HospitalInspections.org

Based on interviews and record review, the facility failed to ensure that adequate numbers of Registered Nurses (RN) staffed the Intensive Care Unit (ICU) as evidenced by one RN for 4 of 4 patients (#1, #12, #13, and #14).

Findings included:
Record review of census report dated 02/29/2016 revealed 4 patients (#1, #12, #13, and #14).

Record review of the nursing staff schedule for 2/27/2016 revealed two RNs (RN #53 and RN #61) and one monitor technician with four patients (#1, #12, #13 and #14) in ICU.

In an interview with RN #53 on 9/29/2016 at 1245, he stated:
- He remembered the incident on 2/27/2016 involving Patient #1. He remembered the incident because the Texas Board of Nursing investigated it. He did not know the results of the investigation.
- Patient #1 was assigned to him on that date.
- On 2/27/2016, "I did go off the floor for a few minutes to get food from the vending machine. Then I went into the back room to eat." This left one nurse on the unit with five critical care patients."
- The house supervisor was supposed to cover lunch breaks.
- "We do not call the house supervisor for a break. On weekends we just cover each other."
- We're not supposed to leave one nurse on the unit. It is expected that we cover each other."

In an interview with RN #59 on 9/29/2016 at 1330, she stated:
- "We usually just grab some food and come back to the unit when we're on break."
- "We eat and work in the back if needed."
- The house supervisor does not ask if breaks were taken.
- "Even if we were on a real break, the expectation of Kindred is, 'You would come off your break any way and take care of the patient.'"

In an interview with CCO #52 on 9/29/2016 at 1030, she stated the nurses in ICU were supposed to call the house supervisor to cover their breaks when there is only have two nurses.

In an interview with RN House Supervisor #54 on 9/29/2016 at 1106, she stated, "If there are only two nurses on [duty], they take turns [to take breaks] while the house supervisor is there to cover."