HospitalInspections.org

Based on the review of policies and procedures, hospital staffing documents for November 2021, and staff interviews, it was determined that the Hospital failed to ensure that policies/procedures specific to staffing and acuity were implemented appropriately to ensure safe staffing on one (1) inpatient unit (AP5) for day shift on two (2) days, November 27, 2021, and November 28, 2021. This deficient practice poses a risk to the health and safety of patients and staff when the hospital does not have the minimum number of personnel that is required to meet the needs of the patients.

Findings include:

The policy titled "Inpatient Acuity Guidelines" revealed: "...Policy: Acuity levels are assigned an approximate time allowance to help determine staffing needs and may be used as a guideline for making assignments with the understanding that ongoing situations on a given unit may result in a need for enhanced staffing during a shift and attempts will be made to meet needs. Procedure: I. Acuity levels: Level 1: 1-10 minutes each hour...Level 2: 10-20 minutes each hour...Level 3: 20-30 minutes each hour...Level 4: 30-45 minutes each hour, 1:1 required for patient/others safety...II. Anytime a patient is on 1:1 on a given unit, the staffing matrix will be adjusted for the unit by deducting the number of patients on 1:1 from the total number of patients on the unit...III. Acuity Tool: 1. The charge RN (registered nurse) will date and sign the assignment sheet which includes acuity levels...Acuity-Based Staffing Guidelines: AP5: acuity under 28 points DAYS 1 RN, 2 BHT, NIGHTS 1 RN, 1 BHT, acuity 29-40 points DAYS and NIGHTS: 2 RN, 2 BHT; acuity 41-55 points DAYS and NIGHTS: 2 RN, 3 BHT; acuity 56-70 points DAYS 3 RN, 4 BHT, NIGHTS 2 RN, 3 BHT, acuity 71 or more points DAYS 3 RN, 5 BHT, NIGHTS 2 RN, 3 BHT;...."

A review of the Staffing Assignment sheet for the 11/27/2021 day shift for AP5 revealed: the patient census 23, total acuity 64 points, 2 RN, 3 BHT, 1 BHT in at 0900, and 1 BHT in at 1100, 1 BHT with 1:1 patient. A review of the staffing matrix revealed based on the acuity of 64, the unit should be staffed with 3 RN, 4 BHT, and 1 BHT for 1:1 patient monitoring.

A review of the Staffing Assignment sheet for the 11/28/2021 day shift for AP5 revealed: the patient census 23, total acuity 80 points, 3 RN, 3 BHT, and 1 BHT with 1:1 patient. A review of the staffing matrix revealed based on the acuity of 80, the unit should be staffed with 3 RN, 5 BHT, and 1 BHT for 1:1 patient monitoring.

Employee #8 confirmed during an interview conducted on 01/19/2022 that the hospital remains understaffed but staffing has improved over the last few months.

Employee #20 confirmed during an interview conducted on 01/19/2022 that the hospital is short-staffed almost every day. Employee #20 stated the units typically continue to work short as there are no resources to pull from to help with staffing issues.

Employee #21 confirmed during an interview conducted on 01/19/2022 that the hospital is consistently understaffed. Employee #21 stated units are consistently short 1 RN and 1 BHT almost every day.

Employee #3 confirmed during an interview conducted on 01/20/2022 that the hospital has had shifts that have been understaffed. Employee #3 reviewed the staffing assignment sheets and confirmed unit AP5 was understaffed on 11/27/2021 and 11/28/2021 day shifts.