Nurses covering two units at once were counted towards staffing ratios for both

The Agency for Health Care Administration (AHCA) found that University Behavioral Health Center violated state rules for hospital nursing services by failing to comply with its own staffing policies.

When AHCA inspectors visited the ASAP and Solutions adolescent male units, they found that the two units did not meet the facility’s staffing ratio of one direct care staff person for every four patients (1:4). AHCA wrote:

The units share the same nurses’ station. The licensed practical nurse (LPN) on duty for the two units was interviewed. … The shift supervisor, who was present during the visit, stated that the nurse covered both units as the nurse and was also in the ratio for direct care. However, she was observed at the nurses’ station and not actually supervising the patients.

Another two units, Stars and Promises, were observed to have a similar staffing deficiency, with one nurse being counted towards the staffing ratio for two units simultaneously. The next day, the ASAP unit was again observed to be under the required staffing ratio. At one point, the only nurse covering both the ASAP and Solutions units left for a period of 45 minutes to attend treatment team.

In an interview, the director of nursing “indicated that since the nurses were in the milieu, they were included in the ratio, although there [sic] were not assigned to direct care as were the MHTs. She stated that ‘we are probably not in compliance with our policy.'”

In order to correct this deficiency University Behavioral Health was required to submit a plan of correction.