HospitalInspections.org

Based on document review and interview, the facility failed to follow their staffing guidelines to provide the medical surgical unit with the number of registered nurses (RN's) and/or certified nursing assistants (CNA's) to ensure adequate patient care in nine (9) instances.

Findings include:

1. Review of the hospital's "staffing pattern worksheet, daily census sheet and staffing plan guideline" provided by administrative staff member A # 2 (Chief Clinical Officer-CCO), indicated the medical/surgical unit to be inadequately staffed on the following dates according to the staffing guidelines:
a. The patient census was thirty (30) on 07/01/2019 night shift (7:00 pm to 7:00 am). Five (5) RN's were staffed and there should have been five and a half (5.5) RN's.
b. The patient census was thirty (30) on 07/02/2019 night shift. Two (2) CNA's were staffed and there should have been three (3.0) CNA's.
c. The patient census was thirty-one (31) on 07/03/2019 day shift (7:00 am to 7:00 pm). Six and a half (6.5) RN's were staffed and there should have been seven (7) RN's. The night shift had one (1.0) CNA staffed and there should have been three (3) CNA's.
d. The patient census was thirty-two (32) on 07/04/2019 day shift. Five and a half (5.5) RN's were staffed and there should have been seven (7) RN's. The night shift had five and a half (5.5) RN's staffed and there should have been six (6) RN's. There was two (2) CNA's staffed on nights and there should have been three (3).
e. The patient census was thirty-one (31) on 07/05/2019 day shift. Six (6) RN's were staffed and there should have been seven (7) RN's.
f. The patient census was thirty-one (31) on 07/06/2019 day shift. Six and a half (6.5) RN's were staffed and there should have been seven (7) RN's.

2. On 07/11/2019 at approximately 1:00 pm with administrative staff member A # 2, confirmed that "we stopped using agency" staff on June 8, 2019. "I agree we have a problem with staffing". With just "one (1) call off and everything has to be switched around". We interview CNA's (Certified Nursing Assistant's), hire them and "they can't pass the background check or the drug screen".

3. On 07/11/2019 at approximately 4:35 pm with administrative staff member A # 3 (Chief Executive Officer-CEO), confirmed the "hospital does not have a criteria/number system or a ratio system for staffing". The House "Supervisor decides" how/who gets what patients by experience.

Based on document review and interview, the facility failed to ensure the patient's medical record (MR) contained complete information/documentation regarding a "Code Blue" intervention in one (1) of ten (10) MR's reviewed (Patient # 1).

Findings include:

1. The hospital policy titled, "Code Blue Emergency", indicated "documentation should include events immediately preceding the arrest". This policy was last revised 01/15/2018.

2. The hospital policy titled, "Guidelines for Nursing Care", indicated patients on telemetry will have "rhythm strips run, analyzed and mounted on medical record for all monitored patients" at the beginning of each shift and "with significant changes". This policy was last revised 09/10/2018.

3. The "Code Blue Log" for the months of 05/01/2019 through 07/10/2019 were reviewed and indicated patient # 1 was found unresponsive on 07/05/2019 at approximately 8:49 pm.

4. Review of patient # 1's open MR indicated the patient was a 82 y/o (year/old) admitted to H # 1 (Long Term Acute Care Hospital) on 06/25/2019. The patient had a past medical history which included, but not limited to, acute respiratory failure and had a tracheostomy. The patient in room 301 was found on 07/05/2019 at 8:49 pm to be "non-responsive and pulseless" at which time a "Code Blue" was called. The Code was successful and terminated at 8:59 pm. The family and physicians were notified. The MR lacked any documentation related to rhythm strips just prior to the "Code Blue" being called.

5. On 07/11/2019 at approximately 4:50 pm with administrative staff member A # 1 (Director of Quality Management(DQM) -RN), confirmed "all the telemetry information is gone because they had to change the telemetry monitor in room 301 after the code". At 5:15 pm A # 1 confirmed that A # 2 was "calling the telemetry monitor company to see where the information goes" (F #1).

6. On 07/11/2019 at approximately 5:30 pm with administrative staff member A # 4 (Director of Plant Operations [DPO]), confirmed "there was a problem with the monitor in room 301 and it needed to be changed". A portable monitor was placed in the room 301 while the original monitor was sent out to be repaired. The patient code occurred while the patient was on the portable monitor. We received the original monitor back on Monday 07/10/19 and it was installed back in room 301. According to the company F # 1 anytime a patient "is discharged from one of the monitors all of the data is lost" and the representative indicated he/she would send a letter as such. "We don't have" the telemetry monitor data prior to the patient being found unresponsive.

7. On 07/11/2019 at approximately 5:42 pm an email was received by H # 1 from F # 1, which indicated "our DS-7700 series of central monitoring stations, once a patient is discharged, their data is deleted and designated to be overwritten. Recovery is not possible".