HospitalInspections.org

A. Based on document review and interview, it was determined that for 20 of 69 shifts between 8/1/17 to 8/8/17 and for 35 of 84 shifts between 8/29/17 to 9/5/17, the Hospital failed to ensure adequate staffing was available to provide patient care.

Findings include:

1. On 9/6/17 at 10:00 AM, the Hospital policy titled, "Patient Care Assignment", revised 4/2016, was reviewed. The policy required, 1. The assignments of patient care to nursing personnel shall be made in accordance with the qualifications of nursing personnel... and the assessed needs and complexity of care and location of the patient... 2. Acuity is assessed every shift by nurses scoring acuity in Meditech. Follow acuity staffing grid..."

2. On 9/5/17 at 1:00 PM, the acuity staffing grid ("Schwab Nursing Staffing Grid Hours") was reviewed. There are 5 in-patient Hospital Units divided into Acute and Subacute. Acute Units include: 2 South, 3 South East (3SE), and 3 South West (3SW). Subacute Units include: 3 South and 3 East. The grid divided each day into 3 shifts: Day, PM, and Night. The grid divided staff into 2 groups: Registered Nurse/ Licensed Practical Nurse (RN/LPN) and Certified Nurse Assistants (CNA). The minimum number of staff required for each shift was included. On an Acute Unit, with a census of 20, on the day shift, there should be 3 RN/LPNs and 3 CNAs.

3. On 9/5/17 at 2:30 PM, the staffing for 2 separate weeks (8/1/17 to 8/8/17 and 8/29/17 to 9/5/17 were reviewed. Units 2 South and 3 East were frequently closed and required no staff for those shifts. The daily census for each unit was reviewed to determined the targeted staffing for each shift. For 8/1/17 to 8/8/17, the targeted staffing was not met for 20 of 69 shifts (29%). For 8/29/17 to 9/5/17, the targeted staffing was not met for 35 of 84 shifts (42%).

4. On 9/5/17 at 9:35 AM, an interview was conducted with the Nursing Manager of 3SE & 3SW (E #4). E #4 stated "there has been a [staffing] crunch the last month or so". On 9/5/17 at 1:40 PM, E #4 confirmed the staffing shortage audit for two weeks. E #4 stated that the nurses hired in July and August are still in orientation and are not counted as actual staff yet.

5. On 9/5/17 at 11:00 AM, an interview was conducted with the Senior Recruiter in Human Resources (E #18). E #18 stated that when he was appointed to nurse recruitment duties on 7/1/17, there was a "dire" need for nursing staff. "There were approximately 17 vacancies", which is now down to 4 vacancies.

A. Based on document review, observational tour, and interview, it was determined that for 3 of 3 hemodialysis "dummy drip chambers" (devices that allow a dialysis machine to start up without checking machine safety), the Hospital failed to ensure dummy drip chambers were not available for nursing staff use, potentially affecting the dialysate safety of 15 to 20 hemodialysis patients per month.

Findings include:

1. On 9/5/17 at 9:55 AM, a "Dummy Drip Chamber" policy was requested. At 10:15 AM, the Dialysis Unit Manager (E #5) stated there was no Dummy Drip Chamber policy.

2. On 9/5/17 at 12:10 PM, Hospital policy titled, "Testing the Fresenius 2008K Dialysis Machine", updated April 2013, was reviewed. The policy required, "Prior to the initiation of treatment, the machine shall undergo pressure and alarm tests... A primed circuit must be in place before the tests can be completed..." The policy failed to include, a dummy drip chamber should never be used by nursing in place of a primed circuit and should not be available for use to start up a dialysis machine, invalidating safety checks and placing the hemodialysis patient in potential danger.

3. On 9/5/17, between 9:35 AM and 9:55 AM, an observational tour was conducted on the 3 South West Acute Care Unit. A dialysis room was equipped and available to treat dialysis patients. In a drawer with nursing dialysis supplies (urine culture cups) were 3 dummy drip chambers, available for use.

4. On 9/5/17 at 10:15 AM, an interview was conducted with the Dialysis Unit Manager (E #5). E #5 stated dummy drip chambers are only used by biomedical technicians when repairing dialysis machines and should not be kept with nursing dialysis supplies.




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B. Based on document review and interview, it was determined that the Hospital failed to ensure crash cart on the second floor was checked each day shift. This failure has the potential to affect 7 out of 7 patients on the second floor.

Findings include:

1. On 9/5/17 at 9:00 AM, Hospital policy titled, "Crash Cart Check", revised/reviewed 8/17, was reviewed. The policy required, "All unit crash carts are checked every shift by the nurse..."

2. On 9/5/17 at 9:15 AM, the Hospital's second floor crash cart checklist was reviewed. The crash cart checklist indicated that the crash cart was not checked on the day shift for 9/2/17, 9/3/17 and 9/4/17.

3. On 9/5/17 at 9:20 AM, a Registered Nurse (E # 1) stated that the crash cart should have been checked on the day shift on 9/2/17, 9/3/17, and 9/4/17.