HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure that surgical services were consistent with needs and resources, by not ensuring that nurse staffing was in accordance with policy. This has the potential to affect the average daily census of 2 patients that receive surgical services at the Hospital.

Findings include:

1. The Hospital's policy titled, "Perioperative Surgical Services, Operating Room: Staffing (including vacation/holiday/on call)," dated 9/1/2020, was reviewed on 5/3/2021, and included, "...6. The Post-Anesthesia Care unit will be staffed with two licensed nurses, of whom is a RN [Registered Nurse] competent in Phase 1 Post Anesthesia Nursing..."

2. The Surgical Staffing Schedule for 4/2021 was reviewed for RN's who were assigned to the PACU (Post-Anesthesia Care/Post-Operative). On 4/30/2021, there was only one RN (E #6) in PACU, with 2 other RN's assigned who were in orientation (E #7, E #9), that cannot function independently in that role. On 5/3/2021, there was only one RN assigned to the PACU area.

3. On 5/4/2021 at 11:25 AM, an interview was conducted with the Operating Room Supervisor (E #6). E #6 stated that there should be 2 RN's in the PACU for safety reasons. E #6 stated that nurses in orientation should not be counted as one of the nurses because they can't function in that role independently. E #6 stated that, in regards to 4/30/2021, there was only one PACU RN because there were 2 nurses that called off.