HospitalInspections.org

Based on document review and staff interview, it was determined the facility failed to follow their procedure for staffing by not following their staffing matrix. This failure has the potential to impact all patient care at the facility.

Findings include:

A policy was reviewed, titled "Nursing Services Policy", last revised 12/19. The policy states, in part: "Policy: A sufficient number of qualified registered nurses and other nursing staff are on duty at all times to meet the patient's needs, to be responsive to our patients and their families and to promote efficient operation of the hospital. Through the budget process, sufficient resources are allocated to continuously improve the quality of Nursing Care delivered ... Procedure: 1. Staffing patterns are established by the unit director for each department utilizing historical data, volume, and Acuity information with approval by the chief nursing officer. 2. These patterns are reviewed annually or more frequently if necessary, considering the following: patient outcome data, patient satisfaction data, severity, complexity and intensity of the expected patient population, skill set and expertise of staff, ancillary Services available, review of West Virginia code and guideline documents from the State Board of nurse examiners, guidelines and evidence-based standards from professional nursing organizations, external and Regulatory standards, nursing staff and medical staff feedback ..."

The "Staffing Table Level 8 [eight]" was reviewed. The staffing table lists how many staff members should be present for the number of patients. The table starts at eighteen (18) patients through forty-eight (48) patients. For example, for forty-five (45) patients on "Days (7:00 a.m. though 3:00 p.m.)", the staffing numbers show: "MGR-1, CS-1, CHG-2, RN-8, PCT-5, WC-2.5 [Manager-One, Clinical Supervisor-One, Charge Nurse-Two, Registered Nurse-Eight, Patient Care Technician-Five, Ward Clerk-Two point five]." For "Evenings (3:00 p.m. through 11:00 p.m.)", the staffing numbers show: "CHG-2, RN-8, PCT-5, WC-2.5. For "Nights (7:00 p.m. through 7:00 a.m.)", the staffing numbers show: "CHG-2, RN-8, PCT-4."

For forty-one (41) patients on "Days (7:00 a.m. though 3:00 p.m.)", the staffing numbers show: "MGR-1, CS-1, CHG-2, RN-7, PCT-5, WC-2.5." For "Evenings (3:00 p.m. through 11:00 p.m.)", the staffing numbers show: "CHG-2, RN-7, PCT-5, WC-2.5." For "Nights (7:00 p.m. through 7:00 a.m.)", the staffing numbers show: "CHG-2, RN-7, PCT-4."

For thirty-seven (37) patients on "Days (7:00 a.m. though 3:00 p.m.)", the staffing numbers show: "MGR-1, CS-1, CHG-2, RN-7, PCT-5, WC-2.5." For "Evenings (3:00 p.m. through 11:00 p.m.)", the staffing numbers show: "CHG-2, RN-7, PCT-5, WC-2.5." For "Nights (7:00 p.m. through 7:00 a.m.)", the staffing numbers show: "CHG-2, RN-7, PCT-3."

Staffing was reviewed for the past six (6) months on Unit 8. On 07/12/23 for 7:00 p.m. through 11:00 p.m., the patient census was forty-one (41) with five (5) RNs, one (1) Charge RN, one (1) Ward Clerk and two (2) PCTs. On 07/12/23 for 11:00 p.m. through 7:00 a.m. shift, the patient census was forty-five (45) with five (5) RNs, one (1) Charge RN, and two (2) PCTs. On 11/02/23 at 3:00 p.m. through 7:00 p.m., the patient census was thirty-seven (37) with seven (7) RNs, one (1) Charge Nurse, three (3) PCTs and one (1) Ward Clerk. On 11/02/23 at 7:00 p.m. through 11:00 p.m., the patient census was forty-one (41) with seven (7) RNS, two (2) Charge Nurses, and three (3) PCTs. Several shifts and days were observed to not be staffed according to the staffing matrix.

An interview was conducted with employee (emp) #4 on 11/13/23 at 4:00 p.m. Regarding staffing, RN #4 states, in part, "We have not been fully staffed with techs for a long time. Unit 8 actually has the most techs. If we know that we're going to be short-staffed, first, we call the float pool staff, then we call the administrator on call to see if we can offer critical pay. The Charge Nurse on the floors can call their own staff. We have had holds in the ED if there's not enough staff on the floor. We usually work it out. We don't like staff to go above nine (9) patients a piece at night, and the Charge Nurse can always take a couple patients. It's a normal thing for all staff to complain about staffing but if we don't have any to give, they seem to make it work."

An interview was conducted with emp #8 on 11/14/23 at 8:52 a.m. Regarding staffing, emp #8 states, in part, "We make routine calls first to ask if anybody will pick up an extra shift. We see if the float pool is available, then we see if staff can be available from another floor. If still no one, then critical pay is given to any staff that pick up ... Our staffing Matrix was made long before I started, years ago. No one has reviewed or revised the Staffing Matrix in a long time, but we still use it."

An interview was conducted with emp #10 on 11/14/23 at 11:27 a.m. Regarding the staffing matrix, emp #10 states, "I am unsure why this is being used; this is a very old matrix. I'm going to go look to see if there's an updated Matrix available."

On 11/14/23 at 12:15 p.m., emp #10 confirmed the staffing matrix presented was the one currently in use, and it had not been updated.