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Based on interview and record review, the facility failed to provide sufficient Registered Nurses (RNs) to be immediately available for bedside care and to meet patients' healthcare needs when the State mandated staffing ratio (California State mandated nurse staffing ratios are one RN to five [1:5] medical-surgical and 1:4 for telemetry patients) was not followed and RNs were assigned primary responsibility for up to eight mixed medical-surgical and telemetry (use of specialized instruments attached to a patient's body that automatically transmits data to a remote location for trained medical individuals to monitor a patient's physical status) patients during their assigned shift.

This failure resulted in one of 24 sampled patients (Pts), Pt 1 to be left unattended by RN 1 after a one to one constant observer (CO) (sitter) had been implemented. Pt 1 fell while attempting to get out of bed alone and sustained a left hip fracture that required surgical intervention and placement in a skilled nursing, rehabilitation facility.

Findings:

During a concurrent hospital tour and interview on 2/4/20 at 10:10 a.m., with the medical-surgical and telemetry west wing Charge Nurse (CN) 1, the hospital's processes for determining how staff assignments were made and for completing patients' physical assessments were reviewed with CN 1. CN 1 stated one of his responsibilities was to determine how patient care assignments were made during his scheduled shifts and Licensed Vocational Nurses (LVNs) along with RNs were included in the unit staffing mix. CN 1 stated it was common practice for LVNs to be paired as a team with an RN, and the RN/LVN team would be assigned to care for a mix of up to eight medical-surgical and telemetry patients. CN 1 stated the 1:8 RN to patient staffing ratio was not aligned with the State mandated 1:5 staffing ratio. CN 1 stated it was their usual practice and the facility policy required the 1:8 staffing ratio when the RN was assigned an LVN to assist with the eight assigned patients. CN 1 stated the 1:8 staffing ratio would be too much for just the one RN without an LVN to assist.

During a concurrent hospital tour and interview on 2/4/20 at 10:25 a.m., with RN 4, the hospital's process for determining how staff assignments were made and for completing patients' physical assessments was reviewed with RN 4. RN 4 stated currently she was assigned as the primary RN on the medical-surgical and telemetry east wing for the day shift (7 a.m. to 7:30 p.m.). RN 4 stated she could not recall the date but had in the past, been assigned as a team (team nursing) along with an LVN to care for eight patients. RN 4 stated team nursing was a common practice on the medical-surgical and telemetry units and the RN/LVN team would be assigned to care for a mix of up to eight medical-surgical and telemetry patients. RN 4 stated eight patients was too much for one RN, it was unsafe and patients did not get the best care.

During a concurrent interview and record review on 2/5/20 at 9:35 a.m., with the Director of Medical Surgical Services (DMSS), Pt 1's clinical records dated 12/15/19 to 12/22/19 and the medical-surgical and telemetry west wing staffing assignment sheets dated 12/18/19 were reviewed with the DMSS. The DMSS validated, on the 12/18/19 RN 1 and LVN 1 were assigned as a team on the evening shift (7 p.m. to 7 a.m.) to provide care to eight patients (two medical-surgical and six telemetry patients), including Pt 1.

A review of the document titled, "Patient Information" indicated Pt 1 was admitted to the hospital on 12/15/19 at 5:13 p.m. and discharged on 12/22/19 at 4:45 p.m.

A review of the document titled "Discharge Summary, dated 12/22/19 at 1:49 p.m., indicated " ... Discharge Diagnosis ... (11) mechanical fall and hip fracture ... pain control, PT [physical therapy] cont. [continued], DVT [deep vein thrombosis (blood clots that move through the veins into the heart, lungs, brain and other major organs in the body)] .. .given high risk post op [operative] ..."

Review of the document titled, "CM [case management] Supplemental Assessment" dated 12/22/19 at 12:30 [p.m.], indicated, "...met with pt [patient], notified of D/C [discharge] plan. Pt complained of pain ... Baseline is: Home in Madera ... States she is able to be independent at home with ADLS [activities of daily living] except uses a walker for amb. [ambulation (walking)] ... She [Pt 1] said she did stay at [skilled nursing facility] in the past but prefers to return home at discharge ..." The DMSS stated Pt 1 was not discharged to her own home and was discharged to a skilled nursing rehabilitation facility on 12/22/19.

During a concurrent interview and record review on 2/5/20 at 9:40 a.m., the DMSS validated Pt 1's clinical record documents and stated based on hospital policy, according to the team nursing model, it was acceptable for one RN to be assigned the overall responsibility for up to eight mixed medical-surgical and telemetry patients as long as an LVN was assigned to assist the RN. The DMSS stated she was aware of the State mandated staffing ratio of 1:5 RNs for medical-surgical units and 1:4 RNs for telemetry units but the hospital followed the 1:8 staffing ratio and not the mandated staffing ratios when they used the team nursing model. The DMSS stated LVNs could perform most of the same tasks as LVNs, except LVNs could not give IV (interveinous) (in the vein) medications. The DMSS stated the hospital did not have a unit specifically licensed for telemetry patients, medical-surgical patients were combined with telemetry patients, they used the 1:5 staffing ratio and 1:8 for team nursing. The DMSS stated she had been employed at the hospital for 18 years and the hospital had followed the 1:8 staffing ratio for RN/LVN team nursing during her entire employment.

During interview on 2/6/20 at 2:45, p.m., the Chief Nursing Officer (CNO) stated, "... We don't have a supply of RNs to make it work without LVNs ... yes, I replaced LVNs with RNs ...LVNs can be in a clinic, but not appropriate for acute care [acute care hospitals] ..." The CNO validated on 12/18/19 during the evening shift, RN 1 and LVN 1 had been assigned as a team to care for eight patients. The CNO stated RN 1 was considered a new graduate RN and had been employed by the hospital for her first RN job about a year prior. The CNO stated she would not have teamed up RN 1 with an LVN to care for eight patients. The CNO stated, "New graduates do not think through their role and what knowledge they do have...In hindsight, I would not have made that assignment ..." The CNO stated she had not considered the correlation of State staffing guidelines with the federal healthcare regulations and she doesn't use [federal healthcare resources] as her "go to place for regulations."

During a review of the facility policy and procedure titled, "Staffing Plan for Nursing and Patient Care Departments," dated 9/19, the policy indicated, "...Policy: The Vice-President/Chief Nursing Officer (CNO) of Patient Care Services is responsible to insure adequate pt [patient] care staffing 24 hours per day. The Vice-President Patient Care Services develops the [hospital name] Plan for the Provision of Care with the Directors and approves for each unit...3. Criteria for deployment of staff among units...Minimum state mandated nursing staff ratios...Number of qualified RNs required for delivering nursing care to patients...Significant staffing variances are reported to the Directors...and CEO as necessary..."

During a review of the facility policy and procedure titled, "Patient Classification System for Transitional Care Unit, Telemetry and Medical/Surgical Unit," reviewed date 1/20, the policy indicated, "...Policy...8. Minimum nurse to patient ratios ar per CDPH [California Department of Public Health] guidelines...10. When minimum staffing guidelines are not met, CDPH will be notified..."

A review of the Professional reference titled "California RN Staffing Ratio Law," dated 2/10/04, indicated, "...With passage of AB 394 in 1999, California became the first state to establish minimum registered nurse (RN)-to-patient ratios for hospitals. Final regulations to implement the law were issued in the summer of 2003, with hospitals required to meet the staffing ratios as of January 1, 2004. AB 394 establishes specific numerical nurse-to-patient ratios for acute care, acute psychiatric, and specialty hospitals in California. The ratios are the maximum number of patients that may be assigned to an RN during one shift. The law requires additional RNs be assigned based on a documented patient classification system that measures patient needs and nursing care, including severity of illness and complexity of clinical need. The law also restricts assignment of unlicensed staff and nursing staff in hospital clinical areas where they do not have demonstrated competency, training, and orientation...The final ratios are listed below in Table 1...Telemetry, 2008 1:4... Medical/Surgical, 2008 1:5..."

Based on interview and record review, the facility failed to provide sufficient Registered Nurses (RNs) to supervise and evaluate the bedside care to meet patients' healthcare needs when Licensed Vocational Nurses (LVNs) were assigned primary care responsibilities and performed direct patient care tasks outside their scope of practice, including patients' comprehensive ongoing physical assessments, generally required to be completed by RNs.

This failure resulted in the comprehensive physical assessments for three of 24 sampled patients (Pts), Pts 1, 23, and 24 to be completed by LVNs without adequate supervision by an RN and had the potential to affect the overall plan of care and contribute to negative health outcomes for Pts 1, 23, and 24 and all other patients not assessed by an RN.

Findings:

During a concurrent hospital tour and interview on 2/4/20 at 10:10 a.m., with the medical-surgical and telemetry west wing Charge Nurse (CN) 1, the hospital's processes for determining how staffing assignments were made and for completing patients' physical assessments were reviewed. CN 1 stated one of his responsibilities was to complete the RNs and LVNs patient care assignment during his scheduled shifts and Licensed Vocational Nurses (LVNs) along with RNs were included in the unit staffing mix. CN 1 stated it was a common practice for LVNs to be paired as a team with an RN and the RN/LVN team would be assigned to care for eight mixed medical-surgical and telemetry patients. The CN stated, the RN on the team was responsible to assign patient care tasks to the LVN, including patients' head to toe (comprehensive) physical assessments. CN 1 stated patients' comprehensive physical assessments could be assigned to the LVN and the RN was responsible for signing off at any time during the shift that they (RN) had reviewed and agreed with the LVNs patient assessments. The CN stated it was not necessary and according to the facility policy, the RN did not have to complete patients' full physical assessments after the LVN had completed them. The CN stated the RN would not have time to do another full physical assessment for all eight patients, it would be too much.

During a concurrent hospital tour and interview on 2/4/20 at 10:25 a.m. with RN 4, the hospital's processes for determining how staff assignments were made and for completing patients' physical assessments were reviewed. RN 4 stated currently she was assigned as the primary RN on the medical-surgical and telemetry east wing for the day shift (7 a.m. to 7:30 p.m.). RN 4 stated she could not recall the date but had in the past been assigned to care for patients as a team with an LVN. RN 4 stated it was a common practice on the medical-surgical and telemetry units for an RN/LVN team to be assigned to care for up to eight mixed medical-surgical and telemetry patients. RN 4 stated she would delegate patient care tasks to the LVN, including responsibility to complete patients' physical assessments. RN 4 stated she would review the LVNs assessments, make sure everything was in the right place, and ensure the documentation in the patients' medical records reflected what had been reported by the RN on the previous shift during the change of shift report. RN 4 stated even though LVNs were included in the team, she would generally see all the patients during the shift and she had primary responsibility for all eight patients. RN 4 stated she did not generally perform a full physical assessment after the LVN, completing a full physical assessment for all eight patients was too much for one RN, it was unsafe, and patients did not get the best care when they were not assessed by an RN.

During a concurrent interview and record review on 2/4/20 at 2 p.m., with the Director of Medical Surgical Services (DMSS), Pt 1's clinical records dated 12/15/19 to 12/22/19 were reviewed. The document titled, "Patient Information" indicated Pt 1 was admitted to the hospital on 12/15/19 at 5:13 p.m. and discharged on 12/22/19 at 4:45 p.m.

Pt 1's nursing progress notes dated 12/18/19 at 8 p.m., indicated LVN 1 had completed the following assessments: Physical Assessment (comprehensive, head to toe); Patient Handling Assessment; Fall Risk Assessment; Skin Assessment; Patient Activity Assessment; and Pain Assessment. The DMSS validated Pt 1's assessments were completed by LVN 1 on 12/18/19 at 8 p.m.

The DMSS stated on 12/18/19 p.m. shift, RN 1 and LVN 1 were assigned as a team to provide care to a total of eight patients (two medical, surgical and six telemetry patients), RN 1 was responsible for all eight patient assigned to the team and had the authority to delegate patient care tasks to LVN 1, including Pt 1's physical assessments.

The DMSS stated on 12/18/19 during the change of shift, at approximately 6:30 p.m. Pt 1's status changed, she became more confused, not using call light, unsteady gait, not following directions and RN 1 assigned a sitter to provide one to one observation (constant observer [CO] face to face, within arm's reach at all times) to Pt 1. There was no documentation by RN 1 or LVN 1 in Pt 1's nursing progress notes or the clinical record to indicate Pt 1's change of condition symptoms to necessitate implementation of a one to one sitter or that the physician was notified about Pt 1's change of condition. The DMSS stated, RN 1's decision to provide a sitter for Pt 1 was based on nursing judgement and it was not necessary to contact the physician for an order prior to implementing a sitter. The DMSS stated, RN 1 should have documented Pt 1's change of condition in the nursing progress notes and notified the physician.

During a concurrent interview and record review on 2/4/20 at 2:10 p.m., with the DMSS, Pt 1's nursing progress note dated 12/18/19 at 11:10 p.m. indicated LVN 1 documented, CO was at Pt 1's bedside. The nursing progress note at 11:20 p.m. by RN 1 indicated report was given by the RN to the CO. The document titled, "Continuous Observation Form [a form that has spaces to document patients' activities and who observed the patient every 15 minutes]," dated 12/18/19 indicated the CO was at Pt 1's bedside at 11 p.m. The space to indicate Pt 1's activities at 11:15 was blank and the CO's initials were lined out in the space for 11:30. The DMSS stated on 12/18/19 at approximately 11:15 p.m., RN 1 relieved the CO for a meal break and assumed sitter responsibilities for Pt 1, RN 1 assumed Pt 1 was asleep, left Pt 1 alone and unattended in her room at about 11:20 and at 11:30 RN 1 heard an alarm sound in Pt 1's room. The DMSS stated when RN 1 returned to the room, Pt 1 was lying on the floor, complaining of hip pain.

Pt 1's nursing progress notes dated 12/18/19 at 11:40 p.m., the nursing progress note indicated, RN 1 documented " ...Critical Value(s) Pt fell in room ..." During a review of the Continuous Observation Form, dated 12/18/19 at 11:30 and 11:45, the Continuous Observation Form indicated, Pt 1 fell on the floor. The DMSS stated as a result of the fall, Pt 1 sustained a left hip fracture that required surgical intervention and Pt 1 could not be discharged to her home where she had resided on her own prior to hospitalization. The DMSS validated there was no documentation in Pt 1's clinical record or nurses progress notes to indicate RN 1 performed a physical assessment either before or after Pt 1 fell on 12/18/19 and RN 1 had only signed off on 12/19/19 at 7:38 a.m. that she agreed with LVN 1's assessment of Pt 1. Pt 1 was discharged to a skilled nursing rehabilitation facility on 12/22/19 at approximately 4:45 p.m.

Pt 1's Discharge Summary, dated 12/22/19 at 1:49 p.m., the Discharge Summary indicated, " ...Discharge Diagnosis ...(11) mechanical fall and hip fracture ...pain control, PT [physical therapy] cont. [continued], DVT [deep vein thrombosis (blood clots that move through the veins into the heart, lungs, brain and other major organs in the body)] ...given high risk post op [operative] ..."

The DMSS stated it was an acceptable practice and according to facility policy, RN's were required to do only the initial assessments when patients were first admitted or when a patient's condition changes (significant change of condition). The DMSS stated RNs were permitted to delegate to LVNs the responsibility to complete patients' comprehensive physical assessments thereafter. The DMSS stated RN 1 should have assessed and documented Pt 1's change of condition that warranted the need for a CO (sitter) and completed a head-to-toe assessment after Pt 1 fell. The DMSS stated RN 1 had the overall responsibility for all eight patients assigned to the RN1/LVN 1 team, the assignment of eight (one RN to eight [1:8] ratio) mixed medical, surgical and telemetry patients was not within the State mandated nurse to patient staffing ratio (California has mandated staffing ratio of 1:5 for medical surgical patients and 1:4 for telemetry patients) and the 1:8 ratio was acceptable because RN 1 and LVN 1 were assigned as a team.

During a concurrent interview and record review on 2/5/20 at 9:50 a.m., with the DMSS, Pts 23's and 24's clinical records were reviewed and indicated the findings as follows:

Pt 23's clinical record document titled, "Patient Information [personal information that includes date and time of admit, discharge, address, and other personal identifying information]" indicated Pt 23 was admitted to the hospital on 12/22/19 at 8:57 p.m. There was no discharge date on the Patient Information form. The DMSS stated Pt 23 was in-patient and had not been discharged from the hospital. The document titled, "Care Activity - Assessments - Filtered" dated 12/20/19 at 12:30 p.m. through 12/28/19 at 8:07 a.m., indicated the following:

" ...12/22/19 08:03 [8:03 a.m.] Physical Assessment [LVN 2's name] ..." Pt 23's day shift physical assessment was completed by LVN 2 at 8:03 a.m. and RN 4 signed off, reviewed and agreed with LVN 1's assessment of Pt 23 at 10:31 a.m. and

" ...12/22/19 19:40 [7:40 p.m.] Physical Assessment [LVN 1's name] ..." Pt 23's evening shift physical assessment was completed by LVN 1 at 7:40 p.m. and there was no documentation to indicate an RN had reviewed and agreed with LVN 1's physical assessment for Pt 23 at any time during the evening shift on 12/22/19.

Pt 24's clinical record document titled, "Patient Information, indicated Pt 24 was admitted to the hospital on 12/14/19 at 9:09 p.m. and discharged on 1/1/20 at 6:26 p.m. The document titled, "Care Activity - Assessments - Filtered" dated 12/14/19 at 9:46 p.m. through 1/1/20 at 10 a.m., indicated the following:

" ...12/31/19 20:00 [8 p.m.] Physical Assessment [LVN 1's name] ..." Pt 24's evening shift physical assessment was completed by LVN 1 at 8 p.m. and there was no documentation to indicate an RN had reviewed and agreed with LVN 1's physical assessment for Pt 24 at any time during the evening shift on 12/31/19.

The DMSS stated all RNs who were assigned to team nursing were responsible to go back and sign off that they reviewed and agree with the LVNs' assessments and the RN generally does not go back and perform a full physical assessment of the patient. The DMSS stated Pt 22's and Pt 23's physical assessments were completed by LVN 1 and LVN 2. The DMSS stated she had been an RN at the facility for 18 years, this was how the process had been conducted during her employment, and she had not received any different directions related to staffing and how patients' assessments were to be completed. The DMSS stated she was not aware of any facility policy that defined the difference between RN's and LVN's scopes of practice.

During an interview on 2/6/20 at 2:45 p.m., with the Chief Nursing Officer (CNO), the CNO stated, "...We don't have a supply of RNs to make it work without LVNs ...yes, I replaced LVNs with RNs ...LVNs can be in a clinic, but not appropriate for acute care [acute care hospitals] ..." The CNO validated on 12/18/19 during the evening shift, RN 1 and LVN 1 had been assigned as a team to care for eight patients, Pt 1's physical assessment was performed by LVN 1, and RN 1 did not sign off on Pt 1's assessment until the end of the shift. The CNO stated RN 1 was considered a new graduate RN and had been employed by the hospital for her first RN job about a year prior. The CNO stated she would not have teamed up LVN 1 with RN 1 to care for eight patients, and new graduates do not think through their role and what knowledge they do have, " ...In hindsight, I would not have made that assignment ..."
The CNO stated the scope of practice for an LVN was basic assessments involving data collection, she would not have teamed up an LVN 1 with RN 1, and new graduates do not think through their role and what knowledge they do have. The CNO stated she had reviewed patients' records at various times including patients' assessments and from what she saw, she did not see any red flags and she was comfortable with LVNs completing patients' physical assessments and RNs signing off that they reviewed and agreed with the assessments, once the initial admit assessment was completed. The CNO stated she had not considered the correlation of State staffing guidelines with the federal healthcare regulations and she doesn't use [federal healthcare resources] as her "go to place for regulations."

During a review of the facility policy and procedure titled, "Assessments/Reassessments," dated 12/19, the policy indicated, "...Policy: Each patient who receives services will have an initial RN assessment that is to be documented in the Electronic Health Record (EHR)...physical assessment...An evaluation of physical, psychological, social and spiritual needs as well...Additional areas of assessment such as nutritional, functional and discharge needs are assessed when warranted by patient's condition...Care decisions will be based upon data gathered at the time of the initial assessment and reassessments [physical assessment completed each shift]. Assessment date will be utilized to determine appropriate interventions...Assessment and Reassessment Procedure by Department...4. It is the responsibility of the RN to notify the physician when there is a change in the patient's condition..."

Professional reference, California Code of Regulations, Title 22, Section 70215 titled "Planning and Implementing Patient Care," indicated, "(a) A registered nurse shall directly provide: (1) Ongoing patient assessments as defined in the Business and Professions Code, section 2725(b)(4). Such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area ..."

Professional reference, California Nursing Practice Act, Business and Professions Code Chapter 6, Article 2, titled "Scope of Regulation," indicated, " ...(b) The practice of nursing within the meaning of this chapter means those functions, including basic health care ...and that require a substantial amount of scientific knowledge or technical skill, including ...(1) Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures ...(4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures.

Based on observation, interview, and record review, the hospital failed to provide a patient with a nurse who had the appropriate competencies (having a specific knowledge base, skills in using equipment and performing procedures, and behaviors that integrate critical thinking and standards to meet the patient's needs and achieve desired outcome) and qualifications for one patient (Pt 4) when a nurse was floated from another area of the hospital to the intensive care unit to care for the patient without having received the appropriate training .


This failure had the potential to result in patient needs not being met and changes in patient's condition going unnoticed.

Findings:

During a concurrent observation and interview on 2/4/2020 at 9:25 a.m., in the Intensive Care Unit (ICU) (a department of a hospital in which patients who are dangerously ill are kept under constant observation), RN 3 was assigned to care for Pt 4. RN 3 stated Pt 4 was admitted with respiratory (breathing) failure and was on a ventilator (a life-saving machine that keeps a patient breathing). RN 3 stated he had not been trained to care for patients on ventilators and that he was not competent to care for patients in the ICU. RN 3 stated "I don't think it's safe for the patient." RN 3 stated, "If I were a family member of this patient I would be concerned" ...that an unqualified nurse was caring for this patient."

During an interview with CN (Charge Nurse) 1 on 2/4/2020 at 2:42 p.m., CN 1 stated the ICU was short-staffed when she came in that morning, and two nurses from other areas of the hospital were sent to the ICU to care for patients. CN 1 stated RN 3 was assigned to Pt 4. CN 1 stated Pt 4 is dependent on a ventilator and medications that are only managed by ICU trained nurses. CN 1 stated that she assists RN 3 with the care of Pt 4, but that she is assigned two ICU patients of her own. CN 1 stated when other nurses go on lunch break, she covers their patients, and during that time she is covering her own two patients, two patients for the nurse on break, and assisting RN 3. CN 1 also stated if there is a Code Blue (patient emergency) in another part of the hospital, she is expected to leave the ICU and assist with the emergency, and when this occurs she hands off care of her patients to the other nurses in the ICU.

During a concurrent interview and record review of the employee competency file for RN 3 on 2/4/20 at 3 p.m., with the informatics nurse (IN), the IN was unable to locate ICU competencies in RN3's file.

During a review of hospital policy titled "Staffing Plan for Nursing and Patient Care Departments dated 9/19, the policy indicated, "... 3. Criteria for deployment of staff among units considering...qualified RNs required for delivering nursing care to patients requiring a specific level of care..."