HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting in 2 of 10 patients. (P 1 and P2) See tag 0144


The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to ensure care in a safe setting in 2 of 10 patients. (P 1 and P2)

Findings include:

1. The hospital policy titled, "Patient Rights And Responsibilities", PolicyStat ID 13517670, last reviewed 01/2021, indicated patients have the right to receive care in a safe setting.


2. P 1's Medical Record (MR) indicated falls on the following dates:
a. 3/27/23 at 1:40 pm. Fall precautions remained at every 15 minute level of observation, red non-skid socks and pt education. Post-Fall Huddle indicated the staffing ratio was 1:16. Morse Fall Scale score pre fall was 25 and post fall was 95.
b. 3/30/23 at 8:20 pm. Fall precautions remained at every 15 minute level of observation, red non-skid socks, bed alarm, moved to milieu for easier observation. Post-Fall Huddle indicated the staffing ratio was 1:13. Morse Fall Scale score post fall was 80.
c. 3/30/23 at 9:45 pm. Fall precautions remained at every 15 minute level of observation, red non skid-socks, bed alarm, moved to milieu for easier observation. Post-Fall Huddle indicated the staffing ratio was 1:13. Morse Fall Scale score post fall was 95.
d. 3/31/23 at 9:56 am. Fall precautions remained at every 15 minute level of observation, red non skid-socks, bed alarm when in bed. Post-Fall Huddle indicated the staffing ratio was 1:13. Morse Fall Scale score post fall was 95.
e. 4/12/23 at 11:50 pm. Post-Fall Huddle indicated the staffing ratio was 3 RN/LPN and 2 BHA for both units 100 and 200 combined. Morse Fall Scale score post fall was 55. Fall precautions remained at every 15 minute level of observation, red non-skid socks, bed alarm when in bed.
f. 4/15/23 at 3:30 pm. Post -Fall Huddle indicated the staffing ratio was 1:15. Morse Fall Scale score post fall was 55 and staff sat with patient 1:1 as much as possible d/t having 1 BHA (Behavior Health Associate).Fall precautions remained at every 15 minute level of observation, red non skid socks, bed alarm when in bed
g. 4/16/23 at 1:15 pm. Fall precautions remained at every 15 minute level of observation, red non skid-socks, bed alarm when in bed. Post fall patient kept closer to nurses station while awake and 1:1 during meal times. Post-Fall Huddle indicated the staffing ratio was 1:13. Factors leading to fall was lack of staff. Morse Fall Scale score post fall was 75.
h . 4/19/23 at 11:55 pm. Fall precautions remained at every 15 minute level of observation, red non-skid socks, bed alarm when in bed. 1:1 order requested. Staffing ratio 3: 14. Required an emergency send out for head injury.
i. Provider Orders dated 4/7/23 at 3:41 and 4/28/23 at 3:00 pm indicated an of 1:1 level of observation during meals, snacks, and once a day ambulation with staff, 4/28/23 at 12:40 pm 1:1 level of observation from now through discharge.
j. The MR lacked documentation of increased fall risk precautions after repeated falls until 1:1 ordered and lacked documentation of 1:1 level of observation on Patient Observation Rounds charting for dates 4/7/23-4/8/23 and 4/27/23- 5/7/23.

3. Review of P2 medical record indicated falls on the the following:
i. 4/14/23 at 11:37 pm. Post-Fall Huddle Form indicated fall precautions remained at every 15 minute level of observation and red non-skid socks after pt fell tying to go the restroom on his/her own.
ii. 4/16/23 at 10:50 am. Post-Fall Huddle Form indicated the staffing ratio for unit 100 was 1:5 and factors that led to fall was lack of enough staff.

4. In interview on 9/20/23 at 2:30 pm with AH 1 (Licensed Staff) indicated staffing is not acceptable based on acuity of patients and there is push back on ordering 1:1 observation from administration due to staffing concerns.

Based on document review and interview, nursing administration failed to provide adequate staffing for 19 of 23 days on unit 100.

Findings Include:

1. Review of policy titled: Clinical Staff (Nurse) Staffing Plan (PolicyStat: 12279065) last approved 08/2022, indicated there will be 1 nursing staff to every 4 patients.

2. Staffing Pattern Worksheet review indicated unit 100 was understaffed 19 of 23 days per the facility's staffing policy. Short staffed shifts are indicated as follows:
a. 3/27/23 - 1 RN/ 1 LPN / 2 BHA for day shift ( RN / LPN 7:00 am - 7:30 pm, BHA 7:00 - 3:30 pm), 1 RN / 2 BHA for evening shift ( RN 7:00 am - 7:30 pm, BHA 3:00 pm - 11:30 pm), 2 RN / 1 BHA for night shift (RN 7:00 pm - 7:30 am, BHA 3:00 - 7:30 am) with a patient census of 16.
b. 3/30/23 - 1 RN / 2 BHA for day shift, 1 RN / 1 BHA for evening shift, 1 RN / 2 BHA for night shift with a patient census of 13.
c. 3/31/23 - 1 RN / 1 LPN / 2 BHA for day shift, 2 RN/2 BHA for night shift with a patient census of 15.
d. 4/3/23 - 1 RN / 1 BHA for day shift, 1 RN / 1 BHA for evening shift, 2 RN / 1 BHA for night shift with a patient census of 15.
e. 4/4/23 - 1 RN / 1 LPN / 1 BHA for day shift, 2 RN / 1 BHA for night shift with a patient census of 15.
f. 4/12/23 - 2 RN / 1 BHA for night shift with a patient census of 15.
g. 4/15/23 - 2 RN / 1 BHA for night shift with a patient census of 14.
h. 4/16/23 - 1 RN / 2 BHA for day shift, 1 RN / 2 BHA for evening shift with a patient census of 16.
i. 4/17/23 - 1 RN / 1 LPN / 1 BHA for evening shift, 1 RN / 2 BHA for night shift with a census of 14.
j. 4/19/23 - 1 RN / 1 LPN / 1 BHA for day shift, 1 RN / 2 BHA for night shift with a patient census of 16.
k. 5/2/23 - 1 RN / 2 BHA for day shift, 1 RN / 2 BHA for evening shift, 1 RN / 1 BHA for night shift with a patient census of 16.
l. 5/7/23 - 1 RN / 2 BHA for day shift, 1 RN / 2 BHA for evening shift, 2 RN / 1 BHA for night shift with a patient census of 14.
m. 5/15/23 - 1 RN / 2 BHA for evening shift, 2 RN / 1 BHA for night shift with a patient census of 14.
n. 5/18/23 - 1 RN / 1 LPN / 1 BHA for evening shift, 2 RN / 1 BHA for night shift with a patient census of 13.
o. 5/31/23 - 1 RN / 1 BHA for night shift with a patient census of 16.
p. 6/4/23 - 1 RN / 1 BHA for evening shift with a patient census of 14.
q. 7/30/23 - 1 RN / 1 BHA for day shift, 1 RN / 2 BHA for evening shift, 2 RN / 1 BHA for night shift with a patient census of 15.
r. 8/6/23 - 2 RN / 1 BHA for day shift, 2 RN / 1 BHA for evening shift, 2 RN / 1 BHA for night shift with a patient census of 16.
s. 9/3/23- 2 RN / 1 BHA for day shift, 2 RN / 1 BHA for evening shift, 2 RN / 1 BHA for night shift with a patient census of 15.


3. Interview on 9/20/23 at approximately 5:13 pm with administrative staff member A 4 (Administrative Staff) confirmed the minimum staffing ratio is 1 clinical staff member to every 4 patients.

4. In interview on 9/20/23 at approximately 5:15 pm with administrative staff member A 3 (Administrative Staff) confirmed 1: 1 observation requires additional staff not included in the minimum staffing ratio.

5. In interview on 9/20/23 at 2:30 pm with AH 1 (Licensed Staff) indicated staffing is not acceptable based on acuity of patients and there is push back on ordering 1:1 observation from administration due to staffing concerns.

Based on document review the facility failed to document 1:1 observation rounding for 1 of 10 patients. (P 1)

Findings include:
1. Facility policy titled, "Patient Observation", PolicyStat ID 12931622, last revised 01/2023, indicated to document all observations in the patient record per their ordered observation status

2. P 1's medical record was reviewed and indicated:
a. Provider Orders dated 4/7/23 at 3:41 pm and 4/28/23 at 3:00 pm indicated an of 1:1 level of observation during meals, snacks, and once a day ambulation with staff, 4/28/23 at 12:40 pm 1:1 level of observation from now through discharge was renewed and was to continue until discharge.
b. The MR lacked documentation of 1:1 level of observation on Patient Observation Rounds charting for dates 4/7/23-4/8/23 and 4/27/23- 5/7/23.