HospitalInspections.org

Based on document review and interview, the hospital failed to ensure for adequate numbers of licensed/registered nurses and other personnel to provide nursing care to all patients as needed between the dates of 9/12/21 to 9/18/21.

Findings include:

1. A. Review of the policy titled Nursing Staffing Plan Policy, Last Reviewed May 2019, indicated the following: Staffing Guidelines: The Staffing Plan shall include a method of adjusting the staffing plan from shift to shift for each patient care unit based on factors such as the staffing grid, intensity of patient care and time off for nurses who have worked extended hours within a certain period of time at the facility.

B. Review of the staffing grid for the geriatric unit indicated the following:
Day shift: Census 9 - RN or LPN = 1; LPN = 1; MHT = 3. Day shift: Census 10 - RN or LPN = 1; LPN = 1; MHT = 4.
Evening shift: Census 9 - RN or LPN = 1; LPN = 1; MHT = 3.
NOTE: All night shifts, regardless of census (1 to 24 patients) called for only 1 "RN or LPN".

2. Review of the One Week Staffing Pattern Worksheet, completed for the geriatric/adult unit the weeks of 9/12/21 - 9/18/21 indicated the following:
On 9/13/21 day shift, with a census of 9, was short 1 RN/LPN and evening shift, with a census of 9, was short 1 RN/LPN.
On 9/17/21 day shift, with a census of 9, was short 1 RN/LPN.
On 9/18/21 day shift, with a census of 10, was short 1 RN/LPN.

3. In interview on 10/13/21, beginning at approximately 4:30 PM, A2, Chief Nursing Officer, verified staffing shortages.

Based on document review and interview, the Director of Social Services failed to ensure services were furnished in accordance with established policies and procedures for 1 of 10 patients (P2).

Findings include:

1. Review of the policy titled Communication Protocol, Last Reviewed January 2019, indicated the following: POLICY: It is the policy of (The Center) to communicate with families, guardians and treatment providers regarding the care of patients. PROCEDURE: Care Coordinators will give updates to families regarding progress in treatment, discharge and placement. Nursing staff will communicate with the physician on call, the chief nursing officer and guardians... Attempt to communicate should be made within 24 hours of the incident occurring.

2. The MR of patient P2 indicated that on 9/7/21 at 1250 (hours) an order was placed by physician MD2 to make an appointment for follow-up with MD3, Orthopedic Specialist. The MR indicated an order from Orthopedic Specialist MD3, dated 9/8/21, was scanned into the MR. The order indicated the patient was to follow-up in one week for re-X-ray. Contact note by A5, "TSA" (undefined/indicated discharge planner) on 9/14/21 at 2;23 pm, indicated the following: Spoke with F2, family member/POA (Power of Attorney) of patient P2, and discussed that physician wanted to discharge P2 in the morning so that he/she could get to the follow up appointment. F2 stated that he/she would have to reschedule the appointment with an "Ortho" in their hometown. The MR lacked documentation of why the patient would need to be discharged to attend an appointment and lacked documentation of the family having been notified of the appointment or plan for discharge within 24 hours of the order and/or prior to 9/14/21.

3. On 10/13/21, beginning at approximately 4:30 PM, MR findings for patient P2 were verified by A1, Executive Director, and A3, Chief Administrative Officer.