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Based on observation, staff interview and documentation review it was determined the facility failed to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient. This failure created the potential for negative outcome to patients.

On 10/25/2010 at approximately 10:00 a.m., on Phase One, the Medication Registered Nurse was observed down the hall while the Charge Registered Nurse was observed giving a daily update to the Medical Director. The telephone was ringing and the Medication Nurse had to rush back down the hall to the nurses' station to answer it so the Charge Nurse would not be interrupted.

On 10/25/10 at approximately 10:15 a.m., on Phase One, the Charge Nurse was observed answering the telephone, putting the caller on hold to see if the Intake Nurse was available in her/his office, then returning to that caller to take a message while the other telephone line was ringing. The Activity Director was in the nurses' station and s/he answered the second telephone line, who wanted to speak with the Charge Nurse, so that caller was put on hold. Then two more calls came in, with the other caller still on hold, and the Charge Nurse and Activity Director answered the next two telephone calls.

In an interview with the Medication Nurse on 10/25/10 at approximately 9:45 a.m., it was revealed that the Phase One Nurses' Station is the "switchboard" for the entire facility. It was revealed that admission, marketing, family, transfers, and many other different types of telephone calls come into the Phase One Nurses' Station. There was no secretary or ward clerk working at the facility. Further observations on 10/25/10 at approximately 11:15 a.m., revealed that the Certified Nursing Assistants were providing care to the patients, the Medication Nurse was passing medications, and the Charge Nurse was responsible for patient assessments, correspondence with doctors and facilities, as well as transcribing orders from the patients' charts and answering telephones/transferring calls. Observations revealed that the Phase One Nurses's Station had four different telephones, with no designated person to answer them throughout the busy hours of the day.

In an interview with the facility's Nurse Practitioner earlier that day at approximately 8:00 a.m., s/he stated, "Sometimes the nurses are so busy that I'll write an order and it won't get taken off until 5:00 pm when it is quiet..."

Review of the staffing schedules for the week on 10/17/10 through 10/23/10 revealed documentation of the additional staff that needed to be called into provide 1:1 observation, cover new admissions, and replace staff who called in sick. Due to the ability to call in extra staff or agency, staffing was usually adequate. However, some shifts did have to work short.

Review of the policy titled "Nursing Evaluation of Facility" was completed on 10/27/2010. In the policy section, it stated the following in pertinent part: "The Director of Nursing will review with nursing staff on a routine basis the adequacy of facilities in terms of patient and nursing needs. This will occur during staff meetings and informal discussions..." When the new Director of Nursing was questioned about this policy on 10/27/10 at approximately 8:30 a.m., s/he stated that s/he would begin to do this at his/her staff meetings. However, there was no evidence that such had been done in past staff meetings prior to the new Director's arrival, especially in regards to the possible need of a designated person to answer telephones during the hospital's busiest times of the day so that nurses were more readily available to patients.