HospitalInspections.org

Based on document review and interview, Nursing Administration failed to provide the appropriate staffing on Units 100, 200 and 300 during the week of 07/04/21 through 07/10/21 and 07/12/21 on unit 300.

Findings Include:

1. Review of policy titled: Nursing Staffing Plan (PolicyStat ID: 8818485) last approved 01/2020 indicated that the DON (Director of Nursing) maintains 24-hour accountability for adequate staffing.

2. Review of staffing for 07/04/21 through 07/10 indicated patient census for the 100 Unit was 18 to 19 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 to 12 and indicated 2 nurses and 2 aides on day and night shift; and the 300 Unit was 14 requiring 2 nurses and 2 aides, up to 18 which requires 3 nurses and 3 aides. If there was a 1:1, another person would need to be staffed.for census:
07/04/21 day shift - 100 Unit short 1 aide; 200 Unit short 1 nurse; and 300 Unit short 1 nurse, 2 aides and the 1:1.
07/05/21 day shift - 100 Unit short 1 nurse; 200 Unit short 1 nurse; and 300 Unit short 2 nurses, 1 aide and someone for the 1:1. Night shift short 1 nurse on the 200 Unit.
07/06/21 day shift - 100 Unit short 1 nurse; 200 Unit short 1 nurse and 1:1; and 300 Unit short 1 nurse.
07/07/21 day shift - 100 Unit short 1 nurse and 1 aide; 200 Unit short for 1:1; and 300 Unit short 1 nurse.
07/08/21 day shift - 100 Unit short 1:1; 200 Unit short 1 nurse; and 300 Unit short 1 nurse and 1 aide.
07/09/21 day shift - 100 Unit short 1 nurse and 1 aide; 200 Unit short for 1:1; and 300 Unit short 1 nurse and 1 aide.
07/10/21 day shift - 100 Unit short 1 nurse; 200 Unit short 1 nurse and 1:1; and 300 Unit short 1 nurse and 1 aide.

3. Tour of the 300 Unit on 07/12/21 at 2:35 pm, this surveyor noted 18 patients with 1 nurse and 2 aides for staff. The Staffing Matrix indicated 3 nurses and 3 aides for 18 patients; short 2 nurses and 1 aide.

4. Interview on 07/13/21 at approximately 10:40 am with P53 (Interim Director of Compliance) confirmed that facility was short staffed during 07/04/21 through 07/10/21 on all 3 units and 07/12/21 on the 300 Unit.

Based on document review and interview, Nursing Administration failed to ensure that policies were followed in Bath/shower documentation and Therapy Services.

Findings Include:

1. Review of policy titled: Patient Personal Care (PolicyStat ID: 8816845) last approved 01/2020, indicated that "All patients shall be encouraged or assisted in grooming daily...personal care includes bathing/showering, dressing, walking, using the toilet and eating".

2. Review of policy titled: Therapy Services (P{PolicyStat ID: 8821106) last approved 01/2020, indicated "Patients admitted to the hospital will receive therapy on a daily basis...One-to-one therapy will be offered to those patients that are not physically or emotionally able to tolerate group".

3. Review of Patient 4's MR lacked documentation of daily offering of bath/shower; Patient refused 3 of 11 days (05/29/21, 05/30/21 and 05/31/21) and had shower on 2 days (05/25/21 and 05/27/21); 6 of 11 days lacked documentation.

4. Review documentation of daily activity from 05/21/21 to 05/30/21 with comments that Patient wandering in and out of activity, sleeping or indicating "sick". Lack of documentation of activity before 05/29/21 (admitted 05/21/21). MR lacked documentation of alternative individualized activiity if unable to participate in group.

5. Interview on 07/13/21 at 10:40 am with P53 (Interim Director of Compliance) confirmed that Patient 4's MR lacked complete documentation of daily bath/shower being given or refused; confirmed lack of documentation of Patient receiving daily activity or therapy.