HospitalInspections.org

Based on document review and interview, the hospital failed to ensure that 1) there were sufficient numbers of staff on each unit; and 2) the nursing department defined and implemented a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention and priority of care based on an acuity staffing system with objective assessment tools that qualified the number of nursing staffing members needed to fulfill patient needs on each unit, in accordance with their policy for 1 facility.

Findings include:

1. Review of the policy titled Plan for the Provision of Nursing Care in Psychiatric Specialty Areas, Last Revised 8/2020, indicated the following:
Assignment of Staff to Provide Nursing Services:
Individual patient care assignment is based upon:
The complexity of the patient's condition and requirements for nursing care
The dynamics of the patient's status, including frequency with which the need for nursing care activities changes
Staffing Plan Guidelines:
There shall be a sufficient number of qualified and competent Registered Nurses (RN) and Patient Care Assistants (PCA) on each unit to provide patients with nursing services that require the judgment and specialized skills of the competent nursing staff.
The Nursing Department shall define, implement, and maintain a system for determining patient requirements for nursing care on the basis of demonstrated patient needs...This acuity staffing system shall be based upon objective assessment tools that qualify the number of nursing staffing members needed to fulfill patient needs on each unit.
Procedure:
The unit has a master/core staffing grid that identifies the size of the unit, skills mix utilized on the unit, and minimum number of staff...
Staffing is based upon patient census, acuity, and relevant treatment needs.

2. Staffing documentation:
A. Review of the document titled Nursing Unit Staffing Matrix - Unit 1 indicated the following for staffing Manhours per Shift:
Census 1-10: Shift 1 (7am-3pm) = 1 RN and 1 PCA. Shift 2 (3pm - 11pm) = 1 RN and 1 PCA. Shift 3 (11pm - 7am) = 1 RN and 1 PCA
Census 11: Shift 1 (7am-3pm) = 1 RN and 1 PCA. Shift 2 (3pm - 11pm) = 2 RN and 1 PCA. Shift 3 (11pm - 7am) = 1 RN and 1 PCA
Census 12: Shift 1 (7am-3pm) = 2 RN and 1 PCA. Shift 2 (3pm - 11pm) = 2 RN and 1 PCA. Shift 3 (11pm - 7am) = 1 RN and 1 PCA
Census 13: Shift 1 (7am-3pm) = 2 RN and 2 PCA. Shift 2 (3pm - 11pm) = 2 RN and 2 PCA. Shift 3 (11pm - 7am) = 1 RN and 1 PCA
Census 14-16: Shift 1 (7am-3pm) = 2 RN and 2 PCA. Shift 2 (3pm - 11pm) = 2 RN and 2 PCA. Shift 3 (11pm - 7am) = 1 RN and 2 PCA
Census 17 - 20: Shift 1 (7am-3pm) = 2 RN and 2 PCA. Shift 2 (3pm - 11pm) = 2 RN and 2 PCA. Shift 3 (11pm - 7am) = 2 RN and 2 PCA
Census 21: Shift 1 (7am-3pm) = 2 RN and 3 PCA. Shift 2 (3pm - 11pm) = 2 RN and 3 PCA. Shift 3 (11pm - 7am) = 2 RN and 2 PCA
Census 22-24: Shift 1 (7am-3pm) = 3 RN and 3 PCA. Shift 2 (3pm - 11pm) = 3 RN and 3 PCA. Shift 3 (11pm - 7am) = 2 RN and 2 PCA

B. Review of the One Week Staffing Pattern Worksheet, completed by A2, Director of Nursing (DON), for 9/6/20 through 9/12/20 and 9/20/20 through 9/26/20, lacked documentation of appropriate staffing numbers in accordance with the document titled Nursing Unit Staffing Matrix - Unit 1 as follows:
Willow unit:
i.. 9/6/20: Day shift, census 16, lacked 1 RN* and evening shift, census 14, lacked 1 RN*. 9/7/20: Day shift, census 16, lacked 1 RN* and evening shift, census 14, lacked 1 RN*. 9/8/20 Day Shift, census 14, lacked 1 RN* and evening shift, census 14, lacked 1 RN*. 9/9/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*. 9/10/20: Day shift, census 16, lacked 1 RN* and evening shift, census 15, lacked 1 RN*. 9/11/20: Day shift, census 16, lacked 1 RN and evening shift, census 16, lacked 1 RN - House Supervisor as the only RN indicated on worksheet on this date for day and evening shift. 9/12/20: Day shift, census 16, lacked 1 RN* and evening, census 16, shift lacked 1 RN*
ii. 9/20/20: Day shift, census 16, lacked 1 RN; evening shift, census 14, lacked 1 RN and night shift, census 14, lacked 1 PCA after 3:00 AM. 9/21/20: Day shift, census 14 lacked 1 RN*and evening shift, census 15 lacked 1 RN*. 9/22/20: Day shift, census 16, lacked 1 RN* and evening shift, census 15, lacked 1 RN*. 9/23/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*. 9/24/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*. 9/25/20: Day shift, census 15, lacked 1 RN*, evening shift, census 12, lacked 1 RN* and night shift, census 16, lacked 1 PCA. 9/26/20: Day shift, census 16, lacked 1 RN* and evening shift lacked 1 RN*.

Cedar unit:
iii.. 9/6/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*. 9/7/20: Day shift, census 16, lacked 1 RN* and evening shift,census 16, lacked 1 RN*. 9/8/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*. 9/9/20: Day shift, census 16, lacked 1 RN*and evening shift, census 16, lacked 1 RN*. 9/10/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*. 9/11/20: Day shift, census 16, lacked 1 RN. 9/12/20: Day shift, census 16, lacked 1 RN*, evening shift, census 16, lacked 1 RN* and night shift, census 16, lacked 1 PCA.
iv. 9/20/20: Day shift, census 16, lacked 1 RN and evening shift, census 16, lacked 1 RN. 9/21/20: Day shift, census 16, lacked 1 RN*, evening shift, census 14, lacked 1 RN* and night shift, census 15, lacked 1 PCA. 9/22/20: Day shift, census 16, lacked 1 RN* and indicated the 1 RN was assigned an orientee and evening shift, census 15, lacked 1 RN* with the 1 nurse assigned an orientee. 9/23/20: Day shift, census 16, lacked 1 RN* and indicated the 1 RN was assigned an orientee and evening shift, census 16, lacked 1 RN* with an orientee assigned to the RN. 9/24/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*. 9/25/20: Day shift, census 16, lacked 1 RN*, evening shift, census 16, lacked 1 RN* and 1 PCA and night shift, census 16, lacked 1 PCA. 9/26/20: Day shift, census 16, lacked 1 RN* and evening shift, census 16, lacked 1 RN*.

*On the corresponding dates, the House Supervisor was indicated as a 2nd nurse/float for each of 2 units - thereby creating a deficiency of 1 RN on 1 unit at any given time.

B. Review of facility staffing sheets/schedules indicated the following:
i. Staffing sheets for 9/6/20 through 9/12/20 and 9/20/20 through 9/26/20 lacked documentation of objective patient acuity.
ii. On 9/11/20, the staff assigned as House Supervisor was also indicated to have worked day shift on the Willow unit as the RN with the assist of a float nurse for a patient census of 16. The schedule further indicated that the house supervisor also worked a portion of the evening shift as the only RN with a patient load of 16 and worked again on night shift with the charge nurse to cover the shift.
iii. On 9/20/20 day shift, the schedule indicated that on the Willow unit census was 16, there was 1 RN assigned to those 16 patient plus assigned an orientee. The schedule lacked documentation of a House Supervisor for either day or night shift.
iv. On 9/22/20 night shift, the schedule lacked documentation of a House Supervisor and the schedule lacked documentation of census for Willow or Cedar units.
v. On 9/25/20, the schedule lacked documentation of a night shift House Supervisor.
vi. Review of staffing documentation for 9/13/20, date of employee injury, indicated the following:
Willow unit: Day shift, with a census of 16, lacked 1 RN* and the evening shift, with a census of 15, lacked 1 RN*. The schedule indicated the House Supervisor was to work also as float staff on both the Willow and Cedar units.
Cedar unit: Day shift, with a census of 16, lacked 1 RN* and the evening shift, with a census of 16, lacked 1 RN* and lacked 1 PCA after 3:00 AM.
vii. Review of staffing documentation for 9/22/20, date of employee injury, indicated the following:
Willow unit: Day shift, with a census of 16, lacked 1 RN*and evening shift, with a census of 15, lacked 1 RN*.

3. Review of employee injury documents, titled "Incident Abstract Report", indicated that within the past month 2 staff injuries were reported; one on 9/13/20 and one on 9/22/20.

4. The following was indicated in interview on 10/19/20, beginning at 10:00 AM:
A3, PCA, when asked about general staffing adequacy, indicated that, at times, they may be understaffed due to call-ins, etc.
A4, PCA, indicated that he/she believed there were staffing issues with some shifts more than others. A4 indicated that, while not often, he/she had worked in under staffed conditions. A4 indicated that previously, they did at most times have 2 RNs plus a charge nurse, but lately there has only been one RN.
A5, RN, indicated that changes in staffing had caused struggles. A5 indicated that staffing was not good. A5 indicated that they were short on this day due to the call in of one nurse. A5 indicated that on each side the nurses have 16 patients with floats. In clarification, A5 indicated that a nurse from the outpatient department floats in to either department, but will return to his/her regularly assigned/scheduled job and that some staff are floating between units as well as performing other duties. A5 indicated it was not unusual to run with 3 nurses in that manner (1/each unit and 1 float). A5 indicated this was not too bad for night shift, but was a struggle for 2nd shift for 1 float to run back and forth. A5 indicated this to be most problematic if code issues arise. A5 indicated that recently there had been two employees injured and that the hospital had lost a lot of staff due to being short-handed. A5 indicated that staff were scared for safety of patients and staff as well as their license. A5 also noted that PCAs cannot adequately perform the 15 minute (q15) checks and also float to group sessions when they are understaffed. A5 indicated that day shift was not as bad due to having more staff available in time of a code/crisis, i.e. office staff, administration, etc. A5 indicated that 12 hour shifts often become 14 hour shifts due to lack of staffing.
A6, RN, indicated that staffing previously included 2 RNs per unit for the 7 AM to 7 PM shift and that grid called for 12 patients maximum per RN on days. A6 indicated that recent changes now required a nurse to take 16 patients by themselves. A6 indicated that number of patients per 1 RN could be overwhelming at times and noted that this requirement also limited time with individual patients. A6 indicated that he/she is normally on the unit with no other nurse. A6 indicated that the DON was having the Outpatient (OP) nurse go back and forth to assist or sometimes the supervisor would float while also performing the supervisor role. A6 also indicated that there had been recent staff injuries on the evening shift and believed this was due to less available people.
A7, RN, indicated that on this day, he/she was the only nurse on the unit with 16 patients. When asked about the frequency of which he/she was the only nurse with that number of patients, A7 indicated that recently, that was often due to the new staffing changes. A7 further indicated that at times 2 nurses were scheduled, but if they call-in, there is not an on-call back-up maintained. A7 voiced concerns for patient safety and his/her license.
A8, RN, indicated that previous staffing was pretty good; usually had 2 RNs on each side and an LPN (Licensed Practical Nurse) for med pass assistance with 6 PCAs (3 on each unit). Now, staffing has been decreased with only 4 PCAs/day (2 on each side/unit) and 3 RNs (1 per unit and 1 float). A8 indicated that recently a patient "went wild" and it took all staff to attend to the situation which therefore left no staff available for the other patients. A8 indicated he/she felt his/her license and the safety of staff and patients was at risk. A8 indicated the facility could be better staffed.
A9, PCA, indicated that he/she felt unsafe at times due to being left short-handed, on 10/19/20 during interviews with staff starting at 10:00AM but not reporting on which shifts he/she was referring to.

Between approximately 1:30 PM and 2:30 PM:
A2, reported that where he/she had written "S" on the One Week Staffing Pattern Worksheet indicated that the House Supervisor was counted as a 2nd nurse/float for each unit. A2 verified that the facility did not have/use an objective assessment tool to qualify the number of nursing staff members needed to fulfill patient needs on each unit.

Between approximately 7:00 PM and 8:00 PM:
A2 verified that the 2 units were separated by doors and hallways. A2 verified that the float nurse/supervisor could not be two places at one time and therefore when on one unit left the other unit with only 1 nurse.

Based on document review the hospital failed to evaluate and ensure all elements of incident reports were completed, as per policy, for one facility.

Findings include:

1. Review of the policy titled Incident Report Protocol, Last Revised: 01/2020, indicated the following:
Document all pertinent, objective facts, and complete all sections of the incident report.

2. Review of employee injury reports, titled "Incident Abstract Report", lacked documentation of all sections having been completed as follows:
a. Incident Date: 9/13/20. The form lacked completion of (not all inclusive) the following sections: Cause, Detail Cause, Disposition, Nature of the Injury, Time of the Incident and Shift.
b. Incident Date: 9/22/20. The form lacked completion of (not all inclusive) the following sections: Cause, Detail Cause, Disposition, Time of the Incident. Note: The name indicated in the section titled Involved Party Name was different than the name of the person who was indicated to have been injured in the section titled Incident Description, and that was a first name and title only. The incident report lacked documentation of the employees last name/pertinent documentation of who was the injured party.