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Based on observation, interview and document review the facility failed to provide organized nursing services with sufficient numbers of nursing staff to follow the nursing process of identifying and responding to patient needs through assessment, care planning and documentation resulting in increased risk of unmet care needs for all patients. Findings include:

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A 0392 - Adequate Nursing staff to meet patient needs

Based upon interview and document review, the facility failed to ensure they had adequate numbers of nursing staff to provide assessment and monitoring, nursing care and appropriate documentation of care per policy and standards of practice for 6 (#26, 27, 28, 29, 31, 34) of 11 patients reviewed for care resulting in the potential for missed care needs and less than optimal outcomes for all patients served by the facility. Findings include:

On 6/8/2022 at 1015 during the entrance conference, Chief Nursing Officer (CNO) Staff C gave a review of units in the facility occurred revealing approximately 18 open inpatient units and 3 closed units. General medical and telemetry units had 15 beds; however, only 12-13 of the beds were currently being filled due to decreased numbers in staff. The emergency department had 64 bays and several hallway areas designated as patient stations. ED length of stay could be from 6-7 days for patients who were admitted and waiting for a bed.

On 6/8/2022 at 1035, CNO Staff C was queried as to the facility's staffing ratios and use of travel/agency staff. She stated the ratios as follows: Medical/Surgical (med/surg) 1:6-7, Intensive Care Units (ICU) 1:1-2 dependent on acuity, Stepdown 1:3-4 dependent on acuity. She clarified that the med/surg units occasionally had a 7 patient assignment to "help decompress the ED." Patient Care Associates (PCA) were 1 per unit "on a good day." When queried as to staffing in the ED, she replied that it was "the same as the floor."

Staff FFF stated on 6/8/2022 at 1043 that the facility was averaging 10-20 resignations each month. "We are losing faster than we can hire." She also stated those nursing staff who were being hired were not experienced nurses, but new graduates who lacked experience and required some training.

During the initial tour of the facility, the ED was entered on 6/8/2022 at 1103. Seventy-six patients were currently present and the hallways were noted to have patient stations painted on the walls. ED Staff F stated on 6/8/2022 at 1105 that attempts were made to cohort patients and keep them out of the hallways but it was not always possible. He stated there were six modules plus a transitional care unit (TCU). The TCU was originally used for patient who were stable awaiting dicharge; however, it was currently being used as another module.

An intensive care unit was entered on 6/8/2022 at 1133 and immediate attention was drawn to Staff R who was on the phone, appeared upset, and was speaking loudly. She stated, "I'm getting really tired of this." Upon completion of the phone call, Staff R was queried as to what the call had been about to which she stated they were "receiving another patient" and there were "not enough staff." She further stated it was "a challenge to have enough staff to adequately take care of the patient population."

On 6/8/2022 at 1210, a nurse on the med/surg unit, Staff L, stated staffing ratios had increased to 1:7 and she did not think it was safe. She stated she has made complaints about staffing; however, "leadership doesn't listen at all." She cited night shift "rarely" had a rapid response team to assist with emergencies, "increasing issues" with respiratory therapy not having night staff available, and the IV (intravenous) team had shortened their hours and were focused only on PICC lines (peripherally inserted central catheter). "We voice concerns day in and day out and they never get addressed..."

A second nurse, Staff U, on the med/surg unit, was interviewed on 6/8/2022 at 1240. She stated over the "past couple of years" they decreased the staffing on the unit to 2 RNs for 12 patients. "Now, we have 13 patients and things can get really bad. Many times we do not have a tech (PCA) all day." She also stated there was increased frustration because of one nurse having to take 7 patients. "The problem is we generally will have one staff nurse and one agency nurse. The agency nurse is not necessarily familiar with the unit processes and will often refuse the 7 patient assignment stating it is not in their contract. This leaves the staff nurse to serve as the charge nurse, help the agency nurse, and take care of 7 patients." She stated the manager and the clinical coordinator jumped in to help staff whenever they could; however, they both covered three separate units and were often unavailable.

Staff U was then queried as to if they received help from any ancillary units or teams. She stated the IV team "changed their hours to just daytime with a focus on PICC lines. I've heard there is no rapid response team at night. Many times they (the rapid response team) gets pulled into staffing in the ED. ICU doctors have had to come and stay with patients because there is no rapid response team. We just need more people. It's too heavy. It's too much. We need better (staffing) ratios." Staff U went on to say that their "typical med/surg patient requires more than the average med/surg patient" because of increased psychiatric and behavioral issues in the area surrounding the facility. Suicidal patients were often placed on the unit with no patient sitters available. If a PCA was working, they would have to fill the role of sitter; however, if no PCA was working, the nurses were responsible for watching and safety checks. Staff U stated, "I'm very concerned for our hospital."

CNO Staff B, who had been employed at the facility for four months, was queried on 6/8/2022 at 1449 as to if any staff had brought any staffing complaints to her. She stated, "No one has contacted me directly." She stated the facility was using agency staff to help alleviate staffing shortages." Staff C, who was also present during this interview stated the facility had recently started hiring LPNs (licensed practical nurse) and were using them to supplement the PCA staffing. "It is a huge help to have them for the nursing staff."

The Nursing Office Manager Staff TT, who managed agency staff, IV team, observation, rapid response team, nursing supervisors, sitters, and telemetry, stated during an interview on 6/9/2022 at 1338 that the IV team had significantly decreased over the years. The hours for the team had been changed to 0700-1630 with a focus on PICC lines because those could be scheduled out based on information obtained from interdisciplinary rounding on the units. She was unaware of any delays in care. Discussion ensued regarding staffing of the rapid response team. Staff TT stated she had "two full-time people covering each shift" leaving one day that was not covered. "If there's no coverage, everyone is notified." When queried as to what unit nurses should do, for example, if they had a difficult IV start during the off hours of the IV team, Staff TT stated, "They need to utilize their resources. Rapid Response can help. Go to a person that is good with IVs. Call the nurse supervisor."

On 6/10/2022 at 1452, Staff UU reported there was only one rapid response team member that day. Typically, the rapid response team would cover 160-180 patient beds, all of the clinics, and the doctors offices on site.

Review of patient medical records began on 6/9/2022 and revealed the following:

On 6/9/2022 at 1010, the medical record for Patient #26 revealed he was a 62-year old male who was transferred to the facility on 4/26/2022 at 0815 from a nearby sister facility following a fall out of bed with subsequent confusion. The patient was on an anticoagulant (blood thinner). Upon arrival, Patient #26 was treated as a Code II Trauma (a triage response based on multiple criteria one of which includes hitting the head while taking anticoagulants). It was noted he was unable to ambulate or transfer without assistance. Past medical history included the following: deep vein thrombosis (DVT-blood clot), hypertension (HTN-high blood pressure), high cholesterol, kidney failure, epilepsy, Stage III colorectal cancer with colostomy, Lynch syndrome (a hereditary disorder that increases the risk of many types of cancer, particularly cancers in the colon), obstructive uropathy requiring bilateral nephrostomy tubes.

Patient #26 had had a recent admission (4/13/2022) to a nearby cancer hospital where he had been diagnosed with a urinary tract infection (UTI), and C.diff (clostridium difficile-inflammation of the colon caused by the bacteria clostridium difficile. Highly contagious with symptoms of copious liquid diarrhea; can cause severe damage to the colon and can be fatal). Once cleared by the trauma team, Patient #26 awaited bed placement between two different facilities, both of which were waiting for patients to be discharged.

Review of physician notes dated 4/26/2022 at 0915 revealed that staff were considering restraining the patient as the patient was becoming more agitated and had pulled out his nephrostomy tube. He was attempting to get out of bed, fell, and hit his head again.

Throughout his stay in the ED, vital signs were obtained at the following times:
4/26/2022 0814, 0815, 1121, 1145, 1200, 1345, and 1919
4/27/2022 0930, 1209, 1630, 2044

Other than a nursing note on 4/26/2022 at 1138 stating Patient #26 was placed into restraints and a nursing note dated 4/27/2022 at 0745 that he was found in restraints, no documentation was found for restraint checks every two hours as had been ordered.

Nursing notes for events that occurred at 0745 and were documented at 0922 on 4/27/2022 revealed Patient #26 "was found in the aisle of module 3 at shift chagne (sic). no report was given to oncoming shift. pt is not on ED tracking board. upon assessment pt is covered in feces, colostomy bag ripped off, in 2point soft restraints, confused with a forehead (laceration)." Further documentation revealed extensive time and resources were needed to clean the patient and the environment as the patient was still receiving treatment for C.diff. It was unknown how long the patient had been in that condition.

Physician notes dated 4/27/2022 at 1522 detailed the following: "Overnight, the patient was lost on the tracking shell, and found by ED staff and the Oncology team in the aisle covered in his own feces ...

On 6/9/2022 at 1212, ED Manager Staff E stated he had been made aware of Patient #26 as there had been a grievance filed by the family. He stated, "There was a capacity issue that day (high volume)."

Review of the incident report log from 1/1/2022-present revealed an entry detailing the finding of Patient #26 covered in feces and in restraint as well as the patient not being on the tracking board. No entries, however, were found for Patient #26 detailing his fall and subsequent laceration on the forehead. The Fall Log from 1/1/2022-present was also reviewed and no entries were found regarding Patient #26.

Review of the medical record for Patient #27 revealed she was a 73-year-old female with a past medical history of asthma, hypertension (high blood pressure), diabetes (high blood sugar), hyperlipidemia (high fat content in the blood), and GERD (gastroesophageal reflux disease-heartburn). She arrived in the ED on 2/20/2022 with shortness of breath and wheezing. ED physician notes indicated she was hypoxic (low oxygen levels) and tachypnic (fast breathing). While in the ED, she received three nebulized breathing treatments of albuterol and ipratropium (generic name for Atrovent). She also received solu-medrol (steroid), and magnesium sulfate (bronchodilator). Despite treatment, Patient #27 continued to do "poorly." She was placed on a BiPAP machine (bilateral positive airway pressure-a type of ventilator that is used to treat sleep apnea, COPD [chronic obstructive pulmonary disease], and other conditions in which the patient is still able to breathe on their own, but assistance is needed) and was admitted to MICU (medical intensive care unit) for acute hypoxemia respiratory failure secondary to COPD exacerbation.

Review of physician's orders revealed an order for continuous BiPAP on 2/20/2022 at 1037. This was changed on 2/22/2022 at 1835 to "routine, qhs (every night), and during naps."

Review of BiPAP documentation revealed multiple entries on 2/20/2022 and no documentation for the BiPAP on 2/21/2022. Patient #27 was moved from ICU to a step-down telemetry unit on 2/22/2022. BiPAP documentation there was on 2/22/2022 at 0501, 2/23/2022 at 2200, 2/24/2022 at 0200 and 2115, and 2/25/2022 at 0100.

On the evening of 2/22/2022 at approximately 2100, Patient #27 began having some shortness of breath. Nursing notes revealed an abnormal ABG (arterial blood gas) result had been called to the physician. The physician ordered a redraw of the ABG. The medical record does not indicate that the BiPAP was placed on the patient as ordered.

Review of the Incident Reporting Log from 1/1/2022-present revealed an entry for Patient #27 dated 2/23/2022 stating the respiratory therapist was called for the repeat ABG and the rapid response nurse came to do it instead. The entry also included information that the patient was requiring increasing interventions throughout the day and had an oxygen saturation of 98% on 25 liters (L) oxygen via nasal cannula (sic).

Review of the medical record for Patient #28 revealed she was a 75-year-old female who was brought to the ED on 2/18/2022 after sustaining a fall in her home. Past medical history included COPD (chronic obstructive pulmonary disease), atrial fibrillation (abnormal heartbeat involving the atria), and Grave's disease (an immune system disorder of the thyroid). She was admitted on 2/18/2022 to MICU with CHF (congestive heart failure) exacerbation needing oxygen and encephalopathy. She was later moved to a medical surgical unit on 2/22/2022.

Review of physician's orders revealed an order given on 2/20/2022 at 0700 for continuous BiPAP. This was later amended on 2/20/2022 at 1049 to "Routine, QHS/PRN (as needed)/NAP."

Review of nursing documentation revealed an incident note dated 2/28/2022 at 0517 in which the nurse practitioner documented she had attempted to put the BiPAP on the patient, but the patient was confused and kept pulling it off. There is no documentation present that the BiPAP had been placed as ordered by the physician. This correlated with an incident report dated 2/28/2022 regarding Patient #28 which stated the incident occurred on 2/27/2022 at 2100. Respiratory therapy had been called twice for placement of the BiPAP and to draw ABG's but failed to respond. The rapid response nurse arrived on the unit on 2/28/2022 at 0600 to draw the ABG's.

Physician progress notes dated 2/28/2022 at 0640 states, "Overall not better ... Alert and oriented, Mild distress ... Impression 1-acute/chronic hypercapnic/hypoxic (respiratory) failure CHF (exacerbation) ON O2 (oxygen) NEEDS BPAP (sic) ...Recommendations/Plan BPAP (sic) 16/8 AS ordered AT BEDSIDE, NEED TO USE, RT (respiratory therapy) TO PLACE qhs (every night) and prn (as needed) ..."

On 6/9/2022 at 1443, Staff L was queried as to why the nurses did not place the BiPAP back on either Patient #27 or #28 to which she stated it was facility policy that it be done by respiratory therapy. Nursing staff were permitted to remove the BiPAP; however, could not place the patient back on.

Review of facility policy #2RT219 titled "Non-Invasive Positive Pressure Ventilation (NIPPV)" effective 6/26/2020 states, "SCOPE: Licensed Respiratory Therapists (LRT)... Non-invasive ventilation (NIPPV) is performed per physician order on patients who are spontaneously breathing with a patent airway (non-intubated)... the patient may be placed in a non-ICU setting such as intermediate care as long as frequency of monitoring is congruent with available nursing and respiratory level of care is provided."

Respiratory Therapy Manager Staff ZZ stated on 6/10/2022 at 1016 in regard to Patients #27 and 28 mentioned above that it was "not that respiratory therapy was not here, they were just unavailable."

On 6/10/2022 at approximately 0845, a request was made for a list of patients from the ED satellite pharmacy who did not receive their ordered medications from 5/1/2022-6/10/2022 for reasons other than patient refusal. This resulted in a 7-page report of approximately 982 medications that had not been given. A majority entries were present for reasons such as not appropriate to be given, within ordered parameters, orders cancelled or changed, and duplicate entries. More concerning, however, were several entries with the comments "Equipment/Supplies Unavailable (42)", "Unknown if given by previous shift (8)", and "Not given (47)." Additionally, there were 4 entries with the comment, "Not done 27 patient 2 RN's (registered nurses) in module. (sic)" A random sampling revealed the following:

On 6/10/2022 at 1122, a targeted review of the medical record for Patient #29 revealed he was to the ED 5/6/2022 with tachycardia and shortness of breath and was boarded in the ED until 5/12/2022. Review of the MAR (medication administration record) summary revealed orders were given on 5/7/2022 for Gentamicin (antibiotic) 400 mg (milligrams) IVPB (intravenous piggyback) every 24 hours. The Gentamycin was not given on 5/8/2022. Additionally, there was an order given on 5/7/2022 for Daptomycin (antibiotic) 350 mg IVPB to be given daily. The Daptomycin was not given on 5/8/2022.

On 6/10/2022 at 1133, a targeted review of the medical record for Patient #31 revealed he was admitted to the ED on 5/2/2022 with shortness of breath and was boarded there until 5/13/2022. Review of the MAR summary revealed orders dated 5/8/2022 for Vanyomycin (antibiotic) 1500 mg IVPB, one time only. The MAR summary also shows the medication was given on 5/8/2022 at 1721. Review of laboratory blood testing for a Vancomycin trough revealed on 5/9/2022 at 0354 the value was <2.0. Physician Staff WW stated on 6/9/2022 at 1741 that the value of the Vancomycin trough being <2.0 indicated that the medication had not been given as documented on 5/8/2022 at 1721.

Review of the Incident Report Log from 1/1/2022-present revealed multiple entries for medications including missed medications, adverse reactions, and count errors.

On 6/10/2022 at 1149, a targeted review of the medical record for Patient #34 was conducted. Patient #34, a 64-year-old female, was sent by a nearby eye institute for evaluation of a left eye infection. She was diagnosed with "acute on subacute corneal ulcer with concern for near blindness." The discharge summary states, "The patient was admitted during this time and was placed on fortified vancomycin (antibiotic) and tobramycin (antibiotic) q2h (every two hours) alternating between the two every hour ...MICU (medical ICU) was consulted as patient need eyedrops every hour which unable to be done in the regular medical floor. (sic)" The discharge summary detailed Patient #34 was getting better, was transferred back to a general medical unit despite still having pain, and then developed severe pain on 3/2/2022 when the globe of the eye perforated. The eye was surgically removed on 3/2/2022.

During an interview on 6/9/2022 at 1741, Physician Staff WW stated physician orders not being carried out for medications or anything else was "routine in our department because the nurses are so overwhelmed." He further stated the ED was technically the largest inpatient unit in the hospital because of the average 30-50 boarded patients per day "and we also have to continue providing high level care to our ED patients... I have never seen anything like this before. There is a callous disregard over issues. Everyday care just isn't there. Yes, there is a national nursing shortage, but administration is hiding behind this. We are much worse than other area hospitals ...The other night (6/7/2022), TPA (tissue plasminogen activator - used in ischemic strokes to help restore blood flow to the brain) was delayed because there were only 4 nurses on the night shift, and no one was available to (monitor) the patient ..."

On 6/10/2022 at 1200, review of the staffing schedule for 6/7/2022 revealed 10 nurses were staffed that night. The lowest number of nurses on the schedules for the previous 3 weeks (5/15/2022 through 6/10/2022) was 9. It should be noted that the schedules did not reflect who may have called off work, who might have been a no show, nor who might have been pulled to work on another unit. It also did not reflect the type of nurse (ICU, med/surg, step-down, agency) who might have been assigned to work in the department.

While in the ED on 6/10/2022 at approximately 0930, Staff MM was queried as to if there were any services not provided to patients because of staffing issues. Staff MM stated there were "no resources here. No equipment working, staff is bare bones minimum ... It's sad. They have 2 RNs per module with 22 patients ... Half the staff leave at 11 a.m. 11 patients are ICU's ...7 are vented. Then the second nurse has to go to a code or trauma, and you're left all alone. There are no extra monitors, only a few mounted on the walls work, but they will be missing the pulse oximeter. Supplies are requestable through (Staff EEE) but he doesn't stock anything. The IV carts are bare. I have two IV start kits and its 10 a.m. No syringes, No cups! How do you take care of such a sick population with no Syringes and no cups? They're all on 'backorder'. No pillows, no sheets, no wedges for turning/propping patients. No one to start a line. No call-lights, but why would that matter? Who can come help? This is war-zone nursing! We can't do 1 hour neuro checks; we can't do admission assessments. Patient sit soiled all day. We can't do turns on our patients and there is no one to escalate issues to." Staff MM was then queried as to the lowest number of nurses she has seen or heard of on shift to which she stated there were "four total RNs last night (6/9/2022)."

ED Technician Staff PP was asked on 6/10/2022 at approximately 0942 as to if there were some services ordered for patients that couldn't be provided due to staffing issues. "Yes, there are 30 patients in a (module) sometimes with 2 nurses. She can't do labs and meds by herself. Sometimes I can help, but they get behind." When queried as to how many nurses were on shift, he replied, "6-8 on days, 3-6 on nights." He was then asked the lowest number of nurses on shift he had seen or heard of to which he replied, "2 RNs. I stayed over on nights that night to help."

On 6/10/2022 at approximately 0955, ED Technician Staff QQ stated there were "a lot" of services that were not provided to patients because of staffing. Typically, there were "6-10 nurses. 2 in (each module), and 2-3 in TCU, plus a triage and a charge nurse. 3 per pod is rare. We get random staff when CMS (Centers for Medicare and Medicaid Services) is here. We had 6 med/surg nurses yesterday (6/9/2022)." Staff QQ also recalled nurse staffing as low as 2 on a night shift.

Review of the Incident Report Log from 1/1/2022-present revealed a quite a large number of concerns over staffing issues. For example, one unit had 12 patients, 2 RNs, 0 PCAs. 7 patients were on telemetry, 8 patients were COVID+, and all were "bedridden" except for 1. On 5/10/2022, an ED patient eloped. He had been in an module with 2 RNs for 25 patients with 5 of those patients described as "ICU patients." Both nurses had been busy with other patients at the time the patient eloped. On 5/13/2022, the nursing unit had 13 patients with 2 RNs, and 1 PCA that had just completed orientation. Nine of the patients required neurological checks every 4 hours; 6 patients required assistance for repositioning every 2 hours; 3 patients had a language barrier that required translation services; 1 patient was suicidal and had a sitter; and several of the patients required "frequent bladder scans."

CEO Staff B was interviewed on 6/10/2022 at 0856. She stated she was well aware of the staffing issues and emphasized that it was currently a national crisis. Rounding had increased and administration and management were working with physicians to try to keep the levels of boarded patients in the ED "to a minimum." They were working with 2 agencies to provide staff. "We can't fill spots quickly enough. It is a known struggle here that is dealt with on a daily basis."

Staff B was queried as to why the ED did not help consolidate staff by closing a module or divert patients to another facility for a brief period of time. She stated they were under the control of DEMCA (Detroit East Medical Control Authority) who dictated they could not close any parts of the ED nor divert any patients because of staffing issues as they were the only Trauma I facility in the area. Additionally, she stated the closing of a module in the ED would only serve to back the ED up even further. "...We have an obligation to care for (these patients)."