HospitalInspections.org

Based on a review of facility documents and staff interview (EMP), it was determined the facility failed to ensure adequate staffing on the Medical/Surgical Units for 21 of 21 days. (December 19, 2016 through January 8, 2017).

Findings include:

Review on January 12, 2017, of policy Staffing Plan and Schedules, last reviewed July 2016, revealed, "Policy: Nursing personnel shall be assigned to each unit to meet patient care needs as required by the Plan for Patient Care. Procedure: 1. Patient care units are staffed as described in the Plan for Patient Care for each unit to ensure staff allocation is sufficient to meet the changing needs of the patients. ... 3. Daily staffing profiles are maintained in the Nursing Office. These records identify the staffing needs of each patient care unit and reflect the actual staffing for each shift. The staffing profiles are continually reviewed and adjusted accordingly to meet changing patient care needs. 4. The staffing pattern shall provide for an appropriate number of registered nurses to ensure 24 hour supervision seven days per week for the following: graduate nurses, licensed practical nurses, nursing assistants, clinical secretaries and telemetry technicians. A Registered Nurse must be present on each unit at all times. ... 11. Director/Nurse Manager is responsible for: A. Scheduling and providing 24 hour unit coverage. B. Monitoring overtime and budgeted nursing hours. C. Ensuring the accuracy of daily staffing profiles. ... 13. Staffing - General Information: A. Adjustments in staff assignment are made through collaboration with Director, Nurse Manager, Supervisors, and/or patient placement Coordinator. Procedural steps may include but are not limited to: (a) The use of per diem/part time personnel. (b) Reassignment of staff from unit that has lower census and/or acuity to one with higher census and/or acuity. (c) Contacting personnel of next shift to come to work earlier than scheduled. (d) Contacting personnel who are on or off duty to work additional hours ... ."

Review on January 19, 2017, of facility document Plan for Providing Patient Care Medical Surgical Division East Campus 2016, revised January 2016, revealed, "II. Level of Care 6 North and 5 North staff consists of Registered Nurses, Licensed Practical Nurses, Nursing Assistants and Clinical Secretaries. One Telemetry Technician is required each shift on 6 North to observe the central monitors. There is also one Clinical Manager on each unit. Staffing Plan (43 patients) 7-3 Shift 6.5 RN, 6.5 LPN/NA, 1 CS. 3-11 Shift 6.5 RN, 6.5 LPN/NA, 1 CS. 11-7 Shift 4 RN, 4 LPN/NA, 0.5 CS. Staffing Plan (26 patients) 7-3 Shift 5 RN, 5 LPN/NA, 1 CS. 3-11 Shift 5 RN, 5 LPN/NA, 1 CS. 11-7 Shift 3 RN, 3 LPN/NA, 0.5 CS. Adjustments in staffing ratios may be necessary based on availability of staff/unit needs. Staffing is based on nursing hours, census and acuity. ... ."

Review on January 12, 2017, of policy Nursing Personnel Policy, last reviewed July 2016, revealed, "Policy: In an effort to provide uniformity, the Nursing Department will enforce the policies involving scheduling, use of fringe time, evaluations, overtime and the disciplinary process fairly throughout the organization. Procedure: 1. Time Scheduling: ... B. General Policies: 1.). The Director/Nurse Manager is responsible for planning and implementing staffing schedules which are consistent with the needs of the patients, the nursing personnel and the cost center ' s budget. Schedules will be utilized at discretion of the Director/Nurse Manager to enhance patient care and maximize unit productivity. ... ."

Review on January 13, 2017, of facility document Med Surg Staffing Guidelines, no date, revealed, "... Census 42. 7-3 staffing 6.5 RN, 6.5 CP [care partner], 1 CS [clinical secretary], 3-11 staffing 6.5 RN, 6.5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5 CS.
Census 41. 7-3 staffing 6.5 RN, 6.5 CP, 1 CS, 3-11 staffing 6.5 RN, 6.5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 40. 7-3 staffing 6.5 RN, 6.5 CP, 1 CS, 3-11 staffing 6.5 RN, 6.5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5 ...
Census 38. 7-3 staffing 6.5 RN, 6.5 CP, 1 CS, 3-11 staffing 6.5 RN, 6.5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 37. 7-3 staffing 6.5 RN, 6.5 CP, 1 CS, 3-11 staffing 6.5 RN, 6.5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 36. 7-3 staffing 6.5 RN, 6.5 CP, 1 CS, 3-11 staffing 6.5 RN, 6.5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 35. 7-3 staffing 6.5 RN, 6.5 CP, 1 CS, 3-11 staffing 6.5 RN, 6.5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 34. 7-3 staffing 6 RN, 6 CP, 6.5 1 CS, 3-11 staffing 6 RN, 6 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 33. 7-3 staffing 6 RN, 6 CP, 6.5 1 CS, 3-11 staffing 6 RN, 6 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 32. 7-3 staffing 6 RN, 6 CP, 6.5 1 CS, 3-11 staffing 6 RN, 6 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 31. 7-3 staffing 6 RN, 5 CP, 1 CS, 3-11 staffing 6 RN, 5 CP, 1 CS, 11-7 staffing 4 RN, 4 CP, 0.5.
Census 30. 7-3 staffing 6 RN, 5 CP, 6.5 1 CS, 3-11 staffing 6 RN, 5 CP, 1 CS, 11-7 staffing 4 RN, 3 CP, 0.5.
Census 29. 7-3 staffing 6 RN, 5 CP, 1 CS, 3-11 staffing 6 RN, 5 CP, 1 CS, 11-7 staffing 4 RN, 3 CP, 0.5.
Census 28. 7-3 staffing 6 RN, 5 CP, 1 CS, 3-11 staffing 6 RN, 5 CP, 1 CS, 11-7 staffing 4 RN, 3 CP, 0.5 ...
Census 26. 7-3 staffing 6 RN, 4 CP, 1 CS, 3-11 staffing 6 RN, 4 CP, 1 CS, 11-7 staffing 3 RN, 3 CP, 0.5 ...
Census 24. 7-3 staffing 5 RN, 4 CP, 1 CS, 3-11 staffing 5 RN, 4 CP, 1 CS, 11-7 staffing 3 RN, 3 CP, 0.5.
Census 23. 7-3 staffing 5 RN, 4 CP, 1 CS, 3-11 staffing 5 RN, 4 CP, 1 CS, 11-7 staffing 3 RN, 3 CP, 0.5.
Census 22. 7-3 staffing 5 RN, 3 CP, 1 CS, 3-11 staffing 5 RN, 3 CP, 1 CS, 11-7 staffing 3 RN, 2 CP, 0.5 ...
Census 18. 7-3 staffing 4 RN, 3 CP, 1 CS, 3-11 staffing 4 RN, 3 CP, 1 CS, 11-7 staffing 3 RN, 2 CP, 0.5 ... ."

Medical Surgical Unit 5N

Review on December 13, 2017, of the facility nursing staffing schedule for December 19, 2016, for 11-7 revealed 5N had 31 patients and was staffed with 3 RNs and 4 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 21, 2016, for 3-11 revealed 5N had 36 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 22, 2016, for 7-3 revealed 5N had 35 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 22, 2016, for 11-7 revealed 5N had 33 patients and was staffed with 4 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 23, 2016, for 7-3 revealed 5N had 33 patients and was staffed with 5 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 6 care partners.

December 23, 2016, for 11-7 revealed 5N had 18 patients and was staffed with 2 RNs and 2 care partners. The facility requirement for patients was 3 RNs and 2 care partners.

December 25, 2016, for 3-11 revealed 5N had 23 patients and was staffed with 3 RNs and 2 care partners. The facility requirement for patients was 5 RNs and 3 care partners.

December 25, 2016, for 11-7 revealed 5N had 26 patients and was staffed with 3 RNs and 2 care partners. The facility requirement for patients was 3 RNs and 3 care partners.

December 26, 2016, for 7-3 revealed 5N had 29 patients and was staffed with 5 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 5 care partners.

December 26, 2016, for 3-11 revealed 5N had 30 patients and was staffed with 4 RNs and 2 care partners. The facility requirement for patients was 6 RNs and 5 care partners.

December 26, 2016, for 11-7 revealed 5N had 30 patients and was staffed with 3 RNs and 1 care partners. The facility requirement for patients was 4 RNs and 3 care partners.

December 27, 2016, for 7-3 revealed 5N had 33 patients and was staffed with 5 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 6 care partners.

December 27, 2016, for 3-11 revealed 5N had 32 patients and was staffed with 5 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 6 care partners.

December 28, 2016, for 3-11 revealed 5N had 35 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 28, 2016, for 11-7 revealed 5N had 31 patients and was staffed with 4 RNs and 2 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 29, 2016, for 11-7 revealed 5N had 29 patients and was staffed with 3 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 3 care partners.

December 30, 2016, for 3-11 revealed 5N had 28 patients and was staffed with 6 RNs and 4 care partners. The facility requirement for patients was 6 RNs and 5 care partners.

December 30, 2016, for 11-7 revealed 5N had 24 patients and was staffed with 3 RNs and 2 care partners. The facility requirement for patients was 3 RNs and 3 care partners.

December 31, 2016, for 3-11 revealed 5N had 24 patients and was staffed with 5 RNs and 3 care partners. The facility requirement for patients was 5 RNs and 4 care partners.

December 31, 2016, for 11-7 revealed 5N had 22 patients and was staffed with 3 RNs and 1 care partners. The facility requirement for patients was 3 RNs and 2 care partners.

January 1, 2017, for 3-11 revealed 5N had 26 patients and was staffed with 5 RNs and 3 care partners. The facility requirement for patients was 6 RNs and 4 care partners.

January 1, 2017, for 11-7 revealed 5N had 28 patients and was staffed with 3 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 3 care partners.

January 2, 2017, for 7-3 revealed 5N had 32 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 6 care partners.

January 3, 2017, for 7-3 revealed 5N had 35 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 4, 2017, for 3-11 revealed 5N had 38 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 4, 2017, for 11-7 revealed 5N had 38 patients and was staffed with 4 RNs and 2 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 5, 2017, for 3-11 revealed 5N had 38 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 5, 2017, for 11-7 revealed 5N had 38 patients and was staffed with 4 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 6, 2017, for 3-11 revealed 5N had 37 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 6, 2017, for 11-7 revealed 5N had 35 patients and was staffed with 4 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 7, 2017, for 3-11 revealed 5N had 38 patients and was staffed with 6 RNs and 3 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 7, 2017, for 11-7 revealed 5N had 38 patients and was staffed with 4 RNs and 2 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 8, 2017, for 3-11 revealed 5N had 37 patients and was staffed with 7 RNs and 3 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 8, 2017, for 11-7 revealed 5N had 37 patients and was staffed with 3 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

Medical Surgical Unit 6N

Review on December 13, 2017, of the facility nursing staffing schedule for December 19, 2016, for 3-11 revealed 6N had 35 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 19, 2016, for 11-7 revealed 6N had 32 patients and was staffed with 3 RNs and 4 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 20, 2016, for 3-11 revealed 6N had 37 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 20, 2016, for 11-7 revealed 6N had 40 patients and was staffed with 4 RNs and 2.75 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 21, 2016, for 7-3 revealed 6N had 41 patients and was staffed with 7 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 21, 2016, for 3-11 revealed 6N had 41 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 23, 2016, for 7-3 revealed 6N had 37 patients and was staffed with 5 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 23, 2016, for 3-11 revealed 6N had 35 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 24, 2016, for 3-11 revealed 6N had 36 patients and was staffed with 7 RNs and 3.5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 25, 2016, for 11-7 revealed 6N had 31 patients and was staffed with 4 RNs and 2 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 26, 2016, for 7-3 revealed 6N had 32 patients and was staffed with 5 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 6 care partners.

December 26, 2016, for 3-11 revealed 6N had 30 patients and was staffed with 4 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 5 care partners.

December 26, 2016, for 11-7 revealed 6N had 30 patients and was staffed with 3 RNs and 2 care partners. The facility requirement for patients was 4 RNs and 3 care partners.

December 27, 2016, for 3-11 revealed 6N had 34 patients and was staffed with 5 RNs and 5 care partners. The facility requirement for patients was 6 RNs and 6 care partners.

December 28, 2016, for 3-11 revealed 6N had 37 patients and was staffed with 6.5 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 29, 2016, for 3-11 revealed 6N had 38 patients and was staffed with 7 RNs and 3 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 29, 2016, for 11-7 revealed 6N had 32 patients and was staffed with 3 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 30, 2016, for 3-11 revealed 6N had 35 patients and was staffed with 6 RNs and 6 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

December 30, 2016, for 11-7 revealed 6N had 37 patients and was staffed with 4 RNs and 2 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

December 31, 2016, for 7-3 revealed 6N had 37 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners

December 31, 2016, for 11-7 revealed 6N had 32 patients and was staffed with 3 RNs and 2 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 1, 2017, for 3-11 revealed 6N had 32 patients and was staffed with 6 RNs and 4 care partners. The facility requirement for patients was 6 RNs and 6 care partners.

January 1, 2017, for 11-7 revealed 6N had 33 patients and was staffed with 4 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 2 2017, for 7-3 revealed 6N had 37 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 4, 2017, for 11-7 revealed 6N had 41 patients and was staffed with 4 RNs and 2.5 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 5, 2017, for 3-11 revealed 6N had 42 patients and was staffed with 6 RNs and 5 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 7, 2017, for 3-11 revealed 6N had 40 patients and was staffed with 5 RNs and 4 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

January 7, 2017, for 11-7 revealed 6N had 40 patients and was staffed with 3 RNs and 3 care partners. The facility requirement for patients was 4 RNs and 4 care partners.

January 8, 2017, for 3-11 revealed 6N had 38 patients and was staffed with 5 RNs and 4 care partners. The facility requirement for patients was 6.5 RNs and 6.5 care partners.

Interview on December 13, 2017, at approximately 8:26 AM with EMP1 confirmed a care partner is an LPN or Nursing Assistant assigned to provide care to patients under direction of an RN. EMP1 confirmed the staffing numbers for RNs and Care partners on 5N and 6N from December 19, 2016 through January 8, 2017. EMP1 confirmed they have vacant positions on 11-7.