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Based on document review and interview, it was determined that the Hospital failed to ensure adequate qualified staff were available for patient care. Therefore, the Condition of Participation, 42 CFR 482.23, Nursing Services, was not met, as evidenced by:

Findings include:

1. The Hospital failed to ensure an adequate number of qualified staff were available to provide safe patient care. A-392.

Based on document review and interview, it was determined the Hospital failed to ensure an adequate number of qualified staff were available to provide safe patient care. This has the potential to affect all inpatients, outpatients and staff, as evidenced:

Findings include:

1. On 12/8/2021 at 11:00 AM, the document titled the "Position Description/Competency Based Evaluation" for Registered Nurses in the Adult Behavioral Health Unit, Registered Nurse in the Emergency Department, Emergency Department Technicians and Adult Behavioral Health Certified Nurse Aides: noted they must have documentation of restraint/seclusion training, CPI training and BLS (Basic life Support) certification.

2. On 12/8/2021 at 11:30 AM, the document titled the The "Position Description/Competency Based Evaluation" for Registered Nurses noted, "Must obtain and maintain ... Current certification in Advanced Cardiac Life Support (ABCS) and Pediatric Advanced Life Support (PALS) ..."

3. On 12/8/2021 at 11:45 AM, the document titled The "Position Description Title: Registered Nurse: Emergency Department" (not dated) noted; "Must obtain and maintain current certification in /Basic Life Support (BLS). Current certification in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) is required within (6) months of hire."


4. The employee file of E#21 (Emergency Department Registered Nurse) was reviewed on 12/8/21 at approximately 12:00 PM. The Contingent Job Offer letter dated 11/16/21 noted that E #21 was hired by the hospital. The Human Resources Department New Employee Checklist for E #21, noted "Hospital Orientation (if applicable) 12/13/21. The employee file lacked documentation of an orientation. The employee file noted ACLS certificate and the PALS certificate expired on 9/2021. The employee file had a sticky note which noted "Picked up one shift on 11/24 still needs to present certifications". The November Staff scheduled noted E#21 worked 11/24/21 from 11:00 PM to 3:00 AM.


5. The employee file of E#22 (Operating Room Surgical Technician/Date of Hire: 6/15/04) was reviewed on 12/8/21 at approximately 12:15 PM. E #22's "Department Orientation and Initial Competency Assessment (DOICA) Behavioral Health Unit- Float Staff" form dated 11/29/21 noted " ... Performance Criteria ... CPI (Crisis Prevention Intervention) training- required to have prior to assisting with physical hold ... Te comment section contained "Didn't have any preceptor Just observed myself ... All myself by watching others". The employee file lacked documentation of restraint training and CPI training. The staff assignment sheet dated 12/6/21 noted E#22 was assigned in the Behavioral Health Unit from 3:00 PM to 7:00 PM.

6. The "Nursing Supervisor Report Sheet" dated 12/3/21 noted "12-2-21 Pt #2 (Medical/Surgical inpatient) was administered 2 U PRBC (units/packed red blood cells). Both units pulled from Lab at same time ... Second unit sat out 1845 (6:25 PM) until started at 2315 (11:15 PM). ERS (Electronic Record System) entered both units verified by the same nurse (E#23)." The attachments to the Report Sheet noted Pt #2 was admitted on 11/29/21 with an infected wound to the Medical Surgical Unit room #216 and the 2 units of PRBC were administered by E#23."

7. The employee file of E#23 (Older Adult Behavioral Health Unit Registered Nurse/Date of Hire: 10/4/21) was reviewed on 12/8/21 at approximately 12:30 PM. The employee file lacked documentation E#23 was oriented to the Medical/Surgical Unit and/or competent to administer blood products.

8. The employees files of E#21, E#23, E#24 E#25, E#26, E#27 were reviewed on 12/8/2021 at 2:00 PM. The employee files lacked the following documentation:: E#24, OABH RN, DOH: 5/17/18, lacked CPI training and a BLS certification; E#25, Certified Nurse Aide OABH, DOH: 6/4/21 lacked restraint training; E#26, Certified Nurse Aide OABH, DOH: 9/20/21 lacked restraint, CPI training and BLS certification; and E#27, Emergency Department RN, DOH: 7/28/21 lacked CPI training, ACLS and PALS certification.

9. The staffing sheets were reviewed throughout the survey on 12/7/21 through 12/10/21. The following was identified:
a) The staffing sheet noted on 11/11/21, 11/12/21, 11/13/21. 11/14/21, 11/17/21, 11/18/21, 11/19/21, 11/20/21, 12/4/21 and 12/7/21, E#1 (Emergency Department Manager) was assigned patients in the Emergency Department.
b) The staffing sheet dated 12/1/21 noted E#2 (Director of Nursing) was assigned patients on the Medical Surgical Unit from 7:00 AM to 7:00 PM and was also the House Supervisor from 7:00 AM to 3:00 PM.
c) The staffing sheet dated 12/2/21 noted the following:
1) E#28 (ED RN) was assigned to patients from 7:00 AM to 7:00 PM in the Emergency Department as well as a House Supervisor from 3:00 PM to 7:00 PM.
2) E#2 (Director of Nursing) was assigned to patients from 7:00 AM to 3:00 PM and was also assigned as the House Supervisor.
3) E#23 (OABH RN) was assigned patients on the Medical Surgical Unit from 3:00 PM to 7:00 AM (see #3).
d) The staffing sheet dated 12/3/21 noted the Medical Surgical Unit was staffed only with 2 Registered Nurses in orientation (E#29, DOH: 12/1/21 and E#30, DOH: 11/24/21) from 7:00 AM to 7:00 PM.
e) The staffing sheet dated 12/4/21 noted the Medical Surgical Unit was staffed from 7:00 AM to 7:00 PM with E#29 (orientation) and E#31 (Recovery Room Nurse).
f) The staffing sheet dated 12/5/21 noted the Medical Surgical Unit was staffed from 7:00 AM to 7:00 PM with E#29 (orientation) and from 7:00 AM to 11:00 AM with E#32 (Operating Room Nurse), 11:00 AM to 3:00 PM with E#33 (Operating Room Registered Nurse) and 3:00 PM to 7:00 PM with E#34 (Operating Room Nurse) and lacked a House Supervisor from 7:00 AM to 3:00 PM.
g) The staffing sheets for November and December 2021 noted the following staffing assignments for E#28 (Emergency Department Registered Nurse orientee, DOH: 10/11/21)
1) Orientation on 11/5/21, 11/8/21, 11/12/21, 11/13/21, 11/23/21, 11/29/21, 12/2/21, 12/6/21 and 12/7/21.
2) Staff Nurse assigned to patients on 11/16/21, 11/22/21, 12/3/21 and 12/5/21.

10. During an interview on 12/8/21 at approximately 3:00 PM, E#1 (Manager of Emergency Department) verified the findings and stated "ED (nurse) orientation is at least 12 weeks (long). It's pretty intense." E#1 reviewed the November and December 2021 staffing sheets and verbally agreed E#28 was in orientation and stated "I had to use E #28 as a staff nurse because we don't have enough staff to cover shifts." During an interview on 10/9/21 at approximately 11:00 AM, E#1 stated "Over the weekend (12/3/21, 12/4/21, 12/5/21) a nurse in orientation from Med/Surg quit because he/she wasn't comfortable working by his/herself."