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Based on record review, observation, document review, and staff interview it was determined the facility failed to ensure care in a safe setting for patient #1 by not ensuring a Registered Nurse (RN) was present, available and readily accessible on Units A6 and A5, as there was no RN present on the units (See Tag A 144). This failure has the potential to cause great harm or death to patient #1, and all patients on the units. As a result of this failure, Immediate Jeopardy (IJ) was identified and the facility was notified on 12/14/22 at 8:15 a.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 12/14/22 at 11:00 a.m.

The following interventions were implemented to resolve the IJ: Education of all RNs will be completed for one (1) RN remaining on the unit at all times. Training will continue until 100% of all RNs are educated. Spot checks and video review will be performed every shift to ensure there is a RN on each unit. The Nursing Supervisor will no longer be assigned supervisor duties when assigned to a unit as the only RN.

Based on record review, observation, document review, and staff interview, it was determined the facility failed to ensure care in a safe setting for all patients by failing to ensure a Registered Nurse (RN) was present on Units A5, and A6. This failure has the potential to cause great harm or death to all patients receiving care at the facility.

Findings include:

A review was conducted of the medical record for patient #1. The patient was admitted to the facility on 08/11/22 at 11:24 p.m. with a diagnosis of unspecified psychotic disorder. The patient had a wound on their right foot and was unsteady at times with ambulation. The patient had four (4) falls reported, with one (1) transfer to the hospital for evaluation on 08/24/22. On 11/22/22, the patient suffered another fall. A note by the RN Supervisor at 11/22/22 at 10:27 p.m., states in part: "Staff was alerted by pt's [patient's] roommate that pt had fallen out of bed. This nurse who is also working supervision was on another unit attending a code. I was alerted by staff that a code orange [fall] had been called on A6 and we responded from A2, bringing crash cart as per code orange policy." The patient was taken via Emergency Medical Services (EMS) to a local facility. The patient was diagnosed with a subacute hemorrhage. The patient returned to the facility on 11/29/22. The patient remains hospitalized on Unit A6 under high fall precautions.

A video review was conducted on 12/13/22 of Unit A6 on 11/22/22 from 6:55 p.m. through 10:15 p.m. The video shows the following:

6:55:00 p.m. RN Supervisor is at the Unit A6 Nurse's Station

7:15:00 p.m. Day shift RN leaves. RN Supervisor only RN present on unit

8:13:49 p.m. RN Supervisor enters into elevator and leaves the unit

8:23:57 p.m. RN Supervisor returns to unit, sits at nurse's station

9:20:06 p.m. RN Supervisor enters into elevator and leaves the unit

9:48:38 p.m. Health Service Worker (HSW) exits patient #1's room, appears to signal for help

9:50:00 p.m. Licensed Practical Nurse (LPN) responds to patient #1's room

9:57:00 p.m. RN #1 arrives onto unit, responds to patient #1's room

10:01:44 p.m. RN Supervisor returns to unit

10:04:00 p.m. RN #1 leaves the unit

10:05:00 p.m. EMS arrives

10:14:11 p.m. Patient #1 taken out via stretcher by EMS

A review was conducted of the Timesheets for the RNs at the facility on 11/22/22. Six (6) RNs were present in the facility from 7:00 p.m. until 11:00 p.m., including one (1) RN in Orientation, and one (1) RN Supervisor.

A review was conducted of the facility "Nursing Staff Worksheet" for 11/22/22. One (1) RN was scheduled on each unit, including the RN Supervisor, scheduled to work Unit A6 from 7:00 p.m. through 11:00 p.m.

A review was conducted of the facility "Master Staffing Plan," last revised 07/22/19. The plan states in part: "A. 1. RN staffing is to include at least one (1) scheduled RN per shift per patient care unit."

A telephone interview was conducted on 12/13/22 at 1:19 p.m. with the LPN. When asked about a RN not being present on the unit, the LPN stated, "I was a little bit worried. I kind of expected if there was a code on another unit that the supervisor would go. The nurse from [Unit] 5 came first and took control of the code. The supervisor came shortly after. Usually if there's only one (1) RN, they don't leave."

A telephone interview was conducted on 12/13/22 at 7:32 p.m. with the RN Supervisor. Regarding patient #1 and not being present on the unit, the RN Supervisor stated, "I was in a situation of being supervisor and working on Unit 6. They try to place us on a unit with calm, stable patients so we can also do supervision work. I responded to the code and I felt it was a prudent thing to do. Even though I was assigned a unit, I am still in charge of the patient and staff safety. The patients on Units 2, 3 and 4 are volatile, things can go south very quickly. They notified me [patient #1] fell and I knew the patient would be taken care of. Everyone did what they were supposed to, and when I got back up to the unit, I took over. No way would I have left if I knew the people were not dependable. I felt I would have been negligent when I had staff fighting to maintain control of their unit and my unit was relatively calm. I made the decision because I felt staff and patients were in jeopardy. I felt I needed to do what was most important to protect the staff and the other patients. If I fill in on the floor, I still have to be in charge of that unit and take all the calls for supervision. My decisions were based on the protection and safety of everyone. I thought it was the best decision based on the situation at the time."

During the video review, on 12/13/22 at approximately 4:00 p.m., Nurse Manager #1 and the Chief Nursing Executive both concurred the RN Supervisor left Unit A6 with no RN from 8:13 p.m. through 8:23 p.m. and 9:20 p.m. through 9:57 p.m. and RN #1 left Unit A5 with no RN from 9:57 p.m. through 10:04 p.m.

An interview was conducted with the Chief Executive Officer (CEO) and Assistant CEO on 12/13/22 at 5:30 p.m. They both agreed the nursing staff is aware they are not to leave the unit if they are the only RN.