HospitalInspections.org

Based on document review, observation and interview, nursing administration failed to provide adequate staffing for 4 of 4 days on units 100, 200, 300 and 400.

Findings Include:
1. Facility staffing grid indicated from 7:00 am - 11:30 pm with a patient census of 9-12 there was to be 1 RN (Registered Nurse) & 2 BHAs (Behavior Health Aide), a patient census of 13-16 there was to be 2 RNs with 2 BHAs.

2. Staffing Pattern Worksheet review indicated units 100, 200, 300 and 400 were understaffed per the facility's staffing grid. Unit numbers, dates, amount, type of staff member(s) lacked and patient census are indicated as follows:
a. 11/18/23
i. Unit 200 short 1 BHA from 7:00 am - 3:30 pm with a patient census (PC) of 13.
ii. Unit 300 short 1 BHA from 7:00 am - 11:30 pm with a PC of 11
b. 11/19/23
i. Unit 100 short 1 BHA from 7:00 am - 11:30 pm with a PC of 14.
ii. Unit 200 short 1 RN from 7:00 am - 7:30 pm with a PC of 13.
iii. Unit 300 short 1 BHA from 7:00 am - 11:30 pm with a PC of 11.
iv. Unit 400 short 1 BHA from 7:00 am - 11:30 pm with a PC of 12
c. 11/20/23
i. Unit 100 short 1 BHA from 7:00 am - 3:30 pm with a PC of 16.
ii. Unit 200 short 1 BHA from 7:00 am - 3:30 pm with a PC of 14.
iii. Unit 400 short 2 BHAs from 7:00 am - 3:30 pm with a PC of 13
d. 11/21/23
i. Unit 100 short 1 RN from 7:00 am - 7:30 pm with a PC of 16.
ii. Unit 300 short 2 BHAs from 7:00 am - 3:30 pm with a PC of 13.
iii. Unit 400 short 1 RN from 7:00 am - 7:30 pm and short 1 BHA from 7:00 am-3:30 pm with a PC of 16.


3. During facility tour on 11/21/23 at 5:00 pm with A2 (Director of Nursing) it was observed the actual working staff did not match the indicated amount of staff members accounted for on the staffing pattern worksheet. Observations are as follows:
a. Unit 400 had a patient census of 15, 1 RN (N5) and 1 BHA (N6) were present providing care. A second RN (N4), whom was on his/her second day of facility orientation, was also present. LPN (N2) who was on light duty, does not take a patient assignment and was not on duty at the time of tour, was listed as the second nurse on the staffing pattern worksheet.
b. Unit 100 had a patient census of 16, 1 RN (N7) and 2 BHA's were present providing care. RN (N4) was listed as the second nurse on the staffing pattern worksheet was noted to be with N6 on Unit 400 for orientation.

4. In interview on 11/21/23 at approximately 5:10 pm with staff member A2 (Director Of Nursing) indicated N2 and N4 were counted in the staffing numbers that should not have been and were short staffed on the other days also.