HospitalInspections.org

Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure patients were free from neglect.

Patient #2 punched Patient #3 on 09/15/19, resulting in both patients being placed on one-on-one (1:1) supervision after the altercation which occurred at approximately 7:00 PM. However, review of the staffing on the Integrity Unit from 7:00 PM on 09/15/19 through 7:00 AM on 09/17/19, revealed insufficient numbers of staff to provide one-on-one (1:1) supervision for both patients.

The findings include:

Review of the facility "Levels of Observation and Precaution Levels" Policy, last revised 06/2019, revealed one-to-one (1:1) observation as ordered by a physician consisted of a dedicated staff member within arms length of the patient at all times. The Policy further revealed the Registered Nurse (RN) may not decrease any level of ordered supervision, only a physician's order may do so.

Review of the facility "Patient Rights and Responsibilities" Policy, revised 01/2019, revealed patients have the right to be free of neglect, and be treated in a safe environment with respect to personal dignity, autonomy, and privacy.

Review of the facility "Abuse and Neglect Reporting" Policy, revised 09/2019, revealed Neglectful Supervision was defined as placing in, or failing to remove, the person from a situation that a reasonable individual would realize required judgement or actions beyond that persons level of maturity, physical condition or mental abilities and results in bodily injury or substantial risk or immediate harm to the person."

Review of Patient #2's medical record revealed the facility admitted the resident on 09/01/19 with diagnoses to include Dementia with Behavioral Disturbance. Further, Patient #2 transferred from the local emergency room where he/she had been admitted from a facility due to aggression towards staff. Continued review of the medical record, revealed Patient #2 exhibited wandering behaviors in addition to aggression, and was placed on one-on-one (1:1) supervision following an altercation with another patient on 09/15/19.

Review of Patient #3's medical record revealed the facility admitted the resident on 09/15/19 with a diagnoses to include Unspecified Psychosis. Further review of the medical record, revealed Patient #1 was placed on one on one (1:1) supervision following an altercation with another resident on 09/15/19.

Review of an Incident Report, dated 09/15/19, revealed at 7:00 PM, on the Integrity Unit, Patient #2 attempted to harm staff after punching Patient #3. The Summary Section of the Incident Report, revealed Patient #2 was placed in a physical hold until he/she was able to calm down and receive PRN (as needed) medication.

Review of the staffing for 09/15/19, on the Integrity Unit, revealed there was a census of nine (9) patients on the unit following two (2) admissions, including Patient #3. From 7:00 AM to 3:00 PM, on 09/15/19, no direct care staff was assigned to the unit, only Registered Nurse (RN) #1. From 3:00 PM on 09/15/19 through 7:00 AM on 09/16/19, the following morning, there was one (1) direct care staff assigned in addition to an RN. There was no documented evidence a staff member was assigned to one-to-one (1:1) care for Patient #2 or Patient #3, following the 7:00 PM incident on 09/15/19.

Review of the staffing for 09/16/19, on the Integrity Unit, revealed there was a census of eight (8) patients on the unit, necessitating one (1) direct care staff. However, two (2) patients were identified as requiring one-to-one (1:1) supervision, meaning each of these patients required a direct care staff be assigned to them. Documentation revealed from 7:00 AM to 3:00 PM, on 09/16/19, only two (2) direct care staff were assigned to the unit, indicating only one (1) patient received one-to-one (1:1) supervision. From 3:00 PM to 11:00 PM, on 09/16/19, only one (1) direct care staff was assigned to the unit, indicating neither of the two (2) patients received one-to-one (1:1) supervision. From 11:00 PM on 09/16/19 through 7:00 AM on 09/17/19, only two (2) direct care staff were assigned to the unit, indicating only one (1) patient received one-to-one (1:1) supervision.

Interview with RN #1, on 09/30/19 at 11:56 AM, revealed the Integrity Unit was so short staffed on 09/15/19, she did not feel it was safe for the patients. She stated the Integrity Unit, which was the geriatric unit, had been moved from a full-sized unit to a small back hallway due to census. Continued interview revealed the facility was often short staffed, yet the facility continued to admit patients despite not having the staff numbers to appropriately care for the patients. Further interview revealed the facility also admitted patients without sufficient room on the unit. She stated the Integrity Unit had six (6) rooms for two (2) patients each, to hold a maximum census of twelve (12) patients; however, recently a thirteenth (13th) patient had to be assigned a room on a neighboring unit.

Interview with RN #3, on 10/01/19 at 4:42 PM, revealed she was assigned to the Integrity Unit on 09/16/19 from 7:00 AM to 7:00 PM. She stated she did not recall the date in question, so everything must have gone well. She further stated when there was not a specific staff member assigned to provide one-to-one (1:1) supervision as required, she would stay with the patient, and then have a SRNA stay with the patient when she attended to other duties. Further interview revealed she was unaware of any incidents occurring due to lack of staff assigned to provide one-to-one (1:1) supervision; however, she stated there was the potential for patient harm when there was not specific staff assigned to patients that required one-to-one (1:1) supervision.

Interview with State Registered Nurse Aide (SRNA) #3, on 10/01/19 at 9:59 AM, revealed the Integrity unit only had twelve (12) beds, but the unit admitted a thirteenth (13th) patient with one (1) patient having to be placed on the neighboring unit. SRNA #3 confirmed sometimes there was only one (1) direct care staff on the unit, even if there was a patient who required one-to-one (1:1) supervision, and the SRNA would be expected to provide the one-to-one (1:1) supervision while caring for the other patients as well.

Interview with SRNA #4, on 10/01/19 at 1:42 PM, revealed sometimes if there was not enough staff on the Integrity Unit, she would provide one-to-one (1:1) supervision as required, while also providing care for other patients. She stated there had been times when she had been responsible for supervising three (3) or four (4) residents requiring one-to-one (1:1) supervision by herself. She further stated Patient #2 was very hard to redirect, liked to fight, and she had heard he/she had punched Patient #3 two (2) weeks ago. Per interview, it was important to provide the one-to-one (1:1) supervision to these patients as ordered due to their aggression and behaviors.

Interview with SRNA #5, on 10/01/19 at 4:06 PM, revealed often the Integrity Unit was short staffed and did not have the staff needed in order to provide one-to-one (1:1) supervision. She stated when a SRNA was assigned to one-to-one (1:1) supervision for a patient, they could not keep their eyes on the patient all the times if the needed to help another patient. She further stated staff was supposed to sit with patients who required one-to-one (1:1) supervision; however, if there was not enough staff to provide the one on one (1:1) supervision, there was a risk to the patients.

Interview with the Direct Care Supervisor, on 10/01/19 at 10:30 AM, revealed the staffing requirements for the Integrity Unit, was one (1) nurse and one (1) SRNA or Mental Health Technician (MHT). Further, when census reached twelve (12), the staffing requirements was two (2) nurses and two (2) SRNAs or MHTs. He further stated one-to-one (1:1) supervision was considered outside of the regular census, with each patient on one-to-one (1:1) supervision assigned a specific staff member. Continued interview with the Direct Care Supervisor, on 10/01/19 at 12:13 PM, revealed review of the staffing sheets for the past few months indicated staffing was too low for one-to-one (1:1) supervision to take place.

Interview with the Director of Quality, on 10/01/19 at 2:14 PM, revealed the staffing grid the facility utilized was a guideline based on national standards, with schedulers and house supervisors involved in staffing coverage to ensure patients were safe. She stated she knew Patient #2 had multiple incidents of aggression due to his/her confusion and mental status, but was unaware of the incident on 09/15/19 or the staffing sheets which indicated one-to-one (1:1) needs were not being met, prior to this survey.

Interview with the Assistant Director of Nursing (ADON), on 10/01/19 at 5:08 PM, revealed she did not know if the the staffing sheets were correct, as they indicated insufficient numbers of staff. She stated it was her expectation any patient requiring one-to-one (1:1) supervision was to be in visual sight and within arms length of a staff member at all times.

Interview with the Chief Nursing Officer (CNO), on 10/01/19 at 5:43 PM, revealed the staffing sheets may not have been updated and may not be accurate. However, he stated without accurate documentation there was no way to prove appropriate supervision had been provided. He stated, aside from the staffing sheets, he was uncertain of any place else one-to-one (1:1) supervision would be documented. He further stated he felt the facility did not have a good process to show coverage was being provided. However, he acknowledged the facility should ensure there was adequate staff on the units in order to provide one-to-one (1:1) supervision as required.

Based on interview, record review, and review of the Staffing Grid, it was determined the facility failed to provide adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel to provide nursing care to all patients as needed. Review of staffing for the months of July, August, and September 2019, revealed multiple instances in which there was a lack of sufficient staff on various units.

The findings include:

Review of the facility "Levels of Observation and Precaution Levels" Policy, last revised 06/2019, revealed one-to-one (1:1) observation as ordered by a physician consisted of a dedicated staff member within arms length of the patient at all times. The Policy further revealed the Registered Nurse (RN) may not decrease any level of ordered supervision, only a physician's order may do so.

Review of the Staffing Grid submitted for review for the Bridges, Integrity, Foundations, and Compass Units, revealed all units required the same minimum staffing numbers. Further review revealed the required minimum number of licensed staff and Mental Health Technicians (MHT) changed depending on the census.

Review of facility staffing for July 2019, revealed the following:

On 07/04/19, on the Foundations/ Compass Units, there was a census of fifteen (15) patients for the two (2) units combined, from 7:00 PM to 7:00 AM, and there was one (1) licensed staff assigned for the two (2) units combined. However, according to the Staffing Grid, there should have been two (2) licensed staff for the two (2) units combined for a census of fifteen (15) patients.

On 07/05/19, on the Foundations/Compass Units, there was a census of sixteen (16) patients for the two (2) units combined, from 7:00 AM to 7:00 PM, and there was one (1) licensed staff for the two (2) units combined. However, according to the Staffing Grid, there should have been two (2) licensed staff for the two (2) units for a census of fifteen (16) patients.

On 07/06/19, on the Integrity Unit, there was a census of five (5) patients including one (1) patient requiring one-to-one (1:1) supervision. There was one (1) direct care staff assigned from 7:00 AM on 07/06/19 through 7:00 AM on 07/07/19. According to the Staffing Grid, there was insufficient staffing for the one-to-one (1:1) patient coverage as required from 7:00 AM on 07/06/19 through 7:00 AM on 07/07/19.

On 07/07/19, on the Integrity Unit, there was a census of six (6) patients including the need for one one-to-one (1:1) supervision for one (1) patient. Only one (1) direct care staff was assigned from 7:00 AM on 07/07/19 through 7:00 AM on 07/08/19. According to the Staffing Grid, there should have been one (1) direct care staff if there was no requirement for one-to-one (1:1) patient supervision. There was insufficient staffing from 7:00 AM on 07/07/19 through 7:00 AM on 07/08/19, for the one-to-one (1:1) patient coverage as required.

On 07/09/19, on the Integrity Unit, there was a census of six (6) patients including two (2) patients requiring one-to-one (1:1) supervision. According to the staffing Grid and the staffing numbers on the unit, one (1) patient requiring one-to-one (1:1) supervision was not covered from 7:00 AM to 11:00 PM, and two (2) patients requiring one-to-one (1:1) supervision were not covered from 11:00 PM on 07/09/19 through 7:00 AM on 07/10/19.

On 07/10/19, on the Integrity Unit, there was a census of six (6) patients including one (1) patient requiring one-to-one (1:1) supervision; however, there was only one (1) direct care staff assigned from 3:00 PM to 11:00 PM. According to the Staffing Grid, and the staffing numbers on the unit, there was not sufficient staffing coverage on the unit in order to ensure one-to-one (1:1) coverage for one (1) patient.

On 07/11/19, on the Integrity Unit, there was a census of six (6) patients including two (2) patients requiring one-to-one (1:1) supervision. According to the Staffing Grid, and the staffing numbers on the unit neither patient requiring one-to-one (1:1) supervision was covered from 7:00 AM to 11:00 PM on 07/11/19; and one (1) patient requiring one-to-one (1:1) supervision was not covered from 11:00 PM on 07/11/19 through 07/12/19.

On 07/12/19, on the Integrity Unit there was a census of six (6) patients, including two (2) patients requiring one-to-one (1:1) supervision. According to the Staffing Grid, and the staffing numbers on the unit, there was not enough staff on the unit to provide one-to-one (1:1) supervision to either patient from 7:00 AM on 07/12/19 through 7:00 AM on 07/13/19.

On 07/29/19, on the Integrity Unit, there was a census of eight (8) patients, including one (1) patient requiring one-to-one (1:1) supervision. However, according to the Staffing Grid and the staffing numbers on the unit, there was not enough staff on the unit to provide one-to-one (1:1) supervision from 3:00 PM to 11:00 PM.

Review of facility staffing for August 2019, revealed the following:

On 08/04/19, on the Integrity Unit, there was a census of thirteen (13) patients, and there was only one (1) direct care staff assigned. However, according to the Staffing Grid, for a census of thirteen (13), there should be a minimum of two (2) direct care staff from 3:00 PM to 7:00 PM, revealing the unit was not sufficiently staffed.

On 08/16/19, on the Bridges Unit, there was a census of thirty (30) patients, with only two (2) direct care staff assigned from 7:00 AM to 3:00 PM. However, according to the Staffing Grid, for a census of thirty (30) patients, there should be three (3) direct care staff, revealing the unit was not sufficiently staffed.

On 08/18/19, on the Integrity Unit, there was a census of seven (7) patients, including three (3) patients requiring one-to-one (1:1) supervision; and only two (2) direct care staff assigned from 3:00 PM to 7:00 PM. According to the Staffing Grid, for a census of seven (7) patients, there should be one (1) direct staff member. This revealed two (2) patients on the unit requiring the one-to-one (1:1) supervision did not receive supervision as required.

On 08/19/19, on the Bridges Unit, there was a census of nineteen (19) patients, with only one (1) direct care staff assigned from 7:00 AM to 7:00 PM. According to the Staffing Grid, there should have been two (2) direct care staff on the unit, revealing insufficient staffing coverage.

On 08/20/19, on the Integrity Unit, there was a census of seven (7) patients and three (3) patients required one-to-one (1:1) supervision. However, there were only three (3) direct care assigned from 3:00 PM until 11:00 PM, revealing there was one (1) patient who would not have received one to one (1:1) supervision as required.
In addition, there was no licensed nurse assigned to the Integrity unit from 7:00 PM on 08/20/19 until 7:00 AM on 08/21/19; however, according to the Staffing Grid there should have been at least one (1) licensed nurse on the unit. This revealed insufficient staffing coverage.

On 08/22/19, on the Integrity Unit, there was a census of seven (7) patients and three (3) patients required one-to-one (1:1) supervision. However, there was only three (3)direct care staff assigned from 3:00 PM to 7:00 PM. This revealed one (1) patient requiring one on one (1:1) supervision did not receive the supervision as required.

On 08/24/19, on the Integrity Unit, there was a census of six (6) patients and two (2) patients required one-to one (1:1) supervision. However, there was only one (1) direct staff member from 7:00 AM on 08/24/19 until 7:00 AM on 08/25/19. According to the Staffing Grid, there would not have been coverage to assign the two (2) patients requiring one-to one (1:1) supervision a staff member. In addition, there was no licensed nurse to cover the unit from 7:00 PM on 08/24/19, through 7:00 AM on 08/25/19, and according to the Staffing Grid there should have been at least one (1) licensed nurse on the unit. This revealed insufficient staffing coverage.

On 08/25/19, on the Bridges Unit, with a census of thirty-three (33) patients, and there were only two (2) direct care staff to cover from 7:00 AM to 3:00 PM. However, according to the Staffing Grid, there should have been at least three (3) direct care staff.

On 08/25/19, on the Integrity Unit, there was a census of five (5) patients with two (2) patients requiring one-to-one (1:1) supervision from 7:00 AM on 08/25/19 through 7:00 AM on 08/26/19. However, according to the Staffing Grid, there should have been at least one (1) direct care staff for five (5) patients. This indicated there was not sufficient staffing coverage to supervise the two (2) patients requiring one-to one (1:1) supervision.

On 08/26/19, on the Integrity Unit, there was a census of six (6) patients and two (2) patients required one-to-one (1:1) supervision from 7:00 AM until 7:00 PM. According to the Staffing Grid, there was insufficient staffing to provide one-to-one (1:1) supervision for the two (2) patients as required.

On 08/27/19, on the Integrity Unit, there was a census of seven (7) patients and two (2) patients required one-to-one (1:1) supervision. According to the Staffing Grid, there was insufficient staffing to provide one-to-one (1:1) supervision for one (1) of the patients requiring the supervision from 3:00 PM on 08/27/19 through 7:00 AM on 08/28/19.

On 08/31/19, on the Bridges Unit, there was a census of twenty-seven (27) patients, and one (1) patient required one-to-one (1:1) supervision. However, there was only two (2) direct care staff assigned from 3:00 PM to 7:00 PM. According to the Staffing Grid, there was insufficient numbers of staff in order to provide supervision to the one (1) patient requiring one-to-one (1:1) supervision.

On 08/31/19, on the Integrity Unit, there was a census of eight (8) patients, including two (2) patients requiring one-to-one (1:1) supervision. According to the Staffing Grid, there was insufficient numbers of direct care staff to supervise one (1) of the patients requiring one-to-one (1:1) supervision from 7:00 AM until 7:00 PM, and again from 11:00 PM on 08/31/19 until 7:00 AM on 09/01/19.

Review of facility staffing for September 2019, revealed the following:

On 09/01/19, on the Bridges Unit, there was a census of twenty-nine (29) patients, and two (2) licensed staff were scheduled from 3:00 PM until 7:00 PM. However, according to the Staffing Grid, there should have been four (4) licensed staff. In addition, there were two (2) direct care staff from 3:00 PM until 7:00 PM, when there should have been three (3) direct care staff.

On 09/01/19, on the Integrity Unit, there was a census of eight (8) patients with two (2) patients requiring one-to-one (1:1) supervision. However, there was only one (1) direct care staff assigned from 7:00 AM until 3:00 PM, indicating neither of the two (2) patients requiring one-to-one (1:1) supervision received adequate supervision as required. Starting at 3:00 PM until 7:00 PM, an additional direct care staff was assigned, indicating only one (1) of the patients requiring one-to-one (1:1) supervision did not receive the supervision as required.

On 09/07/19, on the Integrity Unit, there was a census of eight (8) patients and two (2) patients required one-to-one (1:1) supervision. There was only one (1) direct care staff assigned. According to the Staffing Grid, there was insufficient numbers of staff to provide one-to-one (1:1) supervision for the two (2) patients requiring one-to-one (1:1) supervision from 7:00 AM on 09/07/19 through 7:00 AM on 09/10/19.

On 09/12/19, on the Foundations Unit, there was a census of thirteen (13) patients, only one (1) direct care staff was assigned from 3:00 PM until 7:00 PM. According to the Staffing Grid, there should have been two (2) direct care staff.

On 09/13/19, on the Bridges Unit, there was a census of twenty (20) patients and only two (2) licensed staff were assigned from 3:00 PM until 5:00 PM. Also, there was only one (1) licensed staff assigned from 5:00 PM until 7:00 PM. However, according to the Staffing Grid, there should have been three (3) licensed staff from 3:00 PM through 7:00 PM.

On 09/13/19, on the Integrity Unit, there was a census of seven (7) patients and one (1) patient requiring one-to-one (1:1) supervision. However, there was only one (1) direct care staff assigned from 7:00 AM on 09/13/19 until 7:00 AM on 09/14/19, revealing there was insufficient staffing to provide one-to-one (1:1) supervision to the patient who required this supervision.

On 09/14/19, on the Bridges Unit, there was a census of twenty-nine (29) patients, and only two (2) direct care staff were assigned from 7:00 AM until 7:00 PM. However, according to the Staffing Grid, there should have been three (3) direct care staff. Also on the Bridges Unit, on 09/14/19, there was only three (3) licensed staff scheduled from 3:00 PM until 7:00 PM, and according to the Staffing Grid, there should have been four (4) licensed nurses during this time period.

On 09/15/19, on the Bridges Unit, there was a census of thirty-six (36), and only two (2) direct care staff were assigned from 7:00 AM until 11:00 PM. However, according to the Staffing Grid, there should have been three (3) direct care staff. Also, on 09/15/19 from 11:00 PM until 09/16/19 at 7:00 AM, there was only two (2) licensed nurses, and according to the Staffing Grid, there should have been three (3) licensed nurses during this time period.

On 09/15/19, on the Integrity Unit, there was a census of nine (9) residents on the unit following two (2) admissions. From 7:00 AM to 3:00 PM, on 09/15/19, no direct care staff was assigned to the unit, only a licensed nurse. However, according to the Staffing Grid, there should have been one (1) direct care staff and one (1) licensed nurse. On 09/15/19 from 3:00 PM through 09/16/19 at 7:00 AM, there was one (1) direct care staff and one (1) licensed nurse; however, starting at 7:00 PM on 09/15/19, two (2) patients required one-to-one supervision. According to the Staffing grid, there was not sufficient staffing to provide one-to-one (1:1) supervision to either of these two (2) patients.

On 09/16/19, on the Integrity Unit, there was a census of eight (8) patients on the unit, necessitating one (1) direct care staff. However, two (2) patients were identified as requiring one-to-one (1:1) supervision. From 7:00 AM to 3:00 PM, on 09/16/19, only two (2) direct care staff were assigned to the unit, indicating only one (1) patient received one-to-one (1:1) supervision. From 3:00 PM to 11:00 PM, on 09/16/19, only one (1) direct care staff was assigned to the unit, indicating neither of the two (2) patients received one-to-one (1:1) supervision. From 11:00 PM on 09/16/19 through 7:00 AM on 09/17/19, only two (2) direct care staff were assigned to the unit, indicating only one (1) patient received one-to-one (1:1) supervision.

On 09/16/19, on the Bridges Unit, there was a census of thirty-seven (37) patients and only two (2) licensed nurses from 3:00 PM on 09/16/19 until 7:00 AM on 09/17/19, and according to the Staffing Grid, there should have been at least three (3) licensed nurses. Also, on 09/16/19 from 7:00 AM until 11:00 PM, there was only two (2) direct care staff, and according to the Staffing Grid, there should have been three (3) direct care staff.

On 09/23/19, on the Bridges Unit, there was a census of thirty-eight (38) patients and only two (2) direct care staff were assigned from 7:00 AM until 11:00 PM. However, review of the Staffing Grid, revealed there should have been three (3) direct care staff.

On 09/23/19, on the Integrity Unit, there was a census of seven (7) patients and one (1) patient required one-to-one (1:1) supervision. There was only one (1) direct care staff from 3:00 PM on 09/23/19 until 7:00 AM on 09/24/19. According to the Staffing Grid, there was insufficient staff to provide one-to-one (1:1) supervision to the patient.

On 09/25/19, on the Integrity Unit, there was a census of seven (7) patients and two (2) patients that required one-to-one (1:1) supervision. There was only two (2) direct care staff assigned from 09/25/19 at 11:00 PM until 09/26/19 at 7:00 AM. According to the Staffing Grid, there was insufficient staff to provide one-to-one (1:1) supervision to one (1) of the patients.

On 09/26/19, on the Integrity Unit, there was a census of five (5) patients and two (2) patients required one-to-one (1:1) supervision. There was only two (2) direct care staff from 3:00 PM until 11:00 PM, and according to the Staffing Grid, there was insufficient staffing to provide one-to-one (1:1) supervision for one (1) of the patents.

On 09/27/19, on the Integrity Unit, there was a census of five (5) patients and two (2) patients required one-to-one (1:1) supervision. There was two (2) direct care staff assigned from 7:00 AM until 11:00 PM, indicating one (1) of the patients requiring one-to-one (1:1) supervision was not properly supervised. From 11:00 PM on 09/27/19 until 09/28/19 at 7:00 AM, there was only one (1) direct care staff, indicating neither of the patients who required one-to-one (1:1) supervision were properly supervised.

On 09/28/19, on the Bridges Unit, there was a census of thirty (30) patients. There was only three (3) licensed staff from 7:00 AM to 7:00 PM, and only two (2) direct care staff from 7:00 AM to 7:00 PM. However, according to the Staffing Grid, there should have been four (4) licensed staff and three (3) direct care staff during this time period.

On 09/28/19, on the Integrity Unit, there was a census of four (4) patients and two (2) patients required one-to-one (1:1) supervision. There were only two (2) direct care staff from 7:00 AM until 7:00 PM, and again from 11:00 PM on 09/28/19 until 7:00 AM on 09/28/19. According to the Staffing Grid, there was insufficient staff to ensure one (1) of the patients who required one-to-one (1:1) supervision was adequately supervised during these timeframes.

On 09/29/19, on the Bridges Unit, there was a census of thirty-five (35) patients, and there was only two (2) direct care staff assigned from 7:00 AM until 7:00 PM. According to the Staffing Grid, there should have been three (3) direct care staff.

On 09/30/19, on the Integrity Unit, there was a census of six (6) patients and two (2) patients required one-to-one (1:1) supervision. There was only one (1) direct care staff assigned from 3:00 PM on 09/30/19 until 7 AM on 10/01/19. According to the Staffing Grid, there was insufficient numbers of direct care staff to provide one-to-one (1:1) supervision to either of the patients who required this supervision.

Interview with Registered Nurse (RN) #1, on 09/30/19 at 11:56 AM, revealed the Integrity Unit was so short staffed on 09/15/19, she did not feel it was safe for the patients. She stated the Integrity Unit, which was the geriatric unit, had been moved from a full-sized unit to a small back hallway due to census. Continued interview revealed the facility was often short staffed, yet the facility continued to admit patients despite not having the staff numbers to appropriately care for the patients. Further interview revealed the facility also admitted patients without sufficient room on the unit. She stated the Integrity Unit had six (6) rooms for two (2) patients each, to hold a maximum census of twelve (12) patients; however, recently a thirteenth (13th) patient had to be assigned a room on a neighboring unit.

Interview with State Registered Nurse Aide (SRNA) #3, on 10/01/19 at 9:59 AM, revealed the Integrity unit only had twelve (12) beds, but the unit admitted a thirteenth (13th) patient with one (1) patient having to be placed on the neighboring unit. SRNA #3 confirmed sometimes there was only one (1) direct care staff on the unit, even if there was a patient who required one-to-one (1:1) supervision, and the SRNA would be expected to provide the one-to-one (1:1) supervision while caring for the other patients as well.

Interview with SRNA #4, on 10/01/19 at 1:42 PM, revealed sometimes if there was not enough staff on the Integrity Unit, she would provide one-to-one (1:1) supervision as required, while also providing care for other patients. She stated there had been times when she had been responsible for supervising three (3) or four (4) residents requiring one-to-one (1:1) supervision by herself. Per interview, it was important to provide the one-to-one (1:1) supervision to these patients as ordered due to their aggression and behaviors.

Interview with SRNA #5, on 10/01/19 at 4:06 PM, revealed often the Integrity Unit was short staffed and did not have the staff needed in order to provide one-to-one (1:1) supervision. She stated when a SRNA was assigned to one-to-one (1:1) supervision for a patient, they could not keep their eyes on the patient all the times if the needed to help another patient. She further stated staff was supposed to sit with patients who required one-to-one (1:1) supervision; however, if there was not enough staff to provide the one on one (1:1) supervision, there was a risk to the patients.

Interview with RN #3, on 10/01/19 at 4:42 PM, revealed when there was not a specific staff member assigned to provide one-to-one (1:1) supervision as required, she would stay with the patient, and then have a direct care staff member stay with the patient when she attended to other duties. Further interview revealed she was unaware of any incidents occurring due to lack of staff assigned to provide one-to-one (1:1) supervision; however, she stated there was the potential for patient harm when there was not specific staff assigned to patients that required one-to-one (1:1) supervision

Interview with the Direct Care Supervisor, on 10/01/19 at 10:30 AM, revealed one-to-one (1:1) supervision was considered outside of the regular census, with each patient on one-to-one (1:1) supervision assigned a specific staff member. Continued interview with the Direct Care Supervisor, on 10/01/19 at 12:13 PM, revealed review of the staffing sheets for the past few months indicated staffing was too low for one-to-one (1:1) supervision to take place.

Interview with the Director of Quality, on 10/01/19 at 2:14 PM, revealed the staffing grid the facility utilized was a guideline based on national standards, with schedulers and house supervisors involved in staffing coverage to ensure patients were safe. She stated she was unaware staffing sheets indicated one-to-one (1:1) supervision needs were not being met, prior to this survey.

Interview with the Assistant Director of Nursing (ADON), on 10/01/19 at 5:08 PM, revealed she did not know if the the staffing sheets were correct, as they indicated insufficient numbers of staff. She stated it was her expectation any patient requiring one-to-one (1:1) supervision was to be in visual sight and within arms length of a staff member at all times. Per interview, she acknowledged it was important to have sufficient numbers of staff to deliver all care.

Interview with the Chief Nursing Officer (CNO), on 10/01/19 at 5:43 PM, revealed the staffing sheets may not have been updated and may not be accurate. However, he stated without accurate documentation there was no way to prove appropriate staffing and supervision had been provided. He stated, aside from the staffing sheets, he was uncertain of any place else one-to-one (1:1) supervision would be documented. He further stated he felt the facility did not have a good process to show coverage was being provided. However, he acknowledged the facility should ensure there was adequate staff on the units in order to provide one-to-one (1:1) supervision and delivery of all care as required.