HospitalInspections.org

Based on record review and interviews, the hospital failed to adjust staffing of skilled nurses and techs sufficiently to prevent falls and allow nurses to dispense medications on time. This failure put patients at risk for falls and created recurring issues such as missed or late medications. The findings are:

A. Record review of the hospital's monthly incident reports indicated the following:
1. April 2016, three (3) witnessed falls; ten (10) patients found on the floor, two (2) sent to an emergency department for a higher level of care because of suspected injury.
2. May 2016, fourteen (14) witnessed falls; thirteen (13) patients found on the floor, two (2) sent to an emergency department for a higher level of care because of suspected injury.
3. June 2016, two (2) witnessed falls; five (5) patients found on the floor, two (2) sent to an emergency department for a higher level of care because of suspected injury.
4. July 2016, three (3) witnessed falls; thirteen (13) patients found on the floor.

B. Record review of the hospital's quality data regarding medication administration indicated the following:
1. Total medications dispensed for May 2016, 9,197; number of medications out of compliance 1,256 (missed windows to administer medications)
2. Total medications dispensed for June 2016, 10,718; number of medications out of compliance 1,063
3. Total medications dispensed for July 2016, 10,285; number of medications out of compliance 907

C. On 08/16/16 at 8:04 a.m. during interview, the pharmacist stated, "I have started tracking on drug administration times for the last 3 months. The medication errors are trending up. A lot of the med[ication] pass problems have to do with the patient acuity going up. The average number of medications for patients has gone from 5 medications per patient to 10 medications per patient....I see when three nurses are on duty things flow better.... Constant interruptions contribute to medication errors by nurses. A second dispensing machine would help with med passes. One of the problems is with the pharmacy getting into the machines to stock when nurse are trying to dispense."

D. On 08/16/16 at 10:15 am during interview, the pharmacist offered the following additional comments to his earlier remarks: "Changing the starting time for nurses to 6:00 a.m. from 7:00 a.m. has allowed the nurses to reduce the missed doses of medications. But the medication room is too small for nurses to gather medications at the same time. [There is only one dispensing machine on the floor.] We [pharmacy staff] are often trying to stock the machines when the nurses are trying to pull. Our patients' acuity levels are increasing with more medical problems [diagnoses] and many more medications, maybe as many as 10 medications per patient. The dispensing of medication is much more efficient with three nurses instead of two. Admissions and discharges also make it hard for nurses to give [their patients] medicines on time."

E. On 08/16/16 at 2:15 p.m. during interview, the Director of Nursing stated, "We have a problem with too many medications not dispensed within the window prescribed by pharmacy. I think part of the problem is staffing. I do the staffing. I think we should have three nurses on the floor when the census is 12 or greater. The matrix we follow says we should have two [nurses] until there are 26 patients. This model is appropriate for a skilled nursing facility, not a psych facility like ours. I have argued with the corporate folks about this. But they don't understand the clinical need or the impact on patient safety. I also have to help on the floor regularly with admissions and discharges."

F. Record review of the hospital's staffing matrix indicated two nurses and three techs for a census between 13 and 26. Acuity of patients is not mentioned.

G. Record review of the hospital's policy on staff indicated:
"Section VII: Human Resource Planning
Subject: Staffing
Policy: The Facility's Leadership will provide a sufficient number of staff to successfully implement patient/resident-focused functions.
1. Provides qualified personnel based on the organization's mission, scope of services provided, the populations served, and federal and state certification and licensing requirements.
2. The adequacy of staff is demonstrated by meeting patients'/residents' care needs in accordance with their care plans:
A. Nursing:
1. Care needs are consistent with patient/resident needs, provides sufficient numbers of licensed nurses and other nursing staff (RNs, LPNs/LVNs, Nurse Aides) on a 24-hour basis."

Based on record review and interviews, the governing body failed to acknowledge and address problems identified by the hospital's quality data regarding falls and medication errors. This failure resulted in no plan of action to reduce falls and medication errors and respond to the concerns about nurse-to-patient ratios -- ratios which may have contributed to the increase in falls and medication errors. The findings are:

A. Record review of the governing body minutes for the hospital for January 2016, March 2016, and May 2016 indicated only a brief notation about increased falls. No plan was evident in the minutes to address the problem. No mention of missed medications or staffing concerns was found.

B. On 08/17/16 at 11:15 am during interview, the Chief Executive Officer was asked to review the minutes to find reference to the above missing issues in the minutes. He confirmed that the minutes contained only a passing mention of falls and that medication errors and the staffing issue were not mentioned.

Based on record reviews and interviews, the hospital failed to staff nurses and techs to meet the needs of patients. Changes in the staffing matrix, reducing the number of nurses on day shift from three to two when the patient census ranged from 15 to 26, resulted in increased falls, delayed medication administration and medication errors. The hospital thereby did not deliver the care required for the well-being of the patients. The findings are:

A. Record review of staffing assignments for April 2016, May 2016, June 2016, July 2016, and 08/16/16 indicated the census range from 16 to 26 patients. Nurse staffing through this same period was two nurses and three techs on day shift.

B. Record review of the hospital staffing matrix indicated two nurses and three techs were required for a census between 13 and 26 patients. Acuity of patients is not mentioned.

C. Record review of the hospital's policy on staff indicated:
"Section VII: Human Resource Planning
Subject: Staffing
Policy: The Facility's Leadership will provide a sufficient number of staff to successfully implement patient/resident-focused functions.
1. Provides qualified personnel based on the organization's mission, scope of services provided, the populations served, and federal and state certification and licensing requirements.
2. The adequacy of staff is demonstrated by meeting patients'/residents' care needs in accordance with their care plans:
A. Nursing:
1. Care needs are consistent with patient/resident needs, provides sufficient numbers of licensed nurses and other nursing staff (RNs, LPNs/LVNs, Nurse Aides) on a 24-hour basis."

D. On 08/16/16 at 10:15 a.m. during interview, the hospital pharmacist offered the following (among other statements) : "Our patients' acuity levels are increasing with more medical problems [diagnoses] and many more medications, maybe as many as 10 medications per patient. The dispensing of medication is much more efficient with three nurses instead of two. Admissions and discharges also make it hard for nurses to give their medicines on time."

E. On 08/16/16 at 2:15 p.m. during interview, the Director of Nursing expressed the following: "I do the staffing. I believe we should have three nurses on day shift with a patient census of 13 or more. I have argued with the corporate folks about this. But they don't understand the clinical need or the impact on patient safety. I also have to help on the floor regularly with admissions and discharges."

Based on record review and interviews, the hospital failed to increase staffing of skilled nurses and techs sufficiently to allow nurses to dispense medications on time. This failure created recurring issues such as missed or late medications and other medication errors for patients, which in turn jeopardized the health and well-being of the patients. The findings are:

A. Record review of the hospital's quality data regarding medication administration indicated the following:
1. Total medications dispensed for May 2016, 9,197; number of medications out of compliance 1,256 (missed windows to administer medications)
2. Total medications dispensed for June 2016, 10,718; number of medications out of compliance 1,063
3. Total medications dispensed for July 2016, 10,285; number of medications out of compliance 907

B. On 08/16/16 at 8:04 a.m. during interview, the pharmacist stated, "I have started tracking on drug administration times for the last 3 months. The medication errors are trending up. A lot of the med[ication] pass problems have to do with the patient acuity going up. The average number of medications for patients has gone from 5 medications per patient to 10 medications per patient....I see when three nurses are on duty things flow better.... Constant interruptions contribute to medication errors by nurses. A second dispensing machine would help with med passes. One of the problems is with the pharmacy getting into the machines to stock when nurse are trying to dispense."

C. On 08/16/16 at 2:15 p.m. the Director of Nursing stated, "We have a problem with too many medications not dispensed within the window prescribed by pharmacy. I think part of the problem is staffing. I do the staffing. I think we should have three nurses on the floor when the census is 12 or greater. The matrix we follow says we should have two until there are 26 patients. This model is appropriate for a skilled nursing facility, not a psych facility like ours."

Based on record review and interviews, the hospital failed to complete charts by obtaining the signatures and dates of responsible physicians for the history & physical (H&P) documentation and treatment orders in the charts of 13 (P#1 and 2, 4, 6, and 8 through 16) of 16 (P#1 - #16) sampled patients. The findings are:

A. Record review of the medical charts of P#1 and 2, 4, 6, and 8 through 16 revealed evidence of missing signatures and dates for H&Ps and treatment orders.

B. On 08/07/16 at 2:35 p.m. during interview, the Director of Nursing confirmed the absence of signatures and dates on the medical charts of P#1 and 2, 4, 6, and 8 through 16. Many of the charts were for patients discharged in April 2016 and May 2016, more than 60 days past due.