HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to ensure adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed as numerous staff reported problems with nursing staffing and accurate nurse to patient ratios were impossible to ascertain according to facility documentation.

Findings were:

A review of the nurse Assignment Sheet of the 5th and 6th floors for March 2015 revealed entries that did not accurately reflect how many patients were assigned to each nurse or nursing assistant/tech. That is, entries gave a span of rooms, with no information about how many rooms were actually occupied. Several shifts in March included what appeared to be a general nurse to patient ratio of 1:7. In addition, admissions and discharges were not listed on the assignment sheets which made it impossible to review actual nurse to patient ratios.

For example, a review of the 5th floor Staffing Assignment Sheet on 3/2/15 for the day shift included the following entries:
"[staff name], RN Assignments: 502-511
[staff name], RN Assignments: 545-550 ...
[staff name], NT [nursing tech] Assignments: 80s, 6, 7 ... "
On the evening shift on 3/3/15, the Assignment Sheet included:
"[staff name], RN Assignments: 584-591
[staff name], RN Assignments: 565-574 ...
[staff name], RN Assignments: 541-516 ...
[staff name], RN Assignments: 545-590 ... "

A review of the 6th floor Staffing Assignment Sheet on 3/12/15 for the day shift revealed similar issues as follows:
"[Unit Charge Nurse] Assignments: Chg - 1
[staff name], RN Assignments: Outpatient
[staff name], RN Assignments: NIMW
[staff name] RN Assignments: 80, 81, 82, 83, 84, 85, 86
[staff name], RN Assignments: 48, 47, 50, 61, 62, 63, 64 ... "
With other 2 additional RNs each being assigned 6 patients; 1 float RN with one patient assigned and two nursing assistants. There was no patient census recorded on the staffing Assignment Sheet.
The day shift of 3/15/15 included:
"[Unit Charge Nurse], RN Assignments: Chg - 1
[staff name], RN Assignments: NIMU
[staff name], RN Assignments: 81, 86, 87, 88, 89, 90, 91
[staff name], RN Assignments: 2, 80, 82, 83, 84, 85, 50
[staff name], RN Assignmetns: 48, 49, 50, 60's ... "
There was no patient census recorded on the Staffing Assignment Sheet.

In an individual interview with Staff #3, RN, Director of Medical/Surgical, 5th floor, on the morning of 3/18/15 in a facility administrative office, she discussed the Staffing Assignment Sheet. Specifically, she was asked if it was possible to obtain the census of each unit and the exact rooms occupied, so as to ascertain nurse to patient ratios. She stated, "There's no way to do that." She stated there was no way to look back at the specific date and ascertain how many patients a particular nurse was assigned. She acknowledged that admissions and discharges were not reflected on the assignment sheets.

In an individual interview with both Staff #4, Director of Neurology/NIMU/Oncology/Rehab, on the morning of 3/18/15 in an administrative office, he agreed there was no method of determining the exact numbers that the nurses were assigned on any given past day. Thus, there was no way to review staffing levels or to determine in retrospect whether nurse staffing was adequate. He agreed the staffing assignment sheets generally did not include the patient census, nor were admissions and discharges made during the shift recorded on the assignment sheet.

Facility policy #77.786, entitled Nurse Staffing Plan, last reviewed/revised 5/13, stated in part:
IV. Staffing Performance Assessment ...
B. Generally, the licensed nurse to patient ratio on the general med/surg floors shall be 1:5 or 6 ...
V. Staffing Alternatives ...
A. Insufficient personnel to meet coverage demands will trigger the following:
1. The Director or House Supervisor shall evaluate the need for alternative staffing:
a. Assignment/reassignment of float/resource staff
b. Schedule any available staff willing to report for extra hours/shifts
B. If still unable to consistently address staffing needs, the Director and Vice President of Patient Services shall discuss other strategies.

These findings were again confirmed in an interview with the Vice President of Patient Services on the morning of 3/18/15 in an administrative office.