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 5 of 24 shifts on the medical surgical unit X3.

Findings include:

1. F1 Nurse Staffing Plan: of A2/3N-CV Surg indicated the purpose of the academic health center nurse staffing plan is to ensure an adequate number of team members are available to meet patient needs on this unit.

2. Hospital staffing guidelines indicated for RN(s) (Registered Nurse) and PCT(s) (Patient Care Technician) Nurse to patient ratio RN assignments can be up to 6 (six) patients per shift. PCT to patient ratio is 10 (ten) to 12 (twelve) patients per 1 PCT every shift.


3. Review of the staffing Schedules for the A3N completed for the following dates 02/28/2023, 03/01/2023, 03/02/2023, 03/03/2023, 03/04/2023, 03/05/2023, 03/06/2023, 03/07/2023, 03/08/2023, 03/09/2023, 03/10/2023 and 03/11/2023, indicated the unit lacked documentation of adequate numbers of patient care staff as follows:
A. On 02/28/2023: Census 24 patients: Night shift: 5 RN, 1 PCT 1900 hours - 2300 hours lacked 1 PCT.
B. On 03/01/2023: Census 24 patients: Night shift: 5 RN, 1 PCT 1900 hours - 2300 hours lacked 1 PCT.
C. On 03/02/2023: Census 24 patients: Night shift: 5 RN, 1 PCT, lacked 1 PCT.
D. On 03/06/2023: Census 24 patients: Night shift: 5 RN, 1 PCT, lacked 1 PCT.

4. On 03/20/2023 between approximately 1400 hours and 1500 hours, A3, Clinical Nurse Manager, provided this surveyor with the staffing documention for the unit X3 indicated that the staffing for the time reviewed was correct.

5. On 03/30/3023 at approximately 1445 hours A2 (Director of Operations) verified staffing ratios to be Nurse to patient ratio RN assignments can be up to 6 (six) patients per shift. PCT to patient ratio is 10 (ten) to 12 (twelve) patients per 1 (one) PCT every shift. Indicated on the staffing documentation the unit X3 did not have adequate numbers of patient care staff on dates/times above in accordance with their guidelines.

Based on document review and interview, the facility failed to ensure that oral intake meal percentage was recorded for 9 (P1, P2, P3, P5, P6, P7, P8, P9 and P10) out of 10 patients medical record reviewed.

Findings include:

1. Policy titled "Documentation Standards", PolicyStat ID: 10127210, last revised 07/27/2021, indicated purpose provides standards for clinical documentation. 3. Registered Nurses are accountable for the patient assessment and documentation process.

2. Review of patient medical record indicated the following:
a. Review of P1 medical records indicated documentation of P1 having only 1 (one) documented oral intake during his/her stay 03/04/2023 through 03/05/2023. Lacked documentation of 2 (two) recorded oral intake.
b. Review of P2 medical records indicated documentation of P2 having only 1 (one) documented oral intake during his/her stay 03/04/2023 through 03/06/2023. Lacked documentation of 8 (eight) recorded oral intake.
c. Review of P3 medical records indicated documentation of P3 having only 7 (seven) documented oral intake during his/her stay 03/01/2023 through 03/11/2023. Lacked documentation of 26 (twenty-six) recorded oral intake.
d. Review of P5 medical records indicated documentation of P5 having only 1 (one) documented oral intake during his/her stay 03/04/2023 through 03/05/2023. Lacked documentation of 2 (two) recorded oral intake.
e. Review of P6 medical records indicated documentation of P6 having only 8 (eight) documented oral intake during his/her stay 03/03/2023 through 03/20/2023. Lacked documentation of 46 (fourty-six) recorded oral intake.
f. Review of P7 medical records indicated documentation of P7 having only 1 (one) documented oral intake during his/her stay 03/01/2023 through 03/04/2023. Lacked documentation of 11 (eleven) recorded oral intake.
g. Review of P8 medical records indicated documentation of P8 having only 7 (seven) documented oral intake during his/her stay 03/05/2023 through 03/15/2023. Lacked documentation of 26 (twenty-six) recorded oral intake.
h. Review of P9 medical records indicated documentation of P9 having only 9 (nine) documented oral intake during his/her stay 03/13/2023 through 03/20/2023. Lacked documentation of 21(twenty-one) recorded oral intake.
i. Review of P10 medical records indicated documentation of P10 having only 8 (eight) documented oral intake during his/her stay 03/10/2023 through 03/20/2023. Lacked documentation of 26 (twenty-six) recorded oral intake.


3. Interview on 03/20/2023, at approximately 1405 hours with A2 (Director of Operations) confirmed that "we are supposed to chart intakes on all patients".

4. On 03/20/2023, beginning at approximately 1430, A1 (Clinical Nurse Specialist) indicated that she/he was not able to obtain any more oral meal intake recorded for P1, P2, P3, P5, P6, P7, P8, P9 and P10 from MR reviewed.