HospitalInspections.org

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Based on document review and interview, the hospital failed to ensure that each inpatient unit had a qualified charge nurse to determine staff shift assignments based on patient acuity and individual needs.

Failure to staff each inpatient unit with a qualified charge nurse risks patients not receiving nursing care based on individual, sudden, or emergent nursing/medical needs.

Findings included:

1. Review of the hospital policy titled, "Staffing Assignments," policy number PC.L.900, last reviewed 01/19, showed that at the beginning of each shift, the Charge Nurse will ensure that patient care assignments divided evenly among staff, based on the qualifications of each nursing staff and the identified nursing need of the patient according to acuity. The document showed that staffing assignments, including the staff name, title, assigned patients, and assigned meals and rest breaks are entered on the staffing sheet and posted for staff to review throughout the shift. Staffing Assignment Sheets are sent to the Director of Nursing at the end of each shift for review and maintenance.

Review of the hospital policy titled, "Contractor and Temporary Agency Employees," policy number HR - 103, revised 08/18, showed that contract staff, temporary, and agency employees will not be allowed to supervise Acadia or Acadia facility employees.

Review of the hospital policy titled, "Orientation," policy number EHB.O.100, reviewed 01/22, showed that nursing staff are required to attend competency training following general orientation, and Unit Specific orientation to each position and area will be provided by the department.

Review of the hospital document titled, "Charge Nurse RN Job Description," approved 01/20, showed that the purpose of the charge nurse is to supervise a work group or unit for a specified shift, with a priority on patient safety. The document showed that essential functions of the charge nurse included coordinating patient care and workflow of nursing staff on the unit, coordinating services and communicating with other units and departments as needed, overseeing, and providing direct nursing evaluation, consultation, and related care to patients as needed, communicate effectively, and maintain required documentation. The document showed that the charge nurse position qualifications included two or more years' experience as a registered nurse (RN) was required and two or more years' behavioral health experience was preferred.

Review of the hospital document titled, "2021 - 2024 Agreement Between Cascade Behavioral Hospital and SEIU Healthcare 1199NW (Registered Nurses)," approved 11/21, showed that charge nurse responsibilities include facilitating work flow, serving as a clinical resource to staff, making patient rounds, matching nursing competencies with patient needs, monitoring documentation and compliance with standards, promoting patient and environmental safety, relieving floor nurses for rest and meal periods, and responding to customer concerns. The document showed that charge nurses on all units shall use a patient acuity assessment tool at the start of each shift to assess the acuity of patients on the unit.

2. Document review of daily staffing report sheets dated 05/20/22 to 06/02/22 showed that the facility did not have a charge nurse scheduled for every unit and every shift for 14 of 14 days reviewed.

3. Investigators reviewed the personnel records of 4 RNs assigned to the role of charge nurse between 05/20/22 and 06/02/22. The records showed that

a. 3 of 4 RNs did not have a signed Charge Nurse RN job description in their personnel file (Staff #1202, #1213, and #1215).

b. Staff #1202's Unit Specific Orientation Checklist, signed 01/23/22, did not include information on the staff member's assigned program area(s), how the staff member was evaluated on the use of seclusion (observation, document review, and/or skills demo) or how the staff member was evaluated on use of the medication record (observation, document review, and/or skills demo).

c. Staff #1213's Unit Specific Orientation Checklist, signed 04/28/22, did not include information on the staff member's assigned program area(s).

d. Staff #1215's Unit Specific Orientation Checklist, signed 05/25/22, did not include information on the staff member's assigned program area(s), and none of the check boxes under Contraband Monitoring, Admission Process, Discharge Process, Seclusion and Restraint were marked indicating which skills were evaluated.

4. On 06/01/22 at 9:00 AM, investigators toured the 2 West inpatient adult psychiatric unit and interviewed a staff RN (Staff #1215) and the charge nurse (Staff #1213). The interviews showed the following:

a. Staff #1215 stated that she had worked at the facility for 2 months, and she had no prior experience working with behavioral health patients before she started working at the hospital.

b. Staff #1213 stated that she began working at the hospital in February and recently completed her 90-day probationary period. Staff #1213 stated that she has been assigned the role of charge nurse twice since she started. When asked what type of training she received prior to taking on the role of charge nurse, Staff #1213 stated that the facility did not provide her with any charge nurse orientation. Staff #1213 stated that when making assignments, they would reassign staff the same patients if they worked the previous day.

5. On 06/03/22 at 10:04 AM, Investigator #12 interviewed the staffing coordinator (Staff #1218). Staff #1218 stated that he receives copies of each unit's daily Staffing Assignment Sheets, faxes them to corporate each day, and provides copies to the Chief Executive Officer (CEO) and Chief Nursing Officer (CNO). Staff #1218 stated that the hospital did not always have an assigned charge nurse to each inpatient unit during a 24-hour period.

6. On 06/06/22, the Director of Quality (Staff #1207) provided investigators with names of charge nurses assigned to inpatient units between 05/20/22 and 06/02/22. The document showed the following:

a. Staff #1202 was charge nurse on 2 North, a chemical dependency (CD) unit, on 05/20/22, 05/21/22, 05/25/22, and 05/26/22.

b. Staff #1213 was charge nurse on 2 West, an adult psych unit, on 05/20/22, 05/21/22, 05/22/22, 05/23/22, 05/27/22, and 06/01/22.

c. Staff #1215 was charge nurse on 2 North, on 05/24/22.

d. Staff #1215 was charge nurse on 2 West, on 05/25/22 and 05/27/22.

e. Staff #1216, an agency RN, was charge nurse on 2 West on 05/21/22.

f. Staff #1217, an agency RN, was charge nurse on 2 West on 05/22/22.

g. Staff #1217, an agency RN, was charge nurse on 2 North on 05/27/22, 05/28/22, and 05/29/22.

7. On 06/08/22 at 9:05 AM, Investigators #12 and #15 interviewed the Chief Nursing Officer (Staff #1219). Staff #1219 stated that the hospital did not require any special training or competency for its charge nurses, and if no charge nurse is assigned, "anyone" can assume the duties. When asked what duties the charge nurses perform, Staff #1219 stated that the charge nurse duties included attending treatment team meetings, discharging and admitting patients, and making staff assignments.
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