HospitalInspections.org

Based on document review and interview, the facility failed to ensure adequate numbers of licensed nursing staff necessary for the provision of appropriate care to all patients, as needed for: 34 of 42 shifts.

Findings include:

1. Review of established hospital policy titled: "Nurse Staffing and Assignments", PolicyStat ID: 12508509, indicated on page 1, D. "The DON" (Director of Nursing) "is accountable to ensure a sufficient number of qualified staff are on duty at all times to provide patients with quality care", and on page 4, under Staffing Plan, Core Staffing Matrix per unit, B. 1-12 Patients: 1 Registered Nurse, 1 Aide/Tech (technician); 13-25 Patients: 1 Registered Nurse, + 1 Nurse, 2 Aide/Tech; 26-38 Patients: 1 Registered Nurse + 2 Nurses, 3 Aide/Tech. Last revised 2/2022.


2. Review of staffing pattern worksheet provided by the facility for unit 200, for weeks of December 18 - 24/2022 and December 25 -31/2022, indicated the following:
A. Day shifts: 12/18/2022, census = 15; 2 RN's (Registered Nurse), 1 BHA (Behavioral Health Associate) staffed; 1 BHA short. 12/19/2022, census = 16: 1 RN, 2 BHA's staffed; 1 Nurse short. 12/20/2022, census = 14: 2 RN's, 1 BHA staffed; 1 BHA short. 12/21/2022, census = 15: 2 RN's, 1 BHA staffed; 1 BHA short. 12/22/2022 census = 14: 2 RN's, 1 BHA staffed; 1 BHA short. 12/23/2022, census = 13: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/24/2022, census = 13: 1 LPN (Licensed Practical Nurse), 1 BHA staffed; 1 RN & 1 BHA short. 12/26/2022, census = 14: 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/28/2022, census = 14: 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/29/2022, census = 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/30/2022, census = 13: 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/31/2022, census = 13: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short.

B. Evening shifts: 12/18/2022, census = 15: 2 RN's, 1 BHA staffed; 1 BHA short. 12/19/2022, census = 16: 1 RN, 2 BHA's staffed; 1 Nurse short. 12/23/2022, census = 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/25/2022, census = 1 LPN, 2 BHA's staffed; 1 RN short. 12/25/2022, census = 14: 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/26/2022, census = 14: 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/27/2022, census = 15: 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/31/2022, census = 13: 1 RN, 2 BHA's staffed; 1 Nurse short.

C. Night shifts: 12/18/2022, census = 15: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/19/2022, census = 16: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/20/2022, census = 14: 1 LPN, 1 BHA staffed; 1 RN & 1 BHA short. 12/21/2022, census = 15: 1 LPN, 1 BHA staffed; 1 RN & 1 BHA short. 12/22/2022, census = 13: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/23/2022, census = 13: 1 RN, 2 BHA's staffed; 1 Nurse short. 12/25/2022, census = 14: 1 RN, 1 LPN, 1 BHA staffed; 1 BHA short. 12/26/2022, census = 14: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/27/2022, census = 15: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/28/2022, census = 14: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/29/2022, census = 13: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/30/2022, census = 13: 1 RN, 1 BHA staffed; 1 Nurse & 1 BHA short. 12/31/2022, census = 13: 1 LPN, 1 BHA staffed; 1 RN & 1 BHA short.

3. In interview on 2/14/2023, at approximately 1:13 pm, and at approximately 1:34 pm, with A # 5 (Vice President - Quality & Compliance), confirmed that staffing was short in December 2022; agreed/confirmed shortages on more than one shift, more than one day.