HospitalInspections.org

Based on review of policy, review of facility video recording, staffing assignment sheets, review of staff monthly meeting minutes, and interviews with staff, the facility failed to ensure nursing staff was available to provide nursing staff supervision on patient care floor.

The findings include:

Review of the policy titled "Staffing Plan for Provision of Care" with approval date of 10/2015, revealed "...a. A registered nurse ensures the unit is covered at all times, including lunch and breaks. A nurse can not leave the unit without another nurse covering at any time....1. There shall be sufficient number of qualified and competent registered nurses on the unit to provide patients with nursing services which require the judgment and specialized skills of the competent registered nurse. Nursing staffing shall also be sufficient to promptly recognize untoward changes in a patient's condition and to intervene appropriately utilizing nursing, medical or hospital staff."

Review of facility video surveillance footage dated 09/16/2019 at 2104 of patient care hall revealed MHT #1 was sitting outside of Patient #13's door. RN #1 was observed in field of view entering the patient care floor through the double doors. RN #1 spoke with MHT #1 for 25 seconds then RN #1 leaves the floor for another 2 minutes returning to RN #1 returned and obtained dynamap (Vital sign machine) and again exited the patient care doors. Review of video revealed no evidence of RN #1 on patient care floor for eight minutes.

Review of staffing sheets dated 09/16/2019 for night shift (1900-0700) revealed one RN assigned to patient care floors, with census of 18 patients.

Review of "Acute Nursing Monthly Meeting" agenda dated April 16, 2019, June 18, 2019 and July 23, 2019 revealed "...Multiple staff leaving hall at same time. There must be a nurse physically on the unit at all times." Review revealed RN #1 had signed the roster for all three meetings.

Interview on 10/24/2019 at 0715 with RN #1 revealed, remembered the night, she was the only RN for both patient care halls for 20 patients. Interview revealed RN #1 had received an admission that evening and was down the hall performing the admission. Interview revealed she was aware of an incident between two patients once she arrived on the floor and spoke with MHT #1. Interview revealed another nurse was not assigned to the floor.

Interview on 10/24/2019 at 0820 with CNO revealed the nurse should not leave the floor to perform an admission. Interview revealed RN #1 had been counseled three times since April 2019 on the requirements to stay on the floor. Interview revealed RN #1 should not have left the floor.