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Based on observation, interview and record review the hospital failed to maintain an effective quality assessment and performance improvement program. The hospital's Performance Improvement committee failed to identify and document variances in nurse staffing in the "1st Quarter 2013 Performance Improvement Dashboard report." The hospital failed to ensure a Registered Nurse was on duty in the hospital at all times from the period reviewed "January 1st 2013 through May 8th, 2013.

Cross-reference to Fed-A-0385 Nursing Services

Findings include:

Observation upon initial arrival to the hospital on 5/8/13 at 7:50 a.m. revealed only one Licensed Vocational Nurse on duty (ID# 2). The hospital census was zero (0) according to the LVN. The LVN stated she relieved a Registered Nurse at 7 a.m. that morning.

Record review of nurse staffing schedules dated 1/1/13 to 5/8/13 revealed 26 occurrences of no Registered Nurse on duty, only a Licensed Vocational Nurse was on duty. The nursing schedule and inpatient log revealed Licensed Vocational Nurses were used to staff the hospital when the hospital had no inpatients.

The Director of Nursing acknowledged 5/9/13 at 10:15 a.m. that he had identified times when only a Licensed Vocational Nurse (LVN) was used to staff a shift. The Director of Nursing stated that LVN's were used to staff the hospital only when there were no inpatients. The Director stated that "talks" were held about the staffing but the information was not documented in the Quality Assessment and Performance Improvement Committee meeting minutes.

Record review of a document titled "Performance Improvement 1st Quarter 2013" revealed the following:
"Governing Board Dashboard Report: Staffing Plans - Meeting Goal - No variances beyond staffing requirements."

Record review of a "Quality Improvement Committee" meeting dated 4/17/13 revealed no discussion regarding the requirement to staff the hospital with a Registered Nurse 24 hours a day, seven days a week. A reference in the meeting to staffing stated "Staffing: Includes nursing hours per patient day. This is looked at under staffing and tied back to the Quality Indicator, re: falls with and without injury, nosocomial, call lights,. This comes from nursing supervisors information..."

The Director of Quality Assurance (ID# 8) acknowledged 5/9/13 at 2:30 p.m. the Director of Nursing is responsible for reviewing nurse staffing. The Director of Quality Assurance was not aware that LVN's were being staffed without Registered Nurse supervision when there were no inpatients.

Record review of a policy titled "Performance Improvement, Medical Error Reduction and Patient Safety Policy" dated August 1, 2012 stated "Policy: To implement a planned, systematic, organization wide approach to performance improvement and safety improvement that responds to organizational priorities and is inclusive of the scope of care and services provided.......Overview: The performance improvement program is an ongoing, collaborative process designed to measure and evaluate the quality and functioning of important processes and services; implement corrective actions and improvement activities when opportunities to enhance performance and outcomes are identified; identity underlying causes: and, monitor to ensure that implemented improvements are sustained..."

Based on observation, interview and record review the facility failed to have systems in place that ensure a Registered Nurse( RN) is on duty in the hospital at all times;
The facility failed to implement it's Patient Rights policy which require the immediate availability of an RN 24 hours per day, 7 days per week.
This failed practice had the potential to adversely affect all patients, visitors and staff that comes to the Hospital. Citing 26 occurrences of no RN on duty between January 1,2013 and May 8,2013.

Findings:

Observation on 5/8/2013 at 7:50 am at the facility revealed one staff (#26) at the desk in the lobby who identified herself as the Director of Human Resources. Staff (26) stated there was no patients and there was one Nurse on the second floor.

The Nurse (#2) came to the lobby identified herself and gave her job title as Licensed Vocational Nurse (LVN).

During an interview on 5/8/2013 at 7: 56 am with Staff (#2) she informed the Surveyor she was the only nurse in the facility since 7:00 am that morning.

Staff (#2) was asked how she would handle a patient walking in at that moment with an emergency medical condition, she stated she would triage the patient and call the Chief Nursing Officer.

Observation at the facility on 5/8/2013 at 8:10 am revealed two (2) State Surveyors entering the facility, Staff (#2) was asked how she would deal with three (3) patients entering the facility with an emergency medical condition the Staff stated she was used to "working under pressure".

Review of Nurse Staffing schedules dated 1/1/2013 - 5/8/2013 revealed the following information:

The schedules did not always identify the shift a nurse was assigned and they only indicated the number of hours worked. The facility had two (2) twelve (12) hours shifts beginning 7:00 am - 7:00 pm and 7:00 pn to 7:00 am.

Schedules for January 2013 - April 2013

The schedules revealed on 1/30/2013 no Registered Nurse (RN) was scheduled on either shift. Licensed Vocational Nurses (LVN) were assigned to both shifts.

On 1/19/2013, 1/20/2013, 1/29/2013 and 1/31/2013 there was no Registered Nurse for a twelve(12) hour shift .The facility was staffed by a Licensed Vocational Nurse.

March 2013

The schedules revealed on 3/7/2013 no Registered Nurse (RN) was assigned on either shift. Licensed Vocational Nurses (LVN) were assigned both shifts.

On 3/6/2013, 3/14/2013 and 3/18/2013 there was no Registered Nurse for a twelve(12) hour shift. The facility was staffed by a Licensed Vocational Nurse for twelve (12) hour periods.

On 3/21, 3/22, 3/28 and 3/29/2013 LVNs were assigned six (6) hour shifts with no RN assigned.

April 2013

On 4/2, 4/3, 4/8, 4/10, 4/14, 4/17,4/18, 4/19 and 4/27/2013 LVNs Only were , assigned 12 hour shifts with no RN scheduled to be on the premises.

During an interview on 5/8/2013 at 10:50 am with the Chief Nursing Officer Staff (#1) regarding validation of times worked by the nurses, he stated the time clock was broken and staff were currently using paper sign in sheets also used for payroll purposes.

Review of the sign in sheets for the Period January 1,2013 through May 8, 2013 revealed the staff did not always document time in or out only the number of hours worked.

During an interview on 5/9/2013 at 9:45 am with Staff (#1) he stated his job title is Chief Executive Officer/ Chief Nursing Officer. He stated there were days when he worked in the role of the second Registered Nurse (RN) on duty but could not verify because he does not sign in and was not always identified on the staffing schedule.

Review of the facility's Nurse Staffing Policy/Procedure dated 8/1/2012 presented during the survey,documented the following information :

"There will be adequate numbers of Registered Nurses (RNs) Licensed Vocational Nurse (LVN/LPNs) and other personnel to provide nursing care to all patients.
An RN will be immediately available to assist and supervise patient care as well as to respond to emergency situations".

Review of the facility's Policy/Procedure for Scope of Services dated 8/1/2012 documented the following information:

"Nursing Services--The facility maintains twenty-four hour, seven day nursing coverage with a combination of Registered Nurses, Licensed Vocational Nurses, Certified Nursing Assistants and Unit Secretaries on the main campus".

Review of the facility's Patient Rights, Responsibilities and Consent to Treat Admission Form documented in part the following information:

"Facility B does not offer the on-site availability of a physician 24 hours per day, 7 days per week. Thus, in order to ensure the safety of our patients Hospital B has put the following processes in place to meet the needs of any patient who develops an emergency medical condition at a time when there is no physician immediately present in the hospital.
A qualified RN will be immediately available to provide bedside care to any patient while at the facility. A qualified RN will be immediately available to recognize and react to a person needing emergency care."


During an interview on 5/9/2013 with the Chief Nursing Officer (CNO) he stated the facility identified there were shifts when no RN was on premises, the CNO was unable to provide documentation there was a plan to correct the problem.

Based on record review and interview the facility failed to provide documented evidence a Registered Nurse assessed and evaluated patient care needs during a twenty-four (24) hour period. Citing 3 of 20 sampled patients #s 4,8 and 15.


Findings:

Patient # 4

Review of Nursing admission assessment data for Patient (#4) revealed the patient was admitted to the facility on 5/6/2013 with stage four Breast Cancer.
On 5/7/2013 there was documentation that a Licensed Vocational Nurse (LVN) was assigned to the patient.
Review of the Nurses notes dated 5/7/2013 from 7:00 am through 5:10 pm revealed all patient assessment and care was documented as done by the LVN.

Review of the Nurses notes dated 5/7/2013 at 1445 revealed documentation by the LVN that the patient had a change in condition,( not able to arouse, unable to obtain blood pressure and o2 sat. RN (# 1) assessed and confirmed).
The notes were signed by the LVN. There was no documentation by the RN of the assessment, findings and plan of care.
The only documentation by the Registered Nurse was completed at 1720 hours that the "patient death was confirmed and the patient pronounced".

Patient # 8

Review of admission record for patient revealed documentation dated 12/3/2012 that the patient came to the hospital at 12:00 pm as a new admission with complaints of discomfort in bilateral hips and rectal pain of "9" on a scale of 1-10.
There was documentation that a "full assessment was done"The notes were
signed by Staff (#12) Licensed Vocational Nurse. All subsequent patient assessment and care done at 14:00,16:00 and 1800 hours was documented as done by the LVN.

Patient # 15

Review of RN admission notes dated 12/15/2012 revealed the patient was admitted for Hospice care with diagnoses of end- stage dementia ,CVA and Ischemic Colitis.

Review of nurses notes dated 12/16/2012 from 7:30 am through 6:30 pm revealed all patient care and assessments were documented as done by Staff (# 27) Licensed Vocational Nurse.

Nurses notes dated 12/16/2012 at 7:19 pm until 6:00 am on 12/17/2012 revealed all nursing assessment and care was documented as done by Staff (#24) LVN.
There was no documentation that a Registered Nurse assessed the patient during the 24 hour period.

Review of Nurses notes dated 12/18/2012 revealed documentation that at 7:00 am the care of the patient was taken over by Staff (12) LVN. There was documentation the patient had a stage 4 sacral wound, a hip wound that is scabbed over, generalized edema, oxygen via nasal canula, Foley catheter and was being fed by nasogastric tube.
Subsequent assessment and care at 09:00,11:00,13:00,15:00, 17: 00 and 1835 hours was documented as done by the LVN.

Nursing documentation dated 12/18/2012 at 19:00 revealed the patient's care was handed over to Staff (23) Licensed Vocational Nurse. Subsequent assessment and care at 00:00 on 12/19/2012 and 0430 hours was documented as done by the LVN.
There was no documentation that an assessment was conducted by a Registered Nurse during the 24 hour shift.

During an interview on 5/8/2013 at 2:15 pm with the Chief Nursing Officer he stated he should have documented his assessment on patient # 4. He further stated he would tell the Registered Nurses that just signing the patient's record is not considered an assessment.