Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 010001	(X3) Date Survey Completed 08/24/2017
Name of Provider or Supplier Southeast Health Medical Center	Street Address, City, State 1108 Ross Clark Circle, Dothan, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag

Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)

A0392

STAFFING AND DELIVERY OF CARE
CFR(s): 482.23(b)

The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

This STANDARD is not met as evidenced by:
Based on review of facility policies, Unit Profile reports and interviews, it was determined the facility failed to ensure 2 North and 3 North were staffed according to their budgeted target hours, which increased the patient work load for licensed, unlicensed and clerical staff caring for those patients. This had the potential to negatively affect all patients admitted to the facility. Findings include: Facility Policy: Staffing and Scheduling Guidelines Effective Date: 1/11/2006 Purpose: ... it is essential to provide skilled staff at budgeted levels on all shifts to care for our patients. The following delineates a proactive staffing process utilizing OptiLink software (Scheduling and Workload) to allocate nursing resources based on the constantly changing volume and severity levels of our patients. Procedure: Applicability I. These guidelines are applicable to all Patient Care Services personnel involved in: A. Planning staffing prior to the start of a shift. B. Reallocation of staffing during the shift. C. Monitoring staffing levels to the approved budget. II. This includes the: A. Vice President of Patient Care Services/ Chief Nursing Officer and Associate Chief Nursing Officer. B. Nursing Coordinators, Directors and Charge Nurses who are responsible for planning staffing levels based on patient needs. C. Nursing Resources staff that handles the day-to-day input of staff specific into the OptiLink software. The procedure for ensuing that appropriate staffing by skill level is in place for a shift requires advanced planning. Having appropriate staffing levels requires the balancing of the time off needs of staff with the knowledge of expected census and acuity for each unit. I. Scheduling of Staff Prior to Publishing Schedules: ... Each Director is responsible for completing the schedule(s) for his/her assigned unit(s) and ensuring that it is appropriately "balanced" based on the type of unit and patient population... Staffing Oversight:Actual staffing to budgeted levels by unit will determine how closely and how well each unit is balancing staff to patient needs. It is the responsibility of the individual Director to manage the staffing on his/her unit(s). There are a number of tools/reports available in OptiLink to assist the Director in achieving this goal. ****** Facility Policy: Position Control Plan Effective Date: 1/1/1980 Policy: The Position Control Plan is based on scientific principles and an organized nursing process that shall be used to establish staffing levels for each nursing unit based on past trends and projections of future changes in patient load. Purpose:To establish staffing allocation for each nursing unit based on an average daily census, acuity of patients, care hours per day, skill mix, and standards of care that provide safe care for our patients. To provide a computation of required full time equivalents (FTE's) by employee type and shift. Procedure: The Position Control Plan is a delineation of the professional and no-professional division, shift division, FTE composite, average occupancy, bed capacity, and fiscal year of each designated unit. In order to derive the Position Control Plan for each designated nursing unit, the Master Staffing Pattern for said unit shall be adhered to in its entirety. FTEs may not be added nor may the average occupancy be changed unless approval has been granted by the Vice President/Patient Care Services to change the Master Staffing Pattern... Review of the Unit Profile reports for 2 North revealed the following: 5/30/17: Patient census: 21 Day Shift: Targeted hours for Licensed staff: 24.0 hours Actual staffed hours: 16.05 hours Hours Variance: -7.95 hours Staff: Patient Ratio, Targeted: 1:6.67 (1 Licensed staff member to 6.67 patients) Staff: Patient Ratio, Actual: 1:9.97 (1 Licensed staff member to 9.97 patients) Evening Shift: Targeted hours for Licensed staff: 24.0 hours Actual staffed hours: 16.60 hours Hours Variance: -7.10 hours Staff: Patient Ratio, Targeted: 1:6.67 (1 Licensed staff member to 6.67 patients) Staff: Patient Ratio, Actual: 1:9.64 (1 Licensed staff member to 9.64 patients) 6/8/17: Patient census: 23 Day Shift: Targeted hours for Licensed staff: 24.0 hours Actual staffed hours: 16.05 hours Hours Variance: -7.95 hours Staff: Patient Ratio, Targeted: 1:6.33 (1 Licensed staff member to 6.33 patients) Staff: Patient Ratio, Actual: 1:9.47 (1 Licensed staff member to 9.47 patients) Evening Shift: Targeted hours for Licensed staff: 24.0 hours Actual staffed hours: 16.05 hours Hours Variance: -7.95 hours Staff: Patient Ratio, Targeted: 1:7.67 (1 Licensed staff member to 7.67 patients) Staff: Patient Ratio, Actual: 1:11.46 (1 Licensed staff member to 11.46 patients) 6/9/17: Patient census: 23 Evening Shift: Targeted hours for Licensed staff: 24.0 hours Actual staffed hours: 16.05 hours Hours Variance: -7.95 hours Staff: Patient Ratio, Targeted: 1:7.67 (1 Licensed staff member to 6.67 patients) Staff: Patient Ratio, Actual: 1:11.46 (1 Licensed staff member to 11.46 patients) The actual licensed staff members present to care for patients on 2 North for 5/30/17, 6/8/17 and 6/9/17 were below the budgeted expectations for the unit for those dates. Review of the Unit Profile reports for 3 North revealed the following: 6/8/17: Patient census: 22 Day Shift Targeted hours for Licensed staff: 24.0 hours Actual staffed hours: 15.95 hours Hours Variance: -8.05 hours Staff: Patient Ratio, Targeted: 1:7 (1 Licensed staff member to 7 patients) Staff: Patient Ratio, Actual: 1:10.53 (1 Licensed staff member to 10.53 patients) Targeted hours for unlicensed staff: 24.0 hours Actual staffed hours: 23.95 hours Hours Variance: -.05 hours Staff: Patient Ratio, Targeted: 1:7 (1 unlicensed staff member to 7 patients) Staff: Patient Ratio, Actual: 1:7.01 (1 unlicensed staff member to 7.01 patients) Targeted hours for Clerical: 8.0 hours Actual staffed hours: 7.60 hours Hours Variance: -.40 hours Staff: Patient Ratio, Targeted: 1:21 (1 clerical staff member to 21 patients) Staff: Patient Ratio, Actual: 1:22.11 (1 clerical staff member to 22.11 patients) 6/9/17 Patient census: 23 Day Shift: Targeted hours for Licensed staff: 24.0 hours Actual staffed hours: 21.75 hours Hours Variance: -2.25 hours Staff: Patient Ratio, Targeted: 1:7.33 (1 Licensed staff member to 7.33 patients) Staff: Patient Ratio, Actual: 1:8.09 (1 Licensed staff member to 8.09 patients) The actual licensed, unlicensed and clerical staff members present to care for patients on 3 North for 6/8/17 and the licensed staff members present to care for patients 6/9/17 were below the budgeted expectations for the unit for those dates. An interview was conducted on 8/24/17 at 10:45 AM with Employee Identifier # 2, Interim Director Behavioral Health verified the above.