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Based on record review and interview, the hospital failed to ensure the licensed nurse-to-patient ratios on the Medical/Surgical units were maintained during staffing meal breaks. This failure had the potential to contribute to inadequate patient supervision and unsafe patient care.

Findings:

Review of the hospital's P&P titled CORE: Plan for the Provision of Patient Care dated June 2023 showed the leadership of the hospital recognizes its role in providing the framework for directing health care services that are responsive to patient needs and that result in positive patient care outcomes. The Chief Clinical Officer is responsible for ensuring the hospital's plan for Provision of Care is complete and up-to-date.

Review of the hospital's P&P titled CORE: Patient Classification System dated June 2023 showed this policy is to ensure the nursing supervisor has the ultimate authority in determining final number of staff by skill mix needed for each shift. The Unit Summary Review section of the Screenings Review-Supervisor Responsibility showed this screen summarizes the staffing requirements for the next shift; a description of some of the major items on this screen includes the staffing needs based on KHAT screening results AND title 22 staffing ratio requirements.

Review of the California Code of Regulations Title 22 - Social Security Division 5 - Licensing and Certification of Health Facilities, Chapter 1 General Acute Care Hospital Article 3 - Basic Services 70217 - Nursing Service Staff (a) (11) showed the licensed nurse-to-patient ratios in the medical/surgical care units shall be 1:5 or fewer at all times.

On 10/29/24 at 1311 hours, an interview with concurrent review of the Kronos time reports dated 10/21/24 for 2 West-Med/Surg unit night shift (1900 hours - 0700 hours) was conducted with the Nursing Supervisor. The Kronos time report showed the staff meal break schedules were as follows:

RN 1's meal break: 02:11 - 02:42 hours

RN 2's meal break: 01:07 - 01:37 hours

RN 3's meal break: 01:40 - 02:10 hours

LVN 1's meal break: 01:08 - 01:38 hours

LVN 2's meal break: 01:39 - 02:13 hours

On 10/24/24 at 1131 hours, an interview and concurrent review of the Daily Staffing Sheets was conducted with the Director of Quality Management. The Director of Quality Management reviewed the above time slots and confirmed the staffing was overlapping their meal breaks for RN 2 with LVN 1, and RN 3 with LVN 2. During these staffing meal breaks, the Nursing Supervisor was responsible for more than five patients and the staffing ratio of 1 licensed nurse to 5 patients was not maintained.

On 10/29/24 at 1509 hours, during an interview with the Nursing Supervisor, the Nursing Supervisor confirmed the above meal breaks were provided to the staffing; and during staffing meal breaks, the Nursing Supervisor covered for the nurse's patient assignments.

On 10/29/24 at 1325 hours, the Chief Clinical Officer was interviewed regarding the out-of-ratio event on 10/21/24. The Chief Clinical Officer stated they were unaware of the event until they received from third party later. The Chief Clinical Officer acknowledged they were ultimately responsible for all the nursing services, including maintaining the nurse-to-patient ratio.