HospitalInspections.org

Based on document review and interview, the hospital failed to have adequate numbers of personnel to provide care to all patients as needed in accordance with their staffing guidelines for 2 (two) of 21 (twenty-one) shifts on the medical surgical unit 3GM.

Findings include:

1. 3GM Medical Surgical nurse staff matrix, effective 02/25/2021, indicated its use is to identify personnel required per patient day.


2. Review of the staffing schedules for 3GM completed for the following dates 02/26/2023, 02/27/2023, 02/28/2023, 03/01/2023, 03/02/2023, 03/03/2023, and 03/04/3023 indicated the unit lacked documentation of adequate numbers of patient care staff as follows:

A. According to H #1 staffing matrix, for a patient census of 23 on day shift (0700 hours - 1500 hours) : 5 RNs and 3 PCTs are required.
On 03/04/2023, patient census was 23 on day shift: 4 RNs and 3 PCTs were scheduled. The facility was lacking 1 RN.

B. According to H #1 staffing matrix, for a patient census of 23 on night shift (2300 hours - 0700 hours): 5 RNs and 3 PCTs are required.
On 03/04/2023, patient census was 23 on night shift: 4 RNs, 2 PCTs were scheduled. The facility was lacking 1 RN and 1 PCT.


3. On 03/29/2023 at approximately 1420 hours, A2 (Quality and Risk Director), provided this surveyor with the staffing documention for the unit 3GM. A2 indicated that the staffing for the time reviewed was correct.