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Based on observation, review of schedules, policy and procedures and interview, it was determined the facility failed to assure patient care assignments for clinical staff were based on the acuity of patients. Failure to provide acuity based staffing did not increase patient safety or assure the needs of patients would be met. The failed practice affected 19 of 19 units observed on tour and had the potential to affect the 257 patients present on the affected units, and the total census of 321 inpatients. The findings were:

1. The facility policy "Staffing Process" was reviewed on 10/02/12.
The policy stated "Each nursing unit/patient care area will establish a staffing plan that will function as a staffing guideline when planning staffing for a unit.
A. Staffing is determined by census and aggregate patient needs. The staffing plan will indicate the appropriate number of staffing and skill mix needed to provide care to an identified number of patients under usual circumstances and typical acuity for the patient population.
B. The goal is to provide staff based on unit staffing plan as a guideline considering patient acuity with the level of preparation, competency and experience of direct care nurses.
C. All patient needs will be taken into account as staffing in the organization if finalized on a shift by shift basis."

2. "The Staffing Office operates 24/7 365. There will be discussion with the nurse in charge of the unit, the staff that is available and the staffing plan for the department. If the decision is made by the nurse in charge to work differently than the staffing plan a note will be made in the staffing office records indicating the nurse in charge's name and reason for the change. The approval/notification process within the department can be established within each department (outside of the staffing office). If at any time the nursing unit/patient care area needs additional staff to meet the needs of the department, the call for additional staff may be made to the staffing office."

3. In an interview on 10/02/12 from 1030-1050, the CNO stated the facility "does not use an acuity system for staffing. The staffing was based on DRGs (Diagnosis Related Group) and the national average of hours per patient day. The DRG is based on the patient's diagnosis code. There is a standard number set for staffing based on the diagnosis code. This is based on national standards. The DRG is supposed to be individualized by the Case Manager every day, but this may not be captured until discharge in some instances. The House Supervisor calls each Unit two hours before the end of the a.m. and p.m. shift and reviews the census and staffing with the Charge Nurse. This would be the time the Charge Nurse would report any increased staffing needs.

4. The facility Staffing Plan for each Unit was reviewed. The target HPPD (hours per patient day) was listed in one column, the census number was listed and the number of RN, PCT, and Unit clerks were listed. The staffing plan did not list specific acuity changes for staffing purposes. The findings were confirmed by the Chief Nursing officer on 10/02/12.

Based on observation, clinical record review and interview, it was determined the facility failed to assure an initial patient care assessment and nursing care plan was complete for 6 (#7-#9, #17, #18, and #24) of 26 (#1-#26) inpatient records reviewed. The patient's nursing care needs were not identified and nursing interventions were not developed in response to assessed needs. The failed practice affected Patient (Pt.) #7-#9, #17, #18 and #24 and had the potential to affect any patient admitted. The findings were:

A tour and clinical record review was conducted on 19 patient care areas of the hospital with the following results:

A. Patient #7 was admitted on 09/27/12 with a diagnosis of Urinary tract infection, decubiti, and Hypothyroidism. The patient had a Stage IV sacral ulcer and Stage II bilateral heel breakdown documented on admission and was placed on a specialty mattress 09/28/12. Review of the Interdisciplinary Plan of Care 10/04/12 at 1002 revealed neither potential nor actual skin breakdown were addressed. Wound care orders were documented on 09/28/12 at 1630 for daily wound care, soft heel protection and turn side to side every 1 - 2 hrs.

B. Patient #8 was admitted on 09/25/12 with a diagnosis of Stage IV decubitus on the left buttocks and a Stage III decubitus on the right buttocks. Review of the History and Physical revealed a past surgical history of bilateral below-knee amputations for peripheral arterial disease. The patient had daily dressing changes and and a specialty mattress was ordered. The Interdisciplinary Plan of Care listed "Skin integrity actual or potential, Goal: No redness/breakdown, Decubiti stage on (admission and discharge) this was blank. The plan of care interventions list Braden Scale daily, obtain orders for wound care consult and specialty bed/mattress. The instructions for the use of the form stated to date and initial applicable interventions. The plan of care for Patient #8 who was admitted with a Stage III and IV, did not specify if the patient had breakdown, the stage of the breakdown, reposition frequency, or daily dressing changes. The findings were confirmed by R.N. #8 on 10/04/12 at 1100.

C. Patient #9 was admitted on 10/01/12. The Adult Nursing Admission Record, Nutritional Screening total score was two, which according to the directions, a core greater than or equal to two, a Nutrition Consult should be made. There was no evidence of a nutrition consult. The findings were confirmed by RN #10 on 10/04/12 at 1145.

D. Patient #17 was admitted on 10/01/12. The Interdisciplinary Plan of Care listed an admission diagnosis of Seizure Monitoring. The instructions for the use of the Care Plan form stated "Need, Date identified & initial (if applicable)". The four page form was incomplete and lacked documentation of "Needs" or problems. There were no goals selected for eight of nine needs listed on the form that had a date and initials in the interventions section. The findings were confirmed by RN #9 at 1430 on 10/04/12.

E. Patient #18 was admitted on 09/26/12. The patient was a 56 year old male admitted with Altered Mental Status, nausea and vomiting and possible wound infection. The Adult Nursing Admission Record was reviewed on 10/04/12. The "Pressure Ulcer Risk Assessment/Braden Scale" on page four of the admission document was blank. The "Nutritional Screening" on page five of the document was also blank. The findings were confirmed by R.N. #9 on 10/04/12 at 1440.

F. Patient #24 was admitted on 09/21/12. The "Adult Nursing Admission Record" was not completed for sections: Nutritional Screening, Activity/Mobility Screening, Fall Risk Assessment/Screening; Fall Injury Risk Assessment; Cultural/ Spiritual Screening; Anticipated Teaching/Learning Needs. The findings were confirmed by R.N. #8 on 10/04/12 at 1030.