HospitalInspections.org

Based on a review of documentation, the governing body was not responsible for all services furnished in the hospital.

Findings were:

Facility policy 77.786 titled " Nurse Staffing Plan " stated, in part, " IV. Staffing Performance Assessment ...D. The RN supervises the nursing care provided by others for whom they are administratively or professionally responsible. "

In an interview with staff #1 on 4-22-13, he stated that he was the Director of the 8th floor and that staff #2 had been orienting, as a new graduate nurse, with the charge nurse on duty at the time of patient #1's fall from the edge of her bed.

A review of the 8th Floor census/staffing assignment sheet for the 7a-7p shift on 2-27-13 revealed that staff #2 was orienting on the day of the incident and was under the supervision of the charge nurse. 36 patients were on the unit. The staffing for the shift consisted of a charge nurse (who did not have a patient assignment), staff #2 (who was orienting and did not have a patient assignment), 5 registered nurses, 2 licensed vocational nurses, 3 unlicensed technicians and a unit clerk.

A review of the 8th Floor staffing grid/matrix revealed that, for a total number of 36 patients, staffing should be comprised of a charge nurse, 7 registered nurses, 3 unlicensed technicians and a unit clerk.

The above was confirmed in a meeting with the Vice President of Patient Services, the Regulatory Compliance Coordinator and the Director of Patient Safety on the afternoon of 4-22-13 in the facility conference room.

Based on a review of documentation and an interview with staff, the nursing care for patient #1 was not adequately supervised or evaluated by a registered nurse.

Findings were:

On 2-27-13, a nursing note (for patient #1) written at 4:29 pm states, " Pt placed onto the bedpan per request. Bed is locked and in low position, call light in reach. Pt states ' I will use my call light when I am finished so ou (sic) can take me off the bedpan. ' Respirations even and unlabored. Pt denies needs at this time. "

Also on 2-27-13, a nursing note (also for patient #1) written at 4:41 pm states, " Pt found on floor. Pt stated ' I was on the bedpan and I slid off onto the floor and bumped my head on the floor. ' Pt has bump to the back of the head, no bleeding or discharge present at site. All skin intact. Pt assisted off of the floor and into bed. Physician and family notified. Respirations even and unlabored. Pt denies needs at this time. "

A review of the 8th Floor census/staffing assignment sheet for the 7a-7p shift on 2-27-13 revealed that staff #2 was orienting on 2-27-13 and was under the supervision of the charge nurse.

In an interview with staff #1 on 4-22-13, he stated that he was the Director of the 8th floor and that staff #2 had been orienting, as a new graduate nurse, with the charge nurse on duty at the time of patient #1's fall from the edge of her bed. He stated that, although staff #2 was orienting under the supervision of the charge nurse at the time of the fall, the charge nurse was administering medications to a patient and that staff #2 answered the call light for patient #1.

The above was confirmed in a meeting with the Vice President of Patient Services, the Regulatory Compliance Coordinator and the Director of Patient Safety on the afternoon of 4-22-13 in the facility conference room.