HospitalInspections.org

Based on document review and interview, the hospital failed to ensure for adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients as needed between the dates of 4/19/21 and 5/8/21.

Findings include:

1. A. Review of the document titled "CVICU Scope of Service Statement and Department Staffing Plan:CVICU Scope of Service Statement and Department Staffing Plan, FY (Fiscal Year) 20, by failing to ensure skill mix included 22% "Patient Care Tech IIs" (PCT).
The hospital did not follow their "5 C PCCU/OBS Staffing Guidelines" by failing to ensure guidelines were utilized in determining staffing levels", FY (Fiscal Year) 20, together with the staffing grid, Revised 7/31/19, indicated the following:
Staffing Plan: Skill mix in CVICU (Cardiovascular Intensive Care Unit) is 78% Director/Registered Nurse (RN), and 22% Patient Care Tech IIs.
The grid indicated Day Shift would staff 0.25 PCT (Patient Care Technician) for a census at or above 4 patients. Night shift for a census of 5 = 3 RNs.

B. Review of the document titled , "5 C PCCU/OBS Patient Placement Guidelines", date of approval/revision not provided, indicated the following:
To staff using the chart, you will look at the census in each hallway to determine the resources and placement of resources.
Review of the staffing grid titled "5 C PCCU/OBS Staffing Guidelines", date of approval/revision not provided, indicated the following:
The following guidelines are to be utilized in determining staffing levels...
Day shift: Census of 28 = 8 RNs. Census 30 and 31 = 9 RNs and 4.33 PCTs. Census 32 = 9 RNs and 5 PCTs. Census 33 = 9.66 RNs and 5 PCT. Census 34 = 10 RNs and 5 PCTs. Census 35 = 10 RNs and 5.33 PCTs. Census 36 and 37 = 11 RNs and 5.33 PCT.
Night shift: Census 26 = 6.33 RNs. Census 27 and 28 = 7.33 RNs. Census 29 and 30 = 8 RNs. Census 31 = 8 RNs and 4 PCTs. Census 33 = 8.33 RNs. Census 34 = 9 RNs and 4 PCTs. Census 36 = 9.33 RNs. Census 37 = 10.33 RNs.
Note: The grid did not expand beyond a census of 37.

2. Nursing and/or staffing reviews: Review of the One Week Staffing Pattern Worksheet, completed for the weeks of 4/19/21 - 4/24/21; 4/25/21 - 5/1/21; and 5/2/21 - 5/8/21 indicated the facility unit as indicated was short nursing staff as follows:
CVICU: The Staffing Pattern Worksheet lacked documentation of the unit having staffed PCTs on any shift during the 3 week time period. The One Week Staffing Pattern Worksheet indicated a census of 4 or more patients on the following dates: 4/20/21, 4/22/21, 4/23/21, 4/26/21, 4/27/21, 4/28/21, 4/30/21, 5/1/21, 5/2/21, 5/3/21, 5/4/21, 5/6/21 and 5/7/21. On 4/22/21 night shift, with a census of 5; on 4/28/21 night shift, with a census of 5; and on 5/2/21 with a census of 6, the unit was short 1 RN.
PCCU (Progressive Coronary Care Unit):
On 4/19/21: Day shift with a census of 30 was short 2 RNs and 1.33 PCTs. Night shift with a census of 30 was short 2 RNs.
On 4/20/21: Day shift with a census of 40* was short at least 4 RNs. Night shift with a census of 33 was short 1.33 RNs.
On 4/21/21: Day shift with a census of 34 was short 1 RNs and 1 PCT. Night shift with a census of 26 was short 1.33 RNs.
On 4/22/21: Day shift with a census of 33 was short 2.66 RNs and 1 PCTs. Night shift with a census of 27 was short 1.33 RNs.
On 4/23/21: Day shift with a census of 35 was short 3 RNs and 1.33 PCTs. Night shift with a census of 34 was short 3 RNs and 1 PCT.
On 4/24/21: Day shift with a census of 35 was short 1 RN and .33 PCTs. Night shift with a census of 31 was short 2 RNs and 1 PCT

On 4/25/21: Day shift with a census of 36 was short 2 RNs. Night shift with a census of 34 was short 1 RN.
On 4/26/21: Day shift with a census of 39* was short at least 2 RNs and at least 1.33 PCTs. Night shift with a census of 37 was short 4.33 RNs.
On 4/27/21: Day shift with a census of 43* was short at least 2 RNs and at least .33 PCTs. Night shift with a census of 36 was short 1.33 RNs.
On 4/28/21: Day shift with a census of 45* was short at least 3 RNs and at least .33 PCTs. Night shift with a census of 37 was short 2.33 RNs.
On 4/29/21: Day shift with a census of 42* was short 2 RNs and .33 PCTs. Night shift with a census of 34 was short 1 RNs and 1 PCT.
On 4/30/21: Day shift with a census of 43* was short at least 3 RNs and .33 PCTs. Night shift with a census of 38* was short 3.33 RNs.
On 5/01/21: Day shift with a census of 39* was short at least 2 RNs and .33 PCTs. Night shift with a census of 29 was short 1 RN.

On 5/02/21: Day shift with a census of 33 was short 2.66 RNs. Night shift with a census of 28 was short .33 RNs.
On 5/03/21: Day shift with a census of 33 was short 1.66 RNs. Night shift with a census of 28 was short .33 RNs.
On 5/04/21: Day shift with a census of 28 was short 1 RN.
On 5/05/21: Day shift with a census of 31 was short 2 RNs and 1.33 PCTs. Night shift with a census of 27 was short .33 RNs.
On 5/06/21: Day shift with a census of 35 was short 2 RNs and 1.33 PCTs. Night shift with a census of 27 was short 3 RNs.
On 5/07/21: Day shift with a census of 32 was short 3 RNs. Night shift with a census of 29 was short 3 RNs.
On 5/08/21: Day shift with a census of 31 was short 2 RNs. Night shift with a census of 28 was short .33 RNs.

*NOTE: grid highest census ended at 37

3. On 9/22/21 the following was indicated in interview:
Beginning at approximately 12:00 PM, A3, Director of Critical Care, verified the unit had not staffed any PCTs during the 3 weeks recorded on the Staffing Pattern Worksheet and confirmed that if the staffing grid for the unit called for PCTs then they would/should be staffed.

Beginning at approximately 12:20 PM, A5, Manager of PCCU, verified the unit was often short staffed.

Based on document review and interview, the hospital failed to ensure that nursing care was assigned in accordance with patients needs to meet call light demand on 2 units [Cardiovascular Intensive Care Unit (CVICU) and Progressive Coronary Care Unit (PCCU)] in 1 facility.

Findings include:

1. Review of the policy titled Alarm Management, Last Revised 4/22/21, indicated the following:
Clinical Alarm Definitions: Catastrophic. Major (Example: call light). Moderate. Minor.
Clinical Staff Interventions: Clinical Staff shall respond to activated clinical alarms as follows: Catastrophic - Less than 1 minute. Major - Less than 2 minutes. Moderate - Less than 3 minutes. Minor - Less than 5 minutes.

2. Review of Unit Activity Report(s) for CVICU lacked documentation of response to patient call lights having been in less than 2 minutes as follows in section A.
A. CVICU call light responses taking greater than 2 minutes for patients as indicated:
P2: On 4/30/21, placed at 1:22 am. On 4/30/21 at 4:40 am. On 4/3/21 at 4:43 am. On 5/1/21 at 6:40 am. On 5/2/21 at 10:09 am.
P6: On 5/3/21 at 6:30 pm. On 5/3/21 at 7:57 pm.

Review of Unit Activity Report(s) for 5 Central (PCCU) lacked documentation of response to patient call lights having been in less than 2 minutes as follows in section B and lacked documentation of call light responses having been less than 5 minutes in section C (Not all inclusive, patient names not provided, only room numbers provided):

B. PCCU call light responses taking greater than 2 minutes for patients as indicated:
Room 5408 - 1: On 5/5/21 at 3:20 am. On 5/5/21 at 10:33 am. On 5/6/21 at 4:42 pm and at 6:07 pm.

C. Call light responses taking greater than 5 minutes for patients as indicated:
Room 5408 - 1: On 5/3/21 at 3:19 pm. On 5/5/21 at 11:43 am. On 5/5/21 at 11:45 am. On 5/6/21 at 10:32 pm (>14 minutes).

D. The Unit Activity Report Totals By Date for room 5408 on 5/5/21 indicated the following*:
Total Number of Patient Calls: "In Pain" - 2. Average Voice Response Time: 5:42 (minutes).
Total Number of Patient Calls: "Patient" - 3. Average Voice Response Time: 4:24 (minutes).
Total Number of Patient Calls: "Water" - 1. Average Voice Response Time: 3:04 (minutes).
*Note: On this date all "Average Staff Response Time" was indicated as 00:00:00.

The Unit Activity Report Totals By Date for room 5408 on 5/5/21 indicated the following:
Total Number of Patient Calls: "Bed Out" - 1. Average Voice Response Time: 13:57 (minutes). Average Staff Response Time: 14.41 (minutes).

3. On 9/22/21, beginning at approximately 11:30 AM, A1, Manager/Risk Management, indicated the Unit Activity Reports showed when patients activated call lights and the time staff responded to needs.

Based on document review and interview, the hospital failed to ensure adequate medical record (MR) documentation of laboratory services rendered for 3 of 10 patients (P2, P4 and P9) and failed to ensure medical records were documented accurately for 1 of 1 patients who passed away (P2).

Findings include:

1. A. Review of the policy titled Adult Venipuncture Specimen Collection, Last Revised 6/3/2021, indicated the following:
Peripheral Collection Procedure: Document procedure in EMR (electronic medical record).

B. Review of the document titled Phlebotomy Competency, Version 12/19/18, indicated the following: To assure competency in practice, the learner must successfully perform phlebotomy on a patient under direct observation of a trained clinician.

2. Review of laboratory/specimen collection reports for patients P2, P4 and P9 indicated the following:
Patient P2 had blood draws/labs collected on the following dates: Every day beginning 4/19/21 through 5/9/21.
Patient P4 had blood draws/labs collected on the following dates: Every day beginning 4/23/21 through 5/1/21.
Patient P9 had blood draws/labs collected on the following dates: Every day beginning 4/19/21 through 4/23/21.

3. A. Review of the medical record (MR) for patient P2 indicated the following in Interdisciplinary Note(s) - Nursing (IDNN): Note authored 4/21/21 at 0542 hours documented labs collected. Note authored 4/25/21 at 0915 hours documented phlebotomy specimen(s) collected. Note 5/7/21 at 0316 hours documented phlebotomy specimen(s) collected. Note authored 5/7/21 at 0317 hours documented phlebotomy performed. The MR lacked documentation of who performed and/or collection times of other blood draws/labs/phlebotomy specimens on 4/19/21, 4/20/21, 4/22/21, 4/23/21, 4/24/21, 4/26/21, 4/27/21, 4/28/21, 4/29/21, 4/30/21, 5/1/21, 5/2/21, 5/3/21, 5/3/21, 5/5/21, 5/6/21, 5/8/21 or 5/9/21.
The MR Death Note indicated the patient passed away on 5/9/21 at 1205 hours. An IDNN (Interdisciplinary Note-Nursing) dated 5/10/21 at 2133 hours [without any other date(s) noted], authored by RN (Registered Nurse) S12, indicated the following: Patient called out for help at approximately 2200 (hours). He/she had taken his/her nasal cannula out of his/her nose. The PCT (Patient Care Technician) entered the room first and noticed that his/her lips looked a little blue, and he/she replaced the nasal cannula and called for the RN... RN assessed the patient and began trending his/her VS (vital signs)... The charge nurse also assessed the patient and both nurses agreed that the pulse oximeter could not be correct. RN noticed that the patient's blood pressure was trending down and called the CT (cardiothoracic) surgeon, MD1... notified the MD (physician) that the patient was in a junctional rhythm and his/her heart rate had been trending down, as well as his/her bp (blood pressure) and oxygenation. MD1 gave a verbal order to transfer the patient to CVICU (Cardiovascular Intensive Care Unit). RN immediately called the charge RN and asked him/her to get an ICU (Intensive Care Unit) bed asap (as soon as possible). Pt (patient) was transferred to CVICU at 2245 (hours). The MR lacked documentation of the note being a late entry.

B. The MR of patient P4 lacked documentation of who collected lab specimens/performed blood draws.

C. The MR of patient P9 indicated that labs were collected by venipuncture and documented on IDNNs as follows: Note authored 4/21/21 at 0416 hours documented lab collection. Note authored 4/22/21 at 0428 hours documented lab collection. Note authored 4/23/21 at 0413 hours documented lab collection. The MR lacked documentation of who performed and/or collection times of other blood draws/labs/phlebotomy specimens on 4/19/21 or 4/20/21.

4. On 9/21/21, beginning at approximately 5:00 PM, A1, Manager/Risk Management indicated that documentation of who performed blood draws/lab collection is to be recorded in the IDNN of the EMR and if the documentation is not there, it could not be determined from the MR who collected the specimen. A1 verified patients P2, P4 and P9 had labs performed which lacked EMR documentation of the phlebotomy service.