HospitalInspections.org

Based on document review and interview, the facility failed to communicate patient's plan of care in 1 out of 10 (Patient 6) medical records reviewed.

Findings Include:

1. Facility policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, last approved 04/2023, indicated family and/or agent, when appropriate, be informed of your care including unanticipated outcomes in order to participate in current and future decisions affecting the patient's care and to participate in the development and implementation of your plan of care.

2. Review of Patient 6's medical record indicated that the patient indicated to include a family member in their treatment planning. Medical record lacked documentation of involvement of family member in the treatment plan.

Based on document review and interview, the facility failed to follow the staffing policy for 58 of 168 shifts reviewed and failed to staff a registered nurse on every unit for 2 of 168 shifts reviewed.

Findings include:

1. Facility policy titled, Clinical Staff (Nurse) Staffing Plan, PolicyStat ID 12279065, last approved 08/2022, indicated there will be one clinical staff member for every four patients from 7:00 a.m.-11:00 p.m., one clinical staff member for every 8 patients from 11:00 p.m.-7:00 a.m. and there must be at least one Registered Nurse in every unit at all times. .

2. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 100 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/27/2024:
a. 04/14/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
b. 04/15/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present.
c. 04/19/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present.
d. 04/20/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present.
e. 04/21/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
f. 04/23/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present.
g. 04/25/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present.
h. 04/27/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 14 which required 4 clinical staff members and only 3 present.

3. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 200 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/20/2024:
a. 04/14/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 14 which required 4 clinical staff members and only 3 present.
b. 04/15/2024: lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 staff members and only 3 present and lacked a registered nurse from 11:00 p.m. to 7:00 a.m. with a census 12, which required 1 registered nurse and none present.
c. 04/17/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present.
d. 04/19/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
e. 04/20/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
f. 04/21/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
g. 04/22/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
h. 04/23/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
i. 04/24/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 clinical staff members and only 3 present.
j. 04/27/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 clinical staff members and only 3 present.

4. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 300 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/27/2024:
a. 04/14/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 15 and one 1:1 which required 5 staff members and only 3 present and lacked 1 clinical staff member from 3:00 p.m. to 7:00 a.m. with a census of 15 and one 1:1 which required 5 staff members and only 4 present.
b. 04/15/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 13 and one 1:1 which required 5 staff members and only 3 present and lacked 1 clinical staff member from 3:00 p.m. to 7:00 a.m. with a census of 13 and one 1:1 which required 5 staff members and only 4 present.
c. 04/16/2024 lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 12 and one 1:1 which required 5 staff members and only 4 present and lacked 1 clinical staff member from 11:00 p.m. to 7:00 a.m. with a census of 12 and one 1:1 which required 3 clinical staff member and only 2 present.
d. 04/19/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 13 which required 4 staff members and only 3 present.
e. 04/20/2024: lacked a registered nurse from 11:00 p.m. to 7:00 a.m. with a census 12, which required 1 registered nurse and none present.
f. 04/21/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 which required 4 staff members and only 3 present.
g. 04/22/2024: lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 staff members and only 3 present.
h. 04/25/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 staff members and only 3 present.
i. 04/27/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 14 which required 4 staff members and only 3 present.

5. Review of the Staffing Pattern Worksheet completed by the facility, indicated the 400 unit was not appropriately staffed per staffing policy guidelines on the following days for the weeks of 04/14/2024 through 04/27/2024:
a. 04/14/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 15 which required 4 staff members and only 3 present.
b. 04/15/2024: lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 14 which required 4 staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 14 which required 4 staff members and only 3 present.
c. 04/18/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 14 and one 1:1 which required 5 staff members and only 4 present.
d. 04/19/2024 lacked 2 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 12 and one 1:1 which required 5 staff members and only 3 present.
e. 04/20/2024: lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 16 which required 4 staff members and only 2 present and lacked 1 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 which required 4 staff members and only 3 present.
f. 04/21/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00p.m. with a census of 16 which required 4 staff members and only 3 present; lacked 2 clinical staff member from 3:00 p.m. to 11:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 3 present.
g. 04/22/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present.
h. 04/23/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present.
i. 04/24/2024 lacked 1 clinical staff member from 7:00 a.m. to 3:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present.
j. 04/25/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 16 and one 1:1 which required 5 staff members and only 4 present.
k. 04/26/2024 lacked 1 clinical staff member from 7:00 a.m. to 11:00 p.m. with a census of 15 and one 1:1 which required 5 staff members and only 4 present.
l. 04/27/2024 lacked 2 clinical staff members from 7:00 a.m. to 3:00 p.m. with a census of 13 and one 1:1 which required 5 staff and only 3 present.

6. Interview with A4 (Director of Nursing) on 05/23/2024 at approximately 1:50 p.m. confirmed the facility was short staffed on the dates and shifts listed above.

Based on document review and interview, nursing services failed to ensure that provider orders were transcribed and noted in 1 out of 10 (patient 6) medical records, failed to ensure that dietary orders were followed in 1 of 10 (patient 6) medical records, and failed to document patient personal belongings upon admission in 1 out of 10 (patient 6) medical records reviewed.

Findings include:

1. Facility policy titled, Physician Orders/Receipt and Notation, PolicyStat ID 12197185, last approved 08/2022, indicated under Procedure: 5. Provider orders are to be noted and transcribed by RNS, LPNs, or Pharmacists.

2. Facility policy titled, Standards of Nutrition of Care, PolicyStat ID 12511831, last approved 10/2022, indicated under Diet Orders: The patient's food intake and diet acceptance will be monitored by the nursing staff, the dietary director, and other hospital staff with appropriate referrals being made accordingly to Nutrition Services staff.

3. Facility policy titled, Management of Patient Belongings, PolicyStat ID 13950524, last approved 07/2023, indicated upon admission staff will inventory all patient belongings and sign Personal Belongings Inventory Form. Patient will then sign the form.

4. Review of Patient 6's medical record indicated an intravenous catheter (IV) with normal saline 0.9% at 50 milliliters (ml) per hour was started on 04/27/2024. Medical record lacked documentation of provider telephone IV order. On 04/21/2024, medical record indicated patient was placed on honey thick liquids and on 04/22/2024 medical record indicated that patient had multiple cups of water to drink and lacked documentation that the water was thickened. Medical record lacked documentation of the Personal Belongings Form.

5. Interview with A4 (Director of Nursing) on 05/23/2024 at approximately 3:45 p.m. confirmed that patient 6's medical record lacked documentation of the intravenous orders on 04/27/2024.

6. Interview with A5 (Dietary Manager) on 05/23/2024 at approximately 4:30 p.m. confirmed patient 6 had a mechanical soft diet and liquids were to be thickened due to risk of aspiration ordered on 04/21/2024.