EMBARGOED until 11/2/17 at 11 AM

Unable to Provide
Safe Patient Care

The Consequences of Short

Staffing at Tenet DMC Huron
ValleySinai Hospital

November 2, 2017

Professional Nurses Association of Huron Valley-Sinai Hospital

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UnabletoProvideSafePatientCare
TheConsequencesofShortStaffingat
TenetDMCHuronValleySinaiHospital
ExecutiveSummary
AsHuronValleySinaiHospital(HVSH)haschangedfromastandalonenonprofitcommunityhospitalto
justoneunitofagiantforprofithealthcarechain,workersandpatientshavefelttheimpactof
corporatecostcuttingpolicies.Withanincreasedfocusongeneratingrevenues,manynursingand
supportstaffpositionsarenotpostedandgounfilled,creatingtremendouspressureonHVSHworkers
todomorewithless.NursesatHuronValleySinaiHospitalareinactivecontractnegotiationswith
managementtryingtoaddresstheworkingconditionsandstaffingconcernsreflectedinthisreport.

Thispatientcarereportisasummaryofover240AssignmentDespiteObjection(ADO)formsfilledout
byPNAHVSHnursesbetweenJanuary1,2017andSeptember1,2017nearlyoneunsafeincident
everyday.Asaresultofcutbacks,numerousunsafesituationswerereported,including:

1. PatientfallsinMedical/SurgicalandIntensiveCareUnits
2. Latemedications
3. Failuretodeliverbasichygieneandhumancare
4. Patientsleftunattendedduringcriticalsituations
5. Over150instancesofnursesgoingwithoutbreaksorlunchesduringshiftsthatlastas
longas12hours,despitetheimpactonpatientcare
6. Nursesassignedwithoutpropertraining;Managementcondoningorignoringunsafe
practices;Equipmentfailure
IntheirAssignmentDespiteObjections(ADO)forms,nurseshavereported:

Beingunabletoprovidesafepatientcarebecauseofinadequatestaff
Medicationswereterriblylate
Medicationsweregivenlate,IVsranlateordry
[P]atientssittinginurineandfecesmaynotgetabathforseveraldays
NursesweresenttoassistinICUwithoutintensivecaretraining
NursesoftheProfessionalNursesAssociationofHuronValleySinaiHospital(PNAHVSH)have
repeatedlyattemptedtonotifyhospitalmanagementoftheseissuesinwriting,butmanagementhas
consistentlyrefusedtoacceptthisinformationaboutproblemswithpatientcarefromnurses.Sincethe
hospitalcannotsolveaproblemitrefusestoacknowledge,theProfessionalNursesAssociationofHuron
ValleySinaiHospital(PNAHVSH)ismakingthisdataavailabletothepublicandsubmittingittothe
MichiganDepartmentofLicensingandRegulatoryAffairsforreview.

NursesatHVSHvotedtoformtheirunionin2016inordertoimprovetheirworkingconditions.Theyare
currentlynegotiatingtheirfirstcontract.Securingsafeandeffectivenursetopatientstaffinglevelsis
theirhighestbargainingpriority.TheProfessionalNursesAssociationofHuronValleySinaiHospital
welcomescommunitysupporttoachievetheirgoals.

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Introduction
HuronValleySinaiHospital(HVSH),a158bedfacilityinCommerceTownshipnorthofDetroit,was
foundedasanonprofithospitalin1986.In1997,HVSHwasacquiredbytheDetroitMedicalCenter,a
groupofseveralhospitalsthatalsooperatedasanonprofitorganization.

In2010,DMCwaspurchasedfor$1.5billionbyVanguardHealthSystems,aforprofithealthcare
companybasedinTennessee.Shortlyafterward,Vanguardwaspurchasedfor$1.8billionbyTenet
HealthcareCorporation,aforprofitDallasbasedmultinationalcompanywith130,000employeesand
over$19billioninannualrevenues.

Theimpactofcostcuttingonpatientsandnurses:AsHVSHhaschangedfromastandalonenonprofit
communityhospitaltojustoneunitofagianthealthcarechain,workersandpatientshavefeltthe
impactofcorporatecostcuttingpolicies.Withanincreasedfocusongeneratingrevenues,manynursing
andsupportstaffpositionshavenotbeenpostedandoftengounfilled,creatingtremendouspressure
onHVSHworkerstodomorewithless.

Nursesstandupforqualitypatientcare:Regardlessofhospitalownership,policies,orcostpressures,
nurseshaveaprofessionalresponsibilitytodeliverpropercaretopatientsatalltimes.Inresponseto
concernsaboutpatientcare,HVSHnurseshavedocumentedunsafeconditionsbypreparingAssignment
DespiteObjection(ADO)forms.ADOformsareusedtodocumentshortstaffing,lackoftraining,
improperequipmentorotherconditionsthatmayhaveanadverseimpactonpatients.

Thispatientcarereportisasummaryofover240AssignmentDespiteObjection(ADO)formsfilledout
byHVSHnursesbetweenJanuary1,2017andSeptember1,2017nearlyoneunsafeincidentevery
day.TenetandDMCexecutivesatHuronValleyhaveconsistentlyrefusedtoaccepttheseformsfrom
nurses.

SinceTenetandDMCexecutivescannotsolveaproblemtheywillnotacknowledge,theProfessional
NursesAssociationofHVSHispresentingitsfindingstothepublicandtotheMichiganDepartment
LicensingandRegulatoryAffairs.

NursesatHVSHvotedtoformtheirunioninApril2016andarecurrentlynegotiatingafirstcontract.
Safestaffinglevelstoensurethehigheststandardofcareforpatientsisatopbargainingpriorityfor
HuronValleySinaiHospitalnurses.

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TheProblem:
UnsafeStaffingatTenetDMCHuronValleySinaiHospital

NursesatHuronValleySinaiHospitalinCommerceTownship,afacilityownedbyTenet,havereported
unsafeconditionsonover240ADOformsbetweenJanuary2017andSeptember2017nearlyone
unsafeincidenteveryday.Numerousunsafesituationswerereported,including:
1. PatientfallsinMedical/SurgicalandIntensiveCareUnits
2. Latemedications
3. Failuretodeliverbasichygieneandhumancare
4. Patientsleftunattendedduringcriticalsituations
5. Over150instancesofnursesgoingwithoutbreaksorlunchesduringshiftsthatmaylastas
longas12hours
6. Nursesassignedwithoutpropertraining;Managementcondoningorignoringunsafe
practices;andequipmentfailure
CutbacksinnursingandsupportstaffhaveforcedHuronValleySinaiHospitalnursestoworkshortas
aroutinematter.Workingshortisdefinedasnothavingenoughnursesineachunittosafelycarefor
patients.Thisisbasedonthehospitalsownstaffingguidelinesandtheclinicaljudgmentofprofessional
nurseswhoencountertheseunsafecircumstances.
BelowareissuesrelatedtopatientcareatTenetDMCHuronValleySinaiHospital,asdocumentedbynursesat
thefacility:

1.PATIENTFALLSINMEDICAL/SURGICALANDINTENSIVECAREUNITS

NurseshavedocumentedfourinstancesofpatientfallsatHuronValleySinaiHospitalduringanine
monthperiod,includingtwointhesameunitonthesameday.(ADO2,19,20)
OnJune18,2017,aMedical/Surgicalnursereportedthatshewasunabletoprovide
adequatecareduetoanunstablepatientandincontinentpatients.Onepatientfalltook
placeonthenightshift,andanotheronthedayshift.

OnMarch9,2017,aMedical/Surgicalnursereportedthatshewasunabletoprovidesafe
patientcareasaresultofinadequatestaff.ApatientfalloccurredresultinginSTATXrays.

OnFebruary20,2017,anICU/CriticalCarenursereportedthatthecensuswassixpatients
fortwonurses(noAideorTech).Mostpatientswereunstable,resultinginapatientfall
requiringSTATXrays.

TheU.S.CodeofFederalRegulations,Part482.23states,Thenursingservicemusthaveadequate
numbersoflicensedregisterednursesandotherpersonneltoprovidenursingcaretoallpatientsas
needed.1
2.LATEMEDICATIONS
Duetoshortstaffing,nursesatHVSHareunabletofollowordersbyphysicianstodelivermedications
immediately,orSTAT.Instead,medicationshavebeengivenlateandpainmedicationshavebeen
givenasmuchasonehourafterrequested.(ADO4,16,21)

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OnJune16,2017,anEmergencyDepartmentnursereportedthatatonetimethecensuswas
7patientswith2nurses.Asaresult,STATmedicationswereterriblylate.

OnApril30,2017,anurseontheMed/Surgunitreportedthatstaffingforthenight
negativelyaffectedpatientcare.Asaresult,medicationsweregivenlate,IVsranlateordry,
andthenursesreceivednobreakina12hourshift.
Latemedicationisnotjustaninconveniencetopatients.Medicinesdeliveredlatecancauseor
prolongaseriousillnessorbelifethreatening,dependingonapatientscondition.
3. FAILURETOPROVIDEBASICHUMANECAREANDHYGIENE
ShortstaffinghascompromisedtheabilityofnursesatHuronValleySinaiHospitaltoprovidebasic
carefortheirpatients.Thisincludesfailuretodeliverpainmedicationontime,patientsleftsittingin
theirownurineandfeces,andlabworknotbeingcompletedinatimelymanner.(ADO12,22)
OnAugust3,2017,aMedical/Surgicalnursereportedthatsimplecarewasnotbeingdone
becauseofshortstaffing.
OnJune26,2017,aMedical/Surgicalnursereportedduetoshortstaffingsomepatients
hadtowaituptoonehourforpainmeds.
[B]athesarentgettingdoneontime,patientssittinginurineandfecesmaynotgetabath
forseveraldays.
AnICU/CriticalCarenursereportedthatbecausetherewasnosupportstaff,medications
weregivenlate,labswerenotdone,andpatientswerenotturnedorcleanedup.Thenurses
alsoreceivednobreakina12hourshift.
4. PATIENTSBEINGLEFTUNATTENDEDORINADEQUATELYTENDEDTODURINGCRITICALSITUATIONS(ADO14,15)
Duetochronicshortstaffing,nursesatHuronValleySinaiHospitalreportinstancesinwhichpatients
arenotreceivingpropercareorinsomecasesareleftunattendedwithnocareatall.
OnSeptember9,2017,anurseintheCardiacTelemetryunitreported,Unsafestaffing!No
onetorecoverpatientincathlab.
OnJanuary25,2017,anurseinIntensiveCarereportedthatshewasaloneontheunitwith
2ICUpatientsandnootherstaff.
AccordingtoastudypublishedintheNewEnglandJournalofMedicine,apatientsriskofdeath
increases2percenteachtimethepatientwasexposedtoshiftswithlowRNstaffing.Thatsamestudy
goesontosaythatahighnursingworkloadlimitsanursesabilitytokeepaclosewatchovertheir
patients,whichincreasestheriskofadverseevents.2
5. OVER150INSTANCESOFNURSESGOINGWITHOUTBREAKS,LUNCHESDURINGSHIFTSTHAYMAY
LASTASLONGAS12HOURS(ADO1)
Becausetheyarecommittedtoprovidingthebestpossiblepatientcaredespiteongoingstaffshortages,nurses
atTenetDMCHuronValleySinaiHospitalfrequentlyworkwithoutanylunchorrestbreaks,duringshiftsthat
maylastaslongas12hours.
OnJanuary19,2017,theProgressiveCare(2WEST)unitwasshortstaffed.Asupervisorcameto
help,butdidnotansweranypatientcalllightsandwasoccupiedwithsupervisorydutiesinthe

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hospital.Asaconsequence,thenursesdidnotreceiveabreakandtheabovesupervisortoldthem
toeatatthedeskforlunch.

Whileeatingatonesdeskmaybeacommonpracticeinsomeworkplaces,itisasignificanthealthrisk
inahospitalsetting,duetopossibleexposuretobacteria,pathogensandotherpotentialhazards.The
US. Occupational Safety and Health Administration (OSHA) standard on bloodborne pathogens
(Standards29CFR1910.1030(d)(2)(ix)).states:Eating,drinkingareprohibitedinworkareaswhere
thereisreasonablelikelihoodofoccupationalexposure3
Inaddition,longworkhourswithoutadequatebreaksarealsoaknownhazardforhealthcare
workersandpatientsundertheircare.TheJointCommission,whichaccreditsmorethan21,000
hospitalsandhealthcareorganizationsintheUnitedStates,hasnotedthewelldocumentedlink
betweenhealthcareworkerfatigueandadverseevents.4
6. NURSESASSIGNEDWITHOUTPROPERTRAINING;MANAGEMENTCONDONINGORIGNORING
UNSAFEPRACTICES;EQUIPMENTFAILURE
Failuretoprovideadequatelytrainedandexperiencedstafftounits(ADO9a,9b,9c,11)
OnJanuary18,2017anursewaspulledfromherunittotheICU/Telemetryunitwithout
orientationortrainingintelemetryprotocols.

OnJanuary18,2017,anurseintheICUreportedthattwonursesweresenttoICUtohelp
buthadneverbeentrainedtoworkthere.

AccordingtotheAmericanNursesAssociation,Floatingisanotherstaffingpracticethatisofconcern
toregisterednursesandcanaffecttheacceptanceofapatientassignment.Floatingisusedby
institutionstomeettheirobligationstoensurethatallpatientcareareasareadequatelystaffed.
Unitstemporarilyoverstaffedeitherduetolowpatientcensusoralowerpatientacuitymayassign
nursingstafftounitslesswellstaffed.Acceptingsuchanassignmentcanplacethenurseinjeopardy
ofcaringforpatientsforwhichthenurseisnotadequatelyprepared.5

Equipmentfailureresultinginshortstaffing:(ADO3)
OnJanuary19,2017,thepneumatictubesystemwasinoperable.Thenursesonthe
Medical/Surgicalunitwereforcedtowalkdowntothepharmacytogetmedications,and
downtothelabtodeliverspecimensdelaysthatinterferewithdeliveringtimelycareto
patients.

TheInstituteofMedicineCommitteeonAdequacyofNurseStaffinginHospitalsstates
Anunsafepracticesituationcanarisefrominappropriatestaffingorstaffingmixes,improper
policiesandprocedures,oralackofsuppliesorequipment.6
Managementcondoningorignoringunsafepractices:(ADO11,17,18,23)

OnJanuary11,2017,apatientundergoingalcoholwithdrawalontheIntermediateCare
Unitbegantodeteriorate.WhenthenurseaskedifthepatientcouldbesenttotheICU,she
wastold,Its11pm.Iwillhavetopaytimeandahalf.Consequently,thepatientremained
onthefloorandrestraintswereappliedinstead.

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OnApril6,2017,thePACU(PostAnesthesiaCareUnit)wasshortstaffed.Anursenotified
thesupervisorofthisat6pm,anddidnothearbackfromthesupervisoruntil1pmthenext
day.

OnMay3,2017,anurseontheMedical/SurgicalUnitnotedthattheunitwasshortstaffed.
Shenotifiedtheinterimmanager,whotoldher:[Nurses]havetositinpatientroomsand
chart.Whenthisdidnotresolvetheissue,shenotifiedthesupervisorat9:10pm.The
supervisordidnotresponduntil4:45thenextmorning.

The2016AmericanNursesAssociationCodeofEthicsstatesinProvision3.5that,Whennurses
becomeawareofinappropriateofquestionablepractice,theconcernmustbeexpressedtothe
personinvolved,focusingontheintegrityofnursingpractice.Whenpracticesinthehealthcare
deliverysystemororganizationthreatenthewelfareofthepatient,nursesshouldexpresstheir
concerntotheresponsiblemanageroradministratoror,inindicated,toanappropriatehigher
authoritywithintheinstitutionoragencyortoanappropriateexternalauthority.

Provision6ofthesamedocumentgoesontosaythatNurseexecutiveshaveaparticular
responsibilitytoassurethatemployeesaretreatedfairlyandjustly,andthatnursesareinvolvedin
decisionsrelatedtotheirpracticeandworkingconditions.Unsafeorinappropriateactivitiesor
practicesmustnotbecondonedorallowedtopersist.Organizationalchangesaredifficulttoachieve
andrequirepersistent,oftencollectiveeffortsovertime.Participationincollectiveandinter
professionaleffortsforworkplaceadvocacytoaddressconditionsofemploymentisappropriate
(ANA).7

CONCLUSION
ItisclearfromtheAssignmentDespiteObjection(ADO)reportssubmittedbetweenJanuary1,2017and
September1,2017thatHuronValleySinaiHospitalhasseriousissuesincludingRNunderstaffing
whichaffectpatientsafety.TenetDMCHuronValleySinaiHospitalhasfailedtoaddresspersistent
problemsinternally.WeurgetheStateofMichigantoinvestigatethesereportsandtakeprompt
remedialaction.WealsourgetheHospitaltoengageingoodfaithnegotiationswiththenursesto
securesafeandenforceablestaffinglevelsintheirlaboragreement.

Note:Numberedendnotesappearbeginningonthefollowingpage.EndnotesbeginningwithADOxxx
refertoselectionsfromAssignmentDespiteObjections(ADO)formssubmittedbyHVSHnurses.These
formsareappendedtothisreportfollowingendnotesandreferences.

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References

1. U.S.DepartmentofHealthandHumanServices,CentersforMedicareandMedicaidServices.Public
HealthServices,ChapterIV.ConditionsforParticipation.Retrievedfrom
https://www.gpo.gov/fdsys/granule/CFR2011title42vol5/CFR2011title42vol5sec48223

2. Needleman,Jack,etal.NurseStaffingandInpatientHospitalMortality.NewEnglandJournalof
Medicine,vol.364,no.11,2011,pp.10371045.Retrievedfrom
http://mechroom.technion.ac.il/serveng/Lectures/nurse_staffing.pdf

3. InterpretationletterfromRichardE.Fairfax,Director,DirectorateofEnforcementPrograms,OSHAtoBarbara
Caporusso,RN(May17,2006)availableat
https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS&p_id=25506.

4. TheJointCommission,48SentinelEventAlert(2011)availableat
https://www.jointcommission.org/assets/1/18/SEA_48.pdf.

5. AmericanNursesAssociation.PatientSafety:RightsofRegisteredNursesWhenConsideringaPatient
Assignment(2009).Retrievedfromhttp://nursingworld.org/rnrightsps.

6. InstituteofMedicine(IOM),KeepingPatientsSafe:TransformingtheWorkEnvironmentofNurses
Washington:NationalAcademiesPress(2004)2,availableat
https://www.nap.edu/read/10851/chapter/1.

7. AmericanNursesAssociation.CodeofEthicsforNurseswithInterpretiveStatements(2015).Pg.24
SilverSpring,MD.Retrievedfromhttp://nursingworld.org/DocumentVault/Ethics1/CodeofEthicsfor
Nurses.html

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ADOAppendix
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MINURSES
Association . - .
. ...
Michigan Nurses Association Assignment Despite Objedion (ADO) Form /

Name(s) of Registered Nurse(s) objecting (please print):

IM/._e objecting to my/our assignment based on the following: (check all that apply)
18-1-Jnadequate nurse to patient ratios for patient acuity based on my/our clinical judgment
harge nurse responsibilities may/did not allow time for direct patient care assignments
-_
he
ew patient(s) were transferred/admitted/discharged without adequate staff to care for them t2.\$ \)e
unit is/was not staffed with an adequate number of support staff (examples: PCAs, techs, lift teams, 1-to-1 patient sitte)
-t-v 6 ,to+a.__{/0/ v-
0 Patient(s) who require a higher level of care are placed inappropriately on the unit

I
0 EMR documentation systems override RN judgment and interfere with direct patient care responsibility or do not function properly
- ufficient or faulty equipment or supplies (including lack of appropriate patient treatment areasr1Jb sy&-+U'Vl otw.)Y\
O RN(s) not oriented to or experienced in the area they were assigned or floated to
0 Other (please explain): _______- ___________________________
I

Name of RN who delivered form to manager:

- - anager's response when receiving Assignment Despite Objection form: ------,---------------

. f

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