HospitalInspections.org

Based on documentation review and staff interview, the Director of Nursing failed to ensure that the staffing matrix was followed on 3 (three) West forensic unit. This failure has the potential to affect all patients who receive care in the facility.

Findings include:

The Staffing Matrix for 3 West was reviewed, and stated in part, "4. The 'Staff to Patient Ratio Skill Mix' (SPR) may vary depending on patient needs, but the total number of staff will not necessarily change. For example, with a census of 28 [twenty-eight], the day shift calls optimally for 5 [five] nursing staff. This may be 2 [two] RNs and 3 [three] OHPs [other health professionals] or 1 [one] RNs, 2 LPNs [Licensed Practical Nurses] and 2 [two] other OHPs or 1 [one] RNs and 4 [four] other OHPs." The minimum staffing requirements for twenty-three (23) to twenty-eight (28) patients was five (5) staff on day shift and three (3) staff on night shift.

A review of the staffing sheets from 06/01/25 through 09/08/25 revealed that 3 West had between twenty-seven (27) and twenty-eight (28) patients throughout the time frame, and was below the minimum requirements for staff forty-six (46) shifts; forty-one (41) day shifts and five (5) night shifts.

A review of the Behavioral Health Incident Log for 3 West from 06/01/25 to 08/31/25 revealed twenty-seven (27) incidents - fourteen (14) of which occurred when staffing did not meet the minimum requirement of the staffing matrix.

An interview was conducted on 09/08/25 at 3:10 p.m. with staff #4, who expressed concerns about 3 West being chronically short staffed, and that it created an unsafe work environment. Staff #4 stated, " I am currently working a sixteen [16] hour shift to cover the shortage. It seems like they prioritize the other units and always pull from us. If we complain, we are told to 'suck it up'. We don't get a lot of help from administration. The shortages are ongoing and getting worse. There is a high turnover rate, and it places the staff and the patients at risk. It affects our ability to run groups and go off the unit on outings. The kitchen is short staffed too, and the kitchen manager is rude. There isn't enough staff to have the cafeteria open for the staff to eat or the patients to go to the dining room. They bring meals to the floor at least three (3) or four (4) times a week. It upsets the patients because they can't get out of the unit."

An interview was conducted on 09/09/25 at 8:33 a.m. with staff #8 regarding staffing. Staff #8 stated, "Staffing is a daily problem. We offer monetary incentives for staff to pick up shifts. We have had a lot of turnover, and have a lot of call-offs. We always have an RN on duty on every floor and on every shift. We may be short staffed with MHTs on some units, but there are therapists, recreational therapists, and milieu staff available who can assist with transporting the patients off the units and doing hall monitoring. Sometimes the nursing supervisor has to work a floor along with the supervisory duties when we are short an RN. We are actively recruiting, but rely heavily on our current staff to pick up shifts. We are short staffed with kitchen help as well, so the dining room is closed several days a week, so the meals and snacks are brought to the floors. Staffing is definitely an issue."

A telephone interview was conducted on 09/10/25 at 12:06 p.m. with staff #13 related to staffing. Staff #13 stated, "Staffing is a big issue here. I think there is an increase in patient behavior when we are short staffed. Forensic patients are mischievous. They see it, and one patient may distract the hall staff so the other one can get into mischief. Patients get upset when there is not enough staff to take them off the unit. The kitchen has been short staffed, so they can't go to the dining room a few days of the week. Or if it is time to go to the dining room, or even outside, we sometimes have to track down and wait for additional staff to come to take them."

An interview was conducted on 09/10/25 at 10:15 a.m. with staff #16. After reviewing the staffing sheets from 06/01/25 to 09/08/25, staff #16 confirmed that forty-six of the shifts were short-staffed on 3 West according to the staffing matrix. Staff #16 also confirmed that the facility does not track the correlation of incidents to low staffing.