HospitalInspections.org

21496

Repeat Deficiency

Based on a review of the facility's policies and procedures, a review of unit assignment sheets, and an interview with facility staff, it was determined that the facility failed to ensure that adequate staffing on units TU1 and TU4 was provided in accordance with their direct care staffing ratio.

Findings include:

REFERENCE: Policy/Procedure, Title: Nursing Staffing Plan, Policy No: NR.008 under PROCEDURE, Direct care staffing ratio: Child and Adolescent (TU4) Day shift 5:1, Evening shift 5:1 Night shift 6:1. Adult Psychiatric (TU1) Day shift 6:1, Evening shift 6:1, Night shift 7:1.

1. A review of the assignment sheets, in the presence of Staff #4, for the Adult Psychiatric Unit TU1 for the dates of 3/11/10 through 3/21/10 revealed the following:

a. On 3/11/10, the census on the 3-11 shift was 28 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 6:1, there should have been 6 staff members. The facility was 1 staff member short. On the 11-7 shift, the census was 28 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 3 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 4 staff members. With a patient to staff ratio of 7:1, there should have been 5 staff members. The facility was 1 staff member short.

b. On 3/14/10, the census on the 7-3 shift was 26 patients with 2 patients on 1:1 observation. Documented on the assignment sheet was, 3 staff members on the unit plus 2 staff members with the 1:1 patients, for a total of 5 staff members. With a patient to staff ratio of 6:1, there should have been 6 staff members. The facility was 1 staff member short.

c. On 3/17/10, the census on the 3-11 shift was 28 patients with 2 patients on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 2 staff members with the 1:1 patients, for a total of 6 staff members. With a patient to staff ratio of 6:1, there should have been 7 staff members. The facility was 1 staff member short.

d. On 3/19/10, the census on the 11-7 shift was 25 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 3 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 4 staff members. With a patient to staff ratio of 7:1, there should have been 5 staff members. The facility was 1 staff member short.

e. On 3/20/10, the census on the 7-3 shift was 28 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 6:1, there should have been 6 staff members. The facility was 1 staff member short. On the 3-11 shift, the census was 27 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 6:1, there should have been 6 staff members. The facility was 1 staff member short.

f. On 3/21/10, the census on the 7-3 shift was 27 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 6:1, there should have been 6 staff members. The facility was 1 staff member short. On the 3-11 shift, the census was 27 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 6:1, there should have been 6 staff members. The facility was 1 staff member short.

2. A review of the assignment sheets, in the presence of Staff #4, for the Child and Adolescent Unit TU4 for the dates of 3/9/10 through 3/14/10 revealed the following:

a. On 3/9/10, the census on the 3-11 shift was 22 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 5:1, there should have been 6 staff members. The facility was 1 staff member short. On the 11-7 shift, the census was 22 patients. Documented on the assignment sheet was, 3 staff members on the unit. With a patient to staff ratio of 6:1, there should have been 4 staff members. The facility was 1 staff member short.

b. On 3/10/10, the census on the 7-3 shift was 22 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 5:1, there should have been 6 staff members. The facility was 1 staff member short. On the 11-7 shift, the census was 22 patients. Documented on the assignment sheet was, 3 staff members on the unit. With a patient to staff ratio of 6:1, there should have been 4 staff members. The facility was 1 staff member short.

c. On 3/12/10, the census on the 7-3 shift the census was 22 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 5:1, there should have been 6 staff members. The facility was 1 staff member short. On the 3-11 shift, the census was 22 patients with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 5:1, there should have been 6 staff members. The facility was 1 staff member short. On the 11-7 shift, the census was 22 patients. Documented on the assignment sheet was, 3 staff members on the unit. With a patient to staff ratio of 6:1, there should have been 4 staff members. The facility was 1 staff member short.

d. On 3/13/10, the census on the 7-3 shift was 22 patients, with 1 patient on 1:1 observation. Documented on the assignment sheet was, 4 staff members on the unit plus 1 staff member with the 1:1 patient, for a total of 5 staff members. With a patient to staff ratio of 5:1, there should have been 6 staff members.




21844

Repeat Deficiency

Based on observation, it was determined that the facility failed to ensure that it complied with the suicide prevention regulations as provided in the most recent edition of the Federal Guidelines for Construction and Equipment of Hospital and Medical Facilities.

Findings include:

1. On a tour of the Child/Adolescent Treatment Unit (TU4) on 3/23/10 between 10:30 AM and 12:30 PM, in the presence of Staff #8, the following conditions were observed that indicated that the hospital environment was not safe:

a. The sink plumbing fixtures in the patient bathrooms were exposed, and were of the type and design that could support a patient's weight in a suicide attempt.

b. Non-vandal-proof fasteners, such as phillip's-head and flat-head screws, were observed throughout the unit. For example, on electrical outlet faceplates and switchplates.



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21844