HospitalInspections.org

Based on interview and record review the facility failed to ensure the patient's right to a safe and secure environment when the facility failed to ensure there was a sufficient number of Registered Nurses (RNs) on duty to provide care at all times and failed to schedule Registered Nurses according to the facility's approved staffing plan.
This deficient practice was found on four (4) of nine (9) of the weekend staffing plans reviewed. (7/11, 7/12, 7/25, 7/26, 8/8, 8/9, 8/22, and 8/23)

This deficient practice had the likelihood to cause harm to all presenting as new admissions and in-patients in the hospital.

Findings included:

Review of the facility provided nurse staffing plan (undated),currently in use by the hospital reflected, included unit nurse staffing levels for the hospital ' s various shifts and units. The nursing units were identified as follows:

Adult Psychiatric Services (APS) East patio included nursing 3 units: 1, 2, 6
APS West patio included 5 nursing units: B, C, D, E, F
Specialty Services (SS) included 6 nursing units: A/B, C/D, E/F
Children & Adolescents Psychiatry Services (CAPS) included 3 nursing units: A, B, C

The staffing levels listed in the plan for the day shift were as follows, the plan did not differentiate between week days and week ends:

7am - 3pm Day Shift:
· Each APS unit - 1 RN
· Each of SS units A/B and E/F - 2 RNs
· SS unit C/D - 1 RN
· CAPS unit A - 2 RNs
· CAPS units A, B and C
· Shift totals = 16 RNs

Review of the Day Shift RN Staffing Plan dated 7/1/2015 - 7/31/2015 reflected:

On 7/4/15 (15) RNs were scheduled to work and
on 7/5/15 (15) RNs were scheduled to work.
On 7/11/15 (10) RNs were scheduled to work and
on 7/12/15 (10) RNs were scheduled to work.
On 7/25/15 (8) RNs were scheduled to work and
on 7/26/15 (8) RNs were scheduled to work.

Review of the Day Shift Nursing Daily Staffing Worksheet (the number of staff that actually worked) dated 7/25/15, reflected:
· APS West Unit B had a census of 22 patients with one LVN passing medications on the unit and a shared RN from Unit 6. The RN was responsible for 43 patients. The two units were physically separated by a large distance of at least 50 to 75 yards.
· APS West Unit C had a census of 10 patients with one RN passing medications on the unit and no LVN.
· APS West Unit D had a census of 22 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and one RN.
· APS (Adult Psychiatric Services) West Unit E had a census of 22 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS West Unit F had a census of 22 patients with one LVN passing medications on the unit and a shared RN
· Unit E & F shared one RN for both units for a total of 44 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.

Review of the Nursing Daily Staffing Worksheet Day shift dated 7/25/15, reflected:
· APS East Ward 1 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 2 had a census of 18 patients with one LVN passing medications on the unit and a shared RN.
· APS East Wards 1 & 2 shared one RN for both units for a total of 39 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS East Ward 6 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 6 & APS Unit B shared one RN for both units for a total of 43 patients. The two units were physically separated by a large distance of at least 50 to 75 yards.

Review of the Nursing Daily Staffing Worksheet Day shift dated 7/26/15 reflected:
· APS West Unit C had a census of 10 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS West Unit D had a census of 22 patients with one LVN passing medications on the unit and a shared RN.
· Unit C & D shared one RN for both units for a total of 32 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS West Unit E had a census of 22 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS West Unit F had a census of 22 patients with one LVN passing medications on the unit and a shared RN.
· Units E & F shared one RN for both units for a total of 44 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS West Unit B had a census of 22 patients with one LVN passing medications on the unit and a shared RN.

Review of the Nursing Daily Staffing Worksheet Day shift dated 7/26/15 reflected:
· APS East Ward 1 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 2 had a census of 18 patients with one LVN passing medications on the unit and a shared RN.
· APS East Wards 1 & 2 shared one RN for both units for a total of 39 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS East Ward 6 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 6 & APS West Unit B shared one RN for both units for a total of 43 patients. The two units were physically separated by a large distance of at least 50 to 75 yards.

Review of the the Day Shift RN Staffing Plan dated 8/1/2015 to 8/31/2015 reflected:

On 8/8/15 (8) RNs were scheduled to work and on 8/2/15 (8) RNs were scheduled to work.
On 8/22/15 (11) RNs were scheduled to work and on 8/23/15 (10) RNs were scheduled to work.

During an interview on the nursing unit on 8/6/15 at 9:45 a.m. Nurse #D stated, "It is typically on the weekends when we are short staffed. Two weeks ago I was asked to cover two (2) units," "I was lucky I was able to manage."

During an interview with Nurse #A, RN, on 8/6/15 at 11:00 a.m. in the conference room, Nurse # A stated, "We've had major staffing problems lately...Since December (2014), there's only been about two weeks when we had a full complement of nurses...We regularly have to rely on the House Supervisor to send us staff. There have been days when I've been the only RN for 20 patients - and the acuity is high here...There have been times when I've been the only nurse period, or times when I'm here and one LVN. A lot of times it's staffed to where I'm the only nurse...And if staffing's really bad, I frequently can't get a hold of the House Supervisor, either because she's calling people or they're calling her, or it's just so busy...There have been times when we haven't had enough staff to restrain a patient ...We've had some restraints we couldn't do because we had no one to assist us and there were only maybe two of us and we just couldn't do it. Then I had one staff member tell me he wasn't going to restrain anyone when we were the only two here ...The staffing's gotten worse over the last 6 months, but it's been particularly bad lately."

During an interview on the nursing unit on 8/6/15 at 11:15 a.m. Nurse #B, RN stated, "I have been asked to cover two (2) units. (7/11/15)" "We are not staffed well....There used to be two (2) RNs on each unit and an LVN to pass medications...I can tell you I know the evening shift has been run out of compliance a few times. There weren't enough staff to handle 1:1s (1 staff to 1 patient ratio, ordered by a physician, for the safety of the patient and/or other patients)
...On the units I've been on, we've generally been able to handle it, but I've had to do things like watch the unit while the one PNA (Psychiatric Nursing Assistant) on the unit goes to help out with a crisis on another unit - that just left me...Weekends are worse than during the week. That's when nurses have had to cover two units...One nurse...constantly said she wanted to call Safe Harbor. She ended up quitting. I've never called Safe Harbor and, honestly, I wouldn't quite know how to go about it...It is very rare when we are fully staffed."

In an interview with Nurse #C, LVN on the morning of 8/6/15 at 11:40 a.m., he stated, "So, a couple of weekends or so ago, it was my weekend to work. I was in here and we didn't have an RN on the unit to work. I had to get...the RN on [another unit], to cover over here. She was covering both units. I came in and I didn't know what to do. I said I'd try to manage...She checked in maybe 5 or 6 times with me over the course of the shift. That was on Saturday AND Sunday...The patients are rarely safe here. There just aren't enough staff to be safe here ..."

In a telephone interview with Nurse #E, RN, at 1:55 p.m. on the afternoon of 8/7/15, she was asked about staffing levels on the weekend. She said, "Everyone's aware that we're short on RNs. I want to be clear, this [isn't] the result of people calling in. We're critically short of RNs...It's bad all the time, but this was REALLY bad [referring to a specific weekend]. A lot of people have had babies, injuries. There are vacancies ...I think some of the supervisors should have come in ...We were doing the best we could do, but there was a lot of stress because of the low staff. No one got hurt - but maybe we were just lucky ... "

Review of the facility provided Employee List (undated) reflected (21) PNA, (10) RN and (5) LVN vacant positions.

During an interview in the conference room on 8/6/15 at 2:30 p.m. Staff # 1, the Chief Nurse Executive (CNE) stated, "We do not use as many RNs on the weekend, there is not as much structured activity." When asked if these were minimum staffing levels for each area, the CNE stated, "There is no minimum staffing. This is really what we want to have, but there is no minimum ...We've occasionally had to ask that one RN to cover a corner on one of the patios, but those units are very near each other ...Usually that kind of thing happens on weekends ..."

During an interview in the conference room on 8/6/15 at 3:00 p.m. Staff # 2, Nursing Administrator, when asked about the staffing for 8/8/15 RN coverage for the day shift, he confirmed the RN staffing level for tomorrow's (8/8/15) schedule was low."

During an interview in the conference room on 8/6/15 and on 8/7/15 on several occasions Staff #1, the CNE stated the facility was aware of the staffing shortages. "On the weekends, we're working at almost half staff. That's one of the benefits that everyone really wanted to keep. They wanted that every other weekend off. We never use agency staff - never use them. Because there's less structure on the weekends - the nurses don't have to attend staffings, there's no treatment team, and so on - so we don't need quite as many staff on the weekends...So we've put this new staffing plan into place. We re-figured how FTEs (Full Time Employees) are counted, and now this new plan is based more on the reality of the staff that we have available." When asked how the facility is determining whether the plan is working well, she stated, "Well we just started this staffing plan. [Staff #2] refigured all this about the FTEs. The older nurse staffing plan - the one prior to this - the plan...by Central Office - the required number of staff was higher than the hospital's FTE count would allow. We determined that the previous plan was not realistic..." When asked if they were tracking the facility's use of nursing overtime The Staff #1 stated, "We started to track overtime but then we decided not to use that, I think." Staff #1 stated the Unit Staffing Schedules should be completed for the next month by the 20th of the previous month to ensure adequate time to cover the scheduling gaps. The Staff #1 confirmed the shortages in the RN coverage every other weekend.

A document entitled Austin State Hospital Governing Body Report, dated August 27, 2014, included a section entitled Nursing Services Staffing Plan. This plan was identified by the CNE and RN Administrator as being the " old " nursing staffing plan. Upon further discussion, it was revealed the "new" Nursing Services Staffing Plan had not yet been approved by the hospital governing board. The board-approved Nursing Services Staffing Plan, effective date May 14, 2014, included the following:
" II) Nurse Staffing Committee
C) Nurse input to the Nurse Staffing Committee: The Committee is scheduled to meet at least quarterly ...
IV) Plan Consideration by Hospital Leadership and in the Budgeting Process: The Chief Nurse Executive reports to the Senior Leadership Team regarding the Committee and its progress ...The Chief Nurse Executive contributes pertinent information to the hospital ' s leadership regarding nursing staff needs ...
V) Standards and Evidence Utilized in Plan Development: The Committee will utilize The Joint Commission Standards and CMS Standards to assist in developing the plan, as well as the American Nurses Association Principles of Safe Staffing. Specific outcome data selected by the Committee includes: Patient injuries; staff injuries related to patient care; overtime expenses; call-ins; and, restraints/seclusions ...
VIII) Plan Evaluation: Evaluation of the Staffing Plan is ongoing and changes will be made as appropriate based on outcome data as detailed in item IV ... "

Appendix I was entitled Minimum Staffing Levels and included the following, in summary:
Adult Psychiatric Services East and West:
o Day Shift: 6 RNs, 4 LVNs, 12 Psychiatric Nursing Assistants (PNAs)
o Evening Shift: 6 RNs, 4 LVNs, 12 PNAs
o Night Shift: 4 RNs, 2 LVNs, 12 PNAs

Specialty Services:
o Day Shift: 6 RNs, 5 LVNs, 22 PNAs
o Evening Shift: 6 RNs, 5 LVNs, 22 PNAs
o Night Shift: 5 RNs, 2 LVNs, 22 PNAs

Child and Adolescent Services (ages 3-17 years old):
o Day Shift: 2 RNs, 1 LVN, 11 PNAs
o Evening Shift: 2 RNs, 1 LVN, 11 PNAs
o Night Shift: 1 RN, 1 LVN, 7 PNAs

Review of the facility provided Policy and Procedure Staffing Plan (dated July, 1998) and (reviewed 5/2015) reflected:

"1. Overview
1.1 The chief nurse executive, in collaboration with other members of the hospital leadership is responsible to provide staffing twenty-four hours daily, seven days a week, to meet the nursing needs of the patients.
1.2 The chief nurse executive and the nurse administrators determine the level and mix of nursing staff positions assigned to each unit.
1.2.1. The nursing service staffing plan serves as the foundation for nursing staffing. Staffing plans are developed based on census, service mission, and building configuration, number of projected admissions, discharges, and transfers, patient acuity, and availability of support services.
1.2.2. Daily staffing decisions are based on the plan for functional staffing, census, patient acuity, utilization of special precautions, restraint and seclusion, and staff skills mix.
1.5.1. Adherence to and/or appropriateness of the staffing plans are monitored on an ongoing basis by nursing administrators and revisions are implemented as needed throughout the year.

2. Annual Planning
2.1. During annual planning the nurse management team review staffing needs and approves a staffing plan for the upcoming year.
2.1.2. The plan provides for a higher number of FTEs than required by staffing formula to accommodate every other off weekend rotation, monitoring required for special precautions, staff participation in assigned committees/meeting, educational, and performance improvement activities.

3. Monthly Planning
3.3 Projected staffing shortages are communicated to the CNE and action is taken as needed. Critical staffing shortages may be addressed in the following ways:
3.3.1. Staffing incentives, e.g., bonus program for those who agreed to specific amount overtime over a period of time.
3.3.2. A request for additional staff may be submitted to BAC for approval.
3.3.3. Program realignments and or/or unit closure may be recommended to the CEO.
3.3.4. The CEO may be requested to approve administrative staff transfers."

Review of the facility provided Policy and Procedure, Work Schedules (dated 8/2004) and (reviewed 5/2015) reflected,
"Purpose: To plan staffing levels to ensure adequate care for our patients.
1.3. Nurse supervisors ensure that each unit has a minimum of two staff (licensed staff included) scheduled at all times, and enough licensed staff to maintain safe patient care.

4. Weekend staffing is crucial as we have an increased number of staff scheduled off on weekends."

During an interview in the conference room on 8/7/15 at 4:00 p.m. Staff # 5, the hospital Superintendent, stated he was only aware of a few instances when there were not enough nurses. He stated that 20% of the FTE (full time equivalent) Nursing staff is out on FMLA. He stated the facility had considered closing units but that Central Office had mandated the facility be kept at 90% full..."Again, looking at the FTEs that we have available is new to us - just in the last 10 days or so I've been made aware of how many people are off. We're already looking at whether we want to go with agency nursing ...I hadn't been notified that we didn't have enough RNs. This is the first I've heard of it...I know sometimes we have call-ins and people get stretched - we'll have to hold people over into the next shift..." When asked if he believed that only two RNs covering a patio, for example APS West, which might include as many as 100 patients (Units B, C, D, E and F), might be a dangerous situation for staff and patients, he stated, "My role as a superintendent is limited. Administratively, I have very little to do with how nursing services are directed...Nursing Services has a chief nursing exec at the central office, so I assumed they were taking care of nursing services ...Psychiatric hospitals are just by their very nature - by the services we provide - dangerous ... "

A report entitled State Hospital Safety Improvement Report dated October 15, 2014, compared data "tracked and trended across the hospital system to measure progress on the goal of improving patient safety for the patient care areas..." The report included data from July 2013 through August 2014, and revealed the following:
"The mean rate for patient injuries across the hospital system was 12.66 injuries per 1000 patient days for the reporting period ...the highest reporting hospital was ASH (Austin State Hospital) at 23.80 injuries per 1000 patient days ...
The mean rate for Restraint & Seclusion events across the hospital system was 18.46 events per 1000 patient days for the reporting period ...the highest reporting hospital was ASH ...at 34.0 per 1000 patient days ...
The mean rate for Patient Injury Resulting from Aggression events across the hospital system was 4.08 events per 1000 patient days for the reporting period ...the highest reporting hospital was ASH at 10.7 events per 1000 patient days ... "

Based on a review of facility documentation and staff interviews, the facility failed to implement safe and appropriate restraint and seclusion techniques as determined by hospital policy for 1 of 7 patients [Patient #8] undergoing an episode of restraint or seclusion.

Findings were:

Review of the clinical record of patient Patient #8 revealed a mechanical chair restraint was initiated on 8/2/15 at 1:30 p.m. The restraint was documented to have been initiated by Staff #16, a psychiatric nursing assistant.

Facility policy entitled, "Behavioral Restraints," effective date March, 1992, included the following:
"BEHAVIORAL RESTRAINT/SECLUSION ...
"2. General principles for the use of behavioral restraint/seclusion:
2.3 Only RNs who have completed the facility's Restraint/Seclusion Training Program and demonstrate competency are authorized to initiate and assess/reassess restraint/seclusion episodes ...
4. Initiating Emergency Restraint/Seclusion...
4.2 Only a physician or clinically competent RN may initiate behavioral mechanical restraint or seclusion..."

In an interview with Staff #3, Quality Management, on the afternoon of 8/7/15 in the administration meeting room, she confirmed Staff #16 was a psychiatric nursing assistant and that it was documented in the patient record that he had inappropriately initiated a mechanical restraint on Patient #8.

Based on observation, review of facility documentation and staff interviews, the hospital failed to provide an organized nursing service that ensured nursing services for all patients were furnished or supervised by a registered nurse. The hospital failed to:

A. Ensure there was a sufficient number of registered nurses, licensed vocational nurses and psychiatric nursing assistants on duty to provide safe patient care at all times. They failed to ensure minimum staffing requirements were met for each nursing unit across the hospital, and failed to staff at the minimum levels required by the board-approved nurse staffing plan. This deficient practice was found on all units on a variety of shifts, most notably weekend shifts. Cross refer to 482.23(b) Staffing and Delivery of Care for additional information.

B. Ensure nursing services were provided according to the nurse staffing plan currently in effect and approved by the hospital governing body in May 2014. Related to this, the facility could not provide documented evidence that indicators approved by the board to assess the effectiveness of the nurse staffing plan were being monitored as required. Cross refer to 482.23(a) Organization of Nursing Services for additional information.

Based on a review of facility documentation and staff interviews, the hospital nursing management failed to follow the nurse staffing plan which had been approved by the hospital's governing body, and instead had implemented a "new" nurse staffing plan without board approval. In addition, the facility could provide no documented evidence that indicators approved by the board to assess the effectiveness of the nurse staffing plan were being monitored as required.

Findings were:

A hospital nurse staffing plan identified by both Staff #1, Chief Nursing Executive (CNE), and Staff #2, RN Administrator, as the "new" nurse staffing plan currently in use by the hospital, was provided for surveyor review. No evidence of it having been approved by the hospital's governing body was provided. It included unit nurse staffing levels for the hospital's various shifts and units. The nursing units were identified as follows:

Adult Psychiatric Services (APS) East patio included 3 nursing units: 1, 2, 6
APS West patio included 5 nursing units: B, C, D, E, F
Specialty Services (SS) included 6 nursing units: A/B, C/D, E/F
Children & Adolescents Psychiatry Services (CAPS) included 3 nursing units: A, B, C

The staffing levels listed in the plan were as follows:

7am - 3pm Day Shift:
· Each APS unit (East Patio 1,2 and 6 and West Patio A, B, C, D, E and F) - 1 RN, 1 LVN, 3 Psychiatric Nursing Assistants (PNAs).
· Each of SS units A/B and E/F - 2 RNs, 2 LVNs, 7 PNAs
· SS unit C/D - 1 RN, 1 LVN, 6 PNAs
· CAPS unit A (CAPS A, B and C) - 2 RNs, 1 LVN total which served all of the units on CAPS
· CAPS units A, B and C - 4 PNAs
· Shift totals = 16 RNs, 13 LVNs, 58 PNAs

3pm - 11pm Evening Shift:
· Each APS unit (East Patio 1, 2 and 6 and West Patio A, B, C, D, E and F)- 1 RN,
1 LVN, 3 PNAs, exception of Unit D on APS West - no LVN.
· Each of SS units A/B and E/F - 2 RNs, 2 LVNs, 7 PNAs
· SS unit C/D - 1 RN, 1 LVN, 6 PNAs
· CAPS unit A (CAPS A, B and C) - 2 RNs, 1 LVN total which served all of the units on CAPS
· Each of CAPS units A, B and C - 4 PNAs
· Shift totals = 16 RNs, 12 LVNs, 58 PNAs

11pm - 7am Night Shift:
· Each of APS East units 1 and 6 - 1 RN, 3 PNAs
· APS East unit 2 - 1 RN, 1 LVN, 3 PNAs
· Each of APS West units D and F - 1 RN, 3 PNAs
· Each of APS West units B, C and E - 1 RN, 1 LVN, 3 PNAs
· SS unit C/D - 1 RN, 5 PNAs
· Each of SS units A/B and E/F - 1 RN, 1 LVN, 5 PNAs
· CAPS unit A (CAPS A, B and C) - 1 RN and 1 LVN total which served all of the units on CAPS
· CAPS units A - 2 PNAs; each of CAPS units B and C - 3 PNAs
· Shift totals = 13 RNs, 7 LVNs, 50 PNAs

When asked if these were minimum staffing levels for each area, the Chief Nursing Executive stated, "There is no minimum staffing. This is really what we want to have, but there is no minimum..."

In an additional interview with Staff #1, Chief Nursing Executive, and Staff #2, RN Administrator, on 8/6/15 at 1:38 p.m. in the administration meeting room, the CNE stated, "On the weekends, we're working at almost half staff. That's one of the benefits that everyone really wanted to keep. They wanted that every other weekend off. We never use agency staff - never use them. Because there's less structure on the weekends - the nurses don't have to attend staffings, there's no treatment team, and so on - so we don't need quite as many staff on the weekends...So we've put this new staffing plan into place. We re-figured how FTEs (Full Time Employees) are counted, and now this new plan is based more on the reality of the staff that we have available." When asked how the facility was determining whether the plan was working well, she stated, "Well we just started this staffing plan. [Staff #2] refigured all this about the FTEs. The older nurse staffing plan - the one prior to this - the plan...by Central Office - the required number of staff was higher than the hospital's FTE count would allow. We determined that the previous plan was not realistic ..." When asked if they were tracking the facility's use of nursing overtime, the CNE stated, "We started to track overtime but then we decided not to use that, I think. "

A review of the minutes of the State Hospital Board Meeting - Austin State Hospital on January 9, 2015, revealed the following the reference:
"Nurse Staffing Plan ...Nursing Services Staffing Plan can be found in the State Board book listed under Attachment I ...The Nursing Staffing Plan is being updated and will be approved at the next State Hospital Board Meeting... "

In a subsequent interview with Staff #1, CNE, and Staff #2, RN Administrator, at 3:24 p.m. on 8/6/15, in the administration meeting room, the surveyors requested the Nursing Services Staffing Plan referred to in the above board meeting minutes. They said, "That is our old nurse staffing plan." When asked for the staffing plan most recently approved by the board, they confirmed that it was this "old" nurse staffing plan which was dated May 14, 2014. When asked if the "new" nurse staffing plan already implemented by the CNE had been approved by the hospital board, the CNE stated, "It's about to get approved at the next meeting." The nurse staffing plan most recently approved by the board read as follows:

The Nursing Services Staffing Plan, effective date May 14, 2014, included the following:
"II) Nurse Staffing Committee

C) Nurse input to the Nurse Staffing Committee: The Committee is scheduled to meet at least quarterly ...

IV) Plan Consideration by Hospital Leadership and in the Budgeting Process: The Chief Nurse Executive reports to the Senior Leadership Team regarding the Committee and its progress ...The Chief Nurse Executive contributes pertinent information to the hospital's leadership regarding nursing staff needs ...

V) Standards and Evidence Utilized in Plan Development: The Committee will utilize The Joint Commission Standards and CMS Standards to assist in developing the plan, as well as the American Nurses Association Principles of Safe Staffing. Specific outcome data selected by the Committee includes: Patient injuries; staff injuries related to patient care; overtime expenses; call-ins; and, restraints/seclusions ...

VIII) Plan Evaluation: Evaluation of the Staffing Plan is ongoing and changes will be made as appropriate based on outcome data as detailed in item IV ... "

Appendix I was entitled Minimum Staffing Levels and included the following, in summary:
"Adult Psychiatric Services East and West:
o Day Shift: 6 RNs, 4 LVNs, 12 Psychiatric Nursing Assistants (PNAs)
o Evening Shift: 6 RNs, 4 LVNs, 12 PNAs
o Night Shift: 4 RNs, 2 LVNs, 12 PNAs

Specialty Services:
o Day Shift: 6 RNs, 5 LVNs, 22 PNAs
o Evening Shift: 6 RNs, 5 LVNs, 22 PNAs
o Night Shift: 5 RNs, 2 LVNs, 22 PNAs

Child and Adolescent Services (ages 3-17 years old):
o Day Shift: 2 RNs, 1 LVN, 11 PNAs
o Evening Shift: 2 RNs, 1 LVN, 11 PNAs
o Night Shift: 1 RN, 1 LVN, 7 PNAs"

The staffing plan approved by the hospital governing body continued with:

"Appendix II: Quarterly Evaluation of Nursing Services Staffing Plan
Indicators Used to Evaluate Staffing Plan:
At least two indicators must be selected and evaluated each quarter. The Committee has determined that the following indicators will be evaluated:

· Patient injuries
· Staff injuries
· Overtime expense
· Call-ins
· Restrains/seclusions ... "

Nurse Staffing Committee Meeting minutes were reviewed for the following dates in 2015: January 21, February 18, March 18, and April 22. No additional meeting minutes from 2015 were available for surveyor review. Select excerpts from the minutes related to staffing and indicator discussion follow:

· January 21, 2015: "Staffing was discussed; Bare coverage: 1 RN, 1 LVN and 3 PNAs; Ideal coverage: 2 RNs, LVN, and 4 PNAs. More information and numbers will be discussed via email... "

· February 18, 2015: "Weekend staffing continues to be challenging to cover and staff will continue to be pulled even with unit scheduling completed due to allotted FTEs ...The number of available staff on the units is consistent with minimum staffing numbers and depending on various factors such as 1-1s those number may fall below minimum ...The use of overtime allows the hospital to fill staffing needs on the units at minimum levels. The overall sign-ups for overtime are down ...Next Steps: ...Review the indicators so once they are approved and the staffing plan is finalized then the plan can be evaluated ... "

· March 18, 2015: "Allen presented the proposed staffing plan at the meeting ...Weekend total are reduced by 20 to 25%...The committee shared that staff RNs cover both RN and LVN positions ...We have been using over-time to assist with total census ...Review of the five nursing sensitive indicators [review of what the board-approved indicators actually were - no evaluation of indicator values or trends] ...Action Plan: Copy of the TAC (Texas Administrative Code) to review indicators will be sent to Committee ...The committee will review the TAC to guide the indicator discussion. The selected indicators once agreed on will be in place for one year. The indicator discussion will be pended for next meeting ... "

· April 22, 2015: "The staffing plan has been previously sent out to staff. The voting members present at this meeting voted to approve the staffing plan and move it forward. The staffing plan will tentatively go into effect beginning on June 01 ...The committee discussed the five nursing sensitive quality indicators. The TAC and the state hospital procedures spell out how the staffing plan is completed and refers to the indicators ...The indicators are: restraint and seclusion, staff injuries, turnover rates ..., over-time use ...and staffing complaints from the patients ...The data for the nursing sensitive indicators will need to be reviewed once the plan is accepted ...The committee discussed decreasing the indicators from five to three. The committee approved the following three indicators to move forward are: over-time use, staffing complaints from the patients, restraint and seclusion ...[Chief Nursing Executive] will work with QM staff to develop a tracking tool ... "

The most recent discussion noted in a staffing committee set of minutes regarding report and evaluation of actual indicator values appears to have been in the minutes of the Austin State Hospital Staffing Committee meeting of April 10, 2014. These minutes included the following entry most relevant to demonstrating possible review and evaluation of indicator values which might have been used to assess the effectiveness of the nurse staffing plan:

"7) Reports:
i) Review Restraint/Seclusion Report: Jan 2013 - Jan 2014
ii) Patient Injuries ...
Handouts in packet ..."

A review of the facility provided Policy and Procedure Staffing Plan (dated July, 1998) and (reviewed 5/2015) reflected:

"1. Overview
1.1 The chief nurse executive, in collaboration with other members of the hospital leadership is responsible to provide staffing twenty-four hours daily, seven days a week, to meet the nursing needs of the patients.
1.2 The chief nurse executive and the nurse administrators determine the level and mix of nursing staff positions assigned to each unit.
1.2.1. The nursing service staffing plan serves as the foundation for nursing staffing. Staffing plans are developed based on census, service mission, and building configuration, number of projected admissions, discharges, and transfers, patient acuity, and availability of support services.
1.2.2. Daily staffing decisions are based on the plan for functional staffing, census, patient acuity, utilization of special precautions, restraint and seclusion, and staff skills mix.
1.5.1. Adherence to and/or appropriateness of the staffing plans are monitored on an ongoing basis by nursing administrators and revisions are implemented as needed throughout the year.

2. Annual Planning
2.1. During annual planning the nurse management team review staffing needs and approves a staffing plan for the upcoming year.
2.1.2. The plan provides for a higher number of FTEs than required by staffing formula to accommodate every other off weekend rotation, monitoring required for special precautions, staff participation in assigned committees/meeting, educational, and performance improvement activities.

3. Monthly Planning
3.3 Projected staffing shortages are communicated to the CNE and action is taken as needed. Critical staffing shortages may be addressed in the following ways:
3.3.1. Staffing incentives, e.g., bonus program for those who agreed to specific amount overtime over a period of time.
3.3.2. A request for additional staff may be submitted to BAC for approval.
3.3.3. Program realignments and or/or unit closure may be recommended to the CEO.
3.3.4. The CEO may be requested to approve administrative staff transfers..."

These findings were again confirmed in an interview with the facility Superintendent, Chief Nursing Executive and other administrative staff on the afternoon of 8/7/15 in the administration meeting room. It was confirmed that the new staffing plan had already been implemented and was to be approved by the hospital governing board at its next meeting.

Based on interview and record review the facility failed to ensure there was a sufficient number of a Registered nurse (RN) on duty to provide care at all times and failed to schedule Registered nurses according to the facilities approved staffing plan. This deficient practice was found on four (4) of nine (9) of the weekend staffing plans reviewed (7/11, 7/12, 7/25, 7/26, 8/8, 8/9, 8/22, and 8/23) and affected four (4) of six (6) patients records reviewed for care. (Patient #1, #3, #4, and #6)


Findings include:

Review of the facility provided staffing plans for the months of July 2015 and August 2015 revealed a staffing pattern that left every other weekend below the facility's current staffing plan for Registered Nurses on the units.

Review of the facility provided Policy and Procedure, Work Schedules (dated 8/2004) and (reviewed 5/2015) reflected:

Purpose: To plan staffing levels to ensure adequate care for our patients.
1.3. Nurse supervisors ensure that each unit has a minimum of two staff (licensed staff included) scheduled at all times, and enough licensed staff to maintain safe patient care.

4. Weekend staffing is crucial as we have an increased number of staff scheduled off on weekends.


Review of the facility provided Policy, Patient Assignment and Accountability (dated 2/1999) and (reviewed 5/2015) reflected:
"2. Staff Responsibility for Monitoring Patients
2.3. An RN will make rounds at least twice each 8-hour shift for the purpose of evaluating his/her assigned patients and ensuring the patients are monitored as identified on the patient assignment sheet.

10.5. Routine documentation
10.5.1. A nurse (RN or LVN) is required to document on every patient every shift."

A review of patient medical records on 8/7/15 revealed the following:

Patient # 1's Nursing Obsrvation notes dated 7/12/15, reflected the current Level of Observation: Routine

Review of Patient #1's Nursing Observation Note reflected,
On 7/12/15 there was no observation note from the day nurse.
On 7/13/15 there was no observation note from the day nurse.

Review of Patient # 4's Nursing Observation Note reflected, Current Level of Observation: Routine.

Review of Patient #4's Nursing Observation Note reflected,
On 7/11/15 there was no observation note from the day nurse.
On 7/12/15 there was no observation note from the night nurse.

Review of Patient # 3's Nursing Observation Note reflected, Current Level of Observation: Routine.

Review of Patient #3's Nursing Observation Note reflected,

On 7/25/15 there was no observation note from the evening nurse.
On 7/26/15 there was no observation note from the day nurse.


Review of Patient #6's Nursing Observation Note reflected, Current Level of Observation: Routine.

Review of Patient #6's Nursing Observation Note reflected,
On 7/26/15 there was no observation note from the night nurse.
On 7/28/15 there was no observation note from the day nurse.


During an interview in the conference room on 8/7/15 at 1:20 p.m. Staff #3 confirmed there were no further documented nursing observation notes available for the patients reviewed.

Review of the Day Shift RN Staffing Plan dated 7/1/2015 - 7/31/2015 reflected:

On 7/4/15 (15) RNs were scheduled to work and
on 7/5/15 (15) RNs were scheduled to work.
On 7/11/15 (10) RNs were scheduled to work and
on 7/12/15 (10) RNs were scheduled to work.
On 7/25/15 (8) RNs were scheduled to work and
on 7/26/15 (8) RNs were scheduled to work.

Review of the Day Shift Nursing Daily Staffing Worksheet (the number of staff that actually worked) dated 7/25/15, reflected:

· APS West Unit B had a census of 22 patients with one LVN passing medications on the unit and a shared RN from Unit 6. The RN was responsible for 43 patients. The two units were physically separated by a large distance of at least 50 to 75 yards.
· APS West Unit C had a census of 10 patients with one RN passing medications on the unit and no LVN.
· APS West Unit D had a census of 22 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and one RN.
· APS (Adult Psychiatric Services) West Unit E had a census of 22 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS West Unit F had a census of 22 patients with one LVN passing medications on the unit and a shared RN
· Unit E & F shared one RN for both units for a total of 44 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.

Review of the Nursing Daily Staffing Worksheet Day shift dated 7/25/15, reflected:
· APS East Ward 1 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 2 had a census of 18 patients with one LVN passing medications on the unit and a shared RN.
· APS East Wards 1 & 2 shared one RN for both units for a total of 39 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS East Ward 6 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 6 & APS Unit B shared one RN for both units for a total of 43 patients. The two units were physically separated by a large distance of at least 50 to 75 yards.

Review of the Nursing Daily Staffing Worksheet Day shift dated 7/26/15 reflected:
· APS West Unit C had a census of 10 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS West Unit D had a census of 22 patients with one LVN passing medications on the unit and a shared RN.
· Unit C & D shared one RN for both units for a total of 32 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS West Unit E had a census of 22 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS West Unit F had a census of 22 patients with one LVN passing medications on the unit and a shared RN.
· Units E & F shared one RN for both units for a total of 44 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS West Unit B had a census of 22 patients with one LVN passing medications on the unit and a shared RN.

Review of the Nursing Daily Staffing Worksheet Day shift dated 7/26/15 reflected:
· APS East Ward 1 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 2 had a census of 18 patients with one LVN passing medications on the unit and a shared RN.
· APS East Wards 1 & 2 shared one RN for both units for a total of 39 patients. The two units were physically separated by a nursing station and both units are not visible at the same time.
· APS East Ward 6 had a census of 21 patients with one Licensed Vocational Nurse (LVN) passing medications on the unit and a shared RN.
· APS East Ward 6 & APS West Unit B shared one RN for both units for a total of 43 patients. The two units were physically separated by a large distance of at least 50 to 75 yards.

Review of the the Day Shift RN Staffing Plan dated 8/1/2015 to 8/31/2015 reflected:

On 8/8/15 (8) RNs were scheduled to work and on 8/2/15 (8) RNs were scheduled to work.
On 8/22/15 (11) RNs were scheduled to work and on 8/23/15 (10) RNs were scheduled to work.

During an interview on the nursing unit on 8/6/15 at 9:45 a.m. Nurse #D stated, "It is typically on the weekends when we are short staffed. Two weeks ago I was asked to cover two (2) units," "I was lucky I was able to manage."

During an interview with Nurse #A, RN, on 8/6/15 at 11:00 a.m. in the conference room, Nurse # A stated, "We've had major staffing problems lately...Since December (2014), there's only been about two weeks when we had a full complement of nurses...We regularly have to rely on the House Supervisor to send us staff. There have been days when I've been the only RN for 20 patients - and the acuity is high here...There have been times when I've been the only nurse period, or times when I'm here and one LVN. A lot of times it's staffed to where I'm the only nurse...And if staffing's really bad, I frequently can't get a hold of the House Supervisor, either because she's calling people or they're calling her, or it's just so busy...There have been times when we haven't had enough staff to restrain a patient ...We've had some restraints we couldn't do because we had no one to assist us and there were only maybe two of us and we just couldn't do it. Then I had one staff member tell me he wasn't going to restrain anyone when we were the only two here ...The staffing's gotten worse over the last 6 months, but it's been particularly bad lately."

During an interview on the nursing unit on 8/6/15 at 11:15 a.m. Nurse #B, RN stated, "I have been asked to cover two (2) units. (7/11/15)" "We are not staffed well....There used to be two (2) RNs on each unit and an LVN to pass medications...I can tell you I know the evening shift has been run out of compliance a few times. There weren't enough staff to handle 1:1s (1 staff to 1 patient ratio, ordered by a physician, for the safety of the patient and/or other patients)
...On the units I've been on, we've generally been able to handle it, but I've had to do things like watch the unit while the one PNA (Psychiatric Nursing Assistant) on the unit goes to help out with a crisis on another unit - that just left me...Weekends are worse than during the week. That's when nurses have had to cover two units...One nurse...constantly said she wanted to call Safe Harbor. She ended up quitting. I've never called Safe Harbor and, honestly, I wouldn't quite know how to go about it...It is very rare when we are fully staffed."

In an interview with Nurse #C, LVN on the morning of 8/6/15 at 11:40 a.m., he stated, "So, a couple of weekends or so ago, it was my weekend to work. I was in here and we didn't have an RN on the unit to work. I had to get...the RN on [another unit], to cover over here. She was covering both units. I came in and I didn't know what to do. I said I'd try to manage...She checked in maybe 5 or 6 times with me over the course of the shift. That was on Saturday AND Sunday...The patients are rarely safe here. There just aren't enough staff to be safe here ..."

In a telephone interview with Nurse #E, RN, at 1:55 p.m. on the afternoon of 8/7/15, she was asked about staffing levels on the weekend. She said, "Everyone's aware that we're short on RNs. I want to be clear, this [isn't] the result of people calling in. We're critically short of RNs...It's bad all the time, but this was REALLY bad [referring to a specific weekend]. A lot of people have had babies, injuries. There are vacancies ...I think some of the supervisors should have come in ...We were doing the best we could do, but there was a lot of stress because of the low staff. No one got hurt - but maybe we were just lucky ... "

Review of the facility provided Employee List (undated) reflected (21) PNA, (10) RN and (5) LVN vacant positions.

During an interview in the conference room on 8/6/15 at 2:30 p.m. Staff # 1, the Chief Nurse Executive (CNE) stated, "We do not use as many RNs on the weekend, there is not as much structured activity." When asked if these were minimum staffing levels for each area, the CNE stated, "There is no minimum staffing. This is really what we want to have, but there is no minimum ...We've occasionally had to ask that one RN to cover a corner on one of the patios, but those units are very near each other ...Usually that kind of thing happens on weekends ..."

During an interview in the conference room on 8/6/15 at 3:00 p.m. Staff # 2, Nursing Administrator, when asked about the staffing for 8/8/15 RN coverage for the day shift, he confirmed the RN staffing level for tomorrow's (8/8/15) schedule was low."

During an interview in the conference room on 8/6/15 and on 8/7/15 on several occasions Staff #1, the CNE stated the facility was aware of the staffing shortages. "On the weekends, we're working at almost half staff. That's one of the benefits that everyone really wanted to keep. They wanted that every other weekend off. We never use agency staff - never use them. Because there's less structure on the weekends - the nurses don't have to attend staffings, there's no treatment team, and so on - so we don't need quite as many staff on the weekends...So we've put this new staffing plan into place. We re-figured how FTEs (Full Time Employees) are counted, and now this new plan is based more on the reality of the staff that we have available." When asked how the facility is determining whether the plan is working well, she stated, "Well we just started this staffing plan. [Staff #2] refigured all this about the FTEs. The older nurse staffing plan - the one prior to this - the plan...by Central Office - the required number of staff was higher than the hospital's FTE count would allow. We determined that the previous plan was not realistic..." When asked if they were tracking the facility's use of nursing overtime The Staff #1 stated, "We started to track overtime but then we decided not to use that, I think." Staff #1 stated the Unit Staffing Schedules should be completed for the next month by the 20th of the previous month to ensure adequate time to cover the scheduling gaps. The Staff #1 confirmed the shortages in the RN coverage every other weekend.

A document entitled Austin State Hospital Governing Body Report, dated August 27, 2014, included a section entitled Nursing Services Staffing Plan. This plan was identified by the CNE and RN Administrator as being the " old " nursing staffing plan. Upon further discussion, it was revealed the "new" Nursing Services Staffing Plan had not yet been approved by the hospital governing board. The board-approved Nursing Services Staffing Plan, effective date May 14, 2014, included the following:
" II) Nurse Staffing Committee
C) Nurse input to the Nurse Staffing Committee: The Committee is scheduled to meet at least quarterly ...
IV) Plan Consideration by Hospital Leadership and in the Budgeting Process: The Chief Nurse Executive reports to the Senior Leadership Team regarding the Committee and its progress ...The Chief Nurse Executive contributes pertinent information to the hospital ' s leadership regarding nursing staff needs ...
V) Standards and Evidence Utilized in Plan Development: The Committee will utilize The Joint Commission Standards and CMS Standards to assist in developing the plan, as well as the American Nurses Association Principles of Safe Staffing. Specific outcome data selected by the Committee includes: Patient injuries; staff injuries related to patient care; overtime expenses; call-ins; and, restraints/seclusions ...
VIII) Plan Evaluation: Evaluation of the Staffing Plan is ongoing and changes will be made as appropriate based on outcome data as detailed in item IV ... "

Appendix I was entitled Minimum Staffing Levels and included the following, in summary:
Adult Psychiatric Services East and West:
o Day Shift: 6 RNs, 4 LVNs, 12 Psychiatric Nursing Assistants (PNAs)
o Evening Shift: 6 RNs, 4 LVNs, 12 PNAs
o Night Shift: 4 RNs, 2 LVNs, 12 PNAs

Specialty Services:
o Day Shift: 6 RNs, 5 LVNs, 22 PNAs
o Evening Shift: 6 RNs, 5 LVNs, 22 PNAs
o Night Shift: 5 RNs, 2 LVNs, 22 PNAs

Child and Adolescent Services (ages 3-17 years old):
o Day Shift: 2 RNs, 1 LVN, 11 PNAs
o Evening Shift: 2 RNs, 1 LVN, 11 PNAs
o Night Shift: 1 RN, 1 LVN, 7 PNAs

Review of the facility provided Policy and Procedure Staffing Plan (dated July, 1998) and (reviewed 5/2015) reflected:

"1. Overview
1.1 The chief nurse executive, in collaboration with other members of the hospital leadership is responsible to provide staffing twenty-four hours daily, seven days a week, to meet the nursing needs of the patients.
1.2 The chief nurse executive and the nurse administrators determine the level and mix of nursing staff positions assigned to each unit.
1.2.1. The nursing service staffing plan serves as the foundation for nursing staffing. Staffing plans are developed based on census, service mission, and building configuration, number of projected admissions, discharges, and transfers, patient acuity, and availability of support services.
1.2.2. Daily staffing decisions are based on the plan for functional staffing, census, patient acuity, utilization of special precautions, restraint and seclusion, and staff skills mix.
1.5.1. Adherence to and/or appropriateness of the staffing plans are monitored on an ongoing basis by nursing administrators and revisions are implemented as needed throughout the year.

2. Annual Planning
2.1. During annual planning the nurse management team review staffing needs and approves a staffing plan for the upcoming year.
2.1.2. The plan provides for a higher number of FTEs than required by staffing formula to accommodate every other off weekend rotation, monitoring required for special precautions, staff participation in assigned committees/meeting, educational, and performance improvement activities.

3. Monthly Planning
3.3 Projected staffing shortages are communicated to the CNE and action is taken as needed. Critical staffing shortages may be addressed in the following ways:
3.3.1. Staffing incentives, e.g., bonus program for those who agreed to specific amount overtime over a period of time.
3.3.2. A request for additional staff may be submitted to BAC for approval.
3.3.3. Program realignments and or/or unit closure may be recommended to the CEO.
3.3.4. The CEO may be requested to approve administrative staff transfers."

Review of the facility provided Policy and Procedure, Work Schedules (dated 8/2004) and (reviewed 5/2015) reflected,
"Purpose: To plan staffing levels to ensure adequate care for our patients.
1.3. Nurse supervisors ensure that each unit has a minimum of two staff (licensed staff included) scheduled at all times, and enough licensed staff to maintain safe patient care.

4. Weekend staffing is crucial as we have an increased number of staff scheduled off on weekends."

During an interview in the conference room on 8/7/15 at 4:00 p.m. Staff # 5, the hospital Superintendent, stated he was only aware of a few instances when there were not enough nurses. He stated that 20% of the FTE (full time equivalent) Nursing staff is out on FMLA. He stated the facility had considered closing units but that Central Office had mandated the facility be kept at 90% full..."Again, looking at the FTEs that we have available is new to us - just in the last 10 days or so I've been made aware of how many people are off. We're already looking at whether we want to go with agency nursing ...I hadn't been notified that we didn't have enough RNs. This is the first I've heard of it...I know sometimes we have call-ins and people get stretched - we'll have to hold people over into the next shift..." When asked if he believed that only two RNs covering a patio, for example APS West, which might include as many as 100 patients (Units B, C, D, E and F), might be a dangerous situation for staff and patients, he stated, "My role as a superintendent is limited. Administratively, I have very little to do with how nursing services are directed...Nursing Services has a chief nursing exec at the central office, so I assumed they were taking care of nursing services ...Psychiatric hospitals are just by their very nature - by the services we provide - dangerous ... "

A report entitled State Hospital Safety Improvement Report dated October 15, 2014, compared data "tracked and trended across the hospital system to measure progress on the goal of improving patient safety for the patient care areas..." The report included data from July 2013 through August 2014, and revealed the following:
"The mean rate for patient injuries across the hospital system was 12.66 injuries per 1000 patient days for the reporting period ...the highest reporting hospital was ASH (Austin State Hospital) at 23.80 injuries per 1000 patient days ...
The mean rate for Restraint & Seclusion events across the hospital system was 18.46 events per 1000 patient days for the reporting period ...the highest reporting hospital was ASH ...at 34.0 per 1000 patient days ...
The mean rate for Patient Injury Resulting from Aggression events across the hospital system was 4.08 events per 1000 patient days for the reporting period ...the highest reporting hospital was ASH at 10.7 events per 1000 patient days ... "