HospitalInspections.org

Based on observation, interview and record review the facility failed to:

A. ensure adequate numbers of nursing staff was available to deliver care to critical patients in 2 of 2 ICU units reviewed (Medical ICU and CVICU).

Refer to tag A0392

Based on observation, interview and record review the facility failed to ensure adequate numbers of nursing staff was available to deliver care to critical patients in 2 of 2 ICU units reviewed (ICU and CVICU)
This deficient practice had the likelihood to cause harm in all patients admitted to ICU.
Findings include:

During confidential interviews on 01/14/2014 after 9:35 a.m., the following was reported about staffing:
*There were problems with staffing during vacation times.
*Staffing on weekends is the worst.
*Some days you feel like you're pulled in different directions and cannot take care of the patients appropriately. The example given was if your assignment was 3 patients and 2 were on ventilators. The focus would be on the ones with the ventilators.
*Three patients were received at the beginning of the shift and a fourth patient which was a Bypass patient was given to the nurse. The charge nurse was unwilling to change the assignment so the director had to be called to get the assignment changed.

During an interview on 01/14/2014 after 11:00 a.m., Staff #5 reported Staff #17 took over care for Staff #18's two patients (Room #223 and 224) at 11:00 a.m... Staff #18 was going to take over care for a heart bypass patient who was coming from surgery (Room #226) and they required 1:1 care.
During an observation on 01/14/2014 at 11:27 a.m. a heart bypass patient came to Room #221 and Staff #17 went into Room #221 with other staff members to assist with the patient. Staff #5 reported Staff #18 was on her lunch break. At 11:33 a.m., Staff #5 was questioned about who was monitoring care of the patients in Room #223 and 224 while Staff #17 was in the Room #221. Staff #5 reported there was a ward clerk (monitor tech) and there were bed alarms.
During an interview on 01/14/2014 at 11:38 a.m., Staff #17 reported she did not designate anyone to watch her patients.

Review of ED notes on Patient #11 dated 01/02/1014 revealed she was a 59 year old female admitted at 2:19 p.m. in respiratory failure. Patient #11 was on a ventilator and placed on IV drips Neosynephrine, Versed, Diprivan and Nitroglycerin. An admit order was written at 7:00 p.m. for ICU care.
Review of ICU nurses notes dated 01/03/2013 revealed Patient #11 was admitted into the ICU unit over 14 hours later at 9:45 a.m.
Review of the "ICU\CVICU Assignment" sheet dated 01/02/2013 revealed 6 out of 9 nurses working the 11p.m.-7a.m. shift had a total of 3 patients each. The 3 nurses left had 2 patients each, but could not take another one because of patient acuity and their experience. There was a total census of 24 and one bed left.
During an interview on 01/15/2014 after 3:00 p.m., Staff #5 confirmed the staffing and that Patient #11 remained in the ED until they had available staff and bed. Staff #5 also reported her staffing goal was to have a 2:1 ratio.

Review of ED nurses notes dated 01/09/2014 revealed Patient #1 was a 53 year old female who arrived at 4:45 p.m. Diagnoses on admit were Status Epilepticus (seizures), Respiratory Failure, Cardiopulmonary Resuscitation Successful and Hypothermia.
Review of the "ICU\CVICU Assignment" sheet dated 01/09/2014 (11:00 p.m.-7:00 a.m.) revealed Staff #19 had one patient and was expecting a patient from the ER.
Review of ICU nurses notes revealed Patient #1 was admitted to ICU at 1:30 a.m. to Staff #19 who already had a patient. Review of the nurse's notes revealed Patient #1 was on Hypothermal Protocol (HACA) and had a drip of Levophed (used to increase acute low blood pressure). Staff #19 signed the patient care nurses notes from 1:30 a.m. until 6:51 a.m.
During an interview on 01/14/2014 at 3:07 p.m., Staff #5 confirmed Patient #1 was supposed to receive 1:1 care. She reported another nurse came in at 2:46 a.m. (over an hour later) and took over Patient #1's care. Staff #5 confirmed there was no documentation of this on the assignment sheet nor was there documentation of any other staff on the unit assisting with the patient for the hour timeframe.

Review of the "Nursing Organization Plan For Providing Patient Care" updated 12/2013 revealed the following:
"Staffing levels are determined according to the identified patient population of each individual clinical area, assessed patient needs, census trends, and activity of the unit.Staff needs are monitored closely through the use of daily census on each unit as well as the type of patients assigned to the specific units and the trends in the unit census.
Each Clinical area has a staffing matrix that has been developed to establish staffing guidelines to provide adequate hours to meet the standard of care for the identified patient population served based on the expected patient needs for that patient population .... In addition, each clinical area has defined a Safe Minimal RN to Patient Ratio by which the standard of care has been determined will be met safely in each area. ..... "
Medical/Surgical l- "Safe Minimal RN to Patient Ratio 7-8:1"
ICU and CVICU- "Safe Minimal RN to Patient Ratio 1-3:1"

Review of the Staffing Matrix for ICU revealed the following required numbers for the CVICU:
Census Day Shift Evening Shift Night Shift

1 2 RN 2 RN 2 RN
2 2 RN 2 RN 2 RN
3 2 RN 2 RN 2 RN
4 3 RN 2 RN 2 RN
5 3 RN 3 RN 3 RN
6 4 RN 4 RN 3 RN
7 5 RN 5 RN 4 RN
8 5 RN 5 RN 5 RN
Review of the Staffing Matrix for ICU revealed the following required numbers for the ICU:
Census Day Shift Evening Shift Night Shift

10 6 RN 6 RN 6 RN
11 7 RN 7 RN 7 RN
12 7 RN 7 RN 7 RN
13 8 RN 8 RN 8 RN
14 8 RN 8 RN 8 RN
15 9 RN 9 RN 9 RN
16 9 RN 9 RN 9 RN
17 10 RN 10 RN 9 RN


Review of "ICU\CVICU Assignment" sheets dated 01/01-14/2014 revealed the following number of RNs providing direct patient care:
1st- Dayshift 21 Patients with 10 RNs; Evening shift 23 Patients with 10-11 RNs; and Night shift 24 Patients with 11 RNs. (The staffing matrix required a total range of 13-14 RNs for Days and Evening shift and 13 for Nights.)
2nd- Dayshift 21 Patients with 10 RNs; Evening shift 22-24 Patients with 9-11 RNs; and Night shift 24 Patients with 9 RNs. (The staffing matrix required a total range of 13-14 RNs for Days and Evening shift and 14 for Nights.)
3rd- Dayshift 23 Patients with 12 RNs; Evening shift 23 Patients with 11 RNs; and Night shift 23 Patients with 11 RNs. (The staffing matrix required a total 14 RNs for Days, Evening shift and Nights.)
4th- Dayshift 24 Patients with 12 RNs; Evening shift 21-24 Patients with 10 RNs; and Night shift 23 Patients with 10 RNs. (The staffing matrix required a total range of 14 RNs for Days, 13 for Evening shift and 14 for Nights.)
5th- Dayshift 25 Patients with 10 RNs; Evening shift 25 Patients with 10-11 RNs; and Night shift 23 Patients with 9 RNs. (The staffing matrix required a total range of 15 RNs for Days and Evening shift and 13 for Nights.)
6th- Dayshift 25 Patients with 10 RNs; Evening shift 24-25 Patients with 11 RNs; and Night shift 24 Patients with 13 RNs. (The staffing matrix required a total range of 15 RNs for Days 14-15 for Evening shift and 14 for Nights.)
7th- Dayshift 24 Patients with 12 RNs; Evening shift 23 Patients with 10-12 RNs; and Night shift 24 Patients with 11 RNs. (The staffing matrix required a total range of 15 RNs for Days 15 for Evening shift and 13 for Nights.)
8th- Dayshift 22 Patients with 11 RNs; Evening shift 22 Patients with 11-12 RNs; and Night shift 22 Patients with 11 RNs. (The staffing matrix required a total range of RNs for Days, Evening shift and Nights was 13 per shift.)
9th- Dayshift 22 Patients with 11 RNs; Evening shift 20-22 Patients with 10-11 RNs; and Night shift 22 Patients with 10.5 RNs. (The staffing matrix required a total range of 13 RNs for Days, 11-13 for the Evening shift and 13 for Nights.)
10th- Dayshift 22 Patients with 11 RNs; Evening shift 20-21 Patients with 10-11 RNs; and Night shift 21 Patients with 9 RNs. (The staffing matrix required a total range of RNs for Days, Evening shift and Nights was 13 per shift.)
11th- Dayshift 22 Patients with 10 RNs; Evening shift 20 Patients with 10 RNs; and Night shift 19 Patients with 10 RNs. (The staffing matrix required a total range of 13 RNs for Days, 12 for Evening shift and 11 for Nights.)
12th- Dayshift 18 Patients with 9RNs; Evening shift 21 Patients with 10-11 RNs; and Night shift 19 Patients with 9 RNs. (The staffing matrix required a total range of 11 RNs for Days, 12-13 and Evening shift and 11 for Nights.)
13th- Dayshift 21 Patients with 11 RNs; Evening shift 20 Patients with 11RNs; and Night shift 22 Patients with 11 RNs. (The staffing matrix required a total range of 13 RNs for Days and 12 for Evening and Night shift.)
14th- Dayshift 22 Patients with 11.5 RNs; Evening shift 22 Patients with 11 RNs; and Night shift 23 Patients with 11 RNs. (The staffing matrix required a total range of 13 RNs for Days/Evening shift and 12 for Nights.)
During an interview on 01/14/2014 at 3:02 p.m. and 01/15/2014 after 3:00 p.m., Staff #5 confirmed the staffing assignments and patient census for the timeframe from 01/01-14/2014. Staff #5 reported she needed more nurses to cover for staff when off on paid time off and family medical leave.