HospitalInspections.org

Based on document review and interview, it was determined for 3 of 4 (2 North, 2 South, and 3 South ) nursing units, the Hospital failed to ensure adequate staffing was provided. This potentially affected an average daily census between 30 to 38 patients admitted to each unit.

Findings include:

1. On 3/28/17 at approximately 11:00 AM, the Hospital's policy titled "Staffing Plan/Patient Acuity" (reviewed 12/16) was reviewed and required, "Daily Staffing Plan: Nurse manager works collaboratively with staffing coordinator in maintaining a schedule system that provides appropriate skilled personnel, twenty four a day seven days a week... Nurse Manager/Staffing Coordinator/House Supervisor adheres to staffing guidelines as outlined in the grid..."

2. On 3/28/17 at approximately 11:30 AM, the Hospital's "Staffing Guidelines" for all units were reviewed. The staffing guidelines indicated that on the day and evening shifts for 2 North, 9 staff (3 Registered Nurses [RN]/Licensed Practical Nurses [LPN] and 6 Mental Health Specialists [MHS]) was required for 35 to 39+ patients); for 2 South, 7 staff (2 RNs/LPNs and 5 MHS) was required for 32 to 36 patients; and for 3 South, 8 staff (2 RNs and 6 MHS) was required for 31 to 36 patients.

3. On 3/29/17 at approximately 11:00 AM, the staffing assignment sheets for all units (2 North, 2 South, 3 North, and 3 South) for 3/2/17, 3/4/17, and 3/5/17 were reviewed and included the following staff shortages per the unit staffing grid:

- 3/4/17, 3 South evening shift's census was 34 (with 2 patients requiring 1:1 monitoring). There were 9 staff (2 RN and 7 MHS) scheduled. The unit was short of 1 MHS for the shift.

- 3/5/17, 2 North day and evening shift's census was 40 and 41 respectively (each shift with 1 patient requiring 1:1 monitoring). There were 9 staff (3 RNs and 6 MHS) scheduled for each shift. The unit was short of 1 MHS on both day and evening shifts.

- 3/5/17, 2 South day and evening shift's census was 35. There were 6 staff scheduled (2 RNs and 4 MHS) for each shift. The unit was short of 1 MHS on both day and evening shifts.

- 3/5/17, 3 South evening shift's census was 34 (with 2 patients requiring 1:1 monitoring). There were 9 staff (2 RNs and 7 MHS) scheduled. The unit was short of 1 MHS for the shift.

4. On 3/29/17 at approximately 1:00 PM, findings were discussed with E #2 (Director of Nursing), who stated, "Ideally, staffing is based on the grid." E #2 agreed that the units were short staffed on 3/4/17 and 3/5/17.