HospitalInspections.org

The Condition of Participation of Nursing Services has not been met.

Based on clinical record reviews, review of hospital documentation, review of staffing plans, review of nursing assignments, review of policies, tour of the hospital, and interviews for 6 of 13 sampled patients (Patients # 1, 2, 3, 7, 8 and 10) who were reviewed for staffing and delivery of care, the hospital failed to ensure that staffing levels were adequate to provide timely patient assessments, critical medication administration, timely meals, and supervision of a patient at risk to fall.


Please see A392

Based on clinical record reviews, review of hospital documentation, review of staffing plans, review of nursing assignments, review of policies, tour of the hospital, and interviews for 6 of 13 sampled patients (Patients # 101, 102, 103, 107, 108 and 110) who were reviewed for staffing and delivery of care, the hospital failed to ensure that staffing levels were adequate to provide timely patient assessments, critical medication administration, timely meals, and supervision of a patient at risk to fall. The findings include:

a. Patient #101 was admitted on 10/25/22 with diagnoses to include hypertension, symptomatic anemia, and duodenal ulcer.

A review of the Physician's progress note dated 11/16/22 identified Patient #101 underwent an Esophageal Gastro-Duodenoscopy (EGD-test to examine the lining of the esophagus, stomach and first part of the small intestine) which showed one vessel with a spurting hemorrhage. The note identified Patient #1 had a history of recurrent hematemesis and directed to continue high dose intravenous Protein Pump Inhibitor (Pantoprazole) and to monitor for signs of active bleeding.

The physician's order dated 11/16/22 at 4:01 PM directed Pantoprazole 40 mgs (8 mgs/hr) sodium chloride 0.9% drip 100 ml.

Review of Patient #101's Medication Administration Record (MAR) dated 11/16/22 identified Pantoprazole was administered at 6:48 PM (2 hours and 48 minutes after the physician's order).
Review of hospital documentation by RN #18 dated 11/16/22 identified a Pantoprazole drip was ordered for Patient #101 on 11/16/22 at 4:01 PM. The report identified the RN was unable to start the drip until 6:48 PM due to the RN caring for 9 patients.

A review of the staffing sheet dated 11/16/22 identified the cardiac telemonitoring unit had a census of 41 patients between 3:00 PM - 11:00 PM and was staffed with 5 RNs (RN: Patient ratio 1:8 and 1:9).

An interview and review of patient assignments for 11/16/22 with RN #18 on 12/20/22 at 3:16 PM identified that RN #18 had a 9- patient assignment. RN #18 indicated that Patient #101 had an endoscopy completed in which a bleed was identified, and the physician ordered for Pantoprazole drip to be started. RN #18 stated she was unable to administer Patient #1's medication in a timely manner and consistent with the hospital's policy and identified she was having challenges meeting the needs of the patients as the hospital was short staff.

A review of the Hospital's staffing plan with the Chief Nursing Officer (CNO) on 11/22/22 at 11:28 AM identified the RN to patient ratio of 1:4-7 for Telemetry unit.
Review of the Hospital's Administration of Medication Policy directed medications can be given 1 hour before and 1 hour after the scheduled time.

The Hospital failed to ensure there was adequate staff to administer required medication in a timely manner.


b. Patient #102 was admitted on 11/13/22 with diagnoses to include Gastrointestinal bleed, sepsis secondary to aspiration pneumonia and a history of tachypnea and tachycardia.

The physician's order dated 11/14/22 at 4:00 PM directed to administer Ampicillin- sulbactam (Unasyn) 3 grams intravenous piggyback every 6 hours 100 ml.

Review of Patient #2's MAR dated 11/14/22 identified Unasyn was due at 4:00 PM was administered at 6:55 PM (nearly 3 hours from the time medication was due).

Review of hospital documentation completed by RN #18 dated 11/16/22 identified that Patient #102's Unasyn was due to be administered at 4:00 PM. The report identified the RN was unable to administer Unasyn until 6:55 PM due to the RN caring for 9 patients.

A review of the staffing sheet dated 11/16/22 identified the cardiac telemonitoring unit had a census of 41 patients between 3:00 PM - 11:00 PM and was staffed with 5 RNs (RN: Patient ratio 1:8 and 1:9).

An interview and review of patient assignments for 11/16/22 with RN #18 on 12/20/22 at 3:16 PM identified that RN #18 had a 9-patient assignment. RN #18 indicated she was unable to administer Patient #102's medication in a timely manner and consistent with the hospital's policy and identified she was having challenges meeting the needs of the patients as the hospital was short staff.

A review of the Hospital's staffing plan with the CNO on 11/22/22 at 11:28 AM identified an RN to patient ratio of 1:5-7 for medical and surgical units.

The Hospital failed to ensure there was adequate staff to administer required medication in a timely manner.

c. Patient #103 was admitted on 12/8/22 with diagnoses to include non-stemi (heart attack) and with history of dyspnea and chest tightness. Review of the Patient #103's laboratory results dated 12/12/22 at 5:52 AM identified a potassium level of 3.0 (normal range 3.5-5.3).

A physician's order dated 12/12/22 at 6:56 AM directed Potassium chloride 40 meg orally (po) x 2 doses every 2 hours first dose "now".

Patient #103's MAR dated 12/12/22 identified Potassium chloride was administered at 10:23 AM (4 hours from the time of physician's order).

Interview with RN #6 and review of the staff/patient assignment log on 12/12/22 at 12:10 PM identified RN #6 was assigned 3 patients in the Intensive Care Unit. RN #6 indicated she was unable to administer the potassium chloride as ordered timely as she was assigned to care for 3 patients as well as assuming charge responsibilities and duties and could not get to the patient in a timely manner.

An interview with Assistant Manager #2 on 12/12/22 at 11:51 AM identified the nurse-to-patient ratio for ICU patients was 1:2. Assistant Manager #2 indicated it was a common occurrence to have the nurse-to-patient ratio of 1:3, especially on the night shifts. The assistant manager stated it was not uncommon for a patient that required 1:1 care for 24 hours to be removed from 1:1 sooner than outlined in the policy due to issues with short staff.

An interview with Nurse Educator #1 on 12/20/22 at 2:26 PM identified that a Physician's order that directed medications to be administered 'NOW' meant as soon as possible. Nurse Educator #1 indicated that administering a medication directed to be administered 'now' 2-3 hours from the time of the order would be too long between the order and the administration of the medication and not acceptable.

A review of the Hospital's staffing plan with the CNO on 11/22/22 at 11:58 AM identified a RN to patient ratio of 1:1-2 for the Intensive care unit.

The Hospital's Administration of Medication policy directed medications can be given on hour before or after the scheduled time. The policy did not address the administration of medications directed to be administered 'NOW.'

The Hospital failed to ensure there was adequate staff to ensure the patient received required medication in a timely manner.


d. Patient #107 was admitted on 8/8/22 with diagnoses to include meningitis. Review of Patient #107's History and Physical dated 9/2/22 at 12:43 PM identified a Rapid Response (Fast team emergency care) was called on 12/2/22 at 12:00 PM as patient was noted to be hypotensive, hypothermic, and only arousable by sternal rub. The History and Physical identified Patient #107 was admitted to the critical care unit for worsening of metabolic encephalopathy and sepsis in the setting of meningitis.

Review of the Fast Team record identified the Rapid Response team arrived at 11:45 AM and noted Patient #107 unresponsive with a rectal temperature of 93.4 degrees (low) and blood pressure of 80's- 90's/50's. The record identified interventions included warming blanket, monitoring of arterial blood gas, and noted Patient #107 was transferred to the Progressive care unit (step down) at 12:40 PM.

Review of Patient #107's clinical record dated 9/2/22 identified vital signs documentation by Patient Care Technician (PCT) #1 to include: 9/2/22 at 9:36 AM Heart rate 94, respiratory rate 16, oxygen saturation of 99% (No temperature documented at this time). 9/2/22 at 10:00 AM - Temperature 34.1 degrees Celsius 93.4 degrees Fahrenheit (low).

A provider notification note dated 9/2/22 at 11:19 AM identified Patient #107's temperature was noted to be 93.4-degree Fahrenheit, identified Patient #107 was unresponsive and indicated the physician ordered warming blanket and directed to recheck Patient #107's temperature in one hour.

The Provider notification note dated 9/2/22 at 11:30 AM identified Patient #107 was unresponsive with critical temperatures, pale with shallow breathing and identified multi-specialist team (Rapid Response) was contacted to evaluate the patient and make recommendations.

Interview with RN #3 on 12/12/22 at 10:30 AM identified Patient #107 experienced changes in mental status leading to activation of the rapid response team and transfer of Patient #107 to a higher level of care. RN #3 stated that with her assigned patients (8 patients) she was unable to adequately assess and monitor Patient #107 in a timely manner as the unit was short staff.

Review of the nurse patient assignment for the unit dated 9/2/22 identified RN #3 was assigned to care for 8 patients and in addition had the responsibility of precepting another staff.

An interview with PCT #1 on 12/20/22 at 1:22 PM identified she was unable to recall Patient #107 but indicated when she obtained abnormal vital signs as was the case for Patient #107, she would inform the RN immediately.
Review of Patient #107's clinical record lacked documentation that Patient #107 was assessed, and hypothermia addressed for over 1 hour and 19 minutes after the hypothermia was recognized.

A review of the Hospital's staffing plan with the CNO on 11/22/22 at 11:58AM identified a RN to patient ratio of 1:5-7 for the medical/Surgical units.

The Hospital failed to ensure there was adequate staff to ensure the patient received timely assessment and intervention when hypothermia (low temperature) was identified.


e. Patient #108 was admitted on 10/27/22 with diagnoses to include gallbladder cancer, abscess of liver and anemia.
Review of Patient #108's laboratory results dated 10/27/22 identified a hematocrit level of 24.5 % (measures the red blood cells in the blood -normal range 42-54%) and a hemoglobin level of 8.1g/dl (measure of the oxygen carrying capacity of the blood- normal range 14- 18 g/dl in males).

Review of hospital documentation identified Patient #108 fell twice in a 24-hour period between 11/2/22- 11/3/22. The event report dated 11/2/22 at 8:33 PM identified the Patient fell from a chair, reported hitting head and sustained laceration. The report indicated a rapid response was called, and a head computerized Tomography (CT) was ordered.

Review of Patient #108 Fall risk scale assessment identified on 11/2/22 at 8:00 PM the patient was assessed at a fall score of 35 (low fall risk) prior to the first fall and a fall score of 60 (high fall risk) was assessed on 11/3/22 at 8:42 AM after the first fall.

A Physician's Progress Note Event discussion dated 11/2/22 at 8:12 PM identified the physician was called to evaluate the Patient after a rapid response when Patient #108 fell from the chair. The progress note identified the exam was notable for posterior scalp laceration. The note identified CT of head and spine were ordered because patient did not remember why or how s/he fell. The progress note indicated to continue to monitor for symptoms.

Review of an Event report dated 11/3/22 at 4:44 PM identified Patient #108 was brought to the bathroom and instructed by the Patient care technician (PCT) to call when done using the bathroom. The report identified Patient #108 leaned forward to clean self, felt his/her legs weak and lowered self to the floor.

The Physician's Event note dated 11/3/22 identified a rapid response was called for patient #108's fall in the bathroom. The note indicated Patient #8 was sitting on the toilet and about to wipe when the patient started feeling weak and lightheaded and lowered self to the floor. The note identified Patient #8 complained of left lateral rib pain around the surgical drain. The physician's exam identified patient had bilateral para vertebral tenderness but with no midline bony tenderness and no neurological defects.

An interview with RN #3 on 12/12/22 at 10:30 AM identified on the day of Patient #108's falls the unit was short staff, indicated the PCT had too many patients, and was unable to get back to Patient #108.

An interview with Nurse Educator #1 on 12/20/22 at 2:26 PM identified patients with fall risk scores of 45-120 were considered high fall risks and stated that staff should be within arm's length of the patient when in the bathroom. Nurse Educator #1 identified that the patient should not be left alone in the bathroom.

An interview with Patient Care Technician (PCT) #2 on 12/20/22 on 3:51 PM identified she was aware Patient #108 was a high fall risk and should not have been left alone on the toilet. PCT #2 identified she was assigned 12 patients, stated she had 2 patients on toilets and indicated she had to leave Patient #108 to check on another patient who was also left on the toilet. PCT #2 indicated the unit was short staffed and she was unable to remain with patient #8.

A review of the hospital's staffing plan with the CNO on 11/22/22 at 11:58 AM identified a PCT/CNA to patient ratio of 1:8-10 for the medical/Surgical units.
The Hospital failed to ensure there was adequate staff to ensure the patient received adequate supervision to prevent a fall.


f. Patient #110 was admitted on 11/19/22 with diagnoses of anemia and renal disease and a chief complaint of increased confusion, lethargy, and poor intake.

Review of the History and Physical (H&P) dated 11/20/22 identified Patient #110 presented to the hospital with shortness of breath, confusion, generalized weakness and a drop in blood pressure while undergoing a computerized tomography (CT scan). The H&P identified that Patient #110's hypotension was in the setting of dehydration and poor intake.

A review of communication by the patient/family with the hospital after patient's discharge identified that no one assisted the patient with ordering of meals. Hospital documentation failed to address the events of 11/22/22 when Patient #110 was not provided a breakfast meal until 11:58 AM.

Review of the meal order documentation identified on 11/20/22 that the order for the first meal of the day was placed at 10:45 AM, identified that on 11/21/22 Patient #110 refused breakfast at 10:10 AM and identified that on 11/22/22 the first meal order of the day for patient #110 was placed at 11:58 AM.

An interview with RN #13 on 12/13/22 at 2:42 PM identified she was caring for Patient #110 on the morning of 11/22/22 when the patient requested assistance with ordering his/her meal. RN #13 indicated she was unable to get back to the patient for 3 hours resulting in patient not having breakfast meal until noon. RN #13 identified that due to short staff she was unable to assist Patient #110 with meals in a timely manner and stated the patients she was assigned were all high acuity (needed close attention). The unit census was 42 patients with 7 nurses for a ratio of 1:6.

A review of the hospital's staffing plan with the CNO on 11/22/22 at 11:58 AM identified the RN to patient ratio of 1:5-7 for the medical/Surgical units.

The Hospital failed to ensure there was adequate staff to ensure the patient with history of dehydration and poor intake received meals timely.

An interview with the CNO on 12/21/22 at 3:00 PM identified the Hospital's staffing plan was prepared and submitted to the state agency annually and was only a guideline that could be adjusted as needed.

On 12/21/22 at 3:00 PM, the Hospital's CNO identified the hospital was addressing the issue of short staffing with short term plans to include offering incentives, utilizing staff in leadership positions, intermittently closing of 6 beds on one unit, closure of the stroke unit and utilizing the staff on other units, midrange plans to include travelers to return and 18 new PCTs to start on 1/3/23, recruiting high school and LPN students as PCTs and long term goal to include 32 new recruited RNs to start 7/2023.