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Based on document review and interview, the facility failed to supply an adequate number of nurses and other personnel on 2 of 2 units reviewed.

Findings include:

1. Policy titled, Nursing - Unit Guidelines for Staffing and Scheduling Procedure, PolicyStat ID 12044268, last revised 8/15/22, indicated the number of staff per shift is determined by the standardized Unit Guidelines template (UG).

2. Staffing pattern worksheet (SPW) for Medical Surgical Unit Telemetry Unit (med/surg tele), also known as 7C, and Medical Surgical Orthopedic Unit (med/surg ortho), also known as 4C, revealed less staff worked than indicated per UG.
a. Between the dates of 9/3/23 to 9/16/23, med/surg tele was not fully staffed with registered nurse (RN) coverage per UG including day, evening and night shifts, a sampling of dates included but not limited to:
1. 9/3/23, unit census 18, night shift UG indicated 5 nurses total with charge nurse and floor nurses. Staffing Pattern Worksheet (SPW) indicated 4 nurses total.
2. 9/9/23, unit census 24, day shift UG indicated 6 nurses total with charge nurse and floor nurses. SPW indicated 5 nurses total.
3. 9/13/23, unit census 32, night shift UG indicated 7 nurses total with charge nurse and floor nurses. SPW indicated 6 nurses total.
4. 9/16/23, unit census 20, night shift UG indicated 5 nurses total with charge nurse and floor nurses. SPW indicated 4 nurses total.
b. Between the dates of 9/3/23 to 9/16/23, med/surg tele was not fully staffed with Patient Care Technician (PCT) coverage per UG including day, evening and night shifts, a sampling of dates included but not limited to:
1. 9/10/23, unit census 25, night shift UG indicated 3 PCTs. SPW indicated 2 PCTs.
2. 9/11/23, unit census 27, day shift UG indicated 3 PCTs. SPW indicated 2 PCTs.
3. 9/14/23, unit census 26, night shift UG indicated 3 PCTs. SPW indicated 2 PCTs.
c. Between the dates of 9/03/23 to 9/16/23, med/surg ortho was not fully staffed with RN coverage per UG including day, evening and night shift, a sampling of dates included but not limited to:
1. 9/4/23, unit census 12, night shift UG indicated 3 nurses total with charge nurse and floor nurses. SPW indicated 2 nurses.
2. 9/8/23, unit census 15, day shift UG indicated 4 nurses total with charge nurse and floor nurses. SPW indicated 3 nurses.
3. 9/10/23, unit census 14, day shift UG indicated 4 nurses total with charge nurse and floor nurses. SPW indicated 3 nurses.
4. 9/15/23, unit census 13, night shift UG indicated 4 nurses total with charge nurse and floor nurses. SPW indicated 3 nurses.
d. Between the dates of 9/03/23 to 9/16/23, med/surg ortho was not fully staffed with PCT coverage per UG on 2 of 42 shifts, including day, evening and night shift.
1. 9/8/23, unit census 15, evening shift UG indicated 2 PCTs. SPW indicated 1 PCT.
2. 9/8/23, unit census 15, night shift UG indicated 2 PCTs. SPW indicated 1 PCT.

3. In interview on 10/27/23, at approximately 9:50 am, A3 Manager of Nursing Medical Surgical Telemetry Unit (MN med/surg tele) verified staffing sheet was correct and they were short on RN and PCT coverage per standard UG for med/surg tele as indicated above.

4. In interview on 10/27/23, at approximately 9:50 am, A5 Manager of Nursing Medical Surgical Orthopedic Unit (MN med/surg ortho) verified staffing sheet was correct and they were short on RN and PCT coverage per standard UG as indicated above.

Based on document review, observation, and interview, the facility failed to provide nursing care per policy/procedure on 8 of 12 patients reviewed (P3, P4, P6, P7, P9, P10, P11, and P12).

Findings include:

1. Facility policy titled, Bathing/Showering Patient, PolicyStat ID 9344825, indicated nursing staff should facilitate bathing daily.

2. Facility policy titled, Fall Precautions Procedure, PolicyStat ID 8956014, indicated high risk fall patients will wear red non-skid slippers.

3. Review of medical records (MR) indicated the following:
a. P3's MR indicated facility admission from 10/15/23 through 10/22/23. The MR lacked documentation of bath or refusal of bath on 10/16/23, 10/17/23, 10/18/23, 10/19/23, 10/20/23, 10/21/23, and 10/22/23.
b. P4's MR indicated facility admission from 09/04/23 through 9/10/23. The MR lacked documentation of bath given or refusal of bath on 9/5/23, 9/8/23, 9/9/23 and 9/10/23.
c. P6's MR indicated facility admission on 10/20/23. The MR lacked documentation of bath or refusal of bath on 10/21/23, 10/23/23, 10/24/23, and 10/25/23. The MR indicated patient was a high fall risk.
d. P7's MR indicated facility admission on 10/18/23. The MR lacked documentation of bath or refusal of bath on 10/19/23, 10/20/23, 10/21/23, 10/23/23, 10/24/23, and 10/25/23.
e. P9's MR indicated facility admission on 10/21/23. The MR lacked documentation of bath or refusal of bath on 10/22/23 through 10/25/23. The MR indicated patient was a high fall risk.
f. P10's MR indicated facility admission on 10/21/23. The MR lacked documentation of bath or refusal of bath on 10/22/23, 10/24/23, and 10/25/23.
g. P11's MR indicated patient was a high fall risk.
h. P12's MR indicated patient was a high fall risk.

4. On 10/27/23 from approximately 10:20 am to 11:40 am on tour of med/surg tele unit and med/surge ortho unit, observations of failure to follow fall precautions procedure as described below:
a. P6 observed to be wearing green non skid socks.
b. P9 observed to be wearing regular socks from home.
c. P11 observed to be wearing regular socks from home.
d. P12 observed to be wearing green non skid socks.

5. In interview on 10/27/23, at approximately 9:15 am, A1 (DON), A2 (CNO, VP Patient Services), A3 (MN med/surg tele), A4 Manager of Nursing 6C, A5 (MN med/surg ortho), all verified there would be no contraindications for a daily head to toe bath on any patients.

6. In interview on 10/27/23, at approximately 11:24 am, A5 (MN med/surg ortho) verified that all patients who are high risk for falls should be wearing red non skid socks.

Based on document review and interview the facility failed to maintain an accurate medical record (MR) on 1 of 5 charts reviewed for fall incidents during admission (P4's MR).

Findings include:

1. Facility procedure titled, Fall Precautions Procedure, PolicyStat ID 8956014, last revised 1/27/21, indicated when a patient falls there will be a significant event note with details of the fall in the MR.

2. Facility policy titled, Charting By Exception Documentation Procedure, PolicyStat ID 13326602, last revised 3/22/23, attachment ANA's Principles for Nursing Documentation, indicated document entries were to be accurate, and complete.

3. Incident report, dated 9/10/23, indicated P4 was left alone in bathroom, and found on floor by Patient Care Technician (PCT).

4. Nurses note, dated 9/10/23 at 8:30 am, indicated P4 fell while ambulating with PCT.

5. P4's MR lacked documented "Post Fall Assessment" flowsheet.

6. In interview on 10/27/23, at approximately 9:00 am, A3 Manager of Nursing Medical Surgical Telemetry Unit (MN med/surg tele) verified the events in the incident report, dated 09/10/23, were accurate and the the nurses note for the fall was not accurate. A3 (MN med/surg tele) verified that after a fall, the significant event note for the fall was supposed to be charted on the "Post Fall Assessment" flowsheet.