HospitalInspections.org

Based on document review and interview, the facility failed to follow the facility staffing policy for 4 of 4 units.

Findings Include:

1. Review of policy "Clinical Staff (Nurse) Staffing Plan" PolicyStat: 12279065, last approved 08/2022, indicated there will be 1 nursing staff to every 4 patients ratio maintained.

2. Review of staffing in all 4 units between 10/1/2023 and 11/1/2023 indicated overall the facility was staffed inappropriately according to policy 39% of the 32 days reviewed. Unit 100 - 37.5%, Unit 200 - 31%, Unit 300 - 50%, Unit 400 - 40%.

a. Review of unit 100 staffing from 10/1/23 to 11/1/23 based off of policy indicating 1 nursing staff to every 4 patients are indicated as follows:
(missing staff could be a nurse or a tech per policy).
10/01/23 - short 1 staff for night shift. Census 11. Staffing 1/1 Night (1 licensed/1 unlicensed).
10/02/23 - short 1 staff for night shift. Census 11. Staffing 1/1 Night.
10/05/23 - short 1 staff for night shift. Census 11. Staffing 1/1 Night.
10/10/23 - short 1 staff for night shift. Census 12. Staffing 1/1 Night.
10/14/23 - short 1 staff for night shift Census 12. Staffing 1/1 Night.
10/15/23 - short 1 staff for day shift. Census 15. Staffing 1/1 Day.
10/16/23 - short 1 staff for day and 1 for night shift. Census 15. Staffing 1/2 Day, 1/1 Night.
10/17/23 - short 1 staff for night shift. Census 15. Staffing 1/2 Day.1/1 Night.
10/18/23 - short 1 staff for night shift. Census 15. Staffing 1/2 Day, 1/1 Night.
10/19/23 - short 1 staff for night shift. Census 15. Staffing 2/1 Night.
10/20/23 - short 1 staff for night shift. Census 15 Staffing 1/2 Night.
10/21/23 - short 1 staff for day and 2 staff for night shift. Census 15. Staffing 1/2 Day, 1/1 Night.

b. Review of unit 200 staffing from 10/1/23 to 11/1/23 based off of policy indicating 1 nursing staff to every 4 patients indicated as follows:
(missing staff could be a nurse or a tech per policy)
10/01/23 - short 2 staff for day shift and 2 staff for night shift. Census 13. Staffing 1/1 Day, 1/1 Night.
10/03/23 - short 2 for staff night shift. Census 13. Staffing 2/2 Day, 1/1 Night.
10/07/23 - short 2 for day shift and 2 staff for night shift. Census 13. Staffing 1/1 Day, 1/1 Night.
10/08/23 - short 1 staff for day shift. Census 12. Staffing 1/1 Day, 2/1 Night.
10/09/23 - short 1 staff for night shift Census 12. Staffing 1/2 Day, 1/1 Night.
10/13/23 - short 1 staff for night shift. Census 12. Staffing 1/2 Day, 1/1 Night.
10/17/23 - short 2 staff for night shift. Census 15. Staffing 2/2 Day, 1/1 Night.
10/19/23 - short 2 staff for night shift. Census 15. Staffing 2/2 Day, 1/1 Night.
10/20/23 - short 1 staff for day shift and 2 staff for night shift. Census 15. Staffing 1/2 Day, 1/1 Night.
10/21/23 - short 2 staff for night shift. Census 15. Staffing 2/2 Day, 1/1 Night.

c. Review of unit 300 staffing from 10/1/23 to 11/1/23 based off of policy indicating 1 nursing staff to every 4 patients indicated as follows:
(missing staff could be a nurse or a tech per policy)
10/01/23 - short 1 staff for night shift. Census 9. Staffing 2/1 Day, 1/1 Night.
10/02/23 - short 1 staff for day shift and 1 staff for night shift. Census 9. Staffing 1/1 Day, 1/1 Night.
10/04/23 - short 1 staff for day shift and 1 staff for night shift. Census 9. Staffing 1/1 Day, 1/1 Night.
10/05/23 - short 1 staff for day shift. Census 9. Staffing 1/2 Day, 1/1 Night.
10/09/23 - short 1 staff for day shift. Census 10. Staffing 1/1 Day, 2/1 Night.
10/10/23 - short 1 staff for night shift. Census 10. Staffing 1/2 Day, 1/1 Night.
10/12/23 - short 1 staff for night shift. Census 10. Staffing 1/1 Day, 2/1 Night.
10/16/23 - short 1 staff for day shift and 1 staff for night shift. Census 13. Staffing 1/1 Day, 2/1 Night.
10/17/23 - short 1 staff for night shift Census 13. Staffing 2/2 Day, 1/1 Night.
10/18/23 - short 1 staff for night shift. Census 13. Staffing 2/2 Day, 1/1 Night.
10/19/23 - short 1 staff for day shift and 1 staff for night shift. Census 13. Staffing 1/2 Day, 1/2 Night.
10/20/23 - short 1 staff for day shift and 1 staff for night shift. Census 13.
10/21/23 - short 1 staff for day shift and 2 staff for night shift. Census 13. Staffing 1/2 Day, 1/1 Night.
10/22/23 - short 1 staff for day shift and 1 staff for night shift. Census 11. Staffing 1/1 Day, 1/1 Night.
10/23/23 - short 1 staff for day shift. Census 11. Staffing 1/1 Day, 2/1 Night.
10/25/23 - short 1 staff for night shift. Census 11. Staffing 2/2 Day, 1/1 Night.

d. Review of unit 400 staffing from 10/1/23 to 11/1/23 based off of policy indicating 1 nursing staff to every 4 patients indicated as follows:
(missing staff could be a nurse or a tech per policy)
10/01/23 - short 2 staff for day shift and 2 staff for night shift. Census 16. Staffing 1/1 Day, 1/1 Night.
10/02/23 - short 2 staff for day shift and 1 staff for night shift. Census 16. Staffing 1/1 Day, 2/1 Night.
10/03/23 - short 1 staff for day shift and 2 staff for night shift. Census 16. Staffing 1/2 Day, 1/1 Night.
10/04/23 - short 1 staff for day shift and 2 staff for night shift. Census 16. Staffing 1/2 Day, 1/1 Night.
10/05/23 - short 2 staff for day shift and 1 staff for night shift. Census 16. Staffing 1/1 Day, 1/2 Night.
10/06/23 - short 1 staff for day shift and 1 staff for night shift. Census 16. Staffing 1/2 Day, 2/1 Night.
10/07/23 - short 1 staff for day shift and 2 staff for night shift. Census 16. Staffing 2/1 Day, 1/1 Night.
10/15/23 - short 1 staff for day shift and 1 staff for night shift. Census 11. Staffing 1/1 Day, 1/1 Night.
10/16/23 - short 1 staff for day shift and 1 staff for night shift. Census 11. Staffing 1/1 Day, 1/1 Night.
10/17/23 - short 1 staff for night shift. Census 11. Staffing 1/2 Day, 1/1 Night.
10/18/23 - short 1 staff for night shift. Census 11. Staffing 2/2 Day, 1/1 Night
10/20/23 - short 1 staff for night shift. Census 11. Staffing 1/2 Day, 1/1 Night
10/21/23 - short 1 staff for night shift. Census 11. Staffing 2/2 Day, 1/1 Night

3. Interview on 11/2/2023 at 1600 hours with S4, Director of Nursing, confirmed that the facility is short staffed, and a plan of correction had been sent to the state that day.

4. Interview on 11/2/23 at 1700 hours with S5, Chief Executive Officer, confirmed staffing is to be 1 clinical nursing staff member to every 4 patients and that staffing is still an issue. A new plan of correction was sent for review on 11/2/2023.

Based on document review and interview, the facility failed to ensure that provider orders were noted by a Registered Nurse (RN) or Licensed Practical Nurse (LPN) in 4 out of 10 (patients 2, 3, 9, and 10) MRs, completion of transfer order forms were completed in 8 out of 10 (patients 2, 4, 5, 6, 7, 8, 9, and 10) MRs, documentation of vital signs in 7 out of 10 (patient 2, 3, 6, 7, 8, 9 and 10) MRs, and completion of observation reports in 1 out of 10 (patient 10) MRs reviewed.

Findings include:

1. Review of policy titled, "Physician Orders/Receipt and Notation", PolicyStat ID 12197185, last approved 08/2022, indicated all provider orders are to be noted and transcribed by RNs, LPNs, or Pharmacists. All provider orders should be second noted by RN or LPN and noted orders are to be dated, timed, and signed.

2. Review of policy titled, "Transfer of Patient", PolicyStat ID 10623375, last reviewed 06/2023, indicated that a transfer order form is required to be completed when transporting a patient.

3. Review of policy titled, "Vital Signs and Weight", PolicyStat ID 12386461, last approved 09/2022, indicated vital signs will be taken a minimum of once per shift and that vital signs are to be recorded in patient's medical record.

4. Review of policy titled, "Patient Observation", PolicyStat ID 12931622, last approved 01/2023, indicated that documentation of all observations will be completed in the patient's medical record per their ordered observation status.

5. Review of the following MR lacked documentation of nursing signature, date, and time to note provider orders:
a. Patient 2's provider order dated 10/02/2023
b. Patient 3's provider order dated 08/15/2023
c. Patient 10's provider orders dated 10/02/2023, 10/04/2023, and two orders on 10/05/2023.

6. Review of patients 2, 4, 5, 6, 7, 9, and 10's MR lacked a transfer report form and Patient 8's MR lacked a complete transfer report form.

7. Review of Patients 2, 3, 6, 7, 8, 9, 10's MR lacked vital signs documentation on the Vital Signs and Weight Flow Sheet on the following days:
a. Patient 2's MR lacked vital signs on 10/2/2023 pm, 10/03/2023 pm, 10/05/2023 am, 10/06/2023 am, 10/07/2023 pm, and 10/10/2023 am.
b. Patient 3's MR lacked vital signs on 08/03/2023 pm, 08/04/2023 am and pm, 08/16/2023 am, 08/17/2023 am, 08/18/2023 am and pm, 08/19/2023 am, 08/20/2023 am and pm, 08/21/2023 am and pm, 08/22/2023 am and pm, 08/23/2023 am, 08/24/2023 am, 08/25/2023 am, 08/26/2023 am, 08/27/2023 am and pm, and 08/28/2023 am.
c. Patient 6's MR lacked vital signs on 10/20/2023 pm, 10/21/2023 am and pm, 10/22/2023 am and pm, 10/24/2023 pm, 10/25/2023 pm, 10/28/2023 am, 10/30/2023 pm, 10/31/2023 am, and 10/31/2023 vital signs every 15 minutes after patient documented fall.
d. Patient 7's MR lacked vital signs on 06/29/2023 pm, 07/01/2023 am, 07/02/2023 am, 07/03/2023 am, 07/04/2023 am, 07/05/2023 am, 07/08/2023 am, 07/09/2023 am, 07/10/2023 pm, 07/11/2023 am, 07/13/2023 pm, 07/15/2023 pm, 07/16/2023 am, 07/17/2023 am, 07/18/2023 am, 07/19/2023 am, 07/20/2023 am and pm, 07/21/2023 am and pm, 07/22/2023 am, 07/23/2023 am, 07/25/2023 am, 07/23/2023 am, 07/25/2023 am, 07/26/2023 am, 07/26/2023 am, 07/29/2023 am, 07/30/2023 am, 08/02/2023 am, 08/03/2023 am and pm, and 08/07/2023 pm.
e. Patient 8's MR lacked vital signs on 10/11/2023 pm, 10/17/2023 am and pm, 10/18/2023 pm, 10/20/2023 pm, 10/21/2023 am and pm, 10/22/2023 am and pm, 10/23/2023 pm, 10/24/2023 am and pm, 10/25/2023 pm, and 10/27/2023 am.
f. Patient 9's MR lacked vital signs on 09/02/2023 am, 09/03/2023 am, 09/05/2023 am and pm, 09/09/2023 pm, 09/16/2023 am, 09/17/2023 am, 09/18/2023 pm, 09/19/2023 pm, 09/23/2023 pm, 09/24/2023 pm, 09/25/2023 pm, and 09/26/2023 am.
g. Patient 10's MR lacked vital signs on 10/02/2023 pm, 10/03/2023 pm, and 10/05/2023 am.

8. Review of patient 10's MR lacked the Patient Observation Monitoring Form for 10/2/2023.

9. Interview with A4, (Director of Nursing), on 11/02/2023, at approximately 4:20 pm, confirmed patients 2, 3, and 10's MR lacked nursing documentation to note orders, completion of transfer reports in 8 out of 10 (patients 2, 4, 5, 6, 7, 8, 9, and 10) MRs, documentation of vital signs in 7 out of 10 (patients 2, 3, 6, 7, 8, 9 and 10) MRs, and patient 10's Patient Observation Monitoring Form was not in MR. A4 indicated registered nurses should document vital signs on the Vital Signs and Weights Flowsheet, should note all provider orders, and complete the Patient Transfer/Transport Report.