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Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure the patients in the Intensive Care Unit received care in a safe setting by exceeding the staffing guide of 12 patients in the Intensive Care Unit (ICU) for 13 of the 30 days in September 2013.

Findings include:

Review on October 4, 2013, of the facility's "Board of Trustee Bylaws," dated approved September 6, 2012, revealed "Article IX- Patient Bill of Rights ... 9.1 Bill of Rights ... For the purpose of promoting the interests and well-being of the patients and residents of the hospital, the Board shall provide for implementation, dissemination and enforcement of a Patient's Bill of Rights. ... 9.2 ... Implementation ... The Patient's Bill of Rights shall contain at a minimum the following provisions: 9.2 (a) A patient has the right to respectful care given by competent personnel. ... 9.2 (g) The patient has a right to good quality care and high professional standards that are continually maintained and reviewed. ..."

Review on October 4, 2013, of the facility document "Rights and Responsibilities" revealed "Patient Rights ... We believe that patients who understand and participate in their treatment achieve better results. ... You have the right to ... Receive care in a safe and dignified environment, free from all forms of abuse, neglect, harassment and/or exploitation. ..."

Review on October 1, 2013 of the facility's Critical Care Unit Meeting Minutes January 2013 to July 2013 revealed documentation of a loss of core nursing staff over the last year. Documentation revealed discussions regarding possible set up of an Intensive Care Unit (ICU) step down department and more compliance with physicians moving their patients out of the department once they had improved. One of the facility's heart surgeons suggested the possibility of closure of some ICU beds rather than mandating overtime so the department could provide the 1:2 nurse/patient ratio. Continued review of documentation revealed the facility was utilizing the use of traveling nurses. The meeting minutes noted the traveling nurses refused to care for the 1:1 patients. There was no documentation that administration had met with the Critical Care Committee to help rectify the issues.

Review on October 1, 2013 of the facilty policy "Monitoring Open Heart Surgical Patients," last reviewed on November 29, 2012, revealed "All open heart surgical patients, upon return from the OR (operating room), will remain a 1:1 Registered Nurse to patient ratio until the Open heart Surgeon, after discussion with the registered nurse deems this is no longer required. An order to discontinue the 1:1 is to be written on the physician order sheet."

Interview with EMP1 on October 1, 2013, at approximately 11:00 AM confirmed the staffing for the department was based on a census of 12 patients and the established practice for staffing the ICU was 1:1 [1 nurse to 1 patient] for open heart patients, CRRT (continous renal replacement therapy) patients, CVVH (continuous veno-venous hemofiltration) patients, and hypo-hyper thermia (warming and cooling phases) patients; and 1:2 [1 nurse to 2 patients] for all other ICU patients.

Review of facility document "Schedules" for the month of September revealed the following staffing:

September 1, 2013- 3 PM-7 PM: 16 patients - 7 nurses - 2 nurses with 1:1 assignment;
September 3, 2013- 3 AM-7 AM: 13 patients - 6 nurses - 1 nurse with 1:1 assignment;
September 8, 2013- 5 AM-7 AM: 13 patients - 5 nurses- 2 nurses with 1:1 assignment;
September 9, 2013- 3 PM-7 AM: 15 patients - 7 nurses- 1 nurse with 1:1 assignment;
September 11,2013- 3 PM-7 AM: 15 patients - 8 nurses- 1 nurse with 1:1 assignment;
September 12, 2013- 3 PM-7 AM: 16 patients - 8 nurses- 1 nurse with 1:1 assignment;
September13, 2013-11 PM-3 AM: 16 patients - 2 nurses called off; 3 AM-7AM 6 nurses;
September 14, 2013-7 AM- 3 PM: 16 patients -7 nurses;
September 15, 2013- 3 PM-7 PM: 16 patients - 7 nurses;
September 16, 2013- 11PM-3 AM-7 nurses-1 nurse with 1:1 assignment; 3 AM-7AM - 15 patients - 6 nurses;
September 20, 2013-7 AM-11 AM: 14 patients - 5 nurses; 11AM-3PM - 14 patients - 6 nurses; 3PM-7 PM - 15 patients - 4 nurses - 1 nurse with 1:1 assignment;
September 22, 2013- 5 AM- 7 AM: 13 patients - 6 nurses - 1 nurse with 1:1 assignment;
September 24, 2013- 3 PM- 11PM: 15 patients - 7 nurses - 1 nurse with 1:1 assignment;

EMP1 confirmed the Critical Care Department had a large turnover of nurses, and it was difficult to keep the department staffed adequately. EMP1 confirmed the staff was asked each pay period if they were interested in overtime. EMP1 confirmed the department was short staffed for awhile. EMP1 noted the staff was fatigued from the additional work. EMP1 confirmed it was almost a daily routine to call staff to come in to work in the Critical Care Department. EMP1 confirmed there was discussion of the staffing needs in the daily interdepartmental safety huddle and the daily hospital wide safety huddle.

Interview with OTH1 on October 1, 2013, at approximately 10:30 AM confirmed the staffing in the ICU was not optimal, especially over the past month (September). OTH1 confirmed texting the Chief Executive Officer (CEO) concerning the need for additional staff. OTH1 confirmed agency nurses helped to fill the void. OTH1 stated the agency nurses were not up to standard or refused to take care of the 1:1 patients.

Interview with OTH2 at approximately 10AM confirmed the established practice for staffing patterns in the ICU was 1:1 [1 nurse to 1 patient] for open heart patients, CRRT (continous renal replacement therapy) patients, CVVH (continuous veno-venous hemofiltration) patients, and hypo-hyper thermia (warming and cooling phases) patients; and 1:2 [1 nurse to 2 patients] for all other ICU patients.

Interview with OTH3 on October 1, 2013, at approximately 12:30 PM confirmed there was a major loss of the ICU nursing compliment over the past year and finding competent replacements was very difficult. OTH3 confirmed the past month (September) the staffing was an anomaly. OTH3 confirmed they contacted administration regarding possibly limiting admissions to the department. OTH3 confirmed no formal plan was developed.

Cross reference:
482.23(b) Staffing and Delivery of Care

Based on review of facility policy, medical records (MR), and interview with facility staff (EMP), it was determined the unit director failed to ensure the Intensive Care Unit (ICU) staffing pattern was maintained at acceptable levels.

Findings include:

Review on October 2, 2013, of the facility policy "Director Responsibilities for Critical Care," dated last reviewed November 29, 2012, revealed "The Critical Care Director will assume responsibility for both administrative and clinical functions of the ICU. Procedure: The following responsibilities apply to Department directors: 1 to review the daily patient census with attention to their diagnosis, progress, prognosis and qualification for discharge from the ICU. ... 2. To communicate with the Nurse Manager/designee and staff regarding the day-to-day concerns as they arise in the ICU in matters that might impact on the quality of care."

Review on October 4, 2013, at 10AM of census schedules revealed the following:

On September 1, 2013, there were 16 patients in the ICU between the hours of 3:00 PM and 7:00 PM with one patient on a 1:1 status. There were seven nurses staffing the ICU at 3:00 PM and eight nurses at 7:00 PM.

On September 13, 2013, there were 16 patients in the ICU between the hours of 11:00 PM to 7:00 AM. There were seven nurses staffing the ICU at 11:00 PM and six at 3:00 AM.

On September 20, 2013 there were 16 patients in the ICU between the hours of 3:00 PM and 7:00 PM. One patient was on a 1:1 status. There were four nurses staffing the ICU at 3:00 PM and eight nurses at 7:00 PM.

The ICU staffing pattern of 1:1 and 1:2 was not maintained on these randomly selected days in September.

Cross reference:
482.23(b) Staffing and Delivery of Care

Based on review of facility documents, medical records (MR), and interview with facility staff (EMP), it was determined the facility failed to ensure the patient care assignments in the Intensive Care Unit met the needs of the patients and the prescribed medical regimen for four medical records reviewed (MR1, MR2, MR3, and MR4).

Findings include:

Review on October 1, 2013 at approximately 11AM of the facilty policy, "Monitoring Open Heart Surgical Patients" last reviewed on November 29, 2012, revealed "All open heart surgical patients, upon return from the OR (operating room), will remain a 1:1 Registered Nurse to patient ratio until the Open heart Surgeon, after discussion with the registered nurse deems this is no longer required. An order to discontinue the 1:1 is to be written on the physician order sheet."

Interview with EMP2 on October 1, 2013, at approximately 10:00 AM confirmed the established practice for staffing patterns in the ICU were as follows: 1:1 [1 nurse to 1 patient] for open heart patients, CRRT (continous renal replacement therapy) patients, CCH (continuous veno-venous hemofiltration) patients, and hypo-hyper thermia (warming and cooling phases) patients; and 1:2 [1 nurse to 2 patients] for all other ICU patients. EMP2 confirmed there was no patient assignments sheet maintained in the Intensive Care Unit to document the nursing assignments on a daily basis. EMP2 confirmed at the time of the unannounced onsite investigation there were four open nursing positions. EMP2 stated the facility was using traveling nurses to supplement the schedule. EMP2 confirmed the staffing for the ICU was based on a census of 12 patients.

1) Review on October 2, 2013, of MR1 revealed an admission date of September 19, 2013, with a diagnosis of triple vessel disease. Open heart surgery was performed on September 19, 2013.

Review on October 2, 2013, of MR2 revealed an admission date of August 31, 2013, with a diagnosis of pneumonia and respiratory distress, requiring mechanical ventilation. MR2 remained ventilated on September 19, 2013.

Continued review of MR1 and MR2 revealed EMP2 was assigned to MR1 immediately upon return from the OR and MR2. MR1 was on a 1:1 nursing care (1 nurse to 1 patient) at that time.

2) Review on October 2, 2013, of MR3 revealed the patient was admitted for open heart surgery for an aortic valve replacement on September 12, 2013. The patient required mechanical ventilation post surgery and was on 1:1 nursing care.

Review on October 2, 2013, of MR4 revealed the patient was admitted on August 24, 2013, with a diagnosis of chronic obstructive pulmonary disease exacerbation. The patient required mechanical ventilation. MR4 was continued on mechanical ventilation (intubated) in the ICU on September 12, 2013.

Continued review of MR3 and MR4 revealed EMP7 was assigned to MR3 immediately upon return from the OR, and MR4. MR4 was on a 1:1 nursing care at that time.

Interview on October 2, 2013, at approximately 12:30 PM with EMP2 confirmed that due to short staffing the nursing assignments on September 19, 2013, and September 12, 2013, required EMP2 and EMP7 to have a patient assignment of 1:2 (1 nurse to 2 patients) even though they were assigned to a 1:1 open heart patient (MR1 and MR3).

Interview with OTH1 on October 1, 2013, at approximately 10:00 AM confirmed there were issues with staffing, and the staffing concerns were discussed with administration.

Interview with OTH2 on October 1, 2013, at approximately 10:30 AM confirmed the nurse to patient ratios enumerated above had been established for many years, and due to the loss of staff in recent months, the ICU was unable to maintain the nurse to patient ratios.

Interview with OTH3 on October 1, 2013, at approximately 12:30 PM confirmed the nurse to patient ratios enumerated above had been established for many years and were an issue in the ICU since the loss of staff a few months ago. OTH3 confirmed it was difficult recruiting experienced critical care nurses to work in the department. Continued discussion with OTH3 confirmed they discussed their concerns with administration.

Interview with EMP3 on October 1, 2013, at approximately 11:30 AM confirmed that on September 20, 2013, EMP3 started with a four-patient assignment in the ICU and was forced to take a fifth ICU patient after a rapid response resulted in another admission to ICU. EMP3 further confirmed that an ICU staff nurse was unable to respond to the rapid response as there were four nurses for the 14 ICU patients at that time. EMP3 confirmed one of the ICU patients was an open heart patient on a 1:1 nursing care assignment. EMP3 noted this situation existed until 7:00 PM when more nursing staff came on duty.

Interview with EMP4 on October 1, 2013, at approximately 9:45AM confirmed that in the past month it was a usual occurrence to be assigned to three ICU patients. EMP4 stated on one day EMP4 had a patient care assignment of three patients. Two of these ICU patients had balloon pumps and one was having an esophogastroduodenoscopy (EGD) in the ICU. EMP4 could not recall the date or the patient names.

Interview with EMP5 on October 1, 2013, at approximately 10:15 AM confirmed the staffing issues were brought to the attention of the supervisors and administration. EMP5 confirmed there was no relief. EMP5 confirmed they would try and call additional staff in to work. EMP5 confirmed most of the nursing staff were working additional shifts. EMP5 stated it was difficult to complete the nursing assignments, and the nursing documentation (charting) was not started until 2:00 PM. EMP5 stated it was difficult to reposition patients, every two hours, as most of the ICU patients required at least two nursing staff to accomplish the repositioning. EMP5 stated that skin integrity was at risk.

Interview with EMP6 on October 2, 2013, at approximately 10:55 AM confirmed the ICU was staffed for 12 patients.

Interview with EMP7 on October 2, 2013, at approximately 10:55 AM confirmed the staff filled out "Short Staffing Sheets" many times. EMP7 stated these "Short Staffing Sheets" were given to administration, alerting them to the staffing issues in the ICU. EMP7 confirmed the patients requiring 1:1 nursing care were the open heart patients, those requiring hypothermia and the CVVH and CRRT patients. EMP7 stated there were many times when they would have a patient on 1:1 and an additional ICU patient assigned to their care. EMP7 confirmed the ICU staff did not utilize patient care assignment sheets for their nursing assignments. EMP7 further stated the ICU used a whiteboard to designate patient assignments, and there was no other way to track patient assignments.

Review of staffing schedules confirmed 14 days in September when the census exceeded 12 patients. These dates included: September 1, 3, 12, 13, 14, 16 and 20, 2013, when there were 16 ICU patients; September 9, 24 and 25, 2013, when there were 15 patients; and September 11 and 14, 2013 14 patients and September 18 and 22, 2013, when there were 13 patients.

Review on October 4, 2013, at 10AM of the patient census schedules revealed the following:

On September 1, 2013, there were 16 patients in the ICU between the hours of 3:00 PM and 7:00 PM with one patient on a 1:1 status. There were seven nurses staffing the ICU at 3:00 PM and eight nurses at 7:00 PM.

On September 13, 2013, there were 16 patients in the ICU between the hours of 11:00 PM to 7:00 AM. There were seven nurses staffing the ICU at 11:00 PM and six at 3:00 AM.

On September 20, 2013 there were 16 patients in the ICU between the hours of 3:00 PM and 7:00 PM. One patient was on a 1:1 status. There were four nurses staffing the ICU at 3:00 PM and eight nurses at 7:00 PM.

Review of Notice of Unsafe staffing situation filed on September 20, 2013, at 3:00 PM revealed the following comment: SICU (Surgical Intensive Care Unit) 1 nurse charge with one 1:1 patient plus another [patient], and 2 other nurses with a three patient assignment, CCU (Coronary Care Unit) 6 patients with 2 nurses.