HospitalInspections.org

Based on document review, observation and interview, nursing administration failed to provide adequate staffing for 20 of 28 days on units 100, 200, 300 and 400.

Findings Include:

1. The facility policy titled, "Clinical Staff (Nurse) Staffing Plan", PolicyStat ID 12279065, last revised 08/2022, indicated under PROCEDURE: Staffing Plan: B. Core Staffing Matrix per unit: Inpatient Programs for Days (7 am-11 pm). One clinical staff member for every four (4) patients.

2. Staffing Pattern Worksheets review indicated units 100, 200, 300 and 400 were not adequately staffed per facility policy. Unit numbers, dates, number of clinical staff member(s) lacked and patient census are indicated as follows:
a. Unit 100:
3/24/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a patient census (PC) of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
3/25/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
3/31/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 11. 3 clinical staff members needed but only 2 clinical staff members were present.
4/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 2 clinical staff members were present.
4/4/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/7/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/12/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.
4/20/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 3 clinical staff members needed but only 2 clinical staff members were present.

b. Unit 200:
3/24/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
3/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/1/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 11. 3 clinical staff members needed but only 2 clinical staff members were present.
4/5/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 2 clinical staff members were present.
4/6/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a P C of 13. 4 clinical staff members needed but only 3 clinical staff members were present.
4/7/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 3 clinical staff members were present.
4/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
4/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present.
4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
4/17/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
4/19/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present.
4/20/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.

c. Unit 300:
3/24/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 4 clinical staff members were present.
3/25/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 14. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 3 clinical staff members were present.
4/12/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 15. 2 Patients requiring 1:1 observation. 5 clinical staff members needed but only 3 clinical staff members were present.
4/13/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 1 Patient requiring 1:1 observation. 4 clinical staff members needed but only 4 clinical staff members were present.
4/14/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 15. 2 Patients requiring 1:1 observation. 6 clinical staff members needed but only 4 clinical staff members were present.
4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 4 clinical staff members were present.
4/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 3 clinical staff members were present.

d. Unit 400:
3/24/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 2 clinical staff members were present.
4/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 11. 3 clinical staff members needed but only 2 clinical staff members were present.
4/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/11/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/12/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/13/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/15/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
4/18/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 4 clinical staff members were present.
4/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 12. 1 Patient requiring 1:1 observation. 4 clinical staff members needed but only 3 clinical staff members were present.
4/20/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 1 Patient requiring 1:1 observation. 5 clinical staff members needed but only 3 clinical staff members were present.

4. In interview on 5/3/24 at approximately 5: pm with staff member A6 (Director Of Nursing) confirmed units 100, 200, 300, 400 were not adequately staffed per policy and should have been.