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 document review and interview, it was determined that for 20 of 30 days in November 2020, and five of seven days in December 2020, at the Hospital's Emergency Department (ED) at Campus #1, the Hospital failed to ensure that there was adequate number of nursing personnel qualified in emergency care to meet the needs anticipated by the Hospital, as required, potentially affecting an average daily census of 32 patients in the ED.

Findings include:

1. On 12/9/2020, the Hospital's policy titled, "Emergency Department Staffing Plan" 2000.2040.13 (reviewed by the Hospital 3/2019) was reviewed and included, "...II. Policy... The ED Nurse Manager is responsible for nursing and ancillary staff schedules... B... 1. Registered Nurses are staffed optimally in the department based on acuity and volume. Typically, the nurse to patient ration is 1:3, but may vary. 2... The minimum number of RNs (Registered Nurses) staffing should not fall below five at any time..."

2. On 12/9/2020, the ED Daily Staffing Sheets for Hospital campuses 1 and 2 from November 2020 through December 8, 2020 were reviewed. The staffing sheets indicated that for the following dates, there were one to three four-hour blocks of times when only two registered nurses were scheduled at campus #1's ED: November 1, 4, 6, 7, 9-16, 18, 20, 21, 23-25, 29, and 30, 2020; and December 2-5, and 7, 2020.

3. On 12/8/2020 at approximately 12:00 PM, an interview was conducted with campus #1 ED Charge Nurse (E #5). E #5 stated that there has been instances when the ambulance crew rings the bell and nurses were busy with other patients. E #5 said that there had been times when there was nobody available to open the door for the ambulance crew to bring in patients. E #5 added that most of the time, only two to three nurses were working each shift.

4. On 12/08/2020 at approximately 12:15 PM, the ED Physician (MD #1) was interviewed. MD #1 stated that there had been instances when he asked the ambulance crew to stay back with the patient until the nurse is at the bedside because of lack of available nurses in the ED. MD #1 said that the ED recently have been having problem with nursing staffing and the administration is aware of it.

5. On 12/9/2020 at approximately 10:20 AM, an interview was conducted with the Interim ED Manager (E #3). E #3 stated that at the minimum, the campus #1 ED requires 2 nurses at all times. However, E #3 stated, "I am concerned when there are only two nurses in the ED ..." E #3 said that if there were an instance when a patient would require 1:1 monitoring by a nurse in the ED, there won't be anyone else available to care for that patient. The ED Daily Staffing Sheets for campus #1 were reviewed with E #3. E #3 verified that for the above dates in November 2020 and December 2020, there were only two registered nurses were scheduled in the ED. E #3 stated that the ED Staffing Plan 2000.2040.13 currently applies to campus #1 ED.

6. On 12/10/2020 at approximately 9:44 AM, an interview was conducted with E #1 (Systems Chief Nurse/Vice President of Hospital Operations). Regarding the staffing plan for Hospital campus #1 ED, E #1 stated that the Hospital is still writing the current staffing guidelines.

7. On 12/10/2020 at 10:15 AM, a phone interview was conducted with the Emergency Physician (MD #3). MD #3 stated that campus #1 may have 3 critical patients with only two nurses. MD #3 stated that staffing is a problem in the ED at campus #1. MD #3 stated that lack of staffing in the ED is a concern at campus #1 MD #3 stated that the lack of staffing has contributed to a sense of overwhelmed feeling in addition to the stress from COVID-19.