RN Staffing Ratios: 2026 State Laws & Federal Guide

You’ve seen nurses protest, demanding better working conditions. You’ve read the headlines announcing the introduction of numerous bills aiming to regulate nurse-to-patient ratios once and for all. You read about the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting back in 2023, but the One Big Beautiful Bill Act repealed those provisions.

It’s all—understandably—quite confusing.

So, which are the current RN-to-patient staffing ratio laws?

This ultimate guide to registered nurse-to-patient ratios provides state-specific regulations to help you understand the current laws in your area.

Staffing laws change frequently. Always confirm requirements with state regulators.

Nursa connects clinicians and facilities directly to put nurses at the bedside of patients in need. Sign up today and start picking up shifts.

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Why are nurse-to-patient ratios important?

With physicians spending only 30 to 45 minutes a day with even critically ill patients, nurses stand out as essential healthcare providers, responsible for monitoring patients’ status, providing potentially lifesaving care, and acting as liaisons between physicians, pharmacists, patients, their families, and all other members of the healthcare team.

However, the quality of care nurses can provide is directly related to the number of patients they must take care of.

If nurses must care for more patients than they realistically can—given the setting and level of acuity of their patients—their ability to provide safe care naturally decreases. For example, a British study, titled “'Care left undone' during nursing shifts: associations with workload and perceived quality of care,” found that a higher number of patients per nurse was strongly associated with episodes of missed nursing care. The consequences of missed nursing care for patients include:

Medication errors
Infections
Falls
Pressure injuries
Readmissions
Failure to rescue

Furthermore, a systematic review published in 2007, titled “Public Reporting of Nurse Staffing in the United States,” found that a lower patient-to-RN ratio was associated with:

Lower hospital-related mortality
Death from complications
Cardiac arrest
Healthcare-associated infections

More recent studies have supported these findings by demonstrating associations between staffing ratios and healthcare-associated infections, medication errors, and patient falls.

What are safe nurse staffing ratios?

A nurse staffing ratio is the minimum number of nurses required to provide safe nursing care. Nurse staffing ratios can vary significantly from one healthcare setting to the next. For example, a safe nurse-to-patient ratio in an intensive care unit (ICU) differs from that in a long-term care setting.

Overview of nurse staffing ratios in the United States

While the average number of nurses per hospital or other healthcare facility varies significantly by bed count and patient acuity, maintaining high-quality care across these varied settings remains a universal priority.

The Nursing Home Reform Act of 1987 required that nursing homes participating in Medicare and Medicaid have a minimum of 8 hours per day of registered nursing (RN) service and 24 hours per day of licensed nursing (LN) service. Additionally, federal regulations require nursing homes to provide “sufficient nursing staff to attain or maintain the highest practicable...well-being of each resident.”

A female nurse visiting two elderly male patients — Understanding the evolution of RN mandates to protect resident health

However, the Nursing Home Reform Act did not mandate a specific staff-to-resident ratio or a minimum number of hours per resident day for resident care.

Fast forward to September 1, 2023.

The Centers for Medicare & Medicaid Services (CMS) issued the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting proposed rule. This proposed rule established comprehensive nurse staffing requirements to hold nursing homes accountable for providing safe, high-quality care daily to the over 1.2 million people in Medicare- and Medicaid-certified long-term care facilities.

Following a historic public comment period involving nearly 47,000 responses, the Biden-Harris Administration officially finalized the rule on April 22, 2024, turning the proposals into a federal mandate with a staggered implementation timeline. The final rule solidified the 3.48 hours per resident day (HPRD) standard, requiring:

0.55 HPRD from registered nurses
2.45 HPRD from nurse aides
0.48 HPRD from any nursing staff (RN, LPN/LVN, or nurse aide) to reach the total

It also required facilities to have an RN on-site 24 hours a day, 7 days a week, and introduced enhanced facility assessment requirements.

Fast forward to December 2, 2025.

The U.S. Department of Health and Human Services (HHS) repealed provisions of the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule.

The HHS determined that the rule disproportionately burdened facilities, especially those serving rural and Tribal communities, and ultimately jeopardized patients’ access to care instead of guaranteeing safe care as intended.

In alignment with the One Big Beautiful Bill Act, the HHS has stated that the decision to repeal these provisions was guided by a commitment to practical, sustainable approaches to improving nursing home care.

“Safe, high-quality care is essential, but rigid, one-size-fits-all mandates fail patients…This Administration will safeguard access to care by removing federal barriers—not by imposing requirements that limit patient choice.” - HHS Secretary Robert F. Kennedy, Jr.

What are the current federal guidelines (2026)?

As of February 2, 2026, the federal "floor" for staffing has returned to the standards that existed prior to the 2024 rulemaking, with one significant addition regarding facility assessments.

The RN baseline: Facilities must provide RN services for at least 8 consecutive hours a day, 7 days a week.
The 24-hour licensed nurse rule: A licensed nurse (RN or LPN) must be on duty in the facility 24 hours a day.
Full-time director of nursing (DON): Healthcare facilities must designate an RN to serve as the full-time director of nursing, unless otherwise waived.
The "sufficient staffing" standard: Federal law continues to mandate that facilities provide "sufficient nursing staff" to meet the highest practicable physical, mental, and psychosocial well-being of each resident.
Enhanced facility assessments (the 2026 difference): While the specific hourly ratios (3.48 HPRD) were repealed, the enhanced facility assessment requirement from the 2024 rule remains in effect.

Note: Facilities are now legally required to use data-driven assessments to prove they are staffing based on the actual acuity (severity of illness) of their residents. Even without a federal numeric ratio, a facility can be cited if its internal assessment shows it needs more staff than it currently has.

Joint Commission National Performance Goal 12 (NPG 12)

Starting January 1, 2026, the focus on nurse staffing transitioned from purely legislative debates to a core accreditation requirement. The Joint Commission, having renamed its "Safety Goals" to National Performance Goals, now includes Goal 12, which specifically targets nurse staffing as a fundamental element of patient safety.

The following are key 2026 accreditation requirements under NPG 12:

Mandatory policy compliance: Healthcare organizations must demonstrate strict adherence to internal policies and procedures related to nurse staffing and enumeration.
Continuous RN presence: Critical access hospitals are now required to have a registered nurse on duty at all times whenever the facility has 1 or more inpatients.
Impact on reimbursement: Because Joint Commission accreditation is often a prerequisite for participation in Medicare and Medicaid, failure to meet these staffing performance goals carries significant financial and operational risks for hospitals.
Evidence-based advocacy: The inclusion of staffing in the National Performance Goals follows a sustained campaign by the American Nurses Association (ANA) and the National Nurse Staffing Task Force, underscoring the essential role of adequate staffing in preventing patient harm and improving clinical outcomes.

Putting National Performance Goal 12 into practice through data-driven staffing and clinical excellence

Compliance with Joint Commission National Performance Goal 12 provides a baseline for hospital nurse staffing across the United States. This accreditation standard effectively creates a single imperative that applies to every accredited healthcare system, regardless of varying state-level guidelines.

Because a majority of U.S. hospitals rely on Joint Commission accreditation to maintain "deemed status" for federal programs, this requirement makes safe staffing a functional condition for receiving Medicare and Medicaid reimbursement. While hospitals may technically substitute private accreditation for a direct survey by a State Survey Agency, the Joint Commission remains the primary pathway for the vast majority of acute care facilities.

What are the nurse-to-patient staffing ratios by state?

According to the American Nurses Association, as of March 2022, only 16 states addressed hospital nurse staffing through either laws or regulations. Although 2022 may not seem distant, nurse-to-patient staffing ratios have come a long way since then, with additional states mandating specific ratios and others requiring disclosure and/or reporting of actual ratios.

In numerous states, bills have been introduced to address this pressing issue, so stay tuned for updates on nurse-to-patient staffing ratios in your state.

The following table categorizes states based on the primary legal mechanism they use to regulate nurse staffing as of February 2026.

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Quick reference: Which states have nursing ratios?

Policy type	Description	States
Mandated ratios	Legally enforceable numerical patient limits for nurses	CA, OR
Targeted ratios	Ratios mandated only for specific units*	NY (ICU), MA (ICU), AZ (ICU), WV (psych/specialty), UT (dialysis/ED), KS (crisis centers)
Staffing committees	Hospitals obligated to form committees of nurses to set enforceable unit plans	CO, CT, IL, NV, OH, WA, TX, MN, MT, NY, WV
Public disclosure	Hospitals obligated to publicly post or report actual staffing levels	NJ, VT, RI
LTC/nursing home only	States with zero hospital ratios but rigid numbers for nursing homes	DE, FL, ME, MD, AR, MI, MS, NJ, OK, PA, RI, SC
Sufficient staffing	Follow federal/accreditation "floor" with no state-specific numbers	AL, AK, AZ, GA, HI, ID, IN, IA, KS, KY, LA, MD, MA, MS, MO, NE, NH, NM, NC, ND, SD, TN, UT, VA, WI, WY

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*For all other hospital units not specified in the mandate, these states default to the sufficient staffing standard or staffing committee models.

Alabama

Alabama does not use state-mandated numeric nurse-to-patient ratios; instead, it relies on "sufficient staffing" models across all healthcare settings.

Hospital staffing requirements

Supervision: Hospitals must provide 24-hour nursing services that are either furnished or supervised by a registered nurse.
Bedside availability: An RN must be "immediately available" for bedside care in every department or nursing unit.
Staffing authority: The director of nursing is legally responsible for determining the specific number and mix of staff required to provide care.
Real-time documentation: As of 2026, hospitals are expected to provide shift-level acuity justification for their staffing grids during state surveys.

Nursing facility requirements

DON requirements: A facility must have a full-time RN as its DON. For facilities with 60 or fewer residents, the DON may also serve as the charge nurse.
Assessment-based levels: Staffing levels are legally determined by the facility’s annual resident assessment, which must evaluate the specific care needs and acuity of the current population.

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Alaska

Alaska does not mandate specific nurse-to-patient ratios in state law. Instead, staffing is governed by general "sufficient staff" requirements and individual facility governance.

Hospital staffing requirements

While not mandated by state law, most hospitals utilize staffing committees to develop internal plans.

Nursing facility requirements

The following are the specific nursing service requirements for facilities in Alaska:

Registered nurse coverage: A nursing facility must have a registered nurse on duty 7 days a week on the day shift and 5 days a week on the evening shift.
Bed capacity increases: A facility with more than 60 occupied beds must have 2 RNs on duty during the day shift and 1 RN on duty during other shifts.
LPN role: A licensed practical nurse must be on duty during all shifts when an RN is not present.
24-hour telephone access: Facilities must have telephone access to at least 1 RN at all times, with the RN’s name and phone number posted at each nurse's station.
Combined hospital facilities: Facilities sharing a building with a hospital must have an RN on duty 7 days a week on the day shift. On other shifts, an LPN may serve as the charge nurse, provided an on-duty hospital RN is available for rounds and assistance.

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Arizona

Arizona law mandates that hospitals and other health institutions maintain staffing levels to ensure the health, safety, and individual needs of every patient are met.

Hospital staffing requirements

Intensive care units: There must be at least 1 registered nurse for every 2 patients.
Nursing leadership: All nursing services in a hospital must be provided under the direction of a registered nurse.

Recovery care center requirements

Specific personnel rules apply to licensed recovery care centers:

On-duty staff: At least 1 RN and 1 other nursing staff member must be on duty at all times when patients are in the facility.

Nursing facility requirements

Direct care baselines: At least 1 nurse must be present and responsible for providing direct care to not more than 64 residents.
DON direct care role: In facilities with an average daily occupancy of 1–59 residents, the director of nursing may provide direct care on a regular basis.

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Arkansas

Arkansas law establishes specific average care hour requirements for nursing facilities, while hospitals are governed by a broader "sufficient staffing" standard.

Nursing facility requirements

Certified nursing facilities must meet a monthly average direct-care-hour standard.

Average direct care hours: Certified nursing facilities must provide direct care services each month by direct care staff equivalent to at least 3.36 average direct care hours per resident day.
Monthly reporting: On or before the 15th day of each month, facilities must report electronically to the department their actual average direct care HPRD for the prior month.
Charge nurse flexibility: The DON may serve as the charge nurse only when the skilled nursing facility has an average daily occupancy of 70 or fewer residents.

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California

California maintains the most comprehensive mandatory nurse-to-patient staffing ratios in the nation, applying to all general acute care, acute psychiatric, and specialty hospitals.

Hospital staffing requirements

Hospitals must maintain minimum licensed nurse-to-patient ratios at all times, with no averaging allowed over a shift.

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California mandated RN-to-patient ratios (2026 update)

Hospital unit	Nurse-to-patient ratios	Notes/2026 updates
Intensive care/critical care	1:2	Must be maintained "at all times," including breaks
NICU	1:2	RNs only (1:1 in some high-acuity cases)
Operating room	1:1	Mandatory 1:1 for the duration of the procedure
Trauma (emergency department)	1:1	RNs only
Critical care (emergency department)	1:2	Applies once a patient is triaged as critical
Emergency department	1:4	1:4 for general ER (triage by RN only)
Labor & delivery (active)	1:2	Active labor only
Antepartum (not in active labor)	1:4
Postpartum (mother-baby couplet)	1:4	Maximum 8 individuals (4 mothers and 4 infants)
Postpartum (mothers only)	1:6
Pediatrics	1:4
Step-down units	1:3
Telemetry	1:4	Often, the most cited unit for violations
Specialty care (e.g., oncology)	1:4
Medical-surgical	1:5
Psychiatric units (acute)	1:6	2026 update: New emergency regulations now apply to standalone psych hospitals (previously mostly for acute care wings).

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Acute psychiatric hospital (APH) update

Emergency regulations: The California Department of Public Health (CDPH) is mandated to adopt specific numerical ratios for free-standing acute psychiatric hospitals.
Implementation delay: Originally set for January 31, 2026, the adoption of these emergency APH regulations has been delayed until June 1, 2026, to prevent a crisis in bed availability.
Proposed standards: Stakeholders have recommended ratios of 1:6 for adult patients and 1:4 for pediatric/adolescent patients in these settings.

2026 enforcement and penalties

Effective January 1, 2026, new legislation has strengthened the enforcement of existing staffing mandates:

Daily counting: Each day a facility is out of compliance with mandated ratios now constitutes a separate and distinct violation.
On-call list requirements: Hospitals must maintain current, verifiable on-call lists. Contacting nurses not assigned to a float pool or scheduled for on-call duty no longer counts as a "good faith effort" to meet ratios.

Clinical judgment and acuity

Patient classification system: Ratios represent only the minimum baseline; hospitals must assign additional staff based on a documented system that evaluates patient severity, clinical judgment needs, and self-care ability.
RN assessment role: Only an RN is authorized to perform initial and ongoing patient assessments to determine if staffing above the minimum is required.

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Colorado

Colorado does not mandate "one-size-fits-all" numerical nurse-to-patient ratios for all hospital units. Instead, the state utilizes a committee-driven staffing model that empowers frontline nurses to contribute to decision-making regarding appropriate ratios based on patient acuity and clinical judgment.

Hospital staffing requirements

Under the Hospital Nurse Staffing Standards (HB 22-1401) and updated Chapter 4 regulations, Colorado hospitals must follow a structured process to ensure safe staffing levels:

Nurse staffing committees: Every hospital must establish a nurse staffing committee, with at least 60% of its members being clinical staff nurses (frontline workers) who provide direct care. The committee must include a designated leader of workplace violence prevention and reduction efforts.
Master staffing plans: This committee is responsible for annually developing and overseeing a master nurse staffing plan, which must be recommended by at least 60% of the committee.
Acuity-based adjustments: Staffing plans must include guidance and a process to reduce nurse-to-patient assignments to align with patient acuity.
Transparency and rights: Hospitals must provide the relevant unit-based staffing plan to any applicant for a nursing position upon an offer of employment and to any patient upon request.
Training and competency: A hospital shall not assign a clinical staff nurse, nurse aide, or EMS provider to a unit unless personnel records include documentation that the individual has successfully completed training and competency.
Enforcement: The Colorado Department of Public Health and Environment (CDPHE) is authorized to survey and investigate hospitals to ensure compliance and can fine facilities up to $10,000 per day for certain failures related to surge capacity.

Nursing facility requirements

For long-term care and skilled nursing facilities, Colorado adheres to specific state standards for nursing services:

24-hour RN baseline: Colorado requires 24/7 RN presence in skilled nursing facilities.
Minimum care hours: Colorado state rules require nurse staffing sufficient to meet resident needs, with a state baseline of no less than 2.0 hours of nursing time per resident per day. In facilities with 60+ residents, the director of nursing's time cannot be used to meet this ratio unless providing direct care.

2026 updates and enforcement

As of 2026, Colorado maintains strict oversight regarding "staffed-bed capacity" to ensure the public health system can meet patient needs:

Reporting baseline: Hospitals must report to the state the baseline number of beds they can staff and their current bed capacity.
Capacity alerts: If a hospital’s ability to meet its staffed-bed capacity falls below 80% of its reported baseline for 7 to 14 consecutive days, it must notify the CDPHE and submit a corrective plan.
Non-compliance fines: Failure to meet the reported 80% staffed-bed capacity or accurately report the baseline can result in fines up to $10,000 per day.
Emergency expansion: Each hospital with more than 25 beds must demonstrate the ability to expand staffed-bed capacity up to 125% of its baseline within 14 days of a declared statewide public health emergency.

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Connecticut

Connecticut does not mandate a single, state-wide numerical nurse-to-patient ratio for hospitals. Instead, the state utilizes a committee-driven model that empowers direct care nurses to develop unit-specific staffing plans. However, the state has recently implemented rigorous mandated ratios and minimum care hours for nursing homes.

Hospital staffing requirements

Under Public Act 23-204 and CGS § 19a-89e, Connecticut hospitals must follow strict governance and transparency standards:

Dedicated staffing committees: Each hospital must establish a committee where direct care registered nurses account for at least 50% plus 1 member of the total membership.
Mandatory staffing plans: The committee is responsible for developing a nurse staffing plan that specifies the patient-to-registered nurse ratio for each patient care unit.
Compliance threshold: Hospitals must report biannually whether they have complied with at least 80% of the nurse staffing assignments required by their plan.
Right to object or refuse: A registered nurse may object to or refuse an assignment if they are not competent to perform the task based on their education or training, without compromising patient safety.
Retaliation protections: Hospitals are legally prohibited from retaliating or discriminating against a nurse for participating in the staffing committee or filing a staffing complaint.
Public transparency: Staffing plans must be posted in a conspicuous location on each patient care unit, visible to staff, patients, and the public.

Nursing facility requirements

Connecticut has established specific, legally mandated minimum direct care hours per resident day for nursing homes. Additionally, Connecticut nursing homes are required to provide 24-hour RN staffing at all times.

As of early 2026, Connecticut nursing homes must adhere to a baseline of 3.0 hours per resident day of total nursing and nurse aide care. Under the direction of the Department of Public Health (DPH), this minimum must be allocated as follows:

Licensed nursing staff (RN and LPN): 0.83 hours
Nurse aide personnel: 2.17 hours

Scheduled staffing increases (2026–2028)

Connecticut has passed legislation to gradually increase these mandates. While earlier drafts proposed a 2024 implementation, the current law staggers these increases to give facilities time to recruit.

Effective July 1, 2026, the mandate increases to at least 3.6 HPRD of direct care, categorized as follows:

Registered nurse: 0.66 hours
Licensed practical nurse: 0.49 hours
Nurse aide: 2.45 hours

Effective January 1, 2028, the mandate increases to a final standard of at least 4.1 HPRD of direct care, categorized as follows:

Registered nurse: 0.75 hours
Licensed practical nurse: 0.54 hours
Nurse aide: 2.81 hours

Compliance and reporting

Shift scheduling: Current policies require nursing homes to provide at least 2.17 hours of total care between 7 a.m. and 9 p.m., and 0.83 hours between 9 p.m. and 7 a.m.
Enforcement: Starting July 1, 2026, substantial failure to comply with these specific direct care levels is classified as a Class B violation, carrying potential civil penalties of up to $10,000 per violation.

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Delaware

Delaware does not mandate specific numerical nurse-to-patient ratios for hospitals. However, it maintains some of the most rigorous and shift-specific staffing laws in the country for residential health facilities.

Hospital staffing requirements

Delaware relies on a "sufficient staffing" model for acute care settings rather than statewide fixed ratios.

Nursing facility requirements

Delaware law establishes strict minimum shift-based ratios for licensed nurses (RN/LPN). As of February 2026, these mandatory ratios are once again in full effect.

RN/LPN-to-resident ratios

Day shift: 1:15
Evening shift: 1:20
Night shift: 1:30

Facilities must provide a minimum of 3.67 hours of direct care per resident per day.

2026 enforcement in residential health facilities

Staffing transparency: Every residential health facility must conspicuously post the names and titles of the direct caregivers assigned to each floor or unit for every shift.
Outcome-based protocols: If the state finds "unsatisfactory outcomes," it may impose staffing protocols that require levels above the legal minimums.
Waiver process: Facilities facing exigent circumstances may apply for a time-limited waiver of these requirements, but they must provide documented evidence of their best efforts to meet the minimums.

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Florida

Florida does not use state-mandated numeric nurse-to-patient ratios in hospitals, relying instead on a "sufficient staffing" standard. However, the state has clear, legally mandated minimum staffing ratios and care hours for nursing homes.

Hospital staffing requirements

Florida law requires hospitals to maintain staffing levels that ensure patient safety and quality of care, but it leaves the specifics to hospital administration. All nursing services must be supervised by a registered nurse.

Nursing facility requirements

Florida Statutes establish strict minimum staffing levels and hours of direct care per resident day for nursing homes:

Combined direct care baseline: Facilities must provide a minimum weekly average of 3.6 hours of direct care per resident per day.
Licensed nurse minimum: At least 1.0 HPRD must be provided by licensed nurses. Facilities may not staff below a ratio of 1 licensed nurse per 40 residents.
Staffing documentation: Nursing homes must document compliance and post daily the names of licensed nurses and CNAs on duty in a place visible to residents and the public.

Pediatric nursing facility standards

Stricter standards apply to persons under 21 years of age residing in nursing facilities:

Skilled care (under 21): A minimum combined average of 3.9 HPRD is required, with at least 1.0 hour provided by licensed nurses.
Medically fragile (under 21): A minimum combined average of 5.0 HPRD is required, with at least 1.7 hours provided by licensed nurses.
RN presence: 1 registered nurse must be on-site, on duty, 24 hours per day on the unit where children reside.

2026 updates and enforcement

Licensure status: The Agency for Health Care Administration (AHCA) evaluates facilities at least every 15 months and assigns a status of "Standard" or "Conditional" based on compliance with staffing and safety rules.
Penalties: Class I deficiencies (presenting immediate danger or death) are subject to civil penalties ranging from $10,000 to $15,000 per deficiency, which are doubled if the facility has previous citations.

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Georgia

Georgia does not currently mandate specific numerical nurse-to-patient ratios for all hospital units. While legislative efforts like the Georgia Safe Staffing Act (HB 298) seek to establish a committee-driven model, this bill has not yet been enacted into law as of February 2026.

Hospital staffing requirements

Georgia currently relies on a "sufficient staffing" standard for hospitals, primarily governed by state licensure and Joint Commission standards:

Proposed legislation (HB 298): This bill remains under consideration for the 2026 session. If passed, it would require hospitals to form committees in which at least 75% of the members are direct-care registered nurses.
Proposed reporting: The act would also require hospitals to report staffing plan evaluations to the Department of Community Health (DCH) annually.
Anonymous reporting portal: A key component of the pending legislation is the creation of a secure online portal for staff to submit anonymous reports of unsafe staffing conditions.

Nursing facility and assisted living requirements

Unlike hospital rules, Georgia has active, state-specific staffing laws for long-term care and assisted living facilities:

Assisted living and personal care homes (25+ beds): These facilities must maintain an average monthly on-site ratio of 1 direct care staff person for every 15 residents during waking hours and 1 for every 20 residents during non-waking hours.
Memory care standards: Certified units must adhere to stricter ratios of 1:12 during waking hours and 1:15 during non-waking hours.
On-site nurse presence: Assisted living communities must have an RN or LPN on-site for a minimum number of hours per week based on resident count, ranging from 8 hours/week (1–30 residents) to 40 hours/week (90+ residents).

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Hawaii

Hawaii does not currently mandate specific numerical nurse-to-patient ratios for all hospital units. Instead, the state relies on a "sufficient staffing" standard, although landmark legislation introduced in early 2026 (SB 2763) seeks to transition the state toward a committee-driven model with enforceable minimums.

Hospital staffing requirements

Hawaii's hospital staffing is primarily governed by Hawaii Administrative Rules (HAR) § 11-93-24, which outlines general safety standards:

Continuous RN presence: At least 1 licensed registered nurse must be on duty at all times to render safe and therapeutic nursing care.
Nursing leadership: The nursing department must be under the direction of an RN who oversees the program full-time.
Written staffing plans: Hospitals must maintain an organized written plan that includes administrative authority, staffing patterns, and job descriptions for every category of nursing personnel.

Proposed legislation (SB 2763)

Introduced in the 2026 session, this bill would require each hospital to establish a Hospital Registered Nurse Staffing Committee by September 1, 2026.

Committee composition: A majority of the members would be nonsupervisory registered nurses currently providing direct patient care.
Mandatory ratios: By July 1, 2027, these committees would be required to adopt annual staffing plans that incorporate minimum nurse-to-patient ratios that meet or exceed standards recommended by national professional specialty organizations.

Nursing facility and subacute requirements

For subacute care and residential settings, Hawaii sets specific direct care standards based on patient acuity and specialized equipment needs:

Subacute unit supervision: Each subacute unit must be supervised by a registered nurse 24 hours a day.
Minimum care hours: Subacute units must employ sufficient licensed staff to provide a minimum daily average of 5.0 licensed and certified nursing hours per patient.
Ventilator-dependent care: Units authorized to care for respirator or ventilator-dependent patients must provide a minimum daily average of 9.0 nursing care hours, with at least 5.0 hours provided by licensed nursing staff.
Experience requirements: Licensed nurses (RN/LPN) in subacute settings must have at least 6 months of experience in a general acute care facility within the past 2 years, specifically where the caseload included intensive care.

2026 updates and enforcement

Proposed anonymous reporting: If SB 2763 is enacted, it would empower the Department of Labor and Industrial Relations (DLIR) to investigate complaints regarding deviations from staffing plans.
Proposed penalties: Hospitals that fail to file an annual staffing plan would face a fine of $25,000 under the proposed law, with subsequent violations carrying fines up to $5,000.
Transparency dashboard: The bill would require the Hawaii Center for Nursing to develop an online dashboard that tracks staffing standards recommended by professional specialty organizations, such as the American Association of Critical-Care Nurses.

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Idaho

Idaho does not mandate specific numeric registered nurse-to-patient ratios for hospitals. Instead, the state relies on a "sufficient staffing" model.

Hospital staffing requirements

Idaho's hospital regulations are defined primarily by IDAPA 16.03.14, which focuses on safety and competency standards:

Nursing leadership: The nursing service must be under the overall direction of a qualified RN with education and experience commensurate with the hospital's size and complexity.
Written staffing patterns: Hospitals must maintain monthly staffing patterns that include daily staff, staff titles, and patient census.
Acuity-based planning: RNs are legally responsible for assigning nursing care, including assignments to nursing assistants.
Supervision: New nursing graduates practicing on a temporary license must be under direct RN supervision and are prohibited from assuming charge responsibilities.

Nursing facility requirements

For skilled nursing and long-term care facilities, Idaho relies on general standards of care and federal baselines.

2026 updates and enforcement

As of February 2026, Idaho facilities are navigating significant changes in federal oversight and national performance standards:

Shift limits: No person may be assigned nursing duties if they have been on duty in the facility during the preceding 12 hours, except in a declared emergency.
Critical care requirements: There must be 24-hour RN coverage in critical care areas. For small hospitals, an RN may be available on-call to the unit only when there are no patients present in the critical care area.

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IDAPA 16.03.14 – Rules and Minimum Standards for Hospitals in Idaho

Illinois

Illinois does not mandate state-wide numerical nurse-to-patient ratios for all hospital units. Instead, the state uses an acuity-based staffing model.

Hospital staffing requirements

Under the Nurse Staffing by Patient Acuity Act and the Hospital Licensing Act, Illinois hospitals must follow collaborative planning and transparency standards:

Nursing care committees: Every hospital must establish a nursing care committee, with at least 55% of the members being registered professional nurses who provide direct inpatient care. A direct care nurse is selected annually to serve as co-chair.
Written staffing plans: The committee is responsible for developing a hospital-wide plan that specifies the minimum direct care RN-to-patient staffing requirements for each inpatient unit and the emergency department.
Annual notifications: Each year, the nursing care committee must notify the hospital nursing staff of their rights under the law, including a phone number and email address for reporting noncompliance.
Prohibition on mandated overtime: Illinois law prohibits hospitals from mandating nurse overtime, except in unforeseen emergency circumstances. In such cases, a nurse can only be required to work up to 4 hours beyond their agreed-upon shift.
Transparency and reporting: Staffing plans must be posted in a conspicuous location and provided to any member of the public upon request. Committees must also issue semi-annual reports on staffing effectiveness.

Nursing facility requirements

For long-term care facilities, Illinois law mandates specific direct care hours based on the level of care required by residents:

Direct care minimums: Facilities must provide a minimum of 3.8 hours of direct care per resident day for residents requiring skilled care, and 2.5 HPRD for residents requiring intermediate care.
Nursing mix: At least 25% of direct care time must be provided by licensed nurses (RNs/LPNs), with at least 10% specifically provided by registered nurses.
Continuous coverage: A facility must schedule nursing personnel so that the needs of all residents are met.

2026 updates and enforcement

Anonymous reports: Registered nurses may report variations from the adopted hospital staffing plan directly to the nursing care committee.
Retaliation protections: Hospitals are legally prohibited from disciplining or discharging an employee solely because they express concerns or file a complaint regarding staffing violations.
State investigations: Any employee may file a complaint with the Department of Public Health regarding a violation of the Nurse Staffing by Patient Acuity Act, which the Department must investigate.

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Indiana

Indiana does not currently mandate specific numerical nurse-to-patient ratios for hospitals. The state follows a sufficient staffing model.

Hospital staffing requirements

Indiana's hospital regulations are primarily defined by 410 IAC 15, which focuses on maintaining a safe environment and adequate personnel:

Continuous RN presence: Hospitals must have at least 1 licensed registered nurse on duty at all times.
Leadership: The nursing department must be under the direction of an RN who oversees the program full-time.
Real-time documentation (2026 update): As of 2026, the Indiana Department of Health (IDOH) has increased expectations for real-time staffing documentation. Surveyors now request acuity-based justification for staffing grids to ensure assignments align with patient severity.
Competency validation: New 2026 standards require hospitals to conduct annual skills assessments for all clinical staff to validate their competency in their assigned units.
Voluntary initiatives: In the absence of state mandates, some hospitals have adopted safe staffing ratios independently. For example, in late 2025, Goshen Hospital in Indiana announced a permanent 1:4 nurse-to-patient ratio across all inpatient units to improve safety and retention.

Nursing facility requirements

For skilled nursing and long-term care facilities, Indiana sets strict minimums for licensed nurse hours:

Licensed nurse ratio: Facilities must provide a licensed nurse-to-resident ratio of at least 0.5 hours per resident per day, averaged over a 1-week period.
Director of nursing: In facilities with an average daily occupancy of 60 or fewer residents, the DON may also serve as the charge nurse.
Residential facilities: Indiana law established a minimum ratio of 1 nursing staff person for every 50 residents in residential care facilities.

2026 updates and enforcement

Effective in fiscal year 2026, the state is transitioning to a multi-measure system for assessing facility performance, which includes tracking total nursing staff turnover and total nurse staffing HPRD.

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Iowa

Iowa does not mandate specific numerical nurse-to-patient ratios for hospitals. The state utilizes a "sufficient staffing" model.

Hospital staffing requirements

Iowa’s hospital regulations are defined by IAC 481—51, which focuses on safety and competency standards:

Continuous RN presence: Each hospital is required to have a minimum of 1 registered nurse on duty at all times.
Nursing leadership: The nursing service must be under the direction of a director of nursing with administrative and executive competency who holds an active Iowa license.
Unlicensed personnel: All unlicensed personnel performing patient-care service must be under the supervision of a registered nurse.
Specialty units: In units such as obstetric, neonatal, and pediatric areas, the supervision of the area must be under the direction of a qualified registered nurse.

Nursing facility requirements

For long-term care and skilled nursing facilities, Iowa follows IAC 481—58, which sets specific minimum standards for nursing hours and coverage:

RN coverage: A nursing facility of 75 beds or more shall have a qualified nurse on duty 24 hours per day, 7 days a week.
Nursing supervision: In facilities under 75 beds, if the health service supervisor is a licensed practical nurse, the facility shall employ a registered nurse for at least 4 hours each week for consultation.
Relief personnel: A qualified nurse must be employed to relieve supervising nurses, including charge nurses, during holidays, vacations, or other absences.
24-hour baseline: There shall be at least 2 people capable of rendering nursing service, awake, dressed, and on duty at all times.
Acuity-based staffing: The department may establish staffing numbers and qualifications on an individual facility basis using the needs of the residents as the primary criterion.

2026 updates and enforcement

The Iowa Department of Inspections, Appeals, and Licensing (DIAL) continues to enforce strict documentation and transparency standards:

Staffing notifications: Facilities must notify the department within 48 hours of any reduction of nursing staff lasting more than 7 days that places staffing below licensing requirements.
Admission freeze: No additional residents may be admitted to a facility until the minimum staffing requirements are achieved following a reported loss of staff.
Payroll availability: Nursing facilities are required to make payroll records and staffing patterns available for departmental review to ensure compliance with staffing mandates.

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Kansas

Kansas does not mandate specific numerical nurse-to-patient ratios for all hospital departments. Instead, the state relies on a "sufficient staffing" model for acute care while maintaining rigid, shift-specific minimum ratios and hourly care standards for nursing facilities and specialized crisis centers.

Hospital staffing requirements

Staffing in Kansas hospitals is primarily governed by K.A.R. § 28-34-7, which outlines the following standards:

Organized nursing department: Each hospital must maintain an organized nursing department with a written plan of administrative authority.
Continuous RN presence: There must be at least 1 registered nurse on duty in the hospital at all times.
Supervisory authority: All licensed practical nurses and other ancillary personnel performing patient care services must be under the supervision of a registered nurse.
Written policies: Nursing care policies and procedures must be written, consistent with generally accepted practice, and reviewed and revised as necessary.
Licensure requirements: All RNs and LPNs employed by the hospital to practice professional nursing must be licensed in Kansas.

Nursing facility requirements

Kansas laws for nursing facilities, found in K.A.R. § 28-39-154, are prescriptive regarding staff-to-resident ratios and care hours:

Minimum direct care hours: Facilities must provide a weekly average of 2.0 hours of direct care staff time per resident, with a daily average of no fewer than 1.85 hours during any 24-hour period.
Mandated staffing ratios: The ratio of nursing personnel to residents per nursing unit shall not be fewer than 1 nursing staff member for every 30 residents.
Shift-specific requirements: On the day shift, the facility must have the same number of licensed nurses on duty as there are nursing units in the facility.
LPN oversight: If a licensed practical nurse is the only licensed nurse on duty, a registered nurse must be immediately available by telephone.
Safety baseline: At least 2 nursing personnel must be on duty at all times and immediately accessible to ensure prompt response to the resident call system.

Additional legislation regarding adult care homes

Staffing schedule retention: Facilities are required to maintain staffing schedules on file for 12 months, including hours actually worked and the classification of personnel per shift.
Prohibition on duty sharing: Nursing facilities are strictly prohibited from assigning nursing personnel routine housekeeping, laundry, or dietary duties.
Identification standards: All direct care staff must wear identification badges that clearly identify their name and position.
Acuity-based adjustments: The state licensing agency may mandate an increase in nursing personnel above minimum levels if resident acuity is high or if health and safety needs are not being met.

Crisis intervention center requirements

Specialized staffing regulations for crisis intervention centers are established under K.A.R. § 26-52-11, requiring a higher intensity of care:

Minimum staffing ratio: Licensees must implement a written daily schedule providing a minimum staffing ratio of 1 direct care staff member for every 4 patients.
Direct care qualification: Only personnel designated as direct care staff members may be counted toward the required staffing ratio.
Minimum personnel baseline: At no time shall there be fewer than 2 direct care staff members present in the center when 1 or more patients are admitted.
Gender-matched staffing: At least 1 direct care staff member of the same sex as the patients must be present, awake, and available at all times.
Multi-floor coverage: If the center is located on multiple floors or in multiple buildings, at least 2 direct care staff members must be present in each patient area on each floor.

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Kentucky

Kentucky does not establish a specific, state-mandated numerical ratio for the number of patients assigned to a nurse in acute care or nursing facilities. Instead, the state relies on a "sufficient staffing" model.

Nurse staffing requirements

Staffing in Kentucky healthcare facilities is governed by administrative regulations from the Cabinet for Health and Family Services:

Specialized reassignment: Nurses temporarily assigned to unfamiliar or "high-tech" areas must be under the on-site supervision of a registered nurse who is educationally prepared and experienced in that specific specialty.
Mandatory refusal: According to the Kentucky Board of Nursing (KBN), if a nurse determines they cannot provide safe care due to the number of patients assigned, they are obligated to refuse the assignment and notify their supervisor.
Understaffing reports: If a nurse judges that an assignment is unsafe due to understaffing, they are encouraged to report the situation to the Cabinet for Health and Family Services or the appropriate accrediting organization.

2026 legislative updates

Legislative status of HB 810: While House Bill 810 was introduced in 2025 to propose fixed ratios in long-term care facilities (such as 1:21 for licensed nurses during the day shift), it remains in the committee phase and has not been enacted.

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Louisiana

Louisiana does not establish fixed, state-mandated nurse-to-patient ratios for general acute care hospitals. Instead, the state follows a "sufficient staffing" model.

Nursing facility requirements

Louisiana nursing home laws, specifically LAC 48:I.Chapter 98, establish direct care minimums and shift-based posting requirements:

Minimum care hours: Facilities must provide a minimum of 2.35 hours of care per patient per day.
Director of nursing: A nursing facility must designate an RN to serve as the DON on a full-time basis during the day shift. The DON may only serve as the charge nurse if the facility has an average daily occupancy of 60 or fewer residents.
Floor coverage: While specific unit-based ratios are determined by resident acuity and census, the facility must post the actual hours worked by RNs, LPNs, and CNAs at the beginning of each shift in a prominent place.
Direct care computation: Ward clerk hours may be included in the care hour calculation, up to a maximum of 8 hours per day.

Specialized facility requirements

Specific numerical mandates are established for hospice and respite care settings:

Inpatient hospice facilities: These facilities must maintain a ratio of at least 1 nurse to every 8 patients. Each shift must include at least 2 direct patient care staff, at least 1 of whom must be an RN providing direct care.

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Maine

Maine does not establish specific numerical nurse-to-patient ratios by state law for general hospital units. While a major legislative effort—An Act to Address the Safety of Nurses and Improve Patient Care by Enacting the Maine Quality Care Act (LD 1281)—seeks to mandate such ratios, it remains a bill and is not yet enacted law. Currently, Maine hospitals operate under a "sufficient staffing" model, while long-term care and residential facilities follow rigid, shift-specific minimums.

Hospital staffing requirements

Staffing in Maine hospitals is governed by professional competency standards and internal facility policies:

Whistleblower protections: Maine law protects nurses who report unsafe practices or violations of policy from retaliation.
Legislative status of LD 1281: This bill proposes fixed ratios such as 1:1 for intensive care, 1:3 for pediatrics, and 1:1 for the operating room, among others. It also seeks to prohibit mandatory overtime and require public posting of actual ratios for each shift. As of 2026, these remain proposed standards and are not currently enforceable laws.

Nursing facility requirements

Maine establishes strict, shift-based minimums for nursing facilities under 10-144 C.M.R. ch. 110, § 9:

Direct-care staff-to-resident ratios

Day shift: 1 direct-care provider for every 5 residents
Evening shift: 1 direct-care provider for every 10 residents
Night shift: 1 direct-care provider for every 15 residents

Licensed nurse minimums

Day shift coverage:

In facilities with more than 20 beds, there must be a licensed nurse on duty in addition to the director of nursing.
An additional licensed nurse is required for every 50 beds above the initial 50.
For facilities with 100 beds or more, the additional licensed nurse for each multiple of 100 beds must be an RN.

Evening shift coverage:

A licensed nurse must be on duty for the full 8-hour shift.
An additional licensed nurse must be added for every 70 beds.
In facilities with 100 beds or more, at least 1 of the additional nurses must be an RN.

Night shift coverage:

A licensed nurse must be on duty for the full 8-hour shift.
An additional licensed nurse must be added for every 100 beds.
Facilities with 100 beds or more must have an RN on duty during this shift.

Multi-story baseline

Staff must be assigned to each resident-occupied floor at all times.

Residential facility requirements

Maine establishes strict, shift-based minimums for long-term care and residential settings:

Residential care ratios: Facilities with more than 10 beds must maintain a ratio of 1 direct care worker for every 12 residents during the day, 1:18 in the evening, and 1:30 overnight.
Memory care licensing: All memory care units must be licensed as residential care facilities because they require higher levels of safety planning and assessment than standard assisted living.

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Maryland

Maryland does not establish fixed, state-mandated nurse-to-patient ratios for general hospital units. Instead, the state utilizes a "sufficient staffing" model for acute care hospitals while enforcing rigid, shift-based minimum bedside care hours and personnel ratios for nursing facilities.

Proposed legislation for hospital staffing

The Proposed Safe Staffing Act of 2026 (SB 411/HB 905) seeks to transition Maryland toward a committee-driven model where hospitals establish clinical staffing committees with equal representation from management and frontline staff.

If enacted, committees would develop annual unit-specific staffing plans that establish suggested guidelines or ratios indicating how many patients should be assigned to each RN. As of early 2026, this remains a pending bill and is not currently enforceable law.

If SB 411 passes, hospitals would be required by 2027 to implement their plans and publicly post the daily staffing levels and clinical plans on each unit.

Nursing facility requirements

Maryland establishes strict, legally enforceable minimums for nursing homes under Md. Code Regs. 10.07.02.19:

Minimum bedside care hours: Facilities must provide a minimum of 3.0 hours of bedside care per occupied bed per day, 7 days a week.
Bedside care definition: Bedside hours include direct care provided by RNs, LPNs, and certified nursing service personnel.
Personnel-to-resident ratio: The ratio of nursing service personnel on duty providing bedside care may not at any time be less than 1 staff member for every 15 residents.
Continuous RN presence: A nursing home must be staffed with at least 1 registered nurse on duty 24 hours per day, 7 days a week.

RN supervisory minimums

Facilities must have additional full-time RNs based on resident census:

2–99 residents: 1 full-time RN
100–199 residents: 2 full-time RNs
200–299 residents: 3 full-time RNs
300–399 residents: 4 full-time RNs

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Massachusetts

Massachusetts remains unique for maintaining the nation’s strictest specific mandate for ICUs while otherwise following a "sufficient staffing" model for general hospital wards. As of February 2026, major legislative efforts are underway to expand specific limits to all acute care and psychiatric units through the current legislative session. Massachusetts long-term care and residential facilities follow shift-specific minimums.

Hospital staffing requirements

Current staffing in Massachusetts is governed by 958 CMR 8.00, specifically regulating patient assignments in ICUs, though new legislation seeks to broaden this scope:

Mandated ICU ratio: The baseline patient assignment for an ICU registered nurse is 1:1.
Acuity-based ICU adjustments: An RN may be assigned a second patient (1:2 ratio) only if the stability of the patients—as determined by a certified acuity tool and the staff nurses on the unit—justifies the assignment.
Absolute ICU limit: Under no circumstances may an ICU nurse be assigned a third patient.
Non-ICU departments: Outside of the ICU, hospitals must staff at "sufficient levels" needed to provide nursing care that requires the specialized skills of an RN.
Active legislation (S.1522): Entitled "An Act Promoting Patient Safety and Equitable Access to Care," this bill for the 2025-2026 session mandates that the Department of Public Health establish specific statewide limits on the number of patients assigned to a nurse at a time.
Expanded coverage: Unlike previous efforts, S.1522 explicitly includes psychiatric hospitals and various specialized units such as emergency, observational, and rehabilitation departments.
Enforcement and penalties: The bill proposes civil penalties of up to $25,000 per violation, with each day of a continuing violation treated as a separate offense.
Anti-retaliation protections: The 2026 legislation adds that no employee shall be disciplined or retaliated against for complying with these mandated patient limits.

Nursing home staffing minimums

Massachusetts uses an hours of care per resident per day model for nursing homes.

Total care baseline: Level I, II, and III facilities must provide at least 3.58 total hours of care per resident per day.
Mandated RN hours: Within the total care hours, at least 0.508 hours must be provided specifically by a registered nurse.
Shift responsibility: An RN or LPN must be responsible for the total nursing care of residents in their unit during every shift.
Work hour limits: Nursing personnel generally may not serve more than 12 hours per day or 48 hours per week.

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Michigan

Michigan does not establish fixed, state-mandated numerical nurse-to-patient ratios for general hospital units. While significant legislative efforts like the Michigan Safe Patient Care Act have been introduced to mandate specific ratios, they remain proposed bills as of early 2026. Currently, Michigan hospitals follow a "sufficient staffing" model, whereas nursing facilities are subject to rigid shift-based personnel ratios and hourly care minimums.

Proposed hospital staffing legislation

The Safe Patient Care Act, a proposed bipartisan legislative package (including SB 334), seeks to mandate unit-specific ratios such as 1:1 for intensive care, 1:3 for telemetry, and 1:4 for medical-surgical units. As of February 2026, these remain proposed standards that have not been enacted into law.

Nursing facility requirements

Michigan maintains rigid staffing standards for nursing homes under MCL Section 333.21720a, which specifies nursing care hours and personnel-to-patient ratios:

Minimum nursing care hours: Licensees must maintain staff sufficient to provide at least 2.25 hours of nursing care per patient per day.
RN leadership: Every nursing home must have at least 1 registered nurse with specialized training in gerontology serving as the director of nursing.
DON counting rules: In facilities with 30 or more beds, the director of nursing's time may not be included when counting the minimum ratios of nursing personnel.

Shift-specific personnel ratios

Morning shift: Not more than 8 patients for every 1 nursing care personnel
Afternoon shift: Not more than 12 patients for every 1 nursing care personnel
Night shift: Not more than 15 patients for every 1 nursing care personnel

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Minnesota

Minnesota does not currently establish fixed, state-mandated numerical nurse-to-patient ratios for general hospital units. Instead, the state utilizes a "sufficient staffing" model that relies on collaborative planning and transparency. However, specific numerical staff-to-participant ratios are strictly enforced for facility-based day services.

Hospital staffing requirements

Staffing in Minnesota hospitals is primarily governed by professional standards and transparency mandates:

Core staffing plans: Every hospital must develop a written core staffing plan for each inpatient unit specifying the projected number of full-time equivalent non-managerial care staff assigned in a 24-hour period.
Mandatory consultation: Chief nursing executives must consult with and obtain consent from non-managerial care staff (including RNs) and their bargaining representatives regarding the staffing plan and expected patient averages.
Quality Patient Care Act (proposed): This bipartisan bill (HF 2289/SF 2775) seeks to mandate unit-specific ratios, such as 1:1 for operating rooms and trauma, 1:2 for ICUs, and 1:4 for acute psychiatric units. As of early 2026, this remains proposed legislation and is not currently enforceable law.
Adverse event reporting: Hospitals must ask specific staffing-related questions during root cause analyses of serious adverse events, such as whether staff believed staffing was appropriate to provide safe care at the time of the incident.

Day services facility requirements

Under Minn. Stat. § 245D.31, facility-based day services must adhere to specific staff-to-participant ratios determined by the needs of the individuals present:

1:4 ratio: Required for individuals needing total care, constant hand-over-hand physical guidance in 3 or more activities of daily living (ADLs), or those with conduct posing an imminent risk of harm
1:8 ratio: Required for individuals needing verbal prompts or spot checks and minimal physical assistance for at least 3 ADLs
1:6 ratio: The default ratio for individuals not meeting the specific 1:4 or 1:8 criteria

At no time may 1 direct support staff member be responsible for the supervision and training of more than 10 persons.

2026 updates and enforcement

Recent developments in Minnesota focus on increased transparency and proposed safe staffing committees:

Safe Patient Assignment Committee (proposed): If the QPCA is enacted, hospitals would be required to establish committees composed of 60% direct-care nurses to oversee staffing conditions by October 1, 2026.
Public reporting: Beginning September 1, 2026, the Commissioner of Health would be required to publicly report all instances of hospital noncompliance with staffing standards on a quarterly basis.
Quarterly staffing grids: Proposed updates to Minn. Stat. § 144.7055 would require hospitals to submit their staffing grids to the Commissioner quarterly and certify their accuracy by a majority vote of direct-care RNs.
Short staffing alerts: The MNA reports that nurses filed over 3,000 Concern for Safe Staffing reports in a single year, highlighting ongoing friction between frontline assessments and hospital management decisions.

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Mississippi

Mississippi does not currently establish fixed, state-mandated numerical nurse-to-patient ratios for general acute care hospital units. Instead, the state follows a "sufficient staffing" model while enforcing rigid shift-based care hours and personnel minimums for nursing facilities and specialized pediatric settings.

Hospital staffing requirements

Hospital staffing in Mississippi is primarily governed by administrative regulations from the Mississippi State Department of Health (MSDH):

Mandatory professional oversight: Both nurse managers and bedside nurses are held accountable for providing safe nursing care, with nurse managers responsible for assessing personnel capabilities against patient needs.
Obligation to question: RNs and LPNs have a documented professional right and obligation to question orders contrary to acceptable standards and to refuse participation in procedures that may result in patient harm.
Obstetrics system of care (2026): Effective February 22, 2026, Mississippi implemented a tiered system designating hospitals into 4 maternal and 4 neonatal levels of care. Each level has prescriptive requirements for triage, infrastructure, and leadership, such as a mandatory maternal program manager and medical director.

Nursing facility requirements

Mississippi establishes strict, legally enforceable minimums for nursing homes under 15 Miss. Code R. 16-1-45.4.1:

Minimum direct care hours: Facilities must provide a minimum of 2.80 hours of direct nursing care per resident per 24-hour period.
RN coverage: A registered nurse must provide coverage on the day shift, 7 days a week.
Supervisory minimums: Facilities with 180 beds or more are required to have an assistant director of nursing who must be a registered nurse.
Charge nurse limits: In facilities with more than 60 beds, the charge nurse may not also serve as the director of nursing or the medication/treatment nurse.
Emergency staffing: In an emergency, at least 2 employees must be present in a nursing facility at all times.

Specialized facility requirements

Specific numerical mandates apply to specialized pediatric and ventilator-dependent settings:

Pediatric skilled nursing: At no time shall there be fewer than 1 staff member on duty for every 3 children.
Sole staffing requirement: If only 1 staff member is on duty in a pediatric unit, that member must be a registered nurse.

Patient abandonment guidelines

As of December 2024, the Board of Nursing defines patient abandonment as severing a nurse-patient relationship without reasonable notice to a supervisor. Refusal to work mandatory overtime or work in an unfamiliar area without orientation is not considered patient abandonment.

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Missouri

Missouri does not establish fixed, state-mandated numerical nurse-to-patient ratios for general acute care hospital units. Instead, the state relies on a "sufficient staffing" model for acute care hospitals and federal minimums for nursing facilities.

Assisted living staffing mandates (proposed)

New 2026 proposals under SB 1794 specifically target assisted living facilities for stricter oversight.

Registered nurse hours: The bill proposes that assisted living facilities provide RN care for a minimum of 0.55 hours per resident day.
24/7 RN presence: At least 1 registered nurse would be required to be on-site 24 hours a day, 7 days a week.
Designated leadership: Each facility would be required to designate a full-time RN as the director of nursing and an RN to serve as the charge nurse for every shift. The director of nursing may serve as a charge nurse only if the facility has an average daily occupancy of 60 or fewer residents.

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Bill Text: MO SB1794 | 2026 | Regular Session | Introduced

Montana

Montana does not establish fixed, state-mandated numerical nurse-to-patient ratios for general acute care hospital units. The state follows a model based on professional standards and administrative rules, as legislative efforts to mandate ratios and committees have not been enacted.

Registered nurse professional standards

Staffing and practice in Montana are governed by ARM 24.159.1205, which outlines the legal boundaries and responsibilities of registered nurses.

Professional accountability: Nurses must accept responsibility for individual nursing actions and competence, basing their practice on validated data.
Safe assignment acceptance: RNs are required to obtain instruction and supervision as necessary when implementing nursing techniques or practices.
Unsafe practice reporting: Montana law mandates that nurses report unsafe nursing practice to their immediate supervisor and the Board of Nursing.
Policy contribution: Registered nurses must contribute to the formulation, implementation, and evaluation of nursing practice policies within their employment setting.
Collaborative care: Nurses are required to collaborate with other health team members to provide optimum client care.

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Nebraska

Nebraska does not establish fixed, state-mandated numerical nurse-to-patient ratios for general hospital units. Instead, the state utilizes a "sufficient staffing" model.

Hospital staffing requirements

Staffing in Nebraska hospitals is primarily governed by professional accountability standards and state licensure rules:

Professional accountability: Every licensed nurse is directly accountable to the consumer for the quality of care rendered, and both staff nurses and leaders may be subject to discipline if inadequate staffing places patients at risk.
Assignment competency: It is the individual nurse's responsibility to determine if they are clinically competent for an assignment; if not, and no reasonable alternative is identified, the nurse should not accept the assignment.
Fatigue management: Nurses are expected to decline any assignment for which they may be unsafe due to a lack of sleep, fatigue, or prolonged work hours.
Supervisor availability: Employer-assigned nurse leaders must remain available for staffing decisions and providing direct assistance to patient care staff.
Resolution process: When staff numbers or mix are inadequate, nurses are directed to contact their immediate supervisor before accepting an assignment to ask for assistance, which may include acquiring a different staff mix or prioritizing specific care activities.

Nursing facility requirements

Nebraska enforces specific operational standards for skilled nursing facilities under Statute 71-6018.02 and 175 Neb. Admin. Code, ch. 12:

RN leadership: A licensed RN must serve as the full-time director of nursing services; this requirement cannot be waived.
Charge nurse mandate: A facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
DON dual-role limit: The DON may only serve as a charge nurse if the facility has an average daily occupancy of 60 or fewer residents.

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Nevada

Nevada does not currently establish fixed, state-mandated numerical nurse-to-patient staffing ratios. For now, Nevada hospitals must utilize nurse-led staffing committees to develop and implement documented clinical staffing plans.

Hospital staffing requirements

Staffing in Nevada hospitals is governed by NRS 449.242, which emphasizes internal oversight and collaborative planning:

Nurse staffing committees: Hospitals in counties with populations of 100,000 or more and licensed to have more than 70 beds must establish staffing committees where at least 50% of members are direct-care registered nurses and certified nursing assistants elected by their peers.
Documented staffing plans: These committees are legally responsible for developing a hospital-wide staffing plan that specifies the number of nurses required for each unit and shift.
Staffing refusal rights: Licensed nurses and CNAs have the right to refuse a work assignment if they do not possess the necessary knowledge, skill, or experience to provide safe care, as verified by their personnel files.

Nursing facility requirements

Nevada establishes specific operational and leadership standards for skilled nursing facilities under NAC 449.74517:

Chief administrative nurse: Every SNF must employ a full-time RN as the chief administrative nurse (director of nursing), who must possess at least 3 years of experience providing care in a hospital or long-term care setting.
Nurse in charge: A licensed nurse must be designated on each shift as the nurse in charge.
Dual-role restriction: The chief administrative nurse may only be designated as the nurse in charge if the facility has an average daily occupancy of 60 or fewer patients.

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New Hampshire

New Hampshire does not currently establish fixed, state-mandated numerical nurse-to-patient ratios for general acute care hospital units. The state follows a "sufficient staffing" model for most facilities, though landmark legislation is currently moving through the House in 2026 to implement the state's first specific numerical minimums for nursing homes.

Proposed 2026 mandates (HB 1179)

As of February 2026, this active bill proposes requiring at least 1 RN on-site 24 hours a day and a minimum of 4.1 total nursing hours per resident per day, which must include at least 0.75 RN hours.

Staffing in residential care facilities

Stricter, specific presence requirements apply to psychiatric and residential treatment settings:

Acute psychiatric residential treatment programs (APRTPs): These programs must have at least 2 staff members on duty at all times, 1 of whom must be a registered nurse.
SUD residential treatment: Substance use disorder (SUD) facilities must have at least 1 awake personnel member on duty at all times when clients are present.
Assisted living: In supported residential health care facilities, personnel levels are determined by the administrator based on service needs; however, at least 1 awake staff member must be on duty 24/7.

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New Jersey

New Jersey does not currently establish fixed, state-mandated numerical nurse-to-patient ratios for all hospital units. Instead, the state utilizes a public disclosure model for general hospitals while enforcing shift-specific staffing minimums for nursing homes.

Hospital staffing requirements

Staffing in New Jersey hospitals is primarily governed by transparency laws and Department of Health (DOH) licensing rules.

Public disclosure mandates: General hospitals must report aggregate direct care staffing data to the DOH monthly. The DOH makes this information available to the public in quarterly reports, providing ratios of patients to staff for each licensed unit (e.g., medical-surgical, pediatrics, ICU).
Daily clinical postings: Hospitals are legally required to post patient care staffing information in a conspicuous place on each unit no later than 1 hour after the start of a shift. These postings must show the actual number of RNs, LPNs, and CNAs on duty and the prevailing staff-to-patient ratio.
Acuity adjustments: Under N.J.A.C. 8:43G-17.1, hospitals must maintain a documented methodology for adjusting staffing levels based on patient intensity, as determined by professional nursing assessments.
Staffing committees (2026 proposal): Active legislation (Assembly Bill 2418) introduced for the 222nd Legislature seeks to require hospitals to establish nurse staffing committees comprised of at least 55% direct-care RNs.
Committee responsibilities: If enacted, A2418 would empower committees to develop annual shift-based staffing plans that establish upwardly adjustable minimum ratios based on census data, skill mix, and facility geography.

Nursing facility requirements

New Jersey enforces shift-based direct care ratios for nursing homes under N.J.S.A. 30:13-18.

Evening shift ratio: 1 direct care staff member for every 10 residents, provided that at least half are CNAs
Night shift ratio: 1 direct care staff member for every 14 residents, with each staff member required to perform CNA duties

These numerical ratios do not apply to licensed pediatric long-term care facilities.

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New Mexico

New Mexico currently utilizes a "sufficient staffing" model for hospitals based on professional nursing assessments and facility-specific policies. While major legislative efforts—specifically the Safe Staffing Act (HB 172)—seek to establish the state's first specific numerical nurse-to-patient ratios for acute care facilities, these measures remain proposed and are not currently enforceable laws as of February 2026.

Hospital staffing requirements

Staffing in New Mexico hospitals is governed by the state’s Health Care Authority (HCA) licensure regulations and professional competency standards.

Mandatory RN presence: An adequate number of professional registered nurses must be on duty at all times to assess, plan, and direct nursing care for all patients on a 24-hour basis.
Unit supervision: Every patient care unit must be assigned at least 1 professional registered nurse in charge on each shift.

Proposed Safe Staffing Act ratios (HB 172)

In February 2026, the Safe Staffing Act (HB 172) remains a pending bill under consideration by the New Mexico Legislature. If enacted, it would establish the state's first mandated minimum registered nurse-to-patient staffing ratios, including the following specific examples:

1:1 ratio: Required for trauma patients in the emergency department, patients in active labor, and for the duration of operating room procedures
1:2 ratio: Required for critical care and ICU patients, as well as uncomplicated or non-laboring obstetric patients
1:4 ratio: Required for medical-surgical units, specialty care (including oncology, pediatrics, and psychiatry), and general emergency department assignments
1:6 ratio: Required for postpartum and antepartum units, with the specific requirement that each mother and baby is counted as a separate patient

The bill further specifies that these ratios apply to direct-care registered nurses and that charge nurses would not be counted toward any required ratio.

Nursing facility requirements

New Mexico differentiates staffing mandates by facility type rather than a single statewide nursing home standard.

Skilled nursing facility ratios

State licensure rules under 8.370.16.51 NMAC focus on daily care hours.

Hours per patient day: Skilled nursing units must maintain at least 2.5 hours of care per patient day.
Intermediate care standard: Intermediate care units must provide at least 2.3 hours of care per patient day.
Nurse presence: Facilities must have at least 1 nursing staff member on duty at all times.
Shift-by-shift postings: Facilities must post the number of nursing personnel on duty within 1 hour of every shift change for public review.

Assisted living facility ratios

These facilities utilize a tiered model to ensure safety and supervision.

1 to 15 residents: Minimum of 1 direct care worker
16 to 60 residents: Minimum of 1 direct care worker and 1 additional staff person
61 or more residents: At least 3 direct care staff persons on duty and awake, and 1 additional staff person immediately available on the premises for each additional 30 residents (or fraction thereof)

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New York

New York enforces staffing minimums for nursing homes, while general hospitals utilize nurse-led clinical staffing committees to establish unit-specific patient limits. However, the state has established mandatory minimums for intensive care units and critical care units across the state.

Hospital staffing requirements

Hospital staffing is governed by Public Health Law Section 2805-t, which emphasizes collaborative planning and transparency:

Clinical staffing committees: Every general hospital must maintain a committee where at least 50% of members are registered nurses, licensed practical nurses, and ancillary frontline staff chosen by their peers.
Mandated ICU ratios: State law requires hospitals to provide at least 12 hours of RN care per patient per day in intensive and critical care units, which is synonymous with a 1:2 nurse-to-patient ratio.
Annual clinical staffing plans: Committees must adopt and submit a hospital-wide plan by July 1 each year detailing specific staffing grids and ratios for every inpatient and outpatient unit.
Disruption contingencies: Staffing plans must include specific steps for foreseeable staffing disruptions, such as unusual levels of absenteeism or approved time off.
Public transparency: Each general hospital shall post, in a publicly conspicuous area on each patient care unit, the clinical staffing plan for that unit and the actual daily staffing for that shift on that unit, as well as the relevant clinical staffing.
Safe Staffing for Hospital Care Act (proposed): Active legislation (S4003) for the 2025-2026 session seeks to expand these mandates to establish minimum staffing levels for all health care workers and prohibit most mandatory overtime.

Nursing facility requirements

New York maintains rigid daily staffing standards for skilled nursing facilities under Public Health Law § 2895-b:

Total daily care hours: Every nursing home must provide daily staffing equal to at least 3.5 hours per resident day.
CNA and nurse minimums: Of the total hours, at least 2.2 HPRD must be provided by certified nursing assistants and 1.1 HPRD by licensed nurses (RN or LPN).

2026 strike settlement ratios

In February 2026, the New York State Nurses Association (NYSNA) made progress in bargaining for improved staffing ratios and new nurse positions at major health systems like Montefiore to address safety concerns.

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North Carolina

North Carolina does not currently establish fixed, state-mandated numerical nurse-to-patient staffing ratios for general hospital units. The state relies on a "sufficient staffing" model. However, there are specific staffing standards for nursing homes.

In February 2026, Attorney General Jeff Jackson joined an 18-state coalition calling for the reinstatement of federal 24/7 RN mandates and minimum CNA hours, which were recently overturned by federal legislation.

Enforceable state staffing standards

Under current state law, facilities must adhere to the following mandates:

Total daily care minimum: Daily direct patient care nursing staff (licensed and unlicensed) must equal or exceed 2.1 nursing hours per patient.
Multi-story coverage: Facilities with more than 1 story must have at least 1 staff person on duty on each patient care floor at all times.
Support staff exclusion: Ward clerks, secretaries, and administrative managers not involved in direct care cannot be counted toward the 2.1-hour minimum.
Small facility flexibility: In facilities with a total census of 60 beds or less, the director of nursing may be counted toward both administrative requirements and direct patient care staffing.

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North Dakota

North Dakota hospitals and nursing facilities must operate under the direction of a state-licensed registered nurse who maintains documented administrative authority. While the state mandates specific 20-minute response times for on-call hospital leadership, it does not currently enforce fixed numerical staffing ratios for nursing homes, instead requiring "sufficient" personnel to meet resident care plans.

General acute hospital requirements

Nurse executive: Nursing services must be directed by a nurse executive (director of nursing) who is a registered nurse licensed specifically to practice in North Dakota.
Written authority: The nurse executive must have written authority and accountability for integrating and coordinating nursing services.
Absence coverage: When the nurse executive is unavailable, a specific registered nurse must be designated in writing to be available in person or by phone to direct services.
On-call response: The nurse executive or a designated alternate must be on call and able to arrive at the facility within 20 minutes at all times.
Specialized units: Hospitals offering obstetrical or surgical services must provide additional nursing staff as determined by patient needs and facility policy.

Primary care hospital requirements

Leadership: Like general hospitals, these must be under the direction of an RN licensed in North Dakota who retains responsibility for scheduling adequate numbers of RNs, LPNs, and other personnel.
Nursing care assignments: A registered nurse must personally provide or assign nursing care to every patient, including those in skilled nursing "swing beds."
Staff availability: When an RN is not physically on duty, the nurse executive or an alternate RN must be available and on call within 20 minutes.
Empty facility staffing: If no patients are currently in the facility, staffing must still include at least 1 licensed nurse, with an RN on call and available within 20 minutes to respond to new patient needs.

Specialized and rural emergency hospitals

Staffing requirements for other facility types are determined by their classification:

Specialized hospitals: These facilities are generally subject to the same nursing service requirements as general acute hospitals.
Rural emergency hospitals: These are specifically exempted from general acute standards and must instead follow the staffing requirements for primary care hospitals.

Nursing facility requirements

Nursing services must be under the direction of a director of nursing who is employed by the facility and is a registered nurse licensed to practice in North Dakota.

The DON shall:

Have written administrative authority, responsibility, and accountability for the integration of nursing services consistent with the overall facility plan and philosophy of resident care
Be responsible for ensuring the development, maintenance, implementation, and revision of nursing service objectives, standards of practice, policy and procedure manuals, and written job descriptions for each level of nursing personnel, including unlicensed staff
Ensure a resident assessment is completed and a comprehensive care plan is established in coordination with the resident or legal representative within the required timeframes

North Dakota nursing homes average 4.95 nurse hours per resident day, significantly higher than the national average of 3.85.

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Ohio

Ohio hospitals primarily follow a nurse-led committee model for staffing, while nursing homes adhere to fixed direct care minimums under the state administrative code. While the Ohio Nurse Workforce and Safe Patient Act (HB 521) remains a pending legislative effort to establish the state's first mandated numerical ratios, it has not yet been enacted into law.

Hospital staffing requirements

Staffing in Ohio hospitals is currently governed by Ohio Revised Code 3727.50-57, which focuses on collaborative planning through internal committees:

Staffing committees: Every hospital must maintain a nursing care committee where at least 50% of the members are registered nurses who provide direct patient care.
Annual staffing plans: The committee is responsible for developing a hospital-wide nursing care staffing plan that guides assignments based on patient needs and staff competency.

Proposed Safe Patient Act ratios (HB 521)

In February 2026, the Nurse Workforce and Safe Patient Act (HB 521) remains a proposed bill under consideration by the Ohio Legislature. If enacted, it would establish the state's first mandated minimum registered nurse-to-patient staffing ratios, including the following specific examples:

1:1 ratio: Required for trauma emergency units and operating rooms
1:2 ratio: Required for critical care units, including intensive care, neonatal intensive care, labor and delivery, and postanesthesia care
1:3 ratio: Required for emergency department care, pediatric care, step-down, and telemetry units
1:4 ratio: Required for medical-surgical, intermediate care, acute psychiatric, and other specialty care units
1:5 ratio: Required for rehabilitation and skilled nursing units
1:6 ratio: Required for postpartum care (where each mother and infant count as separate patients) and well-baby nurseries

The bill proposes a staggered implementation timeline: Most hospitals would be required to comply 2 years after the effective date, while rural hospitals would have 4 years to reach these targets.

Nursing facility requirements

Staffing for Ohio nursing homes is governed by Rule 3701-17-08 of the Ohio Administrative Code:

Direct care baseline: Facilities must maintain a minimum daily average of 2.5 hours of direct care and services per resident per day.
RN leadership mandate: Every nursing home must employ a registered nurse to serve as the director of nursing, who must predominantly be on duty 5 days per week for 8 hours per day.
Continuous RN availability: Facilities are required to have an RN physically on duty or on call at all times when a resident is present in the home.

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Oklahoma

As of early 2026, Oklahoma continues to operate under a "sufficient staffing" model for general hospitals, while maintaining specific, shift-based minimum ratios for nursing homes under state law.

Hospital staffing requirements

Staffing in Oklahoma hospitals is governed by Okla. Admin. Code § 310:667-15-3:

Registered nurse availability: Hospitals must maintain an adequate number of registered nurses to ensure 1 is immediately available for bedside care for any patient when needed.
Mandatory RN presence: A registered nurse must be on duty at all times and available on-site for all patients on a 24-hour basis every day.
Acuity-based ratios: The ratio of registered nurses to patients and other nursing personnel must be sufficient to provide proper supervision based on patient acuity.

Nursing facility requirements

Staffing for Oklahoma nursing homes is governed by State Statute § 63-1-1925.2:

Direct-care service rate: Facilities are required to maintain a minimum of 2.9 hours of direct-care service per resident per day.
Name and title posting: Facilities must post the names and titles of direct-care staff on duty each day in a conspicuous place, including the name and title of the supervising nurse.

Shift-based staffing ratios

Day shift (7:00 a.m.–3:00 p.m.): 1 direct-care staff member for every 6 residents
Evening shift (3:00–11:00 p.m.): 1 direct-care staff member for every 8 residents
Night shift (11:00 p.m.–7:00 a.m.): 1 direct-care staff member for every 15 residents

Behavioral health and specialty care

Inpatient psychiatric settings follow specific numerical ratios authorized by the Oklahoma Health Care Authority (OHCA):

Acute and PRTF units: General programs require a ratio of 1:6 during waking hours and 1:8 during sleep hours.
Specialty classification: Units classified as "specialty acute II" or "specialty PRTF" require higher staffing levels of 1:4 during waking hours and 1:6 during sleep hours.
RN shift mandate: In acute and acute II settings, at least 1 registered nurse must be on duty per unit at all times.

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Oregon

In 2023, Oregon passed HB 2697, becoming the second state in the nation—after California—to mandate specific nurse-to-patient staffing ratios in statute. While the law is unique for being the first to include a broad range of healthcare workers, like CNAs and respiratory therapists, in its framework, its implementation is a multi-year process. While certain provisions regarding committees and overtime began in late 2023, the phase-in of specific unit ratios continued through 2025, with full enforcement and potential civil penalties for non-compliance active as of 2026.

Hospital staffing requirements

Oregon’s ratios are codified in ORS 441.765 and must be maintained at all times, including during breaks.

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Oregon: Mandated RN-to-patient ratios (2026)

Hospital unit	Nurse-to-patient ratio	Notes
Emergency department	1:4	Averaged over 12 hours; max 5 at once
Trauma (ER)	1:1	Direct care RN
Intensive care (ICU/NICU)	1:2	Maximum assignment
Labor & delivery (active)	1:1	Active labor or complications
Labor & delivery (non-active)	1:2	Standard antepartum/labor
Postpartum/well-baby	1:6	Mother and baby count as separate patients
Specialty	1:4	Includes oncology, pediatric, and cardiac telemetry units
Operating room	1:1
Post-anesthesia care unit	1:2
Intermediate care unit	1:3
Medical-surgical	1:5	Tightening to 1:4 effective July 1, 2026

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The law provides specific mechanisms for clinical innovation and temporary staffing deviations:

Temporary deviations: A unit may deviate from its staffing plan (excluding break requirements) no more than 6 times during a rolling 30-day period without being in violation, provided the committee is notified within 10 days.
Charge nurse assignments: Charge nurses may take patient assignments to cover breaks in units with 10 or fewer beds, or in larger units with committee approval.

Nursing facility requirements

Oregon's nursing home staffing is governed by administrative rules that prioritize sufficient care and specific personnel ratios rather than the statutory mandates applied to hospitals.

Licensed nurse presence: Facilities must provide no less than 1.0 registered nurse hour per resident per week.
Minimum nursing staff: A facility must have at least 2 nursing staff members on duty at all times.
Transparency and reporting: Facilities must publicly post their daily resident census and actual hours worked by RNs, LPNs, and CNAs for each shift.

2026 updates and enforcement

Coverage loopholes have been closed, requiring hospitals to maintain statutory ratios even when a nurse is on a meal or rest break.
Civil penalties for ratio violations or missed meal/rest breaks include assessment of liquidated damages of $200 per violation.
Nurse staffing committees continue to approve staffing plans, but the law now provides a time-limited and legally binding arbitration process to resolve any impasses or disagreements within the committee.
Committees have the power to approve staffing plans that exceed the minimum safe standards defined in the law, as the statutory ratios serve as a "floor" rather than a "ceiling."
Staffing committees are now mandated to review specific performance metrics, including the frequency of missed meal and rest breaks.
In Type A and Type B rural hospitals (under 50 beds), the nurse staffing committee has the sole authority to approve a 2-year variance from the law’s statutory requirements.
A unit may deviate from statutory registered nurse-to-patient ratios by utilizing up to 50% other clinical staff, provided the nurse staffing committee approves the "innovative care model" and re-approves it every 2 years.

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Pennsylvania

As of February 2026, Pennsylvania continues to enforce strict state-level minimums for nursing homes and mental health programs, while hospital staffing remains governed by unit-specific, committee-led plans.

Hospital staffing requirements

Hospital staffing in Pennsylvania is currently regulated through collaborative planning rather than mandated numerical ratios:

Nurse executive: Nursing services must be provided on a continuous basis. These services are defined as those performed or supervised by a registered nurse.
Patient limits: The number of patients admitted to any area of the hospital must not exceed the number for which the area is designed, equipped, and staffed. Exceptions are only permitted in emergencies and must follow the hospital's disaster plan.

Nursing facility requirements

Pennsylvania enforces state-level minimums for skilled nursing facilities:

Total direct care hours: Every nursing home must provide a minimum of 3.2 hours of direct resident care per resident per 24-hour period.
Mandatory RN presence: Facilities must provide at least 1 registered nurse per 250 residents during all shifts.

Partial hospitalization program requirements

Pennsylvania enforces distinct staffing metrics for mental health partial hospitalization programs based on the designed program capacity.

Adult programs (55 Pa. Code § 5210.21): Must maintain a minimum of 1 full-time equivalent clinical staff member for every 6 patients
Children and youth programs (55 Pa. Code § 5210.31): Require a higher staffing level of at least 1 FTE clinical staff member for every 5 patients

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Rhode Island

As of February 2026, Rhode Island hospital staffing is managed through a reporting and peer-involved planning model, while the state formally evaluates a transition toward mandated numerical ratios. Nursing facilities, however, are subject to strict statutory direct care minimums and mandatory RN presence.

Hospital staffing requirements

Rhode Island hospitals follow a transparency-based staffing framework and are currently the subject of a high-level legislative study.

Core-staffing plans: Annually, in January, every licensed hospital must submit a plan to the Department of Health specifying the number of RNs, LPNs, and CNAs assigned to each unit and shift.
Special legislative commission (2026): A 15-member commission has been created via S 2258 to study safe staffing ratios, evaluate the impact on patient outcomes, and review how facilities are implementing the Joint Commission’s 2026 national performance goals.
Overtime restrictions: Healthcare facilities are prohibited from requiring employees to work in excess of an agreed-upon shift or more than 12 consecutive hours, except in unforeseeable emergent circumstances.

Nursing facility requirements

Rhode Island maintains rigorous direct care standards for nursing homes to ensure the health and safety of residents.

Minimum direct care hours: Commencing January 1, 2026, facilities must provide a quarterly minimum average of 3.58 hours of direct nursing care per resident, per day.
24-hour RN mandate: Every nursing facility must have a registered nurse on the premises 24 hours a day.
Administrative exclusions: Time spent by the director of nursing and any staff hours dedicated to administrative or non-direct caregiving tasks are strictly excluded from the minimum staffing hour calculations.
Staffing pattern participation: Facilities must include direct caregivers in the creation of master staffing patterns.
Shift posting: Facilities must post daily direct care staffing levels by shift in a public place accessible to residents, employees, and visitors.

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South Carolina

South Carolina utilizes shift-based minimum resident-to-staff ratios for nursing facilities while maintaining a flexible "sufficient staffing" model for hospitals based on patient care needs.

Hospital staffing requirements

South Carolina mandates specific organizational structures and professional coverage minimums for all licensed hospitals.

Continuous RN presence: A registered nurse must be on duty within the hospital at all times (24/7).
Nursing service direction: The nursing service must be under the direction of a single registered nurse, with another registered professional nurse designated to act in their absence.
Supervision of care: All nursing services must be furnished or supervised by a registered nurse.
Ancillary staff assignments: Licensed practical nurses and other nursing workers must be assigned duties based specifically on their education, training, and documented competency.
Emergency department coverage: A registered nurse and ancillary personnel trained in emergency procedures must be on duty and available 24 hours a day to assist in providing emergency services.
Psychiatric unit mandates: At least 1 registered nurse must be on duty in each psychiatric nursing unit at all times.
Substance abuse unit mandates: At least 1 registered nurse with demonstrable training in chemical and substance abuse treatment must be on duty in each such unit at all times.
Perinatal resuscitation: At least 1 person who has completed the Neonatal Resuscitation Program must be on-site at all times to meet the potential need for resuscitation of every neonate.

Nursing facility requirements

Staffing for South Carolina nursing homes is regulated by specific shift-based resident-to-staff ratios mandated for licensure:

Day shift: 1 staff member for every 9 residents
Evening shift: 1 staff member for every 13 residents
Night shift: 1 staff member for every 22 residents
24/7 RN presence: A registered nurse must be on duty in the facility, or on call, whenever residents are present.

Hospice facilities

Every licensed hospice facility must maintain a minimum baseline of 1 registered nurse and 1 additional direct care staff member on duty at all times.

Facilities must adhere to the following minimum staff counts per shift based on their current patient census:

0–10 patients: 2 staff members for shifts 1, 2, and 3
11–20 patients: 3 staff members for shift 1; 2 staff members for shift 2 and shift 3
21–30 patients: 4 staff members for shift 1; 3 staff members for shift 2 and shift 3
12-hour shift adjustments: For facilities utilizing 12-hour shifts, the minimum staffing levels required for "shift 1" apply to the day shift, while the levels for "shift 2" apply to the night shift.

High-volume requirements: Facilities with more than 30 patients must provide additional staff at a minimum ratio of 1:10.
Professional oversight: All nursing care services must be supervised by a staff registered nurse.
Department discretion: The Department may require a facility to provide additional staff members beyond these minimums if current levels are deemed inadequate for appropriate patient care and supervision.

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South Dakota

South Dakota’s healthcare staffing remains governed by a framework of Administrative Rules (ARSD) that prioritize professional registered nurse oversight and continuous availability across various care settings. While requirements vary by facility type, the common standard across the state is the mandatory presence of qualified nursing leadership and bedside staff to ensure patient safety and individualized care.

Hospital staffing requirements

Hospital staffing in South Dakota is regulated by the Department of Health under ARSD Article 44:75:

Registered nurse leadership: Each facility must have an organized nursing service with a written organizational plan that delineates its functional structure. A full-time registered nurse must be designated as the director of nursing service, who is responsible for the organization of the entire nursing service and serves during the day shift.
Bedside and charge nurse availability: A hospital must maintain sufficient personnel at all times to provide supervision of and nursing care for all patients. A registered nurse must be designated as the charge nurse for each nursing care unit at all times.
Critical access hospital (CAH) exemptions: A critical access hospital is required to staff with a registered nurse only when it admits an acute care patient. When a CAH has only swing-bed patients, it is only required to staff with a licensed nurse.
Surgical and specialized standards: A facility must develop staffing patterns for each patient care unit, including surgical and obstetrical suites, emergency services, and special care units.
Hospice personnel: Personnel providing hospice care in a facility must include at least 1 physician, 1 registered nurse, and 1 social worker.

Nursing facility requirements

Director of nursing: A facility must have a full-time registered nurse designated as the director of nursing who is responsible for the entire nursing service and serves during the day shift. The director is prohibited from serving in a dual role as the facility administrator.
Charge nurse restrictions: In facilities with an average daily occupancy of 60 or more residents, the director of nursing may not also serve as the charge nurse.
Nurse-to-aide ratios: The ratio of licensed nurses to aides must be sufficient to ensure professional guidance and supervision in the nursing care of the residents.
Hospice personnel restrictions: For facilities offering hospice services, unlicensed personnel may not accept any delegated skilled tasks from hospice providers.
Interdisciplinary team requirements: Resident care plans must be developed by an interdisciplinary team that includes at least 1 licensed nurse.

South Dakota home health service requirements

Home health services are regulated under ARSD Chapter 67:16:05:

Registered nurse and skilled services: Skilled nursing services must be provided on a part-time or intermittent basis by a home health agency. These services must be provided by an agency employee who is qualified to perform the required task.
Plan of care and supervision: A home health agency must prepare a written plan of care for each individual based on orders from an attending physician or licensed practitioner. The attending practitioner must periodically review and recertify the plan of care at least every 60 days for nursing, therapy, and home health aide services.
Aide supervision: A supervisory visit is mandatory when home health aide services are being provided.
Service limits: Covered services are generally provided intermittently, not more than once a day, and no more frequently than 5 days a week, unless multiple daily visits are documented as medically necessary.

South Dakota assisted living center requirements

Assisted living centers are regulated under ARSD Chapter 44:70:05:

Licensed nurse oversight: The facility must employ or contract a licensed nurse to assess and document that the resident's personal care and medical needs are addressed.
Service limitations: Nursing or rehabilitation services provided to a resident must be limited to less than 8 hours per day and 28 hours per week.
Total assistance standards: If a facility admits residents requiring total assistance with daily living, a nurse must work the day shift at least 32 hours per week. A nurse must also be on call at all times.
Hospice personnel: At least 2 personnel must be on duty at all times if a resident receiving hospice services is not capable of self-preservation or requires additional staffing.

South Dakota ambulatory surgery center requirements

Ambulatory surgery centers are regulated under ARSD Section 44:76:06:01:

Registered nurse presence: At least 1 registered nurse must be on duty at all times when a patient is in the facility.
Surgical supervision: All nursing personnel involved in patient care must be under the direct supervision of a registered nurse.
Operating room standards: When a general anesthetic is used, at least 1 registered nurse, other than the individual administering anesthesia, must be available in each operating room during surgical procedures.
Sedation monitoring: A perioperative registered nurse monitoring a patient receiving moderate sedation must have no other responsibilities that would require leaving the patient unattended.

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Tennessee

Tennessee regulates nurse staffing through a "sufficient staffing" model for hospitals and mandates direct care hour minimums for nursing homes, overseen by the consolidated Health Facilities Commission (HFC).

Hospital staffing requirements

Tennessee mandates specific organizational structures and professional coverage to ensure continuous safety and oversight in all licensed hospitals.

Immediate RN availability: Supervisory and staff personnel must be available for each department or nursing unit to ensure a registered nurse is immediately available for bedside care of any patient when needed.
Chief nursing officer (CNO) leadership: Every hospital must have a chief nursing officer who is a licensed registered nurse responsible for the operation of nursing services, including determining the types and numbers of staff necessary for all areas of the hospital.
Nurse-led assignments: A registered nurse must assess, supervise, and evaluate the nursing care for each patient. RNs are responsible for assigning patient care to other nursing personnel based on patient needs and the specialized competence of the available staff.
Specialized unit training: All nursing personnel assigned to special care units must have specialized training and a program of in-service and continuing education commensurate with their specific duties. Documentation of annual competency skills is required for each individual.
Critical access hospital variation: In a CAH, a physician, mid-level practitioner, or registered nurse must be on duty and physically available only when there are inpatients. When there are no inpatients, the facility must at least maintain a staff person on duty to provide emergency communication access.

Nursing facility requirements

Tennessee enforces specific state-level staffing minimums for nursing homes under Title 68, Chapter 11 of the Tennessee Code:

Minimum direct care hours: Facilities must provide a minimum of 2.0 hours of direct care to each resident every day.
Licensed nursing baseline: Of the total direct care hours, at least 0.4 hours must be provided by licensed nursing personnel (RN or LPN).
Mandatory nurse on duty: There must be at least 1 licensed nurse on duty at all times.
Minimum shift staffing: At least 2 nursing personnel must be on duty on each shift.
Director of nursing: The nursing service must be under the direction of a full-time, licensed nurse who cannot also function as the facility administrator.

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Texas

Texas maintains a nursing framework focused on mandatory facility-specific staffing committees, enhanced whistleblower protections, and strict professional standards enforced by the Texas Board of Nursing (BON) and the Health and Human Services Commission (HHSC).

Hospital staffing requirements

Hospital staffing in Texas is governed by a committee-led model that ensures frontline nurses have a direct role in determining unit-specific ratios:

Staffing committee mandates: Every hospital must maintain a standing nurse staffing committee where at least 60% of members are direct care registered nurses selected by their peers.
Binding staffing plans: These committees are responsible for developing a written hospital-wide plan that sets staffing levels based on patient acuity, nursing assessments, and evidence-based standards. Committees must evaluate the effectiveness of the staffing plan at least semiannually and submit a formal report to the hospital’s governing body.
Mandatory reporting: The chief nursing officer of each hospital is required to personally attest to the accuracy of the staffing data reported annually to the Department of State Health Services (DSHS). The DSHS must provide all reported staffing information to the HHSC for regulation and enforcement.
Prohibited retaliation: Under HB 2187, hospitals are strictly prohibited from retaliating against a nurse who provides information to a staffing committee or reports staffing violations.
Mandatory overtime protections: Hospitals may not suspend, terminate, or discipline a nurse who refuses to work mandatory overtime, and nurses are protected from discrimination for reporting such violations.

Nursing facility requirements

Staffing for Texas nursing homes focuses on providing specialized professional services to residents whose conditions regularly require licensed nursing skills:

Director of nursing: Every nursing facility must designate a full-time registered nurse to serve as the director of nursing. In facilities with more than 60 residents, the DON generally cannot serve as a charge nurse simultaneously.
Staffing ratios: Texas requires a minimum ratio of 1 licensed nursing staff person for every 20 residents (or 0.4 licensed-care hours per resident day).

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Utah

Utah maintains a clinical staffing framework that combines general "sufficient staffing" requirements for broad hospital operations with strict, state-specific mandates for specialized care units and long-term care facilities. While state law requires 24/7 readiness for all acute facilities, the Utah Department of Health and Human Services enforces precise nurse-to-patient ratios and minute-based care minimums for high-acuity settings like dialysis centers and nursing homes.

General and specialty hospitals

Utah law mandates that hospitals maintain constant readiness and professional staffing to ensure patient safety. General acute hospitals and specialty hospitals must remain open and ready to receive patients 24 hours a day, every day of the year.

Satellite emergency departments

Specialized staffing requirements apply to satellite emergency operations located in larger counties (first or second class).

Registered nurse mandate: At a minimum, 2 registered nurses licensed under the Utah Nurse Practice Act must be available on-site during all operating hours.
Specialized training: These RNs must have specialized training specifically in providing emergency medical services.

Skilled nursing and intermediate care facilities

Staffing for long-term care is determined by a combination of care hours per resident day and mandatory RN presence.

Registered nurse presence: In skilled nursing facilities, a registered nurse must be on duty for at least 16 hours per 24-hour period, 7 days a week.
Care-hour minimums: Nursing facilities must meet daily care-hour minimums that include the combined time of registered nurses, licensed practical nurses, and aides, requiring at least 2.5 hours (150 minutes) per resident every 24 hours for skilled residents and 2.0 hours (120 minutes) for intermediate residents.
Licensed nursing portion: For both resident levels, 30% of total care hours must be provided by licensed nurses (RN or LPN only).
Administrative exclusions: In facilities with more than 60 residents, hours worked by the director of nursing or health services supervisor cannot be counted toward these minimum ratios.

End-stage renal disease (ESRD) facilities

Dialysis facilities follow strict supervision limits for registered nurses and technicians.

Minimum shift staffing: A minimum of 2 clinical staff members must be on duty whenever patients are receiving dialysis, 1 of whom must be a registered nurse for clinical care supervision.
RN supervision limits: A registered nurse may not supervise the clinical care of more than 10 patients in an open setting, or 12 patients if arranged in pods of 4.
Competency requirements: RNs may not provide unsupervised care or supervision until they have completed training and demonstrated competency as determined by facility policy.
Delegation: A registered nurse may delegate specific activities, such as cannulation and the administration of heparin or normal saline, to LPNs or dialysis technicians.

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Vermont

As of February 2026, Vermont maintains a transparency-based model for hospitals and is transitioning to new auditing procedures for nursing facilities to ensure care levels align with resident needs.

Hospital staffing requirements

Public reporting mandate: Hospitals must make public the maximum patient census and the actual number of RNs, LPNs, and licensed nursing assistants (LNAs) providing direct patient care in each unit during every shift.
Shift data posting: Unit-specific staffing information, reported in full-time equivalents, must be posted daily in a prominent location accessible to patients and visitors.
Preceding 7-day data: Postings are required to include staffing information for the preceding 7 days to allow for trend transparency.
Public inquiry access: Hospitals are required to provide a telephone number to the public to request information, and they must fulfill these requests within 24 hours.

Nursing facility requirements

Case-mix validation audits: Beginning in 2026, the state is launching resident case-mix validation audits to ensure that reimbursement and staffing levels accurately reflect the clinical needs of residents.

2026 updates: Senate Bill S.277

Senate Bill S.277, introduced in January 2026, proposes to prohibit mandatory overtime for nurses.

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Virginia

Virginia’s nurse staffing requirements are governed by a combination of longstanding administrative codes for hospital emergency departments and a sophisticated value-based purchasing model for nursing facilities that prioritizes RN presence through significant financial incentives.

General and special hospital emergency services

Virginia law mandates specific clinical staffing for hospitals that operate emergency departments to ensure 24-hour readiness.

Mandatory registered nurse assignment: At least 1 registered nurse must be assigned to the emergency service on every shift.
Assignment priority: While this registered nurse may perform other duties, their emergency service assignment must take priority over all other clinical tasks.

Certified nursing facilities (Medicaid VBP program)

Staffing for nursing facilities is regulated through the state fiscal year (SFY) 2026 Value-Based Purchasing (VBP) program, which allocates approximately $185 million in performance-based funding.

RN coverage incentives: The state uses a high-weight performance measure (20% of total VBP weight) that tracks "Days without 8 Minimum RN hours."
Minimum daily RN hours: For VBP evaluation, a facility's daily RN requirement is considered met at 7.5 hours per day, as this accounts for the exclusion of a required 0.5-hour meal break.
Staffing tiers: To earn maximum "Best" tier funding for RN presence, a facility must have 4 or fewer days in a year without the minimum 8 hours of RN staffing.
Total nursing hour thresholds: The program also measures case-mix adjusted total nursing hours (RN, LPN, and CNA), with the "Best" performance tier set at 3.65 hours or more per resident day.
Maintenance of effort: Federal regulations effective for SFY 2026 require that facilities demonstrate maintenance or improvement over their baseline performance to remain eligible for these Medicaid-directed payments.
2026 workforce evaluation: Under HB 605, the Joint Commission on Health Care is directed to evaluate the nursing facility workforce and report findings to the Governor and General Assembly by December 1, 2026.

Prescribed pediatric extended care centers

Effective July 1, 2026, specialized pediatric centers must follow strict statutory staffing ratios based on the number of children enrolled.

Enrollment-based ratios

Fewer than 13 children: Staffed by 2 registered nurses and 2 other staff members
13 to 18 children: Staffed by 2 registered nurses, 1 licensed practical nurse, and 3 other staff members
19 to 24 children: Staffed by 2 registered nurses, 2 licensed practical nurses, and 4 other staff members
More than 24 children: Require an increase in the number of LPNs and other staff by 1 each for every additional 6 children enrolled

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Washington

As of February 2026, Washington maintains a staffing framework defined by enforceable hospital-specific plans and state-mandated minimum care hours for nursing facilities.

Hospital staffing requirements

Staffing committee mandates: Every hospital must maintain a standing hospital staffing committee where at least 50% of voting members are non-supervisory nursing staff providing direct patient care.
Enforceable staffing plans: Committees must adopt annual shift-based staffing plans by a 50% plus 1 vote; these plans serve as the primary component for the hospital’s staffing budget.
Mandatory implementation: Beginning July 1, 2025, hospitals are required to implement these plans and assign nursing staff to units accordingly, except in unforeseeable emergent circumstances.
Peer selection: Nursing staff on the committee are selected by their collective bargaining representative or, if none exists, by their peers.
Unit-specific orientation: Hospitals are prohibited from assigning a direct care registered nurse to a unit unless they have received orientation sufficient to provide competent care in that specific clinical area.

Nursing facility requirements

Minimum direct care hours: Nursing homes must provide a minimum of 3.4 hours per resident day of direct care.
RN supervision baseline: Large nonessential community providers are required to have an RN on duty directly supervising resident care 24 hours per day, 7 days per week.
Small provider standards: Essential and small nonessential community providers must have an RN on duty for at least 16 hours per day, with either an RN or LPN on duty for the remaining 8 hours.
Behavioral health exceptions: Hours worked by geriatric behavioral health workers may be recognized as direct care hours for residents with behavioral health conditions, provided they meet specific degree or experience requirements.

2026 updates and enforcement

Compliance reporting: Non-exempt hospitals must report to the Department of Health (DOH) on a semiannual basis the percentage of shifts where nursing assignments were out of compliance with the adopted plan.
The 80% threshold: If a hospital's nurse staffing assignments are compliant less than 80% of the time in a given month, they must file a non-compliance report within 7 days of the month's end.
Administrative penalties: If a hospital fails to submit a staffing plan, staffing committee charter, or a corrective plan of action by the relevant deadline, the appropriate department may take administrative action with penalties up to $10,000 per month of failure to comply.
Department of Labor and Industries (L&I) role: L&I is authorized to impose civil penalties of $50,000 per 30 days if a hospital fails to follow an approved corrective action plan.
Meal and rest break reporting: Hospitals must provide quarterly reports to L&I detailing the total number of required and missed meal and rest periods for employees.

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West Virginia

West Virginia’s nurse staffing requirements are governed by legislative rules enforced by the Office of Inspector General (OIG) and the Office of Health Facility Licensure and Certification (OHFLAC). These mandates prioritize continuous professional presence and strict protections against mandatory overtime.

General and specialty hospital staffing requirements

Hospital staffing in West Virginia focuses on ensuring immediate professional availability and qualified leadership across all departments.

Registered nurse shift minimums: Every hospital must provide an RN on duty and immediately available for bedside care on each shift, 24 hours a day, 7 days a week.
Specialized unit oversight: In extended care units operated by a hospital, an RN must be in charge of the unit during each tour of duty.
Competence and orientation: Nursing personnel shall not move between perinatal and non-perinatal units without training and orientation to these areas.
Critical access hospital variance: A CAH must have an RN, a physician, or a mid-level practitioner provide 24-hour on-site care, specifically when the facility is rendering inpatient services.

Nursing facility requirements

West Virginia enforces strict numerical ratios and supervision standards for nursing home licensure.

Minimum care hours: Staffing must not fall below an average of 2.25 hours of nursing personnel time per resident per day.
Minimum RN hours: In facilities with fewer than 60 beds, the director of nursing may serve to meet the minimum RN requirement.
Charge nurse: A nursing home shall designate a licensed nurse to serve as a charge nurse on each shift.
Nurse on call: If there is not a registered professional nurse on duty, there shall be a registered professional nurse on call.
Shift postings: Nursing homes must post the daily shift-based staffing levels and actual hours worked by RNs, LPNs, and aides in a prominent location.

2026 updates and enforcement

Mandatory overtime prohibition: The Nurse Overtime and Patient Safety Act prohibits hospitals from requiring a nurse to work overtime or taking disciplinary action for a refusal. Nurses working 12+ hours must be granted 8 consecutive hours of off-duty time.
Administrative sanctions: The Office of Inspector General, through the Office of Health Facility Licensure and Certification (OHFLAC), is authorized to revoke hospital or nursing home licenses for failure to comply with staffing standards.

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Wisconsin

Wisconsin’s nursing staff regulations are defined by a qualitative "adequate staffing" model for licensed facilities, while new legislative efforts aim to codify strict numerical ratios and enhanced nurse protections.

Psychiatric unit staffing

In psychiatric treatment areas, hospitals must maintain sufficient staffing to respond safely to aggressive behavior without the routine use of weapons, such as firearms or tasers.

Nurse Staffing and Patient Protection Act (proposed 2026)

Introduced on February 25, 2026, this legislation (LRB 3413/1) proposes the first statewide, enforceable numerical ratios for direct-care RNs.

If passed, hospitals must also establish nurse staffing committees with at least a simple majority of non-supervisory, direct-care registered nurses to develop annual staffing plans.

Under the proposal, an RN may refuse an assignment if, in their professional judgment, they are not prepared by education or experience to fulfill it without compromising patient safety or jeopardizing their license.

The legislation would also ban mandatory overtime for nurses, with limited exceptions.

Nursing homes and long-term care facilities

Staffing for long-term care is governed by minimum daily hours of service based on resident care needs.

Facilities must provide a minimum number of service hours per resident day by RNs, LPNs, or nurse aides, excluding hours from feeding assistants:

Intensive skilled nursing: 3.25 hours per day (minimum 0.65 hours by RN/LPN)
Skilled nursing care: 2.5 hours per day (minimum 0.5 hour by RN/LPN)
Intermediate or limited care: 2.0 hours per day (minimum 0.4 hours by RN/LPN)

The Department of Health Services (DHS) utilizes the EMResource Bed Tracking System to monitor statewide bed capacity and the corresponding staffing resources.

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Wyoming

Wyoming’s nurse staffing framework remains focused on a qualitative "sufficient staffing" model that emphasizes clinical competency and professional oversight rather than rigid state-mandated numerical ratios. While the state generally aligns with federal standards, it maintains specific professional presence requirements for acute and long-term care settings to ensure 24/7 readiness.

Hospital staffing requirements

Continuous readiness mandate: All licensed hospitals in Wyoming must be open and ready to provide medical services 24 hours a day, every day of the year.
24-hour RN coverage: Hospitals are required to have at least 1 licensed RN on duty at all times to provide or oversee nursing care.
Specialized unit staffing: Critical care and intensive care units must have at least 1 RN on duty and immediately available for bedside care at all times.
Critical access requirements: Licensed critical access hospitals must provide 24-hour nursing services and have an RN, nurse practitioner, or physician assistant on-site at all times when rendering inpatient services.

Nursing facility requirements

Care-hour minimums: Facilities must provide at least 2.25 hours of nursing personnel time per resident every 24 hours for skilled care residents and 1.50 hours for non-skilled residents.
Night shift standards: Facilities must maintain sufficient "awake and on duty" nursing personnel during the night tour to ensure resident safety and emergency readiness.
DON administrative limits: In facilities with a total occupancy exceeding 60 residents, the DON is prohibited from acting in a charge nurse capacity except in extraordinary circumstances.

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How can facilities maintain optimal nurse-to-patient ratios?

State regulations mandating specific nurse-to-patient ratios only partially solve staffing challenges. Many hospitals and other healthcare facilities struggle to hire and retain sufficient nursing professionals to meet the needs of their patients and residents.

In this context, PRN nursing jobs can be a valuable solution for immediate needs. Short-staffed hospitals and other facilities can turn to PRN nurses to maintain safe nurse-to-patient ratios. Nurses also benefit from this work model since PRN jobs offer clinicians flexibility and high hourly pay.

Nursa offers healthcare facilities and nurses a way to connect directly and reach the common goal of maintaining optimal staffing ratios. Within minutes, you can create an account to begin posting or picking up PRN nursing jobs.

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Find your state’s current RN-to-patient ratios [2026]

Key takeaways:

Table of Contents

Why are nurse-to-patient ratios important?

What are safe nurse staffing ratios?

Overview of nurse staffing ratios in the United States

What are the current federal guidelines (2026)?

Joint Commission National Performance Goal 12 (NPG 12)

What are the nurse-to-patient staffing ratios by state?

Quick reference: Which states have nursing ratios?

Alabama

Hospital staffing requirements

Nursing facility requirements

Alaska

Hospital staffing requirements

Nursing facility requirements

Arizona

Hospital staffing requirements

Recovery care center requirements

Nursing facility requirements

Arkansas

Nursing facility requirements

California

Hospital staffing requirements

California mandated RN-to-patient ratios (2026 update)

Acute psychiatric hospital (APH) update

2026 enforcement and penalties

Clinical judgment and acuity

Colorado

Hospital staffing requirements

Nursing facility requirements

2026 updates and enforcement

Connecticut

Hospital staffing requirements

Nursing facility requirements

Scheduled staffing increases (2026–2028)

Compliance and reporting

Delaware

Hospital staffing requirements

Nursing facility requirements

RN/LPN-to-resident ratios

2026 enforcement in residential health facilities

Florida

Hospital staffing requirements

Nursing facility requirements

Pediatric nursing facility standards

2026 updates and enforcement

Georgia

Hospital staffing requirements

Nursing facility and assisted living requirements

Hawaii

Hospital staffing requirements

Proposed legislation (SB 2763)

Nursing facility and subacute requirements

2026 updates and enforcement

Idaho

Hospital staffing requirements

Nursing facility requirements

2026 updates and enforcement

Illinois

Hospital staffing requirements

Nursing facility requirements

2026 updates and enforcement

Indiana

Hospital staffing requirements

Nursing facility requirements

2026 updates and enforcement

Iowa

Hospital staffing requirements

Nursing facility requirements

2026 updates and enforcement

Kansas

Hospital staffing requirements

Nursing facility requirements

Additional legislation regarding adult care homes

Crisis intervention center requirements

Kentucky

Nurse staffing requirements

2026 legislative updates

Louisiana