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Based on interviews with staff, observations made at the facility, and a review of staffing grids, it was determined that the facility failed to ensure an adequate number of nursing staff to provide nursing care to all patients as needed.

Cross Reference A-0063 as it relates to the Governing Body failing to ensure safe nurse staffing ratios to provide adequate care of patients.

Based on interviews with staff, observations made at the facility, and a review of staffing grids, it was determined that the facility failed to ensure an adequate number of nursing staff to provide nursing care to all patients as needed.

During an interview with the House Supervisor Registered Nurse (RN) EE on 2/9/22 at 11:15 a.m. in the Conference Room, RN EE stated the facility had its challenges. The Emergency Department (ED) had been the shortest staffed area, followed by the Intensive Care Unit (ICU) and the Progressive Care Unit (PCU). The facility was fine during the COVID wave that subsided 12/21, but after the COVID wave subsided and the rate of the contracted service was lowered, the contractors would not renew, and staffing got worse. RN EE stated about three weeks after the contracts were lowered, the current COVID surge began (1/22). The ICU, PCU, and ED frequently did not have charge nurses (the head nurse that heads the day-to-day flow of the unit) because there was not enough staff. RN EE said the ED did not have enough staff for the census, and it was hard to give the best care with the staff-to-patient ratio. RN EE said that the ED usually had five nurses on the day shift, and at night, the ED had 3-4 nurses. One nurse would come between the two shifts. RN EE revealed that the ED did not just have ED patients, but the ED also had medical holds (patients waiting to be admitted).

During an interview with the Director of Emergency Services (RN) AA, on 2/9/22 at 1:08 p.m. in the Conference Room, RN AA stated the staffing grids called for four nurses each shift with one nurse in the middle shifts to bump up the nursing staff based on census. The ED census did not factor in holds. Once the holds were factored in, staffing needs increased. RN AA said there were days with eight medical holds in the ED, and the number of holds had gotten up to 18. RN AA further said the facility was still in a COVID surge, half as much as August 21, and the facility had not seen a decrease in inpatient numbers for the past two weeks, mostly COVID-related.

During an interview with Registered Nurse (RN) DD on 2/9/22 at 1:41 p.m., RN DD stated that there were days that staffing in the ED was not adequate and dropped to three ED nurses if a nurse called out of work. On the day of the interview, 2/9/22, the ED director was out of the department, and the ED manager was attempting to run the Fast Track (lower acuity) area. There were four ED rooms, a trauma room in the psychiatric corner of the ED, two cardiac rooms, and an additional trauma room, which would be eight rooms that RN DD was responsible for by herself. The recommended ratio was five patients (rooms) per nurse in the ED. RN DD said the other nurses in the ED were at a ratio of five patients to one nurse (5:1). RN DD said there was usually not enough staff for a triage nurse and an additional nurse to run the Fast Track area. There were roughly 12 beds in the Fast Track area, in addition to bed holds. One nurse would oversee both triage and the Fast Track area.

During an interview with the Medical-Surgical (Med-Surg) Unit Director (RN) HH on 2/9/22 at 2:03 p.m., RN HH stated that staffing had been tight at times, and the 3-Main Med-Surg unit had recently re-opened after renovations, which made things a little tighter. Part of the 2-Main Unit was currently closed for renovation. RN HH said the nursing ratio for the Med-Surg Units was six patients to one nurse (6:1) and a free charge nurse each shift. RN HH said there had been times the ratio was 7:1 with one Patient Care Technician (PCT); two managers had stepped into staffing. RN HH said the staffing grid was a baseline, and the nurses would meet at 2:00 p.m. daily to talk about staffing for the night shift and the next day to determine how the facility would be staffed with the resources available. The whole house (facility) would be discussed and collaborated to send nurses to other departments. There were times when there were no nurses available to send to other departments. RN HH said one to two times per week; a nurse from Med-Surg would be available to assist with holds in the ED.

During an interview with the Intensive Care Unit (ICU)/Progressive Care Unit (PCU) Program Director (RN) II on 2/9/22 at 2:25 p.m. in the Conference Room, RN II stated there was day to day struggles with call outs. For example, a strong medical-surgical nurse would be pulled to the ICU/PCU from a different unit. The nursing staff would band together, and the house supervisor would find staff willing to work extra hours. RN II said the ICU ratio was normally two patients per nurse (2:1), but there had been a 3:1 ratio in recent months. RN II said there were 12 beds in the ICU. On the day of the survey, 2/9/22, the acuity in the ICU was not severely high. One patient was on a ventilator, and additional patients were waiting to be transferred to the PCU. RN II said the nurse manager and program director would become part of the staffing, at times, to meet the staffing ratio. RN II said there were vacancies in the ICU/PCU, and the facility was in the process of interviewing.

During a telephone interview with the Intensive Care Unit (ICU) Clinical Nurse Coordinator (Charge Nurse) (CNC) RN GG, on 2/9/2022 at 2:36 p.m., RN GG stated that normal staffing in the ICU should be one nurse per patient or one nurse per two patients. RN GG said that ICU had had three patients per nurse for the past six months or longer, and the PCU has had four patients per nurse. RN GG said the nurses could not continue at the current ratios. Initially, the nurses would work together and make it happen, but the nurses were exhausted and burnt out. The PCTs had started to quit to look for places where the workloads were not so high. RN GG said the nurses felt they were not providing the best care because there were not enough resources or time. RN GG said the charge nurses would have to be in the staffing ratio (seeing patients) on many occasions to make up the team of four nurses in the ICU. RN GG stated rounds to check on patient experiences were conducted on the weekends when the charge nurse was out of the staffing ratio. The patients would complain about nursing services taking too long, and the nursing staff would have to explain the situation without saying there was short staffing. RN GG said priorities had to be set with the most critical needs first. Patient's needs were not being met. RN GG said there was always a "fire to put out" on ICU or another unit, and RN GG assisted other units when needed.

During an interview with the Chief Nursing Officer (CNO) on 2/10/22 at 10:28 a.m. in the Conference Room, CNO said that there was no written policy for staffing ratio because staffing was a fluid situation that could change day to day. The CNO said staffing was a challenge everywhere, not just the facility. The facility would try to meet the nurse-to-patient ratios by having the managers and charge nurses participate in the staffing load when possible.


During an interview with Registered Nurse (RN) TT on 2/22/22 at 11:55 a.m. in the Conference Room, RN TT stated she was a travel nurse and worked in the Emergency Department (ED). She said that she had worked at the Facility for ten weeks. RN TT said the Facility was not adequately staffed, especially in the Fast-Track area. RN TT said there were medics in the ED, but they were not allowed to administer some medications and had limited capacity in their use. RN TT said she saw 30-40 patients a day on average. RN TT stated the Facility had lost some contract nurses lately because their contracts expired and left.

During an interview with Patient Care Tech (PCT) WW on 2/22/22 at 12:44 p.m. in the Conference Room, PCT WW said she had worked at the Facility for five years. PCT WW admitted that the Facility had been short-staffed, including RNs and PCTs, since the COVID-19 pandemic. PCT DD said she generally would receive seven to eight patients in her caseload but instead had received 12 to 13 patients. She stated this was true for other PCTS as well. PCT WW said such a large caseload impacted the quality of work she could provide and that she did not have enough time to care for patients properly. PCT WW stated," I do my best." PCT WW said her most significant concern right now was patient safety. She stated RNs and other PCTS expressed the same concerns.

During an interview with Registered Nurse (RN) AAA on 2/22/22 at 1:20 p.m. in the Conference Room, RN HH stated she had worked at the Facility for five years. She stated that the facility experienced nursing staff shortages before the COVID-19 pandemic. RN AAA said many RNs left the Facility before the COVID-19 pandemic, but the situation was worse now. RN AAA stated the ideal ratio for Med/Surg was four to five patients to one RN (4:1 or 5:1), but now the ratio had been six to seven patients to one RN (6:1 or 7:1). RN AAA said with such a load, the nurse was unable to create a connection with the patients. As a result, nurses were only able to provide basic care. When asked about her most significant concern, RN AAA replied that her main concern, for now, was patient safety. RN AAA said there was not enough time to do the hourly rounding by going to each patient's room to check if they were ok.

During an interview with Patient Care Tech (PCT) UU on 2/22/22 at 1:30 p.m. in the Conference Room, PCT BB stated she had worked at the Facility for six years. She continued to say that she worked on one of the Med/Surg Units. PCT UU said there was a nursing staff shortage. She stated she had received 12 patients on her caseload, which put the patients "at risk." PCT UU explained that this risk included the potential for patient falls. PCT UU said her biggest concern right now was safety; she stated patients received less attention, and the quality of care was negatively impacted. She stated the last month had been terrible. PCT UU said that the RNs had the same concerns regarding safety and quality. PCT BB said there were concerns that nursing staff and the PCTs could not answer the bed alarms promptly.

During an interview with Registered Nurse (RN) ZZ on 2/22/22 at 1:50 p.m. in the Conference Room, RN ZZ said she had been working at the Facility for two years and was currently working on the Med/Surg Unit. RN ZZ said some days were better than others, and they had to rely on travel nurses to keep the facility running. RN ZZ said she typically would have six patients, but today she had seven. RN ZZ said she could not communicate with the patients she provided care to because of the significant caseload. Therefore, she did not have the time to connect with her patients.

During an interview with Registered Nurse (RN) VV on 2/22/22 at 3:00 p.m. in the Conference Room, RN VV stated she had been working at the Facility since June as a travel nurse; she worked on the Med/Surg Unit. RN VV admitted the Facility was short in nursing staff. However, she said the nurse-to-patient ratio had gone up a couple of times.

During an interview with Registered Nurse (RN) YY on 2/22/22 at 3:30 p.m. in the Conference Room, RN YY stated she had worked at the Facility for two years. RN YY said the Facility was experiencing a staff nursing shortage. She said that they had fewer RNs on the Med/Surg floor where she was working, but she added it was no different here than it was anywhere else. RN YY said many nurses left the bedside, and many travelers left after their contracts ended. RN YY said they needed more nurses, but people preferred to travel than stay in one place. RN YY explained that the Facility offered incentive bonuses and was trying to recruit student nurses close to graduation. RN YY said her biggest concern right now was patient ' s safety. RN YY stated that the nurses had a larger caseload; therefore, they could not spend much time with patients. RN YY said she had seven patients on her caseload at the time of the interview.

During an interview with Registered Nurse (RN) CCC on 2/22/22 at 4:15 p.m. in the conference room, RN JJ stated she had worked at the Facility for six months in the Intensive Care Unit (ICU). RN CCC said the Facility experienced a shortage in nursing staff more days than being fully staffed. She said that it had been terrible for the past two months. RN CCC said the current patient-to-nurse ratio in the ICU was three patients to one RN (3:1). It was "truly unsafe "because some of the patients were on ventilators (a machine that helped a patient to breathe) or insulin drips (medication that was given intravenously to lower blood sugar). She explained that these patients required constant monitoring. RN CCC stated her biggest concern had been patient ' s safety. RN CCC said she had brought her concerns to the Chief Nursing Officer (CNO) and felt her complaint "was swept under the rug." RN CCC said the only time she remembered the ICU being staffed appropriately was during their recent accreditation survey (an on-site survey that evaluated standard compliance). RN CCC continued to say that nursing administrators staffed the ICU when they knew that the State or an accreditation agency would be visiting.

During an interview with Registered Nurse (RN) BBB on 2/22/22 at 4:40 p.m. in the Conference Room, RN II stated she had worked at the Facility for 15 months in the Progressive Care Unit (PCU). RN BBB said that RNs were short staffed and that every nurse was maxed (at full capacity). RN BBB said the PCTs were stressed and had sixteen patients on their caseload during a shift. RN BBB said they never had a Charge Nurse available; RN BBB said the so-call Charge Nurse had a caseload as heavy as the other RNs. She admitted that the lack of a Charge Nurse was problematic. For example, if she had an unstable patient that required her to be at the patient ' s bedside (i.e., a confused Covid-19 positive patient on a Bilevel Positive Airway Pressure (BiPAP) machine, a machine that helped a patient with breath), she would still be getting calls from doctors and administrators to discharge other patients. In this type of circumstance, a Charge Nurse should be available to assist if needed. RN BBB said nursing staff could barely provide adequate care because they were pulled in different directions. RN II said the patient-to-nurse ratio in both the PCU and the ICU was always higher than it should be for safe delivery of care. RN BBB said the mentality at the Facility was "you do the best you can." RN BBB said when she requested help in staffing, it was like talking to a" brick wall." RN BBB said she was certain other nurses in her department would say the exact same thing. They all had expressed the same concerns.

During an interview with Registered Nurse (RN) DDD on 2/22/22 at 5:27 p.m. in the Conference Room, RN DDD said she worked triage in the Emergency Department (ED). She said that there were days when three to four nurses were staffed for the entire shift. RN DDD continued to say that the ED had five RNs during a shift for the past couple of weeks. However, she added the ED could occasionally operate with six RNs. In addition, RN DDD said the nurses were constantly moving. RN DDD stated that due to the staff shortage, she could not perform checks on her patients as often as she would like. She continued to say that she could not complete patient rounds because of the lack of staff and the volume of patients arriving in the ED. RN DDD said this concerned her because she felt that patients had a right to be cared for appropriately, which she defined as having nurses available to answer patients' needs promptly.

A tour of the Facility was conducted on 2/22/22 at 11:00 a.m., with the Director of Quality that revealed the Emergency Department (ED) had two triage nurses on staff. The Intensive Care Unit (ICU) had 12 beds, four Registered Nurses (RN), and a patient census of 12. The Progressive Care Unit (PCU) had 16 beds and a patient census of 16.


A tour of the facility was conducted on 2/10/22 at 11:45 a.m. with the Director of Quality (LL). The tour started in the ED. It was observed that there was a triage area behind the receptionist with one RN working in both triage and the Fast Track Unit. There were 13 beds/recliners in the Fast Track unit filled with low acuity patients and two patients in the waiting room. The main area of the ED had 16 beds with four observation rooms, mainly used for behavioral health patients. There were 15 ED patients, three nurses, and one PCT. There were eight medical holds at the time of the tour.

A tour of the ICU revealed 12 beds occupied with patients. There were four nurses, with the manager working as a staff nurse. During the tour, Registered Nurse (RN) NN said with the current staffing ratio of three patients per nurse (3:1), there was an increased margin for error, patient falls, and the nursing staff could not do everything the patient needed. The nursing staff would fall behind on medication administration, intake/output monitoring, etc. RN NN said that when nurses were sent to the ICU/PCU from the Med-Surg Unit, the nurses would help on the PCU side, where experienced PCU nurses supervised the nurses.

A tour of the Progressive Care Unit (PCU) revealed 16 rooms occupied with patients. There were four nurses and no PCTs. The RN OO stated there were usually two PCTs, but the PCT that was supposed to work the day of the tour did not make it to work that day. RN OO stated that when the PCTs do not show up, the nurses must do vital signs and complete daily care. A tour of the Med-Surg Unit 2 revealed that there were 24 beds occupied with patients. There were four nurses, a charge nurse, and two PCTs. A tour of the Med-Surg Unit 3 revealed there were 21 beds with 19 patients, four nurses, and two PCTs.

A tour of the Facility was conducted on 2/22/22 at 11:00 a.m., with the Director of Quality that revealed the Emergency Department (ED) had two triage nurses on staff. The Intensive Care Unit (ICU) had 12 beds, four Registered Nurses (RN), and a patient census of 12. The Progressive Care Unit (PCU) had 16 beds and a patient census of 16.

A tour of the Medical-Surgical Unit, 3 Main, on 2/22/22 at 11:45 a.m., revealed the unit had 21 beds and a patient census of 21. In addition, there was a total of three RNs on the floor at the time of the tour.


The Obstetrics (OB) Unit tour revealed ten beds in the mother-baby unit with nine patients: five adults and four babies. There was a staffing ratio of 5:1.


A review of the staffing grids for 2 Main dated 12/24/2021 to 1/22/2022 revealed that clinical staff was combined for 2 Main and 3 Main due to renovation closure on 3 Main.

A review of the policy titled" Plan for Provision of Patient Care," last revised 10/6/2020, revealed the facility's intent for the staff of these services to interact collaboratively to provide a continuum of health care for their patients. The policy stated the leadership collaborated with the staff to evaluate the delivery of care to the patients and the community.
The plan was reviewed annually, revised as necessary, and considered at a minimum the following:
· Patient requirements and subsequent implications for staffing
· The facility's ability to recruit and retain appropriate staff
· Information from staffing variance reports
· Whether a comparable level of care was provided to all patients
· The responsiveness of services to meet the needs and expectations of patients and their families and/or significant others
The purpose of this plan was to provide a framework for planning, directing, coordinating, delivering, and improving healthcare services that would meet the needs of patients and the communities.
The goal of this plan was to provide a structure for efficient, effective, and appropriate patient care in which patients with the same health problems and care needs would receive a comparable level of care by equivalently trained personnel throughout the facility.
The Board of Trustees had the ultimate authority, which was delegated to the Chief Executive Officer, for all patient care activities within the facility.
The policy delineated that the staffing plans for patient care service departments were to be developed based on the level and scope of care that needed to be provided, the frequency of the care to be provided, and a determination of the level of staff that could most appropriately (competently, comfortably, and confidently) provide the type of care needed.
The policy further stated that each department had a formalized staffing plan based on the following:
· Utilization Review
· Employee Turnover
· Performance Assessment
· Improvement Activities
· Changes in Customer Needs and Expectations
Measurement tools were to be utilized to help assess the effectiveness of the staffing plans.
Additionally, the policy revealed that the Progressive Care Unit (PCU) staffing plans were developed based on the level and scope of care and the frequency of the care that needed to be provided.
Departmental staffing plans were reviewed periodically based upon, but were not limited to, the following:
· Projected volumes for the budget year and prior year volumes
· Projected case-mix for the budget year and previous year case mix
· Daily Volumes
· Number of nurses and level of nurses required in providing care
· Supervising nursing care and collaboration with other disciplines
· Number of other patient care providers required to provide technical and basic supportive care for patients
· Changes in customer needs and expectations
· Performance measurement and improvement activities
· Employee turnover and Facility standards
The nursing staff included Registered Nurses (RN) or Licensed Practical Nurses (LPN) and Patient Care Associates (PCA) with appropriate competencies related to critical care theory and practice or respective nursing experience.
The policy stated that it was required that all personnel in PCU complete the following:
· General Hospital Orientation
· Unit-Specific Orientation and Competencies
· Age-Specific Competencies
· Performed population-specific system assessments daily on each patient
· Mandatory Annual Training that included:
a. Fire Safety
b. Infection Control
c. Hazardous Materials
d. Disaster Planning
e. Other training required by the Facility and/or State
All RNs and LPNs had to show valid proof of current licensure by the State of Georgia upon hire and have Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) certification per position description.
The policy indicated that the nurse-to-patient staffing ratio was one nurse to four patients (1:4) in PCU unless otherwise determined by the department director.
The Medical-Surgical (Med/Surg) Units provided 24-hour patient care. The patient population was primarily adult clients of private physicians and hospitalists. In addition, surgical and pediatric patients were admitted to these units. Patients commonly managed on these units included cardiovascular diseases, respiratory illnesses, diabetes, and cancer. The severity of illness and intensity of service criteria described by Inter-Qual (an evidence-based clinical decision support system) was used as a guide for determining the appropriate setting for admission, transfer, and discharge of inpatients to and from these units. RNs, LPNs, and PCAs delivered care. In addition, unit secretaries assisted with the clerical functions of the nursing unit.
Basic requirements for RN staff were current state license, current BLS certification, completion of RN skill checklist, and Glucose Monitoring Certification.
Under the Philosophy of Nursing, the facility's nursing philosophy was based on the principles of the nursing profession and the mission/vision. The facility believed that each patient as an individual had a right to individualized nursing care regardless of age, race, color, creed, national origin, or economic status. The facility believed that nursing possessed a primary responsibility to provide comprehensive, individualized care to the patient through the implementation of standards of practice and collaborating with other members of the patient care team to assure patient care needs were met. Additionally, the facility believed that nursing care was an integral part of the total health care system and that nursing must seek cooperation with all hospital departments, physician offices, and community agencies.
The policy further delineated that the primary goal of Nursing was to provide the highest quality of individualized, comprehensive care in a safe environment meeting the patient's total therapeutic needs.
Objectives to assist in meeting this goal included:
· Creating an environment in which all nursing personnel had an opportunity to develop personal and professional potential
· Establishing and maintaining appropriate staffing patterns and performance standards
· Establishing and maintaining nursing standards of practice and standards of care
· Fostering improvement and innovation through staff participation in performance improvement activities
· Integrating nursing with medical and all other disciplines to develop and integrate plans of care
· Participating in professional activities and community programs
· Providing an effective patient/family education program
· Providing an organizational design by which nursing personnel may accomplish their duties to the best of their ability
· Providing educational opportunities for staff, including orientation, Inservice, and continuing education
· Recruiting and retaining competent personnel to meet established staffing patterns and job qualifications
Above all, the Nursing Department was committed to the care and improvement of human life, focusing on total patient and customer satisfaction.

The staffing grid for 2 Main dated 12/24/21 to 12/30/21 revealed the following:

12/24: Day- 8 RNs, 1 LPN, 6 PCTs with a census of 46 Night- 3 RNs, 5 LPNs, 6 PCTs with a census of 38

12/25: Day- 7 RNs, 1 LPN, 4 PCTs with a census of 37 Night- 6 RNs, 2 LPNs, 4 PCTs with a census of 34

12/26: Day- 7 RNs, 1 LPN, 5 PCTs with a census of 34 Night- 6 RNs, 1 LPN, 5 PCTs with a census of 40

12/27: Day- 9 RNs, 0 LPN, 5 PCTs with a census of 42 Night- 5 RNs, 2 LPNs, 6 PCTs with a census of 41

12/28: Day- 8 RNs, 1 LPN, 6 PCTs with a census of 46 Night- 5 RNs, 2 LPNs, 5 PCTs with a census of 42

12/29: Day- 8 RNs, 1 LPN, 5 PCTs with a census of 46 Night- 4 RNs, 3 LPNs, 5 PCTs with a census of 42

12/30: Day- 6 RNs, 2 LPNs, 6 PCTs with a census of 42 Night- 4 RNs, 4 LPNs, 6 PCTs with a census of 46

The staffing grid for 2 Main dated 1/9/22 to 1/15/22 revealed the following:

1/9: Day- 7 RNs, 2 LPNs, 4 PCTs with a census of 42 Night- 7 RNs, 0 LPNs, 6 PCTs with a census of 39

1/10: Day- 8 RNs, 0 LPNs, 5 PCTs with a census of 42 Night- 6 RNs, 1 LPN, 6 PCTs with a census of 36

1/11: Day- 8 RNs, 1 LPN, 6 PCTs with a census of 41 Night- 6 RNs, 2 LPNs, 6 PCTs with a census of 44

1/12: Day- 7 RNs, 2 LPNs, 5 PCTs with a census of 46 Night- 7 RNs, 1 LPNs, 4 PCTs with a census of 46

1/13: Day- 7 RNs, 1 LPN, 5 PCTs with a census of 46 Night- 7 RNs, 1 LPN, 5 PCTs with a census of 45

1/14: Day- 7 RNs, 2 LPNs, 6 PCTs with a census of 46 Night- 4 RNs, 3 LPNs, 4 PCTs with a census of 41

1/15: Day- 7 RNs, 1 LPN, 5 PCTs with a census of 42 Night- 4 RNs, 3 LPNs, 4 PCTs with a census of 42

The staffing grid for 2 Main dated 1/16/22 to 1/22/22 revealed the following:

1/16: Day- 6 RNs, 2 LPNs, 5 PCTs with a census of 42 Night- 7 RNs, 0 LPNs, 5 PCTs with a census of 42

1/17: Day- 5 RNs, 2 LPNs, 5 PCTs with a census of 42 Night- 6 RNs, 1 LPNs, 6 PCTs with a census of 42

1/18: Day- 6 RNs, 2 LPNs, 5 PCTs with a census of 42 Night- 6 RNs, 2 LPNs, 5 PCTs with a census of 45

1/19: Day- 9 RNs, 0 LPN, 5 PCTs with a census of 46 Night- 4 RNs, 4 LPNs, 4 PCTs with a census of 41

1/20: Day- 6 RNs, 1 LPNs, 5 PCTs with a census of 46 Night- 3 RNs, 4 LPNs, 7 PCTs with a census of 40

1/21: Day- 6 RNs, 3 LPNs, 4 PCTs with a census of 38 Night- 3 RNs, 4 LPNs, 5 PCTs with a census of 30

1/22: Day- 7 RNs, 1 LPNs, 6 PCTs with a census of 34 Night- 5 RNs, 1 LPNs, 5 PCTs with a census of 35

A review of the staffing grid for 2 Main dated 2/1/22 to 2/7/22 revealed the following:

2/1: Day- 4 RNs, 1 LPNs, 2 PCTs with a census of 24 Night- 3 RNs, 1 LPNs, 3 PCTs with a census of 24

2/2: Day- 5 RNs, 0 LPNs, 3 PCTs with a census of 24 Night- 2 RNs, 2 LPNs, 2 PCTs with a census of 24

2/3: Day- 5 RNs, 0 LPNs, 2 PCTs with a census of 24 Night- 2 RNs, 3 LPNs, 2 PCTs with a census of 24

2/4: Day- 5 RNs, 0 LPNs, 2 PCTs with a census of 24 Night- 4 RNs, 0 LPNs, 3 PCTs with a census of 21

2/5: Day- 5 RNs, 0 LPNs, 2 PCTs with a census of 24 Night- 4 RNs, 0 LPNs, 3 PCTs with a census of 24

2/6: Day- 4 RNs, 1 LPNs, 2 PCTs with a census of 24 Night- 2 RNs, 2 LPNs, 3 PCTs with a census of 24

2/7: Day- 5 RNs, 0 LPNs, 3 PCTs with a census of 24 Night- 2 RNs, 3 LPNs, 3 PCTs with a census of 24

A review of the staffing grid for 3 Main dated 2/1/22 to 2/7/22 revealed the following:

2/1: Day- 4 RNs, 0 LPNs, 2 PCTs with a census of 18 Night- 2 RNs, 1 LPNs, 3 PCTs with a census of 18

2/2: Day- 3 RNs, 1 LPNs, 2 PCTs with a census of 21 Night- 1 RNs, 2 LPNs, 2 PCTs with a census of 22

2/3: Day- 3 RNs, 1 LPN, 2 PCTs with a census of 21 Night- 3 RNs, 1 LPNs, 1 PCTs with a census of 21

2/4: Day- 2 RNs, 2 LPNs, 2 PCTs with a census of 21 Night- 2 RNs, 1 LPN, 3 PCTs with a census of 19

2/5: Day- 3 RNs, 1 LPN, 2 PCTs with a census of 19 Night- 2 RNs, 1 LPN, 2 PCTs with a census of 20

2/6: Day- 2 RNs, 2 LPNs, 2 PCTs with a census of 20 Night- 4 RNs, 0 LPNs, 2 PCTs with a census of 20

2/7: Day- 3 RNs, 1 LPNs, 2 PCTs with a census of 20 Night- 2 RNs, 2 LPNs, 2 PCTs with a census of 20

A review of the staffing grid for the ICU dated 12/24/21 to 12/30/21 revealed the following:

12/24- Day- 5 RNs, 0 PCTs with a census of 8 Night- 4 RNs, 1 PCT with a census of 10

12/25- Day- 6 RNs, 1 PCT with a census of 11 Night- 6 RNs, 1 PCT with a census of 9

12/26- Day- 6 RNs, 0 PCTs with a census of 10 Night- 5 RNs, 0 PCTs with a census of 11

12/27- Day- 5 RNs, 1 PCT with a census of 11 Night- 4 RNs, 0 PCT with a census of 12

12/28- Day- 6 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 12

12/29- Day- 6 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 11

12/30- Day- 5 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 10

A review of the staffing grid for the ICU dated 1/9/22 to 1/15/22 revealed the following:

1/9- Day- 5 RNs, 1 PCT with a census of 9 Night- 4 RNs, 1 PCT with a census of 11

1/10- Day- 4 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 9

1/11- Day- 6 RNs, 1 PCT with a census of 11 Night- 5 RNs, 1 PCT with a census of 9

1/12- Day- 6 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 10

1/13- Day- 5 RNs, 1 PCT with a census of 12 Night- 4 RNs, 1 PCT with a census of 11

1/14- Day- 3 RNs, 1 PCT with a census of 10 Night- 4 RNs, 1 PCT with a census of 10

1/15- Day- 4 RNs, 1 PCT with a census of 9 Night- 3 RNs, 0 PCTs with a census of 8

A review of the staffing grid for the ICU dated 1/16/22 to 1/22/22 revealed the following:

1/16- Day- 4 RNs, 0 PCTs with a census of 8 Night- 4 RNs, 0 PCTs with a census of 11

1/17- Day- 5 RNs, 1 PCT with a census of 12 Night- 4 RNs, 1 PCT with a census of 12

1/18- Day- 5 RNs, 1 PCT with a census of 12 Night- 4 RNs, 0 PCTs with a census of 10

1/19- Day- 5 RNs, 1 PCT with a census of 11 Night- 4 RNs, 1 PCT with a census of 12

1/20- Day- 5 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 11

1/21- Day- 5 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 12

1/22- Day- 5 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 11

A review of the staffing grid for ICU East dated 2/1/22 to 2/7/22 revealed the following:

2/1- Day- 5 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 11

2/2- Day- 5 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 12

2/3- Day- 4 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 12

2/4- Day- 4 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 10

2/5- Day- 4 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 12

2/6- Day- 4 RNs, 0 PCTs with a census of 12 Night- 5 RNs, 0 PCTs with a census of 12

2/7- Day- 4 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 10

A review of the

Based on interviews with staff, observations made at the facility, and a review of staffing grids, it was determined that the facility failed to ensure an adequate number of nursing staff to provide nursing care to all patients as needed.


Cross-reference A0392 Staffing and Delivery of Care as it relates to the facility failing to provide adequate nursing staff
to care for patients.

Based on interviews with staff, observations made at the facility, and a review of staffing grids, it was determined that the facility failed to ensure an adequate number of nursing staff to provide nursing care to all patients as needed.

During an interview with the House Supervisor Registered Nurse (RN) EE on 2/9/22 at 11:15 a.m. in the Conference Room, RN EE stated the facility had its challenges. The Emergency Department (ED) had been the shortest staffed area, followed by the Intensive Care Unit (ICU) and the Progressive Care Unit (PCU). The facility was fine during the COVID wave that subsided 12/21, but after the COVID wave subsided and the rate of the contracted service was lowered, the contractors would not renew, and staffing got worse. RN EE stated about three weeks after the contracts were lowered, the current COVID surge began (1/22). The ICU, PCU, and ED frequently did not have charge nurses (the head nurse that heads the day-to-day flow of the unit) because there was not enough staff. RN EE said the ED did not have enough staff for the census, and it was hard to give the best care with the staff-to-patient ratio. RN EE said that the ED usually had five nurses on the day shift, and at night, the ED had 3-4 nurses. One nurse would come between the two shifts. RN EE revealed that the ED did not just have ED patients, but the ED also had medical holds (patients waiting to be admitted).

During an interview with the Director of Emergency Services Registered Nurse (RN) AA, on 2/9/22 at 1:08 p.m. in the Conference Room, RN AA stated the staffing grids called for four nurses each shift with one nurse in the middle shifts to bump up the nursing staff based on census. The ED census did not factor in holds. Once the holds were factored in, staffing needs increased. RN AA said there were days with eight medical holds in the ED, and the number of holds had gotten up to 18. RN AA further said the facility was still in a COVID surge, half as much as August 21, and the facility had not seen a decrease in inpatient numbers for the past two weeks, mostly COVID-related.

During an interview with Registered Nurse (RN) DD on 2/9/22 at 1:41 p.m., RN DD stated that there were days that staffing in the ED was not adequate and dropped to three ED nurses if a nurse called out of work. On the day of the interview, 2/9/22, the ED director was out of the department, and the ED manager was attempting to run the Fast Track (lower acuity) area. There were four ED rooms, a trauma room in the psychiatric corner of the ED, two cardiac rooms, and an additional trauma room, which would be eight rooms that RN DD was responsible for by herself. The recommended ratio was five patients (rooms) per nurse in the ED. RN DD said the other nurses in the ED were at a ratio of five patients to one nurse (5:1). RN DD said there was usually not enough staff for a triage nurse and an additional nurse to run the Fast Track area. There were roughly 12 beds in the Fast Track area, in addition to bed holds. One nurse would oversee both triage and the Fast Track area.

During an interview with the Medical-Surgical (Med-Surg) Unit Director Registered Nurse (RN) HH on 2/9/22 at 2:03 p.m., RN HH stated that staffing had been tight at times, and the 3-Main Med-Surg unit had recently re-opened after renovations, which made things a little tighter. Part of the 2-Main Unit was currently closed for renovation. RN HH said the nursing ratio for the Med-Surg Units was six patients to one nurse (6:1) and a free charge nurse each shift. RN HH said there had been times the ratio was 7:1 with one Patient Care Technician (PCT); two managers had stepped into staffing. RN HH said the staffing grid was a baseline, and the nurses would meet at 2:00 p.m. daily to talk about staffing for the night shift and the next day to determine how the facility would be staffed with the resources available. The whole house (facility) would be discussed and collaborated to send nurses to other departments. There were times when there were no nurses available to send to other departments. RN HH said one to two times per week; a nurse from Med-Surg would be available to assist with holds in the ED.

During an interview with the Intensive Care Unit (ICU)/Progressive Care Unit (PCU) Program Director Registered Nurse (RN) II on 2/9/22 at 2:25 p.m. in the Conference Room, RN II stated there was day to day struggles with call outs. For example, a strong medical-surgical nurse would be pulled to the ICU/PCU from a different unit. The nursing staff would band together, and the house supervisor would find staff willing to work extra hours. RN II said the ICU ratio was normally two patients per nurse (2:1), but there had been a 3:1 ratio in recent months. RN II said there were 12 beds in the ICU. On the day of the survey, 2/9/22, the acuity in the ICU was not severely high. One patient was on a ventilator, and additional patients were waiting to be transferred to the PCU. RN II said the nurse manager and program director would become part of the staffing, at times, to meet the staffing ratio. RN II said there were vacancies in the ICU/PCU, and the facility was in the process of interviewing.

During a telephone interview with the Intensive Care Unit (ICU) Clinical Nurse Coordinator (Charge Nurse) (CNC) Registered Nurse (RN) GG, on 2/9/2022 at 2:36 p.m., RN GG stated that normal staffing in the ICU should be one nurse per patient or one nurse per two patients. RN GG said that ICU had had three patients per nurse for the past six months or longer, and the PCU has had four patients per nurse. RN GG said the nurses could not continue at the current ratios. Initially, the nurses would work together and make it happen, but the nurses were exhausted and burnt out. The PCTs had started to quit to look for places where the workloads were not so high. RN GG said the nurses felt they were not providing the best care because there were not enough resources or time. RN GG said the charge nurses would have to be in the staffing ratio (seeing patients) on many occasions to make up the team of four nurses in the ICU. RN GG stated rounds to check on patient experiences were conducted on the weekends when the charge nurse was out of the staffing ratio. The patients would complain about nursing services taking too long, and the nursing staff would have to explain the situation without saying there was short staffing. RN GG said priorities had to be set with the most critical needs first. Patient's needs were not being met. RN GG said there was always a "fire to put out" on ICU or another unit, and RN GG assisted other units when needed.

During an interview with the Chief Nursing Officer (CNO) on 2/10/22 at 10:28 a.m. in the Conference Room, CNO said that there was no written policy for staffing ratio because staffing was a fluid situation that could change day to day. The CNO said staffing was a challenge everywhere, not just the facility. The facility would try to meet the nurse-to-patient ratios by having the managers and charge nurses participate in the staffing load when possible.


During an interview with Registered Nurse (RN) TT on 2/22/22 at 11:55 a.m. in the Conference Room, RN TT stated she was a travel nurse and worked in the Emergency Department (ED). She said that she had worked at the Facility for ten weeks. RN TT said the Facility was not adequately staffed, especially in the Fast-Track area. RN TT said there were medics in the ED, but they were not allowed to administer some medications and had limited capacity in their use. RN TT said she saw 30-40 patients a day on average. RN TT stated the Facility had lost some contract nurses lately because their contracts expired and left.

During an interview with Patient Care Tech (PCT) WW on 2/22/22 at 12:44 p.m. in the Conference Room, PCT WW said she had worked at the Facility for five years. PCT WW admitted that the Facility had been short-staffed, including RNs and PCTs, since the COVID-19 pandemic. PCT DD said she generally would receive seven to eight patients in her caseload but instead had received 12 to 13 patients. She stated this was true for other PCTS as well. PCT WW said such a large caseload impacted the quality of work she could provide and that she did not have enough time to care for patients properly. PCT WW stated," I do my best." PCT WW said her most significant concern right now was patient safety. She stated RNs and other PCTS expressed the same concerns.

During an interview with Registered Nurse (RN) AAA on 2/22/22 at 1:20 p.m. in the Conference Room, RN HH stated she had worked at the Facility for five years. She stated that the facility experienced nursing staff shortages before the COVID-19 pandemic. RN AAA said many RNs left the Facility before the COVID-19 pandemic, but the situation was worse now. RN AAA stated the ideal ratio for Med/Surg was four to five patients to one RN (4:1 or 5:1), but now the ratio had been six to seven patients to one RN (6:1 or 7:1). RN AAA said with such a load, the nurse was unable to create a connection with the patients. As a result, nurses were only able to provide basic care. When asked about her most significant concern, RN AAA replied that her main concern, for now, was patient safety. RN AAA said there was not enough time to do the hourly rounding by going to each patient's room to check if they were ok.

During an interview with Patient Care Tech (PCT) UU on 2/22/22 at 1:30 p.m. in the Conference Room, PCT BB stated she had worked at the Facility for six years. She continued to say that she worked on one of the Med/Surg Units. PCT UU said there was a nursing staff shortage. She stated she had received 12 patients on her caseload, which put the patients "at risk." PCT UU explained that this risk included the potential for patient falls. PCT UU said her biggest concern right now was safety; she stated patients received less attention, and the quality of care was negatively impacted. She stated the last month had been terrible. PCT UU said that the RNs had the same concerns regarding safety and quality. PCT BB said there were concerns that nursing staff and the PCTs could not answer the bed alarms promptly.

During an interview with Registered Nurse (RN) ZZ on 2/22/22 at 1:50 p.m. in the Conference Room, RN ZZ said she had been working at the Facility for two years and was currently working on the Med/Surg Unit. RN ZZ said some days were better than others, and they had to rely on travel nurses to keep the facility running. RN ZZ said she typically would have six patients, but today she had seven. RN ZZ said she could not communicate with the patients she provided care to because of the significant caseload. Therefore, she did not have the time to connect with her patients.

During an interview with Registered Nurse (RN) VV on 2/22/22 at 3:00 p.m. in the Conference Room, RN VV stated she had been working at the Facility since June as a travel nurse; she worked on the Med/Surg Unit. RN VV admitted the Facility was short in nursing staff. However, she said the nurse-to-patient ratio had gone up a couple of times.

During an interview with Registered Nurse (RN) YY on 2/22/22 at 3:30 p.m. in the Conference Room, RN YY stated she had worked at the Facility for two years. RN YY said the Facility was experiencing a staff nursing shortage. She said that they had fewer RNs on the Med/Surg floor where she was working, but she added it was no different here than it was anywhere else. RN YY said many nurses left the bedside, and many travelers left after their contracts ended. RN YY said they needed more nurses, but people preferred to travel than stay in one place. RN YY explained that the Facility offered incentive bonuses and was trying to recruit student nurses close to graduation. RN YY said her biggest concern right now was patient ' s safety. RN YY stated that the nurses had a larger caseload; therefore, they could not spend much time with patients. RN YY said she had seven patients on her caseload at the time of the interview.

During an interview with Registered Nurse (RN) CCC on 2/22/22 at 4:15 p.m. in the conference room, RN JJ stated she had worked at the Facility for six months in the Intensive Care Unit (ICU). RN CCC said the Facility experienced a shortage in nursing staff more days than being fully staffed. She said that it had been terrible for the past two months. RN CCC said the current patient-to-nurse ratio in the ICU was three patients to one RN (3:1). It was "truly unsafe "because some of the patients were on ventilators (a machine that helped a patient to breathe) or insulin drips (medication that was given intravenously to lower blood sugar). She explained that these patients required constant monitoring. RN CCC stated her biggest concern had been patient ' s safety. RN CCC said she had brought her concerns to the Chief Nursing Officer (CNO) and felt her complaint "was swept under the rug." RN CCC said the only time she remembered the ICU being staffed appropriately was during their recent accreditation survey (an on-site survey that evaluated standard compliance). RN CCC continued to say that nursing administrators staffed the ICU when they knew that the State or an accreditation agency would be visiting.

During an interview with Registered Nurse (RN) BBB on 2/22/22 at 4:40 p.m. in the Conference Room, RN II stated she had worked at the Facility for 15 months in the Progressive Care Unit (PCU). RN BBB said that RNs were short staffed and that every nurse was maxed (at full capacity). RN BBB said the PCTs were stressed and had sixteen patients on their caseload during a shift. RN BBB said they never had a Charge Nurse available; RN BBB said the so-call Charge Nurse had a caseload as heavy as the other RNs. She admitted that the lack of a Charge Nurse was problematic. For example, if she had an unstable patient that required her to be at the patient ' s bedside (i.e., a confused Covid-19 positive patient on a Bilevel Positive Airway Pressure (BiPAP) machine, a machine that helped a patient with breath), she would still be getting calls from doctors and administrators to discharge other patients. In this type of circumstance, a Charge Nurse should be available to assist if needed. RN BBB said nursing staff could barely provide adequate care because they were pulled in different directions. RN II said the patient-to-nurse ratio in both the PCU and the ICU was always higher than it should be for safe delivery of care. RN BBB said the mentality at the Facility was "you do the best you can." RN BBB said when she requested help in staffing, it was like talking to a" brick wall." RN BBB said she was certain other nurses in her department would say the exact same thing. They all had expressed the same concerns.

During an interview with Registered Nurse (RN) DDD on 2/22/22 at 5:27 p.m. in the Conference Room, RN DDD said she worked triage in the Emergency Department (ED). She said that there were days when three to four nurses were staffed for the entire shift. RN DDD continued to say that the ED had five RNs during a shift for the past couple of weeks. However, she added the ED could occasionally operate with six RNs. In addition, RN DDD said the nurses were constantly moving. RN DDD stated that due to the staff shortage, she could not perform checks on her patients as often as she would like. She continued to say that she could not complete patient rounds because of the lack of staff and the volume of patients arriving in the ED. RN DDD said this concerned her because she felt that patients had a right to be cared for appropriately, which she defined as having nurses available to answer patients' needs promptly.

A tour of the Facility was conducted on 2/22/22 at 11:00 a.m., with the Director of Quality that revealed the Emergency Department (ED) had two triage nurses on staff. The Intensive Care Unit (ICU) had 12 beds, four Registered Nurses (RN), and a patient census of 12. The Progressive Care Unit (PCU) had 16 beds and a patient census of 16.


A tour of the facility was conducted on 2/10/22 at 11:45 a.m. with the Director of Quality (LL). The tour started in the ED. It was observed that there was a triage area behind the receptionist with one RN working in both triage and the Fast Track Unit. There were 13 beds/recliners in the Fast Track unit filled with low acuity patients and two patients in the waiting room. The main area of the ED had 16 beds with four observation rooms, mainly used for behavioral health patients. There were 15 ED patients, three nurses, and one PCT. There were eight medical holds at the time of the tour.

A tour of the ICU revealed 12 beds occupied with patients. There were four nurses, with the manager working as a staff nurse. During the tour, Registered Nurse (RN) NN said with the current staffing ratio of three patients per nurse (3:1), there was an increased margin for error, patient falls, and the nursing staff could not do everything the patient needed. The nursing staff would fall behind on medication administration, intake/output monitoring, etc. RN NN said that when nurses were sent to the ICU/PCU from the Med-Surg Unit, the nurses would help on the PCU side, where experienced PCU nurses supervised the nurses.

A tour of the Progressive Care Unit (PCU) revealed 16 rooms occupied with patients. There were four nurses and no PCTs. The RN OO stated there were usually two PCTs, but the PCT that was supposed to work the day of the tour did not make it to work that day. RN OO stated that when the PCTs do not show up, the nurses must do vital signs and complete daily care. A tour of the Med-Surg Unit 2 revealed that there were 24 beds occupied with patients. There were four nurses, a charge nurse, and two PCTs. A tour of the Med-Surg Unit 3 revealed there were 21 beds with 19 patients, four nurses, and two PCTs.

A tour of the Facility was conducted on 2/22/22 at 11:00 a.m., with the Director of Quality that revealed the Emergency Department (ED) had two triage nurses on staff. The Intensive Care Unit (ICU) had 12 beds, four Registered Nurses (RN), and a patient census of 12. The Progressive Care Unit (PCU) had 16 beds and a patient census of 16.

A tour of the Medical-Surgical Unit, 3 Main, on 2/22/22 at 11:45 a.m., revealed the unit had 21 beds and a patient census of 21. In addition, there was a total of three RNs on the floor at the time of the tour.


The Obstetrics (OB) Unit tour revealed ten beds in the mother-baby unit with nine patients: five adults and four babies. There was a staffing ratio of 5:1.


A review of the staffing grids for 2 Main dated 12/24/2021 to 1/22/2022 revealed that clinical staff was combined for 2 Main and 3 Main due to renovation closure on 3 Main.

A review of the policy titled" Plan for Provision of Patient Care," last revised 10/6/2020, revealed the facility's intent for the staff of these services to interact collaboratively to provide a continuum of health care for their patients. The policy stated the leadership collaborated with the staff to evaluate the delivery of care to the patients and the community.
The plan was reviewed annually, revised as necessary, and considered at a minimum the following:
· Patient requirements and subsequent implications for staffing
· The facility's ability to recruit and retain appropriate staff
· Information from staffing variance reports
· Whether a comparable level of care was provided to all patients
· The responsiveness of services to meet the needs and expectations of patients and their families and/or significant others
The purpose of this plan was to provide a framework for planning, directing, coordinating, delivering, and improving healthcare services that would meet the needs of patients and the communities.
The goal of this plan was to provide a structure for efficient, effective, and appropriate patient care in which patients with the same health problems and care needs would receive a comparable level of care by equivalently trained personnel throughout the facility.
The Board of Trustees had the ultimate authority, which was delegated to the Chief Executive Officer, for all patient care activities within the facility.
The policy delineated that the staffing plans for patient care service departments were to be developed based on the level and scope of care that needed to be provided, the frequency of the care to be provided, and a determination of the level of staff that could most appropriately (competently, comfortably, and confidently) provide the type of care needed.
The policy further stated that each department had a formalized staffing plan based on the following:
· Utilization Review
· Employee Turnover
· Performance Assessment
· Improvement Activities
· Changes in Customer Needs and Expectations
Measurement tools were to be utilized to help assess the effectiveness of the staffing plans.
Additionally, the policy revealed that the Progressive Care Unit (PCU) staffing plans were developed based on the level and scope of care and the frequency of the care that needed to be provided.
Departmental staffing plans were reviewed periodically based upon, but were not limited to, the following:
· Projected volumes for the budget year and prior year volumes
· Projected case-mix for the budget year and previous year case mix
· Daily Volumes
· Number of nurses and level of nurses required in providing care
· Supervising nursing care and collaboration with other disciplines
· Number of other patient care providers required to provide technical and basic supportive care for patients
· Changes in customer needs and expectations
· Performance measurement and improvement activities
· Employee turnover and Facility standards
The nursing staff included Registered Nurses (RN) or Licensed Practical Nurses (LPN) and Patient Care Associates (PCA) with appropriate competencies related to critical care theory and practice or respective nursing experience.
The policy stated that it was required that all personnel in PCU complete the following:
· General Hospital Orientation
· Unit-Specific Orientation and Competencies
· Age-Specific Competencies
· Performed population-specific system assessments daily on each patient
· Mandatory Annual Training that included:
a. Fire Safety
b. Infection Control
c. Hazardous Materials
d. Disaster Planning
e. Other training required by the Facility and/or State
All RNs and LPNs had to show valid proof of current licensure by the State of Georgia upon hire and have Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) certification per position description.
The policy indicated that the nurse-to-patient staffing ratio was one nurse to four patients (1:4) in PCU unless otherwise determined by the department director.
The Medical-Surgical (Med/Surg) Units provided 24-hour patient care. The patient population was primarily adult clients of private physicians and hospitalists. In addition, surgical and pediatric patients were admitted to these units. Patients commonly managed on these units included cardiovascular diseases, respiratory illnesses, diabetes, and cancer. The severity of illness and intensity of service criteria described by Inter-Qual (an evidence-based clinical decision support system) was used as a guide for determining the appropriate setting for admission, transfer, and discharge of inpatients to and from these units. RNs, LPNs, and PCAs delivered care. In addition, unit secretaries assisted with the clerical functions of the nursing unit.
Basic requirements for RN staff were current state license, current BLS certification, completion of RN skill checklist, and Glucose Monitoring Certification.
Under the Philosophy of Nursing, the facility's nursing philosophy was based on the principles of the nursing profession and the mission/vision. The facility believed that each patient as an individual had a right to individualized nursing care regardless of age, race, color, creed, national origin, or economic status. The facility believed that nursing possessed a primary responsibility to provide comprehensive, individualized care to the patient through the implementation of standards of practice and collaborating with other members of the patient care team to assure patient care needs were met. Additionally, the facility believed that nursing care was an integral part of the total health care system and that nursing must seek cooperation with all hospital departments, physician offices, and community agencies.
The policy further delineated that the primary goal of Nursing was to provide the highest quality of individualized, comprehensive care in a safe environment meeting the patient's total therapeutic needs.
Objectives to assist in meeting this goal included:
· Creating an environment in which all nursing personnel had an opportunity to develop personal and professional potential
· Establishing and maintaining appropriate staffing patterns and performance standards
· Establishing and maintaining nursing standards of practice and standards of care
· Fostering improvement and innovation through staff participation in performance improvement activities
· Integrating nursing with medical and all other disciplines to develop and integrate plans of care
· Participating in professional activities and community programs
· Providing an effective patient/family education program
· Providing an organizational design by which nursing personnel may accomplish their duties to the best of their ability
· Providing educational opportunities for staff, including orientation, Inservice, and continuing education
· Recruiting and retaining competent personnel to meet established staffing patterns and job qualifications
Above all, the Nursing Department was committed to the care and improvement of human life, focusing on total patient and customer satisfaction.

The staffing grid for 2 Main dated 12/24/21 to 12/30/21 revealed the following:

12/24: Day- 8 RNs, 1 LPN, 6 PCTs with a census of 46 Night- 3 RNs, 5 LPNs, 6 PCTs with a census of 38

12/25: Day- 7 RNs, 1 LPN, 4 PCTs with a census of 37 Night- 6 RNs, 2 LPNs, 4 PCTs with a census of 34

12/26: Day- 7 RNs, 1 LPN, 5 PCTs with a census of 34 Night- 6 RNs, 1 LPN, 5 PCTs with a census of 40

12/27: Day- 9 RNs, 0 LPN, 5 PCTs with a census of 42 Night- 5 RNs, 2 LPNs, 6 PCTs with a census of 41

12/28: Day- 8 RNs, 1 LPN, 6 PCTs with a census of 46 Night- 5 RNs, 2 LPNs, 5 PCTs with a census of 42

12/29: Day- 8 RNs, 1 LPN, 5 PCTs with a census of 46 Night- 4 RNs, 3 LPNs, 5 PCTs with a census of 42

12/30: Day- 6 RNs, 2 LPNs, 6 PCTs with a census of 42 Night- 4 RNs, 4 LPNs, 6 PCTs with a census of 46

The staffing grid for 2 Main dated 1/9/22 to 1/15/22 revealed the following:

1/9: Day- 7 RNs, 2 LPNs, 4 PCTs with a census of 42 Night- 7 RNs, 0 LPNs, 6 PCTs with a census of 39

1/10: Day- 8 RNs, 0 LPNs, 5 PCTs with a census of 42 Night- 6 RNs, 1 LPN, 6 PCTs with a census of 36

1/11: Day- 8 RNs, 1 LPN, 6 PCTs with a census of 41 Night- 6 RNs, 2 LPNs, 6 PCTs with a census of 44

1/12: Day- 7 RNs, 2 LPNs, 5 PCTs with a census of 46 Night- 7 RNs, 1 LPNs, 4 PCTs with a census of 46

1/13: Day- 7 RNs, 1 LPN, 5 PCTs with a census of 46 Night- 7 RNs, 1 LPN, 5 PCTs with a census of 45

1/14: Day- 7 RNs, 2 LPNs, 6 PCTs with a census of 46 Night- 4 RNs, 3 LPNs, 4 PCTs with a census of 41

1/15: Day- 7 RNs, 1 LPN, 5 PCTs with a census of 42 Night- 4 RNs, 3 LPNs, 4 PCTs with a census of 42

The staffing grid for 2 Main dated 1/16/22 to 1/22/22 revealed the following:

1/16: Day- 6 RNs, 2 LPNs, 5 PCTs with a census of 42 Night- 7 RNs, 0 LPNs, 5 PCTs with a census of 42

1/17: Day- 5 RNs, 2 LPNs, 5 PCTs with a census of 42 Night- 6 RNs, 1 LPNs, 6 PCTs with a census of 42

1/18: Day- 6 RNs, 2 LPNs, 5 PCTs with a census of 42 Night- 6 RNs, 2 LPNs, 5 PCTs with a census of 45

1/19: Day- 9 RNs, 0 LPN, 5 PCTs with a census of 46 Night- 4 RNs, 4 LPNs, 4 PCTs with a census of 41

1/20: Day- 6 RNs, 1 LPNs, 5 PCTs with a census of 46 Night- 3 RNs, 4 LPNs, 7 PCTs with a census of 40

1/21: Day- 6 RNs, 3 LPNs, 4 PCTs with a census of 38 Night- 3 RNs, 4 LPNs, 5 PCTs with a census of 30

1/22: Day- 7 RNs, 1 LPNs, 6 PCTs with a census of 34 Night- 5 RNs, 1 LPNs, 5 PCTs with a census of 35

A review of the staffing grid for 2 Main dated 2/1/22 to 2/7/22 revealed the following:

2/1: Day- 4 RNs, 1 LPNs, 2 PCTs with a census of 24 Night- 3 RNs, 1 LPNs, 3 PCTs with a census of 24

2/2: Day- 5 RNs, 0 LPNs, 3 PCTs with a census of 24 Night- 2 RNs, 2 LPNs, 2 PCTs with a census of 24

2/3: Day- 5 RNs, 0 LPNs, 2 PCTs with a census of 24 Night- 2 RNs, 3 LPNs, 2 PCTs with a census of 24

2/4: Day- 5 RNs, 0 LPNs, 2 PCTs with a census of 24 Night- 4 RNs, 0 LPNs, 3 PCTs with a census of 21

2/5: Day- 5 RNs, 0 LPNs, 2 PCTs with a census of 24 Night- 4 RNs, 0 LPNs, 3 PCTs with a census of 24

2/6: Day- 4 RNs, 1 LPNs, 2 PCTs with a census of 24 Night- 2 RNs, 2 LPNs, 3 PCTs with a census of 24

2/7: Day- 5 RNs, 0 LPNs, 3 PCTs with a census of 24 Night- 2 RNs, 3 LPNs, 3 PCTs with a census of 24

A review of the staffing grid for 3 Main dated 2/1/22 to 2/7/22 revealed the following:

2/1: Day- 4 RNs, 0 LPNs, 2 PCTs with a census of 18 Night- 2 RNs, 1 LPNs, 3 PCTs with a census of 18

2/2: Day- 3 RNs, 1 LPNs, 2 PCTs with a census of 21 Night- 1 RNs, 2 LPNs, 2 PCTs with a census of 22

2/3: Day- 3 RNs, 1 LPN, 2 PCTs with a census of 21 Night- 3 RNs, 1 LPNs, 1 PCTs with a census of 21

2/4: Day- 2 RNs, 2 LPNs, 2 PCTs with a census of 21 Night- 2 RNs, 1 LPN, 3 PCTs with a census of 19

2/5: Day- 3 RNs, 1 LPN, 2 PCTs with a census of 19 Night- 2 RNs, 1 LPN, 2 PCTs with a census of 20

2/6: Day- 2 RNs, 2 LPNs, 2 PCTs with a census of 20 Night- 4 RNs, 0 LPNs, 2 PCTs with a census of 20

2/7: Day- 3 RNs, 1 LPNs, 2 PCTs with a census of 20 Night- 2 RNs, 2 LPNs, 2 PCTs with a census of 20

A review of the staffing grid for the ICU dated 12/24/21 to 12/30/21 revealed the following:

12/24- Day- 5 RNs, 0 PCTs with a census of 8 Night- 4 RNs, 1 PCT with a census of 10

12/25- Day- 6 RNs, 1 PCT with a census of 11 Night- 6 RNs, 1 PCT with a census of 9

12/26- Day- 6 RNs, 0 PCTs with a census of 10 Night- 5 RNs, 0 PCTs with a census of 11

12/27- Day- 5 RNs, 1 PCT with a census of 11 Night- 4 RNs, 0 PCT with a census of 12

12/28- Day- 6 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 12

12/29- Day- 6 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 11

12/30- Day- 5 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 10

A review of the staffing grid for the ICU dated 1/9/22 to 1/15/22 revealed the following:

1/9- Day- 5 RNs, 1 PCT with a census of 9 Night- 4 RNs, 1 PCT with a census of 11

1/10- Day- 4 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 9

1/11- Day- 6 RNs, 1 PCT with a census of 11 Night- 5 RNs, 1 PCT with a census of 9

1/12- Day- 6 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 10

1/13- Day- 5 RNs, 1 PCT with a census of 12 Night- 4 RNs, 1 PCT with a census of 11

1/14- Day- 3 RNs, 1 PCT with a census of 10 Night- 4 RNs, 1 PCT with a census of 10

1/15- Day- 4 RNs, 1 PCT with a census of 9 Night- 3 RNs, 0 PCTs with a census of 8

A review of the staffing grid for the ICU dated 1/16/22 to 1/22/22 revealed the following:

1/16- Day- 4 RNs, 0 PCTs with a census of 8 Night- 4 RNs, 0 PCTs with a census of 11

1/17- Day- 5 RNs, 1 PCT with a census of 12 Night- 4 RNs, 1 PCT with a census of 12

1/18- Day- 5 RNs, 1 PCT with a census of 12 Night- 4 RNs, 0 PCTs with a census of 10

1/19- Day- 5 RNs, 1 PCT with a census of 11 Night- 4 RNs, 1 PCT with a census of 12

1/20- Day- 5 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 11

1/21- Day- 5 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 12

1/22- Day- 5 RNs, 1 PCT with a census of 12 Night- 5 RNs, 0 PCTs with a census of 11

A review of the staffing grid for ICU East dated 2/1/22 to 2/7/22 revealed the following:

2/1- Day- 5 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 11

2/2- Day- 5 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 12

2/3- Day- 4 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 12

2/4- Day- 4 RNs, 0 PCTs with a census of 12 Night- 4 RNs, 0 PCTs with a census of 10

2/5- Day- 4 RNs, 0 PCTs with a census of 11 Night- 5 RNs, 0 PCTs with a census of 12

2/6- Day- 4 RNs, 0 PCTs with a census of 12 Night- 5 RNs, 0 PCTs with a census of 12

2/7- Day- 4 RNs, 0 PCTs with a ce