Proposed Bill Would Set Mandatory Nurse-to-Patient Ratios in Puerto Rico

Puerto Rico’s hospital industry is pushing back on a proposal to set mandatory nurse-to-patient ratios, warning that the change could cost facilities up to $100 million a year, The Weekly Journal reported on October 13, 2026.

Nurses and Puerto Rico’s Health Secretary say current patient loads are dangerous. Nurse leaders describe assignments that no one could handle safely, and they argue that patients pay the price when hospitals run thin.

The fight boils down to a question nurses everywhere will recognize: who pays for safe staffing, and what happens to patients while that question goes unanswered?

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Senate Bill 687 would set hard caps on how many patients a nurse can be assigned, based on the unit and the level of care required. The headline numbers for professional (RN) nurses (patients:nurse):

• Intensive care: 2:1
• Operating room and labor-and-delivery: 1:1
• Pediatric ICU and NICU: 2:1
• Emergency triage: 1:1
• Medical, surgical, and ER observation floors: 6:1
• Nursery, OB/GYN general, and primary care clinics: 6:1
• Oncology and rehab (skilled nursing): 5:1
• Pediatrics (general ward): 8:1
• Practical nurses (LPN equivalents): capped at 8:1 on most ward units. Hospitals could temporarily exceed the limits only during a declared emergency, and the bill explicitly says foreseeable staffing shortfalls don’t qualify as justification.

The bill also mandates a 40-hour workweek with no more than 12-hour days, five days a week; it originally required double pay for overtime hours (non-waivable), though that provision was contested during Senate deliberation. It gives the Department of Health authority to fine hospitals up to $10,000 per incident of non-compliance.

Implementation would be fast. Under the as-filed version, the law takes effect 60 days after it’s signed, and hospitals must be in full compliance with the staffing ratios within 180 days. That compressed window is part of what’s driving the industry’s cost warnings. Hospitals say they can’t hire and train thousands of nurses that quickly.

SB 687 was filed in August 2025 by Senate Health Commission President Juan Oscar Morales Rodríguez at the request of the College of Nursing Professionals of Puerto Rico (CPEPR). Morales told reporters at the time that nurses assigned 30 patients can efficiently care for only about 12, and he framed the bill as addressing workload rather than pay. “The excessive workload they’ve faced year after year” is nurses’ bigger concern, he said during the Senate debate, not necessarily salary.

The path through the Senate was contested. At the first public hearing in September 2025, the Department of Health opposed the measure, along with other health-sector organizations, according to Metro Puerto Rico. The opposition surprised CPEPR president Marisel Delgado Ramos, who said Health Secretary Víctor M. Ramos Otero had privately expressed support for the measure at a May meeting. “I have no words,” she told Metro at the time.

The bill also drew pushback from within the nursing community. CPEPR itself recommended cutting the provision that would have required hospitals to pay double for overtime hours, with Delgado Ramos telling Metro that removing it would improve the bill’s chances of passage. “If we take that part out, we’re in good shape to prevail,” she said.

On April 23, 2026, the Senate approved SB 687 with amendments, with support across all delegations. It now sits with the House of Representatives.

Francisco Rodríguez Castro, president and CEO of Birling Capital, estimated the new staffing ratios would cost Puerto Rico hospitals about $64 million a year or roughly 2.9% of their estimated revenue. He warned the proposal “would impose new financial burdens on an already vulnerable industry characterized by massive losses, high debt levels, and the risk of hospital closures.”

The Puerto Rico Hospital Association’s own study came in higher. Executive President Jaime Plá Cortés put the figure at approximately $100 million a year. “If it is going to cost $100 million, hospitals will find it very difficult to implement,” Plá said.  Absorbing the cost would be extremely difficult without a dedicated funding source, especially on an island with limited funding and resources. Both projections come from industry-aligned sources: Birling Capital does advisory work in the health sector, and the Hospital Association commissioned its own study. CPEPR has not released a public counter-estimate. 

There’s also the question of whether there are enough nurses to hire. Plá noted that while recent data show more than 40,000 registered nurses in Puerto Rico, some of them live abroad and others work in health-related jobs outside hospitals. The BLS does not report on the specific number of licensed RNs in Puerto Rico. 

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Nurses and the Health Secretary Push Back

Nurse advocates say the cost argument misses the point. “This isn’t just about improving working conditions for nurses; it’s about improving the service and care provided to patients, because at the end of the day, the patient is the one who suffers,” said Juan Carlos del Valle, a nurse who organized staffing protests in June 2025. 

Health Secretary Víctor M. Ramos Otero, whose department opposed the bill at last year’s hearing, acknowledged the problem. He said that assigning one nurse to 15 to 20 patients makes it impossible to deliver quality care, and that “simply carrying an onerous patient load does not equate to providing the best possible service.”

Nurse leaders have argued that unsafe conditions are part of what drives nurses out of Puerto Rico’s hospitals along with low pay. At the 2025 hearing, CPEPR legal adviser Agnes Martínez Colón attributed the shortage to “deplorable” hospital conditions and said passing the bill would help solve staffing problems. It could also potentially keep nurses on the island. 

This isn’t Puerto Rico’s first attempt.

A 2023 proposal, Senate Bill 1239, would have capped critical care assignments at two patients per nurse and med-surg units at eight. That bill drew on a 2022 Estudios Técnicos study, commissioned to document nursing workload in Puerto Rico, which found nurses routinely working five to six hours of overtime per shift and reported patient-assignment numbers that nurse leaders described as unsafe. The same study is cited in SB 687’s statement of motives.

Puerto Rico’s debate follows the same pattern seen in California, Oregon, and other states that have taken up standardized staffing-ratio laws. Hospitals point to thin margins and workforce shortages. Nurses point to patient safety and burnout. Both sides cite the same staffing shortage as evidence for their position.

Several things are worth watching as SB 687 moves through the House:

• The bill isn’t law yet. The Senate-passed version still needs House approval and the governor’s signature. Under the as-filed version, hospitals would have 180 days to comply with the ratios once the law takes effect.
• Funding is the key issue. The hospital association’s emphasis on a “dedicated funding source” suggests amendments or public funding requests could shape whatever version moves forward.
• Workload, not just pay, is the core issue. CPEPR itself asked lawmakers to drop the double-pay overtime provision, signaling that manageable assignments are the central demand. 

• Retention is the open question. Nursing representatives argue safer assignments could slow the outbound migration of Puerto Rican nurses to the mainland, though whether ratios would prompt returns from stateside nurses remains unproven.

🤔 Nurses, what’s the highest patient load you’ve ever been assigned, and should hospitals’ finances factor into safe staffing laws? Share your thoughts in the comments.