HospitalInspections.org

Based on document review and interview, the facility failed to provide staffing according to the staffing matrix for day shift on 7 days (01/09/22, 01/10/22, 01/11/22, 01/12/22, 01/13/22, 01/14/22 and 01/15/22) reviewed.

Findings Include:

1. Review of policy titled: Nurse Staffing and Assignments (PolicyStat ID: 11178736) last revised 02/2022, specified a staffing grid based off of census.

2. Review of staffing schedule (01/09/22 through 01/15/22) cross-referenced with the census and staffing grid, indicated staff shortages on day shift as follows:
Unit 100
01/10/22 - census of 18 requires 2 nurses; only had 1 - short 1 nurse
01/11/22 - census of 18, requires 2 nurses; only had 1 -short 1 nurse
01/14/22 - census of 17, requires 2 nurses; only had 1 - short 1 nurse
01/15/22 - census of 19, required 3 nurses and 3 aides; only had 2 nurses and 1 aide - short 1 nurse and 2 aides
Unit 200
01/11/22 - census of 9, requires 2 nurses and 2 aides; had 1 nurse and 1 aide - short 1 nurse and 1 aide
01/12/22 - census of 9, requires 2 nurses; had 1 nurse - short 1 nurse
01/13/22 - census of 11, requires 2 nurses and 2 aides; had 1 nurse and 1 aide - short 1 nurse and 1 aide
01/14/22 - census of 10, requires 2 aides; had 1 - short 1 aide
01/15/22 - census of 9, requires 2 nurses and 2 aides; had 1 nurse and 1 aide - short 1 nurse and 1 aide
Unit 300
01/10/22 - census of 17, requires 2 nurses; had 1 nurse - short 1 nurse
01/14/22 - census of 15, requires 2 nurses and 2 aides; had 1 nurse and 1 aide - short 1 nurse and 1 aide

3. Interview on 02/09/22 at 4:35 pm confirmed with P52 (Director of Nursing) confirmed #2 and facility does have staffing shortages.

Based on document review and interview, nursing failed to follow policy in 3 policies (Patient Clothing Laundering, Laboratory Process and Therapy Services) reviewed.

Findings Include:

1. Review of policy titled: Laboratory Process (PolicyStat ID: 9823465) last approved 05/2021, indicated that nurses/unit clerks obtain laboratory results from lab website and print results; place printed results in the patient's MR.

2. Review of policy titled: Patient Clothing Laundering (PolicyStat ID: 11179311) last revised 02/2022, indicated patient laundry will be collected and separated to mitigate risk of contamination.

3. Review of policy titled: Therapy Services (PolicyStat ID: 8821106) last approved 01/2020, indicated that patients will receive recreation therapy on a daily basis.

4. Review of Patients 2, 4, 7, 8, 9 and 10's medical records lacked documentation of ordered laboratory results.
Patient 2 - urinalysis and culture & sensitivity ordered 01/06/22 and stool specimen ordered 01/09/22; lack of results documented in the MR.
Patient 4 - complete blood count, complete metabolic panel, thyroid, hemoglobin A1C ordered 01/18/22; lack of results documented in the MR.
Patient 7 - ammonia level ordered 01/28/22; lack of results documented in the MR.
Patient 8 - lithium and depakote level ordered on 01/28/22, complete blood count, complete metabolic panel ordered on 01/31/22 and complete blood count and complete metabolic panel ordered 02/07/22; lack of results documentked in the MR.
Patient 9 - complete blood count, complete metabolic panel, thyroid, lipid panel, urinalysis and hemoglobin A1C ordered 02/02/22; lack of results documented in the MR.
Patient 10 - vitamin D level ordered 02/04/22; lack of results documented in the MR.

5. Tour of facility on 02/09/22, this surveyor observed multiple patient clothing lumped together in a hamper with a lid.

6. Review of Patient 2's MR lacked documentation of any activity therapy; patients 1, 3, 4, 6, 7, 8, 9 and 10's MR had documentation of Monday through Friday therapy but lacked documentation of therapy on weekends or whom is responsible for activity therapy on the weekends.

7. Interview on 02/09/22 at 11:50 am with P56 (Registered Nurse) confirmed that patient's clothes are mixed together and washed, not separated and washed.

8. Interview at 12:25 pm with P57 (Certified Nurse Aide) confirmed that patient's clothes are mixed together and washed, not separated and washed.

9. Interview on 02/09/22 at 12:25 pm with P57 (Certified Nurse's Aide) confirmed patients have activities Monday through Friday and unscheduled activities (playing cards/games) on the weekends if there is time.

10. Interview on 02/09/22 at 3:45 pm with P52 (Director of Nursing) confirmed that Patients 2, 4, 7, 8, 9 and 10's medical records lack documentation of laboratory results.