HospitalInspections.org

Based on document review of staffing grids and staffing sheets from 01/01/18 to 01/19/18 and interview, the hospital failed to:

A. Ensure the Behavioral Health Unit (BHU) had an RN immediately available to provide supervision of staff or bedside care of any patient during six of 38 shifts.

B. Ensure the Behavioral Health Unit had adequate numbers of staff to meet the needs of the patients in accordance with the hospital's determined staffing grid during two of 38 shifts.

C. Ensure staffing on both units, BHU and Medical-Surgical Unit, included adequate number and qualified staff to remain on the units to meet the routine care and needs of the patients in the event of a potential hospital emergency medical response, during 13 of 38 shifts.

These failed practices had the potential to increase safety risks to patients and staff and neglect the needs of patients.

Findings:

A document titled, "Med-Surg (Medical Surgical Unit)/ BHU (Behavioral Health Unit) Staff Grid" (no date) showed the staffing patterns, per census, for both hospital units per each 12-hour shift. The grid documented not to substitute an aide with a RN if at all possible. The Staffing Grid utilized the word "Nurse" instead of designating a RN assignment within each department.

A document titled, "Daily Staffing" sheets from 01/01/18- 01/19/18 showed when a House Supervisor was on duty for the hospital, the staff assigned to respond to medical emergencies, and the staff assigned to the BHU, Med-Surg Unit, and the Emergency Department for each shift.

On 01/21/18 at 1:15 pm, Staff A stated the "Staffing Grid" (matrix) represented the minimal staffing based on patient census.

A. Behavioral Health Unit staffing with no RN

A review of "Daily Staffing" sheets from 01/01/18- 01/19/18 showed the following shifts on the Behavioral Health Unit in which no RN was assigned to the unit:
*01/03/18 (7pm-7am)
*01/08/18 (7pm-7am)
*01/09/18 (7pm-7am)
*01/10/18 (7pm-7am)
*01/16/18 (7pm-7am)
*01/17/18 (7pm-7am)

B. Behavioral Health Unit inadequate numbers of staff

A review of "Daily Staffing" sheets from 01/01/18- 01/19/18 showed inadequate staffing based on the patient census and patient acuity for the following shifts:

*01/03/18 (7pm-7am) two staff were scheduled to care for nine patients.The staffing grid showed three staff should be scheduled based on patient census and acuity.

*01/08/18 (7pm-7am) three staff were scheduled to care for 10 patients. The staffing grid showed four staff should be scheduled. On this shift, the unit had two patients requiring 1:1 observations, therefore one staff would render care for eight patients.

C. Inadequate staffing during code response

A review of the Code Response Assignments on the "Daily Staffing" sheet from 01/01/18 - 01/19/18 showed the staff who was designated responsibile to respond to any emergent medical event in the hospital for thirty-eight 12- hour shifts.

A review of "Daily Staffing" sheets from 01/01/18- 01/19/18 showed if a medical emergency occurred, which designated staff would stay on the Med-Surg and/or Behavioral Health Units.

A review of "Daily Staffing" sheets from 01/01/18- 01/19/18 showed inadequate staffing remaining on the unit(s) for the patient census in the event a medical emergency occurred in the hospital which required the Code Team to respond, on the following dates and shifts for the following units:

*01/02/18 (7 pm to 7 am) shift:
BHU: nine patients would be left in the care of two staff. The staffing matrix showed three staff should be assigned.
Med-Surg: 10 patients left in the care of one staff. The staffing matrix showed three staff should be assigned.

* 01/04/18 (7 pm to 7 am) shift:
BHU: Nine patients in the care of one staff. The staffing matrix showed three staff should be assigned. There was no House Supervisor on duty.

*01/05/18 (7 pm to 7 am) shift:
BHU: Seven patients in the care of one staff. The staffing matrix showed three staff should be assigned. .
Med-Surg: 11 patients left in the care of one staff. The staffing matrix designated three staff should be assigned.

*01/06/18 (7 pm to 7 am) shift:
BHU: Eight patients in the care of one staff RN. The staffing matrix showed three staff should be assigned.
Med-Surg: Eight patients in the care of one staff for full shift and one staff from 10:50 pm to 7 am. The staffing matrix designated two staff should be assigned.

*01/08/18 (7 pm to 7 am) shift: BHU: 10 patients in the care of two staff. The staffing matrix showed 3 staff should be assigned . On this shift, the unit had two patients requiring 1:1 observations; therefore, no staff would be available to render care for eight remaining patients. There was no House Supervisor on duty.

*01/09/18 (7 pm to 7 am) shift:
BHU: 10 patients in the care of two staff with two patients. The staffing matrix showed 3 staff should be assigned. On this shift, the unit had two patients requiring 1:1 observations; therefore, no staff would be available to render care for eight remaining patients. There was no House Supervisor on duty.

*01/13/18 Sat (7 am to 7 pm) shift:
BHU: Six patients in the care of one staff. The staffing matrix showed two staff should be assigned. There was no House Supervisor on duty.
Med-Surg: Seven patients in the care of one staff, but the staffing matrix showed two staff should be assigned. There was no House Supervisor on duty.

*01/13/18 (7 pm to 7 am) shift: BHU: Six patients in the care of one staff. The staffing matrix showed two staff should be assigned. There was no House Supervisor on duty.

*01/14/18 (7 pm to 7 am) shift:
BHU: Six patients in the care of one staff. The staffing matrix showed two staff should be assigned. There was no House Supervisor on duty.
Med-Surg: Six patients in the care of one staff. The staffing matrix showed two staff should be assigned. There was no House Supervisor on duty.

*01/17/18 97 pm to 7 am) shift:
BHU: Five patients in the care of one staff. The staffing matrix designated two staff should be assigned. There was no House Supervisor on duty.
Med-Surg: Eight patients in the care of two staff. The staffing matrix showed two staff should be assigned. On this shift, the unit had one patient requiring 1:1 observations; therefore, one staff would be available to render care for seven remaining patients. There was no House Supervisor on duty.

A review of the medical record for Patient #18 showed on 01/17/18 the patient coded on the BHU.

*A review of the Daily Staffing showed on 01/16/18, the BHU off going shift (7 pm to 7 am) had four patients and staff consisted of no House Supervisor, 1 LPN (NO RN) and 1 Aide (assigned to Code).

*The on-coming shift on 01/17/18 ( 7 am to 7 pm), the BHU consisted of six patients - no House Supervisor, 1 RN (listed as Charge) and 1 LPN (assigned to Code), and 1 Aide (floated to Med-Surg).

On 01/19/18 at 2:05 pm, Staff J stated the Behavioral Health Unit (BHU) couldn't be run with a LPN only, because there was no House Supervisor.

On 01/19/18 [time omitted], Staff G stated staffing was inadequate. Staff G stated patients who require two staff transfers or have total care needs which require no less than 3 staff for any census would not be safe.