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Based on policy review, medical record review, and interview, in one of nine medical records reviewed, the registered nurse failed to provide care to meet patient needs (Patient #1)

Reference:
§485.635(d): Nursing services must meet the needs of the patients.

Based on policy review, document review, medical record review, and interview, in three of nine medical records reviewed, there was insufficient staffing to provide essential nursing services on 10/10/24. Specifically, there was only one nurse assigned to care for two patients in the intensive/progressive care unit and one patient in the locked correctional unit, located across the hallway from the intensive/progressive care unit. No other staff were assigned to and/or assisted the nurse in caring for the two critical care unit patients and the one correctional unit patient (Patient #1, #2, and #3.)

Findings Include:

Review of the policy "Nursing Staffing, Scheduling and Patient Assignment Plan," last revised 06/11/24, revealed all staffing ratios/numbers are at the discretion of nurse leadership based on patient needs/acuity and volume. Staffing ratios from 07:00 AM to 07:00 PM: one registered nurse to two intensive care unit only patients; one registered nurse to two to three progressive care unit patients; and one registered nurse to three correction services unit patients. Staffing ratios from 07:00 PM to 07:00 AM: one registered nurse to two intensive care unit patients; one registered nurse to two to three progressive care unit patients; and one registered nurse to three correction services unit patients.

Review on 10/23/24 of the "Clinical Staffing Plan," dated 09/16/24, revealed the plan is posted in the intensive/progressive care unit and requires a staffing ratio of one registered nurse for two intensive care level patients, one registered nurse for two to three progressive care level patients, and one registered nurse for three correctional services unit patients (separate unit located across the hallway). The policy does not indicate whether a registered nurse can be alone on the unit with one to three patients.

Review on 10/23/24 of the "Staffing Schedule," dated 10/10/24, revealed three registered nurses were scheduled for the 07:00 AM to 07:00 PM shift. One registered nurse was re-assigned to the medical/surgical unit, and another took a personal day off. This left one registered nurse (Staff U), assigned to the intensive/progressive care unit alone.

Review on 10/23/24 of the "Patient Census," dated 10/10/24 at 06:45 AM, revealed Patient #1 was the only patient in the correctional unit. At 11:00 AM, Patient #2 was admitted to the intensive/progressive care unit. At 01:15 PM, Patient #3 was admitted to the intensive/progressive care unit.



Review on 10/23/24 of the "Hospital Staffing Complaint," revealed a complaint about the intensive/progressive care unit was submitted by Staff (U), Registered Nurse. On 10/10/24, Staff (U) was assigned three patients (two patients in the intensive/progressive care unit, one patient in the correctional unit located across the hall) with no other staff on the unit and/or to assist with care. Staff (U) had to provide medications and meals to Patient #1. One of the intensive/progressive care unit patients was in alcohol withdrawal (a person stops drinking, symptoms range in severity and can be life threatening). "It was scary, up moving about touching things and not following directions." The other intensive/progressive care unit patient had chronic obstructive pulmonary disease (lung disease that block air flow and makes it difficult to breath), was incontinent requiring care, and used the call bell frequently.

Review on 10/23/24 of the medical record for Patient #1 revealed the following:
-On 10/08/24 at 09:10 PM, Patient #1 presented to the emergency department with two correction officers via wheelchair for increased shortness of breath, coughing, and an oral temperature of 100.5 degrees Fahrenheit. At 11:03 PM, Staff (FF), Physician Assistant ordered Patient #1 to be placed in the locked correctional unit.
-On 10/10/24 at 10:30 AM, Patient #1 was to be discharged back to the correctional facility. At 04:59 PM, Staff (U), Registered Nurse documented Xarelto (blood thinner) and Vantin (antibiotic) were administered to Patient #1. At 07:55 PM, Patient #1 was discharged to the correctional facility.

Review on 10/23/24 of the medical record for Patient #2 revealed the following:
-On 10/10/24 at 10:56 AM, Staff (Y) Physician, ordered Patient #2 to be admitted (to the intensive/progressive care unit) for alcohol abuse in withdrawal. At 11:00 AM, Staff (U), Registered Nurse, documented Patient #2 was received from the mental health unit, awake, alert, chatty, manic behavior, anxious, but cooperative. Patient #2 denied any hallucinations, but would burst out in giggles, stating "just laughing at myself." From 11:15 AM to 05:10 PM, Staff (U) Registered Nurse documented that Patient #2's withdrawal symptoms fluctuated and required medication administration: Ativan one milligram by mouth at 01:50 PM, 04:02 PM, and 05:15 PM; Atarax (medication to treat anxiety) 25 milligrams by mouth was administered at 05:15 PM; and one piece of nicotine gum was administered at 04:22 PM and 06:43 PM. From 01:45 PM to 06:30 PM, Patient #2 wandered around the unit, was disoriented not making sense, and asked repetitive questions.
-On 10/13/24 at 09:53 AM, Patient #2 was discharged to the mental health unit.

Review on 10/23/24 of the medical record for Patient #3 revealed the following:
-On 10/10/24 at 10:49 AM, Staff (Y) Physician, ordered Patient #3 to be admitted (to the intensive/progressive care unit) for respiratory failure requiring bipap (a noninvasive breathing machine that delivers pressurized air to help people breathe).
-On 10/10/24 at 01:15 PM, Staff (U) Registered Nurse, documented Patient #3 received via gurney from the emergency department with labored breathing. Patient #3 was unkempt, had body/urine odor present, and refused to remove their home clothing several times. At 02:00 PM, oxygen levels were the 80% range (between 95%- 100%). Patient #3 was encouraged to leave the pulse oximetry (device that measures the amount of oxygen in your blood) device on, after removing it several times. At 02:06 PM, Staff (U), Registered Nurse, administered Methylprednisolone (steroid medication) 40 milligrams via intravenous catheter. At 02:30 PM, Patient #3 stood to void, and continued to refuse to change into a hospital gown. At 02:50 PM, Patient #3 had an increase in difficulty breathing with activity. At 03:35 PM, Staff (Y) was called to Patient #3's room to put Patient #3 on bipap. The respiratory therapy team was notified of request. At 04:11 PM, Staff (U), Registered Nurse, administered Lasix (diuretic medication) 40 milligrams via intravenous catheter. At 05:30 PM, Patient #3 voided and agreed to change out of their soiled clothing into disposable underwear.
-On 10/11/24 at 01:45 PM, Patient #3 was transferred to the medical surgical unit.

Interview on 10/23/24 at 10:30 AM with Staff (U), Registered Nurse, revealed they have worked in the intensive/progressive care unit where one staff member is alone with patients in either in the intensive/progressive care unit and/or in the correctional services unit (located across the hallway from the intensive/progressive care unit). On 10/10/24, Staff (U) arrived at the intensive/progressive care unit and were assigned to care for Patient #1 who was in the correctional unit (across the hallway in a locked unit). There were originally three nurses scheduled for the intensive/progressive care unit, but one nurse took a personal day, and the other nurse was floated to the medical/surgical floor. During the shift, Staff (U) admitted two patients to the intensive/progressive care unit, making their assignment three patients. Staff (U) notified Staff (Q), Chief Nursing Officer, who directed them to notify the nursing supervisor if they needed help. Patient #2 was psychotic and manic, and oral medications were not working. As the only nurse on the intensive/progressive care unit, Staff (U) was unable to give intravenous medications due to the inability to waste medications in a timely manner. Patient #2 continued to pace the unit, touching equipment, and needed constant supervision for safety. At approximately 02:00 PM, Patient #3 was admitted for respiratory distress. Patient #3 was unkempt, resistant to care, and needed additional nursing care to assist in getting cleaned up (incontinence care). Staff (U) gave dietary trays and medications for Patient #1 (located across the hallway in the correctional unit) to a corrections officer to administer so that Staff (U) could maintained visualization of the two intensive/progressive care unit patients that took precedence over Patient #1.

Based on policy review, medical record review, and interview, in one of nine medical records reviewed, the registered nurse failed to provide care to meet patient needs. Specifically, the registered nurse pulled two medications from the intensive/progressive care unit pyxis, met a correctional officer at the door, and gave the medications to the correctional officer to administer to the correctional unit patient located in the unit across the hall. (Patient #1)

Findings include:

Review of policy "Correctional Service Unit Guidelines," last revised 07/10/24, revealed "a correction officer must be in the room (direct visual view) at all times when hospital staff is providing care of an inmate. Oral medications to be dispensed to patient per 'Medication-Administration of Oral Medications' policy.

Review of policy "Medications - Administration of Oral Medications, " last revised 03/31/18, revealed for capsules/tablets/pills: empty medication from the unit dose packet into souffle cup. Scan the barcode on the patient's identification band ensuring that it matches the (electronic medication administration record) prior to scanning medications. Once medication is scanned, it will be automatically charted to the electronic medication administration record.

Review on 10/23/24 of the medical record for Patient #1 revealed on 10/10/24 at 10:30 AM, Patient #1 was to be discharged back to the correctional facility. At 04:59 PM, Staff (U), Registered Nurse documented Xarelto (blood thinner) and Vantin (antibiotic) were administered to Patient #1. At 07:55 PM, Patient #1 was discharged to the correctional facility.

Interview on 10/23/24 at 10:30 AM with Staff (U), Registered Nurse revealed on 10/10/24, they gave Patient #1's dietary trays and medication a corrections officer to give to Patient #1 so that they could maintain visualization of Patient #2 and #3 in the intensive/progressive care unit.

Based on policy review, document review, medical record review, and interview, in three of nine medical records reviewed, there was insufficient staffing to provide essential nursing services on 10/10/24 (Patient #1, #2, and #3).

Reference:
§485.631(a)(3): The staff is sufficient to provide the services essential to the operation of the critical access hospital.