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.

SOUTH DAKOTA HUMAN SERVICES CENTER 3515 BROADWAY AVE POST OFFICE BOX 7600 YANKTON, SD Jan. 31, 2018
VIOLATION: CARE OF PATIENTS - RESPONSIBILITY FOR CARE Tag No: A0068
Based on record review, interview, and policy review, the provider failed to ensure in accordance with hospital policy, a physician, physician assistant, or certified nurse practitioner ceased life-sustaining measures and pronounced one of one patient (1) deceased . Findings include:

1. Review of the 12/20/17 Code Blue Worksheet/Critique form for patient 1 revealed:
*At 10:12 a.m. a code blue was called.
*At 10:16 a.m. the AED was applied, the initial reading was asystole, and no shock was advised.
*At 10:19 a.m. the AED advised no shock.
*At 10:27 a.m. the ambulance arrived.
*At 10:28 a.m. the code blue was cancelled.

Review of the 12/21/17 Death Summary report revealed:
*On 12/20/17 the patient had been found unresponsive during a 15 minute check.
*A Code Blue was called, the patient was not responding to commands.
*The patient had no pulse and was not breathing, and cardiopulmonary resuscitation (CPR) was initiated.
*The ambulance arrived and a paramedic pronounced the patient deceased .

Interview on 1/30/18 at 11:00 a.m. with Certified Nurse Practitioner C regarding patient 1 revealed:
*She had arrived on the unit and CPR was in progress.
*The patient's toes were mottled, she was unable to get the left arm down, it was rigid, stiff, and the arms felt cool.
*There was no flashback from the attempted intravenous start.
*The emergency medical staff put on the Lucas device and the paramedic stated "call it."
*She was unaware of the provider's Death of a Patient policy, and that she was able to pronounce death.

Interview on 1/31/18 at 11:32 a.m. with physician L revealed:
*The paramedics called the code (ceased emergency interventions) because the certified nurse practitioner (CNP) C and physician assistant T had not felt comfortable pronouncing death.
*A nurse practitioner, a physician assistant, or the medical director may pronounce death.

Review of patient 1's medical record revealed CNP C and physician L responded to the Code Blue. CNP C participated in administering CPR.

Review of the provider's 9/11/13 Death of a Patient/Notifying Sheriff, Coroner, and Department of Health policy revealed under the procedure section "Life-sustaining measures, once initiated, shall not be discontinued until pronouncement of death by Physician/PA-C/CNP."
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review, interview, and medical staff rules and regulations the provider failed to ensure a request to go to the emergency room (ER) for one of one patient (1) who had concerns with alcohol withdrawals had been followed-up on by registered nurse (RN) H and RN house supervisor O.

1. Review of the provider's 7/12/17 Rules and Regulations/Medical Staff for Emergencies/On Call/Coverage requirement revealed: "A member of the Medical Staff shall be available by phone at all times for emergencies involving patients. These practitioners shall be designated the "on call/on duty" staff and a rotation schedule established."

Review of RN H's nurses notes dated 12/19/17 at 9:35 p.m. regarding patient 1 revealed:
*The patient was irritable and upset about something for sleep.
*The patient stated "I'm withdrawing." "Why aren't you doing something about my blood pressure."
*The patient was informed "it's coming down on own, and we are taking vital signs every four hours."
*She stated "I think I need to go to the ER, i am in withdrawals."
*The nurse had documented the blood pressures were consistently in the 150s/90s.
*There was no documentation of those blood pressures in the medical record.
*She had completed the patient's Alcohol Withdrawal Assessment Scale (AWAS) evaluations at 8:00 p.m. and 10:00 p.m.
*The AWAS evaluations had been done thirty minutes before and after the patient's request to go to the ER.
*The patient's AWAS scores at 8:00 p.m. and 10:00 p.m. was a one; no blood pressures had been documented for either of the evaluations.
*The last documented vital signs for the patient was on 12/19/17 at 4:01 p.m. her blood pressure was 153/108, pulse 96, respirations 16, and temperature was 98.2 degrees Fahrenheit. There was no documentation the physician had been notified of her 153/108 blood pressure.
*No additional vital signs were documented.

Interview on 1/29/18 at 4:10 p.m. with RN H regarding patient 1 revealed:
*She had administered Ibuprofen for aches and pains.
*The patient had stated to her she was "withdrawing and needed to go to the ER. [That note had been written on 12/19/17 at 9:30 p.m.]"
*She had explained the AWAS to her and the patient had walked away from her.
*She had not completed an assessment of the patient at that time.
*The patient's request to go to the ER had been passed on to the RN house supervisor O.
*RN house supervisor O did not come down to assess the patient.
*At night prior to calling the on-call practitioner the nurses were required to notify the house supervisor and update them on the patient's condition. The house supervisor then made the decision if the practitioner should have been called.
*During day time hours the nurse made calls directly to the patient's physicians.
*She thought the patient's diastolic was 69 and her blood pressure was trending down.
*Whoever had taken the patient's blood pressure should have documented the results in her medical record.
*Her later AWAS assessments at 2:00 a.m. and 6:00 a.m. not been completed. The patient was resting at 2:00 a.m. and according to a coworker refused vital signs at 6:00 a.m. She had documented the patient had refused the AWAS for the 6:00 a.m. evaluation without seeing the patient.

Interview on 1/31/18 at 8:25 a.m. with the house supervisor that worked on 12/19/17 from 8:00 p.m. to 8:00 a.m. regarding patient 1 revealed:
*He had no documentation in the supervisor change notes on 12/19/17 from 8:00 p.m. to 8:00 a.m. from Birch I nursing staff regarding patient 1.
*He filtered phone calls from the nursing staff for the practitioners; the nurses had the option of calling them directly. The practitioners did not want to be bothered with nuisance calls.
*If a patient requested to go to the ER he would have expected a thorough assessment to have been completed, a set of vital signs, and notify the practitioner. The practitioner made the decision to send patients to the ER.
*Sometimes the practitioner asked the house supervisor to go to the unit and complete the assessment.

Review of the 12/19/17 House Supervisor Change of Shift Communications notes revealed there were no notifications documented from Birch 1 or any notes regarding patient 1.

Review of the provider's 4/14/11 Patient Rights Policy revealed the policy had not addressed:
*Patient's requesting ER services.
*The house supervisor's filtering ER requests for patients at night.
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






A. Based on interview and record review, the provider failed to ensure an Alcohol Withdrawal Assessment Scale (AWAS) vital signs were documented for one of one sampled patient (1) who had been monitored for alcohol withdrawal syndrome and was found unresponsive with no respirations and no pulse eighteen and a half hours after admission to the Birch 1 acute care unit.

1. Review of patient 1's Call Intake information on 12/19/17 at 1:16 p.m. revealed:
*She had been in the custody of Yankton County jail on 12/19/17 prior to her hospital admission to the South Dakota Human Services Center (SDHSC).
*She reported to drink at least one pint of vodka daily.
*Two weeks ago she had been released from a detox program.
*She was last discharged from SDHSC on 3/17/17 and had not followed her aftertreatment program.

Review of patient 1's psychiatric evaluation dated 12/19/17 revealed:
*She had contacted the police while intoxicated and stated she wanted to overdose on medication.
*Upon police arrival she had reported taking four narcotic pills, Benadryl, drank mouthwash, and drank vodka.
*She had a long history of depression and substance abuse.

Review of patient 1's history and physical report dated 12/19/17 revealed:
*Her last drink was on 12/18/17 at 9:00 p.m.
*She had a past history of withdrawal seizures.
*She drank one pint of vodka daily.
*She smoked two packs of cigarettes daily.

Review of patient 1's medical record revealed:
*She had been admitted on [DATE] at 3:30 p.m. and was pronounced deceased on [DATE] at 10:26 a.m.
*She had been admitted to the facility on on a five-day emergency hold from the Yankton County jail.
*Admitting physician's admission orders dated 12/19/17 included:
-Diagnosis of unspecified depressive disorder, severe alcohol use disorder, and severe opioid use disorder.
-Due to suicidal ideation she had been:
-Restricted to the unit.
-Placed on 15 minute checks.
-Required to sleep in her room with door open.
*"AWAS then BID" had been hand written over "TPR & B/P daily x 3 days."

Review of the vitals signs located in patient 1's medical record revealed:
*On 12/19/17 the time on the AWAS checklist was difficult to read because it had been written over a previous time. The blood pressure was documented as 173/99 mmHg, there was no pulse, respiration, or temperature documented.
*On 12/19/17 at 2:30 p.m. the same blood pressure of 173/99 mmHg had been documented on the Admission Nursing Assessment, the pulse was 90, and respirations were 16.
*On 12/19/17 at 4:01 p.m. her blood pressure was 153/108 mmHg, pulse 96, respirations 16, and temperature was 98.2 degrees Fahrenheit on the vital sign report. There was no documentation the physician had been notified of her 153/108 mmHg blood pressure.
*No further vital signs were documented for patient 1 on 12/19/17 or 12/20/17.

Review of the AWAS checklist documentation revealed:
*The AWAS checklist had been completed on 12/19/17 (time unknown), at 4:00 p.m., 8:00 p.m., 10:00 p.m., and midnight.
*At 4:00 p.m., 8:00 p.m., 10:00 p.m., and midnight the systolic blood pressure should have been evaluated. The blood pressure assessments had been documented as a one, but no blood pressures had been documented.
*Scoring for systolic blood pressure (SBP) parameters included:
-SBP less than 150 mmHg - score zero point.
-SBP 150 - 175 mmHg - score one point.
-SBP 175 - 200 mmHg - score two points.
-SBP greater than 200 mmHg - score three points.
*There was no blood pressure, pulse, respiration, and temperature documented for the 4:00 p.m., 8:00 p.m., 10:00 p.m., and midnight AWAS patient assessment.
*The AWAS checklist and vital signs had not been completed and staff had documented:
*2:00 a.m. resting.
*6:00 a.m. refused.
*10:00 a.m. resting.
*Approximately 18.5 hours had elapsed since the last blood pressure at 4:01 p.m. had been documented.
*Approximately 14.5 hours had elapsed since the nursing staff completing the last 8:00 p.m. AWAS assessment due to patient resting and refusal.

Interview on 1/29/18 at 12:02 p.m. and again on 1/30/18 at 8:10 a.m. with the director of nursing confirmed:
*The blood pressure had not been documented for the 8:00 p.m., 10:00 p.m., and midnight AWAS assessments, but should have been documented in the medical record.
*The nurses completing those assessments had written a one at the time of assessment which indicated the systolic blood pressure was between 150 to 175 mmHg. No specific numerical value for the systolic and diastolic had been documented.
*She was unsure how the determination would have been made by the nurse completing the AWAS without a documented blood pressure.
*She agreed the blood pressures were missing on the AWAS and if there were no blood pressures it was inaccurate.
*According to the physician orders dated 12/19/17, blood pressures should have been taken per the AWAS protocol every four hours and then BID (twice a day) for seventy-two hours.
*According to the physician's order a blood pressure should have been taken at 4:00 p.m., 8:00 p.m., and midnight. Instead per the AWAS scoring blood pressures had been done at 4:00 p.m., 8:00 p.m., and 10:00 p.m.
*There was no policy for completing the AWAS assessment; it was a protocol developed by the medical staff.

Interview on 1/29/18 at 4:00 p.m. with registered nurse (RN) H regarding patient 1 revealed:
*She had documented the AWAS assessment on 12/19/17 at 8:00 p.m. and 10:00 p.m. and each time she had scored the blood pressure a one.
*She had documented on 12/20/17 at 2:00 a.m. resting and on 12/20/17 at 6:00 a.m. refused. She had not attempted to take the blood pressure at 6:00 a.m. a coworker informed her the patient had refused, she documented refused AWAS.
*The blood pressures for those times were not documented in the chart, but should have been. She was not sure why the blood pressures had not been documented.
*It was facility policy not to wake the patient when they were resting.
*She thought the patient's diastolic blood pressure was 69, and her blood pressure was trending down.
*The patient had approached her during that evening (12/19/18) and stated she needed to go to the emergency room (ER), that she was withdrawing, and she had passed that information to the house supervisor.

Interview on 1/30/18 at 12:15 p.m. with RN R regarding AWAS assessments revealed:
*The nurse was responsible for completing the AWAS assessment.
*There was a protocol to follow.
*Any abnormal findings during the AWAS assessment the physician would have been notified.

Review of RN H's nurses notes dated 12/19/17 at 9:25 p.m. regarding patient 1 revealed:
*The patient was irritable and upset about something for sleep.
*The patient stated "I'm withdrawing." "Why aren't you doing something about my blood pressure."
*The patient was informed "it's coming down on own, and we are taking vital signs every four hours."
*She stated "I think I need to go to the ER, i am in withdrawals."
*The nurse had documented the blood pressures were consistently in the 150s/90s.
*There was no documented nursing assessment at that time.

Review of the provider's 9/19/17 Vital Sign policy revealed:
*"It shall be the policy of the SDHSC that vital signs shall be assessed on patients to monitor changes due to illness or injury.
*The purpose of the policy was to aide in assessment and monitoring of treatment of patients.
*Vital signs should have been documented on the clinical data sheet in the patient's medical record.

B. Based on interview, record review, and policy review, the provider failed to ensure:
*The physician was notified for one of ten sampled patients' (1) high blood pressure.
*Follow-up assessment of the patient's blood pressure and a nursing assessment was completed for one of ten sampled patients (1) with hypertension:
Findings include:

1. Review of patient 1's vital signs report revealed:
*On 12/19/17 at 4:01 p.m. her blood pressure was 153/108, pulse 96, respirations 16, and temperature 98.2.
*No additional blood pressures, pulses, respirations, or temperatures were documented on that form.
*There was no documentation on that form the physician had been notified of the high blood pressure.
*Review of the nurses notes revealed there was no documentation the physician had been notified of the high blood pressure.

Review of the provider's 9/19/17 vital sign policy revealed:
*The staff should have notified the physician if the systolic blood pressure during an orthostatic hypotension assessment decreased by 20 mmHg.
*The policy had not addressed any other times the physician or practitioners should have been notified for abnormal blood pressure readings.

Review of patient 1's AWAS checklist for blood pressure assessments revealed:
*An assessment had been completed at 4:00 p.m., one point had been given for a blood pressure between 150 to 175 mmHg. The blood pressure documented at 4:01 p.m. was 153/108 mmHg.
*The assessment of blood pressures were based on systolic readings.
*A total score of two had been documented at 4:00 p.m. for the overall assessment result.
*Monitoring directions were:
-"Assess and record symptoms on AWAS scale.
-If AWAS is 8 or greater x 2 within 30 minutes contact ordering physician or PA-C/CNP [physician assistant certified/certified nurse practitioner].
-Continue assessing AWAS every 30 minutes until patient achieves a score of less than or equal to 3, then every 4 hours while awake x 72 hours, unless status merits more frequent checks."
*There were no instructions on the form to notify the physician for an increased systolic or diastolic blood pressure reading.

Interview and review on 1/30/18 at 9:20 a.m. with RN E regarding patient 1's medical record revealed:
*He had obtained and documented the 150/108 blood pressure.
*After the 4:01 p.m. blood pressure no additional blood pressures had been documented under the clinical summary area.
*At that time she was not sweating or shaking; it appeared "She wasn't quite right."
*The physician or PA-C/CNP had not been notified of the high blood pressure or the patient wasn't quite right.

C. Based on interview and record review the provider failed to ensure:
*Staff training was provided regarding the AWAS protocol used to assess one of one sampled patient (1) with alcohol withdrawal.
*Staff training was provided to ensure consistency in understanding what every 15 minute checks with door opened meant.
Findings include:

1. Review of patient 1's medical record revealed:
*The physician had ordered AWAS for monitoring alcohol withdrawal.
*Monitoring the patient's systolic blood pressure was one criteria on the checklist.
*Staff had documented an AWAS score of one for the systolic blood pressure on 12/19/17 at 8:00 p.m. and 10:00 p.m.
*The checklist indicated a one meant the systolic blood pressure was between 150 to 175 mmHg.
*No numerical value had been documented for the specific systolic blood pressure results.

Interview on 1/29/18 at 4:10 p.m. with RN H revealed:
*The nurse was responsible for completing the AWAS assessment.
*Anyone could take the blood pressure used to score the systolic parameters.
*The individual taking the blood pressure should have documented it in the medical record.
*She did not know why the blood pressure was not documented in the medical record for the 8:00 p.m. and 10:00 p.m. AWAS evaluation.

Interview on 1/30/18 at 10:15 a.m. with RN F revealed it was nursing responsibility to complete the AWAS.

Interview on 1/31/18 at 11:30 a.m. with mental health counselor S revealed:
*Vital signs and the frequency were ordered by the physician.
*If a patient was sleeping and was a new admission to the unit, she would have awakened the patient to obtain their vital signs in order to establish a pattern for that patient.
*Any abnormal readings the nurse would have been notified.

Interview on 1/31/18 at 12:15 p.m. with RN R revealed:
*The nurse was responsible for monitoring the blood pressure for the AWAS assessments.
*Abnormal findings were reported to the physician assistant immediately.

Interview on 1/30/18 at 8:10 a.m. with the director of nursing revealed:
*The AWAS was a protocol not a facility policy.
*It was the primary tool to assess alcohol withdrawal for patients.
*It had been in use for many years.
*Staff training was done upon first hire and no further training or competency was completed.
*She could see the benefits of training staff on the AWAS.

2. Interview on 1/31/18 at 9:35 a.m. with mental health aide K revealed:
*He had assisted with the 15 minute checks on 12/20/17.
*If the patient was in their room, check for respirations, and the rising of the chest.
*He could not see patient 1 from the hallway, the door was cracked slightly.
*He had left the door sightly open after completing the check.
*"Close observation with door open really was not specified how wide the door had to be open."

Interview on 1/31/18 at 9:59 a.m. with mental health counselor J revealed:
*She assisted with 15 minute checks on 12/20/17.
*Patient 1's door was opened halfway during the check.
*You must visibly see the patient and observe breathing.
*She thought she could see movement but the room was dark; there was no light on in the room.
*There are flashlights or pen lights used at night but not during the day.

Interview on 1/31/18 at 10:24 a.m. with mental health counselor I revealed:
*She had completed the 15 minute check on 12/20/17 at 10:00 a.m. and thought the patient 1's coloring was "funny."
*It was difficult to observe her respirations because the room was dark; it looked like she had a "purple rash around her mouth."
*She told the nurse and it took about ten minutes for the nurse to come to the room.
*The door to the room was cracked and when she did the check it had to be opened to view her. Otherwise she would not have been able to visualize the patient from the door.

Interview on 1/31/18 at 11:58 a.m. with mental health aide Q revealed:
*Every 15 minute checks staff are required to observe the patient's activity.
*Staff observed to make sure the patient was breathing.
*The door to their room could have been cracked or left opened.
*The acoustics are horrible and patients wanted their door shut.

Interview on 1/31/18 at 12:15 p.m. with RN R revealed the physician ordered every 15 minute checks and the physician made the decision in close observation if the door needed to be open.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interview, observation, and record review, the provider failed to ensure a consistent and functional procedure was in place for appropriate staffing on two of two units (Aspen 1 and Aspen II) to safeguard patients with high acuity to care for their current and continuous needs. Finding include:

1. Interview on 1/30/18 at 8:10 a.m. with director of nursing A regarding staffing on the acute patient units revealed:
*If additional staff were needed the charge nurse on the unit would page the resource nurse who would have been a nurse manager that worked 8:00 a.m. to 4:30 p.m. The resource nurse would contact scheduling to assist in finding assistance for the unit.
*Daily at 12:45 p.m. the nurse supervisor, the nurse managers, scheduling, and the director of nursing would meet to ensure appropriate staffing levels for the day shift on the acute care units.
*The staff were required to complete four hours of mandatory overtime every week or eight hours every two weeks.
*Two units had to be shut down because of staffing concerns.

Interview on 1/30/18 at 9:20 a.m. with RN E regarding Birch 1 staffing on the morning of 12/20/17 and staffing for the units revealed:
*He thought the day shift was under staffed the morning of 12/20/17.
*He made a call about staffing to the contact [resource] nurse that morning after several other staff complained about being short staffed. He was unsure of the contact nurse's name.
*The contact nurse then would funnel the request for extra staffing to the scheduling person.
*He felt as though he was actively seeking extra staffing because of the high acuity of patients the morning of 12/20/17.
*There was a 1:1 (meaning one staff continuously for one patient), a whirlpool bath that needed to be completed off the the unit by three staff who were scheduled on the Birch unit, and other staff were called off Birch I to other units to assist because of staffing shortages.
*Two units had been shut down and there were currently two open units (Aspen I and Aspen II) and those units were still busy.
*He felt the increase in the geriatric population with behavioral issues and falls risk, and the increase in jail inmate admissions were putting a strain on the staffing.

Interview on 1/30/18 at 10:15 a.m. with RN F regarding Birch 1 staffing on the morning of 12/20/17 and staffing for the units revealed:
*She was working the day shift on 12/20/17 and had come in at 6:30 a.m. and was completing the medication pass.
*There are never any definitive staff assignments.
*Staffing was "horrible" the morning of 12/20/17. RN E had called someone to obtain more staff due to the high acuity on the unit.
*She was doing medication pass and RN E was assisting patients on the floor.
*There was a patient that had been returned from ECT (electro-convulsive therapy) who needed consistent vital signs completed, there was a 1:1, RN E was passing meal trays for the patients because three of the scheduled staff were off the unit completing a whirlpool bath for a patient, some of the other scheduled staff had been pulled to other units, and it was very busy.

Interview on 1/3018 at 11:00 a.m. with certified nurse practioner (CNP) C regarding the events and staffing on 12/20/17 in Birch 1 unit revealed:
*Staff were spread thin.
*The unit had several geriatric patients on the floor.
*The staff felt stretched and traumatized the day of 12/20/17.

Interview on 1/30/18 at 11:32 a.m. with physician L regarding staffing and events on 12/20/17 in the Birch 1 unit revealed:
*He attended the debriefing meeting with the staff working on the unit after the death of patient 1 on 12/2017.
*The staff had concerns about how busy the unit was that morning.
*Several staff broke down and started to cry during the debriefing, because the staff were so busy.
*There were concerns by staff on 12/201/7 with the amount of patients and the acuity on the unit.
*There were several patients with fifteen minute checks, there was a 1:1, and there was a large geriatric population on the unit with behavioral issues and fall risks.

Interview on 1/30/17 at 11:58 a.m. with RN charge nurse D regarding staffing on the acute care patient units revealed:
*She was the charge nurse on Cedar I, and the resource nurse on 12/20/17.
*She would have the pager as the resource nurse.
*She came to work around 8:00 a.m. the morning of 12/20/17.
*As the resource nurse she would take sick calls, or if a unit needed extra staff.
*When a unit pages the resource nurse an extension comes up on the pager.
*She responds to all calls to the pager.
*The pager does not keep notifying her of the call received on her pager.
*If she would not answer the pager because she was busy she would expect the person to keep attempting to contact her.
*The person making the call to her pager should make the time to continue to re-page her if she was busy on her unit.
*She remembered she had several sick calls the day of 12/20/17. The day of 12/20/17 she was the charge nurse and the resource nurse.
*She stated that the process did not work well, because if she was in a patient room she could not get to the page immediately.
*She as the charge nurse and/or the unit nurse would carry the pager as the resource nurse.
*They had asked administration not to carry the pager because of other duties that needed to be completed.
*She was unaware of any policy related to requesting staff for high acuity on the units.

Interview on 1/30/18 at 3:25 p.m. with director of nursing A and RN nurse manager P regarding staffing issues revealed:
*After the death of patient 1 a debriefing was held for staff that they were not apart of.
*There were two staff identified that were visibly upset regarding the death of patient 1.
*There were concerns of staffing brought up during the debriefing that director of nursing A and nurse manager RN P stated was not brought to their attention by staff on 12/20/17.
*Director of nursing A stated there had been an extra staff member called to Birch I after the death of patient 1.
*Birch 1 was currently closed due to staffing concerns.

Interview on 1/31/18 at 8:25 a.m. with RN house supervisor O regarding staffing revealed:
*He would oversee the entire hospital from 8:00 p.m. until 8:00 a.m.
*If he had the time he would attempt to visit each patient unit. He would usually visit half of the units during his shift.
*His office was in admissions.
*He would complete the scheduling, get reports from the other units, and take calls from nursing staff.
*He would get a call around 6:15 a.m. if the units were short staffed.
*There were set staffing levels but he would have the authority to add staffing if the unit was struggling with high acuity.
*The scheduler would be the one who would know what staff were needed. The scheduler makes the determination if more staff were needed.
*He was unsure if there was a policy related to high patient acuity; he had never seen one.

Interview on 1/31/18 at 8:47 a.m. with RN N regarding staffing revealed:
*Nurses were assigned patients.
*Depending on the staff but usually would not go over a 4:1 ratio with four patients to one staff person.
*There would be two nurses; one to complete the medication pass and the other would complete paperwork.
*On 12/20/17 she recalled there were staff pulls to other units from Birch I. The staff person could be gone from thirty minutes up to two-three hours at a time. Sometimes there would be a gap that the unit would be short staffed.
*Usually the nurse was the team lead and would check on staffing for the unit.
*The staff were busy on the morning of 12/20/17.
*Three staff had been taken off the unit to give a whirlpool bath to a resident on Birch but the whirlpool was on another unit, so that left the Birch I unit short staffed.
*Schedulers do not have a lot to do with staffing.
*Continuous re-assessment of the staffing was needed because the patients status continually changed.
*An email would be sent out by the scheduler to all staff if a staffing shortage was noted.
*Charge nurses meet with the night house supervisor but she was unsure if she met with him the morning of 12/20/17.
*High patient acuity needs to be in continuous motion because the patient's condition was constantly changing.
*She had worked as the resource nurse carrying the pager for units that had concerns about staffing.

Interview on 1/31/18 at 9:35 a.m. with mental health aide K regarding staffing concerns and the day of 12/20/17 revealed:
*He usually worked on Aspen II.
*His supervisor came to him on 12/20/17 at approximately 9:00 am. and asked him to go over to Birch I to help them as they were short staffed.
*He went to Birch I and assisted the staff with fifteen minutes checks. He was there approximately thirty minutes but not sure of the exact length of time.
*Staff on Birch I were very busy on the morning of 12/20/17 taking care of multiple geriatric patients.
*He stated he had seen one nurse passing medication and the other nurse assisting on the floor that morning.
*He only saw the two nurses during his time in Birch I, he saw no other staff on the floor.

Interview on 1/31/18 at 9:59 a.m. with mental health counselor J regarding staffing concerns and the morning of 12/20/17 revealed:
*She has been employed for four and a half years.
*12/20/17 was a very busy day and she had just gotten back from giving one of the patients on Birch I a whirlpool bath off the unit with two other staff members.
*There were multiple geriatric patients on Birch I on 12/20/17.
*She had worked the weekend prior to 12/20/17 and it had been quite busy.
*There were five patients on the unit that required total assistance from two-three staff members at a time. The staff had requested more help for the weekend prior to 12/20/17, and those same five patients were still on the unit on 12/20/17.
*The staff in Birch I had been asking for more staff assistance for several days due to the high acuity of patients on the unit.
*She stated she looked at the schedule and stated, "We need help."
*Staffing was a major concern on the acute care units.
*She has seen the closing of units as a quick fix to the staffing problem.
*Evenings, nights, and weekends were always short staffed.

Interview on 1/31/18 at 10:24 a.m. with mental health counselor I regarding staffing concerns and the morning of 12/20/17 revealed:
*She was pulled from Birch I to work in another unit from 6:30 a.m. until 7:15 a.m.
*Three of her co-workers had left Birch I the morning of 12/20/17 to give a whirlpool bath to a patient off the Birch I unit, and those staff were gone from the unit for approximately one hour.
*Birch I was incredibly busy the morning of 12/20/17 and she confirmed they were busy the weekend prior to 12/20/17.
*The nurses on 12/20/17 in Birch I had called for assistance for extra staffing.
*Another co-worker had been pulled to Oak from Birch I on 12/20/17.
*There were multiple staff pulls to other units from Birch I.
*Both the night shift and day shift were aware of the request for extra help.
*The morning of 12/20/17 there were fifteen minute checks, a 1:1, she had assisted one patient with a shower, there were two to three total care patients through out the day, and three staff were off the unit to give a whirlpool bath that took several staff off the Birch I unit.
*Staff were struggling to get the fifteen minutes checks done on Birch I because of the staff shortage.
*Geriatric patients on Birch I have Hoyer lifts for transfers, aggressive behaviors requiring multiple staff to care for the patient, multiple medications, assist with feeding meals, toileting, dressing, and all other activities of daily living requirements.

2. Observation on 1/31/17 at 11:20 a.m. on the Aspen I unit revealed:
*There was a group session in the day room area.
*There were two 1:1's going on where staff were eyes on the patient at all times.
*There were several geriatric patients on the unit.
*There was a legally blind patient that had been laying down in his room, but when he was up ambulating he was a 1:1.

3. Interview on 1/31/18 at 11:30 a.m. with mental health counselor S regarding staffing on the unit revealed:
*She has been employed since May 2017. Cedar I was her home unit and that unit has been closed due to staffing constraints.
*She has been on Aspen I for approximately two weeks.
*There had been staffing issues due to 1:1 geriatric patients having behavior issues and fall risks.
*There was a total assist geriatric patient currently on the unit as well as a legally blind patient who also had required 1:1's.
*Aspen was currently staffed appropriately during the week on the day shift. It was usually on evenings and the weekends when there were issues with short staffing.
*The patients on the two units that were closed had been split up between Aspen I and Aspen II to keep the census at approximately thirteen patients.
*Geriatrics with behaviors were difficult to place in other health care facilities.
*There were staff pulled from the acute care units due to short staffing in the nursing area of Spruce I and Spruce II which was the long term care units.

Interview on 1/31/18 at 11:58 a.m. with mental health aide Q regarding staffing concerns revealed:
*There have been acute care units closed up to one year.
*He usually worked the day shift.
*There were times the units were short staffed due to the geriatric patients and the care that those patients required.
*The geriatric patients who were on the units were hard to place in other heath care facilities due to the behaviors exhibited by those patients.
*There were staffing shortages on evenings and weekends.
*He thought there were scheduling meetings daily.
*He felt as though the geriatric patient population were taking the staff away from the acute mental health patients that were admitted for care.
*Sometimes patients who had privileges to go off the unit were not given those privileges because of the high care required for the geriatric population. Staff did not have the time because of the total care required for some of the geriatric patients on the unit.

Interview on 1/31/18 at 12:15 p.m. with RN R regarding staffing concerns revealed:
*She has been employed for three years.
*She started out on Pine II, then went to Pine I, then went to Cedar I, and now was working on Aspen I.
*The geriatric patient population has increased along with the total assistance care required.
*There have been two to three geriatric patients on the units that required two to three staff and more at times for their care depending on the patients behaviors. They need toileting, personal care, dressing, and assistance with feeding.

Interview on 1/31/18 at 12:35 p.m. with RN nurse manager P regarding staffing concerns revealed:
*Geriatric patients have increased the past two years and especially the past two months at the facility.
*There was no policy or protocol for patient acuity on the units.
*Staffing has become an issue.

4. Review of the Acute AM Daily Staffing for 1/31/18 from 7:00 a.m. to 2:30 p.m. for Aspen I revealed:
*There were three patients that required 1:1's and one of the patients required a male staff.
*The staff record also indicated several pulls to other units which included:
-One staff to Aspen II.
-One staff to Cedar II.
-One staff to Spruce II from 6:30 a.m. to 7:45 a.m.
-One staff to Spruce II from 10:30 a.m. to 2:30 p.m.
-One staff to Aspen II from 7:45 a.m. to 12:30 p.m.
*There was also an ECT scheduled from 7:00 a.m. to 8:30 am. with two escorts required and staff "stays".
*There was also documentation that there was high acuity on Aspen I.

Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 9th Ed., St. Louis, Mo., 2017, p. 311, revealed:
*"During nursing shortages or staff downsizing periods, the issue of inadequate staffing occurs. The Community Health Accreditation Program (CHAP) and other state and federal standards require agencies to have guidelines for determining the number (staffing ratios) of nurses required to give care to a specific number of patients. Legal issues occur when there are not enough nurses available to provide competent care or when nurses work excessive overtime. One such example is in a class-action suit, Spires v. Hospital Corporation of America, filed on April 10, 2006. The wife claimed there was poor patient care related to insufficient RN staffing and that the poor nurse-staffing levels led to the resultant death of her husband. This suit emphasized the potential seriousness of short staffing and the importance of nurses' asserting employee rights.
*In an attempt to address the short-staffing problem, many states now require that nursing committees in acute care settings determine safe staffing on the basis of the needs of the patients admitted to their facilities. The safe staffing ratio debate is occurring through the country and demands close attention by all nurses (ANA, 2014)."