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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §485.631 Staffing and Staff Responsibilities, was out of compliance.

C-0974 (3) The staff is sufficient to provide the services essential to the operation of the CAH. Based on observations, interviews and document review, the facility failed to adequately staff nursing units to meet the needs of the patients. Specifically, the facility failed to ensure the nurse-to-patient staffing aligned with the inpatient census and the registered nurse (RN) staffing guidelines specified by the facility. Additionally, the facility failed to ensure a RN was immediately available on each inpatient unit to provide patient care. These failures were identified in two of three inpatient nursing units.

Based on observations, interviews and document review, the facility failed to adequately staff nursing units to meet the needs of the patients. Specifically, the facility failed to ensure the nurse-to-patient staffing aligned with the inpatient census and the registered nurse (RN) staffing guidelines specified by the facility. Additionally, the facility failed to ensure a RN was immediately available on each inpatient unit to provide patient care. These failures were identified in two of three inpatient nursing units.

Findings include:

Facility policies:

The Plan of Service policy dated 1/14/21 read, core staffing to meet patient or process needs consists of the following: Inpatient nursing staff, two registered nurses (RNs) are to be available 24 hours/day. Specialty Care Units require nursing staff to receive proper training prior to being assigned patient care in the specialty care unit.

Modification to the nurse staffing matrix will employ the following method: Nurse staffing will be based on individual patient needs, acuity and nursing skill/experience. A patient acuity system will be employed based on the current patient census and the level of patient acuity assigned to each patient.

Facility Guidelines:

The Inpatient Acuity Guideline dated 9/22/2021 read, the purpose of the policy is to provide nursing staff a guideline for how to assign patients a patient acuity score based on the complexity and severity of the patient's medical condition and promote an equitable patient distribution among nursing staff. High-quality nursing care is provided to patients through the systematic assignment of patient care to the nursing staff based on the patient's level of acuity.

The Inpatient Charge Nurse will be informed of all patient admissions to the facility and the Charge Nurse will assign patient assignments to the appropriate nurse based on the patient's level of acuity. The Charge Nurse is responsible to reassess the patient's acuity scores based on reported changes in patient condition. Patient acuity levels will be reported to the Nurse Manager (Manager) or Director of Nursing (DON) should nursing staff challenges occur.

Inpatient Units Nursing Staffing Guidelines dated 4/21, listed the nurse-to-patient staffing ratios (the number of patients a nurse is able to safely provide care to) for each nursing unit within the facility. Nurse-to-patient staffing ratios for each nursing unit varied based on the patient census and patient acuity levels. There are three inpatient nursing units, Medical/Surgical (Med/Surg) Unit, Special Care Unit (SCU) and Coronavirus (COVID) Unit.

Med/Surg unit nurse-to-patient staffing ratios: 1-5 patients require one RN and one certified nursing assistant (CNA) to be staffed on the unit. 5-10 patients require two RNs and one CNA to be staffed on the unit. 11-15 patients require three RNs and two CNAs to be staffed on the unit. 16-20 patients require four RNs and two CNAs to be staffed on the unit. 20-25 patients require five RNs and three CNAs to be staffed on the unit. The standard nurse-to-patient staffing ratio for the Med/Surge is one RN for every five patients with the patient's level of acuity equally distributed among the nursing staff.

SCU nurse-to-patient staffing ratios: 1-2 patients require one RN and one CNA to be staffed on the unit. 3-5 patients require one RN and one CNA to be staffed on the unit. Vented patients require one nurse for every two patients and the RN is not to leave the SCU at any time. RNs caring for medical intensive care unit (ICU) patients (patients who experience addiction detox/withdrawal or diabetic ketoacidosis) will have one nurse for every three patients. RNs providing care for Step-Down patients (patients who have cardiac/respiratory issues) will have one RN for every two patients and the RN will care for an additional two lower acuity patients who are on the Med/Surg unit. A CNA will remain on the SCU at all times and if needed the float RN can cover the CNA job function if there is not a CNA available.

COVID unit nurse-to-patient staffing ratios: 1-3 patients require one RN and one CNA to be staffed on the unit. 4-6 patients require two RNs and one CNA to be staffed on the unit. 7-9 patients require three RNs and two CNAs to be staffed on the unit. 10-12 patients require four RNs and two CNAs to be staffed on the unit. 13-15 patients require five RNs and three CNAs to be staffed on the unit. Vented patients require one nurse for every two patients. RNs caring for COVID unit patients with a lower level of acuity or who are stable may have one RN for every four patients. For 1-2 COVID unit patients consider transitioning the patients back to the Med/Surg unit or the SCU and follow the nurse staffing guidelines indicated for that specific unit.

1. The facility failed to ensure nursing staff were scheduled according to their policy and staffing matrix which determined patient acuity for assignments.

A. Document review revealed facility guidelines were not utilized and resulted in inadequate RN staffing and unsafe nurse-to-patient ratios.

i. According to the Inpatient Acuity Guideline, patients were assigned an acuity score based on the complexity and severity of the patient's medical condition. The charge nurse would distribute patient care assignments among RNs equitably based on patient acuity scores.

ii. According to the Inpatient Units Nursing Staffing Guidelines, each nursing unit had a specified nurse-to-patient staffing ratio indicated to ensure patients were provided safe and effective nursing care. Each inpatient unit's nurse-to-patient staffing ratios were based on patient census and patient acuity levels.

iii. The Inpatient Acuity Guideline and the Inpatient Units Nursing Staffing Guidelines collaboratively determined the number of nursing staff needed to provide safe and effective nursing care to patients.

B. Interviews revealed nursing staff did not utilize guidelines for determining acuity or staff required when making assignments.

i. On 9/30/21 at 12:17 p.m., an interview was conducted with RN #11. RN #11 stated the patient's medical condition, comorbidities and level of assistance needed were not reviewed or assessed to determine a level of acuity for the patient. She stated she was not aware of what the nurse-to-patient ratio was or how it was determined. RN #11 stated there were staffing concerns related to patient acuity.

RN #11 stated RNs who cared for patients on the COVID unit were assigned up to six patients to care for and many times the patients required one on one care, especially when patients required the use of continuous bilevel positive airway pressure (BiPAP) (a non-invasive positive pressure ventilator). She stated RNs working in the COVID unit would be assigned two to three patients who were on continuous BiPAP. RN #11 stated patients who were not COVID positive and needed continuous BiPAP would be placed in the Special Care Unit (SCU) RNs in the SCU would not be required to care for more than three patients.

RN #11 stated she and other RNs have frequently requested staffing assistance from leadership. She stated the nursing staff expressed to facility leadership there was a lack of adequate nursing staff in relation to the patient's level of acuity.

ii. On 10/1/21 at 12:30 p.m., RN #10 was interviewed. RN #10 stated patient acuity scores were not reviewed or assessed prior to creating staffing assignments. RN #10 stated patient acuity scores were not generated by a charge nurse as there was not an "official" charge nurse hired for the units. She stated every shift had an RN delegated to assign nursing responsibilities, but the RN did not review or provide patient acuity scores.

RN #10 stated nursing staff was informed patient acuity scores were not used to determine nurse-to-patient staffing assignments. She stated the nursing staff were not provided updated education or training related to facility processes. RN #10 stated she was not provided the Inpatient Units Nursing Staffing Guidelines or the Inpatient Acuity Guideline processes by leadership and the facility did not communicate the facility used these guidelines to determine nurse staffing assignments.

C. Daily census sheets and RN staffing sheets were reviewed and revealed inpatient units were not staffed according to facility staffing and patient acuity guidelines.

2. The facility failed to staff nursing units to ensure a RN was immediately available to direct and supervise the care of each patient.

A. Observations and document review revealed the facility failed to ensure a RN was present and immediately available for each inpatient unit.

a.According to the facility's Inpatient Units Nursing Staffing Guidelines and the Inpatient Acuity Guideline,

b. On 10/4/21 from 8:00 p.m. until 8:45 p.m., an observation was conducted of the COVID unit at the facility.

At 8:09 p.m., RN #9 was observed leaving the COVID unit. A RN was not present on the COVID unit again until 8:24 p.m. The CNA assigned to work on the COVID unit was not on the unit during the observation.

c.On 10/4/21 at 8:31 p.m., an interview was conducted with RN #9. RN #9 stated a CNA was assigned to the COVID unit, but he was not aware of her location or if the CNA was present on the unit. RN #9 stated he exited the COVID unit in order to use the restroom. He stated there was not a restroom available for staff to use on the COVID unit. RN #9 stated another RN was not available to cover the COVID unit while he went to the restroom.