HospitalInspections.org

Based on staff interviews and review of facility documentation, the hospital failed to meet the condition for Nursing Services as evidenced by:

a. Failing to ensure that all nursing staff met job requirements as numerous nurses were not currently certified in BLS (Basic Life Support), Advanced Cardiac Life Support (ACLS), PALS (Pediatric Advanced Life Support) and/or NRP (Neonatal Resuscitation Program), as required by their job description. (refer to A0392); and

b. Failing to develop and implement a nurse staffing advisory committee to develop, monitor and review the nurse staffing plan or grid as required by facility nursing policies. No committee appeared to exist, nor did a detailed and specific staffing plan or grid. (refer to A0386)

c. Inadequate nurse staffing was previously cited at the facility during a complaint investigation on 9/3/19. The lack of a nurse staffing committee, as per facility policy, was previously cited at a full survey on 1/23/20. These issues had not yet been corrected by the hospital.

These practices endangered the safety and care of all patients at the hospital. The failed and systemic practices resulted in a pattern of nurse staffing which was chaotic and implemented at a potentially unsafe level. They also jeopardized patient lives by ongoing staffing of individuals who did not meet the qualifications of their jobs. The cumulative effect of these failed practices resulted in noncompliance with the Condition of Participation for Nursing Services.

Based on a review of facility documentation and staff interviews, the facility failed to implement its own nursing policies in order to ensure a clear process for determining the types and numbers of nursing personnel and staff necessary to provide patient care for all areas of the hospital. This failed practice jeopardized the safety and care of all patients.

Findings were:

Facility policy #NA-27 entitled "Staffing Plan," effective August 2009 and last reviewed/revised 5/12/2020, read as follows:

"Purpose: The Nursing Department of Brownfield Regional Medical Center supports the provision of quality patient care in a safe cost-effective manner by appropriately using qualified and skilled personnel.

Policy: This document describes the development, implementation, monitoring, evaluation and modification of the staffing plan for patient care.

1. The staffing plan is determined during the budgetary process based on:
* historical data
* projections for future program development and expansion
* analysis of physician practice patterns
* staff input in the needs of the patient, unit and staff

2. There will be adequate numbers of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and other personnel to provide nursing care to all patients.

3. An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations.

4. Staffing Levels are based on the following factors:
a. Patient characteristics and number of patients for whom care is being provided including:
b. Number of admissions
c. Number of discharges
d. Numbers of transfers

5. Acuity as well as the variability of care on the nursing unit, including:
a. Level of patient care required by each patient based on the previous shift's assessment of the patient's condition.
b. Type of patient care required by each patient based on primary diagnosis and/or primary procedure ...

8. Staff characteristics include:
...b. Preparation and experience ...
c. Number of and competencies of clinical and non-clinical support staff that the nurse must collaborate with or supervise
d. Staff consistency (availability of same staff over a given time frame) ..."

9. Staff levels will be set by taking into consideration:
1. Patient population served
2. Intensity of care requirements ...
5. Staff characteristics ...

10. A standardized process for developing the staffing levels includes:
1. The Chief Nursing Officer will recalculate presumptive or initial staffing levels as necessary but no less than on (1) time per year
2. Staffing will be determined on a per unit basis
3. A process for adjustments will be made on a shift-by-shift basis based on the intensity of patient care, census, and staff characteristics by the Charge Nurse ...

15. All nursing employees in orientation are assigned to a preceptor for a period of time as determined by experience, competencies, etc ...

16. Patient assignments are based on:
a. Acuity
b. Safety
c. Infection control considerations ..."

Facility policy #NA-15 entitled "Nurse Staffing Advisory Committee," effective date September 2009; last reviewed/revised 2/5/2020, read as follows:

"POLICY: The role of the Nurse Staffing Committee optimizes positive patient outcomes through development and evaluation of the BRMC (Brownfield Regional Medical Center) nurse staffing plan ....
B. The committee is responsible for developing and recommending a nurse staffing plan to Hospital leadership for the purpose of their adoption of an official nursing services plan. The official plan is subsequently presented to the hospital's Governing Board for adoption, implementation, and enforcement.
C. The committee is also charged with evaluating the official plan that is implemented. Emphasis is placed on the relationship of the official plan and the following:
1. Nursing sensitive indicators
2. Substantiated concerns about staffing issues from nursing staff members and patients ...
Meetings:
The committee shall meet quarterly. In rare instances, a called meeting may be necessary if a decision cannot be reached by consensus ..."

Staff #28,RN, interview on 9/7/21:
"[My job has been] overwhelming. I don't feel like I know what I'm doing..." She identified the OB nurse as the nurse who handled surgeries. When asked if the hospital ever had patients in both OB and requiring surgery, she said, "If there's something going on in both - it would be filled in by whoever they could find to fill in." As a side note, a review of this RN's personnel file revealed no current job description.

Staff #6, RN, interview on 9/7/21:
"Well, yesterday was hell. I'm often the only nurse in the ER. I have a tech with me. Yesterday we had 11 patients. It was also just me and a tech yesterday from 7a to 7p. Here's an example - I put in lab orders. The lab calls me back. They called to ask if I was going to draw the labs. I said, "It's just me in here." The person in the lab said, "It's just me too." As the ER nurse, I'm taking care of everyone that comes in. Now I'm having do the draws, plus I have to take them down there. We're just short-staffed ...

Now, with the REGEN-COV infusions we're doing, we're so busy in the ER ..."

Staffing sheets for 9/6/21 revealed 11 patients were seen in the ED with 5 discharges, 1 admission and 5 patients still in the ER at end of shift. The ER had one nurse scheduled and one nursing assistant/tech. The nursing unit started the shift with 5 patients, with 1 patient on the mother/baby unit. End of shift showed 3 patients on the unit and 2 on mother/baby. There was one RN on the unit and one LVN. One RN had been listed to work on the mother/baby unit, but that conflicted with another schedule had. On the other schedule, the second RN was not listed.

Staff #15, RN, interview on 9/7/21:
"Staffing is done horribly. There needs to be something done. Sometimes shifts don't have enough nurses. The ER will run with one nurse and maybe a tech. Or, they'll pull a nurse from the floor and put them in the ER. Then that takes away from the floor. The charge nurse has patient assignments. I don't think that should happen ...

[The CNO] is never here, but she has some personal stuff going on ... But even before that, we'd tell [her] about an issue and she'd say, "We'll see what we can do." Then nothing ever changed.

Whenever we run short-staffed, I think patient care is jeopardized. There aren't enough nurses. One day both the ED and Med/Surg charge nurses were both out to get covid shots. They both called in and both floors were left without a charge nurse. I couldn't even get hold of [the CNO]. We kept calling her and calling her. We kept saying we don't know what to do. We were all LVNs at the time. That was maybe in January of this year?"

Staff #5, RN, interview on 9/7/21:
When asked if there was anything about the hospital she'd like to tell a surveyor, she said, "Well, there are times we're left with hardly any nurses. I remember times when there were only 3 LVNs left on the floor ..." When asked when that last occurred, she said, "It was sometime in 2020 - I'm not sure what the month was. I was left on the floor with the FEMA nurses and 2 LVNs in the ER. [The CNO] was told about this, and she said, "Ah." I told her FEMA nurses were RNs but they didn't know how to do anything. We had maybe 15 patients. They couldn't do charting or anything ...You never know if we'll have staff or not ...

Staff #9, LVN, interview on 9/8/21:
When asked if there was anything to tell a surveyor, LVN stated, "Sometimes there are problems with staffing. It seems like the administration only goes by the number of patients. Acuity isn't taken into account at all. It's just not evaluated.

Sometimes the charge nurse has to handle outpatient surgery. They'll pull another RN if the charge nurse isn't available. They've had to pull the RN from the ER. It's just chaotic. It's not organized. I never know from day to day what staffing will be ..." When asked if this might all be a result of the covid-19 pandemic, LVN answered, "We've never had that many covid patients at one time. We've maybe had 3 at the most at one time on the unit. But a couple of them were really bad, and again, what worries me most is the patient acuity. It's worrisome. Sometimes I feel like we just have no resources. They're just not there ..."

Staff #11, RN interview on 9/8/21:
" ...Well, there's very much a shortage of nursing ... In the ER itself, because of the high acuity of patients, we need to have 2 nurses in there all the time ... They'll call in agency nurses, but they don't assess whether those nurses are qualified to work in the ER. What they do is call the agency and they have them send whatever. So the RN in there - being myself - has to teach how to do the ER, which makes it very dangerous because patient acuity is increasing every day secondary to covid. I've had the ER full and then have patients down the hallway, and just minimal help. They tell us to go to the floor for help. Well, the floor can't help if they're short too - if they're understaffed themselves. I find it all very dangerous. You put your license at risk working in the ER ... You should know, I've turned in my resignation.

I do labor & delivery, the ER, the OR - but when I'm getting ready to do one of these infusions that we're having to do for covid, and they come in and say "You need to go do a GI procedure" - I need all of my attention for those infusions, and I can't just stop and drop it ...

I see the ADON so exhausted because she's having to fill in day and night. They've got this poor woman doing labor & delivery even ...

There are many staffing issues and the patients are high acuity. Before this pandemic is over, the acuity is going to get higher. I was working with [another RN] on the 4th of this month. They took her to work someplace else in the hospital. I was left by myself in the ED and we're doing these infusions. I texted [the CNO]. I asked, "Am I going to get her [other RN] tomorrow?" All my rooms were full in the ER. This is unacceptable ... We saw about 10 patients. We admitted 2. We transferred 2. And these days, the process of transferring someone takes anyone doing it a long time. No one's taking the patients. So then the ER gets backed up with patients. A lot of times, it's just me and a tech in there. We've got a good tech, but the most she can do is vital signs.

This is dangerous ..."

When RN was asked to look at staffing of 9/4/21 and remark on the accuracy, she stated, "This is misleading. It doesn't show that they moved [other RN] to do covid infusions, and I was in there alone. I was left with only the ER Tech and we saw 7 patients. We discharged 3 and admitted 3. One patient was transferred ..."

In multiple interviews with Staff #1, CEO, on 9/7/21 & 9/8/21:
At approximately 11:35 a.m. on 9/7/21, when asked about situations regarding staffing levels and the CNO, the CEO stated, "I think it's adequate for this place. We always have at least an RN for the ER and an RN for the floor. Then we have a combination of another nurse and a tech for the floor. Then we have on average an RN over OB, and a nursery nurse who works with her if there's a baby - an LVN. That's the only time we really shift our staffing. We don't have a high census - 3.6 - sometimes we're up to nine ...

There was a nurse - [Staff #7]. [Staff #7] and [CNO] got into it one day. They had a low census. We had one patient on the floor. There was an LVN just graduated to an RN - meaning she hadn't tested yet but could work as an RN. There was an incident that happened. [CNO] had called and told her [Staff #7] to send someone home. They had 1 patient on the floor - 1 patient, 2 nurses. [CNO] ended up sending [Staff #7] home for being unprofessional. She [Staff #7] resigned ... They got into an argument with each other.

As far as surgeries - we do colonoscopies, hysterectomies, lap choles - not very many. We've maybe done 20 in the past 4 months. Whoever's our OB nurse is also the OR nurse ...

We do have a nurse staffing grid because it has to be reported about to the board every 6 months." When the surveyor said the ADON had spoken to the CNO on the phone and had been told that no grid existed, he replied, "We have one. She must not be thinking clearly right now. We have that and we have the committee meeting minutes. I'll get you both of those. And we have a tickler sheet for the licenses ... I'll bring them ..."

At approximately 12:05 p.m., the CEO brought in the one set of minutes he had from the nurse staffing committee for the past 2 years. "The fact that we didn't have a committee - we got dinged for that for a survey in 2019. I thought this had been fixed. Apparently this was the only meeting that was held and that was it ... Again, I thought this had all been fixed ... I know she's [the CNO] is going through stuff with her husband, but that's only been about the last month and a half ... She'll say, "Everything stopped because of covid" ... And apparently we don't have a nurse staffing grid...

This has been an ongoing issue. I thought things had gotten better ... [CNO] has been dealing with the situation with her husband, but for example, today I've been calling her. I've left messages. She's not calling me back. She's just not calling me. I can't get hold of her. I've been trying to get her to come in ..." When surveyor told him that the ADON had said that she [the CNO] wouldn't be coming in that day, he stated, "I didn't know that."

In an interview with Staff #2, CNO, and Staff #1 CEO, at approximately 8:30 a.m. on 9/8/21, the CNO began the interview stating, "We hardly have any kind of patient census here. I mean, a lot of times we'll only have 3 patients who are here inpatient ...

We were having the nurse staffing committee up until covid hit. We stopped when the main covid surge hit. We weren't allowed to have any meetings then at all. We had one scheduled at the end of September and the end of December ... The staff voted on the members ..." When surveyor asked if meetings might have been held when covid became less pervasive, the CNO said, "We had a late surge here. [The CEO] didn't notice it ...


Nurse staffing levels were reviewed for several recent dates. As examples, two have been included below. The sources to determine actual staffing were a printed Excel spread sheet used to assign staff, a sheet entitled "Nursing Assignment Sheet" that was supposed to reflect individuals actually present on a specific shift, and a "Nursing Shift Report" which included only numbers of staff and patients. The documents sometimes conflicted, but looking at each and comparing provided a more complete picture, though it was still unclear to individuals questioned.


STAFFING as of SEPTEMBER 1, 2021

Day shift:
On the regular patient unit:
- Charge RN
- LVN
- Nursing assistant/tech
- RN (new nurse)

In the ED:
-Charge RN
- RN assigned to covid infusions
- Nursing assistant/tech

The shift report reflects there were 2 nurses on the regular nursing unit. This was the RN, Staff #5, and LVN, Staff #9. The new nurse was in orientation. Patient census on the unit at the beginning of the shift was 7 patients. At the end of the shift, there were 2 patients on the nursing unit and one (1) patient on the mother/baby unit. It appeared that the med/surg unit RN had also been assigned to the mother/baby unit.

Three (3) patients were seen in the ER with 2 being discharged and one (1) admitted. Staffing appeared adequate for this.

From the FDA regarding Regeneron infusions [available at: https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-monoclonal-antibodies-treatment-covid-19]:

" ...Possible side effects of casirivimab and imdevimab [by Regeneron Pharmaceuticals] include: anaphylaxis and infusion-related reactions, fever, chills, hives, itching and flushing ..."
Anaphylaxis may be a life-threatening situation.


Night shift:
On the regular patient unit:
- RN (indicated as charge nurse on unit and in the ER)
- LVN, (ORT - possibly OR tech)
- LVN (assigned on MBU - mother/baby unit)
- LVN
- Nursing assistant

In the ED:
- RN
- No assistant listed

The shift report reflects 1 RN, Staff #14, on the regular nursing unit and 3 LVNs; however, one LVN, Staff #27, was also assigned to the mother/baby unit. The shift report clearly reflects only one (1) nurse in the ER, Staff #26. Thus, as indicated on the Excel spreadsheet staffing, an RN was serving as charge RN for both the ER and the nursing inpatient unit. An ER assistant was noted as "out," yet the shift report still indicated one assistant.

Patient census was 2 patients on the unit and 1 on the mother/baby unit. There was one patient discharged. However, in the ER, there were 9 patients seen with 7 discharges, one (1) transfer and one (1) still in the ER at shift end. One patient expired during the shift with the funeral home arriving at 6:05 a.m. The ER was staffed with one (1) RN only.


STAFFING as of SEPTEMBER 4, 2021

Day shift:
On the regular patient unit:
- RN
- RN/IM- not on staffing sheet
- LVN (assigned to mother/baby unit)
- Nursing assistant

In the ED:
- Charge RN
- RN assigned to covid infusions (by interview and usual scheduling)
- Nursing assistant/tech

The Nursing Shift Report shows one (1) RN, Staff #5, on the nursing unit and one (1) LVN, Staff #19, who was also assigned to the mother/baby unit. The unit census was 5 with one (1) patient in mother/baby unit and 2 in the nursery. There was no RN assigned to cover the mother/baby unit. At the end of the shift there were 4 patients on the main nursing unit, 1 in the mother/baby unit, and 1 in nursery.

Per the Nursing Shift Report, 10 patients were seen in the ER with 4 discharge, 2 admitted and 2 still in the ER. One (1) had left without being seen. If the second RN was assigned to perform covid infusions, then only an RN, the charge nurse -- Staff #11, and one (1) assistant were managing the ER.


Night shift:
On the regular patient unit:
- RN
- LVN
- LVN (per the Nursing Assignment Sheet, was assigned to mother/baby unit)
- Nursing assistant/tech (listed as assistant for "All")

In the ED:
- RN
- No assistant listed other than as noted above

Per the Nursing Assignment Sheet, no RN was assigned to the mother/baby unit. Patient census on the unit at the beginning of the shift was 3 with one (1) patient on the mother/baby unit and 1 in the nursery. The patient census at the end of the shift was 7 on the regular unit with one (1) on the mother/baby unit and one (1) in the nursery.

In the ER, 7 patients were seen with 3 discharged and 3 admitted. 1 patient was transferred. There was only one RN, Staff #29, working in the ER.


A review of Brownfield Regional Medical Center Nurse Staffing Committee meeting "minutes" revealed only two sets of minutes from 2019. The first was possibly held on 6/5/19, but information provided consisted only of an agenda and some "notes" that had been typed up for the meeting, seemingly prior to the meeting. No minutes were provided for surveyor review.

Another document provided included the following in total:
"Nurse Staffing Committee
DATE: June 5, 2019
Time: 3:15 p.m.

Committee members: [12 member names were listed, including the CEO. 8 names were checked, including the CEO. It is unclear what the check marks meant - presumably they were in attendance]. No agenda was provided. No minutes were provided for surveyor review.

Thus, there were no minutes provided for surveyor review for the above meetings. No additional minutes were provided for late 2019, 2020 or 2021.

Based on review of facility documentation and staff interviews, the facility failed to ensure all registered nurses, licensed vocational nurses and other nursing staff met the requirements for their positions. In addition, by multiple staff interviews, the hospital has allowed one RN to work while altered, even serving as charge nurse for a unit. Thus, there were inadequate numbers of skilled nursing staff required to meet patient care needs on 4 of 4 nursing shifts reviewed in one recent week. This had the potential to result in patient deaths, and jeopardized nursing care on all hospital units, including the emergency department.

Findings were:

Facility policy #NA-13 entitled "Job Descriptions for Nursing Personnel," effective date August 1981; last revised/reviewed 5/12/2020

"POLICY:
The following are Job Descriptions in use for Brownfield Regional Medical Center:

RN Charge Nurse (All Shifts) ...
H. Certifications and Mandatory In-services:
...CPR ...NRP (neonatal resuscitation program) ...ACLS ...TNCC ...

LVN (All Shifts) ...
I. Requirements ...
...CPR ...ACLS ..."

These were the only two job descriptions included with the policy, and the only two made available for surveyor review on the dates of survey.

Multiple interviews with the hospital Staff #1, hospital CEO, on 9/7/21 and 9/8/21, included the following:

At approximately 11:35 a.m. on 9/7/21, when asked about situations regarding staffing levels and the CNO, the CEO stated, "I think it's adequate for this place. We always have at least an RN for the ER and an RN for the floor. Then we have a combination of another nurse and a tech for the floor. Then we have on average an RN over OB, and a nursery nurse who works with her if there's a baby - an LVN. That's the only time we really shift our staffing. We don't have a high census ...

As far as surgeries - we do colonoscopies, hysterectomies, lap choles - not very many. We've maybe done 20 in the past 4 months. Whoever's our OB nurse is also the OR nurse ..."

In a telephone interview with Staff #5, RN, on the morning of 9/7/21 at 11:03 a.m., she stated, " ...The charge nurse, [Staff #18], has worked intoxicated. I think this is a problem. She'll come in slurring, tripping, falling. We've had patients complain about it. Nothing's been done. It's been going a while, and nothing's been done ..."

At approximately 12:05 p.m., on 9/7/21, the CEO stated, "[The CNO] has been dealing with a situation with her husband, but for example, today I've been calling her. I've left messages. She's not calling me back. She's just not calling me. I can't get hold of her ..." Thus, critical questions regarding nurse staffing were answered as possible by the CEO and ADON.

In an interview with Staff #4, ADON, on 9/7/21 at approximately 12:20 p.m., she was asked if she was aware of a nurse who allegedly worked intoxicated at times. She stated she was and gave the nurse's name.

In an interview with Staff #1, CEO, at 1:04 p.m., when asked about his knowledge of a nurse who worked altered or intoxicated, he said, "We know about that. We had complaints from other staff and from patients about this. Staff #8 [a charge RN], first voiced an opinion about it. A family had been concerned and talked to us. Also other staff had said things. We pulled this nurse aside [Staff #18]. She was acting a little bit off. We talked to her. She was on some antidepressants and heart medications - something like that. We suspended her until we could find out what happened to her ... I can't remember now what the exact medication was, but that situation has been addressed ..."

Complaints/Grievances regarding patient care for 2021 were requested. Only 2 patient care complaints/grievances were presented for surveyor review. Neither of these was related to a nurse working in a potentially altered or intoxicated state, despite statements made by staff in interviews.

Staff #1, CEO, also provided the personnel record of the nurse who had allegedly been intoxicated [Staff #18]. He stated, "You'll see in there that we did testing and she was negative for everything that would have caused problems ... She came back and had to get some medications changed - her heart medication maybe? Anyway, she's been able to come back to work ... This was maybe a month and a half ago? Maybe 2 months ago?"

A review of the personnel file for Staff #18 included no disciplinary actions related to intoxication. Two urine drug screen tests included the following results:
3/9/21 - positive for tricyclics
7/25/21 - positive for tricyclics
A "return to work" letter dated 8/3/21 from a physician stated she was able to work.
Side effects of tricyclic anti-depressants can include fatigue, disorientation, drowsiness and low blood pressure. Slurring of speech is generally not a side effect of tricyclic antidepressants.

At approximately 1:40 p.m., the CEO brought the listings for the expiration dates for all nursing staff of BLS/ACLS PALS certifications. He said, "I don't know what's going on here with the BLS certifications. [Staff #17, Administrative Secretary to the CNO] in the office tried to explain it to me." When surveyor remarked that it appeared there were nurses working with expired BLS or other required certifications, he replied, "I know. I'll have to get [Staff #17] in here to tell you what she told me. I didn't understand how she explained it ..."

In an interview with Staff #17, Administrative Secretary to the CNO, and Staff #1, CEO, at approximately 2:15 p.m. on 9/7/21, she said that BLS, ACLS, PALS, NRP and other required certifications were not kept in personnel files. She then reviewed the BLS/ACLS/PALS "tickler" list which included when these items expired for currently working RNs and LVNs of the hospital. She stated, "This is all we have to go by to tell if someone is current or not ... It doesn't say specifically on the job description what is required for that particular position, but we know. So, if that area is "blacked out" on this chart [Excel spreadsheet, the "tickler"], then it means that certification is not required for that position ..." When it was pointed out that a number of the items appeared to be expired, she said, "Yes. If the block is in yellow under the name and certification, it means that the person is currently signed up for a class. If it's red, they were signed up for a class, but then didn't show up." When asked what it meant if there was no date in the block, i.e., if it was left empty, Staff #17 stated, "If it's blank, then they don't have an expiration date because we don't know if they ever had it ... I was told by the CNO not to worry about any of this."

The CEO added, "...There's nothing that we have that says what the particular requirements are for each job description... This is something we need to fix..." When surveyor stated all there was to go by for the requirements was the "tickler sheet," he stated, "I see what you mean."

An interview with Staff #1, CEO, and Staff #2, CNO, on the morning of 9/8/21 at approximately 8:30 a.m., included the following:
The CNO began the interview stating, "We hardly have any kind of patient census here. I mean, a lot of times we'll only have 3 patients on the nursing unit...

As far as the BLS/ACLS being expired, when I became aware they were not going to the classes, they were told they needed to go take the class. So action was definitely taken."

In an interview with Staff #11, RN ED Charge Nurse, at 10:50 a.m. on 9/8/21, she stated, " ...I ... find it dangerous that they allow individuals under the influence to work in the ER that can't even retain what you've told them. The CNO will say, "This is the way you need to handle her." So I go and give information, ask for help, and the situation is turned back on me. I have tried to teach this individual under the influence - and it's happened recently - but nothing is retained. These infusions we're having to do (for covid), she's [Staff #18] so high that she can't remember anything. Several people have already written it up. Her eyes are bloodshot - they're glassy. And then they expect me to go to the floor and ask for help to fix an unresponsive co-worker ...

I do labor & delivery, the ER, the OR - but when I'm getting ready to do one of these infusions that we're having to do for covid, and they come in and say "You need to go do a GI procedure" - I need all of my attention for those infusions, and I can't just stop and drop it ... I see the ADON so exhausted because she's having to fill in day and night. They've got this poor woman doing labor & delivery even ...

There are many staffing issues and the patients are high acuity. Before this pandemic is over, the acuity is going to get higher. I was working with [Staff #15], another RN, on the 4th of this month. They took her to work someplace else in the hospital. I was left by myself in the ED and we're doing these infusions. I texted [the CNO]. I asked, "Am I going to get her [Staff #15] tomorrow?" All my rooms were full in the ER. This is unacceptable. Then the next day, [Staff #15] came in and helped me out. We saw about 10 patients. We admitted 2. We transferred 2. And these days, the process of transferring someone takes anyone doing it a long time. No one's taking the patients. So then the ER gets backed up with patients. A lot of times, it's just me and a tech in there. We've got a good tech, but the most she can do is vital signs.

This is dangerous ..."

Review of the "tickler" list of nursing certification expirations dates, including BLS (Basic Life Support), ACLS (Advanced Cardiac Life Support), PALS (Pediatric Advanced Life Support) and/or NRP (Neonatal Resuscitation Program) revealed the following:

4 of 17 RNs were not currently certified in BLS [Staff #12, #15, #18-19].

7 of 17 RNs were not currently certified in ACLS [Staff #2 (CNO), #8, #12, #15, #18, #21-22].

3 of 17 RNs were not currently certified in either PALS or NRP [Staff #5, #18 and #21].

1 of 9 LVNs was not currently certified in BLS [Staff #13].

2 of 9 LVNs was not currently certified in either PALS or NRP [Staff #23 and #27].

4 of 8 LVNs was not currently certified in ACLS [Staff #13 and #23-25].

1 of 8 CNAs was not currently certified in BLS [Staff #20].

As a more detailed example, a review of staffing schedules from April, 2021 through date of survey revealed Staff #18 had worked throughout this period. The expiration "tickler" chart revealed only a yellow blank for BLS (meaning the facility had never had evidence of her having BLS certification, but she was scheduled for a class), a red blank for ACLS (the facility had no knowledge if she had ever been certified, but she had been scheduled for a class and not attended), a yellow blank each for PALS and NRP (as above). Staff #18 sometimes worked as an ED RN, and as charge nurse on the Med/Surg unit. Per interviews with staff, Staff #18 was the individual reportedly altered or impaired at times. She had been scheduled to work as recently as 9/9/21 as one of the few RNs in the hospital.