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Based on review of hospital documents and staff interview it was determined the hospital failed to provide staffing at established levels to ensure care is provided in a safe setting. This failed practice involved five (5) of five (5) nursing units (A2, A3, A4, A5 and A6). This failure has the potential to adversely impact the care and condition of all patients.

Findings include:

1. Confidential interviews were conducted with direct line nursing staff on both 6/19/12 and 6/20/12. These staff included Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Health Service Workers (HSWs). Staff voiced repeated concerns related to staffing levels being unsafe. Staff voiced concern related to being required to work excessive amounts of overtime leading to staff burnout, exhaustion and unsafe patient conditions.

2. At 1030 on 6/20/12 the May and June 2012 Nursing Daily Snapshots for Unit A5 were reviewed and discussed with the Director of Nursing (DON). Review of these staffing records revealed the A5 Unit was understaffed on twenty-one (21) dates and forty-seven (47) shifts in May. The Unit was also understaffed on nineteen dates (19) and forty-seven (47) shifts in June. The Unit was understaffed on the following dates and shifts:

May 5, Day, Evening, Night
May 6, Day
May 7, Evening
May 10, Evening
May 12, Day, Evening, Night
May 13, Day, Evening, Night
May 17, Day
May 18, Evening, Night
May 19, Day, Evening, Night
May 20, Day, Evening, Night
May 21, Day, Evening, Night
May 22, Day, Evening
May 23, Evening
May 24, Evening
May 25, Day, Evening, Night
May 26, Day, Evening, Night
May 27, Day Evening, Night
May 28, Day, Evening, Night
May 29, Day, Evening, Night
May 30, Evening
May 31, Day, Evening, Night

June 1, Day, Evening, Night
June 2, Day Evening, Night
June 3, Day, Evening, Night
June 4, Day, Evening, Night
June 5, Day, Evening
June 6, Evening, Night
June 7, Day, Evening, Night
June 8, Day, Evening, Night
June 9, Day, Evening, Night
June 10, Day, Evening
June 11, Evening, Night
June 12, Day, Evening, Night
June 13, Evening
June 14, Evening, Night
June 15, Day, Evening, Night
June 16, Day, Evening, Night
June 17, Day, Evening, Night
June 18, Day, Night
June 19, Day

The DON agreed with these findings. She stated that currently ten (10) patients have an order for one on one (1:1) staffing. She stated the Nursing Department currently has thirty (30) vacancies for a combination of RN, LPN and HSW positions. She indicated the combination of high numbers of patients requiring 1:1 staffing and vacant positions has made it increasingly hard to adequately staff the patient units.

At 1345 on 6/20/12 the DON spoke with the surveyor after completing a review of the Nursing Daily Staff Snapshots for June 2012 for the other four (4) nursing units: A2, A3, A4 and A6. She acknowledged this review revealed the other patient units were also understaffed during this time period.

2. An interview was conducted with the Associate Clinical Director on 6/20/12 at approximately 1320. He indicated the medical staff met on 6/19/12 to review and discuss the (two) adverse events which occurred over the weekend. As a result he noted the medical staff planned to address concerns related to vacancies in nursing with the new Chief Executive Officer (CEO).

3. A joint interview was conducted with the DON and Assistant CEO at approximately 1415 on 6/20/12. Both acknowledged the nursing staff shortages are so significant they pose a risk to the safety of patients and staff. The high hospital census was also discussed. The hospital is licensed for one hundred ten (110) beds. The census was one hundred twenty (120) - one hundred twenty one (121) during the course of the survey. The DON acknowledged the nursing staff positions granted the hospital are based on a census of one hundred ten (110) beds.

The Assistant CEO stated various options, including the potential use of contract nurses, were being considered to meet the current urgent need for nursing staff. Both the Assistant CEO and DON stated the new CEO met with the Management team last week and indicted she was going to act quickly to remedy the staffing shortages.

4. At 0830 on 6/21/12 a joint interview was conducted with the CEO, the Clinical Director and the Assistant CEO. She confirmed she has been in her position for less than one (1)month. She stated the current staffing shortage is an immediate priority and will be addressed. She stated the hospital would attempt to utilize contract nurses immediately to help fill gaps in schedule until the vacancies are filled permanently.

Based on review of documents and staff interview it was determined the hospital failed to ensure adequate numbers of licensed registered nurses and health service workers were maintained per the hospital Staffing Policy and Guidelines in the A5 Unit. This failed practice involved a total of twenty-one (21) dates and forty-seven shifts (47) shifts in May and and nineteen (19) dates and forty-seven (47) shifts in June of 2012. This failure creates the potential for the care and condition of all patients on the A 5 Unit to be adversely impacted.

Findings include:

1. The "Nursing Department Staffing Policy," last reviewed 5/16/12, and Nursing Department Master Staffing Plan, 5/15/12, were provided for review. The plan states in part: "Minimum staffing level for any shift will be four (4) staff, one of which will be an RN (Registered Nurse)...All patients requiring High Risk Monitoring shall have nursing staff available every shift to comply with physician orders. All units shall follow the general ratio of patients to staff as 1:7."

2. Review of the 6/19/12 census and staff communication sheet revealed the A5 unit has eighteen (18) patients, three (3) of which are ordered one to one (1:1) staff supervision. Two (2) of the patients require 1:1 staff supervision twenty-four (24) hours a day and one (1) patient requires 1:1 staff supervision from 0600 to 2200 every day.

3. At 1445 on 6/19/12 the A5 Unit staffing for the month of June 2012 was reviewed and discussed with the Nurse Manager. She explained that both day and evening shifts require more staff (than nightshift) to supervise patients who are up and about on the unit. She also indicated extra staff is needed for supervision of patients who go off the unit for dining and activities and patients who leave the hospital grounds on trips. The Nurse Manager agreed the Unit was currently understaffed.

4. At 1030 on 6/20/12 the May and June 2012 Nursing Daily Snapshots for Unit A5 were reviewed and discussed with the Director of Nursing (DON). Review of these staffing records revealed the A5 Unit was understaffed on twenty-one (21) dates and forty-seven (47) shifts in May. The Unit was also understaffed on nineteen dates (19) and forty-seven (47) shifts in June. The Unit was understaffed on the following dates and shifts:

May 5, Day, Evening, Night
May 6, Day
May 7, Evening
May 10, Evening
May 12, Day, Evening, Night
May 13, Day, Evening, Night
May 17, Day
May 18, Evening, Night
May 19, Day, Evening, Night
May 20, Day, Evening, Night
May 21, Day, Evening, Night
May 22, Day, Evening
May 23, Evening
May 24, Evening
May 25, Day, Evening, Night
May 26, Day, Evening, Night
May 27, Day Evening, Night
May 28, Day, Evening, Night
May 29, Day, Evening, Night
May 30, Evening
May 31, Day, Evening, Night

June 1, Day, Evening, Night
June 2, Day Evening, Night
June 3, Day, Evening, Night
June 4, Day, Evening, Night
June 5, Day, Evening
June 6, Evening, Night
June 7, Day, Evening, Night
June 8, Day, Evening, Night
June 9, Day, Evening, Night
June 10, Day, Evening
June 11, Evening, Night
June 12, Day, Evening, Night
June 13, Evening
June 14, Evening, Night
June 15, Day, Evening, Night
June 16, Day, Evening, Night
June 17, Day, Evening, Night
June 18, Day, Night
June 19, Day

The DON agreed with these findings. She stated that currently ten (10) patients have an order for 1:1 staffing. She stated the Nursing Department currently has thirty (30) vacancies for a combination of Registered Nurse, Licensed Practical Nurse and Health Service Worker positions. She indicated the combination of high numbers of patients requiring 1:1 staffing and vacant positions had made it increasingly hard to adequately staff the patient units.

The DON stated she is actively recruiting staff. She stated she is personally attending job fairs and interviewing all nursing applicants. She stated the staffing variances and vacancies are being reported and discussed weekly at Management Committee Meeting.

5. The Management Committee Meeting Minutes were reviewed for February through present. Review of these minutes revealed the DON is submitting weekly reports related to staffing variances including staff vacancies. The Weekly Staffing Report for 2/26 through 3/3/12, which was submitted at the 3/9/12 Management Committee Meeting was reviewed. This report reflects that Nursing had seventeen (17) vacant positions and seven (7) patients were on 1:1 staff monitoring. The current Weekly Staffing Report for 6/10 through 6/16/12 reflects that Nursing now has thirty (30) vacant positions and ten (10) patients are on 1:1 staff monitoring.

At 1345 on 6/20/12 the DON spoke with the surveyor after completing a review of the Nursing Daily Staff Snapshots for June 2012 for the other four (4) nursing units: A2, A3, A4 and A6. She acknowledged this review revealed the other patient units were also understaffed during this time period.