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Based on document review and interview, the facility failed to have adequate numbers of personnel to provide care to all patients as needed in accordance with their staffing guidelines for 5 (five) of 28 (twenty-eight) shifts on unit 5E.

Findings include:

1. 5E Staffing Grid, updated 01/2023, indicated grid applies to day and night shift; to be used in combination with the Charge Nurse's evaluation of staffing experience and patient acuity.


2. Review of the staffing schedules for 5E completed for 8/6/2023 through 8/12/2023 and 9/3/2023 through 9/9/2023 indicated the unit lacked documentation of adequate numbers of patient care staff for daily patient census of 30 (thirty) patients per shift as follows:
a. 8/09/2023 Night Shift 7 RNs needed, 6.6 scheduled, 0.4 RN missing
b. 8/12/2023 Day Shift 7 RNs needed, 6 RNs scheduled, 1 RN missing
c. 9/03/2023 Night Shift 7 RNs needed, 6.6 RNs scheduled, 0.4 RN missing
d. 9/08/2023 Day Shift 7 RNs needed, 6 RNs scheduled, 1 RN missing
e. 9/09/2023 Day Shift 7 RNs needed, 6.3 scheduled, 0.7 RN missing

3. On 09/19/2023 at approximately 1545 hours, A4 (5E Manager), provided this surveyor with the staffing documention for the unit 5E. A4 indicated that the staffing and patient census for the time reviewed was correct.

Based on document review and interview, nursing personnel failed to provide necessary patient hygiene and linen change to 4 of 10 patients (Patient #2, #4, #9 and #10).

Findings include:
1. Facility policy titled "Assessment and Reassessment of Adult Inpatients", no policy number, publication date 04/18/2023, indicated Daily Assessment and Care Standards- ADLs and safety: activity, oral care, nursing respiratory care, hygiene.

2. Medical Record Review of patient #2, lacked documentation of hygiene and linen change from 08/30/2023 through 09/01/2023 and from 09/06/2023 through 09/09/2023; patient #4 lacked documentation of hygiene and linen change from 09/04/2023 through 9/09/2023; patient #9 lacked documentation of hygiene and linen change from 09/07/2023 through 09/09/2023; patient #10 lacked documentation of hygiene and linen change from 09/05/2023 through 9/10/2023.

3. In interview on 09/19/2023 at approximately 1200 hours with A10 (Quality Registered Nurse) he/she confirmed patient #2, #4, #9, and #10 lacked documentation of daily patient hygiene and/or linen change.

Based on document review and interview, Nursing Services failed to safely administer medications to 3 of 10 patients (Patient #2, #4, and #9).

Findings include:
1. Facility policy titled "Pain Management", PolicyStat ID: 9991996, last revised 08/02/2021, indicated when pain is present, pain assessment may include the following characteristics: intensity, location, description; the nurse may use the patient's identified comfort-function goal as part of collaboratively planning pain interventions with the patient; pain intensity levels are meant to be a general guideline to pain intesity: mild pain (self-report of 1-3 on a 0-10 numeric pain scale), moderate pain (self-report of 4-6 on a 0-10 numeric pain scale), severe pain (self-report of 7-10 on a 0-10 numeric pain scale).

2. Medical record review:
a. Patient #2 indicated on 09/07/2023 at 0054 hours patient SpO2 (peripheral capillary oxygen saturation) was 91% on room air, patient was administered 50 mCg (microgram) Fentanyl, IV (intravenous) push for pain rating of 7/10 and ondansetron 4mg (milligram), IV push for nausea. Provider order dated 09/06/2023 indicated to call provider if SpO2 is less than 92 %, MR lacked documentation of provider notification.

b. Patient #4 indicated pain assessment on 09/07/2023 at 0400 hours was 2/10. Patient was administered Fentanyl 50mCg IV push at 0410 hours. MR lacked documentation of pain assessment completed on 09/07/2023 prior to administration of hydromorphone 1mg (milligram) IV push at 0940 hours.

c. Patient #9 indicated MR lacked documentation of pain assessment completed on 09/09/2023 prior to administration of hydrocodone-acetaminophen 5mg-325 mg oral tablet at 2314 hours.


3.In interview on 09/19/2023 at approximately 1300 hours with A10 (Quality Registered Nurse), he/she confirmed lack of documentation of provider notification of oxygen levels below 92% prior to pain medication administration for patient #2. A10 also confirmed lack of documentation of pain assessment prior to administration of pain medication for patient #4 and #9.