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Based on interview and document review the facility failed to measure, analyze, track and trend identified quality indicators related nursing staffing effectiveness in the quality assessment and performance improvement program.

Findings include:

On 08/16/11 at 8:30 AM, the Chief Nursing Officer provided a requested list of the facility's Quality Indicators tracked for 2011. Staffing Effectiveness was listed as one of the quality indicators that was being analyzed, tracked and trended for 2011.

The Chief Nursing Officer acknowledged there have been numerous complaints from staff nurses over the past six months concerning inadequate nursing staffing levels on all the nursing units. The Chief Nursing officer reported a review of the staffing data was conducted and concluded the staff complaints regarding a shortage of nursing staff available to provide patient care were valid on all the nursing units at the facility. The Chief Nursing Officer acknowledged unit coordinators and CNAs (Certified Nursing Assistants) were being pulled off nursing units and shared with other units or sent home due to budget issues and the decision was not based on the facility's staffing policy and procedure that required staffing assignments to be based on patient census and acuity.

The Chief Nursing Officer reported being an active member of the facility's Quality Assurance Performance Improvement Committee and regularly attended meetings. The Chief Nursing officer acknowledged no data regarding staffing effectiveness had been discussed in any of the Quality Assurance Performance Improvement Committee meetings held for the year 2011 and no data regarding staffing effectiveness had been actively analyzed, tracked or trended by the committee for the year 2011.

On 08/16/11 a review of the facility's Quality Assurance Performance Improvement Committee meetings held on 04/12/11, 06/14/11 and 07/12/11 revealed no documented evidence staffing effectiveness had been discussed, analyzed, tracked or trended.

Based on observation, interview, record review and document review, the facility failed to provide adequate number of nursing personnel to provide nursing care to all patients as needed (Tag A0392). The facility failed to develop and keep current nursing care plans and complete admission nursing assessments on patients (Tag A0396).

The cumulative effect of these systemic practices resulted in the facility's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, record review, document review and staffing policy and procedure review, the facility failed to implement its staffing plan and patient acuity assessment policy and procedure in order to maintain adequate levels of nursing staff to provide nursing care to patients as needed.

Findings include:

The facility Nursing Administration Staffing Plan Policy and Procedure last revised 08/18/09 included the following:

I. Purpose: "To provide guidelines for maintaining adequate levels of nursing staff for each unit."

II. Policy: Unit specific competencies, licensure requirements, and methods of patient care delivery are utilized in coordinating the placement of personnel throughout the hospital.

A. "Staffing will be coordinated through the Staffing Office, with input from the Unit Director or Manager, Unit Clinical Supervisor, House Supervisor, and Chief Nursing officer."
B. "Unit staffing needs are based on census and patient activity classification requirements." (acuity tool)
C. "Staff may be added or deleted to a unit to meet patient care needs."

1. Staffing will be reviewed on an ongoing basis regarding the following:

a. Unit needs based on census and patient classification requirements.

b. Supplemental staff will be added as necessary, utilizing on-call personnel, regular staff, or agency personnel with prior approval from Manager or Chief Nursing Officer. Competency standards required by patient acuity must be considered when assigning supplemental staff.

2. Clinical Supervisor reviews the staffing rosters for adequate staffing and variances are adjusted.

The facility's Critical Care Nursing ICU (Intensive Care Unit)/IMC (Intermediate Care Unit)Assigning patients by Acuity Policy and Procedure effective 11/07 included the following:

I. Purpose: "To establish guidelines for assigning patients to Critical Care nursing staff based on the acuity of the patient."

II. Policy: "It is the policy to assess patients prior to the end of an assigned shift for the purpose of determining patient acuity. Patient acuity will be used to help determine assignments for the upcoming shift as well as identify any additional staffing needs."

III. Procedure:

1. "The primary R.N. (Registered Nurse) assigned to the patient will be responsible for assessing patient acuity. If the primary nurse is unavailable to assess the patient acuity, he/she may ask another R.N. to complete the assessment."

2. The acuity information will be translated into an acuity assessment tool.

3. The acuity values will be tracked on the assignment sheets.

4. The acuity tool will be tested annually for validity and reliability.

5. The Critical Care Clinical Supervisor/designee will use the acuity valuations for determining staff assignments for the shift.

6. If there are additional staffing needs based on overall unit acuity, the Unit Director/House Supervisor is to be notified for authorization to adjust shift staffing.

The facility's Patient Care Services Nursing Acuity Guidelines Policy and Procedure last revised 06/16/09 included the following;

I. Purpose: "A Patient Classification Tool will be utilized by (the facility) to help in determining inpatient acuity level of care."

II. Policy: "The Patient Classification Index PCI form is initiated upon admission and completed each shift by the patients nurse. The Charge Nurse will utilize the information on the PCI Summary Form assign patients based on the level of care required. The total score will be utilized by the charge nurse in making decisions about patient care assignments. Additional factors will also be considered such as the nurse's experience level and competency, technology used to care for patients, etc."

A review of the recent Patient Classification Tool Daily Acuity Report for the ICU/IMC and sixth floor nursing units revealed the total acuity score was frequently not filled in on any of the forms and the tool was not completed daily and on each shift on a consistent basis in order to be used in determining staffing levels.

The Patient Classification Acuity form for the sixth floor medical surgical unit was not completed on the following dates:

1. 07/02/11 - 7:00 PM to 7:00 AM.
2. 07/03/11 - 7:00 AM to 7:00 PM.
3. 07/04/11 - None
4. 07/05/11 - 7:00 PM to 7:00 AM.
5. 07/06/11 - 7:00 AM to 7:00 PM
6. 07/07/11 - 7:00 PM to 7:00 AM
7. 07/09/11 None
8. 07/11/11 None
9. 07/12/11 None
10. 07/13/11 None
11. 07/13/11 7:00 AM to 7:00 PM
12. 07/14/11 7:00 Am to 7:00 PM.
13. 07/15/11 7:00 AM to 7:00 PM
14. 07/17/11 7:00 AM to 7:00 PM.
15. 07/23/11 7:00 PM to 7:00 AM.
16. 07/25/11 None
17. 07/26/11 None
18. 08/01/11 7:00 PM to 7:00 AM
19. 08/02/11 None
20. 08/03/11 None
21. 08/07/11 7:00 PM to 7:00 AM.
22. 08/08/11 7:00 PM to 7:00 AM.
23. 08/09/11 None.
24. 08/10/11 7:00 AM to 7:00 PM.
25. 08/11/11 7:00 PM to 7:00 AM.
26. 08/15/11 None.

A review of the IMC Patient Classification Tool revealed the total acuity score was not filled in on the following dates:

1. 07/01/11 7:00 PM to 7:00 AM.
2. 07/06/11 7:00 AM to 7:00 PM.
3. 07/13/11 7:00 AM to 7:00 PM.
4. 07/23/11 7:00 PM to 7:00 AM.
5. 07/25/11 7:00 AM to 7:00 PM.

A review of the ICU Patient Classification Tool revealed the total acuity score was not filled in on the following dates:

1. 07/1/11 7:00 PM to 7:00 AM.
2. 07/06/11 7:00 AM to 7:00 PM.
3. 07/13/11 7:00 AM to 7:00 PM.
4. 07/23/11 7:00 PM to 7:00 AM.

On 08/17/11 at 8:30 AM, the Chief Nursing Officer acknowledged the facility had not been following the staffing plan and staffing policy and procedure that required staffing of the nursing units to be based on census and acuity level of patients. The Chief Nursing Officer acknowledged patient acuity was not being taken into consideration when nursing patient assignments were being made. The Chief Nursing Officer reported per the direction of the corporate office, Chief Executive Officer (CEO) and Chief Operating Officer (COO) staffing levels on nursing units must be based on staffing grids based on hours per patient day and not on the acuity of patients. The Chief Nursing Officer reported the corporate focus was on 100% productivity to control labor costs and staffing was to be based on budget and census.

The Chief Nursing Officer acknowledged there have been numerous complaints from staff nurses over the past six months concerning inadequate nursing staffing levels on all the nursing units. The Chief Nursing officer reported he conducted a review of the staffing data and concluded the staff complaints regarding a shortage of nursing staff to provide patient care were valid on all the nursing units at the facility. The Chief Nursing Officer acknowledged unit coordinators and Certified Nursing Assistants (CNA) were being pulled off nursing units and shared with other units or sent home due to budget issues and the decision was not based on patient census and acuity.

The Chief Nursing Officer reported the hours per patient day for the medical surgical units and ICU/IMC units at the facility were the lowest he had ever seen. The Chief Nursing Officer reported the turnover rate of nurses was very high at the facility. Approximately 50 registered nurses have resigned from the facility since 01/11. The facility currently had 31 vacant registered nursing positions not filled. The Chief Nursing Officer reported direction from the new Regional Staffing Committee required the facility to be at 100% productivity or no new nursing positions would be approved.

On 08/17/11 at 11:00 AM, the COO confirmed the facility had a high turn over of nursing staff. The COO reported approximately 50 registered nurses had left employment at the hospital since 01/11. The COO acknowledged many of the vacancies left for nursing positions had not been filled. The COO acknowledged staffing at the facility was based on staffing grids that were based on hours per patient day allotted. The COO acknowledged there were occasions staffing on units fell below the staffing grids due to inadequate replacement staff when nurses called in sick or registry nurses could not be acquired.

A Nursing Staff Turnover Chart for 2011 provided by the COO documented sixty (60) nursing positions were lost at the facility from 01/11 to 08/11. There were thirty two (32) current R.N. vacant positions.

Documented communication from a Nurse Director to the COO dated 08/15/11 at 10:00 AM included the following: "I will consider flexing a CNA daily from each floor on a day to day basis. According to the grid, we should have 3 on 6th floor today, but will just keep 2."

On 08/17/11 a review of the facility's Staffing Committee Meeting Minutes for 2011 included the following:

February 16, 2011 Staffing Committee Meeting: A result of a patient safety survey result included the following:

1. Working in crisis mode trying to do too much too quickly.
2. Hospital units do not coordinate well with each other.
3. Things fall between the cracks when transferring patients from one unit to the next.
4. Problems often occur when exchanges of information across hospital units.
5. Shift changes are problematic.
6. Concerns regarding the appropriate nurse to patient ratio for psychiatric patients in the emergency department. Staffing concerns regarding inadequate numbers of tech's and nurses at the bedside.

April 20, 2011 Staffing Committee Meeting:

1. Staff feel there is more work with less people.
2. Not seeing any more new hires. second floor short two hires.
3. Staff on the fifth floor would like more CNA staff.
4. During shift change there have been some patients stating they are not receiving any care from 6:00 AM to 7:00 AM.
5. There are two charge nurses on the ICU unit and IMC unit that are finding it hard to take patients while being in charge.

May 18,2001 Staffing Committee Meeting:

1. Some patients that are admitted on the ICU/IMC units are not patients that should be on the fifth floor.
2. The only way you can adequately staff ICU/IMC is having an acuity level.
"Based on what we have in place today, we don't have acuity; we have to staff based on how many hours per patient day we are getting, when you are working with budget Med/Surg and IMC/ICU have a different standard of care when it comes to hours per patient day."

On 08/23/11 at 9:40 AM, the Nursing Director for the ICU/IMC and emergency department reported being hired in June of 2011. The Nursing Director acknowledged there have been staffing issues regarding registered nurses and CNA's not always being available to fill in gaps in the staffing on the ICU and IMC units. The Director acknowledged receiving complaints from critical care nurses regarding the facility not taking into consideration patient acuity when making staffing assignments and at times ICU nurses receiving a 3 patient high acuity assignment.

The Nursing Director acknowledged unit coordinators did not work a full shift on the ICU and IMC unit and were shared between the units. The unit coordinators were not always available on the units to answer phone and transcribe physician orders which increased the workload of the nursing staff who were providing primary care to the patients on the unit. The Nursing Director acknowledged the unit coordinator had been pulled on occasion in the critical care area to fill in as a sitter for Legal 2000 patients and as a telemetry monitor. The Director reported being a member of the Hospital Performance Improvement Committee and acknowledged staffing issues at the facility had not been discussed at the last meeting and were not being actively tracked or trended as a quality indicator.

On 08/16/11 at 9:40 AM, an interview was conducted with an ICU Nurse. The ICU Nurse reported nursing assignments on the ICU unit and IMC unit were based on a staffing grid based on number of hours allotted per patient and not on patient acuity levels. The ICU Nurse reported ICU nurses have been receiving three high acuity patient assignments with no unit coordinator on the unit for half the shift to answer phones and assist in taking off and transcribing physician orders. The ICU Nurse reported with a three patient assignment, patient care suffers. The patients turning schedule, hygiene care, medication administration, suctioning, response to call lights, patient and family teaching and charting were not being completed when needed. The ICU Nurse reported repeated complaints to nurse managers and nursing directors regarding the staffing assignments being made without taking acuity into consideration have met with no resolution or change in the way staffing assignments are determined.

On 08/16/11 at 9:50 AM, an ICU Nurse reported the facility's staffing policy required staffing to be based on patient acuity levels and census was not being followed at the facility. The ICU Nurse reported frequently being given a high acuity three patient assignment in the ICU unit. The unit coordinator on the ICU unit was shared with the IMC unit leaving nursing staff to answer phones, take off orders and provide primary nursing care to high acuity patients. The ICU Nurse reported call lights were not answered in a timely manner and patient hygiene care, medication administration and charting were not completed when needed.

On 08/16/11 at 9:55 AM, while conducting chart reviews at the ICU and IMC unit nursing stations the phones at the nursing station continued to ring on several occasions with no staff available to answer the phone.

On 08/16/11 at 2:00 PM, a nurse on the sixth floor reported nurse managers and directors did not take acuity of patients into consideration when making staffing assignments. Staffing assignments were strictly based on a staffing grid based on census and hours allotted per patient. The nurse reported on 08/15/11, the unit was receiving high acuity post operative orthopedic patients and the census was going to increase to 36 patients which according to the staffing grid justified an additional CNA. The nurse implemented CUSS (Concerned Understand Patient Safety In Jeopardy). A request was made with the Nursing Manager and Director for an additional CNA due to the high acuity level of the patients and the need for assistance in providing patient care. The request was denied. The nurse reported the unit continued to receive post operative orthopedic patients and a second request for an additional CNA was made which was again denied. The nurse reported as a result of inadequate staffing call lights were not answered in a timely manner and medications were given late. Patient bed baths and linen changes were not completed. Three other nurses had to stay late to complete charting requirements. The nurse reported the request for an additional CNA was denied due to budget constraints and not patient needs.

On 08/18/11, at 9:00 AM, an ICU/IMC nurse, was interviewed telephonically. The ICU/IMC nurse indicated that IMC rooms did not have cardiac monitors in the rooms and the patient's cardiac status was monitored using telemetry even when patients were receiving cardioactive intavenous (IV) drips such as Dopamine, Amiodarone and Cardizem. The nurse stated the safety of these patients was left "in the hands of tele techs" (unlicensed assistive personnel). The nurse further stated that when she was the charge nurse, she must abide by the required grid, and had to triple patient assignments in the ICU. The nurse indicated the ICU nurses have been floated to the emergency department "with no training".

On 08/18/11 at 10:00 AM, an ICU nurse, was interviewed telephonically. The ICU nurse stated he was "very stressed" when floated to the emergency department because he had not been properly trained. The nurse also indicated he was assigned three ICU patients approximately one-third of the time, and he felt the staffing was "an accident waiting to happen".

On 08/16/11 at 9:35 AM, ICU Patient #1 reported he activated his call light because he had lost his cell phone. Patient #1 reported it took over ten minutes for a nurse to respond.

On 08/16/11 at 2:45 PM, Patient #2 reported on 08/15/11 at 9:00 PM she activated the call light to request pain medication for post operative pain following lumbar fusion surgery. Patient #2 reported a nurse showed up fifteen minutes later. The patient requested pain medication. Patient #2 reported the nurse left the room and did not return for over an hour. Patient #2 reported her call light was activated for over an hour with no response from the nurse. The patient then called her husband at home who in turn called the nursing station and demanded the patient be medicated for pain. Patient #2 reported by the time she was finally medicated for pain by the nurse the pain level was so severe and it took a long time for the pain to subside. Patient #2 reported the unit appeared understaffed and nurses on the unit were chronically late in answering the call light and seemed rushed.

On 08/16/11 at 2:50 PM, Patient #3 who reported on 08/15/11 the nurse entered the patients room to administer medication. The nurse administered two injections and insisted the patient take all six pills together and stated she was too busy to be in the patients room all day. Patient #3 reported she took all six pills together as requested and developed a stomach ache. Patient #3 reported this morning the nurse responded to the room with medication and she informed the nurse about developing a stomach ache after consuming all six pills together the previous day. The nurse encouraged the patient to take all six pills again together. Patient #3 reported the nursing staff appear rushed and did not respond to the call light when activated. The patient reported the call light was activated hours ago to get nursing staff to empty a bedside commode of urine but no one had responded. The patient reported activating the call light over the past two days and requesting a tooth brush and assistance with oral hygiene. The patient reported no nursing staff had responded yet to assist the patient in oral hygiene or provide the patient with a toothbrush.

A bedside commode with the lid opened was located next to the patients bed. The commode was observed to be partially full of urine. A strong odor of urine was coming from the commode.

Based on record review and document review the facility failed to ensure nursing staff developed and kept current a nursing care plan for 2 out of 11 sampled patients. (Patient #4 and #5)

Findings include:

The facility policy titled, "Nursing Plan of Care" dated 12/01/10 documented the following. Nursing information related to patient assessment, nursing care planned, nursing interventions and patient outcomes are recorded and permanently integrated into the patients medical record so that nursing information can be identified and retrieved. The nursing diagnosis and/or patient care needs are identified from the assessment and documented in the plan of care."

Patient # 4

Patient #4 was admitted to the facility on 08/14/11 with diagnoses that included introgenic bladder, urinary tract infection, MRSA (Methicillin Resistant Staph Aureus) bacteremia and fever.

On 08/16/11 at 11:30 AM, a review of the patients medical record revealed there was no documented evidence a nursing admission assessment and nursing care plan had been completed and was recorded in the medical record.

Patient #5

Patient #5 was admitted to the facility on 08/14/11 with diagnoses that included left sided abdominal pain, severe constipation, multiple sclerosis and history of TIA (Transient Ischemic Attack)

On 08/16/11 at 11:55 AM, a review of the patients medical record revealed there were no documented interventions or goals listed for problem areas on the nursing care plan that included fall risk, medication education, physical impaired ability, knowledge deficit and acute pain.

On 08/16/11 at 11:55 AM, the Nurse Educator reviewed the medical records for both patients and confirmed there was no nursing admission assessment or nursing care plan completed for Patient #4 and no nursing care interventions or goals completed for Patient #5. The Nurse Educator reported according to facility policy a nursing admission assessment was to be completed within twelve (12) hours of the patients admission and a nursing care plan was to be completed with twenty four (24) hours of the patients admission to the facility. The Nurse Educator reported each problem listed on the nursing care plan should have clear documented goals and interventions listed.

Based on interviews with the facility's Pharmacy Director, the Chief Nursing Officer, and a family member, and clinical record and document review, the facility did not ensure that Lovenox was administered to 1 of 11 sampled patients appropriately (Patient #7).

Findings include:

Patient #7 was admitted to the facility on 08/05/2011 with diagnoses that included failure to thrive. The physician ordered Vitamin K 10 milligrams intravenously, one time, fresh frozen plasma (FFP), two units, and Lovenox (enoxaparin sodium) 30 milligrams to be given subcutaneously. Lovenox was a low molecular weight heparin medication.

A physician's progress note, dated 08/07/2011, indicated Patient #7 had pancytopenia secondary to hepatosplenomegaly. On 08/11/2011, the physician noted in a progress note the patient had anemia and thrombocytopenia.

Laboratory results indicated Patient #7's platelet (reference range 186-353 10x9/L, meaning 186,000-353,000) results were as follows:

On 08/06/2011 at 4:00 AM, her platelet count was 67 (67,000 mm(3).
On 08/07/2011 at 4:20 AM, her platelet count was 45 (45,000 mm(3).
On 08/10/2011 at 4:41 AM, her platelet count was 33 (33,000 mm(3).

On 08/16/2011, the facility provided MICROMEDEX documentation for Lovenox. The document stated a precaution included "thrombocytopenia may occur; monitoring recommended; discontinue therapy if platelet count falls below 100,000/mm(3)".

On 08/16/2011 at 4:40 PM, the Chief Nursing Officer was interviewed. The MICROMEDIX information for Lovenox and Patient #7's laboratory results were reviewed with him. the Chief Nursing Officer stated he would expect a nurse would question an order for Lovenox for a patient in Patient #7's condition.

On 08/17/2011 at 2:00 PM, the Director of Pharmacy stated the screen the pharmacist had access to did not contain the diagnoses of pancytopenia. The Director of Pharmacy provided documentation Patient #7 received Lovenox 30 milligrams on 08/07/2011, 08/08/2011, 08/09/2011, and 08/10/2011. The Director of Pharmacy stated the laboratory results were available to the pharmacist, and the pharmacist response to the platelet results should have been to contact the physician and clarify the order for Lovenox.

On 08/31/2011 9:00 AM, the Director of Pharmacy was interviewed telephonically. The Director of Pharmacy stated that on 08/10/2011, a Heparin Induced Thrombocytopenia (HIT) Antibody test was ordered for Patient #7 to screen for thrombocytopenia that could be caused by the Lovenox. A physician's order, dated 08/10/2011, indicated at 12:30 PM, a HIT Ab (Heparin Induced Thrombocytopenia Antibody test) was ordered, and the Lovenox was discontinued and Arixtra was started. The Director of Pharmacy indicated that Arixtra was a medication used as an anticoagulant that works differently than Lovenox, and was an appropriate medication for Patient #7.