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Based on observation, review of records, and interviews, the Governing Body did not monitor nursing to ensure adequate numbers of nursing and supervisory staff to provide safe delivery of direct patient care as needed for each nursing unit.
Cross reference: A0385 and A0392

Based on observation, interview, and record review, the hospital failed to ensure that a RN provided care to a patient for 1 of 1 ventilated patient (Patient #2), hospitalized on 02/17/11 through 02/18/11, who became disconnected from his ventilator.

Findings included:

The CNO failed to ensure that there were adequate number of nursing and supervisory staff to meet the nursing needs of inpatients. The nursing staff was split between two geographically separate units and there was no RN scheduled on each unit that was immediately available to provide care to patients. This left the patient unit uncovered without an RN. Patient #2, who was ventilator dependent, became disconnected from the ventilator and no RN was immediately available to provide care.

Cross reference A0144 and A0392.

The "Plan for the Provision of Patient Care/Services 2010", under the title, "Nursing," required, "Dallas LTAC Hospital, as an employer of licensed nurses, adheres to the general provisions and licensing regulations of the Texas Nursing Practice Act...Recognizes the right of all patients to receive nursing care that is defined by professional standards regardless of setting...evaluation process...quality assurance activities...CCO is accountable for establishing systems to assess, monitor, and verify delegation competence...takes responsibility and accountability for the provision of nursing practice....is dedicated to the provision of competent staff and quality patient care...compliance with standards is determined through policies, procedures, quality improvement activities and performance appraisals...Facility Specific...Chief Clinical Officer," required, "has the responsibility; authority and accountability for the provisions of quality nursing care, which is delivered by Nursing Department employees on a 24 hour basis. The Director serves to plank, organize, coordinate, and manage activities within the department...coordinates activities between Nursing and other hospital departments...:"

In an interview on 02/18/11 at 3:00 PM the CNO (Personnel #2) verified the above findings.

Based on review of records and interview, the hospital failed to actively include 1 of 1 patient (Patient #2) in his plan of care in that when medication was requested by the patient, the RN (Personnel #32) did not respond in a timely manner.

Findings included:

In an interview with Patient #2 on 02/18/11 at 10:00 AM, he stated, he asked for pain medication at 4:30 AM and was given Neurotin which did not help; he then hit the call light at 5:35 AM and there was no answer. He hit the call light again at 5:51 AM and was told the nurse was busy with one of her patients and he would have to wait. He said he saw his nurse (Personnel #32) moving a bed in the hall right after calling the desk. He stated he hit the call light again and she told him she was coming. At 6:31 AM (approximately two hours after the patient's request) Personnel #32 came into his room and gave him a pain pill.

Review of Patient #2's "Interdisciplinary Plan of Care" instituted on 02/07/11, showed, "Management of Pain...Goals...#1 Pain relief as evidenced through functional performance...Interventions/actions: 1. Assess pain on admission and then per hospital policy, 2. Administer pain medications as ordered and assess for pain relief per hospital policy..."

Review of Patient #2's "Medication Administration Record (MAR)" on 02/17/11 from 7PM-7AM showed, Neurontin (used to relieve pain) 100 milligrams given at 4:30 AM and Lortab elixir 7.5/500 milligrams (mg) (narcotic pain medication) at 6:30 AM for complaints of a "7 out of 10" pain level (0 no pain - 10 the worst pain imaginable).

Review of Patient #2's "Daily Focus Assessment Report" revealed on 02/17/11 at 11:23 PM, the nurse performed a "complete pain assessment." The nurse noted, "Intermittent back pain" at this time with no pain scale or intervention documented. At 6:39 AM on 02/18/11, Lortab elixir 15 ml was given through the PEG tube (feeding tube) for complaints of severe back pain (7/10). There was no other documentation addressing pain or the intervention during the 7PM - 7AM shift on 02/17/11.

The "Patient Rights and Responsibilities" policy, revised date April 2010, included, "As a patient...you can expect...pain relief measures...we employ a concerned staff, committed to pain prevention and pain management...we train our health care professionals to respond quickly to reports of pain...ask for pain relief when pain first begins...help your doctor and nurse assess your pain, tell your doctor or nurse if your pain is not relieved..."

In an interview with RN (Personnel #8), on 02/18/11 at 12:30 PM, she was asked to review the medical record of Patient #2. She was asked if the hospital's pain management policy was followed. She stated, "No. [Patient #2] should have received his pain medication within 30 minutes of asking."

Based on review of records and interview, the hospital did not institute a properly executed consent for procedures performed in 2 of 2 patients (Patient #1 and #2) from 10/22/10 through 02/14/11. Adequate information to the patient or patient's representative regarding explanation, discussion or risks and benefits of procedures being performed were not properly documented in the consent.

Findings included:

Review of the "Procedure Notes" in Patient #1's medical record, dated 10/22/10 and 12/21/10 showed the physician (Personnel #24) performed an ultrasound guided placement of right internal jugular vein Perm catheter replacement to provide hemodialysis. The physician did not document in his procedure notes discussion and/or explanation of the procedure or the risks and benefits of the procedure with the family.

The "Medical and Surgical Procedures Disclosure and Consent" forms, dated 10/21/10 timed at 6:30 PM and 12/21/10 at 5:30 PM was not completed. The consents did not include the explanation of the condition being treated, a complete list of risks and/or hazards or a signature of the physician explaining the above noted requirements.

Review of the "Informed Consent Special Procedure - PICC/Midline (peripheral inserted central catheter)" in Patient #2's medical record dated 02/14/11, not timed, showed the explanation of the procedure or alternatives to the procedure were not witnessed by the physician (Personnel #26). There was no documentation in the physician progress notes regarding explanation, alternatives or risks of the procedure to the patient or family. The physician orders on 02/14/11 did not show an order to obtain consent.

The "Medical and Surgical Procedures Disclosure and Consent" form, not dated, required, "You have the right as a patient to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved..."

The Hospital Clinical policy "Consent for Treatment - Informed Consent," dated 04/01/09, required, "Any medical treatment upon a patient requires a signed consent...a witness to the patient's informed consent may be a. another physician (not the physician obtaining the consent), b. RN and/or LVN...Texas Consent Law expressly requires that the medical professional actually performing the procedure provide the information necessary to obtain the patient's informed consent...Procedures that require informed consent...deep or conscious sedation...interventional radiology...surgical operative/invasive procedures...prior to obtaining consent, the physician or responsible practitioner must provide information to the patient and/or surrogate decision maker...the consent form should be complete with...the physician's name and/or responsible practitioner, the specific name of treatment and/or procedure...indications for the treatment or procedure...physician and/or responsible practitioner shall review the consent form with the patient...shall be signed by the physician and/or responsible practitioner obtaining the informed consent...shall contain a statement that the procedure or treatment, including the anticipated benefits, material risks, and alternative therapies was explained to the patient or legal representative..."

The Hospital Administration Policy, "Patient Rights & Responsibilities," dated 04/20/09, required, "The patient or his/her representative has the right to...participate in the development and implementation of his or her plan of care...to make informed decision regarding his/her care...treated with dignity and respect...involved in his/her care planning and treatment..risks, benefits, and side effects of all proposed treatment...other treatments that are available...right to receive care in a safe setting..."

In an interview 02/18/11 at 3:00 PM, the CNO (chief nursing officer) (Personnel #2) verified the consent forms were not properly completed as required by hospital policy and procedure.

Based on observation, review of records and interview, the hospital did not provide safe care to 1 of 1 patient (Patient #2) from 02/17/11 - 02/18/11 in that the RN scheduled for Patient #2 on one unit, was scheduled to take care of 2 other patient's on a separate unit. Patient #2 was ventilator dependent and became disconnected from the ventilator. The RN was not available because she was caring for 2 other patient's on the other nursing unit at that time.

Findings included:

On 02/18/11 at approximately 10:00 AM a tour of the "High Observation Unit (HOU)" and the "Rehab Unit" was conducted with the CNO (Personnel #2). The surveyor observed one patient, (Patient #2), who was on a ventilator, in the High Observation Unit. There was one RN (Personnel #7) assigned to the unit and no other assistive personnel. The RN's (Personnel #7) assignment was split between two different units, one patient in the HOU and two patients on the "Rehab Unit" located down the opposite hall and around the corner from HOU. The CNO confirmed that Personnel #7's assignment was split between two different units and she was the only staff member assigned to the HOU unit.

During the tour, an interview was conducted with Patient #2 and his wife, which lasted for approximately 45 minutes. The surveyor did not observe the RN (Personnel #7) on the unit or within site of the surveyor or the patient. After interviewing Patient #2, the surveyor toured the Rehab Unit and observed Personnel #7 providing care to two other patients. The RN (Personnel #7) confirmed that she was the only staff member assigned to Patient #2 on the HOU unit and that she was responsible and assigned for the care of the two other patients on the Rehab Unit.

During the the same interview with Patient #2 and his wife, he stated, At 6:15 AM of that morning (02/18/11), his ventilator became disconnected and the alarm went off. He stated he was able to breathe while waiting for someone to come and connect him back to the ventilator. He said he hit the call pad so the staff would hear the alarm. After 5 minutes a respiratory technician came in and connected his tubing back up. He said his nurse did not show up until 6:31 AM after the respiratory technician connected him back to the ventilator. Patient #2's wife was asked if the nurses checked on him frequently. She stated, "The nurse is usually pretty busy. She has to take care of other patients on the other hall. When I am here, I let them know if we need anything."

During an interview on 02/18/11 at 11:30 AM with the Respiratory Therapy Technician (Personnel #6) he was asked if he was responsible for Patient #2's ventilator. He stated, "Yes, I came on shift at 5:50 AM this morning." He was asked if he heard Patient #2's ventilator alarm going off this morning. He stated, "Yes, I was sitting in the charting area at the main nursing desk. By the time I got there, the second alarm was going off. The second alarm meant he was disconnected. I suctioned him and placed him back on the ventilator. After that, the nurse came in and he [Patient #2] asked for some pain medication." He was asked if he saw a nurse on the hall that Patient #2's room was located on at that time when the alarm was going off. He stated, "No, I did not see any nurse on the unit at that time." He was asked if he documented the ventilator disconnection in the medical record or notify the nurse of the disconnection. He stated, "No."

During an interview on 02/18/11 at 12:30 PM with Patient #2's nurse (Personnel #7) she was asked if she was responsible for any other patients besides Patient #2. She stated, "Yes, I have two other patients on the other hall I am responsible for. They require a lot of care. Thank goodness his wife is in the room. I try to check on him every hour. I told her if she needed anything she can come and get me." She was asked if anyone else was assigned to help her with Patient #2. She stated, "No, I provide total care. I told the House Supervisor (Personnel #8) this morning this is not safe and I needed help. She told me they were working on it."

During an interview on 02/18/11 at 1:00 PM, the House Supervisor (Personnel #8) confirmed the staffing schedule for 02/18/11 for the 7 AM-7PM shift. She was asked if Personnel #7 had notified her this morning that she felt it was unsafe to be split between two different units when she was taking care of a high observation patient on a ventilator. She stated, "Yes, she notified me this morning." She was asked if she responded to Personnel #7's concerns. She stated, "Yes, I notified the Clinical Coordinator (Personnel #33). He said he would take care of it later." She was asked if she provided any additional help or relief for Personnel #7. She stated, "No, we did not have anyone else to help." She was asked if it was common practice to split the nurse's workload between units. She stated, "Yes, we try to split up the work assignments evenly. Since there was only one patient on this unit, we gave her two other patients on the other hall to make the assignment even." She was asked if the 4th floor high observation unit or the rehab unit had a charge nurse scheduled. She stated, "No, I am the house supervisor and if they need anything they call me."

The hospital policy, "PC 281, Plan for Provision of Patient Care", dated October 2010, required, "Nursing care is provided...The RN and LVN will be responsible and accountable for making clinical decisions that are based upon current licensure, educational preparation and experience ...the RN is responsible and accountable to prescribe, supervise, delegate and coordinate nursing care...the Chief Clinical Officer (CCO) provides supervision of Patient Care Services...the Clinical Coordinator is responsible for the day-to-day operations of the Nursing Department reports to the CCO...the nursing supervisor coordinates all patient care activities throughout the hospital...Nursing services provide...use of nursing process: assessment planning; interventions and evaluation to provide a plan of care based on the patient's individual needs...protection of the patient to include the environment in which care is delivered...the hospital's plan for the provision of nursing care is comprehensive and includes all clinical departments, services, units or areas of the hospital in which nursing care is provided to patients...the plan delineates the categories of nursing personnel and a staffing plan for each unit of the hospital...Staffing: RN, LVN, and CNA (certified nurse aide) provides care on the medical/surgical units...the Charge nurse is responsible for making staff assignments each shift taking into account the needs of the patient and the competency of the staff being assigned on that shift...the unit is staffed with one (1) RN or LVN for every six (6) to seven (7) patients. One (1) CNA is also on duty for every eight (8) to twelve (12) patients...the High Observation Unit ...provides 24-hour intensive care nursing for patients treated for ...respiratory failure...is staffed by RN's functioning in a total care nursing system...the Nursing Supervisor is responsible for appropriate staffing each shift...the charge nurse is responsible for making staff assignments each shift taking into account the needs of the patient and the competency of the staff being assigned that shift...nursing supervisors function as a resource to the rest of the staff on that shift...when more staff are needed for the shift than has been scheduled the charge nurse will notify the nursing supervisor that additional qualified staff required...the quality and appropriateness of nursing care and services provided throughout the hospital will be continuously monitored and evaluated to assess and evaluate compliance..."

During an interview on 02/18/11 at 1:30 PM, the CNO (Personnel #2) verified the staffing schedules. She was asked if it was the hospital policy to schedule each unit without an RN or Charge RN. She stated, "No, it is not." She was asked if it was the hospital policy to schedule a nurse for two different units. She stated, "No, it is not." She was asked to review the Nurse Staffing Plan and Policy. She was then asked if the hospital was following the Nurse Staffing Policy. She stated, "No."

Based on observation, review of records and interview, the hospital did not provide an adequate number of nursing and supervisory staff to 6 of 6 inpatient units (2nd floor long hall and short hall, 3rd floor long hall and short hall and, 4th floor long hall "rehab unit" and short hall "high observation unit") from 02/06/11 - 02/18/11 where patients were present. The hospital had one RN House Supervisor who was also responsible for the Emergency Room (ER). There was no Charge RN assigned to any inpatient unit ensuring immediate availability of an RN. In addition, nursing staff was split between 2 geographically separate units and there was no RN scheduled on each unit or floor, to ensure that there is an RN immediately available to provide care to patients.

Findings included:

During a tour on 02/18/11 at approximately 10:00 AM of the 4th floor, the surveyor observed a main nursing station by the elevator. There were 2 separate hallways; the first hallway was to the left of the main nursing station which included room's 400-407. The second hallway was directly in front of the nursing desk which included rooms 408 - 419. The CNO (Personnel #2) was asked which unit was the "High Observation Unit." She stated, "We really do not consider them separate units. We call them long hall and short hall. The short hall, rooms 400-406 is the high observation unit where we have patients that have a need for higher acuity of care. The long hall are rooms 408 - 419, this is where the Rehab patients go that do not need as high a level of acuity care." She was then asked to show the surveyor on the "Nurse Staffing Sheet" and "Daily Nursing Assignment" sheets how the different halls/units were assigned staffing on a shift to shift and unit to unit basis. She verified the 2 different halls/units were not separate on the staffing sheet and the assignments were based on the total census of the floor, not the unit. She was asked if all three patient floors were staffed the same way. She stated, "Yes."

Review of the "Nurse Staffing Sheets" and "Daily Nursing Assignment" sheets from 02/06/11- 02/18/11 reflected:

(A) 1 RN House Supervisor who was also responsible for the ER.

(B) 2nd floor patient units (Long Hall and Short Hall), where patients were present:
7AM - 7 PM shift: An RN Charge Nurse who did not have additional duties was not assigned during these shifts.
7PM - 7 AM shift: An RN Charge Nurse who did not have additional duties was not assigned during these shifts.

(C) 3rd floor patient units (Long Hall and Short Hall), where patients were present:
7AM - 7 PM shift: An RN Charge Nurse who did not have additional duties was not assigned during these shifts.
7PM - 7 AM shift: An RN Charge Nurse who did not have additional duties was not assigned during these shifts.

(D) 4th floor patient units (Long Hall and Short Hall), where patients were present:
7AM - 7 PM shift: An RN Charge Nurse who did not have additional duties was not assigned during these shifts.
7PM - 7 AM shift: An RN Charge Nurse who did not have additional duties was not assigned during these shifts.

The hospital policy, "PC 281, Plan for Provision of Patient Care," dated October 2010, required, "Nursing care is provided ...the nursing supervisor coordinates all patient care activities throughout the hospital ...Nursing services provide ...use of nursing process: assessment planning; interventions and evaluation to provide a plan of care based on the patient's individual needs...protection of the patient to include the environment in which care is delivered...the hospital's plan for the provision of nursing care is comprehensive and includes all clinical departments, services, units or areas of the hospital in which nursing care is provided to patients...the plan delineates the categories of nursing personnel and a staffing plan for each unit of the hospital...Staffing: RN, LVN, and CNA (certified nurse aide) provides care on the medical/surgical units...the Charge nurse is responsible for making staff assignments each shift taking into account the needs of the patient and the competency of the staff being assigned on that shift...the unit is staffed with one (1) RN or LVN for every six (6) to seven (7) patients. One (1) CNA is also on duty for every eight (8) to twelve (12) patients...the High Observation Unit...provides 24-hour intensive care nursing for patients treated for...respiratory failure...is staffed by RN's functioning in a total care nursing system...the Nursing Supervisor is responsible for appropriate staffing each shift...the charge nurse is responsible for making staff assignments each shift taking into account the needs of the patient and the competency of the staff being assigned that shift...when more staff are needed for the shift than has been scheduled the charge nurse will notify the nursing supervisor that additional qualified staff are required...the quality and appropriateness of nursing care and services provided throughout the hospital will be continuously monitored and evaluated to assess and evaluate compliance..."

During an interview on 02/18/11 at 1:30 PM, the CNO (Personnel #2) verified the staffing schedules. She was asked if it was the hospital policy to schedule each unit without an RN or Charge RN. She stated, "No, it is not." She was asked if it was the hospital policy to schedule a nurse for two different units. She stated, "No, it is not." She was asked to review the Nurse Staffing Plan and Policy. She was then asked if the hospital was following the Nurse Staffing Policy. She stated, "No."

Cross reference A0144