HospitalInspections.org

Based on document review and interview, the facility failed to provide staffing according to the staffing matrix on 7 days (08/01/21, 08/02/21, 08/03/21, 08/04/21, 08/05/21, 08/06/21 and 08/07/21) reviewed.

Findings Include:

A. Policy and Procedure Review:
Review of policy titled: Nursing Staffing Plan (Policy ID: 8818485) last approved 01/2020, indicated that the "Director of Nursing is accountable to ensure a sufficient number of qualified staff are on duty at all times to provide patients with quality care...The Registered Nurse maintains responsibility for coordinating the plan of care for each patient".

B. Facility Administrative Document Review:
Review of staffing for 08/01/21 through 08/07/21 indicated patient census for the 100 Unit was 16 to 18 which indicated need of 3 nurses and 3 aides on day shift and 2 nurses and 2 aides on night shift; 200 Unit census was 11 which indicated need of 2 nurses and 2 aides on day and night shift; and the 300 Unit was 17 to 18 which indicated need of 3 nurses and 3 aides on day shift and 2 nurses and 2 aides on night shift. If there was a 1:1, another person would need to be staffed. Staffing was as follows:
08/01/21: 100 unit - census of 18, day shift short 1 nurses and 2 aides; night shift short 1 nurse.
200 unit - census of 11, day shift short 1 nurse; night shift short 1 nurse.
300 unit - census of 18, day shift short 1 nurse and 2 aides; night shift staffed per matrix.
2 RNs (Registered Nurse) on day shift and 3 RN's on night shift in the building.
08/02/21: 100 unit - census of 18, day shift short 1 nurse, night shift staffed per matrix.
200 unit - census of 11, day shift short 1 nurse, night shift staffed per matrix.
300 unit - census of 18, day shift short 1 nurse, night shift short 1 nurse
2 RN's on day shift and 4 RNs on night shift in the building.
08/03/21: 100 unit - census of 18, day shift short 1 nurse and 1 aide, night shift staffed per matrix.
200 unit - census of 11, day shift short 1 nurse, night shift short 1 nurse.
300 unit - census of 18, day shift short 1 nurse, night shift staffed per matrix.
3 RNs on day shift and 3 RNs on night shift in the building.
08/04/21: 100 unit - census of 18, day shift short 1 nurse and 1 aide, night shift short 1 nurse.
200 unit - census of 11, staffing both shifts staffed per matrix.
300 unit - census of 18, day shift short 1 nurse and 1 aide, night shift staffed per matrix.
08/05/21: 100 unit - census of 18, day shift short 1 nurse and 2 aides, night shift staffed per matrix.
200 unit - census of 11, day shift short 1 nurse, night shift staffed per matrix.
300 unit - census of 18, day shift short 1 nurse and 2 aides, night shift is short 1 nurse and 1 aide.
2 RNs on day shift and 4 RNs on night shift in the building.
08/06/21: 100 unit - census of 17, day shift short 1 nurses and 1 aide, night shift is short 1 nurse.
200 unit - census of 11, day shift short 1 nurse, night shift short 1 nurse.
300 unit - census of 17, day shift short 2 nurses and 1 aide, night shift short 1 nurse.
2 RNs on day shift and 3 RNs on night shift in the building.
08/07/21: 100 unit - census of 16, day shift short 2 nurses and 1 aide, night shift short 1 nurse.
200 unit - census of 11, day shift short 1 nurse and night shift short 1 nurse.
300 unit - census of 17, day shift short 2 nurses and 1 aide, night shift staffed per matrix.
Zero RNs on day shift and 2 RNs on night shift in the building.
Unable to verify if there were any 1:1 situations whereby staff may have been needed or if an RN was available to a unit, if needed.

C. Interview:
Interview on 08/09/21 at 1:10 pm with P51, confirmed 2 RNs (Registered Nurse) working on 08/06/21 (1 on the 100 unit and 1 on the 300 unit for day shift - minimum of 3 needed)...also confirmed facility is unable to staff according to the staffing matrix.