HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure adequate numbers of Registered Nurses (RNs) were on duty in the Emergency Department (ED). This potentially placed ED patients at risk for serious adverse outcomes. As a result, the Condition of Participation, 42 CFR 482.23, Nursing Services, was not in compliance.

Findings include:

1. The Hospital failed to ensure nurse staffing was adequate in the ED to avoid serious adverse outcomes. (A392).

An Immediate Jeopardy (IJ) was identified on 2/4/21 for the Hospital's failure to ensure adequate staffing in the Emergency Department. This failure potentially placed all patients in the ED at risk for serious adverse outcomes. The IJ was announced on 2/4/21 at 3:20 PM, during a meeting with the Chief Executive Officer, Chief Medical Officer, Chief Operating Officer, Chief Nursing Officer, and the Director of Quality. The IJ was not removed by the survey exit date of 2/9/21.

Based on document review and interview, it was determined that for 15 of 15 days (1/24/21 through 2/7/21), the Hospital failed to ensure nurse staffing was adequate in the Emergency Department (ED) to avoid serious adverse outcomes to the average of 69 patients being treated in the ED each day.

Findings include:

1. On 2/4/2021, the ED minimal staffing guidelines for Registered Nurses (RNs), with an average daily census of 135 patients, were reviewed. The guidelines included:

7:00 9:00 11:00 3:00 7:00 11:00 3:00
AM AM AM PM PM PM AM

RN 6 6 6 6 6 6 6
CHR 1 1 1 1 1 1 1
Triage 1 2 2 2 2 2 1
Minor 1 1 1 1 1 1 0
Float 0 0 0 1 1 0 0

Total 9 10 11 11 11 10 8

2. On 2/8/2021, ED staffing records from 1/24/2021 to 2/7/2021 were reviewed. Staffing did not meet the minimum shift requirements for any of the 15 days. The ED was short staffed on these dates as follows:

On 1/24/2021 from 7:00 AM to 9:00 AM, short 3 RNs.
On 1/24/2021 from 9:00 AM to 7:00 PM, short 4 RNs.
Census was 69.

On 1/25/2021 from 7:00 AM to 9:00 AM, short 1 RN.
On 1/25/2021 from 9:00 AM to 11:00 AM, short 2 RNs.
On 1/25/2021 from 11:00 AM to 7:00 PM, short 3 RNs.
On 1/25/2021 from 7:00 PM to 11:00 PM, short 4 RNs.
On 1/25/2021 from 11:00 PM to 3:00 AM, short 3 RNs.
On 1/25/2021 from 3:00 AM to 7:00 AM, short 1 RN.
Census was 79.

On 1/26/2021 from 9:00 AM to 7:00 PM, short 1 RN.
On 1/26/2021 from 7:00 PM to 11:00 PM, short 2 RNs.
On 1/26/2021 from 11:00 PM to 3:00 AM, short 1 RN.
Census was 72.

On 1/27/2021 from 7:00 AM to 9:00 AM, short 1 RN.
On 1/27/2021 from 9:00 AM to 11:00 AM, short 2 RNs.
On 1/27/2021 from 11:00 AM to 3:00 PM, short 3 RNs.
On 1/27/2021 from 3:00 PM to 7:00 PM, short 2 RNs.
On 1/27/2021 from 7:00 PM to 11:00 PM, short 3 RNs.
On 1/27/2021 from 11:00 PM to 3:00 AM, short 1 RN.
Census was 70.

On 1/28/2021 from 7:00 AM to 9:00 AM, short 2 RNs.
On 1/28/2021 from 9:00 AM to 11:00 AM, short 3 RNs.
On 1/28/2021 from 11:00 AM to 7:00 PM, short 2 RNs.
On 1/28/2021 from 7:00 PM to 11:00 PM, short 3 RNs.
On 1/28/2021 from 11:00 PM to 3:00 AM, short 2 RNs.
Census was 101.

On 1/29/2021 from 7:00 AM to 9:00 AM, short 4 RNS.
On 1/29/2021 from 9:00 AM to 7:00 PM, short 3 RNs.
On 1/29/2021 from 7:00 PM to 11:00 PM, short 4 RNs.
On 1/29/2021 from 11:00 PM to 3:00 AM, short 4 RNs.
On 1/29/2021 from 3:00 AM to 7:00 AM, short 2 RNs.
Census was 71.

On 1/30/2021 from 7:00 PM to 11:00 PM, short 5 RNs.
On 1/30/2021 from 11:00 PM to 3:00 AM, short 4 RNs.
On 1/30/2021 from 3:00 AM to 7:00 AM, short 2 RNs.
Census was 74.

On 1/31/2021 from 7:00 AM to 9:00 AM, short 2 RNs.
On 1/31/2021 from 9:00 AM to 11:00 AM, short 3 RNs.
On 1/31/2021 from 11:00 AM to 3:00 PM, short 4 RNs.
On 1/31/2021 from 3:00 PM to 7:00 PM, short 4 RNs
On 1/31/2021 from 7:00 PM to 11:00 PM, short 6 RNs
On 3/31/2021 from 11:00 PM to 3:00 AM, short 5 RNs.
On 1/31/2021 from 3:00 AM to 7:00 AM, short 3 RNs.
Census was 53.

On 2/1/2021 from 7:00 AM to 9:00 AM, short 4 RNs.
On 2/1/2021 from 9:00 AM to 11:00 AM, short 5 RNs.
On 2/1/2021 from 11:00 AM to 3:00 PM, short 6 RNs.
On 2/1/2021 from 3:00 PM to 7:00 PM, short 6 RNs.
On 2/1/2021 from 7:00 PM to 11:00 PM, short 4 RNs.
On 2/1/2021 from 11:00 PM to 3:00 AM, short 3 RNs.
Census was 69.

On 2/2/2021 from 7:00 AM to 9:00 AM, short 5 RNs.
On 2/2/2021 from 9:00 AM to 3:00 PM, short 6 RNs.
On 2/2/2021 from 3:00 PM to 7:00 PM, short 5 RNs.
Census was 87.

On 2/3/2021 from 11:00 AM to 7:00 PM, short 1 RN.
On 2/3/2021 from 7:00 PM to 11:00 PM, short 4 RNs.
On 2/3/2021 from 11:00 PM to 3:00 AM, short 3 RNs.
On 2/3/2021 from 3:00 AM to 7:00 AM, short 1 RN.
Census was 79.

On 2/4/2021 from 3:00 PM to 7:00 PM, short 1 RN.
On 2/4/2021 from 7:00 PM to 11:00 PM, short 2 RNs.
On 2/4/2021 from 11:00 PM to 3:00 AM, short 1 RN.
Census was 54.

On 2/5/2021 from 7:00 AM to 9:00 AM, short 2 RNs.
On 2/5/2021 from 9:00 AM to 7:00 PM, short 3 RNs.
Census was 71.

On 2/6/2021 from 7:00 AM to 9:00 AM, short 4 RNs.
On 2/6/2021 from 9:00 AM to 7:00 PM, short 5 RNs.
Census was 43.

On 2/7/2021 from 7:00 AM to 9:00 AM, short 3 RNs.
On 2/7/2021 from 9:00 AM to 11:00 AM, short 5 RNs.
On 2/7/2021 from 11:00 AM to 7:00 PM, short 4 RNs.
On 2/7/2021 from 7:00 PM to 3:00 AM, short 3 RNs.
On 2/7/2021 from 3:00 AM to 7:00 AM, short 1 RN.
Census was 41.

3. On 2/4/2021 at 9:35 AM, an interview was conducted with the ED Nurse Manager (E #5). E #5 stated that there was no problem with staffing today (2/4/2021 7:00 AM - 3:00 PM), but there was on Monday (2/1/21) and Tuesday (2/2/21), when the ED was short staffed, and E #5 had to "work the floor [provide patient care]". E #5 stated that the ED needs 10 RNs on duty for minimal staffing.

4. On 2/4/2021 at 12:10 PM, an interview was conducted with the Chief Nursing Officer (E #14). E #14 stated that since the announcement [July 2020] that the Hospital was closing, staff have been leaving. The Hospital is doing everything it can to retain staff.

5. On 2/8/21, at approximately 3:00 PM, E#14 presented a new staffing grid for an average ED census of 85 patients (effective 2/8/21 at 2:45 PM). The grid was reviewed on 2/9/21 and required:

7:00 9:00 11:00 3:00 7:00 11:00 3:00
AM AM AM PM PM PM AM

RN 4 5 6 6 6 6 4
CHR 1 1 1 1 1 1 1
Triage 1 1 1 1 1 1 1
Minor 0 1 1 1 1 0 0
Float (not required)

Total 6 8 9 9 9 8 6

6. On 2/9/2021, at approximately 2:45 PM, the ED staffing schedules, based on the new ED staffing grid, were reviewed for 2/9/2021 - 2/23/2021. For 7 of the 15 days, ED staffing was short of nurses and did not meet the staffing requirements per the Hospital's ED staffing grid, indicating that the deficient practice was still evident through the survey exit date of 2/9/2021. Furthermore, the deficient practice was not remedied for the near future.