HospitalInspections.org

Based on a review of facility documentation and interviews with staff, the facility failed to ensure that the facility was staffed with an adequate number of RNs, LVNs and other personnel to provide nursing care to all patients as needed.

Findings were:

Unit censuses, assignment sheets and staffing grids were used to determine current compliance with regard to staffing. The following units reviewed were:
* Cooley 6-B (Intermediate Care Unit)
* Cooley 7-A (Intensive Care Unit)
* Cooley 7-B (Intermediate Care Unit)
* 21 Tower (Medical/Surgical Unit)

Cooley 6-B

Staffing and assignment sheets for the dates of 9-17-23, 9-18-23 and 9-19-23 were reviewed to determine current compliance with facility staffing requirements. 9-17-23 day shift was short-staffed by 1 PCT. 9-17-23 night shift was short-staffed by 1 registered nurse. 9-18-23 day shift was short-staffed by 1 registered nurse. 9-18-23 night shift was appropriately staffed. 9-19-23 day shift was short-staffed by 1 registered nurse. 9-19-23 night shift was short-staffed by 1 registered nurse.

The findings of current non-compliance with facility staffing requirements for 3 of 3 dates sampled were verified with staff #4 (manager of Cooley 6-B) on 9-20-23.

Cooley 7-A

Staffing and assignment sheets for 9-17-23 to 9-19-23 were reviewed to determine current compliance with facility staffing requirements. 9-17-23 day shift was short-staffed by 1 registered nurse. 9-17-23 night shift was short-staffed by 1 registered nurse. 9-18-23 day shift was short-staffed by 1 registered nurse. 9-18-23 night shift was appropriately staffed. 9-19-23 day shift was short-staffed by 1 registered nurse. 9-19-23 night shift was appropriately staffed.

The finding of current non-compliance with facility staffing requirements for 3 of the 3 dates sampled were verified with staff #3 (manager of Cooley 7-A) on 9-20-23.

Cooley 7-B

Staffing and assignment sheets for 9-17-23 to 9-19-23 were reviewed to determine current compliance/non-compliance with facility staffing requirements. On 9-19-23 for the 7a-7p shift, the census was 10 patients plus 1 patient requiring a sitter. Per the staffing grid this would require 4 registered nurses and 2 PCTs be present (with 1 PCT acting as a sitter). On this shift, only 3 registered nurses and 2 PCTS (1 PCT and 1 nurse acting as a PCT) were present on the unit from 7a-11a, at which time a 4th registered nurse came to the unit. The unit was short-staffed from 7am to 11am.

The findings of current non-compliance with facility staffing requirements for 1 of the 3 dates sampled were verified with staff #2 (manager of Cooley 7-B) on 9-20-23.

21 Tower

Staffing and assignment sheets for 9-17-23 to 9-19-23 were reviewed to determine current compliance/non-compliance with facility staffing requirements. On 9-17-23 for the 7a-7p day shift, the census called for the unit to be staffed with 7 registered nurses. Only 5 registered nurses were present for the shift, leaving the unit short-staffed by 2 registered nurses. On 9-17-23 for the 7p-7a night shift, the census called for the unit to be staffed 7 registered nurses. Only 6 registered nurses were present for the shift, leaving the unit short-staffed by 1 registered nurse. On 9-18-23 for the 7a-7p day shift, the census called for the unit to be staffed with 7 registered nurses. Only 6 registered nurses were present for the shift, leaving the unit short-staffed by 1 registered nurse. On 9-18-23 for the 7p-7a night shift, the census called for the unit to be staffed with 6 registered nurses. Only 4 registered nurses were present for the shift, leaving the unit short-staffed by registered nurses. On 9-19-23 for the 7a-7p day shift, the census called for the unit to be staffed with 8 registered nurses and 1 unit secretary. Only 5 registered nurses (and no unit secretary) were present for the shift, leaving the unit short-staffed by 3 registered nurses and 1 unit secretary.

The findings of past non-compliance as well as current non-compliance with facility staffing requirements for 3 of the 3 dates sampled were verified with staff #5 (manager of 21 Tower) on 9-20-23.

Facility policy titled "Nurse Staffing Plan - Nursing Services" states, in part:
"DEFINITION(S)
Nurse Staffing Plan - a written plan used as a guide for effective staffing including the number, competency, and skill mix of staff in relation to the provision of needed care and treatment. The nurse staffing plan includes staffing grids that include minimum staffing levels for individual units, and a method to adjust staffing and a contingency plan when patient care needs unexpectedly exceed staff resources that are applicable hospital-wide.
...
POLICY
A. Baylor St. Luke's Medical Center will provide patient care through appropriate use of qualified and skilled personnel and therefore will adopt, implement, and enforce nurse staffing grids that are based on the needs of each patient care unit, each shift, and on evidence related to patient care needs.
B. Baylor St. Luke's Medical Center's Governing Board of Directors (Board) shall adopt, implement, and enforce Baylor St. Luke's Medical Center's Policy and Procedure, Nurse Staffing Plan - Patient Care to make sure that an adequate number and skill mix of nurses are available to meet the level of care needs of the patients."

In an interview with staff #2 on 9-19-23, staff #2 was asked to explain the function of the nurse staffing grid for each patient care unit (including her own unit, where staffing shortages were identified). She stated that the staffing grid was used as a "guideline" for staffing and that the nurses on her unit understood that, if staff called in and could not be obtained from another unit, a staffing agency or the float pool, that the staffing present would need to "stretch" and take on more patients per nurse than the staffing grid indicated.

The above was confirmed in an interview with the VP of Quality, the Director of Quality and other administrative staff on 9-20-23.