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Based on record review and interview the facility failed to provide adequate numbers of nursing personnel, including Registered Nurses (RN) on the day, evening and night shifts on three (3 ) of five (5) patient care units (1 East: Acute Forensic, 2 East: Acute Geriatric, and 3 East: Child and Adolescent. Frequently, there was only one RN and one Mental Health Technician (MHT) assigned to each of the shifts on these units. Registered Nurses were required to attend code blue and rapid response emergencies on other units, go to the pharmacy to pick-up medication and take lunch breaks. While off their assigned unit to perform the above tasks, the units were left with para-professional nursing staff; Licensed Practical Nurse (LPN) and MHTs. This failure to have a professional nurse on the units at all times to assess patient's care needs, monitor patient care and provide supervision and direction to nursing staff created a potential safety risk for patients and staff. (Refer to B150)

Based on record review and interview, the Director of Nursing failed to provide adequate numbers of nursing personnel, including RNs on all tour of duty (day, evening and night for 1 East, 2 East and 3 East) patient care units. The staffing pattern of one (1) RN and one (1) MHT per shift resulted in the units being left without a professional nurse to assess, monitor and supervise patient care and para-professional nursing staff. RNs were assigned duties such as attending code blue/rapid response, pharmacy pick-up, and lunch breaks which were off unit activities. Also, there were times when the RN was the only nursing staff on the units. This failure to provide adequate levels of nursing staff created a potential safety risk for patients and staff. (Refer to B150)

Based on record review and interview, the Director of Nursing failed to ensure at least one (1) Registered Nurse (RN) was present at all times on three (3) of five (5) patient care units (1 East, 2 East, and 3 East) during each eight-hour shift (day, evening and night). RNs were required to attend off unit activities such as code blue, rapid response, and pharmacy pick-ups during the eight-hour shift. RN may also be absent from their assigned units for their meal breaks. During these periods of absences, there may be an Licensed Practical Nurse (LPN) and Mental Health Technician (MHT) on the unit. On occasions, there were times when the RN was the only nursing staff on the unit with patients. This pattern of staffing resulted in units being without a RN to assess, monitor patient care and provide supervision and direction for para-professional nursing staff. This failure created a potential safety risk for patients and staff.

Findings include:

A. Record Review

1. The staffing matrix date, 1/18/18, required the following staffing levels: Unit 1East (Acute Forensic) to have one 1 RN and 1 MHT for a census of 1 through 10 patients on the day, evening and night shift. Unit 2 East (Acute Geriatric) to have 1 RN for up to 25 patients and 1 MHT for 1 through 9 patients. Unit 3 East (Child and Adolescent) to have 1 RN and 1 MHT for day and night shift for 1 through 10 patients, evening shift 1 RN and 1 MHT for 1 through 10 patients and 1 RN and 2 MHTs for 11 through twelve12 patients.

2. A review of the three units (1 East, 2 East and 3 East), "Patient Care Assignment Sheet" for a two weeks period of 11/21/18 - 11/27/18 and 12/4/18 - 12/10/18 revealed that the RN on duty for day, evening and night shifts were assigned to attend "Code Blue/Rapid Response," even when there was only one RN on duty.

3. The "Direct Nursing Staffing Form" which was completed by the Director of Nursing for the two weeks 11/21/18 through 11/27/18 and 12/4/18 through 12/10/18 (the first day of the survey), revealed the following units had 1 RN and 1 MHT assigned.

I. 1 East - Forensic (11/21/18 through 11/27/18)
A. Census: 8. Date - 11/21/18 1 RN on duty for each shift. 1 MHT night shift.
B. Census: 8. Date - 11/22/18 1 RN on duty for each shift. 1 MHT for each shift.
C. Census: 8. Date - 11/23/18 1 RN on duty for each shift. 1 MHT for each shift.
D. Census: 8. Date - 11/24/18 1 RN on duty for each shift. 1 MHT for each shift.
E. Census: 8. Date - 11/25/18 1 RN on duty for each shift. 1 MHT for each shift.
F. Census: 8. Date - 11/26/18 1 RN on duty for each shift. 1 MHT for each shift.
G. Census: 8. Date - 11/27/18 1 RN on duty for each shift. 1 MHT for evening and night shifts.

II. 1 East - Forensic (12/4/18 through 12/10/18)
A. Census: 8. Date - 12/4/18 1 RN on duty for each shift. 1 MHT for each shift.
B. Census: 8. Date - 12/5/18 1 RN on duty for each shift. 1 MHT for each shift.
C. Census: 8. Date - 12/6/18 1 RN on duty for each shift. 1 MHT for each shift.
D. Census: 8. Date - 12/7/18 1 RN on duty for each shift. 1 MHT for each shift.
E. Census: 8. Date - 12/8/18 1 RN on duty for each shift. 1 MHT for each shift.
F. Census: 8. Date - 12/9/18 1 RN on duty for each shift. 1 MHT for each shift.
G. Census: 8. Date - 12/10//18 1 RN on duty for each shift. 1 MHT for each shift.

III. 2 East - Geriatric (11/21 through 11/27)
A. Census: 11. Date - 11/21/18 1 RN on day shift. 1 RN on the night shift.
B. Census: 11. Date - 11/22/18 1 RN on day shift. 1 RN on the night shift.
C. Census: 11. Date - 11/23/18 1 RN on duty for each shift.
D. Census: 10. Date - 11/24/18 1 RN on duty afternoon shift and night shift.
E. Census: 11. Date - 11/25/18 1 RN on duty on day shift and afternoon shift.
F. Census: 11. Date - 11/26/18 1 RN on duty for the afternoon shift.
G. Census: 12. Date - 11/27/18 1 RN on duty for the afternoon shift.

IV. 2 East - Geriatric (12/4/18 through 12/10/18)
A. Census: 15. Date - 12/4/18 1 RN on duty for afternoon and night shift.
B. Census: 15. Date - 12/5/18 1 RN on duty for afternoon and night shift.
C. Census: 17. Date - 12/6/18 1 RN on the afternoon shift. 1 RN on the night shift.
D. Census: 17. Date - 12/7/18 1 RN on duty for each shift.
E. Census: 16. Date - 12/8/18 1 RN on duty for day and night shift.
F. Census: 16. Date - 12/9/18 1 RN on duty for each of the shifts.
G. Census: 18. Date - 12/10//18 1 RN on duty for the afternoon shift.

V. 3 East - Child/Adolescent (11/21/18 through 11/27/18)
A. Census: 10. Date - 11/21/18 1 RN on duty for afternoon and night shifts. 1 MHT for night shift.
B. Census: 11. Date - 11/22/18 1 RN on duty for each of the shifts. 1 MHT for the night shift.
C. Census: 11. Date - 11/23/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
D. Census: 11. Date - 11/24/18 1 RN on duty for the day and night shifts.
E. Census: 11. Date - 11/25/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
F. Census: 11. Date - 11/26/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
G. Census: 11. Date - 11/27/18 1 RN on duty for each of the shifts. 1 MHT for night shift.

VI. 3 East - Child/Adolescent (12/4/18 through 12/10/18)
A. Census: 10. Date - 12/4/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
B. Census: 9. Date - 12/5/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
C. Census: 7. Date - 12/6/18 1 RN on duty for afternoon and night shifts. 1 MHT for night shift.
D. Census: 9. Date - 12/7/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
E. Census: 8. Date - 12/8/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
F. Census: 8. Date - 12/9/18 1 RN on duty for each of the shifts. 1 MHT for night shift.
G. Census: 8. Date - 12/10//18 1 RN on day shift. 1 MHT for night shift.

B. Interview

1. During an interview on 12/10/18 at 1:35 p.m. with RN Charge Nurse 1, RN meal breaks were discussed. RN1 stated, "the LPN is usually on the unit when I take my lunch break and when the LPN is on lunch I am on the unit."

2. During an interview on 12/10/18 at 2:15 p.m. with RN Charge Nurse 2, coverage for RN meal breaks and other off unit duties were discussed. RN stated that "I stay on the unit if there is not another license nurse, but if the LPN is on the unit I will take my break. We usually schedule our meal break opposite to each other so a license person is on the unit."

3. During an interview on 12/10/18 at 2:45 p.m. with RN 3, RN stated [s/he] calls to be relieved for lunch. "There are times when we have to go to get medications from pharmacy and attend codes then the MHT and LPN, if we have one, will be on the unit. I will take my lunch break if there is a LPN on the unit, if there is no LPN and I am the only RN, I will notify the supervisor and get approval to be paid for not taking a lunch."

4. During an interview on 12/11/18 at 11:00 a.m. with the Interim Nursing Director. Staffing of units were discussed. The DON stated that, "All Registered Nurses are assigned to respond to Code Blue and Rapid Response calls and sometimes the RN have to step off the unit to go to the pharmacy." She concurred there are times when there is no RN on the unit.

5. During an interview on 12/11/18 at 11:35 a.m. with the Clinical Coordinator RN4, RN4 concurred with the findings that there are times when there are no RNs on the unit.

6. During an interview on 12/11/18 at 3:35 p.m. with RN Charge Nurse 6, Staffing on the unit was discussed. RN6 stated, "There are times when the RN is alone on the unit, MHT takes patients to meals and the RN is left with the patients on the unit. I do not feel safe because of the unpredictable behaviors of the patients. Nine (9) out of ten times when we left the unit for lunch, only the techs are on the unit. The staffing is bare bones, based on number of patients on unit and not their behaviors."

7. During an interview on 12/11/18 at 3.54 PM with MHT3 stated, "I don't believe staffing is adequate, we should have another staff working the floor. When the nurse goes to code blue, rapid response and lunch and there is no nurse on the floor, they will send another MHT. Sometimes the nurse is the only staff on the floor."