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Based on the interview and record review, the facility failed to ensure written staffing policies and procedures were followed, affecting three out of three staff (RN1, RN2, and LVN1) sampled. This deficient practice resulted in staff not receiving meal breaks during their eight-hour shift, which has jeopardized staff's health and increased the risk of unsafe patient care.

Findings:


During an observation on 9/6/23 at 3:00 p.m. in the Del Sol unit with the director of risk management and performance improvement (DRMPI), upon entrance, there were patients walking the hallway, chasing after one male staff member, requesting items. Down the hallway, three male patients approach a female staff member. One male staff member was standing at the doorway of the patient room, speaking with one female patient who was using profanity and appeared angry, while two other female patients were standing by, waiting for their turn to approach the staff. As the male staff start to walk away, the other two female patients follow him and ask questions. At the nursing station doorway, there are three male patients waiting at the door.


During an interview on 9/6/23 at 3:15 p.m. with Registered Nurse (RN) 1, RN 1 stated, "Today there is a staffing shortage again; they are short of one RN and short of four hours of an LVN that should be on duty." She explained that sometimes they have 37 patients and only one RN. The RN further stated, "Staffing shortages definitely affect patient care because they take away attention from patients and decrease the time the RN has to monitor patients." She stated that when all units are short of registered nurses, she will miss her meal breaks. She will not be able to have a meal because there is no registered nurse available to cover for her, so she will not eat.


During an interview on 9/6/23 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated that the facility has been having a staffing shortage for the past 5 to 6 months. LVN1 stated that the staffing shortage did not get better. LVN stated that the staffing shortage has been worse for the past two months. LVN stated, "The staffing shortage has affected patient care because it takes away from the time she can spend with the patient." She stated that she never gets a chance to take her 15-minute breaks.

During an interview on 9/11/23 at 12:15 p.m. with Registered Nurse (RN) 2, RN 2 stated that there is a staff shortage. RN2 stated, "Sometimes there is only one RN for the entire unit or just one licensed nurse for the entire unit. This occurs about two to three times every two weeks. RN 2 further stated, "Staff shortages are affecting patient safety."

During a concurrent interview and record review on 9/6/23 at 3:45 p.m. with the DRMPI and the Chief Executive Officer (CEO), the Del Sol's staffing assignment dated from 8/7/23 to 8/14/23 for the a.m. shift and the p.m. shift was reviewed and compared to the facility's "Staffing Ratios," not dated. The CEO stated that these are the guidelines the facility follows for staffing the units. The CEO stated the facility staffing policy references this Staffing Ratios guideline and was reviewed by the board in March of 2022. The DRMIPI explained that there are three shifts: the day shift (7:00 a.m. to 3:30 p.m.), the evening shift (NOC) (3:00 p.m. to 11:30 p.m.), and the night shift (11:00 p.m. to 7:30 a.m.). Staffing assignment reviewed with DRMIPI:

On 9/7/23, on night shift with a census (number of patients on the unit) of 37, one RN was assigned; according to the facility staffing ratio guidelines, the Del Sol unit should have two RN.

On 8/9/23, evening shift with census 38, assigned one LVN for the first half of the shift and two LVN for the other half of the shift, according to the facility staffing ratio guidelines, Del Sol unit should have staff with two LVN for the entire shift.

On 8/11/23, NOC shift, with census 38, assigned one RN for the first half of the shift and two RN for the second half of the shift; according to the facility staffing ratio guidelines, Del Sol unit should have two RN for the entire shift.

On 8/12/23, day shift with census 42 was assigned two RN; according to the facility staffing ratio guidelines, the Del Sol unit should have three RN.

On 8/12/23, the evening shift with census 42 was assigned two RN; according to the facility staffing ratio guidelines, the Del Sol unit should have three RN.

On 8/12/23, NOC shift with census 36 was assigned one RN; according to the facility staffing ratio guidelines, the Del Sol unit should have two RNs.

On 8/13/23, day shift with census 39, assigned two RNs, should have three RNs. Assigned 1 LVN for half the shift and two LVN for the other half of the shift, but should have two LVN for the entire shift in accordance with the facility staffing ratio guidelines for the Del Sol unit.

On 8/13/23, evening shift with census 41, assigned two RN, but should have three RN. Assigned one LVN but should have two LVN in accordance with the facility staffing ratio guidelines for the Del Sol unit.

On 8/13/23, the NOC shift with census 43 should have had one LVN but did not have one. Assigned three mental health technicians (MHT) but should have four MHT in accordance with the facility staffing ratio guidelines for the Del Sol unit.

On 8/14/23, day shift with census 43 was assigned one LVN, but should have two LVN in accordance with the facility staffing ratio guidelines for the Del Sol unit.

During a concurrent interview and record review on 9/6/23 at 4:05 p.m. with the CEO, the facility's policy and procedure (P&P) titled "Hospital Plan for Nursing Services," dated March 2022, was reviewed. The P&P indicated, "It is the responsibility of the RN House Supervisor, in collaboration with the Nursing Administrative Assistant (NAA), to coordinate nursing staffing on the patient care units in accordance with staffing standards. Each unit shall have a charge nurse for each shift who is responsible for assigning, delegating, and coordinating all nursing care provided on the unit or program and for the supervision of nursing staff. They report directly to the RN House Supervisor. Each unit shall have a designated number of licensed psychiatric technicians, licensed vocational nurses, and/or psychiatric assistants working under the charge nurse based on unit census, patient acuity, and other patient care needs. An adequate number and appropriate mixture of competent nursing staff, including RNs, LVNs, LPTs, and PAs, will be provided to assure adequate supervision and safe delivery of patient care within economically responsible guidelines. Please see staffing ratios for each unit."