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Based on interview and record review the facility failed to provide sufficient staffing of Certified Nursing Assistants (CNA's) for bedside patient care on 3 out of 3 hospital nursing units (11-North, 9-South, and 9-North).

Findings include:

Review of the facility's Staffing Matrix for the Certified Nursing Assistants (CNA) assignments and the Daily Staffing Board of the CNA's scheduled revealed the Staffing Matrix was not followed on 01/15/2021 and 01/19/2021 on 11-North , 9-South and 9-North.

Review of the Staffing Matrix for 11-North showed the amount of CNA's needed for the census were as follows:

Review of 7:00AM - 7:00PM shift Staffing Matrix for 11-North documents 3-Certified Nursing Assistants for a Census of 21 to 30 patients.

Review of 7:00PM - 7:00AM shift Staffing Matrix for 11-North documents 3-Certified Nursing Assistants for a Census of 22 to 25 and for a census of 27 to 30 patients. Two (2)-Certified Nursing Assistants for a Census of 26 patients.



Review of the Daily Staffing Board for 11-North: showed:

Review of 7:00AM to 7:00PM Daily Staffing Board for 11-North dated 01/15/2021 documented 2-Certified Nursing Assistant (CNA) for a Census of 26 patients. Each CNA has an assignment of 13 patients.

Review of 7:00PM to 7:00AM Daily Staffing Board for 11-North dated 01/15/2021 documented 2-Certified Nursing Assistant were assigned for a Census of 30 patients. Each CNA has an assignment of 15 patients

Review of 7:00AM to 7:00PM Daily Staffing Board for 11-North dated 01/19/2021 documented 2-Certified Nursing Assistant (CNA) were assigned for a Census of 28 patients. Each CNA has an assignment of 14 patients.

Review of 7:00PM to 7:00AM Daily Staffing Board for 11-North dated 01/19/2021 documented 2-Certified Nursing Assistant were assigned for a Census of 25 patients. One CNA has an assignment of 13 patients.


Review of the Staffing Matrix for 9-South and 9-North showed the amount of CNA's needed for the census were as follows:

Review of 7:00AM - 7:00PM shift Staffing Matrix for 9-South and 9-North documents 3-Certified Nursing Assistants for a Census of 25 to 30 patients. Two (2)-Certified Nursing Assistants for a Census of 13 to 24 patients.

Review of 7:00PM - 7:00AM shift Staffing Matrix for 9-South and 9-North documents 3-Certified Nursing Assistants for a Census of 27 to 30 patients. Two (2)-Certified Nursing Assistant for a Census of 14 to 26 patients.



Review of the Daily Staffing Board for 9-South and 9-North showed as follows:

Review of 7:00AM to 7:00PM Daily Staffing Board for 9-North dated 01/15/2021 documented 2-Certified Nursing Assistant for a Census of 28 patients. Each CNA has an assignment of 14 patients.

Review of 7:00PM to 7:00AM Daily Staffing Board for 9-North dated 01/15/2021 documented 1-Certified Nursing Assistant for a Census of 23 patients.

Review of 7:00AM to 7:00PM Daily Staffing Board for 9-North dated 01/19/2021 documented 2-Certified Nursing Assistant for a Census of 27 patients. One CNA has an assignment of 13 patients and the other CNA has an assignment of 14 patients.

Review of 7:00PM to 7:00AM Daily Staffing Board for 9-North dated 01/19/2021 documented 2-Certified Nursing Assistant for a Census of 28 patients. Each CNA has an assignment of 14 patients.

Review of 7:00AM to 7:00PM Daily Staffing Board for 9-South dated 01/19/2021 documented 1-Certified Nursing Assistant for a Census of 14 patients.

Review of 7:00PM to 7:00AM Daily Staffing Board for 9-South dated 01/19/2021 documented 1-Certified Nursing Assistant for a Census of 16 patients.

Interview with Executive Director Critical Care on 02/08/2021 at 1:46 PM acknowledged for the period of 01/15/2021 to 01/21/2021 multiple day and night shifts, the Certified Nursing Assistant assignments for 11-North, 9-South and 9-North were not in accordance with the standard ratio of 1-CNA to 12-patients.

Based on observation, interview and record review the facility failed to ensure the nursing staff prepared and administered the medication in accordance with the administration instructions for 1 (SP#3) of 3 sample patients (SP).

Findings include:

Review of sample patient (SP) #3 Physician's Order dated 02/04/2021 documented medication order for PEG 3350 (MIRALAX) packet 17gram, 1 packet by mouth daily. Administration Instructions: Stir powder in 4 to 8 ounces (120 milliliters to 240 milliliters) of water, juice, or soda until dissolved and administer immediately. Product Instructions: Mix in 4 to 8 ounces of beverage until completely dissolved, then drink.

Medication administration observation of SP#3 on 02/09/2021 at 10:00AM revealed the medication administration instructions were not followed as ordered. SP#3 requested ice in the cup for medication administration. Staff G poured an unmeasured amount of water into a cup of ice and did not mix medication. SP#3 did not drink the medication as ordered. Staff G documented administration of medication. Stated leaving cup at bedside, SP#3 will eventually finish the medication.

Interview with the Interim Director of Oncology Services on 02/09/2021 at 10:47AM acknowledged Staff G did not measure the liquid or mix the medication as ordered. Stated SP#3 requested the ice and will eventually eat the ice to ensure the medication administration is completed.