nurse-staffing-audits-and-complaints

8/7/2019 nurse-staffing-audits-and-complaints

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Nurse Staffing Ron Prinslow, RN, BS

Manager Health Care Licensing and Certification

[email protected]

971-673-0546





Nurse Staffing Audits and Complaints

5 Audits (not less than 7% annually)

Current selection process: Large and small hospitals

Union and non-union

Currently limited to hospitals without a

previous audit

Complaint Investigations as received



Nurse Staffing Complaints 2004 - 5 complaints, 2 substantiated

2005 - 1 complaint, not substantiated 2006 - 2 complaints, both substantiated

2007 - 4 complaints, 1 substantiated

Only 1 Civil penalty for $2500.



Current Survey Process Two person onsite survey

Includes review of documents and staff

interviews. Survey is focused on the performance of the

Nurse Staffing Committee and the WrittenStaffing plan.

Witness testimony in writing seek out equalrepresentation-management and direct carestaff



Nursing Services Staffing Nursing Services Staffing 333-510-0045 (1)

The hospital must be responsible for the

implementation of a written hospital-widestaffing plan for nursing services. The

staffing plan shall be developed, monitored,

evaluated and modified by a hospital staffing

plan committee.



Survey Guide 0045(1) Review of the hospital wide Written

Staffing Plan for nursing services (copy)

Review individual staffing plans for patientcare units (copy)

Question direct care staff as to whether theyhad input into the staffing plan

Review meeting minutes and confirmdiscussion of staffing issues (copy 2meeting notes)

Question clinical staff as to whether they are

satisfied with the staffing process



Survey Guide 0045(1) Review and confirm that the staffing plan

for each patient unit included the number

and categories of staff needed (copy)

Review job descriptions for each unit to

determine whether each job description

sets forth the required qualifications

(copy)

Review a sample of personnel files - include

individuals from each unit



Survey Guide 0045(1) Review quality assurance

documentation (copy if allowed)

Review any performance indicators for

staffing effectiveness



Nurse Staffing Committee 333-510-0045(1)(a) The committee shall

include equal numbers of hospital nurse

managers and direct care nurses; (1)(b) The committee shall include at least

one direct care registered nurse from eachhospital nurse specialty or unit. The hospital

shall define its own specialties or units; (1)(c) Have as its primary consideration the

provision of safe patient care and anadequate nurse staff pursuant to this section.



Survey Guide 0045 (1)(a) Review the makeup of the hospital

staffing plan committee (copy)

Interview clinical staff regarding their

input into the committee

ommittee shall include equal

numbers of hospital nurse managers

and direct care RNs (copy)



Nurse Staffing Committee 333-510-0045(2) The written staffing

plan shall be evaluated and monitored

for effectiveness and the staffing plan

shall be revised as necessary as part of

the hospital¶s quality assurance

process. Written documentation of these quality assurance activities shall

be maintained.



Survey Guide 0045(2) Review quality assurance

documentation for evidence that the

staffing plan has been evaluated,

monitored, and revised as necessary.

(Copy)



Nurse Staffing 333-510-0045(3)(a)The written staffing

plan shall be based on an accurate

description of individual and aggregatepatient needs and requirements for nursing care and include a periodicquality evaluation process to determine

whether the staffing plan isappropriately and accurately reflectingpatient care needs over time.



Survey Guide (3)(a) Is the written staffing plan based on

individual and aggregate patient needs

and requirements for nursing care?

Has there been periodic quality

evaluation to determine whether the

staffing plan is appropriate?



Nurse Staffing Plan 333-510-0045(3)(b) The written staffing

plan shall be based on specialized

qualifications and competencies of the

nursing staff. The skill mix and the

competency of the staff shall ensure

that the nursing care needs of thepatient are met and shall ensure patient

safety.



Survey Guide 0045(3)(b) Do job descriptions identify specialized

qualifications and competencies required by

nursing staff in the various patient care units? Do personnel files contain documentation of

required licensure and certification for nursing

staff in various patient care units?

Review requirements of individual unit

staffing plans.



Survey Guide 0045(3)(b) Does the hospital have in place systems

to ensure orientation and competencies

of the nursing staff?



Nurse Staffing 333-510-0045 (3)(c) The written staffing

plan shall be consistent with nationally

recognized evidence-based standards

and guidelines established by

professional nursing specialty

organizations and recognize differencesin patient acuteness.



Survey Guide 0045(3)© Review individual unit staffing plans

and staffing schedules. (copy)

Interview administrative, supervisoryand clinical staff regarding thestandards considered in developing thewritten staffing plan.

Were the staffing plans consistent withthe identified standards?



Nurse Staffing 333-510-0045(3)(d) The hospital shall

maintain and post a list of qualified on-call

nursing staff that may be called to providequalified replacement or additional staff in the

event of emergencies, sickness, vacations,

vacancies and other absences... the provides

a sufficient number of replacement staff for the hospital on a regular basis.



Survey Guide 0045(3)(d) What are the resources used by the

hospital? (copy)

What is the system for obtainingreplacement staff?

Who is responsible for obtaining

replacement staff? Does the system meet the needs of the

hospital?



Nurse Staffing 333-510-0045 (4) The written staffing plan for

nursing services shall establish minimum

numbers of nursing staff personnel includinglicensed nurses and certified nursingassistants on specified shifts. The number of nursing staff personnel on duty shall besufficient to assure that the nursing careneeds of each patient are met. In no caseshall fewer than one registered nurse andone other nursing care staff member be onduty in a unit when a patient is present.



Survey Guide 0045(4) Do the individual unit staffing plans

identify the minimum number of nursing

staff required on all shifts?

Review written documentation including

daily staffing schedules, daily house

supervisor reports that identified unitpatient census and staffing, and

individual payroll records.



Nurse Staffing 333-510-045 (5) The written staffing

plan shall include a formal process for

evaluating and initiating limitations onadmission or diversion of patients toanother acute care facility when, in thejudgment of the direct care registered

nurse, there is an inability to meetpatient care needs or a risk of harm toexisting and new patients.



Survey Guide 0045(5) Review process for evaluating and

initiating limitations on admission or

diversion (copy)

Does process include the judgment of

the direct care registered nurse?



Nurse Staffing 333-510-0045 (7)(a) An employer may not

impose upon unionized nursing staff any

changes in wages, hours or other terms andconditions of employment pursuant to astaffing plan developed or modified under subsection (3) of this rule unless theemployer first provides notice to and, onrequest, bargains with the union as anexclusive collective bargaining representativeof the nursing staff in the bargaining unit.



Nurse Staffing 333-510-0045 (7)(b)

(b) A staffing plan developed or

modified under subsection (3) of this

rule does not create, preempt or modify

a collective bargaining agreement or

require a union or employer to bargainover the staffing plan while a collective

bargaining agreement is in effect.



Surveyor Guide 0045(7)(a)(b) This rule is between the hospital and

the Union no survey activity.





Nurse Staffing 333-510-0045 (8) Upon request of a

hospital, the Department of Human

Services may grant variances in thewritten staffing plan requirements based

on patient care needs or the nursing

practices of the hospital. Such requestfor a variance shall follow the procedure

set forth in OAR 333-515-0060.



Survey Guide 0045(8) Does the facility have a nurse staffing

waiver?



333-510-0045 (9) When a hospital learns

about the need for replacement staff, the

hospital shall make every reasonable effort toobtain registered nurses, licensed practical

nurses or certified nursing assistants for

unfilled hours or shifts before requiring a

registered nurse, licensed practical nurse, or certified nursing assistant to work overtime.



Survey Guide 0045(9) Were efforts to seek replacement staff

documented?

Review staffing documentation for

two one-week periods: Select each

week from a different quarter. (if

complaint select dates identified incomplaint intake or interviews)



Survey Guide 0045(9) Review documentation for each unit¶s staffing

plan and scope of care, each unit¶s staffing

schedule, daily ³staffing needs´ forms, dailyhouse supervisor shift reports that identifypatient census, unit activity, and staffing oneach unit, and payroll records for all staff oneach unit to identify planned versus actual

staff worked.

Interview administrative staff to determinewho is responsible for filling unexpected staff vacancies that arise on individual shifts.



Survey Guide 0045(9) Interview direct-care staff (Utilize

witness forms)

Does the hospital have a written

policy that defines the

responsibilities to document all

efforts and results of all efforts toadd or replace staff for identified

staffing needs? (copy)



Survey Guide 0045(9) Reasonable effort includes the hospital

seeking replacement at the time the

vacancy is known and contacting allavailable resources as described in

(3)(d) of this rule. Such efforts shall be

documented.



Nurse Staffing 333-510-0045(10) A hospital may not require

a registered nurse, licensed practical nurse,

or certified nursing assistant to work: (a) Beyond the agreed-upon shift;

(b) More than 48 hours in any hospital-defined work week; or

(c) More than 12 consecutive hours in a 24-hour period, except that a hospital mayrequire an additional hour of work beyond the12 hours if:



Nurse Staffing 0045(10) (A) A staff vacancy for the next shift

becomes known at the end of the

current shift; or

(B) There is a potential harm to an

assigned patient if the registered nurse,

licensed practical nurse or certifiednursing assistant leaves the assignment

or transfers care to another.



Survey Guide 0045(10) Review payroll records for all staff on

all units for the time periods

referenced (if complaint limit tospecific dates)



Nurse Staffing 333-510-0045 (11)(a) Time spent in required

meetings or receiving education or training

shall be included as hours worked for purposes of subsection (9) of this rule.

(b) Time spent on call but away from the

premises of the employer may not be

included as hours worked for purposes of subsection (9) of this rule.



Nurse Staffing (c) Time spent on call or on standby

when the registered nurse, licensed

practical nurse or certified nursingassistant is required to be at the

premises of the employer shall be

included as hours worked for purposesof subsection (9) of this rule.



Survey Guide 0045(11)(a) Does the on call policy meet these

requirements



Nurse Staffing 333-510-0045 (12) The provisions of this rule

do not apply to nursing staff needs:

(a) In the event of a national or stateemergency or circumstances requiring theimplementation of a facility disaster plan;

(b) In emergency circumstances. Emergency

circumstances include, but are not limited to: (A) Sudden unforeseen adverse weather

conditions;



Nurse Staffing 0045(12) (B) Infectious disease epidemic of staff; and

(C) Any unforeseen event preventing

replacement staff from approaching or entering the premises; or

(c) If a hospital has made reasonable efforts

to contact all of the on-call nursing staff or

staffing agencies on the list described in

(3)(d) of this rule and is unable to obtain

replacement staff in a timely manner.



Survey Guide 0045(12) -Does the hospital¶s written staffing plan

reflect these exceptions?



Nurse Staffing 333-510-0045 (13) A registered nurse at a

hospital may not place a patient at risk of

harm by leaving a patient care assignmentduring an agreed upon shift or an agreed-

upon extended shift without authorization

from the appropriate supervisory personnel

as required by the Oregon State Board of Nursing Oregon Administrative Rules 851-

045-0015(1)(j) and (5).



Survey Guide 0045(13) -Does the hospital¶s written staffing plan

acknowledge this responsibility?



Nurse Staffing 333-510-0045 (14) A hospital may not

take retaliatory action against a nursing

staff because the nursing staff person:



Nurse Staffing 0045(14) (a) Discloses or intends to disclose to a

manager, a private accreditation organization,

or a public body an activity, policy, or practiceof the hospital or of a hospital that the nursingstaff reasonably believes is in violation of lawor a rule or is a violation of professionalstandards of practice that the nursing staff

person reasonably believes poses a risk tothe health, safety, or welfare of a patient or the public.



Nurse Staffing 0045(14) (b) Provides information to or testifies before

a private accreditation organization or a

public body conducting an investigation,hearing or inquiry into an alleged violation or law or rule or into an activity, policy or practice that may be in violation of professional standards of practice by a

hospital that the nursing staff reasonablybelieves poses a risk to the health, safety or welfare of a patient or the public;



Nurse Staffing 0045(14) (c) Objects to or refuses to participate in any

activity, policy or practice of a hospital that

the nursing staff reasonably believes is inviolation of law or rule or is a violation of professional standards of practice that thenursing staff reasonably believes poses a riskto the health, safety or welfare of a patient or

the public; or (d) Participates in a committee or peer review

process or files a report or a complaint thatdiscusses allegations of unsafe, dangerous or

potentially dangerous care.



Survey Guide 0045(14) Interview administrative staff and clinical

staff to determine awareness of this

restriction (who did youinterview)(attach interview sheets)



Nurse Staffing 333-510-0045 (15) A hospital shall post

a notice summarizing the provisions of

ORS 441.162, 441.166, 441.168,441.174, 441.176, 441.178, and441.192, in a conspicuous place on thepremises of the hospital. The notice

must be posted where notices toemployees and applicants for employment are customarily displayed.



Survey Guide 0045(15) Has the hospital posted the required

notice? Where posted?



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