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Based on review of hospital policies and procedures, the hospital's master staffing plan and unit specific staffing grids, the hospital complaint/grievance log and staff interview, it was determined the hospital failed to ensure the ICU (Intensive Care Unit ) and IMC (Intermediate Care) units were staffed in accordance with hospital established minimum staffing. This affected all patients on these units with a total census of 49. The hospital failed to ensure the nursing staff develops and keeps current a nursing care plan for each patient. This affected 4 patients (Patients #2, #4, #5 and #6 ) of the 10 patients medical records reviewed . This affected 15 (Patients #11, #12 ,#13, #14, #15, #16, #17, #18, #19, # 20, #21, #22, #23, #24 and #25) patients on the IMC (Intermediate Care Unit ) whose medical records were reviewed in focused areas of the record, from the total unit census of 29. The hospital's total census of patients was 106.

Findings include:

The hospital failed to staff the nursing units of the ICU and IMC as required by the hospital's staffing ratio. Refer to A392, 482.23 (b), for the findings.
The hospital failed to ensure development of nursing care plan for each patient. Refer to A396, 482.23 (b)(4).

Based on review of hospital policies and procedures, master staffing plan and unit specific staffing grids, the hospital complaint/grievance log and staff interview, the hospital failed to ensure the ICU (Intensive Care Unit ) and IMC (Intermediate Care) units were staffed in accordance with hospital established minimum staffing. This affected all patients on these units with a total census of 49. The total hospital census at the time of entrance was 106.

Findings included;

The policy and procedure, titled "Staffing Plan and Assignment Making" was reviewed on 03/24/10 in the morning hours. The policy had a effective date of March, 2009, with no review date or policy number listed. The policy stated each nursing unit has a Master Staffing Plan that is based on the patient population served, acuity, usual nursing care needs, historical census levels, and unit-specific hours per patient day. The policy went on to say the unit level plan is posted in each nursing unit and is available upon request to individuals, by contacting Risk Management at the facility. The master staffing plan for the ICU revealed the RN (Registered Nurse) on day shift and night shift should have a patient to nurse ratio of 1:2 - 1:3. The master staffing plan for the IMC revealed the nurse to patient ratio on day shift should be 1:4-5 for both RNs and Licensed Practical Nurses (LPNs) and 1:5-6 on night shift. Surveyors were presented with a staffing grid of the unit level plan for both the ICU and IMC on this day. The staffing grids utilize the census on the unit to determine the appropriate number of staff to be utilized. The staffing grid for IMC was reviewed in relation to the nursing schedules for the week of 08/16/09 to 08/23/09. The comparison revealed on the dates of 08/17/09, 08/19/09, 08/20/09 and 08/23/09 the unit was staffed with less total nurses than the staffing grid directed for the 3:00 P.M. to 11:00 P.M. shift. On 08/19/09, the day shift (7:00 A.M. to 3:00 P.M.) was staffed with less nursing personnel than required by the staffing grid. On 08/22/09, the night shift (11:00 P.M. to 7:00 A.M.) was staffed with less nurses than required by the staffing grid.

The actual staffing levels on the ICU were also compared with the ICU unit level staffing grid. This comparison revealed less nursing staff were present on the day shift of 08/16/09, second shift on 08/21/09 and night shifts of 08/16/09 and 08/21/09.

The hospital complaint/grievance log for 2009 was reviewed on 03/24/10 and 03/25/10. The log revealed a total of five complaint/grievances were filed between June, 2009 and September, 2009 regarding care on the IMC unit. Two of these grievances were filed regarding the same patient, and one grievance was filed by a staff member. The complaint filed by a staff member stated; "It is very difficult to care for five patients as an RN, cover IV (intravenous) medications for another five patients being cared for by an LPN. It is also difficult for the charge nurse to assist when her phone rings non stop and she is also carrying patient load of her own. the patients are upset because they have to wait for medication, including IV pain medications and this increases the stress level for the nurses caring for these patients." The investigation stated two nurses had called in sick and nurses were pulled from another unit to cover the IMC. In addition the unit was staffed with 2 LPNs and 3 RNs from the IMC unit. The documentation went on to say the charge nurse was counseled on prioritization and delegation. The complaint investigation lacked documentation of how many patients were on the unit this date, how long patients were waiting for their medications and the resolution method the hospital determined to use.

A notation on the bottom of the IMC staffing grid stated; "Charge nurse is included in the number, but should avoid taking an assignment 7a-7p when census is 20 or above and a lighter assignment from 7p-7a". The notation at the bottom of the ICU staffing grid noted; "Charge nurse to be out of count if acuity is high; until 11p. With average census/acuity-charge nurse to take 1 lower acuity pt; in count when down to 4 pts (patients)". Observations conducted on the IMC unit on 03/23/10 in the afternoon hours revealed the charge nurse had a patient assignment of three patients, with two additional patients to be added as admissions. The total census on the unit at the time of observation was 29. Observations on the ICU unit on 03/24/10 revealed the charge nurse had a patient assignment of two patients. The total census on the ICU unit at the time of observation was ten patients. During an interview with Staff C on 03/24/10 at 10:30 AM revealed when a "code blue" is directed in the hospital, it is expected the charge nurse from IMC, ICU, and ED would have to respond to the code. This would leave the patients, assigned to the charge nurses on the IMC and ICU units, in addition to their own assigned patients to the remaining nurses on the unit

Patients were interviewed on the IMC unit on 03/25/10 at 11:10 AM regarding their experience while at the hospital. Patient #4 stated the nurses get to the call light "as fast as they can" but feels the hospital has "some staffing issues. Nurses seem to be rushed and harassed most of the time." Patient #4 was unable to give specifics.

An interview was conducted with Staff C on 03/25/10 in the afternoon hours. Staff C stated the charge nurses were "added back into the count" meaning they were being asked to take a patient assignment as of 01/06/10. Staff C stated a staffing office and a Clinical Resource team was to be added to help with the workload of the charge nurse as they are now taking a patient assignment. Further interview with Staff C verified the staffing office and Clinical Resource team are not in place at this time, although the charge nurses have moved forward with accepting a patient assignment. Staff C was questioned regarding the determination of patient acuity in determining staffing needs. Staff C confirmed acuity was to be used when determining staffing needs, and also confirmed no tool is in place at this time for staff use in order to make this determination. The hospital was unable to provide any evidence of an acuity tool or guideline for use by staff when determining patient assignments or staffing levels.

This allegation substantiates complaint number OH00051499.

Based on staff interview and medical record review, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient. This affected 4 patients (Patients #2, #4, #5 and #6 ) of the 10 patients medical records reviewed . This affected 15 (#11, #12 ,#13, #14, #15, #16, #17, #18, #19, # 20, #21, #22, #23, #24 and #25) patients whose medical records were subject to a review focused on selected areas of the record, on the IMC (Intermediate Care Unit ) from the total census of 29. The total census of patients was 106.

Findings include:

Review of the medical records of Patients #2, #4, #5, #6, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25 were reviewed on 03/23/10 and 03/24/10. The medical records lacked evidence of an interdisciplinary plan of care for these patients.


During tour of the IMC with Staff A in the afternoon hours of 03/24/10, all of the 29 patients medical records were reviewed for care plans. It was identified at this time during the interview with Staff A the patients' record lacked a plan of care. The hospital policy for interdisciplinary plan of care stated: " The Interdisciplinary Plan of Care (IPOC)/Patient Care Plan (PCP) identifies the major patient problems, (past and present"), needs or issues identified on or during admission then determines appropriate interventions and expected outcomes for each identified problem. The IPOC/PCP provides a documentation and tracking format for all disciplines involved in the care of the patient in the acute care environment.- (1) To be used on all patients admitted into the acute care environment. (2) To be initiated by caregiver admitting the patient and updated by any subsequent caregiver who identifies the problem."