HospitalInspections.org

Based on record review and interview, the nursing services department of the hospital failed to provide adequate numbers of other personnel to provide nursing care to all patients as needed. This deficient practice was identified for 5 (07/13/23PM, 07/21/23PM, 07/22/23PM, 07/23/23PM and 07/26/23AM) of the 15 shifts (06/30/2023A, 06/30/23P, 07/13/23P, 07/16/23A, 07/16/23P, 07/18/23P, 07/19/23P, 07/21/23A, 07/21/23P, 07/22/23P, 07/23/23P, 07/24/23A, 07/24/23P, 07/25/23A, 07/26/23P) reviewed and had the potential to affect any of the 19 inpatients receiving care and services during the time of the survey.
Findings:

Review of the job description for the Director of Nursing revealed, in part, the DON is responsible for providing nurse leadership in the 24-hour nursing care delivery system and clinical programming of the hospital. The hospital's model for nursing care will be compatible and reflect the ANA standards for psychiatric mental health service provision. The DON is accountable for determining the qualifications, hiring, assessing competence and utilization of all employees within the hospital.

Review of the job description for the Assistant Director of Nursing revealed, in part, the ADON is responsible for supervising LPNs, CNAs and/or Mental Health Technicians. Responsible for the implementation of a high quality treatment program, overall management of the hospital and supervision of nursing and clinical staff. Assists the DON in budget compliance and assuring guidelines are achieved in the provision of professional nursing services to meet patient needs.

Review of the approved Adult Staffing matrix for location a revised on 12/27/2021 revealed the following:
7A - 7P shift
Census - 27-34 2RNs 1LPN 5MHT
Census - 25-26 2RNs 1LPN 4MHT
Census - 14-24 1RN 1LPN 3MHT
Census - 07-13 1RN 1LPN 3MHT
Census - 00-06 1RN 0LPN 1MHT

7P - 7A shift
Census - 27-34 2RNs 1LPN 5MHT
Census - 25-26 2RNs 1LPN 4MHT
Census - 14-24 1RN 1LPN 3MHT
Census - 07-13 1RN 1LPN 3MHT
Census - 00-06 1RN 0LPN 1MHT

Review of fifteen daily nursing staffing sheets for day and night shifts revealed on the following shifts, nursing services failed to meet the minimal staffing matrix:

07/13/2023 on the PM shift with a census of 16 patients, the staffing matrix called for 1RN, 1LPN and 3MHTs; review of the daily staffing sheet revealed 1RN, 1LPN and 2MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 7/27/2023 at 1:54 p.m., S3ADON verified deficient staffing.

07/21/2023 on the PM shift with a census of 15+1 patients, the staffing matrix called for 1RN, 1LPN and 3MHTs; review of the daily staffing sheet revealed 1RN, 1LPN and 2MHTs making the hospital deficient by 1MHT on that shift; and,

In an interview on 7/27/2023 at 1:55 p.m., S2ADON verified the deficient staffing.

07/22/2023 on the PM shift with a census of 15+2 patients, the staffing matrix called for 1RN, 1LPN and 3MHTs; review of the daily staffing sheet revealed 1RN, 1LPN and 2MHTs making the hospital deficient by 1MHT on that shift; and,

In an interview on 7/27/2023 at 1:57 p.m., S2ADON verified the deficient staffing.

07/23/2023 on the PM shift with a census of 13 patients, the staffing matrix called for 1RN, 1LPN and 3MHTs; review of the daily staffing sheet revealed 1RN, 1LPN and 2MHTs making the hospital deficient by 1MHT on that shift; and,

In an interview on 7/27/2023 at 2:00 p.m., S2ADON verified the deficient staffing.

On 07/26/2023 on the AM shift with a census of 19+2 patients, the staffing matrix called for 1RN, 1LPN and 3MHTs; review of the daily staffing sheet revealed 1RN, 1LPN and 2MHTs making the hospital deficient by 1MHT on that shift; and,

In an interview on 07/27/23 at 2:05 p.m. S2ADON verified the deficient staffing.