HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patient incident of abuse was reported to the Division of Mental Health & Addiction (DMHA), in accordance with applicable local, State, and/or Federal law in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, "Critical Incident Reporting to Department of Mental Health & Addiction (DMHA)", PolicyStat ID 9495113, indicated any event which meets DMHA's definition of a reportable incident would be submitted to ensure compliance with the agency. This policy was last revised in 03/2021.

2. The hospital policy titled, "Patient Abuse and Neglect", PolicyStat ID 8797800, indicated the compliance officer would notify the Division of Mental Health any time there was a confirmed case of patient abuse. This policy was last revised in 01/2020.

3. Review of the medical record (MR) for patient # 10 indicated the following:
a. The patient was a 69 y/o (year/old) who was admitted on 03/06/2022 with dementia.
b. Daily Nursing Assessment dated 03/08/2022 indicated the patient had been in an altercation with his/her roommate. The patient received small laceration above left eyebrow, redness to right side of face and slight bruising to left cheek.

4. In interview on 04/05/2022 at approximately 4:30 pm with administrative staff member A # 3 (Director of Social Services), confirmed the abuse should have been reported to DMHA but he/she had missed that one.

Based on document review and interview, the facility failed to follow their core staffing patient to staff matrix ratio guideline for two (2) of two (2) inpatient care units reviewed. (Unit 100 & Unit 200)

Findings include:

1. Review of the facility policy, "Nurse Staffing and Assignments", PolicyStat ID 11178736, indicated the DON (Director of Nursing) would be accountable to ensure a sufficient number of qualified staff are on duty at all times to provide patients with quality care. The facilities staffing patterns are built from "historical trends, benchmark data and practice guidelines". This policy was last revised in 02/2022.

2. Review of the facility guidelines indicated each unit had a pre-determined core staffing patient to staff ratio. The two (2) inpatient units (100 & 200) should be staffed as indicated:
a. One to twelve (1-12) patients should have one (1) Registered Nurse (RN) and one (1) aide/tech staffed.
b. Thirteen to twenty-five (13-25) patients should have one (1) RN, one (1) Licensed Practical Nurse (LPN) and two (2) aide/techs staffed.
c. Twenty-six to thirty-eight (26-38) patients should have one (1) RN, two (2) Nurses and three (3) aide/techs staffed

3. Review of the "staffing pattern worksheet" provided by the facility, indicated the 100 unit and 200 unit was short staffed on the following days/nights:
a. On 03/07/2022 the patient census on the 100 unit was twenty-two (22). On nights there was one (1) nurse staffed. The staffing matrix indicated there should have been two (2) nurses staffed. On the 200 unit the patient census was fourteen (14). On days there was one (1) nurse staffed. The staffing matrix indicated there should have been two (2) nurses staffed. On nights there was one (1) nurse and one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) nurses and two (2) aide/techs staffed.
b. On 03/08/2022 the patient census on the 200 unit was fourteen (14). On nights there was one (1) nurse staffed. The staffing matrix indicated there should have been two (2) nurses staffed.
c. On 03/09/2022 the patient census on the 200 unit was thirteen (13). On days there was one (1) nurse staffed. The staffing matrix indicated there should have been two (2) nurses staffed.
d. On 03/10/2022 the patient census on the 200 unit was thirteen (13). On days there was one (1) nurse staffed and one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) nurses and two (2) aide/techs staffed. On nights there was one (1) nurse staffed and one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) nurses and two (2) aide/techs staffed.
e. On 03/11/2022 the patient census on the 100 unit was eighteen (18). On nights there was one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) aide/techs staffed. On the 200 unit the patient census was thirteen (13). On days there was one (1) nurse staffed and one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) nurses and two (2) aide/techs staffed. On nights there was one (1) nurse staffed and one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) nurses and two (2) aide/techs staffed.
f. On 03/12/2022 the patient census on the 100 unit was twenty (20). On nights there was one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) aide/techs staffed. On the 200 unit the patient census was fourteen (14). On days there was one (1) nurse staffed. The staffing matrix indicated there should have been two (2) nurses staffed. On nights there was one (1) nurse and one (1) aide/tech staffed. The staffing matrix indicated there should have been two (2) nurses and two (2) aide/techs staffed.

4. Review of the "Daily Census Sheet" provided by A # 2 (Chief Executive Officer-CEO), indicated the facility had vacancies for five (5) full time equivalent (FTE's) and/or 200 hours available for RN's. There were five (5) FTE's and/or 200 hours available for LPN's and eight (8) FTE's and/or 320 hours available for aide/techs.

5. In interview on 04/05/2022 at approximately 5:20 pm with administrative staff member A # 1 (RN/Interim Director of Nursing-DON), confirmed the facility was short staffed on those days (3/07/2022 through 3/12/2022) according to the staffing matrix.

Based on document review and interview, the facility failed to ensure a Registered Nurse (RN) was in the hospital during the second shift per policy, in seven (7) instances. (March 6, 2022 - March 12, 2022)

Findings include:

1. Review of the hospital policy titled, "Staffing Precaution Plan", PolicyStat ID 8820949, indicated under no circumstance shall there be less than one (1) registered nurse in the hospital, if the hospital has more than one patient.
This policy was last revised in 01/2020.

2. Review of the staffing timecards from 3/6/2022 through 3/12/2022 indicated there were no RN's working during the second shift 7:00 pm to 7:00 am for those seven (7) days.

3. In interview on 4/5/2022 at approximately 5:20 pm with administrative staff member A # 1 (RN/Interim Director of Nursing), confirmed an at least one RN should should be in the facility during all shifts according to H # 2's policy.