HospitalInspections.org

Based on record review and interview, the GOVERNING BODY failed to ensure the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital including the ICU (Intensive CAre Unit) and (2) Medical/Surgical Units (Med/Surg), in that,

~ 10 of 28 nurse shifts (7/01/2021, 7/07/2021 nights, 7/08/2021 both, 7/09/2021, 7/10/2021, 7/12/2021 both, 7/13/2021, and 7/14/2021) were understaffed; AND

~ the facility's Plan of Correction for the 11/23/2020 complaint survey was not fully implemented and sustained.

Findings were

~ The 7/01/2021 through 7/14/2021 AM and PM staffing assignment sheets were reviewed. There was no indication of acuity on the assignment sheets. The staffing was found to not meet the Staffing Plan on the following days: (RN-registered nurse; LVN - licensed vocational nurse; CNA - Certified nurse assistant; pts - patients)

7/01/2021 - 7 ICU patients 2 RNs, 1 LVN, No CNA

7/07/2021 - 8 ICU patients 2 RNs, 1 LVN, No CNA (Nights)

7/08/2021 - 7 ICU patients 2 RNs, 1 LVN, No CNA

7/08/2021 - 8 ICU patients 2 RNs, 1 LVN, No CNA (Nights)
- 18 1st floor patients 3 RNs, 1 LVN, 1 CNA
- 10 2nd floor patients 2 RNs, No CNA (36 pts - 7 nurses)

7/12/2021 - 5 ICU patients 2 RNs, No CNA

Also of note: the listed CNA for the ICU was assigned other patients on the Med-Surg floor - not readily available for ICU patient care on 7/09/2021, 7/10/2021, 7/12/2021 (nights), 7/13/2021, and 7/14/2021.

There were no reports for staffing variances.

The facility's Plan of Correction for the 11/23/2020 complaint survey reflected a deficiency for having no staffing matrix for all areas of the hospital. The submitted plan required an acuity checklist, primary nurse reassessment of patient acuity every 12 hours, total unit acuity to be used to assign staff each shift, Quality/Medical Executive/Governing Board approvals, as well as Nurse Staff education for the Nurse Staffing Plan, Acuity Checklist, and Staffing Matrix from December 14th through December 31st.

The 12/09/2020 reviewed and updated Nurse Staffing Plan required, "implementation of a Nurse staffing plan based upon measurable patient intensity criteria input from the nursing team members. The CNO/CCO (Chief Nursing/Clinical Officer) of each facility is responsible for safely staffing...With an adequate number of nurses and licensed vocational nurses, certified nursing assistants, telemetry monitor technicians, and support staff to provide a safe patient care to all patients...Adequate staffing is maintained on a shift by shift basis by adjusting the number of and mix of personnel to meet identified needs and acuity of the patient's.

Each hospital utilizes and acuity checklist to assess and evaluate the needs of each individual patient every 12 hours and as needed according to a change in a patient's condition...Each patient's acuity level is total to identify the unit acuity level. The unit acuity level is then applied to a staffing matrix to identify the time the number of staff needed to provide safe quality care for the night shift...The nurse to patient staff ratio in the ICU/HOU ( High Observation Unit) is 1:3/4 and on the medical units is 1:5/7. All ratios are determined pending on the acuity of the patients.

In addition, certified nurse assistants (CNA or techs) are assigned to assist with an average of 8 to 12 patients. The nurse staffing shall also be sufficient to ensure prompt recognition that any change in the patient's condition and to facilitate a patient care plan providing necessary intervention by the nursing, clinical or medical staff...The acuity checklist and total unit acuity drives nurse staffing."

The undated ICU Staff Matrix required 2 nurses and 1 CNA/tech for 4 patients on either shift; 9 patients required 3 nurses and 2 CNA/techs.

There was no Med-Surg Staff Matrix to determine the types and numbers of nursing personnel and staff.

There was no Acuity Checklist to determine the complexity of the patient's care needs.

The 2021 Quality Dashboard reflected January through June (57.58%/ 65.91%/ 68.18%/ 58.82%/ 64.10%/ 66.67% respectively) tracking for Responsiveness of Hospital Staff was much less than the goal of 90%.

There was no documented Plan of Action to improve Responsiveness of the Hospital Staff.

During an interview during the tour on 7/14/2021 ending at 12:00 PM, Patient #2 stated there are long wait times on help. He stated they come down to see what I need and say they will be back. He stated then you wait 30 minutes or more. They are working on my tube and it has been an hour today.

During an interview during the tour on 7/14/2021 ending at 12:10 PM, Patient #3 stated he has to wait and is told they are short staffed. He stated he understands. He stated he had been here 2 weeks this time, but had been here before. He stated the care was the same - not worse, not better either time.

During an interview during the tour on 7/14/2021 ending at 12:40 PM, Patient #4 stated sometimes he had to wait to be feed and food is cold.

During an interview on 7/14/2021 ending at 15:55 PM, Personnel #2 reviewed the Quality Data and the staffing assignment sheets. Personnel #2 confirmed the short staffing variances during the past 2 weeks. Personnel #2 stated we try every effort to replace call ins, even offering bonus money for shifts. Personnel #2 stated they make more money not working with COVID money.

During a telephone interview on 7/15/2021 ending at 10:25 AM, Personnel #7 stated it was felt staffing was unsafe.

During a telephone interview on 7/15/2021 at 6:57 PM, Personnel #14 stated it was felt staffing was unsafe.

~ During an interview on 7/14/2021 ending at 16:15 PM, Personnel #2 was asked about the previous survey, plan of correction submitted, and lack of implementation. Personnel #2 stated that was before him.

During an interview on 7/14/2021 ending at 16:45 PM, Personnel #6 stated she wrote the 11/23/2020 plan of correction. Personnel #6 was asked why it was not implemented and maintained. Personnel #6 stated they had leadership turnover since then.