Southern California psychiatric hospitals are scrambling to hire nurses to meet new state nurse-to-patient ratios that hospital representatives warn could lead to staff layoffs, fewer beds and delayed care.
It’s “truly a life-or-death situation,” said Kirsten Barlow, vice president of policy at the California Hospital Association.
Starting June 1, the California Department of Public Health began requiring that psychiatric hospitals, which offer inpatient care to stabilize patients in mental health crises, staff a minimum of one licensed nurse for every six adult patients and one for every five patients under the age of 18.
Psychiatric hospitals found not to be in compliance with the new rules face steep penalties: $15,000 for the first day, and $30,000 for each day after.
The new emergency regulations were set to take effect in January, but CDPH delayed implementation to June after outcry from hospitals and other stakeholders. CDPH is expected to adopt permanent regulations by next summer. The department did not respond to emailed questions.
The California Hospital Association estimated that more than 1,500 nurses needed to be hired across the state’s 35 psychiatric hospitals at a cost of at least $275 million. Right before the new regulations took effect in June, hospitals had hired about 1,100, Barlow said.
The California Nurses Association campaigned for the requirements after a 2025 San Francisco Chronicle investigation revealed that low staffing levels at acute psychiatric hospitals had contributed to physical assault, sexual assault and even death. Specific nurse-to-patient ratios have been required in general hospital settings for more than two decades, but similar ratios were not imposed in acute psychiatric hospitals until last month.
These ratios were “a really big victory” for patients and health care workers alike, said Laura Dixon, a registered nurse at Sutter Center for Psychiatry in Sacramento. Before the ratios were enforced, there were times she felt that her safety or a patient’s safety was at risk, said Dixon, the chief nurse representative for the California Nurses Association at her hospital.
Without adequate monitoring, “anything can happen at any time,” she said. Patients can have seizures, get into fights or harm themselves, especially those under 18. “When people are at their most vulnerable, they should be able to expect the safe, appropriate staffing,” she said.
Unintended consequences
But some hospital executives say the new nursing ratios were enacted with little input from those who will have to make them work, and they worry that the new regulations will have unintended consequences, Barlow said.
“The state didn’t provide funding or rate increases for hospitals to hire all of these additional nurses, so, in many cases, to meet the new requirement, hospitals had to displace other workers,” Barlow said. These displacements could lead to longer wait times for patients, many of whom are at high risk of self-harm, she said.
In a March letter to the California Health and Human Services Agency, CHA predicted that more than 760 mental health workers would be laid off to make room in the budget to hire nurses.
Behavioral health specialists — workers who perform tasks such as distributing meals, helping patients with requests, and doing rounds — are “central to the safety of the environment,” said John Meier, CEO of Aurora Charter Oak Hospital in Covina. “They spend the most time with each patient each day.”
Some get waivers
The California Department of Public Health has approved rule waivers for more than 20 hospitals, according to the CHA. Among them is Aurora Charter Oak, which has until Aug. 1 to comply. Hospital administrators there are using those extra two months to continue recruiting, hiring and training the approximately 85 new nurses needed to adhere to the new ratios.
Meier said the new ratios mandate a “stark operational change.”
“This is a regulation that sort of forces an overhaul,” Meier said. “I don’t know if the system requires an overhaul.”
Barlow said the main concern with the waivers is the next six months. “The waivers will expire, and I think we are all very nervous about what will happen,” she said. It’s unclear whether the California Department of Public Health will grant extensions. “They need them to continue to work on hiring and avoid losing more beds,” she said.
Hiring nurses
Al Senella, CEO and president of the Tarzana Treatment Centers, said the facility had to hire about eight new nurses to meet the new staffing ratios, plus cover associated costs with advertising and recruiting for these roles. That’s “hundreds of thousands of dollars in additional payroll expenses that you don’t have budgeted,” he said.
Tarzana Treatment Centers is in compliance, but if any nurses go on leave or resign, the hospital would be in trouble, he worried. “Suddenly, boom, you’re out of compliance,” he said. He believes that with these new requirements, psychiatric hospitals are “set up to fail.”
Glendora Hospital hired 28 additional nurses, and College Hospital Cerritos hired 70. In a joint statement, the hospitals said that because “the market for nurses is very tight,” they were “proactive and got an early start in anticipation of the ratios.”
For Dixon, these new ratios have been a largely positive shift. Before they were enacted, it was difficult for nurses to take breaks, she said. If someone went on break, she said, other nurses would be responsible for that nurse’s patients. “At the end of the day, ratios are about giving every patient the attention and care that they need exactly when they need it.”
But Dixon acknowledged that the rollout of these new ratios has not been seamless. New hires are still going through training and orientation, which has “caused a lot of gaps” and miscommunications that can be dangerous, she acknowledged.
Staffing ratios apply to the night shift as well, Barlow said, which has been the “biggest problem” for many hospitals. Previously, nighttime checks were typically performed by other staff. It’s difficult to find nurses willing to do night shifts, even with increased pay, Barlow said.
Barlow said some hospitals have experienced resignations in the wake of these new rules. “We’re also hearing quite a bit of dissatisfaction among nurses themselves,” she said. Nurses are being asked to do tasks that now-displaced workers used to take care of. “That’s really not what a nurse went through extensive medical training to perform,” she said.
Nursing ratios are forcing hospitals to make “hard decisions,” Meier agreed. “Behavioral health care already operates with razor-thin margins, and adding an unfunded mandate to the tune of millions of dollars a year is something that really worries me,” he said. He fears for the “financial viability” of behavioral health care without some kind of funding or relief.
For some hospitals, it’s been business-as-usual since the new regulation took effect. A representative from the Motion Picture & Television Fund, which operates a 12-bed geriatric psychiatric hospital in Woodland Hills for members of the entertainment industry and their families, said it “is managing the changes without any bed reductions or service changes.”
Similarly, a spokesperson from the UCLA Resnick Neuropsychiatric Hospital said the facility “has for years followed more stringent ratios that previously applied only to general acute care hospitals.”
‘One-size-fits-all’ requirements
Another concern, Senella said, is that the new “one-size-fits-all” requirements ignore the needs of individual hospitals.
Tarzana Treatment Centers is a 60-bed facility that specializes in treating substance abuse disorders. “We’re doing largely medical withdrawal management,” Senella said.
Unlike other hospitals that do involuntary holds, patients at the Tarzana Treatment Centers are there voluntarily, which is a “completely different” kind of care from what’s provided in general acute hospitals, where patients are at a higher risk of harming themselves or others, he said. “The process didn’t take us into account.”
Bed closures
So far, Senella said he’s managed to avoid layoffs and bed closures, but the threat looms. According to the California Hospital Association, psychiatric hospitals statewide have closed at least 67 beds even though nursing staffs have been increased.
So far, Aurora Charter Oak Hospital has not had to close any of its 134 beds yet either. Because the financial penalties are so steep, “being out of compliance is not an option,” said CEO Meier, but bed closures are not off the table. The hospital, which operates 30 beds for patients younger than 18, has been hit especially hard by the more stringent requirements for adolescent patients, he said. It’s one of only a handful of hospitals in the state that offer services for minors.
When beds close, the demand for service doesn’t disappear, Meier pointed out. Patients receive delayed treatment and often spend more time in emergency waiting rooms. “Those patients have to go somewhere, and it creates a big increased responsibility on law enforcement,” he said. The closure of inpatient beds “forces more of their immediate intervention.”
Dixon said concerns about bed closures are overblown, and that if hospitals had to close beds, it would be temporary. “It’s not about closing access,” she said. “It’s about making sure the beds that exist are actually safe for the patients to be in.”
If beds do close, this can create treatment delays, Barlow said. In the Central Valley, she said she’d heard from hospitals where patients were “waiting days to be admitted.” Under federal law, Barlow said emergency departments and psychiatric hospitals cannot turn anyone away — they must at least screen anyone who shows up.
Senella also complained that it’s been difficult to find nurses with experience in mental health and substance abuse treatment, which means new hires require significant training.
Meier agreed that more training is needed, saying hospitals are hiring many recent nursing school grads. “Which is great,” he said. “But someone who is fresh out of nursing school, they may require more training than someone who has worked in a psych facility for 10 years.
“We are not going to hastily accelerate our training and orientation process simply to meet the ratios,” he added.
The Tarzana facility also has relied on on-call and traveling nurses, which Senella said they pay a “premium” to have fill in. This is all compounded by the nationwide nursing shortage, he said. “That is a major impediment to compliance,” Senella said. “It’s been a factor for years, it’s worse now than ever, and no recognition of that at all in this process.”