HospitalInspections.org

Based on document review and interview it was revealed the facility failed to ensure the Nursing Services staffing matrix was enforced. This resulted in staffing on patient units being below the staffing matrix, placing all patients at risk for harm from inadequate care. (See tag A 392).

Based on document review and interview it was revealed the facility failed to ensure the nursing services staffing matrix was enforced. This resulted in staffing on patient units being below the staffing matrix, placing all patients at risk for harm from inadequate care.

Findings include:

1. From 7/25/21 to 7/28/21:
On Three South (3 S) the staffing fell below matrix three (3) times.
On Four South (4 S) the staffing fell below matrix three (3) times.
On Five North (5 N) the staffing fell below matrix one (1) time.
On Five South (5 S) the staffing fell below matrix six (6) times.

2. From 8/29/21 to 8/30/21:
On 3 S the staffing fell below matrix one (1) time.
On 4 S the staffing fell below matrix one (1) time.
On 5 N the staffing fell below matrix one (1) time.
On 5 S the staffing fell below matrix six (6) times.

3. Review of a document titled, "Staffing Matrix -- GENERAL GUIDELINES," undated, revealed in part: "These are general guidelines for staffing and subject to changes based on acuity and needs of the hospital." The matrix does not include consideration for patients being on CCO."

4. Review of a document titled, "Nursing Staffing Plan" revealed it states in part: "Nursing leadership considers the following factors in determining staffing needs...Levels of observation required on each unit, each shift." It is a document outlining the number of staff designated to work each shift for each unit. For 5 N, the matrix indicates two (2) Licensed Practical Nurses (LPNs) can staff the unit without a Registered Nurse (RN) assigned.

5. Review of a document titled, "Levels of Observation," approved 2/24/21, revealed in part: "Close, Constant Observation (CCO) is continual observation of patients (who have been identified as risks to themselves or others) while maintaining both direct visual contact and auditory range at all times...Individual staff accompaniment including individual interaction and therapeutic activity with the patient..."

6. An interview was conducted on 9/1/21 from 9:30 a.m. to 9:55 am. with the Chief Nursing Officer (CNO). She acknowledged one (1) unit on the matrix (5 S) can be staffed with two (2) LPNs and no RNs. This is okay because there are Clinical Managers (CMs) who are RNs who float between the units. She acknowledged having a float RN does not meet the definition of an RN assigned to the unit who would be available to meet the needs of the patients at all times. Staffing is not done to matrix all the time because they do not have enough staff. She acknowledged, after reviewing the above staff sheets, there are times Behavioral Health Technician (BHT) staffing falls below matrix when a patient is on CCO. The staffing level is not where it needs to be, but it's the best they can do at this point.