Observations
Based on the 07/10/19 on-site incident investigation it was determined that
the facility failed to have staff in sufficient numbers to insure safe operation of the facility.
On 07/06/19 at the time of the sentinel event involving client #1, there were 72 consumers on the unit. The facility had seven staff onsite at the time of the event. Two of those staff were conducting intakes, and one staff was observing a client that required a 1:1 staffing status. Six consumers were identified as requiring checks every fifteen minutes, including client #1 . One staff was expected to conduct the 15-minute checks for those six individuals, plus do the hourly rounding for the remaining consumers.
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Plan of Correction
Proper Staffing Policy No. 8000.024 has been revised by the VP of Substance Abuse Services. The policy now has a section to allow for adjustments to staffing based on acuity and activity level. All managers and supervisors have been trained to the expectation that a review of staffing assignments is completed each time a frequency of supervision (FOS) is ordered. If at anytime four or more FOS orders are active, additional staffing will be assigned to monitor patients.
Training: Leadership including, Executive Director, Clinical Director, Director of Nursing, Nurse Manager, and Supervisors have been made aware of the revisions to the staffing policy.
Understanding of the policy is acknowledged through written attestation and included in the employee's HR file
Monitor: A live review of staffing assignments is completed each time a frequency of supervision (FOS) is ordered. If at anytime four or more FOS orders are active, additional staffing will be assigned to monitor patients.
Each shift the supervisor is responsible for reviewing the acuity and staffing for the upcoming shift to ensure the facility is appropriately staffed.
Additionally, in the daily Flash Meeting, the patients on FOS and the overall facility acuity are discussed.
Weekly, a review of staffing will occur to ensure it was appropriate to the acuity. The facility will track times when additional staffing was required to meet the acuity needs.
If at anytime it is discovered the facility did not meet these staffing requirements, the Executive Director will review the circumstances with the appropriate supervisor and provide education and/or progressive discipline.
The staffing policy will be reviewed with all supervisors responsible for staffing in department meetings at least bi-annually.
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