HospitalInspections.org

Based on document review and interview the hospital failed to ensure that adequate numbers of licensed nurses were available to provide nursing care to all patients as needed. In addition the hospital failed to have a Registered Nurse (RN) on call to respond to emergencies. On 02/11/12 beginning at 7:30 pm there were not enough nurses on duty in the hospital to admit 4 patients from the Emergency Room (ER) to the Medical/Surgical (med/surg) floor. This nursing shortage also compromised the ability of the ER to see new patients coming in for care and manage patients needing care. This failure to have enough nurses available to take care of all patients in the hospital resulted in the hospital going on diversion status and an Intensive Care Unit (ICU) patient being sent to another hospital for the convenience of the hospital and had the likelihood to prevent the hospital from providing services to patients in the community seeking medical care. The findings are:

A. The hospital nursing schedule for the month of February 2012 indicates that on 02/11/12 the 1800-0600 nursing shift had only two RN's to take care of 6 patients on the med/surg floor and 2 patients in the ICU. By 7:30 pm the hospital Daily Unit Census documents that there were 4 patients waiting to be admitted to the med/surg floor. One RN was taking care of the 6 patients already on the med/surg floor and the other RN was taking care of the 2 patients in ICU.

B. On 02/21/12 at 11:40 am, the Chief Financial Officer, who was acting as the on-call administrator (OCA), stated that at 7:30 pm she was informed by the RN on the med/surg floor that she could not admit the 4 patients waiting in the ER because of a shortage of nursing staff. The OCA described the following sequence of events that led to the hospital going on diversion status:

1. The OCA, who was in the hospital at the time, then stated that she called all nurses working for the hospital and found that none would or could come in to help with care.
2. The OCA then met with the ER Medical Director and consulted with the CEO by phone. The decision was made to transfer all 4 waiting patients to other hospitals in the area.
3. A medical technician was instructed to advise Emergency Medical Services (EMS) providers that the hospital was on divert status.
4. The local EMS was contacted to request that 4 ambulances be provided to transfer the patients to hospitals in Clovis, NM and Lubbock, TX. The EMS supervisor came to the hospital and told the OCA that they would not be willing to have all of their ambulances out of the county and that they would not transport any of the patients.
5. The decision was then made by the management team to transfer one patient from the ICU to med/surg and transport the other ICU patient by helicopter to a hospital in Lubbock, TX.
6. Once the ICU was freed up the second RN was able to go the med/surg floor and assist with the admission of the 4 patients waiting in the ER for admission to the med/surg floor.
7. The hospital remained in diversion status in the state EMS computer system until 6:00 pm on 02/12/12.
8. In response to a question by the surveyor, the OCA confirmed that she did not attempt to contact any of the EMS services in surrounding counties and towns to provide assistance.

C. During a meeting with the hospital management group consisting of the CEO, CNO, CFO and Chief of Medical Staff on 02/21/12 at 11:45 am, the group was asked by the surveyor to explain their justification for transporting a patient who was in the ICU to another hospital at 2:00 am on 02/12/12. The Chief of Medical Staff stated, "Well, she was stable, but that wasn't the reason she was sent out. She was sent out to close the ICU and free up a nurse." The group was then asked to explain if they had any justification for transferring the patient for any reason except for the convenience of the hospital. The Chief of Medical Staff stated, "This patient was going to be sent to the same hospital on 02/13/12 for a cardiac procedure." The surveyor asked if the patient needed to be sent on 02/12/12 at 2:00 am. The Chief of Medical Staff stated," No, she did not need to go out sooner than Monday, 02/13/12, but either way she was going to be sent to the other hospital."

D. On 02/20/12 at 4:15 pm the CEO was asked why the hospital was unable to provide nursing staff to provide care to patients. He stated that during the past year the average census of the hospital had been 4 and that as the hospital cut back nursing hours to adjust to the census, nurses began to find other employment to replace the shrinking hours worked at RGH. He admitted that they did not have enough nursing staff to deal with the sudden increase in patients needing care on 02/11/12. He was then asked why the hospital did not have a mandatory on-call program to ensure that adequate nursing staff was available for situations like 02/11/12. He stated that he and the CNO had talked to the nursing staff and that the nursing staff did not want to have mandatory on-call so the system had been left for nurses to volunteer for on-call status for which they were paid a higher hourly rate while they were in on-call status. He was unable to explain why the hospital had no on-call staff scheduled for a weekend while the CNO was allowed to be off call.

E. On 02/21/12 at 8:17 am, an interview was conducted with the CNO. When asked if she was aware that the hospital had no nursing supervisor on call for nursing emergences on 02/11/12, she stated "Yes." She further stated that she was off, the hospital doesn't have mandatory on-call and they had been short of nursing staff, "some this month."