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Based on record review, staff interview and policy/procedure review the facility did not develop a complete nursing care plan that developed appropriate nursing interventions in response to the identified nursing care needs and the patient's response to interventions for one of 6 patients reviewed (Patient #1).

Findings included:

Review of the record of Patient #1 revealed that the patient was admitted to the facility on 2/23/19 at 12:59 a.m., with a diagnosis of acute upper GI bleed. The History and Physical, dated 2/23/19 at 8:04 am documented that the patient was brought to the emergency room by EMS with coffee-ground emesis and presyncopal episode. The patient was admitted to ICU for critical care. An EGD (epigastric duodenoscopy) was performed on 2/24/19 and the report documented duodenal bulb ulcer with a large clot. Review of the nursing care plan for Patient #1 did not find a plan of care to address the patient's care needs for his active bleeding from the GI tract. There was no plan consistent with the plan for medical care or plan of reassessment of the patient's nursing care needs and response to nursing interventions. Review of the hospital's policy "Assessment and Plan of Care Development and Implementation" CL.0021, last approved 11/2018, revealed "an individualized plan of care is developed and implemented based on the identified patient needs/diagnosis, taking into consideration of the patient's: (1) desire for treatment, (2) type of care needed, (3) priorities for care and , (4) prior response to condition/illness or treatment."
Interview with the Quality Manager on 8/21/19 at 10:36 a.m., confirmed that there was no plan of care for active bleeding for Patient #1.

Based on medical record review, facility policy review, document reviews, personnel file review and staff interview the registered nurse did not assign the nursing care of each patient for one of 6 patients reviewed (Patient #1) to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

Findings included:

Review of the record of Patient #1 revealed that the patient was admitted to the facility on 2/23/19 at 12:59 a.m., with a diagnosis of acute upper GI bleed. The History and Physical, dated 2/23/19 at 8:04 a.m., documented that the patient was brought to the emergency room by EMS with coffee-ground emesis and presyncopal episode. The patient was admitted to ICU for critical care. An EGD (epigastric duodenoscopy) was performed on 2/24/19 and the report documented duodenal bulb ulcer with a large clot.

The nurse (Nurse A) assigned to care for ICU Patient #1 was a float nurse from another non-ICU nursing unit (M3) according to the RN MICU Manager's account documented on a report, dated 3/1/19 at 11:30 p.m., related to the care of Patient #1.
A review of the policy entitled, "Orientation and Employee Competence," #TA.0060, effective 09/2018, showed a mission carried out by staff properly oriented and educated on safety practices and policies, and competent to perform their job duties. Continued review of the policy showed department specific orientation should be provided to each employee using job-specific orientation plan. The plan is based on specific job roles and tasks...validation of competence in daily practice is achieved through trainer/preceptor/supervisor observations, demonstration of hands of skills, completion of skills checklist and documentation of monitoring. A review of the policy "Floating/Reassignment of Patient Care Staff" #AD.0032, last approved 5/2016 revealed that "formal cross training is a process of allowing an employee the opportunity to be trained and/or oriented to a department or area of specialty they do not currently work in. At the completion of training the employee is competent to perform duties specific to that department as defined by the department's Manager." Further review of the policy found 1. designation of who is reassigned is based upon job code and skills of the employees needed in the pod. 2. Employees with less than six months experience will be exempt from floating.3. Staffing Resource Department (SRD) employees will float first 4. Whenever floated, employees will be:
-given a tour of the department at shift beginning
-assigned with another staff member who is competent to work with the patient population. The floated employee is not given independent responsibility for a team of patients unless the floated employee is currently competent with assigned patient population.
-expected to provide basic care within their licensure to patients, but no expected to administer specialized medication or perform specialized treatments or procedures, or specialized assessment.

Interview with the RN MICU manager on 8-20-19 at 2:05 p.m.. revealed that staffing is normally 2 patients per nurse with 1 Patient Care Assistant for 10 patients. Float nurses are used to supplement staffing. Patients that are "non-ICU" patients are evaluated to see if safe for being cared for by a float nurse. Floats to ICU come from Intermediate Care Units (Drips, Cardiac drips such as Cardizem, Amnio, Nitro) No Vasoactive drugs are given. The nurse can refuse an assignment.

Review of the facility's RN Competency Assessment of Units M2 Trauma and MICU found that the competency skills list for nurses working in MICU contained skills related to "Care of the Critically Ill Patient". These skills were not part of the skills competency assessment for nurses working on M3. Both unit competency skills lists contained a place to document the date the team leader/designee signature indicated RN observed performing and skill competency. Review of the employee personnel files of 5 nurses who "floated" from non-ICU nursing units to MICU, including that of Nurse A, did not find any skills competency documents as described above for nurses who work in MICU to care for the critically ill patients. There was no evidence in the files that these nurses were oriented to work in the MICU or that they were determined by their education and training to be competent to take an assignment of higher acuity patients in the MICU as signed off by a qualified nurse who evaluated their performance of skills needed to work in that area. A computer generated form was found in their files that indicated classes taken and dates taken. Interviw with the HR Director on 8/22/19 at about 2:00 pm, revealed that these forms were evidence of competency and that the original sign off sheets were destroyed.