HospitalInspections.org

Based on record review and staff interviews, the hospital's nursing leadership failed to ensure there was an adequate number of direct care staff to provide care to meet the needs of the patients and follow the hospital's Nurse Staffing Plan and Matrix. Also, the hospital's nursing leadership failed to ensure the LVN (Licensed Vocational Nurse) was always supervised by a Registered Nurse.


A review of the hospital's staffing and patient census levels was conducted in the administrative office with Staff # 3 (Director of Nursing) on 08/13/2024 at 3:30 PM.

A review of the hospital's, "Standard Staffing Guidelines Grid" revealed,

"Census: 1-6 Patients M/S-Swing Bed: 1 RN, 1 licensed nurse and 0.5 CNA
Census: 7-10 Patients M/S-Swing Bed: 1 RN, 2 licensed nurses and 0.5 CNA
ER: 1 RN, 1 licensed nurse, 0.5 CNA"

April 12, 2024
A review of the patient census log for dayshift of April 12, 2024, revealed,

There were 4 patients in the Emergency Room and 7 patients were admitted to the Medical-Surgical Floor.

A review of the nurse staffing on dayshift of April 12, 2024, revealed,

Staff # 33 (Registered Nurse) was scheduled in the Emergency Room from 7 am-7 pm. There was no other staff scheduled in the Emergency Room from 7 am-7 pm.

Staff # 34 (Registered Nurse) and Staff # 35 (Certified Nursing Assistant) were scheduled on the Med-Surg Floor from 7 am-7 pm.

The nursing leadership did not follow the hospital's "Standard Staffing Guidelines Grid" on the dayshift of April 12, 2024.

An interview was conducted with Staff # 3 on 08/13/2024 at 3:45 PM in the administrative office. Staff # 3 acknowledged there was not enough staff present on the dayshift of April 12, 2024, and stated, "I was on vacation and the 7th patient should have never been admitted to the hospital. If I was not on vacation, the 7th patient would not have been admitted."

April 22, 2024
A review of the nurse staffing on nightshift of April 22, 2024, revealed,

Staff # 36 (Registered Nurse) was working in the Emergency Room. Staff # 36 was the only Registered Nurse scheduled to work in the entire hospital on the night shift of April 22, 2024. Staff # 37 (Licensed Vocational Nurse) was working on the Med-Surg Floor on the night shift of April 22, 2024. Staff # 36 was unable to take a lunch break because there was no other Registered Nurse available to work in the Emergency Room and provide oversight to the LVN working on the Med-Surg Floor.

June 1, 2024
A review of the nurse staffing on dayshift of June 1, 2024, revealed,

Staff # 18 (Registered Nurse) was working in the Emergency Room. Staff # 18 was the only Registered Nurse scheduled to work in the entire hospital on the dayshift of June 1, 2024. Staff # 23 (Licensed Vocational Nurse) was working on the Med-Surg Floor. There was no Registered Nurse available to provide oversight to Staff # 23 on the Med-Surg Floor.

In an interview with Staff # 23 (Licensed Vocational Nurse) on 08/13/2024 at 2:00 PM in the administrative conference room, Staff # 23 was asked by the surveyor what kind of intravenous (IV) push medications she administered. Staff # 23 stated, "Dilaudid, Lopressor, Morphine, Digoxin are some examples." The surveyor asked if she had been deemed competent to give those medications via IV push. Staff # 23 stated, "I was checked off years ago but that was at another hospital, not this one."

A review of Staff # 23's personnel files revealed she had not been deemed competent to administer IV push medications such as Dilaudid, Morphine, Lopressor, and Digoxin.

Staff # 23 was working alone, unsupervised on the Med-Surg Floor on the dayshift of June 1, 2024.

According to the Texas Board of Nursing regarding the LVN Scope of Practice,

"The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVNs). The LVN scope of practice is a directed scope of practice and requires the appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist. The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, policies, procedures, and guidelines of the employing health care institution or practice setting. The LVN is responsible for providing safe, compassionate, and focused nursing care to assigned patients with predictable health care needs."

A review of the hospital's policy, "Master Staffing Plan PCMC" with a revision date of 01/2023 revealed,

"Palacios Community Medical Center Emergency Department is a 3-bed Emergency Room that offers 24-hour care 7 days a week including holidays. The Master Staffing plan is designed to meet the patient's needs and the specialized qualifications and competencies of the hospital staff available. Historical data on patient arrival times and lengths of stay is used to determine the number of staff and start times for the department.
A charge nurse is assigned for each 12-hour shift. During periods of high census, the charge nurse collaborates with the Med/Surg nurse to determine staff resources available from other departments to be deployed to the Emergency Department, or to assist in patient throughput. Additional supplemental staff is provided based on the influx, acuity, and assessment of the patient's care needs. Currently, the Emergency Department is staffed by 1 licensed nurse each shift. Shifts are as follows: 7 am-7 pm and 7 pm-7 am. A certified nurse aide or ER tech in the form of an emergency medical technician will be scheduled 7a-7p and 7p-7a."

A review of the hospital's policy, "Nurse Staffing Plan" with a revision date of 08/2024 revealed,

"POLICY: In compliance with Legislative findings, Sec. 257.002, the Nursing Administration of Palacios Community Medical Center, supported by the Board of Directors, shall adopt, implement, and enforce a nurse staffing plan ensuring that an adequate number and skill mix of nurses are available to meet the level of patient care needed at all times.
PROCESS: NURSE STAFFING PLAN: The Nurse Staffing Plan will reflect current standards established by private accreditation organizations, governmental entities, and other health professional organizations. It will follow approved staffing guidelines for patient care units that allow for adequate licensed personnel to provide nursing care to all patients which will be based on multiple nurse and patient considerations.
1. Patient characteristics and number of patient admissions, discharges, and or transfers.
2. Intensity of care provided.
3. Scope of service provided.
4. Considerations of architecture, and geography of the unit, availability of technology.
5. Staff characteristics including tenure, preparation, experience, and competencies of staff.
6. Determined by the nursing assessment and in accordance with evidence-based safe nursing standards.
A. It will set minimum staffing levels for patient care units that are
a. Based on multiple nurse and patient considerations, and
b. Determined by the nursing assessment in accordance with evidence-based safe nursing standards,
c. Include a method of adjusting the staffing plan for each patient care unit to provide staffing flexibility to meet patient needs and,
d. Include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources.
e. A Nursing Leader will be on-call, 24 hours/day, 7 days per week in order to ascertain that staffing is adequate and safe on a daily, shift-by-shift basis.
f. The hospital will report annually to the Department of State Health and Human Services on whether the hospital's governing body has adopted a nurse staffing policy as required by Section 257.003;
MANDATORY OVERTIME: Mandatory overtime is defined as being required to work, other than on-call time, when not scheduled including beyond hours or days scheduled. Neither the length of the shift (whether 4, 8, 12, or 16 hours) nor the number of shifts scheduled to work whether 4, 5, or 6 a week is the determining factor in defining mandatory overtime. When mandatory overtime is utilized as a means of meeting staffing needs, the Nursing Administrator shall:
A. Document the basis and justification for mandatory overtime.
B. Develop an action plan for the reduction or elimination of the use of mandatory overtime o meet staffing needs.
C. Exception: Emergency or unforeseen event of any kind that does not regularly occur and is in accordance with the hospital Disaster Plan ..."

An interview with Staff # 3 (Director of Nursing) was conducted on 08/13/2024 at 4:00 PM in the administrative office. Staff # 3 acknowledged the hospital did not have enough staff to provide appropriate oversight to LVNs as required by the Texas Board of Nursing. Staff # 3 stated, "I try not to admit more than 6 patients because I know staffing is a challenge and I want to make sure the patients and the staff are safe."