HospitalInspections.org

Based on review of hospital policies and procedures, staffing assignment records, and interviews with staff, it was determined the Hospital failed to require nursing staffing schedules were based on a system that included not only the number of patients, but also based on the acuity of each patient including the intensity of illness and nursing needs and the training and experience of each personnel.

Findings include:

The Hospital's Policy titled Nursing Staff Allocation, Policy #: HR-00035, included the following: "POLICY: It is the responsibility of the Director of Nursing Services to develop, approve and implement criteria for employment, deployment and assignment of nursing staff members...PROCEDURE: The mechanism used for determining the deployment of nursing staff members among departments is as follows: 1. Staffing Patterns...A. Number of staff - Nursing units are staffed according to full time 'equivalents'...Hours of nursing care are based on national averages of smaller patient populations and are adjusted to the patient mix...B. Staffing mix...C. Sufficient staffing - Staffing, both in numbers and competency will be sufficient at all times to insure (sic) that: i. A Registered Nursing prescribes, delegates and coordinates care of all patients to assure the following mechanisms are in place...Assessment and meeting of patient care needs occurs in admission, during stay, on transfer and at discharge...Assessment of patients takes place prior to assignment of staff...Staff capability is matched to patient needs...Emergency and safety patient requirements are met...2. Assignment of Nursing Personnel...B. Considerations - Patient care responsibilities are assigned to nursing staff based on four general considerations, including the patient acuity, environment in which nursing care is provided, staff competency, and supervision required by and available to each nursing staff member assigned responsibility...The following variables influence assignments: i. complexity of nursing care required by the patient...ii. dynamics of the patient's status and frequency of nursing care activities...iii. complexity of the assessment required by the patient, including the knowledge and skills required of a nursing staff member to effectively complete the required assessment...iv. type of technology required for case as defined in patient care protocols such as chest tubes, ventilators, invasive lines, etc. v. competency of assigned personnel in relationship to knowledge and skills required to effectively provide care and utilize current technology. vi. competency of delegating RN to carry out clinical and supervisory responsibilities. vii. age of population served. 3. Patient Classification - Patients are classified to identify the intensity of nursing care required by the individual patient/family to aid in decision making regarding staffing and patient care assignment...."

A sample of the daily staffing reports were reviewed for December 2009 and January and February 2010. The staffing reports did not consistently include the census on each unit for each shift, evidence of an assessment of the acuity of each patient and evidence of adjustments to staffing made based on changing acuity and/or activity level of the patients on each unit.

Three Registered Nurses and one Behavioral Health Technician stated during separate interviews on 2/16 and 2/17/2010, that the daily schedule was based on the census of each unit that day. They reported that additional staff would be assigned if a patient required 1:1 observation but were not aware of an acuity system used.

The Director of Nursing reviewed the Hospital's "Staffing Grid" with the surveyors during an interview on 2/17/2010. The Staffing Grid was based on the census of each unit. The Director of Nursing reported that there were times when staffing was adjusted including if a patient required 1:1 observation but acknowledged the Hospital had no acuity system including an on-going assessment of each patient based on their individual needs.