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Based on document review, observation and interview the facility failed to follow their staffing nursing plan matrix for one (1) of three (3) patient care units reviewed. (Unit 200)

Findings include:

1. Review of the facility policy, "Nursing Staffing Plan", policy # II-C.22 issued in 01/2020, indicated the DON (Director of Nursing) would be accountable to ensure a sufficient number of qualified staff are on duty at all times to provide patients with quality care. The facilities staffing patterns are built from "historical trends, benchmark data and practice guidelines".

2. Review of the facilities staffing matrix for the 200 unit, indicated the unit should have staffed two (2) nurses for a patient census of ten (10) to twenty (20) and three (3) nurses for a patient census of twenty-one (21) to twenty-seven (27).

3. Review of the facilities staffing matrix for the 200 unit, indicated the unit should have staffed three (3) nursing aides for a patient census of ten (10) to twenty (20) and six (6) nursing aides for a patient census of twenty-one (21) to twenty-seven (27).

4. Review of the "staffing pattern worksheet" provided by the facility, indicated the 200 unit was short staffed on the following days/nights:
A. On 05/31/2020 the patient census was twenty-six (26). On days there were two (2) nurses and three (3) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed.
B. On 06/01/2020 the patient census was twenty-five (25). On days there were two (2) nurses and three (3) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nurses and four (4) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
C. On 06/02/2020 the patient census was twenty-two (22). On days there were two (2) nurses and five (5) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nurses and four (4) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
D. On 06/03/2020 the patient census was twenty-five (25). On days there were two (2) nurses and five (5) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were four (4) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed.
E. On 06/04/2020 the patient census was twenty-three (23). On days there were two (2) nurses staffed. The staffing matrix indicated there should have been three (3) nurses staffed. On nights there were three (3) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed.
F. On 06/05/2020 the patient census was twenty-two (22). On days there were two (2) nurses and four (4) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nurses and two (2) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
G. On 06/06/2020 the patient census was twenty-four (24). On days there were four (4) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed. On nights there were two (2) nurses and four (4) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
H. On 01/31/2021 the patient census was twenty-two (22). On days there were four (4) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed. On nights there were three (3) nursing aides staffed. The staffing matrix indicated there should have been three six (6) nursing aides staffed.
I. On 02/01/2021 the patient census was twenty-three (23). On days there were three (3) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed. On nights there were three (3) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed.
J. On 02/02/2021 the patient census was twenty-two (22). On days there were two (2) nurses and four (4) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nurses and three (3) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
K. On 02/03/2021 the patient census was twenty-four (24). On days there were two (2) nurses and three (3) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were five (5) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed.
L. On 02/04/2021 the patient census was twenty-five (25). On days there were two (2) nurses and two (2) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nurses and one (1) nursing aide staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
M. On 02/05/2021 the patient census was twenty-six (26). On days there were two (2) nurses and two (2) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nursing aides staffed. The staffing matrix indicated there should have been six (6) nursing aides staffed.
N. On 02/06/2021 the patient census was twenty-five (25). On nights there were two (2) two nurses and two (2) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
O. On 04/25/2021 the patient census was twenty-five (25). On days there were two (2) nurses and three (3) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nurses and two (2) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
P. On 04/26/2021 the patient census was twenty-four (24). On days there were two (2) nurses and four (4) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed. On nights there were two (2) nurses and three (3) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.
Q. On 04/27/2021 the patient census was twenty-three (23). On days there were three (3) nursing aides staffed. The staffing matrix indicated there should have been three six (6) nursing aides staffed. On nights there were two (2) nurses and three (3) nursing aides staffed. The staffing matrix indicated there should have been three (3) nurses and six (6) nursing aides staffed.

5. Review of the "Daily Census Sheet" provided by A # 9 (Compliance), indicated the facility had vacancies for ten and a half (10.5) full time equivalent (FTE's) and/or 420 hours available for registered nurses (RN's). There were seven (7) FTE's and/or 280 hours available for a licensed practical nurse (LPN) and seven (7) FTE's and/or 280 hours available for a nursing assistant.

6. During a tour of the 200 unit on 4/28/2021 at approximately 9:48 am with administrative staff member A # 5 (Interim Director of Nursing), the unit was staffed with three (3) mental health technicians (MHT's). The patient census at that time was twenty three (23) which would have required six (6) MHT's per staffing matrix.

7. In interview on 04/28/2021 at approximately 3:40 pm with administrative staff member A # 5, confirmed the 200 unit was short staffed three (3) MHT's. "We have staffing issues with nurses and MHT's. We have problems getting staff here". At 4:00 pm confirmed the staffing matrix/grid uses the term nursing assistants but they are really MHT's.

8. In interview on 04/28/2021 at approximately 4:00 pm with administrative staff member A # 9 (Compliance), confirmed the staffing policy/matrix was the most current up to date version.

Based on document review, observation and interview the nurse failed to follow facility policy and procedure related to documenting required information on laboratory requisition forms and laboratory log sheets in six (6) of twelve (12) specimens observed. (Patient # 1, Patient # 2 and Patient # 3)

Findings include:

1. Review of the hospital policy titled, "Laboratory Process and Procedures", policy # I-C.29, Issued 1/2020, indicated the provider order is transcribed on the laboratory requisition form. A STAT (instantly/immediately) lab "is identified as a STAT on the requisition form and laboratory log" sheet. The date/time of collection are added to the lab log sheet.

2. Review of the medical record (MR) for patient # 1 on 04/28/2021 at approximately 9:30 am, indicated on 04/27/2021 at 11:10 am the nurse practitioner (NP) ordered "urinalysis/culture & sensitivity STAT".

3. Review of the MR for patient # 2 on 04/28/2021 at approximately 9:35 am, indicated on 04/28/2021 at 11:00 am the NP ordered "urinalysis/culture & sensitivity STAT".

4. During tour on 04/28/2021 at 9:45 am with NS # 1 (Registered Nurse-RN), the patient specimen log sheets and refrigerated specimens were observed. The following six (6) specimens lacked appropriate documentation:
A. Patient # 1 - The urinalysis lab requisition form and lab log sheet lacked documentation indicating the specimen was a STAT order. An additional lab requisition form lacked date of service and ordering provider. The lab log sheet lacked the time the specimen had been ordered.
B. Patient # 2 - The urinalysis lab requisition form and lab log sheet lacked documentation indicating the specimen was a STAT order. Two additional lab requisition forms were lacking documentation indicating date of service and ordering provider.
C. Patient # 3 - The lab requisition form lacked date of service and ordering provider.

5. In interview with NS # 1 on 04/28/2021 at approximately 9:45 am, confirmed the lab requisition forms should be filled out completely with the date of service and ordering provider. The form should also indicate if the test should be performed STAT. The lab log sheet should reflect the same information such as date/time and/or STAT.

6. In interview with administrative staff member A # 5 (RN-Interim Director of Nursing) on 04/28/2021 at 10:05 am, confirmed the nurses are supposed to document the date, time and ordering provider on the lab requisition form. At 12:20 pm indicated if the lab requisition form or lab log sheet doesn't indicate STAT they (lab) "won't know it's a STAT"