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Based on review and interview, the facility failed to provide a written acuity plan for staffing, ensure a registered nurse was always on duty, and represent the psychiatric unit in the staffing advisory or effectiveness committee meetings in 5 of 5 (adolescent, adult, acute adult, geriatric, and child) patient behavioral units.

Refer to Tag A0392

Based on review and interview, the facility failed to provide a written acuity plan for staffing, ensure a registered nurse was always on duty, and represent the psychiatric unit in the staffing advisory or effectiveness committee meetings in 5 of 5 (adolescent, adult, acute adult, geriatric, and child) patient behavioral units.

An acuity system identifies the amount of nursing care needed for each patient on a unit based on the level of intensity, nursing care, and tasks needed for each patient. The system allocates resources based on patients' needs, not according to raw patient numbers. An acuity tool allows each nurse to score his or her patients, based on acuity, for the upcoming shift and can report this information to the charge nurse, who then assigns patients before the shift change. The handoff report between RNs allows each to validate patients' current acuity and care needs.

The psychiatric unit may have a patient that requires a 1:1 observation that would require one staff member to one patient at arm's length, a line of sight that requires a staff member always to keep the patient within their line of sight, a patient that required restraint and needs observation, or the patient needs extensive medical care. There was no acuity plan to show how the staffing would be increased, how many staff would be required, or when to decrease staffing levels. The current staffing plan allows for person-dependent decisions instead of process decisions on increasing or decreasing staffing needs due to patient acuity.

A review of the policy and procedure "Nursing Organization Plan Providing Patient Care" revision date 7/23 revealed on page 16 under "Delivery of Care Methodology", " ... An assessment is made at the beginning of each shift by the nurse manager or nurse in charge utilizing shift reports and patient acuity tool in order to assign the most appropriate staff to meet the identified patient needs ...BEHAVIORAL HEALTH (Page 19 of 22)

Adolescent Unit -Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I: I 0
Adult Unit-Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I: I 0
Acute Unit-Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I:8
Geropsych Unit - Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I:9
Children's Unit- Safe Minimal Staffing: one RN each shift with licensed staff to Patient Ratio I:5.

In Behavioral Health tech staff is utilized to monitor patient/environmental safety and to report identified needs to the RN, thus Psych Techs are added in response to patient monitoring needs. The Staffing Coordinator and/or Nursing Supervisors/Directors may adjust staffing levels up or down as called for by change in complexity of patient needs, or census. Reports are maintained in Kronos for each nursing unit reflecting numbers actual staffing and are available at any time for director review. Monday through Friday nursing directors huddle with the staffing coordinators to review staffing needs for the day and or weekend Nursing directors are notified when there is a staffing variance. Whenever there is a staffing Variance the Staffing Variance Algorithm will be utilized."

An interview was conducted with Staff # 7 on 5/8/24. Staff # 7 reported that the behavioral unit had their own house supervisors, and they would make decisions concerning staffing needs due to patient acuity. Staff #7 confirmed the acuity level was decided by the house supervisor when she was not there.

A review of the Nursing Advisory Council policy and procedures revealed the council was a committee responsible for "the development, ongoing monitoring, and evaluation of the Baptist Hospital Staffing Plan ... The council consists of 60 % direct care registered nurses. Each nurse has one vote and is selected by their peers who provide direct care during at least 50% of their work time. "Behavioral Health Services was one of the units to be represented on the council. the staffing committee or council approach typically involves direct care nurses (e.g., representatives from various clinical areas) and leadership (e.g., management, infection control, quality, education) collaborating to develop staffing plans to guide patient care assignments.

A review of the nursing advisory council meeting minutes for 8/23, 1/17/24, and 3/12/24 revealed there was no nursing representation from the behavioral health unit. An interview with Staff # 4 and 7 on 5/8/24 confirmed that Staff # 7 was the behavioral unit representative. Staff #7 was the unit director that was making all the staffing decisions for the unit and was not elected by her peers. Staff #7 confirmed she had not attended all the meetings and was unsure which ones she had attended. Staff #7 stated that she did talk to her staff about staffing.

An interview was conducted with staff # 16, 17, and 18 on 5/8/24. Staff #16, 17, and 18 all confirmed that they were never informed of any staffing committee, nor have they been asked to vote for a peer to represent them. Staff #18 stated she was not aware there were any meetings. Staff #16 reported she had been left on the unit with patients by herself and felt it was "very unsafe." Staff #16 stated that she had to go several times a week, to a closed room for the IDT meetings, and had to leave the mental health techs on the floor alone with no supervision. Staff #16 stated that she had voiced her concerns about unsafe staffing but there was always some type of retaliation. Staff #17 stated she had been alone as the only nurse with just techs for many shifts. Staff #17 stated that she had to ask for other nurses to come to her unit to assist in emergencies leaving their unit short. Staff #17 stated the house supervisors are always busy and unable to assist with lunch breaks or any break in general. Staff #17 stated they must eat at the desk quite often and not get any breaks. Staff #17 stated she did not feel comfortable expressing her concerns due to retaliation.

A review of the matrix/grid revealed that the minimal nursing staff from 1-5 children was 1 RN. A review of the staffing sheet revealed there was only 1 RN assigned to the child unit from 4/1/24 to 5/7/24 and 2 nurses when the census increased to 6 patients on 5/2/24 and 5/3/24. There was no documentation if the nurse got a meal break or who covered for the nurse. There was no information on the number of admissions, discharges, or who covers for the nurse when attending the treatment team meetings.

A review of the staffing schedule for the geriatric unit revealed the RN had an MHT's and an LVN from 5/4/24 through 5/6/24 but no documentation covered for the RN during meal breaks. The RN must always supervise the LVN and MHT's.

According to the Texas Nurse Association, "Safe staffing is more than a number. It is the right number of nurses and the right match of nurse and patient characteristics that makes staffing "safe." It is the right number of nurses and the appropriate workload. It is the right number of nurses and the right kind of resources to support the nurse in the particular environment. It is the right number of nurses and the right kind of culture - one that supports collaborative, interdisciplinary practice and encourages nurses to identify and report problems and barriers to providing care."


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An interview was conducted with staff # 9, 10, and 11 on 5/8/24. Staff #9, 10, and 11 all confirmed that they were never informed of any staffing committee, nor have they been asked to vote for a peer to represent them. Staff #10 and 11 stated they were unaware there were any meetings or even what nurse staffing committee meetings are. Staff #10 and 11 stated they feel the staffing ratio of 1 nurse to 8 patients was "very unsafe."