HospitalInspections.org

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the Hospital failed to ensure that the nursing assignment sheets accurately reflected the actual staff on the unit and their assignments per hospital policy. This deficient practice poses a risk to the health and safety of patients, when accurate and adequate staffing cannot be determined.

Findings include:

The policy titled "Incident Reporting" requires that " ...any additional staff members who are known to have witnessed, discovered or have direct knowledge of the occurrence should be listed as witnesses. Any additional information that these other witnesses have may be included in the IR ...."

On 09/06/20, Employee #8 documented the following in an incident report: " ...At about 1530 I went to a patient room to check on [her] and I heard noise of staff shouting asking the other patient to stop. I ran to the scene and found this patient on the floor being hit by another patient to the face. The physical altercation was separated and this patient shouted I want to call the police because I most[sic] press charges. Patient vital sign was taken: T: 98.4, P: 100, R: 20, Oxygen at 97% room air. Patient denied of blurred vision and headache. Patient was given PRN Tylenol for body aches. Both the psychiatrist and medical provider was notified. Obtained order from the medical provider to transfer patient to the Valleywise ED for CT scan of the head. Patient responsible party was notified via voice message ...."

During an interview conducted on 01/13/21, Employee #2 revealed that s/he was not able to determine what employee had completed the incident report. Employee #2 needed to place a call to the facility's IT department in order to figure out who authored the incident report. The online incident report form did not capture this information, and the author did not include their name in the report. There was also no indication as to which other employees potentially witnessed the incident or any documentation of the incident by an employee other than the author of the incident report. Additionally, Employee #9 did not mention the incident on the BHT "Patient Observations" form.

The policy titled "Nursing Acuity and Staffing Plan-Phoenix" requires that " ...Nursing leaders will add in comments for any intended variance from recommended staffing versus what is actually planned and scheduled. Data will be saved for reporting and analysis. Daily patient acuity reports and corresponding assignment sheets will be maintained by the Director of Nursing ...."

During an interview conducted on 01/13/21, Employee #6 revealed that s/he was unable to locate the "Supervisor's Report" for 09/06/20. Per Employee #6, this form is where staff call offs and substitutions would likely be noted. Employee #6 acknowledged that staff substitutions should be indicated on the assignment sheets as well.

The policy titled "Nursing Acuity and Staffing Plan-Phoenix" requires that " ...staffing assignments will be documented on the Staffing Assignment Sheet. The name and title of the staff member to be assigned will be entered in the space provided. The names of the patients assigned to the staff member will be entered in the space provided. Break and mealtime assignments will be entered ...."

Review of the House Supervisor-Staff Assignment Sheets for both the day and night shift of 09/06/20 revealed that Employee #7 was assigned to seven patients on the Juniper unit and six patients on the Palo Verde unit.

Employee #9 was the BHT that completed the safety rounds for Patient #1 at the time of the incident and who documented on the "Patient Observations" form. Employee #7 was the BHT that Patient #1 was assigned to, per the "House Supervisor-Staff Assignment Sheet."

During an interview conducted on 01/13/21, Employee #6 acknowledged that Employee #7 could not have worked on two units at the same time. Additionally, there were staff that signed Patient #1's rounds form on 09/06/20 that were not documented on any of the Staff Assignment Sheets for 09/06/20. Employee #6 acknowledged that it was not possible to determine with certainty which staff member a patient was assigned to or on what unit a staff member was working on 09/06/20.