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Based on document review, video surveillance review and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services.

Findings include:

1. The hospital failed to ensure that the nursing service had adequate numbers of licensed Registered Nurses (RNs) to provide nursing care to all patients as required. See deficiency cited at A-392.

2. The hospital failed to ensure that the unit was always supervised by a licensed registered nurse (RN). See deficiency A-393.

The immediate jeopardy (IJ) was identified on 08/02/2024 at 42 CFR 482.23, Nursing Services, due to the hospital's failure to ensure appropriate supervision on 1 of 3 Behavioral Health Units by a licensed Registered Nurse. The IJ was announced on 08/02/2024 at 3:30 PM, during a meeting with the Chief Executive Officer (CEO), Director of Risk, Risk Manager, and Vice President of Quality and Patient Safety. The IJ was removed based on document review, interviews, and observation by the survey exit date of 08/05/2024.

Based on document review and interview, it was determined that for 2 of 3 Behavioral Health Units (2-East and 3-West) reviewed for staffing, the hospital failed to ensure that the nursing service had adequate numbers of licensed Registered Nurses (RNs) to provide nursing care to all patients as required.

Findings include:

1. The hospital's policy titled, "Staffing Plan for Nursing Services" (dated 6/2022) was reviewed and required, " ...The minimum staffing needed for each skill level (RNs, Behavioral Health Associates (BHA), others) is determined by the nurse-patient ratio guidelines and patient care needs of the population ... The exact nurse to patient ratio may differ by population and level of needs but generally there is one nurse per 12 patients."

2. The Staffing grid for the Adult Behavioral Health Units (undated) was reviewed. The staffing grid required the following staff to patient ratio: Day & Evening census 1 to 10 (1 RN, 1 BHA) 11 to 21 (2 RNs and 2 BHAs).

The 2 East (Adult Male) Unit Staffing Assignment sheets from 7/1/2024-7/31/2024 were reviewed and indicated that there was only 1 RN and 2 BHAs working the night shifts from 7/17/2024-7/20/2024 with the census between 13 to 20 patients.

3. The 3 West (Adult Male/Female) Unit Staffing Assignment sheets from 7/1/2024 - 8/1/2024 were reviewed and indicated that there was 1 RN and 2 BHAs working on the following days 7/27/2024 - 7/29/2024, with the census between 15-18 patients.

4. On 08/02/2024 at approximately 11:30 AM to 11:45 AM, interviews were conducted with three RNs (E #14, E #15, and E #16), all RNs stated that there are occasions that the units are short staffed with one RN to cover greater than 13 patients on their unit.

Based on document review, video surveillance review and interview it was determined that for 1 of 3 Behavioral Health Units (BHU), the hospital failed to ensure that the unit was always supervised by a registered nurse (RN). This has the likelihood to cause serious harm to any patient that presents to the hospital.

Findings include:

1. The hospital's policy titled, "Staffing Plan for Nursing Services" (dated 6/2022) was reviewed and required, " ...The minimum staffing needed for each skill level (RNs, Behavioral Health Associates (BHA), others) is determined by the nurse-patient ration guidelines and patient care needs of the population ... Acute Care: Core coverage includes ensuring there is always 1 RN on each unit and that there is at minimum 2 staff on each unit at all times when there is lower census ... To secure optimal patient care, these guidelines outline staffing expectations to be observed by all service lines. Acute Service Line: An RN must always be on the unit. Neither an RN House Supervisor nor LPN (Licensed Practical Nurse) can service as the RN on the unit ..."

2. The "Chief Nursing Officer Job Description" (revised 1/1/2020) was reviewed and required, "... Evaluate service needs and staffing requirements to ensure needs of patients are met ... Assist with direct care as needed."

3. On 08/01/2024, a video surveillance of 3-West, 3-East, administration corridor and employee parking lot for 7/19/24 between 2:43 AM to 4:09 AM, was reviewed with the Director of Risk Management (E#8) and the Risk Manager (E #9). The video showed that at on 07/19/24 at 3:22 AM, the Chief Nursing Officer (CNO/E #1) leaves 3-East and enters 3-West at 3:24 AM. E #1 is observed speaking to a staff (RN/E #6). At 4:09 AM, E #1 is observed getting into an elevator, then exits to the employee parking lot and gets into a car and drives away.

4. The 3-East (Female Adult) Unit Staffing Assignment for 07/18/24 7:00 PM to 7/19/24 7:00 AM, indicated that the census was 11, with one RN and two BHAs.

5. The 3-West (Adult Male/Female) Unit Staffing Assignment for 7/18/24 7:00 PM to 7/19/24 7:00 AM, indicated that the census was 9, with one RN (CNO/E#1), one BHA, and sharing one BHA with 3-East. The patients on both units were on safety precautions that included, Suicide Risk high and low, Assault, Elopement, fall risk, and every 5-minute checks.

6. Interviews were conducted with the Chief Nursing Officer (CNO/E#1) on 8/1/2024, at approximately 12:00 PM and on 8/2/2024 at 11:40 AM. E #1 stated that a nurse called off July 18 for the 7 PM to 7 AM, shift and the day shift nurse (E #4) called E #1 to report that there was no nurse to cover the PM shift. E #1 came in at approximately 8PM to cover the shift on 3-West, there was another nurse (E #6) working on 3-East, which is next to 3-West and is separated by a locked door. E #1 stated census was low, there were approximately 7 patients on 3-West and E #1 worked until around 5 AM, the nurse (E #6) covered 3-West when E #1 left. E #1 stated there were 3 BHAs (3-East & 3-West), there was one BHA on the 2nd floor unit. E #1 stated that typical staffing is based on census and acuity, and there are usually 1-2 nurses. The nurse to patient ratio is 1 nurse to 13 patients. E #1 stated that the hospital is using agency nurses while the hospital is trying to fill current vacancies. E #1 stated that E #1 did not try to get staff to cover the unit prior to E #1 leaving. E #1 stated that the nurse (E #6) was fine covering both units with a total of 20 patients.

7. A telephone interview with the Registered Nurse (E#4) was conducted on 08/01/24 at 2:45 PM. E #4 stated that only one nurse orientee (E #3) showed up to work on 7/18/24 7:00 PM to 7:00 AM. E #4 stated that (E #3) didn't have access to the medication cabinet and there was only one nurse scheduled on the other units, which would serve as a resource to (E #3). (E #3) didn't feel comfortable working alone and refused to take report and left. E #4 stayed on the unit until about 9 PM. E #4 notified (E #2/Staff Coordinator) and (E #1/CNO) ended up coming in to take report and covered the unit. E #4 stated that E #4 became aware that (E #1) left around 3:00 AM, and the unit was left without a nurse until the next shift. E #4 stated that another staff notified Human Resources about this situation but was not aware if this was investigated or resolved.