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Based on record review, staff interview, and review of facility policies, the hospital failed to provide adequate numbers of nursing staff to provide nursing care to all patients as needed (A0392).

Based on record review, facility policy review, and staff interview, the hospital failed to provide adequate numbers of nursing staff to provide nursing care to all patients as needed for three of four patients reviewed who received care in the emergency department (Patient #6, #8, and #13). The sample size was 13 patients. The census was 113.

Findings include:

The facility policy titled, Staffing Guidelines for Clermont Nursing Departments, approved on 01/01/17, was reviewed on 02/11/2020 at 3:00 PM. According to the staffing guidelines for the Emergency Department (ED), on Monday through Friday from 7:00 AM to 3:00 PM there should be one charge nurse, six registered nurses (RN's), and two and a half unit secretary/technicians. Staffing Monday through Friday, from 3:00 PM to 11:00 PM, should include one charge nurse, eight RN's, and three unit secretary/technicians. The night shift, 11:00 PM to 7:00 AM required one charge nurse, five RN's, and two unit secretary/technicians. The staffing guidelines for the ED on the weekends revealed there should be one charge nurse, five RN's, and two and a half unit secretary/technicians for day shift, one charge nurse, seven RN's, and three unit secretary/technicians for evening shift, and one charge nurse, five RN's, and two unit secretary/technicians for night shift.

1. Review of the medical record of Patient #6 revealed the patient presented to the ED on 01/05/2020 at 2:45 PM with complaints of pain in the head and chest area. The patient reported symptoms beginning with a sore throat on Thursday, chest congestion with a cough on Friday. According to the patient care timeline, at 3:06 PM the patient's blood pressure was elevated at 195/102. At 3:09 PM the patient also reported generalized and head pain, rating it a seven on a zero to ten scale. The patient was given an acuity score of "3" or "urgent" on the Emergency Severity Index. The medical record revealed the patient's blood pressure was not re-assessed until 10:27 PM, more than seven hours later. It remained elevated at 178/88. The patient left against medical advice at that time.

ED hourly staffing and census data from 12/2019 through 02/2020 was reviewed on 02/12/2020 at 10:00 AM. On 01/05/2020, a Sunday, from 3:00 PM to 7:00 PM there was one charge nurse, four RN's, and two technicians for a census of 32 patients. Interview with Staff B at the time of the review confirmed there should have been one charge nurse, seven RN's, and three technicians, which was a deficit of three RN's and one technician.

From 7:00 PM to 11:00 PM staffing had increased to one charge nurse, five RN's and two technicians. The census was noted to be 40 patients at 9:30 PM and 38 patients at 10:30 PM.

According to the staffing guidelines for the ED on the weekend evening shift, there should be one charge nurse, seven RN's, and three unit secretary/technicians.

The facility policy titled, Emergency Severity Index Triage, approved on 09/13/19, revealed all patients coming to the ED for care are triaged into one of five different levels depending on the urgency of the condition which is based on the Emergency Severity Index (ESI) which categorizes emergency department patients by evaluating both acuity and resources needed. The policy defined a triage level of "3" as "urgent" which included patients with conditions that required prompt care but would not generally cause loss of life or permanent severe impairment if left untreated for several hours.

The facility policy titled, Assessment/Reassessment of the Emergency Department Patient, approved 07/11/19, revealed all adult patients will have a full set of vital signs assessed to include temperature, pulse, respirations, pain, and blood pressure. Re-assessments are performed at specified intervals related to the patient acuity. The policy instructed staff to re-assess vital signs every 30-60 minutes on "urgent" patients.

Staff B was interviewed on 02/14/2020 at 3:30 PM. He/she confirmed there was no documentation Patient #6's vital signs were re-assessed between 3:06 PM and 10:27 PM.

2. Review of the medical record of Patient #8 revealed this patient also presented to the ED on 01/05/2020 at 4:14 PM with complaints of a lump on the right side of his/her stomach. At 4:54 PM the patient rated pain from the lump at an eight on a zero to ten scale. At 4:56 PM the patient care timeline noted the patient was given an acuity of "3" or "urgent" on the Emergency Severity Index. The patient was placed in a c-chair, a second waiting area within the ED, at 5:21 PM. The medical record lacked documentation the patient's pain was re-assessed. The patient left without being seen by a provider, at 7:51 PM. The outcome note on the Complaint/Grievance log stated the patient went to another hospital where he/she was diagnosed with a strangulated right femoral hernia requiring a bowel resection. It was confirmed during an interview with Staff E on 02/14/2020 at 12:05 PM that the medical record lacked documentation the patient's pain was re-assessed within 30-60 minutes as required by facility policy. This was also confirmed with Staff B during an interview on 02/14/2020 at 3:00 PM.

3. Staffing and census data for 01/13/2020 and 01/16/2020 revealed that on the night of 01/13/2020 from 3:00 AM to 7:00 AM staffing included one RN and one technician caring for 20 patients at 3:30 AM, 17 patients at 4:30 AM, 16 patients at 5:30 AM, and 14 patients at 6:30 AM. On the night of 01/16/2020 from 4:00 AM to 7:00 AM staffing included one nurse and two technicians caring for 12 patients at 4:30 AM, 11 patients at 5:30 AM, and 10 patients at 6:30 AM.

Staffing Monday through Friday, from 3:00 PM to 11:00 PM, should include one charge nurse, eight RN's, and three unit secretary/technicians. The night shift, 11:00 PM to 7:00 AM required one charge nurse, five RN's, and two unit secretary/technicians.

Staff B was interviewed on 02/13/2020 at 5:30 PM. Staff B stated that with no patients in the ED, having only one RN and one or two technicians could be considered unsafe as patients with unexpected diagnoses including trauma could present without notice.

4. The medical record of Patient #13 revealed the patient presented to the ED on 01/13/2020 at 7:38 PM for a psychiatric evaluation after reporting suicidal ideations. At 7:44 PM the patient was assigned an ESI acuity level "3." At 7:45 PM the patient's blood pressure was 194/110. One minute later at 07:46 PM, the patient was taken to room B5, one of the four rooms in the behavioral access center of the ED. The patient was discharged home at 12:07 AM. The medical record lacked documentation the patient's blood pressure was re-assessed prior to his/her discharge from the ED. This finding was confirmed with Staff B on 02/14/2020 at 3:40 PM.

Staffing Monday through Friday, from 3:00 PM to 11:00 PM, should include one charge nurse, eight RN's, and three unit secretary/technicians. The night shift, 11:00 PM to 7:00 AM required one charge nurse, five RN's, and two unit secretary/technicians.

Review of the staffing schedules for 01/13/2020 from 7:00 PM-11:00 PM revealed there were four RN's and and two unit secretary/technicians and from 11:00 PM-1:00 AM there were four RN's but only one unit secretary/technician.

This substantiates Substantial Allegation OH00109570.