HospitalInspections.org

Based on document review and interview, nursing administration failed to provide adequate staffing in 1 of 1 patient units (200).

Findings Include:

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

2. Review of unit 200 staffing from 07/31/23 to 08/26/23 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):
a. 07/31/23 - short 1 staff for day (7:00 am - 7:00pm) and night (7:00 pm - 7:00 am) shift.
b. 08/01/23 - short 1 staff for day and night shift.
c. 08/02/23 - short 1 staff for night shift.
d. 08/05/23 - short 1 staff for day and night shift.
e. 08/06/23 - short 1 staff for night shift
f. 08/07/23 - short 1 staff for day and night shift.
g. 08/08/23 - short 1 staff for day and 2 for night shift.
h. 08/09/23 - short 1 staff for night shift.
i. 08/12/23 - short 1 staff for day and 2 for night shift.
j. 08/13/23 - short 1staff for day and night shift.
k. 08/14/23 - short 1 staff for day and night shift.
l. 08/15/23 - short 1 staff for night shift.
m. 08/16/23 - short 1 staff for night shift.
n. 08/20/23 - short 1 staff for night shift.
o. 08/21/23 - short 1 for day and night shift
p. 08/22/23 - short 1 for night shift.
q. 08/23/23 - short 1 for night shift.

3. Interview on 08/31/23 at 5:00 pm with A 5 (Director of Nursing), confirmed that the facility is short staffed, and every effort being made to hire staff.

4. Interview on 08/31/23 at 5:05 pm with A 8 (Market Chief Executive Officer), confirmed staffing is to be 1 clinical nursing staff member to every 4 patients and every effort is made to hold staff accountable for absences and call offs.

Based on document review nursing administration failed to ensure family notification after a fall.

Findings Include:

1. Review of policy titled: Fall Prevention Program, (PolicyStat: 13554604), last approved 04/2023, indicated the nurse must notify a patient's family after a fall for 1 out of 10 patients (P 10).

2. MR indicated on 8/5/23 P 10 fell resulting in pain in the left shoulder on day shift and a right elbow skin tear with steri strips, an x-ray was ordered for left shoulder and the x-ray showed no fracture or dislocation.

2. Incident Report dated 8/5/23 at 3:00 pm lacked documentation that the family was notified post fall.