HospitalInspections.org

Based on staff interview, facility policy and procedure, and medical record review the facility's organized nursing service failed to ensure appropriate nursing personnel to provide safe care for patients at this facility. This deficient practice can potentially affect all patients receiving treatment at this facility.

Findings include:

The facility's organized nursing service failed to determine appropriate staffing based on acuity and illness of patients. The number of staff directly correlates to patient census only. See A392

The facility's organized nursing service failed to ensure the competency level of staff based on the proper training and education to care for patients diagnosed with brain injuries. See A397

The facility staff failed to complete physician orders related to monitoring patient's medical condition and the staff (CNA's) failed to complete required documentation in patients medical record. See A467

The cumulative effects of these practices could potentially affect the health and safety of all patients receiving care at this facility.

Based on record review and policy and procedure (P&P) review the hospital failed to have complete physician orders for restraint use in 1 of 1 record reviewed with restraint use (pt. #6).

Findings include:

On 12-18-2012 at 3:00 PM a review of the P&P titled, Restraints was completed. The P&P stated in part, under Policy "D.Staff is educated regarding restraint use and associated risk. V. Physician Orders: B. The physician order must indicate, 2. Clinical justification for use and type of restraint"


On 12-18-2012 at 2:00 PM a review of pt. #6's record was completed. Documentation shows orders for restraint use dated 10-7-2012, 10-9-2012, 10-11-2012, 10-17-2012, and 10-24-2012. The documentation is signed by the physicians, however, the "Physician Order Section" is blank as well as the area for "no restraint device ordered," and "no medical reason."

This was confirmed with DON B at the time of discovery.

Based on 5 of 5 staff interview (B, C, D, E, and H) and review of staffing process and staff schedules the facility failed to determine appropriate staffing based on acuity and illness of patients. This deficient practice could possibly affect all patients; census on 12/17/12 was 33 patients; census on 12/18/12 was 31 patients.

Findings include:

Per review of Staffing Pattern grid on 12/17/12 at 2:00 PM, the form indicates: To include charge nurse on each shift as part of the numbers.
Census 16- Day 3 Licensed (LIC) +2 Personal Care Assistants (PCA), PM's 4 LIC + 2 PCA, Nights 2 LIC + 1 PCA.
Census 17- Day 4 LIC + 2 PCA, PM's 4 LIC + 2 PCA, Nights 2 LIC + 1 PCA.

Census 18- Day 4 LIC + 2 PCA, PM's 4 LIC + 2 PCA, Nights 2 LIC + 2 PCA.

Census 19- Day 4 LIC + 2 PCA, PM's 4 LIC + 2 PCA, Nights 3 LIC + 2 PCA.

Census 20- Day 4 LIC + 2.5 PCA, PM's 4 LIC + 2.5 PCA, Nights 3 LIC + 2 PCA.

Census 21- Day 4 LIC + 2.5 PCA, PM's 4 LIC + 2.5 PCA, Nights 3 LIC + 2 PCA.

Census 22- Day 5 LIC + 2.5 PCA, PM's 5 LIC + 2.5 PCA, Nights 3 LIC + 2 PCA.

Census 23- Day 5 LIC + 3 PCA, PM's 5 LIC + 3 PCA, Nights 3 LIC + 2 PCA.

Census 24- Day 5 LIC + 3 PCA, PM's 5 LIC + 3 PCA, Nights 4 LIC + 2 PCA.

Census continues to 40 patients.


26390

On 12-17-12 at 9:40 AM a interview with the Director of Nursing (DON) B was completed. DON B started with the hospital in July of 2012 and explained there is a grid that is followed by the supervisors to determine staffing for the nursing department. The grid is based on census and doesn't include patient acuity, staff experience or availability of other staff. DON B stated they will take into consideration if they have a CNA working as a 1:1 sitter.

On 12-17-12 at 10:30 AM an interview with RN supervisor (RNS) H was completed. RNS H stated it has been 3.5 years since starting at the hospital. In October of 2012 RNS H started in one of 3 new supervisor roles. No additional training was provided. RNS H knew staffing was part of the job. The schedule is reviewed for the next 24 hours and H has to "fill in the holes." "In the last 2 weeks holes have been filled." RNS H explained now they are allowed to use outside pool. RNS H explained when filling the schedule they are to only follow the grid and assign the number of staff per number of patients. RNS H stated it should be an acuity based system, not a numbers based system. RNS H stated there is a concern for patient and staff safety and did share this with the CEO but was "blown off."

On 12-17-12 at 10:55 AM a telephone interview was completed with RNS C. RNS C has been with the hospital for four years and in January of 2012 became a supervisor. RNS C completes the nursing schedule for 4 weeks in advance. RNS C explained it is all based on numbers. The grid is followed and no scheduling is done by acuity or staff experience - that is not allowed. RNS C stated concerns about patient safety due to staffing were shared with the CEO and DON and RNS C received no response. RNS C stated, "I know there is a budget, but I think we need to staff by acuity."

On 12/17/12 at 2:10 PM an interview with RNS D was completed. RNS D has been with the hospital for four years. RNS D started as a staff nurse and an occasional charge nurse. In October of 2012, D started in the supervisor role. RNS D stated a staffing grid is used which is solely based off of patient census. RNS D stated they are expected to work within the numbers allotted by the grid. RNS D stated by basing staffing off of numbers does cause concern with patient and staff safety along with staff burnout. RNS D stated that the patients admitted are more complicated and require more care.

On 12/17/12 at 2:30 PM an interview with Charge Registered Nurse (CRN) E was completed. CRN E has been with the hospital for four years. CRN E stated the staffing is based off a grid depending on numbers of patients. CRN E stated that at times acuity for the patients is high and it would be more helpful to base staffing off of the patients functional independence measure score. CRN E stated concerns about staffing have been shared with supervisors.

Based on staff interview, education records along with attendance records for specialized training for brain injury patients (BI) and daily staff assignments, the hospital staff failed to ensure 11 out of 78 ( K, L, M, N, O, P, Q, R, S, T and U) nursing personnel caring for traumatic brain injury patients have received proper training. This deficient practice could possibly affect all patients. Census on 12/17/12 was 33 patients and census on 12/18/12 was 31 patients.

Findings Include:

On 12/17/12 from 9:00 AM through 12:00 PM, DON B confirmed which staff attended yearly skills fair which covered behavior management and offered coaching strategies to de-escalate behaviors and interventions that can be used when dealing with BI patients. The facility employs 25 CNA's and 53 nurses.

DON B was able to identify the staff who had cared for BI patients in the past 30 days who had not received proper training. 6 out of the 25 CNA's and 5 of 53 nurses did not receive the mandatory training.

DON B confirmed that newly hired staff and agency staff are among some of the staff who have not received specialized training to effectively deal with BI patients.

The staff caring for BI patients in the past 30 days, according to staffing records, without specialized training included CNA K, CNA L, RN M, RN N, CNA O, Agency LPN P, Agency CNA Q, RN R, RN S, Agency CNA T, and CNA U.

CNA K provided care to a BI patient without proper training on the following shifts:
Night shifts:12/18/12, 12/15/12, 12/13/12, 12/10/12, 12/7/12, 12/2/12, 12/1/12, 11/30/12, 11/29/12, 11/24/12, 11/22/12, 11/20/12, and 11/18/12.
PM shifts- 12/14/12.

CNA L provided care to BI patients without proper training on the following shifts:
AM shift: 12/16/12, and 12/15/12.

RN M provided care to BI patients without proper training on the following shifts:
PM shift: 12/15/12, 12/14/12, and 12/6/12,
AM shift: 12/1/12, 11/30/12, and 11/27/12.

RN N provided care to BI patients without proper training on the following shifts:
AM shift: 12/15/12, 12/10/12, and 12/2/12.

CNA O provided care to BI patients without proper training on the following shifts:
Night shifts: 12/4/12, 12/12/12, 12/11/12, 12/9/12, 12/8/12, 12/7/12, and 12/5/12.

Agency LPN P provided care to BI patients without proper training on the following shifts:
PM shift: 12/14/12, and 12/8/12.
AM shift: 12/12/12.

Agency CNA Q provided care to BI patients without proper training on the following shifts:
PM shift: 12/9/12, 12/8/12, and 12/1/12.

RN R provided care to BI patients without proper training on the following shifts:
AM shift: 12/7/12.

RN R provided care to BI patients without proper training on the following shifts:
AM shift: 12/6/12 and 11/22/12.
PM shift: 12/3/12.

CNA U provided care to BI patients without proper training on the following shifts:
PM shift: 11/20/12 and 11/19/12.

Agency CNA T provided care to BI patients without proper training on the following shifts:
AM shift: 12/2/12

DON B stated that the facility is preparing to put together a training session for brain Injury patients in the future. A brain injury behavioral intervention lunch and learn was offered on 10/22/12, according to the attendance sheet only 3 RN's attended the session.

The above findings were confirmed with DON B at time of finding.

Based on record review, staff interview and facily policy and procedure review the facily staff failed to obtain a signed consent for a blood transfusion for 1 of 1 (pt. # 9) patient procedure. This deficient practice could effect all patients at this facility.

Findings include:

Per review of facility policy and procedure on 12/18/12 at 4:00 PM, entitled Blood Products Transfusion, reviewed 7/31/11 states under "II. Procedure K. Preparation of patient for Transfusion 1. It is the physicians responsibility to obtain informed consent: Consent Administration of blood products form should be filled out and signed."

Per record review of pt. #9 medical record on 12/18/12 at 2:50 PM, the consent form for a blood transfusion in the medical record was incomplete. The form contains blanks that require staff to complete with patient name, and doctors names which were left incomplete. The bottom of the form where patient signature is required, has an entry by an RN stating " Consent obtained by Doctor". No patient signature was obtained.

The above findings were confirmed with RNS C on 12/18/12 at 3:00 PM.

Per interview with DON B on 12/18/12 at 3:00 PM confirmed that signed consent for a blood transfusion needs to be obtained prior to the procedure.

Based on medical record review and staff interview the facility staff failed to complete physician orders related to monitoring 5 out of 10 patient's (pt. # 4, 10, 9, 2, 3 and 5) medical condition and the staff (CNA's) failed to complete required documentation in 2 out of 10 patients (#4 and 9) medical record. This deficient practice could possibly affect all patients being treated at his facility; census on 12/17/12 was 33 patients, census on 12/18/12 was 31 patients.

Findings include:

Per review of facility policy and procedure on 12/18/12 at 4:00 PM, entitled Abnormal Vital Signs, reviewed 3/27/12, states "I. Policy- The hospital monitors vital signs of temperature, blood pressure, pulse, respiration and pulse oximetry as ordered."

Per review of pt. # 4's Medical record (MR) review on 12/18/12 at 12:30 PM revealed an order for blood sugars to be monitored 4 times a day written on 12/12/12 at 10:45 AM. Order was not verified until 1:45 PM. 11:00 AM blood sugar on 12/12/12 was not completed. This information was verified with RNS C on 12/18/12 at 1:30 PM.

Per review of pt. # 9's MR review on 12/18/12 at 2:50 PM revealed an order for vital signs to be monitored 2 times a day written on 12/10/12 at 2:40 PM. Order was not verified until 12/11/12 at 5:00 AM. Vital signs on 12/14/12, PM shift was not completed. This information was verified with RNS C on 12/18/12 at 3:30 PM that physician orders had not been followed.

Per review of pt. # 10's MR review on 12/18/12 at 3:40 PM revealed an order for daily weight to be monitored written on 12/7/12 at 5:27 PM. Order was not verified until 12/8/12 at 1:40 AM. Daily weights on 12/15/12 and 12/16/12 were not completed. This information was verified with RNS C on 12/18/12 at 3:55 PM that physician orders had not been followed.

Per review of pt. # 10's MR review on 12/18/12 at 3:40 PM revealed an order for vital signs to be monitored 2 times a day written on 12/7/12 at 5:27 PM. Order was not verified until 12/8/12 at 1:40 AM. Vital signs on 12/17/12, PM shift was not completed. This information was verified with RNS C on 12/18/12 at 3:55 PM that physician orders had not been followed.

Per interview with RNS C on 12/18/12 at 1:30 AM, C stated that CNA's are required to document every shift on the CNA documentation worksheet which is kept in the MR as part of the permanent patient chart.

Per review of pt. #4's MR review on 12/18/12 at 12:30 PM revealed that on 12/17/12 PM shift, 12/15/12 PM shift, 12/15/12 night shift, and 12/14/12 night shift documentation was not completed by CNA staff. This information was verified with RNS C on 12/18/12 at 1:30 PM.

Per review of pt. #9's MR review on 12/18/12 at 2:50 PM revealed that on 12/12/12 night shift, documentation was not completed by CNA staff. This information was verified with RNS C on 12/18/12 at 3:30 PM.

A facility policy and procedure was requested regarding guidelines for CNA documentation requirements and RN assessment documentation requirements on 12/18/12 at 4:00 PM. The facility staff was not able to present a policy that speaks to completion of CNA shift documentation or RN assessment documentation.


26390

On 12/18/2012 at 1:00 PM a review of pt. #2's record was completed with RN Supervisor D. Pt. #2 was admitted on 12/7/2012 with orders for vital signs to be checked twice daily. The documentation shows on 12/14/2012 and 12/15/2012 vital signs were checked once. Weekly weights were ordered and pt. #2 had only been weighed once, on admission.

On 12/18/2012 at 11:05 AM a review of pt. #3's record was completed with RN Supervisor D. Pt. #3 was admitted 11/14/2012 and had an order for vital signs twice daily. Documentation shows on 11/17/2012, 11/23/2012 and 12/17/2012 vitals signs were completed once. Pt. #3 had an order to wear a C collar when not sleeping. Documentation from 12/8/2012 through 12/11/2012 was reviewed and showed no documentation of pt. #3 wearing a C collar on the day shift and PM shift of 12/10/2012 and 12/11/2012.

On 12/18/2012 at 1:37 PM a review of pt. #5's record was completed with RN Supervisor D. Pt. #5 was admitted on 12/13/2012. Wound care was ordered daily and no documentation of completed wound was found on 12/14/2012, 12/15/2012, 12/16/2012 and 12/17/2012.

The above findings were confirmed by RN Supervisor D at the time of discovery.