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Based on review of staffing records, staffing plan, acuity plan, nursing personnel assignments, and interview, it was determined the hospital failed to:

1. provide adequate number of nursing personnel to meet the needs of patients in an emergency situation and maintain ongoing coverage of other patients during the emergency in 12 of 14 shifts reviewed; and

2. comply with the governing board approved acuity plan for determining patient assignments based on the acuity of the patients and the skill level to meet the needs of the patients by the certified nursing assistants in 6 of 14 shifts reviewed for CNA assignments.

Findings include:

The staffing plan dated November 2010 and confirmed as current during interview with the Chief Clinical Officer revealed: "... The Director of Nursing and/or Charge Nurse will assure that patient care assignments are commensurate with the qualifications of nursing personnel involved, patient acuity, prescribed medical regimes, the staffing mix, patient and personal preference, infection control practice and geographic location...."

1. A review of the nurse staffing schedules and the assignments for the dates of December 2, 3, 2013 and January 5, 6, 11, 18 and 24 revealed the assignments included the Code Assignment. This was the projected staffing to handle an emergency (Code) during the shift. The code assignment included the name of person to run the code, which was assigned to the Charge Nurse on duty for both the day and evening shifts; recorder, which was assigned to a registered nurse (RN); chest compression responsibility was assigned to an RN or a certified nursing assistant; medication administration assigned to an RN; the runner and the door for ambulance assignment was generally a certified nursing assistant or a unit secretary; and the defibrillation activity was assigned to an RN. There were some shifts where the medication and defibrillation activity was assigned to the same RN.

The review of the assignments for the stated dates revealed if a code event would have occurred there would have not been enough RNs on staff to provide the assigned code responsibilities and continue caring for patients on a nursing unit. The code assignments would have pulled RNs away from either of the units leaving no RN present on whichever unit the code was not occurring. The RNs for the unit the code would be occurring on would have been assigned to code activities and there would not be an RN available to address patient needs outside of the code activity. This was the assigned situation for both the day shift and the night shift for the dates of December 2 and 3, 2013 and January 5, 6, 11 and 18, 2013.

On 12/03/2013, the only monitor tech for the shift from 7 P.M. to 7 A.M. was assigned to the code arrest responsibilities as a runner. This would have pulled the monitor tech away from the assigned duty and the remaining 5-6 patients on the monitor would not be observed for early intervention or emergent intervention based on the cardiac rhythms.

The Chief Clinical Officer, during and interview on 01/25/2013, stated he felt the coverage was adequate; however confirmed that if an emergency did occur there would be some patients without adequate supervision by RNs.

The Chief Clinical Officer, confirmed during an interview on 01/25/2013, the staff identified on the staffing assignment records were the only staff available on the units for the hospital.

2. The Acuity and Acuity Tool policy and procedure dated Jun 2011 was confirmed by the Chief Clinical Office as being current. The acuity staffing ratios for the number of patients to each CNA revealed the following: "...CNA staffing calculations are as follows: C.N.A. Staffing: Level 4 = 5:1; Level 3 = 6:1; and Level 2&1 = 8-10:1...." Each patient was evaluated and based on criteria and given an acuity number of 1-4. Four was the highest acuity level with one being the lowest acuity level.

On 01/05/2013 7 A.M. to 7 P.M. shift, there were two certified nursing assistants (CNAs) nursing assistants assigned to the shift. One CNA was assigned to sit with one patient in room 106. The other CNA was assigned to patients on two different units for the shift. This CNA had 13 patients assigned to care for and all were considered Level 1 and 2 patients. The maximum number based on the approved acuity policy and procedure would have been 10. This nursing assistant was assigned to 7 patients on the 300 unit and 6 patients on the 100 unit.

On 01/05/2013 7 P.M. to 7 A.M. shift, there were two CNAs assigned to the shift. One CNA was assigned to sit with one patient in room 106. The other CNA was assigned to patients on two different units for the shift. This CNA had 11 patients assigned to her. Ten patients had a documented acuity of Level 1 or 2 and one patient had an acuity Level of 3. The maximum number based on the approved acuity policy and procedure would have been 10. The nursing assistant was assigned 5 patients on the 300 unit and 6 patients on the 100 unit.

On 01/06/2013 7 A.M. to 7 P.M. shift, there was one certified nursing assistant assigned to two different units for a total of 12 patients. The CNA assignment included 11 Level 1 and 2 patients and 1 Level 3 patient. This assignment was outside of the established staffing calculations for the CNA according to the hospital's policy and procedure. This also required the CNA to go from the 300 unit to the 100 unit to provide the care to 6 patients on the 300 unit and 6 patients on the 100 unit.

On 01/06/2013 7 P.M. to 7 A.M. shift, there was one certified nursing assistant assigned to two different units for a total of 12 patients. The CNA assignment included 12 Level 1 and 2 patients. This assignment was outside of the established staffing calculations for the CNA according to the hospital's policy and procedure. This also required the CNA to go from the 300 unit to the 100 unit provide the care to 5 patients on the 300 unit and 7 patients on the 100 unit.

On 01/18/2013 7 P.M. to 7 A.M. shift, there were 2 CNAs assigned to the nursing services. There were two nursing units open with patients. There was one CNA who was assigned to care for patients on both units during this shift. The one CNA was assigned to 6 patient on the 100 unit and 6 patients on the 200 unit for a total of 12 patients to care for during the shift. This also required the CNA to leave one unit and go to the second unit to care of her other assigned patients. This CNA was also assigned to assist another CNA for 6 patients. All of these patients were identified as Level 1 and 2. This was above the maximum staff level for one CNA based on the approved acuity plan for the hospital.

On 01/24/2013 7 A.M. to 7 P.M. shift there were two CNAs assigned to cover the two units. One CNA was assigned 10 patients, 9 on the 100 unit and 1 on the 200 unit. The surveyor was on the unit during this shift observing the care being provided and reviewing patient records.

The surveyor observed on arrival to the unit at 0845 on 01/24/2013, the patient in room 201 had requested to go back to bed. A staff member notified the nurse in charge of the patient's request. At 0930 a family member requested the patient be assisted to get back to bed stating that she was tired and her "bottom" was hurting. This request was made to the staff at the nursing station and the charge nurse was notified of this request. The charge nurse went into the room and spent a few seconds and came out without putting the patient back to bed. The family member repeated the request for the patient to go back to bed at 0939. Another request was made for the patient to go back to bed. Finally the charge nurse and another nursing personnel member assisted the patient back to bed. This patient in room 201 was the patient who was assigned to the CNA who also had 9 patients to care for on the 100 unit.

The second CNA assigned this day was assigned 11 patients to care for. This was beyond the maximum number of patients a CNA should have based on the hospital's policy and procedure.

Interviews were conducted on 01/24/2013 with two patients who indicated the facility seemed to be short staffed with the nursing assistants to assist them with their care.

Based on a review of medical records, policies and procedures, and interview, it was determined the hospital failed to ensure the nursing staff developed and kept current a nursing care plan according to the hospital policy and procedure in 2 of 2 records reviewed for care plans (Patient #'s 3 and 4).

Findings include:

A review of the care plan form revealed the procedure at the top and included the following requirements: "...This Plan of Care is to be initiated at the time of admission, after completion of the admission assessment. All disciplines are to review and contribute to this plan of care, as appropriate to the needs of the patient. Problem/needs must be individualized to the patient. All needs identified to be of priority for this patient's successful discharge are to be addressed...Each shift please note whether the plan of care should be continued or revised. If the plan was revised please explain what and why. This should be documented as a short narrative within the 12 Hour Record. If all the goals of a particular need or problem have been met, and the problem should be discontinued (sic). Write the date discontinued in the problem box with your initials and highlight the entire section with a highlighter. Explain in narrative notes...."

Patient #3's care plan was initiated on 12/25/12 with problems identified and expected outcomes generically listed with a target date of completion for each problem 30 days later. There was no documentation of updates from 12/25/12 through the chart review conducted on 01/24/13. The patient's condition had changed during this timeframe to include an added diagnosis of depression, implementation of contact isolation due to culture reports, mobility changes, and physical restraints required. These were not addressed on the care plan and updated as the patient's condition improved or deteriorated.

The initial plan identified problems for Mobility/Rehab; Infection; Pain; Fall Risk; Abdominal wound; Foley; Nutrition; Gastrointestinal; Respiratory; Cardiovascular; Neurological; Patient Safety; and Education. The interventions were not individualized to the patient. The interventions were generic with no modifications.

The patient had an abdominal wound. The physician ordered, on 01/22/13 at 1050, wound care to include: "...Medihoney to abdominal wounds. Cover (with) damp gauze and ABD pad. (Change) (every) day & PRN soiling...." A review of the wound care documentation form dated 01/22/13, 01/23/13 and 01/24/13, revealed no documentation that the wound orders were followed on 01/22/13 and 01/23/13. This was not identified on the patient's care plan.

The Chief Clinical Officer, during an interview on 01/24/2013, confirmed the procedure identified on the care plan had not been followed. The Chief Clinical Officer stated the interventions and changes are addressed in the weekly multi-disciplinary plans of care.

The surveyor reviewed the Interdisciplinary Team Conference Report. This report identified problems and current status related to physical therapy status; however no interventions related to the concerns. Example: Confusion/Memory, Weakness with no interventions.

Patient #4 was admitted 01/18/13, with a history of Dementia. The admission plan was for pain management, physical therapy, occupational therapy, and fall precaution. The Plan of Care was initiated on 01/17/13 with a target date for completion of 02/17/13. The plan included Education/Knowledge; Patient Safety; Neurological; Cardiovascular/Circulation; Bleeding/Hemorrhage; Respiratory/Pulmonary; Gastrointestinal; Nutrition; Urinary; skin/Wound;Mobility/Rehab; Infection; Pain; Fall risk; Psychosocial; Discharge Plans.

The interventions were exactly the same as Patient #3's for the same problems. There were no individualized interventions. The patient had dementia. There was no specific plan as to how to address this during the patient's hospitalization. The patient had a sitter. There was no plan to identify the process for progressing the patient so that the patient could maintain safety without a sitter or other alternatives. There was no identified individualized plan for the pain management.

For Patients #'s 3 and 4 there was no documented evidence each shift documented whether the plan of care should be continued or revised.