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Based on observation, interview, and record review, the hospital failed to ensure an adequate number of mental health workers and the licensed nurse-to-patient ratio in the psychiatric units were maintained as required. This failure had the potential for poor patient outcomes.

Findings:

Review of the hospital's P&P titled Appendix C Staffing Plans for Nursing Services (undated) showed the staffing ratio/plan in the psychiatric units shall be 1:6 nurse-to-patient ratio for 2 East and 3 South, and 1:4-5 nurse-to-patient ratio for the 5 North Unit. For low acuity, 2 East will have 1 MHW, 3 South will have 2 MHWs, and 5 North will have 1 MHW. The nurse-to-patient ratio is referenced by Title 22 Division 5 Chapter 1 Article 3 (70217). The Charge RN and Nurse Manager serves as backup for 2 East, 3 South, 4 West, 5 North, OR/Procedural Unit. The House Supervisor serves as backup for 1 North. Backup includes breaking and or being charge/lead to ensure ratio consistency when staff call-ins cannot be covered by the staffing coordinator. The Staffing Coordinator will contact additional staff that is needed to meet ratio when staffing it out of ratio for any unit.

Review of the hospital's P&P titled Meal Breaks and Rest Periods dated 6/23/22, showed in order to provide meal periods to employees, supervisors are required to relieve their employees of all duty, relinquish control over their activities and permit them a reasonable opportunity to take an uninterrupted 30-minute break. Supervisors must not impede or discourage employees from taking meal periods. Supervisors must also schedule meal periods and adequate relief coverage where necessary to provide meal periods consistent with this policy. Moreover, non-exempt employees may not be required to be "on-call" during meal periods.

On 2/5/25 at 0915 hours, a tour of the hospital was conducted with the CNO.

On 2/5/25 at 0932 hours, an interview, observation, and concurrent record review of the Daily Patient Assignment dated 2/5/25, was conducted with RN 2 in the 2 East Unit. Two nurses were observed working in the unit. RN 2 stated there were 14 patients in the unit and two nurses assigned in the unit, with each nurse assigned seven patients. RN 2 stated there was currently no MWH in the 2 East Unit as the assigned MWH was floated to the 5 North Unit. RN 2 stated there was supposed to be at least one MHW staffed in the unit, and she had to take over the MHW's tasks and responsibilities in addition to her own. RN 2 stated the nurse-to-patient ratio was supposed to be 1:6 and verified she was out of ratio.

On 2/5/25 at 0938 hours, an interview was conducted with RN 3 in the 2 East Unit. RN 3 stated he was not sure what the nurse-to-patient ratio was supposed to be, but stated he was assigned seven patients. The CNO who was in the vicinity, verified the nurses in the 2 East Unit were not within the required nurse-to-patient ratio.

On 2/5/25 at 1012 hours, an interview was conducted with MHW 1 who was assigned to the 3 South Unit. MHW 1 stated she was the only MHW assigned to the 3 South Unit.

On 2/5/25 at 1046 hours, an interview was conducted with LVN 1 who was assigned to the 3 South Unit. LVN 1 stated she was assigned seven patients today and verified she was out-of-ratio.

On 2/5/25 at 1054 hours, an interview and concurrent record review of the Daily Patient Assignment dated 2/5/25, was conducted with RN 6. The Daily Patient Assignment showed the nurses in the 3 South Unit were assigned six to seven patients each and were also assigned to cover each other's breaks, giving them up to 14 patients while they relieved another nurse. RN 6 verified the findings and stated it was because they did not have a Charge Nurse or Resource Nurse today to cover the nurses' breaks.

On 2/5/25 at 1313 hours, an interview and concurrent record review was conducted with House Supervisor 1, the Director of PI and RM, and the CNO. The CNO stated the nurses were out of ratio today because there were several sick calls including the Charge Nurse who would normally relieve the nurses for their breaks. The Director of PI and RM verified the 2 East Unit required one MHW and the 3 South Unit should have two MHWs and one more nurse. Review of random Daily Patient Assignments showed the following:
- On 12/1/24, the morning and night shift nurses in the 2 East Unit were out of ratio.
- On 12/2/24, on the morning shift, one nurse in the 2 East Unit was not within ratio, one MHW was being shared between the 2 East Unit and 5 North Unit, and there was no MHW in the 3 South Unit until 1530 hours.
- On 2/1/25, on the night shift, four nurses in the 3 South Unit were out of ratio.
- On 2/2/25, on the night shift, the nurse in the 5 North Unit was out of ratio, and four nurses in the 3 South Unit were out of ratio.
On 2/5/25, during the interview and concurrent record review, the Director of PI and RM verified the findings.