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Based on interview and document review the facility failed to provide adequacy of staffing to ensure the immediate availability of nursing staff for bedside nursing care of all patients served and to keep nursing care plans up to date with changes in patient needs resulting in the increased risk for injury and unmet needs.
See specific tag:
A-392 Staffing and the Delivery of care.
A-396 Nursing staff develop and keep a current nursing care plan for each patient.

Based on interview and document review the facility failed to provide adequate numbers of registered nurses (RNs), licensed practical nurses (LPNs), Patient care technicians (PCTs) and other personnel to provide immediate availability of staff for bedside nursing care for two of two fall incidents (patient #8 and #9) reviewed from a total sample of 9 patients resulting in the increased risk of injury and unmet patient needs. Findings include:
On 8/2/2016 at 1130 during the observational tour of the Long Term Acute Care (LTAC) unit a family member was observed pushing a patient in a wheel chair (W/C) into room #19. She consented to be interviewed. The interview was conducted in private. The daughter for patient #1 was interviewed. She stated " I am not happy with the care here. " She went on to explain, " They do not give baths, or do oral care. "

On 8/2/2016 at 1155 during the continued tour the spouse of patient #2 was interviewed in private. The patient was on a ventilator and non-responsive. She stated " I am very unhappy with the care here, the staff just let him lay here, and they do not move him, reposition him or keep him clean. "

On 8/2/2016 at 1215 Staff A was queried about care routines. She explained patients are rounded on hourly and any care needed is provided at that time. She also explained that they use wipes instead of wash cloths with soap and water so patients and their families do not recognize that as a bath.

On 8/3/2016 at 1015 the chart for patient #8 was reviewed. The patient was on a ventilator with a tracheostomy tube that she kept pulling with her hands. The physician gave orders for soft wrist restraints that were reordered every 24 hours (6/4, 6/5, 6/6, 6/7, 6/8, 6/9, & 6/10.) The lower bed rails remained down per policy for the least restrictive amount of restraint to maintain safety.
The Patient had results of a CT scan dated for 6/5/16 for the Orbits of the eyes. The hemoglobin results of 6.8 on 6/9/16 resulted in an order from the physician for 2 units of packed red blood cells. The patient spiked a temperature after the first unit so the second unit was held due to the possibility of a blood reaction.
The documentation of every 2 hour turning was incomplete for the evening shift 6/9/2016 (only 2045 and 2245 are recorded in the electronic medical record.) The documentation did reflect a fall from her bed at 0127 6/10/2016. The documentation stated the patient was found sitting on the floor off the ventilator with her lines dislodged. She was resuscitated and transferred to the Intensive Care unit at Beaumont-Taylor

On 8/3/2016 at 1205 the chart for patient #9 was reviewed and revealed the patient fell from his chair on 7/7/16. The fall was documented with the post fall assessment completed. The care plan did not reflect the patient falling from his chair, no updates were noted.

On 8/2/2016 at 1230 the Quality Assurance Performance Improvement meeting minutes were reviewed for information about care issues and falls. The 2016 trends for patient falls began to climb from a low 2.6 in March, April fall rate was 4.4, May fall rate was 6.0, and June fall rate was 12.8. (July was not calculated yet.) There was nothing documented about care issues in the quality minutes.
Staff A was asked if they had done a root, cause, analysis related to the steady climb in fall rates, she replied " No, we just do a post fall assessment that includes a unit huddle (staff meeting) " .

On 8/2/2016 at 1300 the 2016 complaint and grievance log for June and July was provided and reviewed. For June there were 4 grievances logged: 1) 6/1/16 Call light response time delay. 2) 6/1/16 Call light response time delay. 3) 6/22/16 Call light response time delay, patient not turned every 2 hours, white board not updated with current information, rudeness of staff, and cell phone use by staff at nurses ' station. 4) 6/24/16 poor patient care and lack of communication.

On 8/2/2016 at 1543 staff A was interviewed regarding staff to patient ratios (the number of patients assigned to each staff member) and how the assignments were decided. It was explained that the ratios are set by a National Corporation, it is based on acuity and patient level of need for care. If a sitter is needed the family can provide that or staff can be assigned. Staff A stated " The expected time to respond to a call light is 3 minutes. " Staff A was asked if she had ever done an audit of call light response times. Staff A responded " No I would never do that to my staff. "

On 8/3/2016 at 0830 staff H was interviewed. Staff H stated our patient to Nurse ratio is 4 to 1 today because of the investigation, it is usually 5:1. Staff H went on to explain it is very difficult to complete the work of the day as the Patient care technicians (PCTs) are shared by 10+ patients. If a patient falls or codes it can really make it impossible to give every patient good care.

On 8/3/2016 at 1230 staff K was interviewed. Staff K stated " Nurses often have 5-6 patients each and assistants have 10+ " Staff K went on to explain If someone calls in sick it can make the assignment almost impossible, the supervisors do not assist with care under normal circumstances. Staff K further explained that response time to call lights is expected before 5 minutes but went on to say it often takes a lot longer. Staff K went on to explain if I am in the middle of providing care for another patient I have to finish providing care before answering the call light for someone else.

On 8/2/2016 at 1515 the form " Nursing Service Staffing Pattern " was returned filled out covering the last 3 weeks 7/13/2016 -8/2/2016. Random Daily staffing Sheets were requested and then reviewed. It was noted that each patient is assigned an acuity level 2-3-or 4. The assignment was done by location, the figuring of acuity was not located on the " Daily Staffing sheet. " On the night shift of 6/09/2016 the nurse assigned to patient #8 was assigned 5 patients with the total acuity of 16 and she was assigned to oversee an LPN with 5 patients with the total acuity of 14. 4 other registered nurses (RNs) were assigned- 5 patients with the total acuity of 13, 5 patients with the total acuity of 15, 4 patients with the total acuity of 11, and 4 patients with the total acuity of 11.
On the night shift of 7/7/2016 ( the patient who fell -#9) the patient assignments were done by location each nurse had 5 patients- the acuity assignments were incomplete for 4 patients. The PCTs were assigned 10, 12, and 13 patients respectively. Patient #9 was assigned to the assistant who was assigned 13 patients with an RN who had 5 patients.

Based on document review and interview the facility failed to ensure that the nursing staff kept a current nursing care plan for each patient for 2 of 3 (#7 and #9) records reviewed for changes in care needs from a total of 9 charts reviewed, resulting in the potential for unmet patient needs. Findings include:

Findings include:

On 8/3/2016 at 0917 the chart for patient #7 was reviewed and revealed the patient had Clostridium Difficile (causes infectious diarrhea, loose stools). Documentation reflected frequent large loose bowel movements requiring frequent clean ups in spite of rectal bags used to reduce incontinence for Clostridium Difficile patients. The care plan did not reflect the frequent incontinence requiring additional bed baths or risk for skin integrity issues.

On 8/3/2016 at 1205 the chart for patient #9 was reviewed and revealed the patient had a fall on 7/7/16. The fall was documented with the post fall assessment completed. The care plan did not reflect the patient falling from his chair, no updates were noted.

On 8/2/2016 at 1543 staff A was interviewed. She was queried about care plans. She explained that there are two (2) care plans one is a nursing care plan and the second is an interdisciplinary treatment (IDT) care plan. The nurses are expected to update the patients nursing care plan as needed, this would include bathing, fall precautions, incontinence or any change. The IDT care clan is updated by the team (physical therapy, occupational therapy, respiratory therapy, speech therapy, and the nursing supervisor) as they make rounds daily.