HospitalInspections.org

Based on review of hospital policies, documents, and staff interviews, it was determined that the nurse executive failed to require the registered nurse caring for the patient understood and considered the complexity of individual patients' needs, co-morbidities, and interventions as well as staff members competencies in determining patients' acuities and assignment of appropriate staff, and level of care required. This deficient practice posed the risk that patients would not receive the level of nursing care required to recognize and intervene when a patient's condition changed as demonstrated by failure:

1. of the Staffing Guidelines to differentiate between "licensed" (RN versus LPN) and how staff were assigned according to skills mix and patient acuities;
2. to require the acuity plan/process identified and included all individual patient needs;
3. to explain how/what limits Certified Nursing Assistant (CNA) shift hours to 4 or 8;
4. of the policy to include directions/instructions on how to use the acuity tool; and
5. to orient/train the staff on how to use the acuity tool.

Findings include:

The hospital employs RNs, LPNs, and CNAs. The staff work 12 hour shifts (day/night).

The hospital policy titled Staffing Guidelines #3643110 (last revised and Governing Body approved 05/2017) requires: "...will include a processing for developing, implementing, and enforcing unit/shift based plan...on census, patient needs, and patient acuity...."

The hospital policy titled Nursing Acuity Tool and Guidelines #290043 (last revised 10/2016) requires: "...This tool provides a numerical guideline calculated according to risk criteria categories...rating options are 1 through 4, with a 1 indicating lowest acuity and 4 indicating the highest acuity...."

1. The document titled Staffing Guidelines Revised 05/11/17 revealed 3 columns: Census, Dayshift Staffing, and Nightshift Staffing. The Census column was 10 through 23 (patients), the Staffing columns indicated how many staff were required as a basis for the census i:e: House Supervisor, Licensed, Monitor Tech, Respiratory Therapist, and Certified Nursing Assistant. The staff instructions include: "...our patients are not high observation...ideally we can staff a 6:1 (6 patients to 1 nurse) ratio on day shift and 7:1 ratio on nights but please base the assignment on overall acuity...." The "Licensed" reference did not differentiate between RN or LPN.

The Chief Nursing Officer/Chief Clinical Officer (CNO/CCO) described the scoring process during an interview conducted on 05/23/17, as follows:

The untitled worksheet for recording and determining staff skills and patient needs included multiple columns for the categories of Medications (total number of meds), Complicated Procedures, Education, Psychosocial, Complicated IV (intravenous) and Meds, and Total Score for the RN, LPN and CNA, as well as the patient's name and room number. Each discipline scores their own acuity (1 through 4) for each of the 5 categories for the same patient based on staff skills, tasks, and patient needs. The second and last page of the worksheet requires: "...Staffing Matrix By Acuity...RN acuity not to exceed 15 (total points)...LPN acuity not to exceed 12...CNA acuity not to exceed 28...RN and LPN team not to exceed 24 (12/12)...." The CNO/CCO indicated that this staffing matrix was in effect 03/27/17, amended on 04/28/17, and again on 05/17/17 (current matrix as of survey date).

The untitled acuity tool worksheet 03/27/17 (original) identified the number of staff specific tasks as follows: RN 42, LPN 29, and CNA 15. The worksheet dated 04/28/17 amended the tasks as follows: 6 tasks added for RN, (14.3% increase) 2 tasks for LPN (7% increase) and 1 task for CNA (6.6%). The worksheet dated 05/17/17 amended the tasks as follows: 17 tasks deleted for RN (35.4% decrease from 04/28/17), 13 for LPN (29.5% decrease from 04/28/17) and no tasks deleted or added for CNA.

2. Patient acuities and staff assignments are documented/calculated on the daily day/night Assignment Sheets that include columns to document the patient's name, RN/LPN/CNA assignments, and total acuity scores calculated for each patient and discipline. The untitled worksheets and the Assignment Sheets, selected at random, revealed the following:

05/25/17: Patient #6: The RN scored the patient Acuity 2 based on the RN requirement to perform care for the indwelling catheter, peripheral intravenous line (IV), assistance with activities of daily living (ADL), new meds, and lab draws. The sheet did not allow the nurse to include acuity scores for skin care, suctioning (ventilator), stool incontinence, intake/output, tube feedings with flushes, and documentation (paper charting system) for this patient with multiple co-morbidities which contribute to the patient's total acuity score.

05/24/17: Patient #7: The RN scored the patient Acuity 2 based on the RN requirement to perform care for urinary/stool incontinence, new meds, multiple meds, family dynamics, lab draws and "total care." The sheet did not allow for the nurse to include acuity scores for accucheck (diabetic blood glucose testing), tube feedings, tracheostomy care, suctioning (ventilation care), contact isolation, and documentation for this patient with multiple co-morbidities which contribute to the patient's total acuity score.

3. The Assignment Sheets, selected at random, required the following CNA staffing:
05/14/17 (days): Census 14 "CNA 8 hours only"
05/14/17 (nights): Census 14 "CNA 4 hours only"
05/15/17 (nights): Census 14 "CNA 4 hours only"
05/23/17 (days): Census 11 "CNA 4 hours only"
05/24/17 (days): Census 12 "CNA 4 hours only"

There's no policy, documentation or consensus identifying how/who absorbs the CNA scores when the CNA works only 4 - 8 hours of a 12 hour shift. In addition, there is no policy, documentation or consensus identifying LPN or RN as the second "license".

4. The Staffing Guidelines and the Assignment Sheets revealed the following:

05/17/17 days: Census 14. The hospital staffed 2 RNs, 1 CNA, no LPNs. According the Staffing Guidelines the hospital should have staffed 3 "licensed" personnel. One (1) RN had 7 patients with a total of 22 acuity points, and 1 RN had 6 patients with a total of 21 acuity points. Each RN was assigned 3 patients with acuity of 4 (each). The CNO/CCO indicated during an interview conducted on 05/24/17 that acuity 4 was equivalent to an Intensive Care Unit (ICU) patient of which the hospital did not have/accept.

05/14/17 nights: Census 14. The CNA was scheduled for 4 hours only with 14 patient and 36 total acuity points which exceeded the maximum by 6 points. The CNA was under hours with 4 hours when the Staffing Guidelines required 8 hours.

5. Five (5) of 6 RNs interviewed during the survey indicated that the hospital did not provide the Nursing Acuity Tool and Guidelines policy, and did not provide education/training on how to use the Staffing Guidelines (acuity tool). The staff were unsure of how to use and score the untitled acuity scoring tool especially when the tool did not include all tasks that applied to the patients. In addition, the staff could not articulate when it was appropriate to bring in a second RN versus an LPN based on the patients' total acuities. All 6 RNs confirmed that the acuity/staffing process did not capture all patients' needs or required tasks, and that the process did not reflect the staffing mix requirements.