum, RNs must be staffed at sufficient levels to provide safe, competent, therapeutic, and effective patient care in accordance with their statutory and regulatory duties. Unless regulations limit the RN-to-patient ratio to six or fewer patients, based on the RN's judgement and patient acuity, RNs will be placed in the untenable position of being forced to delegate or leave care undone. The results of understaffing in APHs have been widely publicized. Neither including non-RNs in the ratio nor using the option of delegation as a justification for increasing an RN's patient assignment will resolve the issues currently plaguing APHs. RNs cannot simply formulate a nursing diagnosis and care plan, then delegate care to others and check back at the end of the shift.

• RNs are Key to Ensuring Patient Safety in the APH Setting and Minimum RN-to-Patient Ratios Must Ensure that Units are Staffed at Sufficient Levels to Protect Patients.

When adopting APH nurse staffing ratios, CDPH must also ensure that RNs are staffed at sufficient levels to monitor patients for signs of adverse reactions to medications, prevent suicides, limit and de-escalate patient aggression, reduce the use of restraints and seclusion, and ensure patient safety should restraints or seclusion become necessary. CDPH should adopt minimum registered nurse ratios that limit the number of patients assigned to fewer than six patients for patients who require a more intensive care plan, more frequent assessments and evaluations, or greater collaboration with health care professionals. For those at greatest risk or in need of intensive care, CDPH should adopt a 1:1 registered nurse to patient ratio. Risks to patient safety in APHs affect not only the individual but may also affect other patients, staff, and the general public. RNs are key to ensuring patient safety in APHs because of their critical role in providing direct patient care.[47]

Many APH patients are taking one or more medications or are admitted for medication treatment, which requires monitoring and ongoing assessment by an RN to ensure patient safety. Unlike LVNs and PTs, an RN is equipped by education and clinical experience to evaluate whether a patient's behavior is related to a physical condition and how medication may be exacerbating or improving the behavior or physical condition. Moreover, adverse reactions in hospitalized psychiatric patients are common and have a high rate of preventability.[48] Preventing adverse drug reactions is an especially crucial component of psychiatric nursing care given the unique challenges in the psychiatric inpatient setting, such as the difficulty of distinguishing antipsychotic-induced conditions from underlying anxiety.[49]

Given the high risk of suicide for APH patients, minimum RN staffing is required to ensure that patients are appropriately assessed through the nursing process for these risks. Many patients in APH are at high risk of suicide, and the rate of death by suicide among patients in these settings is estimated to be 50 to 72 times greater than the general population.[50] Preventing these deaths requires intensive monitoring and direct assessment to identify risk factors and warning signs.[51] Shared decision making, educating patients on the treatment process, and communication and coordination among care providers are all crucial to suicide prevention.[52] As discussed above, these functions fall squarely within the RN nursing process and competency standard.[53] The RN competency standard helps ensure that RNs can appropriately identify and respond to patients at high risk of suicide.[54]​

Additionally, because patients in APH settings may lose behavioral control and pose an imminent risk of harm to themselves or others, minimum RN staffing is required to ensure that any nursing interventions, including seclusion or restraint, are done in a manner that is safe and effective for the patient. Importantly, federal Centers for Medicare and Medicaid Services rules govern most APH's use of restraint and seclusion, requiring that the least restrictive restraint or seclusion is used and discontinued at the earliest time possible.[55] Research has shown more frequent registered nurse assessments can decrease duration of mechanical restraint episodes.[56] As the most restrictive intervention, only appropriately trained staff with a duty to patient care should be able to seclude or restrain the patient to ensure their safety and prevent injury to other patients and staff. These interventions, which can lead to death or severe injury if improperly administered, are emergency measures that require ongoing direct observation and assessment by RNs.

A recent report by Disability Rights California regarding College Hospital, a for-profit APH in Cerritos, demonstrates the severe risks to a patient when improperly trained APH staff overuse and over rely on physical and chemical restraints or seclusion.[57] The investigation reported how the hospital's staff used restraints far more often and far longer than other facilities in the state, often without justification, finding that the hospital failed to make appropriate and regular assessments necessary to determine appropriate behavioral health interventions. Sufficient RN staffing is necessary to ensure proper patient assessment and the least restrictive intervention when restraint and seclusion is even considered.

Importantly, minimum registered nurse-to-patient ratios will increase the accessibility of registered nurses to patients and improve patient care. The recent San Francisco Chronicle series on the violence and chaos at a for-profit APH, Aurora Behavioral Healthcare Santa Rosa, is evidence that the current staffing mix, which has low RN hours per patient days (HPPD), simply is not working.[58] As the investigative series reported, when the police arrived at the APH, they found no one in charge and too few employees to keep watch, let alone care for the 18 children who were supposed to be receiving therapy and mental health treatment.[59]

Given the San Francisco Chronicle reports, it is not surprising that Aurora Behavioral Healthcare Santa Rosa, in 2023, had only 1.9 RN HPPD and unlicensed health workers constituted 66.2% of the entire nursing staff (Table 1).[60] The only other California APH with a higher proportion of unlicensed staff is Aurora Vista Del Mar at 75.6% unlicensed mental health workers (Table 1).[61] The 2023 RNHPPD at Aurora Vista Del Mar is correspondingly low. When comparing two other APHs that are nonprofits to the two for-profit Aurora APHs, the differences in RN staffing based upon RNHPPD is dramatic (Table 1).

Table 1. Select APH RN Hours Per Patient Days, 2023[62]

At Langley Porter Psychiatric Institute and Antelope Valley APH, CNA is the collective bargaining representative of RNs and has been able to implement RN-to-patient ratios through the collective bargaining process even though these APHs are not covered by the GACH registered nurse staffing ratios. These APHs, in which RNs have union representation, set a standard of compliance that CDPH should support and require for all APHs. Moreover, the Los Angeles Times database of deaths and assaults at California psychiatric facilities[63] reports that no suicides or deficiencies were documented for either Langley Porter Psychiatric Institute or Antelope Valley APH while all Aurora facilities, including Aurora Behavioral Healthcare Santa Rosa had suicides and deficiencies.[64] While recognizing that there are many environmental precautions that APHs must take to eliminate suicides in the inpatient setting, the recurring theme in the suicides that are reported in the Los Angeles Times database is that the deaths were due to improper monitoring by staff.[65]

• CDPH's APH Staffing Ratios Must Not Enable Facilities to Lower Their Staffing Standards.

CNA is concerned that CDPH's failure to adopt minimum registered nurse-to-patient ratios will have the unintended consequence of permitting for-profit facilities and even some nonprofit facilities that currently have the highest levels of RN staffing to lower RN staffing standards and reduce the number of RNs available to care for patients in APHs. When CDPH determines the minimum staffing ratios that are necessary for and consistent with safe patient care in APHs, the APHs with the best staffing standards should be the model.

The assertion by some hospital representatives at the May 15 stakeholder meeting that there is a lack of evidence supporting specific ratios in APHs is specious. A similar industry's critique was raised when California was considering the adoption and implementation of GACH staffing ratios over twenty years ago. Since adoption of registered nurse staffing ratios throughout California GACHs, studies clearly have demonstrated the patient care benefits of California's registered nurse staffing standards in comparison to states without these patient protections as well as the protective effect of minimum RN staffing standards during an economic downturn.[66] Additionally, studies have found a 30% decline in RN and LVN occupational injuries and illnesses with the adoption of GACH registered nurse staffing ratios.[67]

Importantly, RN-to-patient staffing ratios in APHs will support the retention of RNs in these facilities. Mandatory minimum RN-to-patient ratios create a workplace environment that helps to reduce the moral injury associated with the inability to provide a safe level of professional care to patients. RNs experience moral distress when they are unable to provide the care they know their patients need when a facility is understaffed. Regular exposure to moral distress results in moral injury. This moral injury is also referred to as “burnout,” a state of mental, physical, and emotional exhaustion. A 2010 study found that units with higher levels of psychiatric registered nurse staffing, along with other organizational factors, led to lower levels of psychiatric registered nurse burnout.[68]

Finally, a 2020 research study of safe acute psychiatric registered nurse staffing standards in Korea referenced the California GACH acute psychiatric standard of 1:6 nurse-to-patient ratio as well as Japan's inpatient psychiatric unit ratios which were 1:3 or 1:4.[69] The Korean study's dataset included 70,136 inpatients who were 19 years old and admitted for behavioral disorders due to use of alcohol, schizophrenia, schizotypal and delusional disorders and mood disorders to 453 hospitals for at least 2 days.[70] Better patient outcomes in inpatient psychiatric units were ssociated with higher RN-to-patient ratios including: shorter length of stay, lower risk of readmission, less psychiatric emergency treatment, and less use of hypnotics.[71]

• Minimum RN Staffing Ratios Should Be Required at All Times and on Every Shift.

When adopting nurse staffing standards for APHs, CDPH must apply—as it does for GACHs—minimum RN-to-patient staffing ratios at all times and on every shift. 

First, because APHs provide 24-hour care, by definition,[72] CDPH must require that APHs meet minimum staffing ratio protections at all times. The RN-to-patient ratio must be enforced “at all times” because even existing regulation for APH states: “All hospitals shall maintain continuous compliance with the licensing requirements."[73] As described by CPDH's predecessor department in the rulemaking for GACH staffing ratios, “continuous compliance” means “at all times.”[74] Additionally, the existing statutory language in section 71215, subdivision (c)(3) of the Health and Safety Code, which describes psychiatric nursing service staffing, requires a registered nurse on duty at all times. In litigation over the implementation of the GACH nurse staffing ratios, Superior Court Judge Gail Ohanesian stated in response to the California Healthcare Association's (now California Hospital Association) arguments against the “at all times” requirement:

DHS' interpretation of section 70217 [of the Health and Safety Code], applying ratios to break periods, is not new and it is consistent with the plain language of the regulation […] Any other interpretation would make the nurse-to-patient ratios meaningless.[75]​

Second, research supports the benefit of RN staffing ratios in psychiatric units. One study has shown a significant association between units that were staffed with higher numbers of psychiatric registered nurses relative to the number of patients and reduced burnout or moral injury among RNs, thereby having a positive effect on RNs capacity to sustain safe and effective patient care environments.[76]

Like GACHs, there should be minimum staffing for every shift, and just as in the GACH setting, APHs hire for both 8-hour and 12-hour shifts. Safe staffing is needed both during day shifts and night shifts. For the day shift, patients may require additional staffing based upon the increased likelihood of patient-to-patient interactions as well as the need for additional care based on the care plan developed by RNs and other health care professionals. During late shifts, in particular, there are fewer professional resources present and the ability of late shift RNs and other staff to protect patients and maintain the therapeutic environment is critical. Safe staffing at all times is particularly important in APHs because of the risk of suicide. A study by Perlis, et al. found that the incidence of suicide varied by time of day and was higher between midnight and 6:00 a.m. Based on the amount of time a person was awake, the mean hourly rate of suicide from 6:00 a.m. to 11:59 p.m. was 2.2 percent compared to 10.3 percent between the hours of midnight and 5:59 a.m. The peak incident rate of 16.4 percent was from 2:00 a.m. to 2:59 a.m. Finally, the observed frequency of suicide was 3.6 times higher than expected overnight between midnight and 5:59 a.m..[77]

3. Is there a need for different staffing levels depending on the age of patients, such as children or adolescents? How should other mental health workers be included in the nursing ratio? Please explain.

Based on the developmental differences between children and adolescents and adult patients, CDPH must increase staffing for younger patients such that the minimum RN-to-patient ratio must be 1:4 for children and adolescents. The minimum RN-to-patient ratio in GACH pediatric and adolescent settings is 1:4 because of these differences based on patient age and CDPH should adopt the same ratio for APHs.[78]

Importantly, most children and adolescents in APHs have experienced high levels of trauma and may require more frequent RN assessments and greater collaboration with other health care professionals. For these reasons, CDPH should adopt a minimum RN-to-patient ratio that further limits the patient assignment for children and adolescents with higher acuity. CNA has included additional unit-specific ratios in proposed regulatory language in Attachment 1.

In addition to their different developmental needs, pediatric and adolescent patients often have special psychiatric needs that require more intensive monitoring than adults. RNs must have regular patient interactions to provide care and plan activities appropriate to the age and mental health status of the child or adolescent. RNs have the education and clinical skills necessary to assess a patient's functioning in a variety of situations and create a nursing plan that includes the appropriate nursing and mental health staff. Additionally, RNs' education and clinical skills ensure that they are able to collaborate effectively with other licensed professionals such as psychiatrists, psychologists, and social workers.

When APH adolescent units are understaffed, patients are at tremendous risk of harm and death. Research has shown critical differences between adolescents and adults in suicidal behavior. Adolescents are at a high risk for attempted suicide and, tragically, have an elevated attempted suicide rate compared to adults.[79]​ Indeed, San Francisco Chronicle's investigation of an APH in the Bay Area found that patients in a designated adolescent unit suffered sexual assault and died by suicide because the hospital did not employ enough staff to monitor patients.[80]

In APH settings, aggressive behavior from adolescent patients frequently arises, prompting registered nurses to intervene and ensure safety for patients and staff.[81] Research has shown that RNs are critical for reducing the risk of violent incidents in acute psychiatric settings for children and adolescents. One study over the course of 16 years showed that the total number of registered nursing staff was the most significant factor associated with a decreased risk of violent incidents in acute inpatient units for children and adolescents.[82] The study also found that substituting nursing assistants for registered nurses increased the risk of violence and suggested that registered nurses were more successful in de-escalation.[83]

Additionally, depending on the severity of the situation, nursing interventions to treat patient aggression may include behavioral management techniques, medication administration, as well as seclusion and restraint as the most restrictive intervention.[84] In these cases, CDPH should adopt minimum registered nurse-to-patient ratios below 1:4 and, in some cases, 1:1. In particular, the minimum registered nurse-to-patient ratio for the use of seclusion or restraints should be 1:1. A recent study found that when a registered nurse decides that a seclusion room is necessary to keep the child or others safe, the child needs the RN to remain in close proximity to help calm them by keeping communication open, thereby avoiding retraumatizing the child. This nursing intervention requires the RN to stand by the door and inform the child of their whereabouts, coach the child to practice their coping skills through the door, encourage the child by observing calm behavior, and enter the room with the child as soon as it is safe to do so.[85]

In sum, due to developmental and other differences, CDPH should adopt a minimum registered nurse-to-patient ratio 1:4 and, based on patient acuity, further limit patient assignments including a minimum registered nurse-to-patient ratio for the use of seclusion or restraints of 1:1.

4. Which factors are considered when determining additional staffing requirements above the minimum ratios. Do you include the following?
a. Patient acuity, for example, risk of harm to self or others.
b. The results of an environmental risk assessment completed to ensure the patient receives care in a safe setting pursuant to the Code of Federal Regulations section 482.13(c)(2).
c. The need for active clinical care including assessment, treatment, and discharge planning

All the considerations listed by CDPH in Question 4 are important in determining additional staffing requirements above the minimum ratios. However, additional staffing will always come down to the RN's direct assessment of each patient on the unit. The registered nurse patient assessment should be the basis for the final decision making on staffing needs above the minimum ratio. As the legislature identified and declared in 1999 when it passed A.B. 394, the principles of staffing in the acute care setting should be based on the patient's care needs, the severity of condition, services needed, and the complexity surrounding those services; each of these—each of these factors are included in the RN assessment.

Importantly, CDPH should include in its factors for staffing above the minimum ratio factors that require intensive care and monitoring. This includes the patient's ability to self-care in relation to their acute mental health crisis as well as the risk of harm to self or others. The ability of patients to self-care is important because, as the Los Angeles Times database of APH deaths demonstrates, approximately half of deaths in APHs are attributable to suicide with more than 50 of 100 deaths from suicide from 2009 to 2021.[86] State investigators found that these APH suicides generally resulted from a failure by hospital staff to appropriately monitor or treat patients.

CPDH should consider the high risk of suicide in APHs as a special need of patients served when establishing APH registered nurse staffing ratios. Indeed, Health and Safety Code section 1276.4, instructs CDPH to consider “special needs of the patients served in the psychiatric units” when adopting RN-to-patient ratios. It bears emphasizing that suicide in the inpatient setting is a “never" event that is preventable and that results from errors that should never happen.[87] For example, in 2018, a patient diagnosed with schizophrenia who was admitted to the hospital because of a suicide attempt killed himself by swallowing an object that blocked his airway, according to coroner's records.[88] ​Appropriate monitoring could have prevented his death. Again, suicide in the inpatient setting is a “never” event that is preventable and that results from errors and understaffing that should never happen. In another incident, a hospital failed to closely monitor a patient which resulted in an assault by another patient when staff were distracted by another activity. These incidents illustrate the importance of recognizing, when CPDH establishes minimum safe RN-to-patient staffing ratios, patient acuity in the APH setting that includes the risk of harm to self or others.

5. General Acute Care Hospitals have a process wherein a committee reviews and validates the system used to determine staffing requirements at least annually, should Acute Psychiatric Hospitals have a similar process? Please explain.

As described above in our response to Question 2, the minimum numerical RN-to-patient ratios must be in effect at all times and must be the baseline requirement for any nurse staffing standard regardless of whether there is a committee review or validation of a patient classification system. Additionally, the RN's direct assessment of each patient and their needs should be the basis for the final decision making on staffing needs for additional staffing above the minimum ratio.

It bears repeating that even the best PCS cannot capture all relevant issues that RNs would identify through their direct assessment and professional judgment to inform staffing needs above the minimum ratio. At best, a PCS is based on estimates of an average, presumably similar, patient and not on the actual patients in an APH. Even though individual patient data may be entered into the PCS, the PCS includes standard values and weights for each value entered.

Moreover, in its APH nurse staffing regulations, CPDH must ensure that the RN's direct assessment of each patient and their staffing needs determines staffing above the mandatory minimum staff ratios and not a PCS. As described above, direct care registered nurses have a licensing mandate to advocate for the patients under their care and do not have the conflict of interests that management, which may control a PCS or review committee, may have, particularly in APHs that are owned by private equity. Staffing should be established based on patients' needs, not driven by management bonuses tied to net revenue.

If a review committee is used by an APH, just as in GACHs, at least half of the members of any PCS review committee must be registered nurses who provide direct patient care. This is important because direct care registered nurses are responsible 24 hours a day for developing and implementing the nursing plan.

6. Do you have any further recommendations for the Department to consider when drafting acute psychiatric hospital nurse to patient ratio regulations?

In drafting APH nurse ratios regulation, CNA urges CDPH to consider the risks of admitting children and youth into the same unit, particularly in units with adult patients. The risks of admitting youth to an adult psychiatric ward have been well recognized.[89] However, the current APH regulations fail to require separate units for children and for adolescents, leaving these patients vulnerable to assault and other harms if admitted to an age-inappropriate unit. Children, adolescents, and adults should each have their own unit in APHs, and this should be reflected in the ratios adopted.

In contrast, GACHs have supplemental service requirements for pediatric units when a hospital has more than 8 beds licensed to care for young patients.[90]​ These regulations include general age parameters for admission to the pediatric unit.[91] CDPH should ensure that APHs have similar protections for young patients.

Although the Health and Safety Code's ratios statute does not address the need for these protections for children and adolescents, CDPH can use its authority to adopt standards that protect children and adolescents by ensuring that each age group has its own unit separate from each other and from adults. This is an important step in preventing children and adolescents from being re-traumatized in an APH.

Additionally, adolescents present unique challenges not only because of their near adult size and strength but also because of the special role that peer relationships play in this age group.[92] A key constituent of the therapeutic setting for adolescents is the opportunity for social interaction with peers within communal areas as well as in school, community meetings, and during specific group activities. In fact, one study showed that relationships that were established with peers on the unit predicted a better outcome at discharge.[93]

Developmental theory recognizes adolescents increasingly value their peer relationships over and above other key relationships in their lives.[94] Neuroscientific investigations have found that adolescence is a time of particular brain sensitivity to cues in the social environment; social signals can motivate certain behavioral patterns and have a major impact on the adolescent's life course.[95]​

In sum, there is ample evidence that children, adolescents, and adults should each have their own units, which CDPH should consider when drafting the APH nurse staffing ratios regulation.

• Conclusion.

For all of the above reasons and for the reasons described in CNA's April 15, 2025, letter to Governor Newsom, CNA urges CDPH to adopt our proposed regulatory language, through emergency regulations, which would establish mandatory, minimum, safe registered nurse-to-patient staffing ratios for California's acute psychiatric hospitals.

If you or your office have any questions, please contact me, CNA Government Relations Director Puneet Maharaj, at pmaharaj@calnurses.org or CNA Government Relations Assistant Director Carmen Comsti at ccomsti@calnurses.org.

​Sincerely,

Original Signed by Puneet Maharaj

Puneet Maharaj
Government Relations Director
California Nurses Association/National Nurses United

Cc: Dr. Erica Pan, Director & State Public Health Officer, California Department of Public Health Susan Fanelli, Chief Deputy Director Health Quality & Emergency Response, California Department of Public Health

Attachments:

• CNA Proposed Emergency Regulations – Acute Psychiatric Hospital Safe Staffing Ratios and Standards (PDF)​
• CNA Letter 4-15-25​

[1] See Lasater K., Muir K. J., Sloane D., McHugh M., Aiken, L. (2024). “Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care.” Med Care, 62(7): 434-40.
[2] Staggs, V. (2019). National trends and variation in nurse staffing on inpatient psychiatric units. Research in nursing & health, 42(5): 410-415.
[3] CNA included a list of research literature in support of APH registered nurse-to-patient staffing standards to our April 15, 2025, letter to Governor Newsom. We have attached the April 15 letter in its entirety to these comments as Attachment 2.
[4] Palomino, J. and Dizkies, C. (Feb 26, 2025). “The Mystery shocked San Francisco. This is the story of the 15- year-old-girl found dead in a driveway.” San Francisco Chronicle.;
Palomino, J. and Dizkies, C. (Mar 5, 2025). “California is embracing psychiatric hospitals again. Behind locked doors, a profit-driven system is destroying lives.” San Francisco Chronicle.;
Palomino, J. and Dizkies, C. (Mar 19, 2025). “Violence and neglect plague a Bay Area psychiatric hospital. California has left its patients in danger.” San Francisco Chronicle. Staggs, V. (2019), supra, at note 2.
[5] Kolakowski, D. (2016). Constructing a nursing budget using a patient classification system. Nursing Management, 47(2), 14-16.
[6] Cal. Code Regs., tit. 22, § 70217, subd. (a)(13).
[7] CDPH's predecessor agency implemented GACH regulation on mandatory minimum nurse staffing ratios in California Code of Regulations, title 22, section 70217, repealing the previous regulatory text that was in effect when A.B. 394 was signed into law in October 1999. See Former California Code of Regulations, title 22, section 70217 filed Nov. 26, 1996, became operative 12-26-96 (Cal. Reg. Notice Register 96, No. 48). Amended Sept. 26, 2003, and became operative Jan. 1, 2004 (Cal. Reg. Notice Register 2003, No. 39)
[8] See Stats. 1999, ch. 945, Section 1(d), A.B. 394 (Kuehl).
[9] Stats. 1999, ch. 945, Section 1(d), A.B. 394 (Kuehl).
[10] See Cal. Code Regs., tit. 22, § 70215.
[11] Former California Code of Regulations, title 22, section 70217 filed Nov. 26, 1996, became operative Dec. 26, 1996 (Cal. Reg. Notice Register 96, No. 48). Change without regulatory effect amending subsection (a)(1) filed Jan. 9, 2013, pursuant to section 100, title 1, California Code of Regulations (Cal. Reg. Notice Register 2013, No. 2).
[12] See Cal. Code Regs., tit. 16, § 1443.5.
[13] Former California Code of Regulations, title 22, section 70217 filed Nov. 26, 1996, became operative Dec. 26, 1996 (Cal. Reg. Notice Register 96, No. 48). Amended Sept. 26, 2003, and became operative Jan. 1, 2004 (Cal. Reg. Notice Register 2003, No. 39).
[14] California Nurses Association v. Schwarzenegger et al., (Super. Ct. Sacramento County, 2005, No. 04S01725), (granting CNA's petition in its final decision on June 7, 2005, at p. 8, emphasis added).
[15] Palomino, J. and Dizikes, C. (Mar 19, 2025), supra, at note 4. Karlamangla, S. and Lee, I. (Updated Jun 8, 2021). “Search our database of deaths and assaults at California psychiatric facilities.” Los Angeles Times. https://www.latimes.com/projects/psychiatric-hospital-deaths-incidentsdatabase/.
[16] Dall'Ora, C. et al. (2023). The association between multi-disciplinary staffing levels and mortality in acute hospitals: a systematic review. Human Resources for Health, 21(1): 30. Park, S. et al. (2020). Nurse staffing and health outcomes of psychiatric inpatients: a secondary analysis of national health insurance claims data. Journal of Korean Academy of Nursing, 50(3): 333-348.
[17] See California Department of Health Services. “Nurse-to-Patient Staffing Ratios for General Acute Care Hospitals, Frequently Asked Questions.” R-37-01 (Jan. 2004), at 8 (emphasis added) (A copy of the FAQs distributed by the California Department of Health Services when the GACH ratios were first implemented is available upon request).
[18] See Cal. Code Regs., tit. 16, § 1443.5.
[19] Cal. Code Regs., tit. 9, § 1820.205. Private sector hospital admission criteria typically are not publicly available and often come from a proprietary database.
According to the National Health Law Program, in California, “[P]rivate plans are more likely to apply medical necessity determinations that, while generally accepted in the behavioral health space, are more stringent than the Medi-Cal medical necessity criteria.” In Hernández-Delgado, H. and Lewis, K. (2023, May 21). “Crosswalk Between Coverage of Behavioral Health Services in Medi-Cal and Private Plans in California.” (PDF)
[20] Cal. Code Regs., tit. 16, § 1443.5.
[21] Cal. Code Regs., tit. 9, § 1820.205.
[22] See Cal. Code Regs., tit. 9, § 1820.205, subd. (a)(1).
[23] Cal. Code Regs., tit. 9, § 1820.205, subd. (a)(1).
[24] See Cal. Code Regs., tit. 9, § 1820.205, subd. (a)(2)(A).
[25]​ Cal. Code Regs., tit. 9, § 1820.205, subds. (a)(2)(B)(1) and (a)(2)(B)(2).
[26] Cal. Code Regs., tit. 9, § 1820.205, subd. (b).
[27] Cal. Code Regs., tit. 16, § 1443.5.
[28] Cal. Code Regs., tit. 9, § 1820.205, subd. (a)(1).
[29] See Cal. Code Regs., tit. 16, § 1443.5 and Cal. Code Regs., tit. 22, § 70215.
[30] See Cal. Code Regs., tit. 16, § 1443.5 and Cal. Code Regs
[31] Cal. Code Regs., tit. 16, § 1443.5 and Cal. Code Regs., tit. 22, § 70215.
[32] See Cal. Code Regs., tit. 16, § 1443.5 and Cal. Code Regs., tit. 22, § 70215.
[33] Cal. Code Regs., tit. 22, § 70215, subd. (a)(1).
[34] Cal. Code Regs., tit. 16, § 1443.5, subd. (1) and Cal. Code Regs., tit. 22, § 70215, subd. (b).
[35] Cal. Code Regs., tit. 16, § 1443.5, subd. (2) and Cal. Code Regs., tit. 22, § 70215, subd. (c).
[36] Cal. Code Regs., tit. 16, § 1443.5, subd. (3) and Cal. Code Regs., tit. 22, § 70215, subd. (a)(2).
[37] Cal. Code Regs., tit. 16, § 1443.5, subd. (5) and Cal. Code Regs., tit. 22, § 70215, subds. (a)(2), (a)(3), and (b).
[38] Cal. Code Regs., tit. 16, § 1443.5, subd. (5) and Cal. Code Regs., tit. 22, § 70215, subd. (a)(1).
[39] Cal. Code Regs., tit. 22, § 70215, subds. (a)(1) and (d).
[40] Cal. Code Regs., tit. 16, § 1443.5, subd. (6) and Cal. Code Regs., tit. 22, § 70215, subd. (b).
[41] Cal. Code Regs., tit. 16, § 1443.5, subd. (6).
[42] Cal. Code Regs., tit. 16, § 1443.5, subd. (3) and Cal. Code Regs., tit. 22, § 70215, subd. (a)(3).
[43] Cal. Code Regs., tit. 22, § 70215, subd. (a)(2). Also see Cal. Code Regs., tit. 16, § 1443.5, subd. (4).
[44] Bus. & Prof. Code § 2725.3, subd. (a).
[45] Bus. & Prof. Code § 2725.3, subds. (a)(1), (a)(5), and (a)(6).
[46] See Cal. Code Regs., tit. 16, § 1443.5, subd. (4) and Cal. Code Regs., tit. 22, § 70
[47] De Santis, M. et al. (2015). Suicide-specific safety in the inpatient psychiatric unit. Issues in mental health nursing, 36(3): 190-199.
[48] Thomas, M., Boggs, A., DiPaula, B., and Siddiqi, S. (2010). Adverse drug reactions in hospitalized psychiatric patients. Annals of Pharmacotherapy, 44(5): 819-825. Rothschild, J. et al. (2007). Medication safety in a psychiatric hospital. General hospital psychiatry, 29(2): 156- 162. See Iuppa, C., Nelson, L., Elliott, E., & Sommi, R. (2013). Adverse drug reactions: a retrospective review of hospitalized patients at a state psychiatric hospital. Hospital pharmacy, 48(11): 931-935).
[49] Iuppa, C., supra, at note 4848.
[50]​ Madsen, T., Agerbo, E., Mortensen, P., & Nordentoft, M. (2011). Predictors of psychiatric inpatient suicide: a national prospective register-based study. The Journal of clinical psychiatry, 72(2): 15139. See Gupta, M., Esang, M., Moll, J., & Gupta, N. (2023). Inpatient suicide: epidemiology, risks, and evidencebased strategies. CNS spectrums, 28(4): 395-400.
[51] Gupta, M., Esang, M., Moll, J., & Gupta, N. (2023), supra, at note 50.50
[52] Ibid.
[53] Cal. Code Regs., tit. 16, § 1443.5, subds. (2), (3), and (6) and Cal. Code Regs., tit. 22, § 70215, subds. (a), (b), and (c).
[54] See Manister, N. et al. (2017). Effectiveness of nursing education to prevent inpatient suicide. The Journal of Continuing Education in Nursing, 48(9), 413-419.
[55] 42 C.F.R. § 482.13(e) et seq.
[56] Allen, D. E., Fetzer, S. J., & Cummings, K. S. (2020). Decreasing duration of mechanical restraint episodes by increasing registered nurse assessment and surveillance in an acute psychiatric hospital. Journal of the American Psychiatric Nurses Association, 26(3), 245-249.
[57] Diaz, R. et al. (Mar 21, 2025). “Let Me Go: Excessive Restraint of Patients at College Hospital.” Disability Rights California, Investigations Unit. Palomino, J. and Dizikes, C. (May 19, 2025). “California watchdog finds for-profit psychiatric hospital abused patients.”
[58] Palomino, J. and Dizikes, C. (Mar 19, 2025), supra, at note 4.
[59] Ibid.
[60] See Table 1. Data from the Department of Health Care Access and Information. Annual Financial Reports Jan-Dec 2023.
[61] Ibid.
[62] Aurora Behavioral Healthcare Santa Rosa was selected in this table because it was highlighted in the San Francisco Chronicle series. Aurora Vista Del Mar APH was selected because it had the highest percentage of unlicensed staffing of all APHs in 2023. In contrast, the two other facilities in this table had the highest level of RN staffing of all of the APHs and were not selected because of their nonprofit status. However, the richest RN HPPD in for-profit APHs were 7.5 RN HPPD in Mission Oaks Hospital D/P APH and AHMC Seton with 6.4 RN HPPD. Nine nonprofit APHs had RN staffing that exceeded the best staffed for-profit APH. CNA's data tables can be made available to CDPH upon request but all 2023 data is available at the Department of Health Care Access and Information in healthcare facility “Financial & Utilization Reports.”
[63] The Los Angeles Times reviewed thousands of pages of inspection reports, coroner's reports, death certificates and court documents to assemble a database of more than 400 cases of deaths, assaults and other incidents that have occurred across California's 154 psychiatric facilities since 2009. See Karlamangla, S. and Lee, I. (Updated Jun 8, 2021), supra, at note 15.
[64] See Palomino, J. and Dizikes, C. (Mar 19, 2025), supra, at note 4 (describing reports of suicide at Aurora Behavioral Healthcare Santa Rosa).
[65] Karlamangla, S. and Lee, I. (2021), supra, at note 15Error! Bookmark not defined.
[66] Aiken L. et al. (Aug 2010). Implications of the California nurse staffing mandate for other states. Health Serv Res, 45(4):904-21. Dierkes A. et al. (2022). The impact of California's staffing mandate and the economic recession on registered nurse staffing levels: A longitudinal analysis. Nurs Outlook, 70(2): 219-227.
[67] Leigh J, Markis C, Iosif A, Romano P. (May 2015). California's nurse-to-patient ratio law and occupational injury. Int Arch Occup Environ Health, 88(4):477-84.
[68] Hanrahan, N., Aiken, L., McClaine, L., & Hanlon, A. (2010). Relationship between psychiatric nurse work environments and nurse burnout in acute care general hospitals. Issues in mental health nursing, 31(3): 198-207.
[69] Park, S. et al. (2020), supra, at note 1616.
[70] Ibid.
[71] Ibid.
[72] Health & Saf. Code, § 1250, subd. (b).
[73] Cal. Code Regs., tit. 22, § 71127.
[74] California Healthcare Association v. California Department of Health Services et al., (Super. Ct. Sacramento County, 2004, No/ 03CS01814) (May 24, 2004) (California Department of Health Services stated during GACH ratios rulemaking that, “The minimum standard is just that, a minimum, and patients’ health and safety must be protected at all times. Current regulation 22 CCR 70129 requires, ‘All hospitals shall maintain continuous compliance with the licensing requirement.’ Continuous compliance means ‘at all times.’”).
[75]​ Id. at 5.
[76] Hanrahan, N., Aiken, L., McClaine, L., & Hanlon, A. (2010), supra, at note 6
[77] Perlis, M. et al. (Oct. 2016). Suicide and sleep: Is it a bad thing to be awake when reason sleeps? Sleep Med Rev, 29: 101-7.
[78] Cal. Code Regs., tit. 22, § 70217, subd. (a)(6).
[79] Brière, F. et al. “Adolescent suicide attempts and adult adjustment.” Depress Anxiety, 32(4): 270-276 (Nov. 2014).
[80] Palomino, J. and Dizikes, C. (Mar 19, 2025), supra, at note 4.
[81] Panagiotou, A., Mafreda, C., Moustikiadis, A., & Prezerakos, P. (2019). Modifiable factors affecting inpatient violence in an acute child and adolescent psychiatric unit: A 16‐year retrospective study. International journal of mental health nursing, 28(5), 1081-1092. As cited in Adrian, M., & McCaffrey, G. (2024). Pediatric psychiatric inpatients' perspectives of aggression management: Discernment in the doorway. Journal of child and adolescent psychiatric nursing, 37(3), e12477.
[82] Panagiotou, A., Mafreda, C., Moustikiadis, A., & Prezerakos, P. (2019), supra, at note 8181.
[83] Ibid.
[84] Dosreis, S., Barnett, S., Love, R., Riddle, M., & Maryland Youth Practice Improvement Committee. (2003). A guide for managing acute aggressive behavior of youths in residential and inpatient treatment facilities. Psychiatric Services, 54(10): 1357-1363.
[85] Adrian, M. & McCaffrey, G. (2024). Pediatric psychiatric inpatients' perspectives of aggression management: Discernment in the doorway. Journal of child and adolescent psychiatric nursing, 37(3): e12477.
[86] See Karlamangla, S. and Lee, I. (2021), supra, at note 15Error! Bookmark not defined..
[87] National Quality Forum. (n.d.). “List of Serious Reportable Events (aka SRE or 'Never Events').”
[88] Karlamangla, S. and Lee, I. (2021), supra, at note 15Error! Bookmark not defined.
[89] Worrall, A. et al. (2004). Inappropriate admission of young people with mental disorder to adult psychiatric wards and paediatric wards: cross sectional study of six months' activity. Bmj, 328(7444): 867.
[90] Cal. Code Regs., tit. 22, § 70537, subd. (c).
[91] Cal. Code Regs., tit. 22, § 70537, subd. (d).
[92] Kennedy, J. et al. (2020). Predictors of change in global psychiatric functioning at an inpatient adolescent psychiatric unit: A decade of experience. Clinical child psychology and psychiatry, 25(2): 471-482.
[93] Ibid.
[94] Ibid.
[95]​ Ibid.