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HARTGROVE HOSPITAL 5730 W ROOSEVELT ROAD CHICAGO, IL 60644 Oct. 26, 2016
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on document review and interview, it was determined, for 9 of 130 shifts, in 10 days (9/24/16 through 10/3/16), on 4 nursing units (2South, 2North, 3South, & 3North), the Hospital failed to ensure required staff was on duty.

Findings include:

1. On 10/25/16 at 4:30 PM, Hospital policy #NR 223, titled, "Staffing Plan / Patient Acuity", revised 3/2015, was reviewed. The policy required, "Nurse executive team actively maintains on-going processes to assure that a sufficient number and mix of staff are provided on a 24 hours a day based on census and patient care needs. Nurse Executive reviews the staffing plan and effectiveness of the staffing plan with executive team based on the number, competency and skills and the mix of staff related to the provision of needed care, treatment and services on an annual basis and periodically if needed... Nurse Manager / Staffing Coordinator / House Supervisor adheres to staffing guidelines as outlined in the grid and adjusts staffing according to patient and unit needs..."

2. On 10/26/16 at 9:00 AM, the nursing staffing grid, revised 8/12/16, was reviewed. It included increase numbers of staff for increased numbers of patients.

3. On 10/25/16 at 3:00 PM, staffing from 9/24/16 through 10/3/16, for 3 shifts, for 4 units, was reviewed. There were 9 of 120 shifts with staffing levels below the required grid numbers:

- On 2 South:

(1) 9/25/16 evening shift-33 Pts., 2 (Registered Nurse) RNs & 5 (Mental Health Specialist)MHS; An evening shift census of 32 - 36 patients requires 3 RNs/(Licensed Practical Nurse)LPNs & 5 MHS, per the staffing grid.

(2) 10/2/16 evening shift-28 Pts., 2 RNs & 3 MHS;
An evening shift census of 27 - 31 patients requires 3 RN/LPNs & 4 MHS, per the staffing grid.

(3) 9/26/16 night shift-33 Pts. 1 RNs & 2 MHS; A night shift census over 25 patients requires 1 RN & 3 MHS, per the staffing grid.)

- On 3 North:
no issue

- On 3 South:

(4) 10/2/16 evening shift-29 Pts., 2 RNs & 4 MHS;
An evening shift census of 27 - 30 patients requires 2 RNs & 5 MHS, per the staffing grid.

(5) 10/2/16 night shift-34 Pts., 1 RNs & 2 MHS; A night census over 25 patients requires 1 RN & 3 MHS, per the staffing grid.

- On 3 North:

(6) 9/25/16 evening shift-38 Pts., 2 RNs & 5 MHS;
An evening shift census over 37 patients requires 6 MHS, per the staffing grid.

(7) 9/25/16 night shift-40 Pts., 1 RNs & 2 MHS; A night census over 25 patients requires 1 RN & 3 MHS, per the staffing grid.

(8) 10/1/16 night shift-33 Pts., 1 RN & 2 MHS; A night census over 25 patients requires 1 RN & 3 MHS, per the staffing grid.

(9) 10/2/16, night shift, 34 Pts. 1 RNs & 2 MHS; A night census over 25 patients requires 1 RN & 3 MHS, per the staffing grid.

4. On 10/26/16 between 9:05 AM and 11:35 AM, the staffing sheets were reviewed with the Director of Nursing (E #2) and Chief Clinical Officer (E #5) and interviews were conducted with E #2 & E #5. E #5 stated staffing levels at this Hospital are higher than staffing levels at other Hospitals and they do their best to provide quality staffing.