HospitalInspections.org

42154


Based on facility staffing grids, staffing schedules and assignments, American Association of Critical Care Nurses, policy review, and interviews it was determined that the facility failed to provide supervisory oversight on the nursing care units to ensure the immediate availability of a Registered Nurse (RN) in five (MICU, SICU, CSU, PCU, and the neurology unit) of ten Nursing Care Units.

Findings include:

Review of the facility staffing grids (tool to determine nurse to patient ratios) reveals that for the Medical Intensive care unit (MICU), Cardiac/Surgical intensive care unit (CSU) and Surgical Intensive Care Unit /Trauma unit (SICU) staffing grid is two patients for one Registered Nurse and a Clinical Care Coordinator/Charge Nurse (CNC) with no patients for both night shift and day shift.

Review of the Staffing grid for MICU/ SICU/ CSU showed:
(unit secretary (US)/Certified Nursing Assistant(CNA))
Census RN Charge US/CNA Patient to professional

20 10 1 1 1.82
19 10 1 1 1.73
18 9 1 1 1.80
17 9 1 1 1.70
16 8 1 1 1.78
15 8 1 1 1.67
14 7 1 0 1.75
13 7 1 0 1.62
12 6 1 0 1.71
11 6 1 0 1.57
10 5 1 0 1.67
9 5 1 0 1.50

Review of the facility staffing schedules from three night shifts reveals:
In the MICU:
-02/18/2023 The unit had 20 patients with 6 RN and one CNC who was caring for patients. Per the staffing grid guidelines 10 RN's and one CNC should have been scheduled. This was a deficit of 4 RNs.
-02/19/2023 The unit had 19 patients with 6 RN and one CNC who was caring for patients. Per the staffing grid guidelines 10 RN's and one CNC should have been scheduled. This is a deficit of 4 RNs.
-02/20/2023 The unit had 17 patients with 6 RN and one CNC Per the staffing grid guidelines 9 RN's and one CNC should have been scheduled. This is a deficit of 3 RNs.

In the SICU:
-02/18/2023 The unit had 19 patients with 7 RN and one CNC who was caring for patients. Per the staffing grid guidelines 10 RN's and one CNC should have been scheduled. This is a deficit of 3 RNs.
-02/19/2023 The unit had 19 patients with 8 RN and one CNC who was caring for patients. Per the staffing grid guidelines 10 RN's and one CNC should have been scheduled. This is a deficit of 2 RNs.
-02/20/2023 The unit had 20 patients with 9 RN and one CNC who was caring for patients. Per the staffing grid guidelines 10 RN's and one CNC should have been scheduled. This is a deficit of 1 RN.

In the CSU:
-02/18/2023 The unit had 18 patients with 6 RN and one CNC who was caring for patients. Per the staffing grid guidelines 9 RN's and one CNC should have been scheduled. This is a deficit of 3 RNs.
-02/19/2023 The unit had 19 patients with 5 RN and one CNC who was caring for patients. Per the staffing grid guidelines 10 RN's and one CNC should have been scheduled., a deficit of 5 RNs.
-02/20/2023 The unit had 18 patients with 7 RN and one CNC who was caring for patients. Per the staffing grid guidelines 9 RN's and one CNC should have been scheduled. This is a deficit of 2 RNs.

Review of the staffing grid for Progressive Care Unit (PCU)

Census RN Charge CNA Patient to professional
34 9 1 4 3.40 dayshift/ nightshift
33 9 1 4 3.40 dayshift
8 1 4 3.67 nightshift
32 8 1 4 3.56 dayshift/ nightshift
unit secretary (US)/ 1 for dayshift and none for nightshift
(Certified Nursing Assistant (CNA))

Progressive Care unit (PCU) staffing
-03/04/2023 the unit had 34 patients with 7 RN and one CNC who was caring for 4 patients. Per the staffing grid guidelines 9 RN and one CNC should have been scheduled. This is a deficit of 2 RNs.
-03/05/2023 the unit had 33 patients with 6 RN and one CNC who was caring for 4 patients. Per the staffing grid guidelines 8 RN and one CNC should have been scheduled. This is a deficit of 2 RNs.
-03/06/2023 the unit had 33 patients with 7 RN and one CNC who was caring for 4 patients. Per the staffing grid guidelines 8 RN and one CNC should have been scheduled. This is a deficit of 1 RN.

Review of the Plan of Corrections submitted to the AHCA (Agency for Healthcare Administration) and CMS (Center for Medicare and Medicaid Services), dated 11/21/2022 and signed by the facility CEO (Chief Executive Officer) shows:
The CNO (Chief Nursing Officer) ensures that adequate numbers of registered nurses are available 24/7 to provide nursing care to all patients as needed ... The staffing grids serve as guideline for leaders to provide adequate numbers of licensed nurses and other personnel to provide nursing care to all patients as needed... When the capacity exceeds the available resources, the facility considers other strategies to manage influx, while maintaining safe care and continuity of operations. Examples of the strategies implemented may include but are not limited to: Leaders may go into staffing, Transfer center closure (process where the facility requests closure from the centralized transfer center operations center for an established period of time); EMS Bypass (where EMS service are notifies that the facility requests to be bypassed for any critical needs, with an exception for trauma). ....

Review of staffing sheets shows that the CNC's were assigned to patients.
Review of the Nursing Organizational Charts and the staffing sheets reveals that there was no evidence of managers, or directors of the units were included in the staffing on the days there were a deficit in nurses.

On 02/20/2023 at 10:27 AM an interview with Staff A reveals that she is a newer nurse. She has been out of training for six and a half months. She stated that she has three Patients, two are ICU level and the third patient is a [downgraded] progressive care unit level (PCU).

On 02/20/2023 at 10:35 AM an interview with staff B reveals she has three patients. One is a Cerebral Vascular Accident (CVA) (interruption of blood flow to the brain) , her second patient is severe and has a Glasgow Coma Scale (GCS) of 3-5 a (measures the extent of impairment of responsiveness: eye- opening, motor, and verbal response) and on multiple medications, she disclosed that her third patient has critical labs.

On 02/20/2023 at 10:43 AM an interview with Staff C reveals the struggle for staff is on nightshift with the charge nurse having up to 3 patients. Staff C disclosed that ICU patients are heavy and most of the patients are on ventilator (Machine that supports a patient breathing) with multiple IV (intravenous) medications to keep the heart beating and with 2 to 3 patients, no one can help each other.

On 02/20/2023 at 11:00 AM an interview with Staff E reveals that at the start of shift she had 1 ICU patient and 2 Progressive Care patients.

On 02/20/2023 at 11:16 AM an interview with Staff F reveals that nightshift staffing is "horrendous" and the charge nurse has [three] patients in the ICU.

On 02/20/2023 at 11:37 AM an interview with Staff D reveals that currently, the ICU has 19 patients with 6 nurses and the CNC has 3 ICU patients.

On 02/20/2023 at 6:40 PM an interview with Staff I reveals that nightshift in the ICU is always staffed 3 patients to 1 RN, and the charge nurse has patients also. Nightshift has minimal ancillary staff to assist on nightshift. Staff I disclosed the biggest thing on night shift is staffing with poor supervision and they keep adding things for the nurses to do in ICU.

On 02/20/2023 at 10:11 AM in an interview with the Director of Patient Safety he reviewed of the staffing sheets in ICU, and confirmed that the nurses have 3 ICU patients, and the night charge nurse also has patients.

On 02/21/2023 at 8:30 AM an interview with the CEO reveals that they hired 4 international nurses with one working now on dayshift. The CEO stated that the staffing will change so the CNC will be readily available to assist the ICU nurses.

On 03/07/2023 at 11:17 AM an interview was conducted with Staff N who disclosed that when there is a incident the administration becomes hyperfocused on the event to correct it, but as soon as another issues happens they forget about the first one and put all their focus on the second event.

On 03/07/2023 at 11:39 AM an interview was conducted with Staff M who disclosed that if they are short staffed they get no help from the Manager nor the Director.

On 03/07/2023 at 12:05 PM an interview was held with Staff L where she disclosed that when the Agency for Health Care administration (AHCA) is in the building they find staff, but when AHCA leaves it goes back to being understaffed.

On 03/07/2023 at 3:42 PM an interview with the house supervisor revealed the dayshift supervisor does nightshift staffing and nightshift nursing does the staffing for dayshift. She disclosed staffing is based on the facility staffing grid. She revealed she attends a meeting at 9:00 AM every morning to inform the leadership of the staffing need for the nightshift. She sends out an internal email at 12:00 PM and again at 4:00 PM to leadership to let them know the staffing needs for nightshift and lets them know everything attempted to obtain staff. She disclosed that it is the managers and directors of the units to fill the staffing shortage, she will inquire about to what is the staffing plan for their units. She stated, "If you do not have the staff, it is not safe for the patients or the nurses, so the managers and director better come in and help".

According to the American Association of Critical Care Nurses states, "Appropriate staffing ensures the effective match between patient and family needs and nurse knowledge, skills, and abilities. Evidence confirms that the likelihood of serious complications or death increases when fewer registered nurses are assigned to care for patients. 8,10 A substantial body of evidence indicates better patient outcomes occur when registered nurses provide a higher proportion of care hours in healthy work environments."

Review of the Staffing Grid Department Data Report for the neurology unit, with a scheduled start date of 1/8/23, reflected the following findings:
7:00 AM-7:00 PM, 7:00 PM-7:00 AM
30 patients=1 charge (CNC), 6 RNS, 3 PCAs (patient care assistants), 1 unit secretary (US)
32 patients=1 CNC, 7 RNs, 4 PCAs, 1 US
34 patients=1 CNC, 7 RNs, 4 PCAs, 1 US
36 patients=1 CNC, 7 RNs, 4 PCAs, 1 US
37 patients=1 CNC, 8 RNs, 4 PCAs, 1 US

Review of the staffing assignments for the last two weeks revealed the following:
On 02/20/2023 for 7:00 AM-7:00 PM, the unit had 36 patients with 6 RN's, 1 CNC who was caring for 1 patient, 4 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 7 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 1 RN.

On 02/20/2023 for 7:00 PM-7:00 AM, the unit had 36 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 7 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RN's and 1 PCA.

On 02/21/2023 for 7:00 AM-7:00 PM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 4 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 3RNs.

On 02/21/2023 for 7:00 PM-7:00 AM, te unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patients, 4 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs.

On 02/22/2023 for 7:00 AM-7:00 PM, the unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs and 1 PCA.

On 02/22/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patients, 4 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs.

On 02/24/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patients, 4 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs.

On 02/25/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patient, 4 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs.

On 02/26/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs and 1 PCA.

On 02/27/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 3 RNs, and 1 PCA.

On 02/28/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This a deficit of 3 RNs, and 1 PCA.

On 03/01/2023 for 7:00 PM-7:00 AM, the unit had 34 patients with 5 RNs, 1 CNC who was caring for 1 patient, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 7 RNs, 4 PCAs, and 1 US should be scheduled.This is a deficit of 2 RNs and 1 PCA.

On 03/02/2023 for 7:00 PM-7:00 AM, the unit had 32 patients with 6 RNs, 1 CNC who was caring for 1 patients, 4 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 7 RNs, 4 PCAs, and 1 US should be scheduled.This is a deficit of 1 RN.

On 03/03/2023 for 7:00 PM-7:00 AM, the unit had 30 patients with 6 RNs, 1 CNC who was caring for 1 patients, 4 PCAs, and 1 US. The unit was fully staffed.

On 03/04/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 3 RNs, and 1 PCA.

On 03/05/2023 for 7:00 AM-7:00 PM, the unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patient, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs and 1 PCA.

On 03/05/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 3 RNs, and 1 PCA.

On 03/06/2023 for 7:00 AM-7:00 PM, the unit had 37 patients with 6 RNs, 1 CNC who was caring for 1 patient, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 2 RNs and 1 PCA.

On 03/06/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 3 RNs, and 1 PCA.

On 03/07/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 3 RNs, and 1 PCA.

On 03/07/2023 for 7:00 PM-7:00 AM, the unit had 37 patients with 5 RNs, 1 CNC who was caring for 6 patients, 3 PCAs, and 1 US. Per the staffing grid guidelines 1 CNC, 8 RNs, 4 PCAs, and 1 US should be scheduled. This is a deficit of 3 RNs, and 1 PCA.


On 3/7/23 at 12:30 PM an interview was conducted with Staff Y on the neurology unit, 3 East. Staff Y said usually it's six patients, sometimes seven. One PCT for each hall (3). it's not really manageable with six to seven. Sometimes the charge nurse has patients. Sometimes one. Sometimes five to six.

At 12:39 PM on 3/7/23 an interview was conducted with Staff Z. Staff Z said it's usually one nurse to six patients. It depends on the number of nurses that are present. The charge does take patients. Sometimes they take the same that we do and sometimes they don't take any. Six patients is overwhelming. Especially if they are the type that need a lot of attention.

On 3/7/23 at 12:46 PM an interview was conducted with Staff AA. Staff AA said she has six patients. It's challenging. It depends on the patients' acuity. The charge nurse has to takes patients sometimes. They try not to, but sometimes she has to.

At 12:57 PM on 3/7/23 an interview was conducted with Staff BB. Staff BB said the night shift is definitely having a staffing struggle. The charge on nights generally has six. We have had an increase in falls. With the struggle we have been having with staffing, it has definitely been harder. It's not the management team. It's higher up.

On 3/7/23 at 1:08 PM an interview was conducted with Staff CC. Staff CC disclosed that about forty percent of the time the charge nurses have to take patients. It's both days and nights.

On 3/7/23 at 3:34 PM an interview was conducted with the director of the neurology unit, 3 East. She said when the charge nurse has to go on an assignment it's an escalated situation. We send out messages to the team and hospital, the supervisor is involved. Incentives are offered. Partial shifts are offered. We are continually hiring and having hiring events. We use nurse externs. Core staff have not complained. If there were a concern the house supervisor would be contacted to assist, or the nurse manager comes in, or myself. The gold standard is to not have them on assignments. We look at that every day. We escalate to the supervisor and CNO (chief nursing officer). No one wants the charge on an assignment.

On 3/7/23 at 4:25 PM an interview was conducted with the ACNO (assistant chief nursing officer). The ACNO said the patient safety director prints out a report any time there is an event. We look to see if there is any harm. We look at staffing variances. We haven't had any harm. During the safety huddle we are reporting if there are any safety concerns related to the occurrence. The review is retrospective. There was a staffing variance, but there was no harm. The directors review the event. They can notate if there were any staffing concerns. We will do an intense analysis, where we bring the involved staff in and give them the opportunity to voice what they saw or what the circumstances were. Such as, the charge had four patients last night. We talk about it every day in safety huddle.