HospitalInspections.org

Based on document reviews and interviews, the facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses (RNs) to provide nursing care to all patients as needed, in accordance with the facility's nurse staffing plan in one of three nursing units reviewed (Two South).

Findings include:

Facility policy:

The Master Staffing Plan policy read, its purpose was to establish Colorado hospital provisions as well as standards of performance for safe nursing care. The hospital shall have a staffing system based on the assessment of patient needs in conformance with the accreditation requirements of the Joint Commission and a documented staffing plan in accordance with HB 22-1401: Hospital Nursing Staffing Standards and Colorado Department of Public Health and Environment (CDPHE) Standards for Hospitals and Health Facilities Chapter 4. A nurse staffing plan shall be developed based on scope of care that meets the needs of the patient population, acuity, and frequency of care to be provided.

References:

According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that: (c) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines.

The staffing plans, which were identified by staff as the facility's staffing grids, were provided by the facility. The staffing plans listed the name of each unit at the facility, specified the variable patient census range for each unit, and the specified number of registered nurses (RN) and certified nursing assistants (CNA) expected to be staffed and present on each unit according to the current patient census. The staffing plans specified the nurse-to-patient ratios according to the patient census and amount of nurses required.

The Scope of Service - Telemetry for the Two South unit read, services provided include diagnosis, treatment, and coordination of care to patients with multiplex complex medical/surgical problems in the inpatient setting. Nurses are competent to care for this wide variety of patient populations and care needs. The unit is staffed based on each shift's patient census.

According to the RN Clinical Nurse Coordinator (CNC) (charge nurse) job description, the CNCs job responsibilities are to provide leadership, support, and coordination of the unit's daily operations during designated shifts. Assists in directing, organizing, and prioritizing all shift activities ensuring patient care and staff needs are met. Ensures appropriateness of admission/cases to the unit/department and appropriate staff skill mix exists to provide safe patient care. Immediate problem-solving patient complaints and other issues that could negatively impact patient care. Functions effectively as relief Nurse Manager as needed/requested. Evaluates staff performance; completes annual staff evaluations as requested.

1. The facility failed to ensure minimum staffing requirements were maintained to allow adequate numbers of licensed registered nurses (RNs) to provide nursing care to all patients as needed.

A. Document Review

i. The Two South staffing assignment sheets revealed multiple occasions between 7/30/24 and 8/6/24 when staffing did not align with the unit staffing plan. Examples included:

a. From 7/30/24 to 8/6/24 for a census of 27 patients Two South was consistently staffed with one charge nurse who was assigned at least two patients and five nurses who were assigned at least five patients.

This was in contrast to the Two South - telemetry staffing grid which read for 27 patients the unit should have been staffed with one charge nurse and six RNs on the 7:00 a.m. to 7:00 p.m. shift and the 7:00 p.m. to 7:00 a.m. shift.

b. On 8/4/24 the Two South staffing assignment sheet for 7:00 p.m. to 7:00 a.m. revealed for a census of 28 patients the charge nurse was assigned five patients from midnight to 7:00 a.m., three RNs were assigned six patients for the shift, and one RN was assigned five patients for the shift. One of the RNs taking a six patient assignment was the unit manager.

This was in contrast to the Two South - telemetry staffing grid which read for 28 patients the unit should have been staffed with one charge nurse and six RNs as opposed to the actual staffing for the shift which was deficient two RNs and had a charge nurse with a five patient assignment.

c. On 8/6/24 the Two South staffing assignment sheet for 7:00 a.m. to 7:00 p.m. revealed for a census of 27 patients the charge nurse was assigned two patients, four RNs were assigned five patients, an LPN was assigned five patients, and three patient care technicians (PCT) were on duty.

This was in contrast to the Two South - telemetry staffing grid which read for 27 patients the unit should have been staffed with one charge nurse, six RNs, and four PCTs. The Two South - telemetry staffing grid did not include LPNs who had a limited scope of practice compared with RNs who were needed due to the complexity of patients on the unit. The actual staffing for the shift was deficient two RNs and one PCT.

d. On 8/6/24 the Two South staffing assignment sheet for 7:00 p.m. to 7:00 a.m. revealed for a census of 26 patients the charge nurse was assigned three patients, three RNs were assigned six patients, and one RN was assigned five patients. Also, there was only one PCT on the assignment sheet for the shift.

This was in contrast to the Two South - telemetry staffing grid which read for 26 patients the unit should have been staffed with one charge nurse, five RNs, and three PCTs. The actual staffing for the shift was deficient two PCTs, an RN, and the charge nurse had three patients.

ii. The Master Staffing Plan policy did not align with the actual implementation of the policy.

a. The Master Staffing Plan policy read, its purpose was to establish Colorado hospital provisions as well as standards of performance for safe nursing care. The policy read the hospital would have a staffing system based on the assessment of patient needs in accordance with HB 22-1401: Hospital Nursing Staffing Standards and Colorado Department of Public Health and Environment (CDPHE) Standards for Hospitals and Health Facilities Chapter 4. Also, the policy read a nurse staffing plan would be developed based on scope of care that met the needs of the patient population, acuity, and frequency of care provided.

This was in contrast to the Scope of Service - Telemetry for the Two South unit which read the unit was staffed each shift based on the patient census.

Additionally, an acuity tool to determine nurse staffing needs was requested and facility leaders stated that an acuity tool was not utilized at the facility.

b. According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee would annually develop and oversee a master nurse staffing plan for the hospital that: (c) Included minimum staffing requirements for each inpatient unit and emergency department that were aligned with nationally recognized standards and guidelines.

The staffing grids provided by the facility were referred to as guidelines by facility leaders which was in contrast to the regulation which stated the nurse staffing committee would annually develop and oversee a master nurse staffing plan that included minimum staffing requirements for each inpatient unit.

Additionally, national guidelines used to determine the facility master staffing plan were requested and facility leaders did not provide any. Furthermore, CNO #5 stated they were unaware of national guidelines for staffing medical-surgical nursing units.

B. Interviews

i. On 9/26/24 at 11:24 a.m. an interview was conducted with RN #1. RN #1 stated Two South was the cardiac and trauma floor with higher acuity patients. RN #1 stated staffing ratios on the unit were one nurse to five or six patients. Also, RN #1 stated on Two South the CNC (clinical nurse coordinator, or charge nurse) would take a patient assignment; however, there were few charge nurse-appropriate patients on Two South due to the higher acuity patients. This made the CNC less available to the staff. RN #1 compared the Two South staffing with nurse staffing on the other medical-surgical units in the facility which utilized a pod concept of RNs and LPNs working as a team. RN #1 stated the RN could assist the LPN but there were few things the RN could delegate to the LPN which created a heavier workload for RNs. Additionally, RN #1 stated they were not aware of a nurse staffing committee in the facility. Further, RN #1 stated front-line nurses did not have a say in staffing decisions.

ii. On 9/30/24 at 12:32 p.m. an interview was conducted with CNC #2. CNC #2 stated Two South was the main telemetry and trauma unit which admitted patients who were ICU stepdown level of care. CNC #2 stated their charge nurse duties included to ensure discharges were timely, assign new admissions, unit throughput (moving admitted and discharged patients in and out of the unit efficiently), assist the nursing staff with clinical questions, round on patients and families, and to ensure patients were cared for while all staff got a lunch break. CNC #2 stated they had supervisory and management duties like coaching staff in the moment when issues occurred.

Also, CNC #2 stated they provided patient care every shift taking two patients. They said the ratio on Two South was one nurse to five patients and they staffed to a census of 27 so the charge nurse always took two patient assignments. CNC #2 said this was decided by a prior CNO when they were adjusting their matrix. CNC #2 stated today staffing on Two South was one CNC, five RNs, and two PCTs with a census of 27 patients. CNC #2 described this as typical staffing except they were short one PCT. CNC #2 stated charge nurse tasks that got delayed due to patient care included shift audits such as neuro checks or restraint use. CNC #2 stated when charge duties got too busy they relied on other RNs and PCTs to help with patient care or patients just had to wait.

Further, CNC #2 stated they did not know if there was a specific staffing committee. They said there was a bed meeting each shift where nursing supervisors and CNCs met to determine staffing needs and allocate resources for a shift and that might be considered a nurse staffing committee. CNC #2 stated frontline nursing staff would bring staffing concerns to the unit manager, staff meeting, or unit-based council (UBC) meetings.

iii. On 9/26/24 at 9:45 a.m. an interview was conducted with nursing supervisor (Supervisor) #3. Supervisor #3 stated their responsibility was to look at the schedule for the day and reallocate resources as needed. Supervisor #3 stated the nursing supervisors received sick calls and recently there had been a high volume. Supervisor #3 stated there was a staffing grid for each unit which was used as a guideline. The goal was to staff each unit according to the grid but they could not always achieve it. Supervisor #3 said if they could not achieve the staffing grid then they had the option to cap the census on a given unit. Also, Supervisor #3 stated Two South was considered a more acute unit which took trauma, stroke, and cardiac patients and needed more staff resources. Finally, Supervisor #3 stated they did not know what the staffing grids were based on and they were not involved in how the staffing grids were developed. Supervisor #3 stated they thought the grids were standard throughout the entire hospital division.

iv. On 9/25/24 at 2:06 p.m. an interview was conducted with nurse manager (Manager) #4. Manager #4 stated the Two South staffing grid was used as a guideline to staff the unit. Manager #4 stated the grids were a guideline, a budgeted amount of staff for the unit. Also, they stated the charge nurse looked at staffing shift by shift and if acuity was high would adjust staff as needed. Manager #4 stated there was no acuity tool used to measure patient acuity. Additionally, Manager #4 stated they did not know what national guidelines were used to make the staffing grids. Further, Manager #4 stated the unit would cap census at times based on census and acuity however this process was not written in policy. Manager #4 described the nurse staffing committee as the unit-based council (UBC) which consisted of themselves and the charge nurses on the unit and others were welcome to attend. Minutes of the UBC meetings were submitted to the CNO for the master staffing plan. Manager #4 stated the CNC council was the hospital-wide staffing committee.

v. On 9/25/24 at 2:40 p.m. an interview was conducted with chief nursing officer (CNO) #5. CNO #5 stated that each unit had a unit-based staffing committee that met monthly. CNO #5 stated UBCs were attended by a combination of the bedside nurses and the CNCs with the nurse manager. According to CNO #5, the UBCs were intended to be a discussion about concerns and suggestions for improvement which were forwarded to the CNO and brought to the quarterly CNC council meetings. CNO #5 stated the CNC council meetings were the quarterly staffing committee review and the recommendations were brought to the quarterly executive review, which was a meeting of all nurse leaders, to determine what recommendations the facility could implement. Also, CNO #5 stated the staffing grids were a budgeted amount of staffing provided on an annual basis and reviewed during the year as needed. CNO #5 stated they did not know how the grids were budgeted and did not know of any national guidelines used to determine staffing on a medical-surgical nursing unit. CNO #5 stated all sister facilities fell into the same grid system based on the type of patient unit.

On 9/30/24 at 1:15 p.m., an additional interview was conducted with CNO #5. CNO #5 stated CNCs were considered front-line staff because, while it was not ideal or an everyday occurrence, CNCs still provided patient care. CNO #5 stated the preference was for CNCs not to have a patient assignment but they were not always able to achieve that.

This interview was in contrast to the Two South daily staffing assignment sheets and previous interviews which revealed the CNCs on Two South took a patient assignment of two or more patients daily.