HospitalInspections.org

Based upon document review and interview, the facility failed to follow its staffing matrix and ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel were available to provide care to all patients for 3 of 9 medical records (MR) reviewed (patients # 6, 7 & 10) - (see tag A 392), failed to follow its policy/procedures and ensure a Registered Nurse (RN) supervised and evaluated the care of all patients for 2 of 10 medical records (MR) reviewed (Patients # 1 & 10) - (see tag A 395) and failed to follow its policy/procedures and ensure patient care plans were developed and maintained for 6 of 10 medical records (MR) reviewed (Patients # 1, 4, 5, 6, 7 & 8) - (see tag A 396).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Nursing Services provided quality health care in a safe environment.

Based on document review and interview, the facility failed to follow its policy/procedures and ensure that all non-employee direct care staff maintained documentation of training in non-physical intervention skills for 29 of 29 direct care staff (CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14, CS15, CS16, CS17, CS18, CS19, CS20, CS21, CS22, CS23, CS24, CS25, CS26, CS27, CS28 & CS29).
Findings include:

1. Review of the policy/procedure Use of Temporary Agency Staff and Independent Contractors (revised 8-17) indicated the following: "Temporary agencies provide personnel to departments that have a need for help during periods when a department may be temporarily short-staffed... Temporary help, however, is expected to adhere to all hospital and departmental policies and procedures. The department to which the temporary employee is assigned is responsible for providing adequate orientation to the job and department, including... for caregivers, the environment of care..."

2. Review of the policy/procedure Staff Orientation and Training for Restraint and Seclusion (reviewed 2-17) indicated the following: "During orientation, direct care staff are assigned to attend non-physical intervention training (CPI) [Crisis Prevention Intervention]."

3. Review of the policy/procedure Crisis Prevention Intervention (reviewed 5-17) indicated the following: "The Nonviolent Crisis Intervention training program focuses on preventative techniques to avoid the use of restraint and seclusion by equipping staff with strategies to intervene through verbal and nonverbal means to create a respectful environment... Prevention and de-escalation are the primary focus of the Nonviolent Crisis Intervention training program... The Nonviolent Crisis Intervention training program instructs participants in recognizing when additional assistance is needed."

4. On 11-6-17 at 1440 hours, the Chief Clinical Officer, staff A4 was requested to provide documentation of training in non-physical intervention skills for the direct care agency staff (CS1, CS2, CS3, CS4, CS5, CS6, CS7, CS8, CS9, CS10, CS11, CS12, CS13, CS14, CS15, CS16, CS17, CS18, CS19, CS20, CS21, CS22, CS23, CS24, CS25, CS26, CS27, CS28 & CS29) identified on the Agency Staffing Sign In & Out Sheet for September and October, 2017 and no documentation was provided prior to exit.

5. On 11-6-17 at 1440 hours, the Chief Clinical Officer, staff A4 confirmed the facility lacked documentation of training in non-physical intervention skills for non-employee nursing staff currently providing direct patient care.

Based upon document review and interview, the facility failed to follow its staffing matrix and ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel were available to provide care to all patients for 3 of 9 medical records (MR) reviewed (patients # 6, 7 & 10).

Findings include:

1. Review of the facility staffing matrix indicated 3 day shift RNs and 3 night shift RNs were indicated for a patient census from 17 to 22 patients.

2. Review of the One Week Staffing Pattern Worksheet for 8/20/17 through 9/16/17 provided by the Director of Nursing, staff A3 indicated the following:
a census of 22 patients on 8/22-23/17, 8/25/17, 8/28/17, 8/30-31/17 & 9/1-14/17,
a census of 21 patients on 8/22/17, 8/26-27/17, 8/29/17 & 9/15/17,
a census of 20 patients on 8/23/17 & 9/16/17, and
a census of 19 patients on 8/24/17
and indicated the following:
14 day shifts were staffed with 1 RN (8/20/17, 8/23-27/17, 8/31/17, 9/1-4/17, 9/8/17, 9/12/17 & 9/15/17) and
14 day shifts were staffed with 2 RNs (8/21-23/17, 8/28-30/17, 9/5-7/17, 9/9-11/17, 9/13/17 & 9/16/17)
and indicated the following:
4 night shifts were staffed with 1 RN (9/7-9/17 & 9/12/17),
18 night shifts were staffed with 2 RNs (8/21-22/17, 8/25-30/17, 9/1-2/17, 9/4-6/17, 9/10/17, 9/12/17 & 9/14-16/17),
5 night shifts were staffed with 3 RNs (8/23-24/17, 8/31/17, 9/3/17 & 9/11/17), and
1 night shift was staffed with 4 RNs (8/20/17).

5. Review of the policy/procedure Treatment Plan (revised 9-17) indicated the following: "Every patient shall have an individualized comprehensive Master Treatment Plan ... Within twenty-four (24) hours of admission, the Registered Nurse (RN) will initiate the treatment plan ..."

6. Review of the Multidisciplinary Treatment Plans for Patients # 6 & 7 lacked documentation indicating it was initiated or staffed by a Registered Nurse.

7. On 11-7-17 at 1555 hours, the Director of Nursing, staff A3 confirmed the MRs for Patient #s 6 & 7 lacked documentation indicating the Multidisciplinary Treatment Plan was initiated and/or staffed by a Registered Nurse.

8. Review of the MR for Patients # 6 & 7 indicated admission orders for high Fall Risk Precautions and the Multidisciplinary Treatment Plans lacked documentation indicating any high risk interventions were implemented on admission in response.

9. On 11-7-17 at 1555 hours, the Director of Nursing, staff A3 confirmed the Multidisciplinary Treatment Plans for Patients # 6 & 7 lacked documentation indicating any high risk interventions were implemented on admission.

10. Review of the policy/procedure Assessment - Falls (revised 1-17) indicated the following: "Nursing Responsibility Post Fall ...Update plan of care (Multidisciplinary Care Plan) with additional precautions."

11. Review of administrative documentation indicated Patient #6 experienced 2 falls on 8/27/17 at 1040 and 1200 hours and the Multidisciplinary Treatment Plan lacked documentation indicating it was updated in response to the two fall events.

12. On 11-7-17 at 1555 hours, the Director of Nursing, staff A3 confirmed the Multidisciplinary Treatment Plan for Patient #6 lacked documentation indicating a fall risk plan was implemented after the patient experienced two fall events.

13. Review of administrative documentation indicated Patient #7 experienced a fall on 9/2/17 at 1130 hours and the Multidisciplinary Treatment Plan lacked documentation indicating it was updated in response to the fall event.

14. On 11-7-17 at 1555 hours, the Director of Nursing, staff A3 confirmed the Multidisciplinary Treatment Plan for Patient #7 lacked documentation indicating a fall risk plan was implemented after the patient experienced a fall event.

15. Review of the policy/procedure Assessment - Falls (revised 1-17) indicated the following: "Nursing Responsibility Post Fall ...Document facts of fall in the patient's medical record."

16. Review of administrative documentation indicated Patient #10 experienced 2 falls on 9/11/17 at 0830 and 1730 hours and review of Patient #10's MR lacked a description of the facts of the fall events.

17. On 11-7-17 at 1705 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #10 lacked documentation of a fall event on 9-11-17 at 0830 and 1730 hours by the Licensed Practical Nurse, staff N20 or Registered Nurse, staff N14 after the patient experienced two fall events.

18. On 11-7-17 at 1230 hours, the Director of Nursing, staff A3 confirmed the facility was not staffing with the number of Registered Nurses in accordance with the staffing matrix for the day shifts and night shifts.

19. On 11-7-17 at 1740 hours, the Chief Clinical Officer, staff A4 confirmed the weekly staffing worksheet failed to indicate the facility was staffed in accordance with the staffing matrix. The Chief Clinical Officer, staff A4 indicated the facility was basing its staffing on 1 licensed nurse for every 8 patients and confirmed that no staffing matrix documentation indicated it was appropriate to staff with 1 licensed nurse for every 8 patients or indicated it was appropriate to staff the facility with 3 licensed nurses for 17 or more patients.

Based upon document review and interview, the facility failed to follow its policy/procedures and ensure a Registered Nurse (RN) supervised and evaluated the care of all patients for 2 of 10 medical records (MR) reviewed (Patients # 1 & 10).

Findings include:

1. Review of the policy/procedure Incident Reports (revised 3-17) indicated the following: "Family/significant other of patient notified of incident/injury after Physician notified.

2. Review of administrative documentation indicated Patient #1 experienced a fall on 9-2-17 at 2330 hours and review of Patient # 1's MR lacked documentation indicating the patient's representative and Power of Attorney, family member FM20 or other family member was notified of the fall event with injury.

3. On 11-6-17 at 1700 hours, the Director of Nursing, staff A3 and the Chief Clinical Officer, staff A4 confirmed the MR for Patient #1 lacked documentation indicating the patient's family member and representative was notified of the fall event.

4. Review of the policy/procedure Content of the Medical Record (reviewed 5-17) indicated the following: "Each medical record contains at least the following... Reassessments are conducted at predetermined and regular intervals or whenever a change in the patient's condition requires his or her re-evaluation."

5. Review of the policy/procedure Assessment - Falls (revised 1-17) indicated the following: "Nursing Responsibility Post Fall... Document facts of the fall in the patient's medical record."

6. Review of administrative documentation indicated Patient #10 experienced 2 falls on 9/11/17 at 0830 and 1730 hours and review of Patient #10's MR lacked a description of the facts of the fall events.

7. On 11-7-17 at 1705 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #10 lacked documentation of a fall event on 9-11-17 at 0830 hours and 1730 hours by the Licensed Practical Nurse, staff N20 or Registered Nurse, staff N14 after the patient experienced two fall events.

Based upon document review and interview, the facility failed to follow its policy/procedures and ensure patient care plans were developed and maintained for 6 of 10 medical records (MR) reviewed (Patients # 1, 4, 5, 6, 7 & 8).

Findings include:

1. Review of the policy/procedure Treatment Plan (revised 9-17) indicated the following: "Every patient shall have an individualized comprehensive Master Treatment Plan... Within twenty-four (24) hours of admission, the Registered Nurse (RN) will initiate the treatment plan..."

2. Review of the Multidisciplinary Treatment Plans for Patients # 1, 6 & 7 lacked documentation indicating they were initiated and/or staffed by a RN within 24 hours of admission.

3. On 11-6-17 at 1148 hours, the Director of Nursing, staff A3 and the Chief Clinical Officer, staff A4 confirmed the Multidisciplinary Treatment Plan for Patient #1 lacked documentation indicating it was initiated and/or staffed by a Registered Nurse.

4. On 11-7-17 at 1555 hours, the Director of Nursing, staff A3 confirmed the MR for Patients # 6 & 7 lacked documentation indicating the Multidisciplinary Treatment Plans were initiated and/or staffed by a Registered Nurse.

5. Review of the policy/procedure Assessment - Falls (revised 1-17) indicated the following: "Nursing Responsibility Post Fall... Update plan of care (Multidisciplinary Care Plan) with additional precautions."

6. Review of Patient #4's MR indicated the patient experienced a fall on 8-31-17 at 1110 hours and the Multidisciplinary Treatment Plan for Patient #4 lacked documentation indicating it was updated after the fall event.

7. On 11-7-17 at 1335 hours, the Chief Clinical Officer, staff A4 confirmed the Multidisciplinary Treatment Plan for Patient #4 lacked documentation indicating it was updated on 8-31-17 after the patient experienced a fall.

8. Review of Patient #5's MR indicated the patient experienced a fall on 8-22-17 at 2230 hours and the Multidisciplinary Treatment Plan lacked documentation indicating it was updated after the fall event.

9. On 11-7-17 at 1450 hours, the Chief Clinical Officer, staff A4 confirmed the MR for Patient #5 lacked documentation indicating the Multidisciplinary Treatment Plan was updated on 8-22-17 after the patient experienced a fall.

10. Review of Patient #6's MR indicated the patient experienced two fall events on 8-27-17 and lacked documentation indicating the Multidisciplinary Treatment Plan was updated after the fall events.

11. On 11-7-17 at 1555 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #6 lacked documentation indicating the Multidisciplinary Treatment Plan was updated on after the patient experienced two fall events.

12. Review of Patient #7's MR indicated the patient experienced a fall event on 9-2-17 at 1130 hours and the Multidisciplinary Treatment Plan lacked documentation indicating it was updated in response.

13. On 11-7-17 at 1555 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #7 lacked documentation indicating the Multidisciplinary Treatment Plan was updated on 9-2-17 after the patient experienced a fall.

14. Review of Patient #8's MR indicated the patient experienced a fall event on 9-2-17 at 0005 hours and lacked documentation indicating the Multidisciplinary Treatment Plan was updated after the fall event.

15. On 11-7-17 at 1705 hours, the Director of Nursing, staff A3 confirmed the MR for Patient #8 lacked documentation indicating the Multidisciplinary Treatment Plan was updated on 9-2-17 after the patient experienced a fall.