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MEMORIAL HERMANN HOSPITAL SYSTEM
STAFFING AND DELIVERY OF CARE
Tag No.: A0392
Based on record review and interview, the facility failed to ensure there were adequate numbers of staffing in a nursing unit, for 6/18 shifts reviewed for the 3A nursing unit.
Findings Included:
Record review of staffing grid provided by facility labeled "Cardiothoracic IMU 3A" with 3A unit charge nurse Staff ID #62 on 6/10/2025 at 11:00 am. She confirmed this was the staffing grid utilized by the 3A nursing unit for staffing the unit.
Record review of staffing sheets from 3/20/2025 until 3/27/2025 with charge nurse staff ID #62. She confirmed the following findings:
3/21/25 7 pm, Census 34, Staffing sheet states Census 34 - 1 charge RN, 10 RNs and 3 PCAs; actual 1 charge RN, 9 RNs, 3 PCAs.
3/22/25 7 pm, Census 33, Staffing sheet states Census 33 - 1 charge RN, 10 RNs and 3 PCAs; actual 1 charge RN, 9 RNs, 2 PCAs.
3/24/25 7 am, Census 35, Staffing sheet states Census 35 - 1 charge RN, 10 RNs and 4 PCAs; actual 1 charge RN, 10 RNs, 3 PCAs.
3/24/25 7 pm, Census 34, Staffing sheet states Census 34 - 1 charge RN, 10 RNs and 4 PCAs; actual 1 charge RN, 9 RNs, 3 PCAs.
3/25/25 7 am, Census 34, Staffing sheet states Census 34 - 1 charge RN, 10 RNs and 4 PCAs; actual 1 charge RN, 10 RNs, 3 PCAs.
3/25/25 7 pm, Census 31, Staffing sheet states Census 31 - 1 charge RN, 9 RNs and 3 PCAs; actual 1 charge RN, 9 RNs, 2 PCAs.
Record review of facility's "Administration: Staffing Effectiveness", last reviewed 12/19/2022, stated "MHSE will ensure that there is an adequate number of multidisciplinary clinical staff to fulfill its mission and meet the needs the needs of the populations served. There is a sufficient number of staff based on the hospital's determination of the approrpiate level of staffing."
Interview 6/10/2025 at 11:00 with Charge RN Staff ID #62. She confrimed the above findings. She stated that the unit occasionally has to utilize PCA's for 1:1 sitters in their unit and other units or occasionally due to staff unexpected call ins. She stated that the staffing office is responsible for allocating staff to the units.