HospitalInspections.org

Based on document review and interview, the hospital nursing staff failed to ensure adequate numbers of licensed nursing staff necessary for the provision of appropriate care to all patients, as needed on 1/3/2022 and 1/7/2022 for 4 shifts of 4 shifts; for staffing reviewed for 5th floor (General -"Garden" - surgical unit). (Day shift {7:00 am to 7:00 pm} for 1/3/2022 and 1/7/2022 and (Night shift {7:00 pm to 7:00 am} for 1/3/2022 and 1/7/2022.

Findings include:

1. Review of established hospital plan titled: "Plan for the Provision of Care", indicated on page 27, under Unit: 5 Garden - Surgical, row 5, "Staffing is adjusted and monitored in 4 hour increments and prn (as needed) per staffing grid and productivity standards while taking the level of acuity into account". Plan last approved 6/2020.

2. Review of "5 Garden Staffing Grid", indicated for census of 32 patients, the following:
A. "DAYS 7a - 7p"; for census of 32 patients: RN's (Registered Nurse) = 8 and PCP (Patient Care Providers) = 4.
B. "NIGHTS 7p - 7a"; for census of 32 patients: RN's = 7 and PCP = 3.
C. Staffing grid lacked standards; ratios.
D. Staffing grid lacked a defined patient acuity level(s) for surgical patients; for staffing ratios.

3. Review of staffing pattern worksheet for 5 Garden - General - Surgical, for week of January 2 - 8, 2022; indicated the following:
A. Census on 1/3/2022 = 32 patients.
1. Day shift staff reflected that of RN's = 7 and PCP's = 1.5. Nurse (RN to patient ratio =/> 1:5).
Short RN's by 1 and short PCP's by 2.5.
2. Night shift staff reflected that of RN's 5 and PCP's 3. Nurse (RN to patient ratio > 1:6).
Short RN's by 2.
B. Census on 1/7/2022 = 32 patients.
1. Day shift staff reflected that of RN's = 8 and PCP's = 2. Nurse (RN to patient ratio =/> 1:4).
Short PCP's by 2.
2. Night shift staff reflected that of RN's = 6 and PCP's = 2. Nurse (RN patient ratio > 1:5).
Short RN's by 1 and short PCP's by 1.

4. In interview on 2/9/2022, at approximately 3:15 pm, with A # 4 (Manager 5th floor - Surgical), indicated that the Garden - General - Surgical unit was short staffed; on 1/3/2022; night of patient # 8 discharge/event. The unit was short by 2 RN's.

5. In interview on 2/9/2022, at approximately 12:35 pm, with A # 11 (Director of Accreditation), confirmed the following:
A. Staff schedule on 1/3/2022, for 5th floor - Garden unit; for night shift noted 32 patients, and was short staffed.
B. Grid showed should have been 7 Nurses, but ended up with only 5. They had a floater; which would have taken them up to 6, but then another nurse called off; so ended up short; only only 5 nurses, and the 3 patient care assistants.

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy& Procedure) related to Medical Records for "accurate" and "complete" entries in the patient's MR (Medical Record); P&P related to discharge instructions for final nurses discharge note, and P&P related to Incident Reporting for an event or situation not consistent with standards of care; for 1 of 4 closed MR's reviewed (Patient # 8).

Findings include:

1. Review of established hospital policy titled: "Documentation in the Medical Record", indicated on page 1, under Policy, 1. "requirements for an accurate..., complete... and timely medical record", and under PROCEDURE, h) "clinical observations"; q) "discharge instructions", and page 3, 15) "Relevant observations". Policy last approved 12/2013.

2. Review of established hospital policy titled: "DISCHARGE INSTRUCTIONS", indicated on page 1, under PROCEDURE, H. "A final nurses discharge/depart note in the electronic Medical Record should indicate to where the patient is being discharged and to whom the discharge instructions are given...including response to the instructions". Policy last approved 3/2021.

3. Review of established hospital policy titled: "Online Incident Reporting", indicated on page 1, under POLICY, 1. AH # 40 (Acute Care Hospital) "endorses a culture of safety", "potential for errors", 6. "It shall be the responsibility of each associate to report all incidents/events at the time they are encountered"; on page 2, e) "Document the nature and facts surrounding the occurrence in the nurse's note of the patient's medical record", and under Definitions: first point "An incident/event is any situation which is inconsistent with" AH # 40's "standards of care or routine". Policy last approved 10/2018.

4. Review of Security Department Officers Daily Report for January 3, 2022, indicated the following:
A. "Key Code" = 34 ("Escort); Time received: 10:46 pm, Time complete: 11:00 pm.
B. Entry noted by SO # 80 (Hospital security officer staff), reflected SO # 80 assisted Surgical in locating a patient who was discharged in the "technical sense" but had left Room # 5514 prior to receiving final assistance or instructions. The discharged female/male patient was then soon after located wandering in the ER lot and was driven over to the Main Visitor's lot in the Security Patrol vehicle to be reunited with her/his vehicle. Previously presiding N # 20 was then notified by SO # 80, of Security's findings and the actions taken to resolve them.

5. Review of incident/event logs (query ran) for 5th floor ("Garden" - General surgical unit), for January 2022, indicated that none were found/noted/completed by N # 20 (5th floor - staff nurse); for patient # 8, related to occurrence of incomplete discharge process, and patient drove self home; evening shift 1/3/2022.

6. Review of MR for patient # 8, indicated the following:
A. Patient admitted on 1/3/2022 for abdominal - surgical procedure by MD # 30 (General Surgeon).
B. Patient into PACU (Post-Anesthesia Care Unit) at approximately 1:26 pm; then to 5th floor (Garden - General surgical unit), to room # 5514 at approximately 5:31 pm.
C. NP # 50's progress note on 1/3/2022 at 10:17 pm, reflected NP # 50 was notified by N # 20 at 9:00 pm; that patient wanted to leave AMA (Against Medical Advice). NP # 50 called N # 20, to discuss the patient's options in regards to patient leaving AMA and being discharged. NP # 50 spoke with patient; care concerns voiced by patient; "did not feel safe at the hospital" and patient informed NP # 50, that FM # 1 (family member) was sitting in the ER (Emergency Room) parking lot to drive her/him home. NP # 50 spoke with MD # 30, and decided that due to the fact that at the time, the patient's pain was under control, tolerating a diet, voiding independently and ambulating without assistance, she/he was stable to be discharged home under care of FM # 1. Discharge orders in and pharmacy sent prescription for pain medication (Percocet). All information relayed to patient and N # 20. NP # 50 did not receive any additional correspondence from N # 20 about the patient. Next morning, checked with N # 20, and was informed that patient was given discharge instructions, N # 20 left patient room to get a wheelchair to take patient out to FM # 1, who was the ride the patient had informed N # 20, would be taking her/him home. By time N # 20 made it back to the room with wheelchair; N # 20 stated patient was gone, had just left. N # 20 was then notified, at a time that was not disclosed to NP # 50, that the patient was wandering around the ER parking lot. N # 20 didn't get another update as to when the patient was gone, but was under the assumption that the patient drove herself/himself home.
D. MR documentation lacked nurse note entries for the following:
1. An entry for the call/contact to NP # 50, in regards to patient wanted to leave AMA.
2. An entry for any discharge instructions/AVS (after visit summary) reviewed with patient and if copy provided to patient.
3. An entry for the call/contact to Hospital security staff at approximately 10:46 pm, that patient left unit; before receiving final assistance or instructions and to assist to locate the patient.
4. An entry for the return call/contact from Hospital security staff on/or before approximately 11:00 pm; for notification of security staff findings and actions taken. Security noted that patient was located wandering in the ER parking lot and was driven to be reunited with her/his vehicle.
5. An entry for any notification to NP # 50 and/or MD # 30, related to incomplete discharge process, and how then the patient left the hospital.
6. An entry for the nature and facts surrounding the event/occurrence; that were not standards of care.

7. In interview on 2/8/2022 at approximately 3:20 pm, with A # 1 (Chief Nursing Officer), the following was confirmed:
A. Would have "preferred" that N # 20 to have completed an incident/event report. Not a normal discharge process.
B. That there was not an incident report completed for event/occurrence, related to patient # 8, on 1/3/2022.

8. In interview on 2/9/2022 at approximately 3:00 pm, with A # 4 (Manager 5th floor - Surgical), the following was
A. Patient left without discharge instructions given; would have expected to see documentation; of a patient with an significant event.
B. That N # 20 should have generated an incident report; was loss of patient, process not completed for discharge plans; would have to be completed for this patient occurrence.

9. In interview on 2/9/2022, at approximately 12:51 pm, with A # 11 (Director of Accreditation), indicated that the nurse should have documented a note in the patient's MR; discharge event; how the patient left and security was called.