HospitalInspections.org

Based on document review and interview, the hospital failed to have adequate numbers of licensed Registered Nurses and other personnel to provide nursing care to all patients as needed in accordance with their staffing guidelines for 11 of 22 days on 3rd floor unit.

Findings include:

1. Review of the hospital staffing grid and guidelines for the F1, (told to this surveyor verbally) indicated the following for staffing of RN(s) (Registered Nurse) and PCT(s) (patient care technician) for census as noted:
A. Census 28: Day shift: 7 RN, 3 PCT. Night shift: 7 RN, 2 PCT.
B. Census 29: Day shift: 7 RN, 3 PCT. Night shift: 7 RN, 2 PCT.
C. Census 30: Day shift: 7 RN, 3 PCT. Night shift: 7 RN, 2 PCT.
D. Census 31: Day shift: 7 RN, 3 PCT. Night shift: 7 RN, 2 PCT.
E. Census 32: Day shift: 7 RN, 3 PCT. Night shift: 7 RN, 2 PCT.



2. Review of the One Week Staffing Schedules for the 3rd floor nursing unit completed for the following dates 07/10/2022, 07/12/2022, 07/13/2022, 07/24/2022, 07/25/2022, 07/27/2022, 07/30/2022, 09/04/2022, 09/05/2022, 09/06/2022 and 09/10/2022 indicated the unit lacked documentation of adequate numbers of nursing/patient care staff as follows:
A. On 07/10/2022: Census 32 patients: Night shift: 7 RN, 0 PCT scheduled.
B. On 07/12/2022: Census 32 patients: Night shift: 7 RN, 0 PCT scheduled.
C. On 07/13/2022: Census 30 patients: Night shift: 7 RN, 1 PCT scheduled.
D. On 07/24/2022: Census 28 patients: Night shift: 7 RN, 1 PCT scheduled.
E. On 07/25/2022: Census 28 patients: Night Shift: 8 RN, 0 PCT scheduled.
F. On 07/27/2022: Census 32 patients: Night shift: 7 RN, 1 PCT scheduled.
G. On 07/30/2022: Census 29 patients: Night shift: 7 RN, 1 PCT scheduled.
H. On 09/04/2022: Census 28 patients: Night shift: 7 RN, 0 PCT scheduled.
I. On 09/05/2022: Census 28 patients: Night shift: 7 RN, 1 PCT scheduled.
J. On 09/06/2022: Census 29 patients: Night shift: 7 RN, 1 PCT scheduled.
K. On 09/10/2022: Census 30 patients: Night shift: 7 RN, 1 PCT scheduled.

3. On 09/12/2022 between approximately 12:00 p.m. and 1:00 p.m., A3, Registered Nurse Director, indicated that the staffing matrix was not a policy/procedure but it was a guideline to follow for nurse/patient care. No staffing matrix was provided to this surveyor prior to exit. A3 verified staffing documentation indicated the nursing unit did not have adequate numbers of patient care staff on dates/times above in accordance with their guidelines.