HospitalInspections.org

Based on observation, document review, and interview the hospital failed to ensure there was safe and adequate nursing staff in 1 (Rehabilitation Unit) of 2 patient care units in 11 of 11 shifts reviewed and Licensed Vocational Nurses (LVNs) always had oversight by a Registered Nurse (RN).

Findings:

A review of the nurse staffing schedule for October 2023 revealed all Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Certified Nurse Aides (CNAs) were scheduled for 1 month at a time. The monthly schedule was divided into two shifts, 7:00 AM-7:00 PM and 7:00 PM-7:00 AM. The hospital had two units. One was the Long-Term Acute Care Unit (LTAC) and the other was the Rehabilitation (Rehab) unit. The schedule failed to document what unit the nurses were assigned to. Further review revealed there was an RN assigned as the Charge Nurse daily, but the schedule did not reflect to which unit.

An interview was conducted with Staff #28 on 10/17/2023 at 1:00 PM. Staff #28 confirmed the hospital had two separate units, but the nurses shared a centralized nursing station. Staff #28 confirmed the Charge Nurse, and the House Supervisor was a dual role. Staff #28 stated, "The house supervisor and the charge nurse are the same person. I am the charge nurse today, but I am also the House Supervisor. Financially, this place can't afford that many nurses for each unit."

A review of the document titled, "Staffing Matrix" was divided into two shifts, 7:00 AM-7:00 PM and 7:00 PM-7:00 AM. During an interview with Staff #4 on 10/17/2023 after 1:00 PM it was confirmed the hospital used the same staffing matrix for the LTAC Unit and the Rehab Unit. Staff #4 confirmed the Staffing Matrix required 2 RNs (one being a charge nurse) and 1 LVN for up to 10 patients.

A review of the daily staffing schedules for 10/10/2023-10/15/2023 for the LTAC unit and the Rehab Unit, (the 10/13/2023, 7:00 AM-7:00 PM shift was not provided for review) revealed the Rehab Unit was short 1 RN for 11 of the 11 shifts reviewed.

When the LVN went to lunch there was no documented relief by another nurse leaving the Rehab unit short 2 nurses during scheduled lunch periods for 11 of 11 shifts reviewed.
Staff #4 was asked who supervised the LVN in the Rehab Unit when the scheduled RN took her 30-minute lunch break. Staff #4 confirmed there was no documentation of who relieved the RN.
Staff #4 confirmed the RN on the Rehab Unit usually notified the charge nurse on the LTAC Unit when she was going to lunch and that charge nurse would cover her and supervise the LVN while she was off the unit.

An interview was conducted with Staff #96 on 10/17/2023 after 1:30 PM. Staff #96 was asked if she was the charge nurse in the Rehab unit. Staff #96 replied, "Well I guess I am since I am the only RN working on the Rehab Unit." She was then asked who relieved her for lunch. Staff #96 stated, "I usually just tell the RN on the LTAC unit when I go to lunch. I usually stay in the building so they know they can get me if they need to."

During an interview with Staff #28 on 10/17/2023 it was confirmed that when she was assigned to the LTAC Unit as the charge nurse and/or the house supervisor she would relieve the Rehab Unit RN while she went to lunch. This placed Staff #28 in two separate units at the same time.

Staff #84 was scheduled as the RN for the LTAC unit on 10/17/2023. An interview was conducted with Staff #84 on 10/17/23 at 4:00 PM. Staff #84 stated, "I was assigned the charge nurse role about ten minutes before our interview. I have never been trained as a charge nurse, nor do I have the desire to be one."

A review of the employee files for Staff #28 and Staff #84 revealed the only signed job description in the employee file was for a Registered Nurse.
Staff #12 confirmed there was no signed job description for the position of Charge Nurse or House Supervisor in the employee file for Staff #28 or Staff #84.

During an interview with Staff #1 on 10/17/2023 after 3:30 PM, Staff #1 confirmed that Staff #84 was the charge nurse on the LTAC unit and Staff #28 was the House Supervisor. Staff #1 stated, "I think the nurses are confused about the difference between a Charge Nurse and a House Supervisor. The Rehab Unit and the LTAC Unit share a House Supervisor."


A review of the Texas Board of Nurses (BON) Licensed Vocational Nurse Scope of Practice was as follows:

" ...15.27 The Licensed Vocational Nurse Scope of Practice
The LVN scope of practice is a directed scope of practice and requires appropriate supervision. The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, and regulations. In addition, the LVN must comply with policies, procedures and guidelines of the employing health care institution or practice setting.

The LVN Scope of Practice
The LVN serves as an advocate for the patient and the patient's family and promotes safety by practicing in accordance with the NPA and the BON Rules and Regulations. LVN's scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. The practice of vocational nursing must be performed under the supervision of an RN, advanced practice registered nurse (APRN), physician, physician assistant, podiatrist, or dentist. Supervision is defined as the process of directing, guiding, and influencing the outcome of an individual's performance of an activity ..."


A review of the hospital policy titled, "STAFFING DETERMINATION" with a review date of 3/2023 was as follows:

" ...POLICY
The methodology used in making staffing determinations is based on the Patient Classification System, the staffing pattern, number of staff (full time and part time equivalents), available nursing care hours in each nursing unit and the categories of staff available for patients care.
Records include, but are not limited to:
1. Daily Shift Assignment Sheets
2. (name of the facility) Staffing grid for Long-Term Acute Care Hospital

PROCEDURE ...
F. Registered nursing personnel shall:
i. Assist the Chief Clinical Officer so that supervision of nursing care occurs on a 24-hour basis
ii. Provide direct patient care
iii. Provide clinical supervision and coordination of the care given by licensed
vocational nurses and unlicensed nursing personnel.
iv. Each patient care unit shall have a registered nurse assigned, present, and
responsible for the patient care in the unit on each shift ..."

Staff #1 and Staff #4 confirmed the staffing matrix was not followed when staffing the Rehab Unit. There was no documentation of RN oversight of the LVN on the Rehab Unit when the RN left the unit for a scheduled lunch break for the dates of 10/10-10/15/2023. Staff #1 and #4 also confirmed the facility policy was not followed.