Reporting a facility for staff ratio issues?

[ICUEDMursenary]

I've exhausted my google resources.

I work at a facility that has been ignoring staffing ratios for the last few months in all the units. Us nurses have been getting ran through a meat grinder the entire time. We've been missing meals and breaks (we work in CA with a union) and now management is threatening punishment for missing meals and breaks when we're out of ratio. The Director of Nursing said "nothing can go wrong in 30 minutes" and encouraged us ICU nurses to go to lunch despite leaving a charge nurse with 3-5 ICU patients. The other night when I had a 1:1 patient, they sent me a 2nd patient regardless of my objection and my 1:1 pulled their central line out. Crisis was averted, but narrowly.

Anyway, sorry for all of the ancillary information. I'm wondering if any CA nurses specifically have any experience with reporting an employer for this behavior (to the state?). Reporting a facility to the CA Dept. of Health entails including patient information rather than it being related to a staffing ratio problem.

The final straw came when a member of management brought up "time management" problems on the end of staff nurses due to recent overtime and missed meals/breaks. They're actually blaming the staff nurses for time management problems when we're out of ratio or have an encumbered charge with no one to relieve us. Any insight would be appreciated. I'm at my wits end

[herring_RN, ASN, BSN]

I'm sorry this is happening to you.

At the start of each shift that is not safe document in writing exactly what the situation is and give a copy to your manager or shift supervisor. If your union provides an "Assignment Despite Objection" (ADO) or "Disclaimer" use that and keep a copy. If you don't have a form use paper. Write, "In our professional judgment this assignment is unsafe because the facility failed to provide sufficient staff. As a result the facility is responsible for any adverse effects on patient care.

Write details on the one given to management.

It is not a HIPAA violation to provide information to hospital management or to a regulatory agency.

Write an exact quote of what you were told and the name of the manager or supervisor. The date, time, location, number of nurses, number of patients, and room numbers of patients should be written on the form or paper.

If something happens remember the name of the patient and the room number. Don't write it anywhere and don't look at the chart when you are not assigned to that patient.

That form can be used in court or a disciplinary hearing. It is best for all nurses on the shift to sign it, but do it alone if they won't.

It can save your license, your job, and protect you in the event of a malpractice lawsuit.

I'll type the text of a flyer on reporting to the state:

Quote

HOW TO COMPLAIN TO THE DEPARTMENT OF PUBLIC HEALTH

INTRODUCTION:

The Department of Public Health (Licensing and Certification Division) is the agency that determines the compliance of health facilities with state and federal laws, rules, and regulations. To accomplish this goal, the Department conducts periodic inspections of health care facilities and is empowered to take remedial action. Such remedial action may involve suspension of licensure, curtailment of public funding, and other enforcement actions. More frequently, the Department will cite the facility for a violation and request an acceptable plan of correction.

Reports on the result of each inspection of a hospital along with the plan of action and hospital comments are kept on file in the department. All inspection records, lists of deficiencies, and plans of correction are open to public inspection.

THE COMPLAINT:

1. Anyone can file a complaint: RN, patient, family member, others.

2. Avoid anonymous complaints. The whistle blower protection laws in long term and acute facilities provide protection against retaliation. Speak to your labor rep first about the problem. Go through the PPC or other facility-based structure. These avenues are often effective in resolving patient safety problems.

3. File the written complaint with the local DPH field office & notify CNA.

A. The DHS evaluator will be best able to investigate the complaint if provided the following:

• Name and address of the facility.
• Date, time, and location (unit or room number). Name(s) or medical record # of patient(s) involved. Names of involved staff.
• Staffing assignment sheets if available.
• Description of incident with quote from Title 22 (include number of section).
• Desired remedy IE Nurse staffing must meet or exceed established ratios at all times.
• Ask for implementation not just improved documentation.

4. The Department will conduct a complaint investigation.

5. The person signing the complaint will be contacted prior to the investigation of the complaint and also will be informed of the Departments findings upon conclusion of the investigation.

Find your local district office and mail your complaint there:

District Offices

This section of hospital licensing law outlines the responsibilities of an RN. It makes it clear that every patient must be assigned to a registered nurse:

§ 70215. Planning and Implementing Patient Care.

The ICU ratio since 1976 is here:

§ 70495. Intensive Care Service Staff.

The "new" section with competency, orientation, and staffing requirements:

§ 70217. Nursing Service Staff.

Feel free to send a PM and I'll try to help.

[morte, LPN, LVN]

find out what law firm represents the hospital in liability issues, have the union start with them. Of course, it should have been reported the first time that it happened..... I know, easier said than done.

[herring_RN, ASN, BSN]

If ordered to go to lunch I would ask, "Who will take over my patient(s) while I'm at lunch?"

If there is no one I would say, "I would if I could, but I cannot abandon my patient.'

If ordered to i would ask with other staff to witness, "Are you ordering me to leave my patients without an assigned nurse?"

Sometimes they then understand that they are ordering you to violate the Nursing Practice Act and the law.

Here is an examples of a hospital fined after a patient was harmed due to ratio violations:

Palomar Medical Center (PDF)

555 E. Valley Parkway, Escondino, CA 820211, San Diego County - The hospital failed to ensure the health and safety of a patient when it did not follow its patient care policies and procedures. This is the first administrative penalty issued to this hospital. The penalty is assessed at $50,000.

The statement of Deficiency is in the column on the left. The right side has the required Plan of Correction.

Generally unless a patient is harmed there is no fine. The hospital must provide an acceptable Plan of Correction.

[herring_RN, ASN, BSN]

morte said:

Find out what law firm represents the hospital in liability issues, have the union start with them. Of course, it should have been reported the first time that it happened..... I know, easier said than done.

I remember being told that an orthopedic unit was horribly under staffed. one of the nursing assistants filled out an incident report because the nurses could not administer pain medication in a timely manner. She sent the hospital attorney an incident report, a copy of the staffing sheet showing nurses assigned up to 12 patients when the ratio at the time was five or fewer patients per nurse, and a written description of how it distressed her to see patients suffer.

The next shift the attorney and upper management were on the unit. That is a great idea, that I'd forgotten about.

[roser13, ASN, RN]

Forgive my ignorance because I've never worked with union protections, but isn't this what your Union is there for?

Why aren't these conditions being monitored by or at least reported to your Union representative?

[morte, LPN, LVN]

roser13 said:

Forgive my ignorance because I've never worked with union protections, but isn't this what your Union is there for?

Why aren't these conditions being monitored by or at least reported to your Union representative?

Ordinarily yes, but this is Cali, where ratios are written in the law. The union shouldn't need to enforce that.... but of course that would be some pressure to bring to bear.

[nightbreak]

This is a terrible and unacceptable situation.

herring_RN has given you the best advice regarding ADOs and filing complaints with the state. Some nurses have a difficult time "making waves", but it is our responsibility as patient advocates to speak-up for safety. If your management is not responding by providing additional staff, then they have given you no recourse but to ask the state to investigate. You should specifically mention the incident of your patient pulling out the CL. Kudos to you for caring!

Side Note/Soap Box: In California, barring an ongoing emergency/disaster situation, no nurse should ever accept a patient or assignment that violates the patient safety ratios. Just say no. And keep saying no. And mention Title 22. And refuse to take report.

[herring_RN, ASN, BSN]

Yes. Give the date and other information to the state.

I'm not sure it is a good idea to refuse the assignment unless there is a plan with all your colleagues.

I heard in a class about a group of nurses who sat in the break room refusing to take report until sufficient staff was provided. They had already planned so the previous shift nurses continued caring for patients.

When handing the ADO to management you have put them on notice that if there is a fall, late medication administration, or failure to rescue it is their responsibility. you then do the best you can under the circumstances because if you leave it will be worse.

BUT don't stop there.

Nurses at this hospital testified before the city council:

RNs at Watsonville Community Hospital to Testify at City Council on Unsafe Patient Care Conditions | National Nurses United

[firstinfamily, RN]

Is there an admission criteria or nurse/pt ratio listed in your nursing requirements/job descriptions? If so, then the facility can be held liable for this---do a little digging, maybe see what they advertise on line etc.

[ICUEDMursenary]

firstinfamily said:

Is there an admission criteria or nurse/pt ratio listed in your nursing requirements/job descriptions? If so, then the facility can be held liable for this---do a little digging, maybe see what they advertise on line etc.

If I recall correctly, there is.

Thanks for all the information. I have been filing ADO's every shift for the last 3 months. Only 2 shifts of the last 3 months have we been staffed where our charge nurse has no patients and can provide relief for breaks/meals -- and both of those times it has been our supervisor in charge.

Last shift, I called another critical care unit who had an unencumbered charge (miracle) and they came and relieved 2 of us for lunch, the other 3 were out of luck.

I'll bring this up and the next union meeting and see what we can do. At this point most of my ADO's say what supervisor I informed, what they said and when they said it. It's always "Informed ___ @ this time, they stated 'no units have unencumbered charge, no break relief available.'"

One problem is one of the ICU's has had a mass exodus every couple months for the past year. So, if we have an unencumbered charge, they float one of us down there to "put them in ratio" (they call it "in ratio," but charge nurse is still encumbered and no break relief nurses) and then we have an encumbered charge and no break relief, too. Management keeps pushing that we all take our meals and breaks anyway, so basically they understaff by 2 RN's and have no financial repercussions.

to add icing to the cake, our DON said "Oh for heaven's sake, nothing can happen in the 30 minutes you're at lunch."

My pancakes are flipping...

roser13 said:

Forgive my ignorance because I've never worked with union protections, but isn't this what your Union is there for?

Why aren't these conditions being monitored by or at least reported to your Union representative?

Theoretically. But they also are the ones that negotiated a contract that doesn't allow for work stoppages and the CNA's are all gone at this hospital for the last 2 years.

[BentHalo]

Try working a shift in a SNF.

40 elderly Residents with Dementia with Sundowning and/or other health issues.

The Staffing Ratio on Days/Eves is 2 Nurses and 3 CNAs (last night it was 2 Nurses and 2CNAs after 7pm),on the overnight shift it's ONE Nurse,1(maybe 2)CNA for 40 Residents. We are also being threatened with punishment for not taking our breaks, Time Management.