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Based on interview and record review, the hospital failed to follow their P&P, staffing matrix, and California Required Ratios for Patient Care Unit, Critical Decision Unit Overflow (a unit known as 2 South, a telemetry unit) on 2/14/25 (for the night shift) and 2/15/25 (for both day and night shifts). This failure created the risk of substandard health outcomes to the patients.

Findings:

Review of the hospital's P&P titled Staffing, GEN-700, last approved dated April 2023 showed the staffing levels are designed to provide the adequate number of registered nurses who are qualified to make decisions for care. The staffing will be increased or decreased to accommodate the fluctuating volume and patient acuity. Each nursing unit identifies the scheduling process based on established guidelines and reflects the appropriate staff for each shift to ensure the skill mix is required to maintain the unit's patient care requirements.

The California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, §70217(a)(10) showed the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times.

Review of the Staffing Matrix for Patient Care unit 2 South showed the following for night shift:

- A census of 16 patients has 4 Registered Nurses (RN's) and 1 Charge Nurse
- A census of 18 patients has 5 RN's, 1 Break Nurse and 1 Charge Nurse
- A census of 22 patients has 5 RN's, 1 Break Nurse and 1 Charge Nurse

On 3/13/25 at 0835 hours, a review of the staffing schedule was conducted with the Patient Safety Officer and the Nurse Manager of Critical Decision Unit Overflow (2 South).

Review of the 2 South Nursing staff schedule dated 2/14/25, night shift with a beginning census of 16 showed the following RN staffing assignments:
- 1 scheduled Charge Nurse.
- RN 2 was assigned 5 patients, one who was admitted from the ER at 0027 hours with cardiac monitoring ordered and was a telemetry patient.
- RN 3 was assigned 5 patients, one patient who was a direct admit at 2232 hours and one patient who was admitted from the ER at 0027 hours. All 5 assigned patients had cardiac monitoring ordered and were telemetry patients.
- RN 4 was assigned 5 patients, one who was admitted from the ER at 0111 hours. All 5 assigned patients had cardiac monitoring ordered and were telemetry patients.
- RN 5 was assigned 5 patients, one who was admitted from the ER at 0031 hours with cardiac monitoring ordered and was a telemetry patient.

Review of the 2 South Nursing staff schedule, dated 2/15/25, day shift with a beginning census of 22 showed the following RN staffing assignments:
- RN 6 was assigned 5 patients, one patient who was admitted from the ER at 0850 hours with cardiac monitoring ordered and one patient was admitted from the ER at 1846 hours.

Review of the 2 South Nursing staff schedule dated 2/15/25, night shift with a beginning census of 18 showed the following RN staffing assignments:
- 1 scheduled Charge Nurse
- RN 2 was assigned 5 patients, one who was admitted from the ER at 0038 hours with cardiac monitoring ordered and was a telemetry patient.
- RN 1's assignment was 5 patients, 4 of which were on cardiac monitoring.
- RN 7 was assigned 5 patients, one who was admitted from the ER at 1846 hours with cardiac monitoring ordered and was a telemetry patient. Another patient was admitted from the ER at 0028 hours. RN 7's assignment was 5 patients, 4 of which were on cardiac monitoring.
- RN 8 was assigned 5 patients, one who was admitted from the ER at 2326 hours with cardiac monitoring ordered and was a telemetry patient. RN 8's assignment was 5 patients, 4 of which were on cardiac monitoring.
- RN 9 was assigned 5 patients, one who was admitted from the ER at 1846 hours with cardiac monitoring ordered and was a telemetry patient. RN 9's assignment was 5 patients, 1 of which was admitted on cardiac monitoring. No time documented for when the patient was admitted from the ED.

On 3/13/25 at 0835 hours, an interview was conducted with the Nurse Manager of Critical Decision Unit Overflow (2 South). The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit admitted patients who were classified as medical, surgical, and telemetry patients. The Nurse Manager of Critical Decision Unit Overflow (2 South) defined telemetry patients as those patients who had a provider order for cardiac monitoring. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit had two shifts, day shift and night shift. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit followed the California title 22 ratios for the unit's patient care requirements. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the purpose for following the California ratios was partly due to the Title 22 requirement, but also for patient safety and acuity. It was followed to ensure patients with higher acuity got the nursing care they needed. Telemetry was considered a higher acuity as those patients needed the monitoring. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated the unit also followed a staffing matrix based on the California ratios and the patient census. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated per the required California ratios, the expectation was for RNs to have no more than a total of 4 patients if they have even 1 patient with cardiac monitoring (telemetry patients). RNs with medical or surgical patients (no telemetry patients) could have up to 5 patients assigned to them. The Nurse Manager of Critical Decision Unit Overflow (2 South) verified on 2/15/25 night shift, the nurse staffing schedule did not follow the requirements of the nurse matrix for a patient census of 18 and 4 scheduled nurses and 1 Charge Nurse. The Nurse Manager of Critical Decision Unit Overflow (2 South) stated per the staffing matrix, 5 RN's, 1 break nurse, and 1 charge nurse should have been scheduled for the shift. The Nurse Manager of Critical Decision Unit Overflow (2 South) also verified the above documents showed the RNs were given assignments out of the required California ratios on 2/14/25 night shift and on 2/14/25 both day and night shift.

Based on interview and record review, the hospital failed to ensure the bed alarm was set for one of 19 sampled patients (Patient 1) who was identified to be high risk for falls. This failure created the risk of substandard health outcomes for the patient.

Findings:

The hospital's P&P titled Fall Risk Assessment and Interventions, PC-168 revised on June 2022 showed patients admitted for an acute hospital stay will be assessed for fall risk by the RN every shift. Fall precaution strategies are to be initiated based on the assessment findings. For patients assessed to be at Moderate/High Fall risk, the fall prevention interventions include activation of the bed alarm.

On 3/12/25 at 1402 hours, review of Patient 1's closed medical record was conducted with Risk Management Analyst.

Patient 1 was admitted to the hospital on 1/26/25, for a chest pain.

Review of the Cardiovascular and Thoracic Surgery Progress Note dated 1/30/25, showed Patient 1 had a Coronary Artery Bypass Grafting Times Four. The patient had a left chest tube, secured pacer wires, and sternal incision.

Review of the nursing assessment dated 1/30/25 at 1345 hours, showed Patient 1 was high risk for falls with a Morse Fall Risk of "60" (a total of 15 for Secondary Diagnosis, 15 for Ambulatory Aids, 20 for IV or IV Access, and 10 for Gait/Transferring).

Review of the nursing assessment dated 1/30/25 at 1427 hours, showed Patient's mobility was independent, needed minimum assistance for mobility and transfer, and patient used a "2 wheeled walker". The Enhanced Safety Measures included bed alarm set.

Review of RN 1's notes dated 1/30/25 at 1836 hours, showed at approximately 1418 hours, the CNA reported to the RN that Patient 1 had fallen on the floor. Patient 1 was found faced down on the floor with the feet a couple of feet from the foot of the patient's bed and the head towards the entrance of the room. Per the CNA, when the CNA approached the door of the room, the CNA heard the patient fall. The patient was unresponsive with no verbal response to any prompts. The patient was breathing at 22 breaths per minute. With the assistance of the surrounding staff, the patient was turned on the side and after the airway was cleared, the patient regained consciousness and was fully oriented to questions.

On 3/12/25 at 1340 hours, CNAs 1 and 2 were interviewed about Patient 1's fall on 1/30/25. Both CNAs were able to recall the fall episode. The CNAs stated because Patient 1 was ambulating, they turned off the bed alarm.

The Risk Management Analyst and Director of Risk confirmed the findings on 3/12/25 at 1516 hours.