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Based on record review and interview, the director of the nursing service failed to enforce their written staffing plan per nursing unit, in that,

The 9/24/2022 Neuro ICU (Neuroscience Intensive Care Unit) and 9/28/2022 PCU (Progressive Care Unit) PM shifts were short nurses.

Findings

The Neuro ICU 9/24/2022 PM staffing assignment sheets reflected staffing ratios were over the staffing plan ratio based on what was documented (ICU tripling 3:1).

The report for 9/28/2022 PM shift reflected charge nurses took patient assignments on 5 nurse units; and PCU (Progressive Care Unit) was short 9 nurses.

During an interview 9/28/2022, Personnel #3 was asked about not meeting the staffing plan for Neuro ICU (Neuroscience Intensive Care Unit). Personnel #3 walked through the 9/24/2022 PM staffing and confirmed staffing ratios were over the staffing plan ratio based on what was documented.

During an interview on 9/29/2022, Personnel #2 was asked how variances were tracked per nursing unit. Personnel #2 reviewed the report for 9/28/2022 PM. Personnel #2 confirmed charges took patient assignments on 5 nurse units; and PCU (Progressive Care Unit) was short 9 nurses.

The facility's 12/2020, effective Staffing Plan required, "Adult ICU 1 RN : 2 Patients...PCU 1 RN : 4 Patients..."

Based on record review and interview, the facility failed to ensure supervisory and staff personnel for each department or nursing unit to provide, when needed, the immediate availability of an RN to provide care for any patient, in that,

on 9/28/2022 PM shift supervisory personnel were not immediately available due to taking a patient assignment on their respective 5 nurse units.

Findings

The facility's Staffing Plan did not require supervisory and staff personnel for each department or nursing unit to provide, when needed, the immediate availability of an RN to provide care for any patient.

The facility's Staffing Effectiveness Council Meeting Minutes 9/8/2022 reflected, "4. Charge Nurses with assignments Discussed how to support the charge nurse when she also has an assignment: Blocking Beds if possible, staffing with additional PCT, support by manager and House Supervisor..."

During an interview 9/28/2022, Personnel #3 was asked about not meeting the staffing plan for Neuro ICU (Neuroscience Intensive Care Unit). Personnel #3 walked through the 9/24/2022 PM staffing and confirmed staffing ratios were over the staffing plan ratio based on what was documented.

During an interview on 9/29/2022, Personnel #2 was asked how variances were tracked per nursing unit. Personnel #2 reviewed the report for 9/28/2022 PM. Personnel #2 confirmed the charge nurses took a patient assignment on 5 nurse units; and PCU (Progressive Care Unit) was short 9 nurses.

During a telephone interview on 9/30/2022, Personnel #8 was asked about the Staffing for Neuro ICU (tripling 3:1 versus 2:1 staffing/Charge nurse taking patients). Personnel #8 stated I don't think it's safe. Should be 2:1. If you can change anything, I think this would be best.

During a telephone interview on 9/30/2022, Personnel #6 was asked about the Staffing for Neuro ICU (tripling 3:1 versus 2:1 staffing/Charge nurse taking patients). Personnel #6 stated we are understaffed. Staff have more patients than they should have. We are Level 1 for trauma, burn (C3), and stoke and can't divert those specialties. Med surg and PCU charge nurses take a patient load frequently. I think it is unsafe. We just kind of roll with it. We all complain about it but they say there is not enough nurses.

During a telephone interview on 9/30/2022, Personnel #7 was asked about staffing issues on Neuro ICU (tripling 3:1 versus 2:1 staffing/charge nurse taking patient assignment). Personnel #7 stated we are understaffed it is not getting better. I think the some nurses get conditioned to being understaffed. I know it isn't okay. Tripling is unsafe and the PCU status patients in unit make it very hard. We have told everybody were not happy. Nothing is getting done.

During an interview on 9/30/2022, Personnel #9 was asked about staffing issues on Neuro ICU (tripling 3:1 versus 2:1 staffing/charge nurse taking patient assignment). Personnel #9 nursing issues effect patient care - it is not safe.

During a telephone interview on 9/30/2022, Personnel #11 was asked about staffing issues on Neuro ICU (tripling 3:1 versus 2:1 staffing/charge nurse taking patient assignment). Personnel #11 stated we are tired. I don't think understaffing is going away. I have been tripled often. Honestly, I don't know what the policy is or if tripling is okay. I do not know if it was normal.

The facility's 12/2020, effective "Nurse Staffing Plan" required, "the department leader has the responisbility to ensure that adequate levels of staffing are scheduled to maintain safe patient care standards and as determined by the unit specific staffing plans..."

Based on record review and interview, the facility failed to ensure a Registered Nurse supervised and evaluated the nursing care for each patient, in that,

Patient #5's record did not reflect nursing care after a neurological (neuro) event on 9/24/2022 from 10:01 AM through 18:59 PM.

Findings

Patient #5's record did not evidence/document nursing care on 9/24/2022 from 10:01 AM through 18:59 PM.

During record review and interview on 9/28/2022 at 12:35 PM, Personnel # 10 confirmed the lack of documentation of care on 9/24/2022 from 10:01 AM through 18:59 PM.

During an interview 9/28/2022 ending at 4:00 PM, Personnel 3 and #4 stated we confirmed the documentation of care is missing on Patient #5 after the 9/24/2022 neuro event.

The facility's 5/2022, effective "Assessment/Re-assessment of Patients and/or Standards of Care" required, "(PCU) Progressive Care Unit...Vital signs...every 4 hours and PRN for any change in condition...Re-assessment every 4 hours unless otherwise ordered..."

Based on record review and interview, the facility failed to ensure orientation of nurses and other personnel who provide nursing care to all units to which they are assigned on either a temporary or permanent basis, in that,

Personnel #6 worked Neuro ICU (Neuroscience Intensive Care Unit) on 9/24/2022 without an orientation to Neuro ICU.

Findings

The 9/24/2022 Nurse Assignment Sheet reflected Personnel #6 was assigned to Neuro ICU.

Patient #5's record reflected Personnel #6 was the nurse.

Personnel #6's employee file did not evidence orientation to Neuro ICU.

The facility's 12/2020, effective date "Facility Nurse Staffing Plan" did not contain a requirement for orientation of nurses and other personnel who provide nursing care to all units to which they are assigned.

During an interview on 9/29/2022 ending at 1:47 PM, Personnel #3 and #4 was asked about Neuro ICU orientation for the floated nurse, Personnel #6. Personnel #3 stated no, I don't think were doing that.