The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observation, staff interview and document review it was determined the hospital failed to ensure there is a Registered Nurse (RN) assigned to each nursing unit on each shift. This failure has the potential to create an unsafe situation when an RN is not available for the bedside care of any patient in the event of an emergency or to meet the nursing needs of all patients.

Findings include:

1. During a tour of all nursing units on 12/12/16 between 3:05 p.m. and 4:20 p.m., observations were conducted and interviews were conducted with the Nurse Manager of the Children and Adolescent units and the Nurse Manager of the Adult and Forensic units who were present.

It was observed there were nine (9) nursing units separated by locked doors. There were two (2) children's units on the first floor, two (2) adolescent units on the second floor, one (1) adult forensic unit on the third floor (3S unit), one (1) adult forensic unit on the fourth floor (4S unit), two (2) adult forensic units (5S and 5N Forensic) and one (1) acute adult unit (5N Adult) on the fifth floor.

The two (2) Nurse Managers were questioned about staffing on each of the units and they stated there are times when there is one (1) RN that is shared between the two (2) children's units, or one (1) RN shared between the two (2) adolescent units or one (1) RN shared between the three (3) adult units on the fifth floor.

It was noted during the tour, there were two (2) adolescent patients on the "diagnostic" unit and five (5) patients on the "acute" unit, on the second floor. The Nurse Manager of the Children and Adolescent unit stated at 3:15 p.m. that there was one (1) RN assigned to care for patients on both units.

2. The daily census and staffing information was requested for review for the month of November 2016. There were several days in which there was no RN assigned to each of the units, including 11/4/16 when there was no RN assigned on 3S with nineteen (19) patients, no RN on 4S with twenty-three (23) patients and no RN assigned on either 5S with twenty-one (21) patients or 5N with seven (7) patients. There was no RN assigned on either 3S or 4S on 11/6/16 with the same number of patients as on 11/4/16. There was no RN assigned on either 3S or 4S on 11/10/16, again with the same number of patients on each unit as listed previously. There were multiple examples of inadequate RN staffing throughout the month reviewed.

3. The policy relative to nursing staffing was requested. The only policy provided, "Staffing Plan", last reviewed 2/23/15, stated: "The Staffing Coordinator/Unit Clerk or designee in conjunction with the Nurse Manager and Program Manager of each service creates a master schedule for each discipline. The master schedule is adjusted up or down, as needed, to provide for patient needs and ensure positive patient outcomes. The shift supervisor/charge nurse, in the absence of the Nurse Manager, makes needed changes to staffing to meet unit needs."

4. The Director of Nursing was interviewed on 12/13/16 at 2:00 p.m. relative to staffing and the staffing policy. She stated there are no other policies which state what the minimum staffing plan is for the hospital. Both the Director of Nursing and the Nurse Manager of the Children and Adolescent units were interviewed on 12/13/16 starting at 2:00 p.m. and they concurred that not every unit is staffed with an RN at all times. They did not concur the units with locked doors in between were separate units and stated the the use of the "shared" RNs is adequate staffing.