HospitalInspections.org

Based on facility documents, policy review, medical record review, and interviews conducted, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) plan, including a complete analysis of an adverse event and the development of an effective plan of correction involving a post operative patient. Failure to develop a complete analysis of the adverse event and plan of correction could result in injury or death to other patients in similar situations.
Refer to A273, A283, A286.

Based on document review, medical record review and interviews, the hospital failed to ensure a comprehensive QAPI (Quality Assurance and Performance improvement) plan was developed and implemented using data collection, analysis, with tracking, trending, and monitoring its effectiveness after an adverse event occurred for 1 (Patient #4) of 1 patient sampled.

Findings included:

Review of the QAPI (Quality and Performance Improvement Plan) plan dated 2025 revealed no board approval has been completed. The QAPI Plan states the data collection is systematic and is used to identify areas for more focused data collection to sustain improvement over time. Data analysis ...[ is used] to identify variation, through the use of statistical tools and methods, helps focus the attention and resources on making improvement changes to the processes that will result in better outcomes. The purpose of the assessment process is to identify opportunities to improve systems or processes and to determine what actions should be taken for improvement.

No evidence was provided of tracking, trending, and monitoring to prevent future recurrence.

Review of Patient #4 medical record revealed missed opportunities when obtaining vital signs, documenting assessments and laboratory results.

During an interview on 02/04/2025 at 3:10 PM, Staff M, Quality Director stated they have begun to track and trend vital signs; the charge nurses perform daily (3) charts for compliance. Quality staff members audit 1 chart per unit per day. There is no tracking or trending started for assessments or lab orders. I am not sure how to track them to prevent it from happening again.

During an interview on 02/05/2025 at 3:45 PM, Staff N, 4th year Surgical Resident stated, "I usually order post-op labs after a big surgery. I did not follow-up with the patients laboratory results post operatively before I went home for the day."

During an interview on 02/06/2025 at 11:30 AM, Staff O, Registered Nurse stated "I had 7 patients so when I received the handoff by PACU ( Post Anesthesia Care Unit) I didn't obtain any vital signs. I know I should have; I admit that. I acknowledged the order for stat labs and assumed they were done; the lab technologist was waiting in the patients' room"

Based on facility documents, medical record review, and interviews conducted, the facility failed to identify opportunities for improvement and develop an effective plan of correction , inlcuding tracking and trending the measures to ensure changes will lead to improvment following an adverse event involving 1 (Patient #4) of 1 patient. Failure to ensure changes make improvement fails to reduce the risk that patients will encounter similar events.

Findings included:

Review of the QAPI (Quality and Performance Improvement Plan) plan dated 2025 revealed no board approval has been completed.
The QAPI Plan states ... the data collection is systematic and is used to identify areas for more focused data collection to sustain improvement over time. Data analysis ...[ is used] to identify variation, through the use of statistical tools and methods, helps focus the attention and resources on making improvement changes to the processes that will result in better outcomes. The purpose of the assessment process is to identify opportunities to improve systems or processes and to determine what actions should be taken for improvement.

No evidence was provided of tracking, trending, and monitoring to prevent future recurrence

Review of the facility's plan of correction revealed "reviewing the importance of post operative vital signs and review of the policy".

Review of Patient #4 medical record revealed missed opportunities when obtaining vital signs, documenting assessments and laboratory results, contributing to the decline of the patient.

During an interview on 02/04/2025 at 3:10 PM, Staff M, Quality Director stated they had already began to track and trend vital signs prior to the incident. The charge nurses perform chart checks daily (3 charts) for compliance. Quality staff members audit 1 chart per unit per day. There is no tracking or trending started for assessments or lab orders. I am not sure how to track them to prevent it from happening again.

Based on facility documents, medical record review and interviews conducted, the facility failed to identify opportunities for improvement and develop an effective plan of correction for an adverse event involving a post operative patient without prompt intervention to seek effective preventive measures to protect in 1 of 1 QAPI program.

Finding included:

During the facility review process, the Council meets on a bi-weekly basis with the CMO (Chief Medical Officer), the physician involved and other members of the council. A meeting request was implemented however, the date is still undetermined.

Review of the QAPI (Quality and Performance Improvement Plan) plan dated 2025 revealed no board approval has been completed. The QAPI Plan states the data collection is systematic and is used to identify areas for more focused data collection to sustain improvement over time. Data analysis ...[ is used] to identify variation, through the use of statistical tools and methods, helps focus the attention and resources on making improvement changes to the processes that will result in better outcomes. The purpose of the assessment process is to identify opportunities to improve systems or processes and to determine what actions should be taken for improvement.

No evidence was provided of tracking, trending, and monitoring to prevent future recurrence.

Review of Patient #4 medical record revealed missed opportunities when obtaining vital signs, documenting assessments and laboratory results.

During an interview on 02/04/2025 at 3:10 PM, Staff M, Quality Director stated they had already begun to track and trend vital signs prior to the incident. The charge nurses perform chart checks daily (3 charts) for compliance. Quality staff members audit 1 chart per unit per day. There is no tracking or trending started for assessments or lab orders. I am not sure how to track them to prevent it from happening again.

Based on staffing grid, staffing assignments, and interviews, the hospital failed to adhere to facility staffing grid on 2 (Medical Surgical) of 6 nursing units.

Findings included:

A review of the Nursing Grid Guidelines revealed Medical Surgical (Med Surg) and Specialty Med Surg nurses should have a maximum of 6 patients.

Review of the last 30 days of staffing assignment sheets for 4 East Med Surg and 4 West Med Surg revealed:

4 West:
01/02/2025 7 PM 1 CN (Charge Nurse) both sides (East and West) for total of 58 patients
3 RN's with 7 patients each
01/05/2025 7 AM 1 CN
5 RN's with 7 patients each
01/06/2025 7 AM 1 CN
5 RN's with 7 patiets each
01/10/2025 7 PM 1 CN both units (4E and 4W) for total of 67 patiemts
3 RNs with 7 patients
01/12/2025 7 AM 1 CN
3 RNs with 7 patients
01/14/2025 7 AM 1 CN
5 RNs with 7 patients
01/16/2025 7 AM 1 CN
5 RNs with 7 patients
01/17/2025 7 AM 1 CN
5 RNs with 7 patients
01/22/2025 7 AM 1 CN with 1 patient
5 RNs with 7 patients
01/24/2025 7 AM 1 CN
5 RNs with 7 patients
01/25/2025 7 AM 1 CNC
2 RNs with 7 patients
01/26/2025 7 AM 1 CNC with 4 patients
4 RNs with 7 patients
01/27/2025 7 PM 1 CNC both units (4 East and 4 West) for a total of 69 patients
4 RNs with 7 patients
01/31/2025 7 AM 1 CNC with 1 patient
4 RNs with 7 patients

4 East:
01/02/2025 7 PM 1 CN both for nursing units (East and West) for a total of 58 patients
5 RNs with 7 patients
01/05/2025 7AM 1 CNC
5 RN with 7 patients
01/6/2025 7 AM 1 CNC
5 RNs with 7 patients
01/09/2025 7 AM 1 CNC with 1 patient
5 RNs with 7 patients
01/10/2025 7 PM 1 CNC with both nursing units (4 East and 4West) for a total of 67 patients
1 RN with 7 patients
01/11/2025 7 PM 1 CNC for both nursing units (4 East and 4 West)
4 RNs with 7 patients
01/12/2025 7 AM 1 CNC
4 RNs with 7 patients
01/19/2025 7 AM 1 CNC with 1 patient
5 RNs with 7 patients
01/22/2025 7 AM 1 CNC
5 RNs with 7 patients
01/23/2025 7 AM 1 CNC
5 RNs with 7 patients
01/24/2025 7 AM 1 CNC
5 RNs with 7 patients
01/26/2025 7 AM No CNC
5 RNs with 7 patients
01/27/2025 7 AM 1 CNC
5 RNs with 7 patients
01/27/2025 7 PM 1 CNC for both nursing units (4 East and 4 West) for a total of 69 patients
5 RNs with 7 patients
01/28/2025 7 AM 1 CNC
5 RNs with 7 patients
01/31/2025 7 AM 1 CNC
5 RNs with 7 patients
02/02/2025 7 PM 1 CNC for both nursing units (4 East and 4 West)

During an interview on 02/03/2025 at 1:15 PM, Staff A, RN CN (Charge Nurse) of 4 West stated we were short that day (01/26/2025). "I had 4 patients and the nurse all had 7 each. We follow the grid. It goes by the census. We have had 7 quite a bit lately. 7 is too many. I take assignments once in a while."

During an interview on 02/03/2025 at 1:32 PM on 2/3/25, Staff B, RN of 4 West stated it's 6 to 7 patients to 1 (nurse). It should be 5, although not sure what the ratio is supposed to be exactly. "I can take care of 7. It's not what I envisioned as a nurse, it's too much. I have 7 patients at least 2 out of every 3 shifts a week and the charge takes patients not often."

During an interview on 02/03/2025 at 1:58 PM, Staff C, RN of 4 West stated i am a contract/travel RN it's 1 (nurse) to 6 or 7 (patients). "It's not safe."

During an interview on 02/03/2025 at 10:41 AM, Staff D, RN of 4 Wes stated "As of lately we have had 7 patients for 2 weeks. 6 is supposed to be our max. RN A, CNC had 4. She took care of her 4 and was trying to do charge duties also. There is not enough staff. I do not feel I can provide quality care with 7 patients."

During an interview on 02/03/2025 at 11:33 AM, Staff E, MT (monitor tech) stated "I used to work on the floor. I know what it's like.That unit was very chaotic. It's a busy floor. If they're short staffed, then it's chaos. We have to call the nurses, not the techs (CNAs-certified nursing assistants). A lot of times they are short on the weekends. They're full and have 5 nurses and 2 techs. But then the charge will take a team."

During an interview on 02/03/2025 at 11:53 AM, the Director of Med-Surg-Tele (telemetry) stated "the grid is 6 patients and then they flex up to 7. Without a grid I don't know what it is. I don't know that I would make anyone primary with 5 patients. We still have positions open. We lost a lot of people in the beginning when I came. I think we may lose some more. We have always had a staffing challenge, but it seems a little different. I think we could do more. I don't think we are as proactive as we could be. We own Agency Name. It's the largest staffing agency in the country. They all do the best they can. It's not their decision. It's over our heads. It's over the CNO (chief nursing officer) and CEO's (chief executive officer) heads. We don't want them to have 7. The new grads are struggling. I have not had the challenges with staffing that I have had here. We try to staff to grid. We are making an effort. We are trying to come up with a plan where we never have to go up to 7 patients again. We have been approved for contracts. Not as many as we need. The charges rarely take patients. We had some people go to PCU (progressive care unit). It's difficult to have 7 patients and precept a new nurse too."

During an interview on 02/03/2025 at 10:43 AM, Staff F, House Supervisor stated "I look at staffing the minute I walk through the door. I am constantly looking at it to tweak it and balance it throughout the facility. We can do 1 to 7 in the evenings. I do staffing for nights. If we need to we can use CNCs or balance from other floors. 72 beds combined (4 east and west). Ideally, we would like 3 PCTs on each side." There have been times a CN had to oversee both 4 east and 4 west.

During an interview on 02/03/2025 at 10:54 AM, 5th floor Nurse Manager stated around 50% of the time they are staffed to grid on his floor. They do contracts, but it's hard to get them approved.

During an interview on 02/03/2025 at 11:11 AM, Staff G, CN of 4 East stated I am a house supervisor also.The charge takes patients 1 to 2 times a month. "Usually if we're waiting for discharges I take 1 patient if they're busy, until they're caught up, and then I give it back. Day shift charge does not have both sides. Night shift charge has both units (4 east and 4 west) at least a couple of times in the last month. We get as many from agency as they will allow us to have. We have to take care of the patients, so we have to put a CN on an assignment." It is not reasonable to have one charge for both sides. "The night shift is not as bad. They shouldn't have 7. There has been a lot of sickness and a lot of call-offs. This floor has the highest number of admissions and discharges. It's a fast turnovee; we discharge and then get admissions. We have 3 PCTs (patient care technicians-CNAs) today, but they get pulled to sit for one to ones. Sitters have also been calling off like crazy, we have to have the sitters. 3 PCTs isn't even enough and 6 patients is too many on this floor. The patients are sicker and the acuity is higher. They really need to reconsider the ratio."

During an interview on 02/03/2025 at 11:29 AM, Staff H, RN of 4 East stated this is a med-tele floor. I have 6 patients today. "Once in awhile it's 7; but it's rare. 6 is manageable. 7, not so much. If we're short a tech, it's tough. There's been a few weeks with 7 and the charge also took 1 or 2. A couple times a month the charge has both units. It happens more often on nights. I have to stay late and don't get a full break. You do what you have to."

During an interview on 02/03/2025 at 11:35 AM , Staff I, RN of 4 East stated "it's 6 patients. 7 is not very often maybe a couple times a month. It happens on nights a lot more. Most days 6 is manageable but the patients are sicker and acuity is higher; they also have multiple comorbidities. So that makes it not manageable. The ratio is supposed to be 6. The charge also takes patients but it's not that often on days. On nights it's a couple times a week. The charge has had both sides at least a couple times a month. I do relief charge sometimes. You become more of a resource nurse when you have both sides. It's a lot and it's not safe. The paperwork is neglected. They hire staff but then they leave and go to other units. There's been codes. They use agency. They can't always get them. They have call offs. Our director is talking about changing the grids so we don't have 7 anymore."

During an interview on 02/03/2025 at 11:47 AM, Staff J, CN of 4 West stated "It's been rougher lately. Last week I had 1 to 2 patients 4 days in a row and one day I had to take 7 patients. The manager did come in to be the CN. Most of the time I don't take patients. One time I had to take both sides (4 East and 4 West) but then the manager from 4 East came in and took over CN for me. They have 7 patients most of the time. It's been that way since August. Often times it's one PCT. Most of the time it's agency staff. They can't take care of 7. Medications and assessments are done, but not always on time. They can't be everywhere; they try. It's not administration; it's above them. It's division. The standard is 6 (nurses) and 3 techs. Since mid-December the call-offs are non-stop. People are leaving. They have hired new grads. But it takes a long time to train them. We have 1 contract starting soon. We use agency, but they don't pick up because they come here and get 7 and they can go elsewhere and get 5 plus incentives. Division has to approve incentives. They have a metrix to follow. There hasn't been any events, but it's a matter of time. Night shift CN doesn't take patients often lately. Night shift nurses regularly take 7. We like them at 6. They are capping us at 35 and blocking a room. Night charge takes both sides more often than day shift. It is not manageable. That's 72 patients. We have lost nurses because of the ratio, and not so much because of the pay. We have a resource nurse on each floor, but it's still too much. They have considered taking away the secretary for another nurse, but then charge has to do the secretary's work too. We don't have secretaries on weekends so we are doing their job then also."

During an interview on 02/03/2025 at 12:10 PM, Staff K, RN stated they don't have 7 very often. "Last week was short. I can take care of 7. I am used to it. It's overwhelming for the new nurses. Some refuse to take 7 so the charge picks up the rest. Usually charge doesn't take patients. It's 2 to 3 PCTs. It's not enough. On good days we have 3. With 7, the patient care is impacted. If you have an emergency, you can't pay attention to your other patients."

During an interview on 02/03/2025 at 12:21 PM, Staff L, RN stated "Staffing is terrible. I think more falls are happening because no one is there. It's hard to get nurses to the floor for sepsis alerts; the sepsis RNs come from ICU. You wait awhile to even get one person here. We have 7 all the time and only about twice a month has it been less. Today is one of them, we have 6. The charge has been taking more lately. There has been no charge at times. When there is no CNC, we help each other and the secretary helps. When it's one shift you can get through it, but it's back to back. Nightshift has no charge more often and mostly during the holidays. It's not possible and it is a little bit scary. They're not doing anything about it. They just tell us to speak more positively. We only have 4 full time nurses and 1 LPN (licensed practical nurse). No other core staff. We want the patients safe. They use agency. They use staff from other units or float pool. The acuity is high and the ratio is high. They can't retain staff; they come then leave. There have been more falls. People leave because it's not safe. We have a lot of near misses."














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