HospitalInspections.org

Based on document review and interview, nursing administration failed to provide adequate staffing in 4 of 4 patient units (100, 200, 300 400).

Findings Include:

1. Review of policy titled: Clinical Staff (Nurse) Staffing Plan (PolicyStat: 12279065) last approved 08/2022, indicated there will be 1 nursing staff to every 4 patients.

2. Review of staffing from 07/11/23 to 07/17/23 based off of policy indicating 1 nursing staff to every 4 patients indicated the facility was short staff including, but not limited to the following:

07/12/23 - short 1 staff on units 100 and 200 on day shift.
07/15/23 - short 1 to 2 staff on units 100, 200 and 400 on both shifts.
07/16/23 - short 1 staff on on units 100, 200, 300, 400 on night shift and unit 300 and 400 on day shift.
07/17/23- short 1 staff on units 200, 300, 400 on both shifts and 100 on night shift.

3. Interview on 08/10/23 at 3:50 pm confirmed that the facility is short staffed and every effort being made to hire staff.

Based on document review and interview, nursing administration failed to follow policy on falls in 3 of 12 (patients 3, 6 and 10) medical records reviewed.

Findings Include.

1. Review of policy titled: Fall Prevention Program, Policy 13554604, last approved 04/2023, indicated that each time a patient falls, the patient will be assessed by the nurse directly after the fall and that the Incident Report will be submitted through Wellsky.

2. Review of patient 3 (fall on 08/10/23), 6 (fall 03/31/23) and 10's (fall on 05/31/23) medical record lacked documentation of a nursing assessment after the patient's fall.

3. Interview with A2 (Director of Quality and Risk) at 3:50 pm confirmed that patient 3, 6 and 10's medical records lacked documentation of after fall assessments by nursing.