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PERIMETER BEHAVIORAL HOSPITAL OF DALLAS
Adequate Staffing
Tag No.: A1704
Based on interview and record review the facility failed to provide adequate staffing on 4 of 4 days, in that the facility failed to follow the facility's staffing matrix on 09/20/23, 09/22/23, 09/24/23/, and 09/25/23.
Findings included:
On 09/20/23 The Positivity Point unit staffing sheet reflected the unit had 11 patients on the night shift and was staffed with 1 Registered Nurse (RN) and 1 Mental Health tech. (MHT).
The Magnolia Mountain (geriatric) unit staffing sheet reflected the unit had 8 patients on the night shift and was staffed with 1 RN and 1 MHT.
On 09/22/23 The Positivity Point unit staffing sheet reflected the unit had 15 patients on the day shift and was staffed with 1 RN and 2 MHTs.
On 09/24/23 The Stargazers unit staffing sheet reflected the unit had 16 patients on the day shift and was staffed with 1 RN and 2 MHTs.
The Trailblazers and Hope Mountain staffing sheet reflected 20 patients on the day shift and the night shift. The staffing sheets for both the day shift and the night shift reflected the unit was staffed with 2 RNs and 2 MHTs.
On 09/25/23 The Positivity Point staffing sheet reflected the unit had 13 patients and was staffed with 1 RN and 2 MHTs.
The staffing matrix that was not dated reflected "...Nurse ratio is 1 to 12. MHT ratio Geri... 1 to 6, Trailblazers 1 to 8, Hope Mountain 1 to 8, Stargazers 1 to 8, Positivity Point 1 to 8..."
During the record review on 11/21/23 ending at 02:40 PM Personnel #3 verified that the above findings. Personnel #3 stated that Trailblazers and Hope Mountain unit census are sometimes combined since there is only one nursing station on that floor.