HospitalInspections.org

Based on document review and interview, nursing administration failed to provide adequate staffing for 17 of 27 days reviewed on units 100 and 200.

Findings Include:

1. The facility policy titled, "Clinical Staff (Nurse) Staffing Plan", PolicyStat ID 12279065, last revised 08/2022, indicated under PROCEDURE: Staffing Plan: B. Core Staffing Matrix per unit: Inpatient Programs for Days (7 am-11 pm). One clinical staff member for every four (4) patients.

2. Nursing and/or Staffing Review: The Staffing Pattern Worksheets were reviewed for H1 units 100 & 200 for the dates 5/19/24 - 6/14/24 and indicated the facility was not appropriately staffed per facility policy as follows:
a. Unit 100:
5/19/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a patient census (PC) of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
5/23/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
5/25/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
5/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
5/31/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
6/1/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present.
6/2/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
6/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
6/4/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 2 clinical staff members were present.
6/5/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
6/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
6/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
6/10/24 short 2 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 2 clinical staff members were present.
6/13/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
6/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present.

b. Unit 200:
5/22/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
5/23/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
5/26/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
5/29/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 13. 4 clinical staff members needed but only 3 clinical staff members were present.
5/31/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
6/1/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 2 clinical staff members were present.
6/2/24 short 2 clinical staff members from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 2 clinical staff members were present.
6/3/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present.
6/4/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 15. 4 clinical staff members needed but only 3 clinical staff members were present.
6/8/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
6/9/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 16. 4 clinical staff members needed but only 3 clinical staff members were present.
6/14/24 short 1 clinical staff member from 7:00 am - 11:00 pm with a PC of 14. 4 clinical staff members needed but only 3 clinical staff members were present.

3. In interview on 6/14/24 at approximately 1:30 pm with staff member A3 (Director Of Nursing) confirmed units 100 and 200 were not adequately staffed per policy and should have been.

Based on documentation review and interview, facility nursing staff failed to document weekly weights and/or monitor fluid and food intake for 6 out of 14 medical records reviewed. (P1, P2, P3, P5, P7, and P13)

Findings include:

1. The facility policy titled, "Intake & Output Monitoring", PolicyStat ID 12386133, last revised 09/2022, indicated under Policy: Fluid and food intake is monitored for all patients.

2. The facility policy titled, "Vital Signs and Weight", PolicyStat ID 12386461, last revised 09/2022, indicated under Procedure: Weights will be taken a minimum of once per week, unless the provider orders a more frequent schedule. Record vital signs and weekly weights in the patient's medical record.

3. Review of P1's MR indicated Daily Nursing Assessment for dates 4/19/24, 4/28/24, 4/29/24, 4/30/24, 5/4/24, 5/5/24, 5/6/24, 5/8/24, 5/11/24, 5/12/24, 5/13/24, 5/16/24, 5/17/24, 5/18/24, 5/19/24, 5/23/24, 5/26/24, 5/31/24, 6/2/24, 6/3/24 lacked documentation that patient food or liquid intake was monitored per facility policy. MR documentation for P1 lacked documentation of weekly weights from 4/18/24-6/9/24.

4. Review of P2's MR indicated Daily Nursing Assessment for dates 6/2/24, 6/3/24, 6/6/24, 6/7/24, 6/8/24, and 6/9/24 lacked documentation that patient food or liquid intake was monitored per facility policy. MR documentation for P2 lacked documentation of a weekly weight on 6/7/24.

5. Review of P3's MR indicated Nursing Admission Assessment documentation dated 5/8/24 at 5:00 pm lacked a documented admission weight. MR for P3 lacked weekly weights for the patient's hospital duration
Daily Nursing Assessment for dates 5/19/24, 5/27/24 and 5/28/24 lacked documentation that P3's food or liquid intake was monitored per facility policy.

6. Review of P5's MR indicated Vital Signs & Weight Flow Sheet documentation lacked weekly weights from 4/19/24-4/27/24.

7. Review of P7's MR indicated a lack of documented weekly weights per policy from 2/17/24-3/01/24.

8. Review of P13's MR indicated Daily Nursing Assessments for 5/2/24, 5/3/24, 5/27/24, 5/28/24, 5/29/24, 6/1/24, 6/2/24, 6/3/24, 6/4/24, 6/10/24 and 6/11/24 lacked documentation of patient food or liquid intake was monitored per facility policy. P13's weekly weights were also ordered on 5/20/24 & 6/4/24 as a result of significant weight loss. The patients' weekly weights were not completed as ordered per policy.

9. In an interview on 5/16/24 at approximately 1:30 pm with A3 (Director of Nursing) confirmed weekly weights and intake monitoring on all patients are not being done per policy and should have been.