HospitalInspections.org

Based on document review and interview, it was determined that for 4 of 9 (Behavioral Health Units -3A, 3B,and 3D and the Intensive Care Unit) units reviewed for staffing, the Hospital failed to ensure that the nursing service had adequate numbers of licensed Registered Nurses and other personnel to provide nursing care to all patients as needed, in accordance with Hospital policy.

Findings include:

1. The Behavioral Health Staffing Matrix (4/1/2021) was reviewed. The staffing matrix required the following staff to patient ratio by unit:
-Unit 3A - Census 1 to 13; RN (Registered Nurse) - 1 and MHC (Mental Health Counselor) 1 to 2.
Census 13 - 24; RN - 2 and MHC - 2
-Unit 3B - Census 1 to 15; RN - 1 and MHC - 4
-Unit 3D - Census 1 to 12; RN - 1 and MHC - 2

2. On 5/17/2021, the April 2021 staffing schedule for the Behavioral Health Units was reviewed and included the following:
4/17/2021:
-Unit 3A - Census was 14 with one RN from 11:00 PM - 7:30 AM (1 RN short)
-Unit 3B - Census was 9 with one RN and one MHC from 3:00 PM - 11:00 PM (1 MHC short)

4/18/2021:
-Unit 3A - Census was 16 from 3:00 PM - 11:00 PM and 17 from 11:00 PM - 7:00 AM including one 1:1 patient (one staff to one patient). There was 1 RN from 7:00 PM - 11:00 PM and 1 MHC from 3:00 PM - 11:00 PM (1 RN short and 1 MHC short).
-Unit 3B Census was 11 with one RN and one MHC from 7:00 AM - 11:00 PM (1 MHC short).

4/19/2021:
-Unit 3A - Census was 18 from 7:00 AM - 3:00 PM with one RN from 7:00 AM - 10:00 AM (1 RN short for 3 hours).
-Unit 3B - Census was 11 from 7:00 AM - 3:00 PM with one RN, one MHC, and one sitter for a 1:1 patient (1 MHC short). The census was 7 from 3:00 PM - 11:00 PM with one RN and no MHC (1 MHC short).

4/20/2021:
-Unit 3A - Census was 21 with one RN from 7:30 PM - 11:00 PM (1 RN short).

4/30/2021:
-Unit 3 A - Census was 21 with one RN from 7:00 AM - 7:30 PM (1 RN short).

3. On 5/19/2021, the Hospital wide staffing and patient census from 4/15/2021 - 4/30/2021 was reviewed.
The Intensive Care Unit (ICU) staffing was not in accordance with the staffing matrix on the following dates:
4/22/2021 - patient census was 10 with 4 RN's from 7:00 PM - 7:00 AM (1 RN short); 4/23/2021 - patient census was 11 from 7:00 PM - 7:00 AM with 4 RN's (1 RN short); 4/29/2021- patient census was 12 with 5 RN's from 7:00 PM - 7:00 AM (1 RN short); and 4/30/2021 - patient census was 11 with 4 RN's from 7:00 PM - 7:00 AM (2 RN's short).

4. On 5/19/2021, the Hospital's Intensive Care Unit staffing matrix was reviewed and included the following guidelines: Patient census of 10 requires five (5) RN's; and patient census of 11 -12 requires six (6) RN's.

5.On 5/17/2021 at 2:30 PM, an interview was conducted with a Registered Nurse (E #3). E #3 stated that there was one occasion (could not recall the date) that she was the only RN working the Behavioral Health Unit, and administration sent another RN a few hours after the start of the shift to help discharge some patients.

6. On 5/17/2021 at 10:53AM, an interview was conducted with the Chief Nursing Officer (E #1). E #1 stated that the staffing matrix is a guide and is based on patient acuity.

Based on document review and interview, it was determined that for 2 of 2 (Pt. #9 and Pt. #10) patients reviewed for 1:1 (one staff to one patient) observation, the Hospital failed to ensure that a Registered Nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and physicians' orders.

Findings include:

1. On 5/17/2021, the Hospital's policy titled, "Precaution Rounds" (revised by the Hospital 10/17/2019) was reviewed. The policy required, "...One-to-One observation: If the patient's acuity requires continual observation, a staff member will remain within arm's length of the patient."

2. On 5/17/2021, Pt. #9's clinical record was reviewed. Pt. #9 was admitted on 4/17/2021 with a diagnosis of bipolar disorder (serious mental illness). Pt. #9's clinical record included a physician's order, dated 4/18/2021, for 1:1 observation.

3. The 3B staff assignment sheet, dated 4/18/2021 from 7:00 PM - 7:30 AM, included documentation that staff was assigned to monitor Pt. #9 for 1:1 observation, while simultaneously being assigned to other patients on the unit. The 3B staff assignment sheet, dated 4/20/2021 from 7:00 PM - 7:30 AM, included documentation that staff was assigned to monitor Pt. #9 for 1:1 observation, while simultaneously being assigned to other patients on the unit.

4. On 5/17/2021, Pt. #10 clinical record was reviewed. Pt. #10 was admitted on 5/1/2021 with a diagnosis of bipolar disorder. Pt. #10's clinical record included a physician's order, dated 5/2/2021, for 1:1 observation.

5. The 3B staff assignment sheet, dated 5/3/2021, 7:00 PM - 7:00 AM, included documentation that staff was assigned to monitor Pt. #10 for 1:1 observation, while simultaneously being assigned to other patients on the unit. The 3B staff assignment sheet, dated 5/4/2021, 7:00 AM - 7:00 PM, included documentation that staff was assigned to monitor Pt. #10 for 1:1 observation, while simultaneously being assigned to other patients on the unit. The 3B staff assignment sheet, dated 5/7/2021, 7:00 PM - 7:00 AM, included documentation that staff was assigned to monitor Pt. #10 for 1:1 observation, while simultaneously being assigned to other patients on the unit.

6. On 5/17/2021 at 10:53 AM, interview was conducted with the Chief Nursing Officer (E #1). E #1 stated that the staffing matrix for Behavioral Health Units was developed to provide additional staff support. E #1 stated that additional staff is added if there is a patient on 1:1 (one staff to one patient). E #1 stated that sitters should not be assigned to monitor any other patients during 1:1 observations.

7. On 5/18/2021 at 10:13 AM, an interview was conducted with a MHC (E #4). E #4 stated that 1:1 is for patient safety and the assigned staff must be within arm's length of the patient during 1:1 observation. E #4 stated that 1:1 means one staff provides care to only one patient.