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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI was out of compliance.

A-0286: PATIENT SAFETY (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Based on interviews and document reviews, the facility failed to ensure a patient adverse event on the labor, delivery, recovery and postpartum (LDRP) unit was investigated, and analyzed to identify contributing factors and implement preventive actions to prevent recurrence.

Based on interviews and document reviews, the facility failed to ensure a patient adverse event on the labor, delivery, recovery and postpartum (LDRP) unit was investigated, and analyzed to identify contributing factors and implement preventive actions to prevent recurrence. (Cross-reference A-0392)

Findings include:

Facility policies:

The Adverse Clinical Event Reporting, Analysis, Disclosure, and Non-Payment policy requires a rapid response team for event investigations, initiated within 72 hours of event awareness and completed within 45 days. Employees are encouraged to report all events that might include or represent a threat to patient safety immediately or by the end of their shift to mitigate harm and evaluate for reportable criteria. The Patient Safety and Quality Department will assemble an internal multidisciplinary team with representatives from Quality, Patient Safety, Administration, and the department involved in the incident as soon as possible to stabilize the situation and determine the next steps including the need for a Root Cause Analysis or Critical Event Analysis. A Safety Event Review Team (SERT) team, made up of clinical and non-clinical associates, will review events to provide oversight and validate consistency in scoring, to identify potential system-wide vulnerabilities and safety improvement opportunities. The policy defined an adverse event as any variance in generally accepted performance standards (GAPS), normal or usual operations of the organization. Adverse patient events are untoward incidents, iatrogenic injuries (caused by a medical activity), or other adverse occurrences directly associated with care or services provided when a GAP has occurred within an entity.

The Clinical Quality Assurance, Patient Safety, and Process Improvement Plan FY2024 (QAPI) mandates oversight responsibilities for ensuring quality care.

National guidelines:

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), Standards for Professional Registered Nurse Staffing for Perinatal Units read, nurse staffing models that may be appropriate for medical-surgical units are not applicable to perinatal care.

Staffing plans for perinatal units should account for the presentations of patients seeking care that are considered observation, admissions, discharges, and "less than full day" patients such as those who present for OB triage. Hours per patient day" and/or "midnight census" models are not applicable in planning perinatal nurse staffing because they are not appropriately adjusted for risk and do not consider the dynamic nature of caring for patients during labor and birth; the frequent admissions and discharges assigned to one nurse on a shift that influences workload or the large volume of triage patients, OB emergency department (ED) patients, and outpatients who often present to the perinatal unit for care.

Safe, effective, high-quality nursing care requires adequate nurse staffing based on patient acuity and census. Childbirth and newborn care in the hospital setting deserve careful attention to appropriate nurse staffing based on individual patient characteristics and clinical situations to promote safe, high-quality nursing care and optimal patient outcomes. A nurse staffing plan, with evidence that its resources are adequate and that it is actively managed, is essential to patient safety. Adequate staffing is critical to providing safe, high-quality nursing care for all those who give birth and their babies. Healthcare leaders are responsible for ensuring adequate nurse staffing to promote the best outcomes for all women who give birth and their babies. Ultimate outcomes are best optimized by making sure childbearing women and their babies are provided with safe and appropriate nurse staffing to promote high-quality nursing care and the best possible outcomes.

According to Table 1 of the AWHONN Professional Registered Nurse Staffing for Perinatal Units guidelines, the Patient Type and or Clinical Situation Nurse-to-Woman or Nurse-to-Baby Ratios were two nurses at the time of birth; one nurse responsible for the mother and one nurse whose sole responsibility is the baby.

References:

The LDRP staffing plans, which were identified by staff as the facility's staffing grids, were provided by the facility. The staffing grids listed the name of each inpatient unit at the facility, specified the variable patient census range for each unit, and the specified number of RNs and the number of ancillary staff expected to be staffed and present on each unit according to the current patient census. The staffing grids specified the nurse-to-patient ratios according to the patient census and amount of nurses required.

1. The facility failed to investigate and identify causative factors related to an adverse event in the LDRP unit.

A. Document review

i. An adverse event occurred on 4/22/24 during the night shift on the LDRP unit. (Cross-reference A-0392)

a. A review of the adverse event log revealed an adverse event occurred on 4/22/24, however, the event was not reported until 4/26/24, four days after it had occurred.

This was in contrast to the Adverse Clinical Event Reporting, Analysis, Disclosure, and Non-Payment policy which read, employees were urged to promptly report any adverse events posing a risk to patient safety immediately and or before the end of their shift to minimize the potential for patient harm.

According to the event report, unsafe staffing practices in the LDRP unit had resulted in Patient #4 being left alone while in active labor. Additionally, a transition nurse a registered nurse (RN) dedicated to caring for the newborn) was not readily available or present to care for Patient #4's newborn infant after Patient #4 gave birth.

However, this was in contrast to the medical record reviews conducted for the LDRP patients who were on the LDRP unit on 4/22/24. The medical record reviews revealed the adverse event reported had occurred for Patient #5.

ii. A review of the LDRP unit 4/22/24 night shift staffing assignment sheet revealed, at the start of the shift, the patient census was four patients which included two postpartum mothers, one newborn infant, and Patient # 4 who was in labor. At that time, two LDRP nurses were working on the unit.

a. At 7:29 p.m., Patient #5 presented to the LDRP unit for triage (an assessment performed to determine if a pregnant woman was in labor). At 8:38 p.m., Patient #5 was admitted to the LDRP unit in labor.

When Patient #5 was admitted to the unit, the patient census increased to five patients, and of the five patients, Patient #4 and Patient #5 were in labor.

b. A review of the Labor and Delivery note for Patient #5 revealed the medical provider and Patient #5's RN had been delivering and transitioning Patient #4 while Patient #5 was in the active pushing phase of the second stage of labor. However, since Patient #5 was left alone, Patient #5 labored down (did not actively push once the active second stage of labor began) until the LDRP nurse and medical provider were able to come into the room to deliver the baby.

According to Patient #5's medical record, there was one RN present at the delivery to care for Patient #5 and their newborn baby when Patient #5 delivered a baby girl on 4/23/24 at 12:56 a.m.

This was in contrast to AWHONN guidelines, which stated an RN needed to be continuously at the bedside with a laboring woman during the active pushing phase of the second stage of labor. Additionally, two registered nurses need to be present at the time of birth, to ensure one LDRP nurse cared for the mother and one neonatal trained (transition) nurse solely cared for the baby.

B Interviews

i. Leadership interviews revealed a lack of investigation and preventative action implementation:

a. On 5/14/24 at 10:21 a.m., an interview was conducted with director of quality (Director) #11. Director #11 stated after an adverse event was received, the event was forwarded to the unit director or unit manager for further investigation.

Director #11 stated after reviewing the adverse event that occurred on 4/22/24, they had concluded there were no concerns warranting follow-up as the patients on the LDRP unit were safe. Director #11 stated the adverse event was closed since no harm had occurred and there were no deviations or variances from facility policies.

Director #11 further stated they considered the adverse event on 4/22/24 more of a "good catch" rather than a breakdown in process or an adverse event.

b. On 5/14/24 at 10:44 a.m., an interview was conducted with director of acute care nursing (Director) #2. Director #2 stated they had conducted the adverse event investigation for the event on 4/22/24. Director #2 further stated according to the adverse event report, the event was for staffing concerns during Patient #4's labor and delivery. Director #2 stated they performed the follow-up investigation for the event and had not identified nurse staffing concerns when Patient #4 was in labor or when Patient #4 gave birth.

Director #2 stated they reviewed the medical records for all inpatients on the LDRP unit the night of 4/22/24. Director #2 stated the number of nurses staffed during the night shift aligned with the staffing plan for the LDRP unit, and they felt the number of nurses working was appropriate and increased nursing staff had not been warranted.

This was in contrast to the medical record review for Patient #5, which revealed when Patient #5 gave birth, there was not a transition nurse (the RN dedicated to care for the baby) present to care for the baby. This was also in contrast to the LDRP staffing plan which read, for a census of five patients, there would be three nurses. (Cross-reference A-0392)

However, the staffing plan for the LDRP unit was in contrast to the AWHONN Professional Registered Nurse Staffing for Perinatal Units guidelines which read, stated staffing models based on hours per patient day or midnight census were deemed inappropriate for perinatal units due to inadequate risk adjustment, failure to account for the dynamic nature of labor and birth care, fluctuations in admissions and discharges, and the presence of perinatal triage patients and OB emergency department patients. Additionally, perinatal staffing should incorporate patient volume and include observation patients, admissions, discharges, and partial-stay patients such as OB triage patients.

Lastly, these interviews were in contrast to the Adverse Clinical Event Reporting, Analysis, Disclosure, and Non-Payment policy which read, any variance in the generally accepted performance standards and or normal operations of the organization were considered adverse events. Furthermore, incidents directly associated with the care or services provided at the facility were considered adverse events. The policy further read adverse events would be reviewed to identify potential system-wide vulnerabilities and safety improvement opportunities.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0392 (b) STAFFING AND DELIVERY OF CARE 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 care of any patient. Based on interviews and documents reviewed, the facility failed to ensure the labor, delivery, recovery, and postpartum (LDRP) unit and the neonatal intensive care unit (NICU) staffing plans aligned with national standards to meet patient care needs and safety requirements as per the Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations. The facility also failed to have an established process to reduce nurse-to-patient assignments to align with patient acuity demands in accordance with the Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations. Additionally, the facility failed to ensure the NICU staffing plan was approved by at least 60% or greater clinical RNs who routinely provided direct care. The facility also failed to ensure the LDRP unit staffing plan was approved by the staffing committee before implementation. Lastly, the facility failed to ensure each open inpatient unit had at least one registered nurse (RN) and one auxiliary personnel staffed on the unit at all times in accordance with Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations. Additionally, the facility failed to ensure at least two NICU RNs worked on the unit at all times in accordance with national standards.

A-0397 (b)(5) PATIENT CARE ASSIGMENTS A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. Based on observations, document reviews, and interviews, the facility failed to ensure a qualified Neonatal Intensive Care Unit (NICU) nurse was immediately available to care for a baby in the NICU. Specifically, a nurse who was not Neonatal Resuscitation Program (NRP) certified was assigned to provide nursing coverage for the NICU nurse. Additionally, the facility failed to ensure staff were trained and qualified to perform specialized care for patients in the Labor, Delivery, Recovery, and Postpartum (LDRP) unit.

Based on interviews and documents reviewed, the facility failed to ensure the labor, delivery, recovery, and postpartum (LDRP) unit and the neonatal intensive care unit (NICU) staffing plans aligned with national standards to meet patient care needs and safety requirements as per the Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations. The facility also failed to have an established process to reduce nurse-to-patient assignments to align with patient acuity demands in accordance with the Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations. (Cross-reference A-0286 and A-0397)

Additionally, the facility failed to ensure the NICU staffing plan was approved by at least 60% or greater clinical RNs who routinely provided direct care. The facility also failed to ensure the LDRP unit staffing plan was approved by the staffing committee before implementation.

Lastly, the facility failed to ensure each open inpatient unit had at least one registered nurse (RN) and one auxiliary personnel staffed on the unit at all times in accordance with Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations. Additionally, the facility failed to ensure at least two NICU RNs worked on the unit at all times in accordance with national standards. (Cross-reference A-0397)

Findings include:

Facility policies:

The Staffing Guidelines policy read, the purpose of the policy was to provide scheduling and staffing guidelines for acute care facilities. The Role & Responsibilities section read, the clinical manager or assistant nurse manager (ANM) will staff to the Average Daily Census per the unit specific staffing plan. The Staffing coordinator will communicate with the nurse in charge prior to the shift start and as needed to obtain up-to-date unit staffing needs and work collaboratively with the nurse in charge and clinical manager/ANM to ensure the unit/department is staffed to the specific unit staffing plan. Under usual patient type and patient acuity, a -1/+1 to staffing plan is within acceptable staffing guidelines. Additionally, the staffing coordinator will document variations on the staffing sheet and in the shift staffing report.

The Staffing Plan section of the policy read, the staffing plan is created collaboratively with unit/department leadership and frontline caregivers, only staffing plans created through the formal approval structure should be used. The staffing plan guides the numbers of caregivers at each census level and the charge nurse should use the staffing plan for guidance and adjust staffing based on clinical judgment of acuity.

The Schedule section of the policy read, the clinical manager or ANM must plan adequate coverage for individual unit/department staffing 24/7.

The Management of Staffing Plans policy read, the purpose of the policy is to ensure staffing plans are created and reviewed collaboratively with frontline caregivers. Staffing summits are meetings to align operational staffing plans and position controls to the budget. The process is designed to have frontline caregiver collaboration in all parts of the process.

The Staffing Plans section read, staffing summits will have 2 frontline employees from a clinical area of the individual department of focus, 1 frontline leader from the the focus area, and will maintain 60% frontline coworkers. A leader and the frontline chair of the unit council (or frontline designee) will sign the staffing plan. Staffing plan sessions will continue working until 60% approval by formal vote of a specific department plan is reached. Initial approval of the staffing plan will occur at the staffing plan session of the staffing summit and quarterly review and approval of all staffing plans will occur at the Facility Senate and Enterprise Assembly.

National guidelines:

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), Standards for Professional Registered Nurse Staffing for Perinatal Units read, safe and effective neonatal nursing care requires a sufficient number of qualified nurses to attend to the care needs of critically ill babies in NICUs (Levels II, III, and IV). Situations involving neonatal specialty care for fewer than 6 intermediate care babies require a minimum of 2 registered nurses with neonatal expertise and training. A minimum of two LDRP-trained nurses should be in the hospital as minimum staffing, even when there are no perinatal patients. Two nurses would be needed to safely care for a woman who presented with an obstetric emergency. Also, adding assistive staff to the staffing numbers would not replace the required RN staffing standards and adequate staffing was critical to providing safe, high-quality nursing care for all those who give birth and their babies. Models of staffing that may be appropriate for medical-surgical units are not applicable to perinatal care.

Staffing plans for perinatal units should account for the presentations of patients seeking care that are considered observation, admissions, discharges, and "less than full day" patients such as those who present for OB triage. Hours per patient day" and/or "midnight census" models are not applicable in planning perinatal nurse staffing because they are not appropriately adjusted for risk and do not consider the dynamic nature of caring for patients during labor and birth; the frequent admissions and discharges assigned to one nurse on a shift that influences workload or the large volume of triage patients, OB emergency department (ED) patients, and outpatients who often present to the perinatal unit for care. Safe, effective, high-quality nursing care requires adequate nurse staffing based on patient acuity and census. Childbirth and newborn care in the hospital setting deserve careful attention to appropriate nurse staffing based on individual patient characteristics and clinical situations to promote safe, high-quality nursing care and optimal patient outcomes. A nurse staffing plan, with evidence that its resources are adequate and that it is actively managed, is essential to patient safety. Adequate staffing is critical to providing safe, high-quality nursing care for all those who give birth and their babies. Healthcare leaders are responsible for ensuring adequate nurse staffing to promote the best outcomes for all women who give birth and their babies. Ultimate outcomes are best optimized by making sure childbearing women and their babies are provided with safe and appropriate nurse staffing to promote high-quality nursing care and the best possible outcomes.

According to Table 1 of the AWHONN Professional Registered Nurse Staffing for Perinatal Units guidelines, the Patient Type and or Clinical Situation Nurse-to-Woman or Nurse-to-Baby Ratios were two nurses at the time of birth; 1 nurse responsible for the mother and 1 nurse whose sole responsibility is the baby.

References:

According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.6 Nurse Staffing Committee (B) The nurse staffing committee shall: (2) Annually develop and oversee a master nurse staffing plan for the hospital; (3) Have at least 60% or greater participation by clinical staff nurses who routinely provide direct care to patients, in addition to auxiliary personnel and nurse management; (a) The nurse staffing committee shall set criteria to determine which clinical staff nurses routinely provide direct care to patients;

According to the Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.7 Nurse Staffing Plans, (A) Master Nurse Staffing Plan, (1) The nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that: (c) Includes minimum staffing requirements for each inpatient unit and emergency department that are aligned with nationally recognized standards and guidelines; (e) Includes guidance and a process for reducing nurse-to-patient assignments to align with the demand based on patient acuity.

According to the Standards for Hospitals and Health Facilities, Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.9 At least one (1) registered nurse and one (1) auxiliary personnel shall be on duty at all times in each open inpatient unit and in the emergency department. Additional staffing needs shall be determined by the hospital's master nurse staffing plan.

The staffing plans, which were identified by staff as the facility's staffing grids, were provided by the facility. The staffing grids listed the name of each inpatient unit at the facility, specified the variable patient census range for each unit, and specified the number of RNs and the number of ancillary staff expected to be staffed and present on each unit according to the current patient census. The staffing grids specified the nurse-to-patient ratios according to the patient census and amount of nurses required.

The RN House Supervisor job description read, the RN House Supervisors are responsible for coordination and direction of safe and efficient patient care and throughput in the hospital by providing a communication link with ED, patient registration, LPs, and nursing units. Serves
as clinical resource person in the delivery and supervision of direct and indirect care processes. Provides competent leadership and direction for all hospital Codes and emergency management. Serves as agent for department and hospital executives when they are not present and reports concerns and events to the designated administrator on call.

According to the Nursing Shared Governance Bylaws, the discipline of nursing intends to establish and uphold its commitment to nursing excellence in accordance with the American Nurses Association (ANA) Code of Ethics for Nurses and the institutional core values of compassion, respect, integrity, spirituality, stewardship, imagination, and excellence. The facility senate will serve as the staffing committee for their hospital. Membership in the senate will be 60% or greater clinical registered nurse (RN). A clinical RN is greater than 50% in direct care by job description.

The American Nurses Association (ANA) Code of Ethics, 2015, retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/ethics/code-of-ethics-for-nurses/ read, nurse executives have a responsibility to assure employees are treated fairly and justly, and that nurses are involved in decisions related to their practice and working conditions. Unsafe or inappropriate activities or practices must not be condoned or allowed to persist. After repeated efforts to bring about change, nurses have a duty to resign from healthcare facilities, agencies, or institutions where nurses are required to compromise standards of practice or personal integrity, or where the administration is unresponsive to nurses' expressions of concern. The needs of patients may never be used to obligate nurses to remain in persistently morally unacceptable work environments. The workplace must be a morally good environment to ensure ongoing safe, quality patient care and professional satisfaction for nurses and to minimize and address moral distress, strain, and dissonance.

1. The facility failed to ensure the NICU and LDRP units were staffed with an adequate number of qualified licensed registered nurses (RNs) to provide nursing care to all patients as needed and in accordance with national standards and the CCR 1011-1 Chapter Four, Part 14.7 Nurse Staffing Plans regulations. Additionally, the facility failed to have an established process to reduce nurse-to-patient assignments to align with patient acuity demands in accordance with the CCR 1011-1 Chapter Four, Part 14.7 Nurse Staffing Plans regulations.

A. NICU

i. A review of staffing assignment sheets revealed the NICU unit staffing plan was not aligned with nationally recognized guidelines and did not provide for continuous NICU RN coverage on the unit. Nurse-to-patient assignments were not based on patient acuity (the nursing care required for safe and effective patient care). Examples included:

a. Review of NICU staffing assignment sheets from 3/18/24 to 5/9/24 (total of 52 days and 104 shifts), revealed there were 90 shifts in which only one NICU RN worked on the unit.

b. On 5/7/24 between 2:25 p.m. and 2:45 p.m., observations were conducted in the NICU.
Observations revealed Patient #1 was cared for by a registered nurse (RN) who did not have an American Academy of Pediatrics Neonatal Resuscitation Program (NRP) certification.

c. Further review of the NICU staffing assignment sheets revealed on 4/26/24 Patient #1 was provided nursing care by a non-NRP certified RN from 7:00 a.m. to 3:00 p.m.

These events were in contrast to AWHONN guidelines which read, a minimum of two NICU trained nurses were to be present at all times, even during non-perinatal periods. Adequate staffing was crucial to ensure safe, high-quality nursing care for babies, and assistive staff could not replace the required NICU trained RN staffing standards.

ii. A review of the NICU staffing plan revealed the staffing plan was established using the worked hours per patient day (WHPPD - a budget-based staffing model) staffing model.

This was in contrast to the AWHONN Professional Registered Nurse Staffing for Perinatal Units guidelines which read, staffing models based on hours per patient day or midnight census were deemed inappropriate for perinatal units due to inadequate risk adjustment, failure to account for the dynamic nature of labor and birth care, fluctuations in admissions and discharges, and the presence of perinatal triage patients and OB emergency department patients. Additionally, perinatal staffing should incorporate patient volume and include observation patients, admissions, discharges, and partial-stay patients such as OB triage patients.

iii. Interviews conducted with nursing staff between 4/29/24 and 5/14/24 revealed the NICU unit was regularly understaffed and not in alignment with national guidelines.

a. An interview was conducted with staff member (SM) #6. SM #6 stated staffing for the NICU unit was not in alignment with AWHONN guidelines and they had experienced unsafe situations. SM #6 stated they were asked to leave the NICU to be the transition nurse during deliveries while they were assigned NICU patients and there was not a second NICU nurse working to care for the patients. SM #6 stated at times, newly hired RNs and new graduate RNs with insufficient training were permitted to care for NICU patients, which was unsafe.

b. An interview was conducted with SM #7. SM #7 stated NICU patients were left alone when only one NICU RN worked. SM #7 stated the RN had to leave the NICU to attend high-risk deliveries and a qualified nurse was not always readily available to care for the NICU patients.

c. On 5/8/24 at 4:10 p.m., an interview was conducted with chief nursing officer (CNO) #1. CNO #1 stated the staffing plan was a guide for how to staff the NICU unit. CNO #1 stated it was acceptable for the NICU unit to be staffed with negative -1 RN. CNO #1 stated both the Staffing Guidelines policy and the unit specific staffing grid outlined staffing a -1 RN was acceptable and still aligned with patient acuity levels on the unit. CNO #1 also stated they were unaware of how it was determined staffing a -1 RN was acceptable. Furthermore, CNO #1 stated they were not aware of any national guidelines which supported a -1 for RN staffing, and requested surveyors to provide such guidelines.

CNO #1 stated they knew there were nurse staffing concerns on the NICU unit. CNO #1 stated the NICU unit had always been able to manage even when short-staffed. CNO #1 stated the NICU staffed only the minimum number of nurses required and did not account for potential, hypothetical, unexpected situations and fluctuations in patient acuity in their staffing decisions. CNO #1 stated when there were not enough nursing staff working on the NICU unit, the charge nurse was able to utilize the Capacity Management Guideline process as a way to notify facility leadership of additional staffing needs and fluctuations in patient acuity.

However, upon request, the facility was unable to provide the Capacity Management Guideline. Additionally, the facility was unable to provide evidence staff had received training or were aware of the Capacity Management Guideline. Also, the facility was unable to provide evidence of additional staff provided when staffing concerns were escalated based on changes in patient acuity.

This was in contrast to the AWHONN Standards for Professional Registered Nurse Staffing for Perinatal Units which read, nurse staffing must align with the various types of patients and clinical situations which could present and be encountered on a perinatal unit.

This was also in contrast to the CCR 1011-1 Chapter Four, Part 14.7 Nurse Staffing Plans regulations which read, the nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that included staffing requirements for each inpatient unit that were aligned with nationally recognized standards and guidelines. The master nurse staffing plan should also include guidance and a process for reducing nurse-to-patient assignments to align with the demand based on patient acuity.

B. LDRP

i. Staffing assignment sheets for the LDRP unit were reviewed and revealed the unit staffing plan was not aligned with nationally recognized guidelines, did not provide for continuous registered nurse coverage on the unit, and nurse-to-patient assignments were not based on patient acuity (the nursing care required for safe and effective patient care). Examples included:

a. A review of the 3/18/24 day shift (7:00 a.m. to 7:00 p.m.) staffing sheet revealed one LDRP nurse worked in the unit with a medical surgical RN who had been re-assigned to the LDRP unit as "helping hands" (an RN sent from a different patient care unit to assist). (Cross-reference A-0397)

b. A review of the 3/29/24 LDRP night shift (7:00 p.m. to 7:00 a.m.) staffing assignment sheet revealed one LDRP nurse worked in the unit with a medical surgical RN who had been re-assigned to the LDRP unit as "helping hands." (Cross-reference A-0397)

These events were in contrast to AWHONN guidelines which read, a minimum of two LDRP trained nurses were to be present at all times, even during non-perinatal periods. Adequate staffing was crucial for ensuring safe, high-quality nursing care for birthing mothers and their babies, and assistive staff could not replace the required LDRP trained RN staffing standards.

c. The LDRP night shift staffing assignment sheet for 4/22/24 revealed the census was six patients. Two LDRP nurses were working, and each LDRP nurse was assigned to be the primary RN for one laboring mother, one postpartum patient, and one infant.

The medical record review for Patient #5 revealed on 4/23/24 at 12:59 a.m., Patient #5 delivered a baby girl. Further review of Patient 5's medical record revealed, when Patient #5 gave birth, there was not a transition nurse (the RN dedicated to care for the baby) present to care for the baby. (Cross-reference A-0286)

d. According to the Staffing Guidelines policy, the clinical manager or ANM must plan adequate nursing coverage for individual units per the department staffing 24 hours a day, 7 days a week. The clinical manager or ANM would also staff the unit to the Average Daily Census per the unit specific staffing plan. Under usual patient type and patient acuity, a -1 to the staffing plan was acceptable staffing guidelines.

These events and the Staffing Guidelines policy were in contrast to AWHONN Professional Registered Nurse Staffing for Perinatal Units guidelines which read, two registered nurses needed to be present at the time of birth, one LDRP nurse responsible for the care of the mother and one neonatal trained (transition) nurse whose sole responsibility was to care for the baby.

ii. A review of the LDRP staffing plan revealed the staffing plan was established using the worked hours per patient day (WHPPD - a budget-based staffing model) staffing model.

This was in contrast to the AWHONN Professional Registered Nurse Staffing for Perinatal Units guidelines which read, staffing models based on hours per patient day or midnight census were deemed inappropriate for perinatal units due to inadequate risk adjustment, failure to account for the dynamic nature of labor and birth care, fluctuations in admissions and discharges, and the presence of perinatal triage patients and OB emergency department patients. Additionally, perinatal staffing should incorporate patient volume and include observation patients, admissions, discharges, and partial-stay patients such as OB triage patients.

iii. Interviews conducted with nursing staff between 4/29/24 and 5/14/24 revealed the LDRP unit was regularly understaffed and not in alignment with national guidelines.

a. An interview was conducted with SM #4. SM #4 stated the LDRP unit was routinely understaffed and patients were at risk for harm. SM #4 stated when nurses were not staffed appropriately patients were at risk for complications during childbirth and there would not be enough staff to address emergencies that may arise.

SM #4 stated the LDRP unit routinely had an inadequate number of nurses working and nursing staff were concerned patient safety was being compromised. SM #4 stated nursing staff had presented their staffing concerns to the facility, however, the staffing concerns had not been addressed. SM #4 stated as a result the nursing staff unionized.

b. An interview was conducted with SM #8. SM #8 stated since the LDRP unit only staffed two RNs the unit was constantly short-staffed when patient acuity increased during the shift. SM #8 stated the day shift and night shift usually had two RNs and a surgical technician working. SM #8 additionally stated during childbirth, it was necessary to have one nurse dedicated to the mother and another solely for the newborn (transition nurse). However, numerous LDRP RNs lacked training for the transition nurse role. SM #8 mentioned NICU nurses were trained for the transition nurse role, but they could not leave the NICU if there were babies in the NICU. As a result, the LRDP unit consistently had a shortage of RNs available during deliveries.

SM #8 stated nursing staff had discussed their staffing concerns with the facility and were told the facility would not schedule more than two nurses to work on the LDRP unit. SM #8 stated when the LDRP unit was short-staffed it compromised the safety of the laboring mother and placed both the mother and baby at risk for experiencing childbirth complications.

SM #8 stated insufficient RN staffing jeopardized patient safety, as it compromised the ability to provide adequate care and detect changes in patient condition. SM #8 stated it was very difficult to get additional RN staff when needed and the unit had to try to provide the best care possible and do what they could. SM #8 further stated they could not recall a time the unit was provided additional nurses to align with the patient acuity on the unit.

c. SM #10 stated they were not aware of a formal process or policy for how to get additional RNs to work on the unit when needed. SM #10 stated when additional nursing staff was needed, the charge nurse called nurses to see if they were willing to work. SM #10 stated if there was not a nurse available to work, the unit would work understaffed. SM #10 stated it was normal for the LDRP unit to work understaffed, especially since the unit was not staffed according to patient acuity. SM #10 further stated the LDRP unit did not staff more than two RNs to work during the shift.

d. On 5/7/24 at 1:11 p.m., an interview was conducted with the director of acute care nursing, (Director #2). Director #2 stated two RNs were present during childbirth, one RN exclusively dedicated to the care of the mother and a transition RN solely dedicated to the care of the newborn. Director #2 stated the NICU RN would usually assume the role of the transition RN during a delivery. Director #2 stated when babies were in the NICU a house supervisor would go to the NICU and monitor the NICU babies to allow the NICU RN to be the transition nurse for newborn babies. Director #2 stated they were aware many of the LDRP RNs lacked the training needed to be a transition nurse, however, nurse staffing was not adjusted to ensure a transition nurse was readily available to care for the newborn.

e. On 5/8/24 at 4:10 p.m., an interview was conducted with chief nursing officer (CNO) #1. CNO #1 stated the staffing plan was a guide for how to staff the LDRP unit. CNO #1 stated it was acceptable for the LDRP unit to be staffed with -1 RNs. CNO #1 stated both the Staffing Guidelines policy and the unit specific staffing grid outlined staffing a - 1 RN was acceptable and still aligned with patient acuity levels on the unit. CNO #1 also stated they were unaware of how it was determined staffing a -1 RN was acceptable. Furthermore, CNO #1 stated they were not aware of any national guidelines supporting a -1 for RN staffing, and requested surveyors to provide such guidelines.

CNO #1 stated they knew there were nurse staffing concerns on the LDRP unit. CNO #1 stated the LDRP unit had always been able to manage even when short-staffed. CNO #1 stated the LDRP unit staffed only the minimum number of nurses required and did not account for potential, hypothetical, unexpected situations and fluctuations in patient acuity in their staffing decisions. CNO #1 stated when there were not enough nursing staff working on the LDRP unit, the charge nurse was able to utilize the Capacity Management Guideline process as a way to notify facility leadership of additional staffing needs and fluctuations in patient acuity.

However, upon request, the facility was unable to provide the Capacity Management Guideline. Additionally, the facility was unable to provide evidence staff had received training or were aware of the Capacity Management Guideline. Also, the facility was unable to provide evidence of additional staff provided when staffing concerns were escalated based on changes in patient acuity.

This was in contrast to the (AWHONN) Standards for Professional Registered Nurse Staffing for Perinatal Units which read, nurse staffing must align with the various types of patients and clinical situations which could present and be encountered on a perinatal unit.

This was also in contrast to the CCR 1011-1 Chapter Four, Part 14.7 Nurse Staffing Plans regulations which read, the nurse staffing committee shall annually develop and oversee a master nurse staffing plan for the hospital that included staffing requirements for each inpatient unit that were aligned with nationally recognized standards and guidelines. The master nurse staffing plan should also include guidance and a process for reducing nurse-to-patient assignments to align with the demand based on patient acuity.

2. The facility failed to ensure the NICU staffing plan was approved by at least 60% or greater clinical RNs who routinely provided direct care to patients. Additionally, the facility failed to ensure the LDRP unit staffing plan was approved by the staffing committee before implementation.

A. NICU

i. Review of Senate Meeting Minutes provided by the facility revealed on 4/22/24 the NICU staffing plan had not been approved by 60 percent (%) or greater direct patient care RNs.

Further review revealed the voting staff members present at the Senate Meeting were as follows: Eight of the 21 committee members (38%) were direct patient care RNs.

This was in contrast to CCR 1011-1 Chapter 4, Part 14.6 which read, the nurse staffing committee would annually develop and oversee a master nurse staffing plan for the facility and would have at least 60% or greater participation by clinical staff nurses who routinely provided direct care to patients, in addition to auxiliary personnel and nurse management.

ii. On 5/14/24 at 9:34 a.m., an interview was conducted with the Director of Acute Care Nursing (Director) #2. Director #2 stated each inpatient unit held a staffing summit annually. After the staffing summit, the staffing plan was reviewed by the Senate for final approval. Director #2 stated they were not aware the staffing plan needed to be approved by 60% of direct patient care RNs.

iii. On 5/14/24 at 1:00 p.m., an interview was conducted with the Chief Nursing Officer (CNO) #1. CNO #1 stated they were aware unit specific staffing plans had to be approved by 60% of direct patient care RNs. However, since the union had determined managers and house supervisors were considered frontline staff (for them to be a part of the union), managers and house could vote and approve the unit specific staffing plans.

iv. According to the house supervisor job description, the house supervisor did not provide direct patient care. The house supervisor was responsible for coordination and direction of safe and efficient patient care and throughput in the hospital. Also, house supervisors served as leadership and direction for all hospital codes and emergency management and were a clinical resource in the delivery and supervision of direct and indirect care processes.

This was in contrast to the Nursing Shared Governance Bylaws which read, direct patient care RNs provided greater than 50% of direct care by job description.

This was also in contrast to the CCR 1011-1 Chapter 4, Part 14.6 which read, the nurse staffing committee would annually develop and oversee a master nurse staffing plan for the facility and would have at least 60% or greater participation by clinical staff nurses who routinely provided direct care to patients.

B. LDRP

i. Review of Senate Meeting Minutes provided by the facility revealed on 4/22/24 the obstetrics (LDRP) Staffing Summit was rescheduled for 4/30/24 due to a lack of RN agreement on the staffing plan.

ii. Review of the LDRP staffing plan revealed the plan was effective 5/8/24.

Upon request, the facility was unable to provide evidence the LDRP staffing plan had been reviewed and approved by at least 60% or greater clinical staff nurses who routinely provided direct care to patients.

This was in contrast to the Management of Staffing Plans policy which read, the purpose of the policy was to ensure staffing plans were created and reviewed collaboratively with frontline caregivers. Staffing plan sessions should continue working until 60% approval by formal vote of a specific department plan was reached.

This was also in contrast to the CCR 1011-1 Chapter 4, Part 14.6 which read, the nurse staffing committee would annually develop and oversee a master nurse staffing plan for the facility and would have at least 60% or greater participation by clinical staff nurses who routinely provided direct care to patients.

iii. On 5/14/24 at 1:00 p.m., an interview was conducted with the Chief Nursing Officer (CNO) #1. CNO #1 stated they were aware that unit specific staffing plans needed to be approved by 60% of direct patient care staff. CNO #1 stated staffing plans were presented at Senate meetings where the full committee would vote to approve the staffing plans that each unit had created. CNO #1 stated the LDRP plan that had been approved at the second summit meeting on 4/30/24 would be fully approved at the May Senate meeting.

This was in contrast to the Staffing Plan section of the Staffing Guidelines policy which read, only staffing plans approved through formal structure should be used.

3. The facility failed to ensure the NICU had at least one registered nurse (RN) and one auxiliary personnel staffed on the unit at all times in accordance with Code of Colorado Regulations (CCR) 1011-1 Chapter Four regulations, Part 14.9. Additionally, the facility failed to ensure at least two NICU RNs worked on the unit at all times in accordance with national standards (Cross-reference A-0397).

A. NICU

i. On 4/29/24, 4/30/24, 5/7/24, and 5/14/24 observations were conducted in the NICU. Observations revealed one NICU RN was staffed on the unit and no auxiliary staff were present.

ii. From 3/18/24 to 5/9/24 (a total of 52 days and 104 shifts), there were 88 shifts in which the NICU was staffed with only one RN and no auxiliary staff member.

iii. A review of the NICU staffing plan revealed, the NICU was to be staffed with one RN for up to two patients with no auxiliary staff. (Cross-reference A-0397)

a. On 5/1/24 from 7:00 a.

Based on observations, document reviews, and interviews, the facility failed to ensure a qualified Neonatal Intensive Care Unit (NICU) nurse was immediately available to care for a baby in the NICU. Specifically, a nurse who was not Neonatal Resuscitation Program (NRP) certified was assigned to provide nursing coverage for the NICU nurse. Additionally, the facility failed to ensure staff were trained and qualified to perform specialized care for patients in the Labor, Delivery, Recovery, and Postpartum (LDRP) unit. (Cross-reference A-0392)

Findings include:

References:

The facility NICU Competency Grid read NICU nurses are required to have Basic Life Support (BLS) and NRP certification.

The facility LDRP Competency Grid read LDRP nurses are required to have BLS and NRP certification. Additionally, it is preferred if they have Advanced Cardiac Life Support (ACLS) and STABLE (a program that provides additional training for nurses who provide stabilization care to sick infants) certification.

The facility LDRP Staffing Grid read for one LDRP patient two LDRP-trained nurses must be on duty at all times.

The facility registered nurse (RN) job description read the RN assumes responsibility and accountability for facilitating, communicating, and collaborating with both the healthcare team, and the patient/family to identify and meet the physical, emotional, and spiritual needs of the patient. The RN promotes the optimal health, well-being, and safety of the patient through use of the nursing process and in accordance with patient care standards, guidelines, and the State Nurse Practice Act. The RN's job responsibilities include the RN will demonstrate competency in a variety of therapeutic /diagnostic interventions.

The facility director of nursing services (director of acute care nursing) job description read, the director is to provide leadership and accountability in the strategic and daily operations of the clinical service. The director is accountable for the quality of patient care provided by the nursing service and oversees the delivery of patient care.

The Scope of Services read patient care responsibilities are assigned to nursing staff based on four general considerations: the patient, environment, staff education, and competency. The plans are based on the number and qualifications of personnel always required to provide safe and effective patient care. These plans are based on accepted standards for the delivery of patient care, the number of patients, the intensity of illness, and the training and competence of the personnel. Staff is provided to serve the patients as determined by staffing plans developed for each department and by need. Required competencies for the care of patients is completed annually and as needed. The Labor, Delivery, Recovery, and Post-Partum (LDRP) unit provides care for 32 weeks gestational age laboring women, women requiring cesarean delivery, women with high-risk pregnancies, and post-partum readmissions. Earlier gestational age may be considered if approved by a pediatrician and PCM. The Neonatal Intensive Care Unit (NICU) cares for newborns 32 weeks gestation and above. The NICU is a Level Two Special Care unit (provides care for babies with moderate medical issues, 32 weeks gestation or more, and weighing more than 3.3 pounds).

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), Standards for Professional Registered Nurse Staffing for Perinatal Units 2022 read safe and effective neonatal nursing care requires a sufficient number of qualified nurses to attend to the care needs of critically ill babies in NICUs (Levels II, III, and IV). Situations involving neonatal specialty care for fewer than six intermediate-care babies require a minimum of two registered nurses with neonatal expertise and training.

Also, the AWHONN guidelines read there should be a minimum of two LDRP-trained nurses in the hospital as minimum staffing, even when there are no perinatal patients. Two nurses are needed to be able to safely care for a woman who presents with an obstetric emergency that may require cesarean birth (one nurse circulator and one baby nurse, one or both of whom should have obstetric triage, labor, and fetal assessment skills). A scrub nurse or surgical tech should be available in the hospital or on call such that an emergency birth can be accomplished in a timely manner consistent with the patient's clinical situation. Another labor nurse should be called in to be available to care for any other pregnant woman who may present for care while the first two nurses are caring for the woman undergoing cesarean birth and during postanesthesia recovery. Adding licensed practical nurses, licensed vocational nurses, doulas, obstetric technicians, or nurses ' aides to the staffing numbers does not preclude requirements to meet staffing standards for registered nurses.

The Standards for Hospitals and Health Facilities Chapter 4 - General Hospitals 6 CCR 1011-1 Chapter 4, Part 14.3 effective 6/14/23 read, the Senior Nurse Executive shall be responsible for ensuring that all nursing staff have the qualifications, competencies, and experience necessary to deliver the care assigned in accordance with professional standards of practice and hospital policy and procedure.

1. The facility failed to ensure nurses who were trained and competent in neonatal resuscitation provided nursing care to babies in the NICU.

A. Neonatal Intensive Care Unit (NICU)

i. Observation and document review revealed non-NRP certified staff provided care to NICU babies.

a. On 5/7/24, from 2:25 p.m. to 2:45 p.m., an observation was conducted in the NICU. Observations revealed Patient #1 was cared for by house supervisor (Supervisor) #3.

b. Review of Supervisor #3's personnel file revealed they did not have an American Academy of Pediatrics (AAP) NRP certification.

ii. Review of the BirthPlace Census Acuity Staff Log (staffing assignment sheet) for 5/7/24 revealed one NICU nurse (a nurse who has specialized training to care for NICU babies) was assigned to care for Patient #1. Additionally, Patient #1 was the only baby in the NICU.

However, during the observation in NICU, the nurse caring for Patient #1 had left the unit and there was not another NICU nurse available to provide nursing care to Patient #1.

a. Further review of the staffing assignment sheets revealed, on 4/26/24, 11 days prior to the observation, Supervisor #3 had cared for Patient #1 from 7:00 a.m. to 3:00 p.m. (Cross-reference A-0392)

This was in contrast to the facility's competency grid which stated NICU nurses were required to have NRP certification.

Additionally, this was in contrast to the AWHONN, Standards for Professional Registered Nurse Staffing for Perinatal Units guideline which read, safe and effective neonatal nursing care required a sufficient number of qualified nurses to attend to the care needs of critically ill babies in NICUs. Situations involving neonatal specialty care for fewer than six intermediate-care babies required a minimum of two registered nurses with neonatal expertise and training.

iii. During a previous survey completed on 6/6/22, the facility was cited due to a failure to ensure a qualified NICU RN was immediately available to assist and supervise patient care and respond to emergent situations.

a. A review of the facility's plan of correction submitted after being cited for deficient practice and non-compliance revealed the facility had hired additional NICU nurses and alleviated the staffing shortage to ensure a qualified registered nurse and/or advanced practice provider would be immediately available for neonatal resuscitation and stabilization. Additionally, a NICU nurse would be available per the staffing matrix when patients required NICU specialized care. (Cross-reference A-0392 from Event ID P9W311).

This was in contrast to the observation conducted on 5/7/24 in the NICU, which revealed a NICU nurse was not available to provide care for Patient #1.

The corrective actions, which included utilizing a neonatal advanced practice provider as the second NICU nurse, implemented by the facility on 6/6/2022 were also in contrast to the CCR 1011-1 Chapter Four, Part 14.3 Nursing Services regulations, effective 6/14/23 which read, nursing services shall be provided by a registered nurse qualified by education, training, competencies, and the experience necessary to deliver patient care in accordance with professional standards of practice.

Upon request, the facility was unable to provide evidence they had revised nurse staffing to align with the updated CCR 1011-1 Chapter Four, Part 14 Nursing Services regulations, which had become effective as of 6/14/23.

B. Interviews

i. Interviews conducted with nursing staff between 4/29/24 and 5/14/24 revealed staff who cared for NICU babies were required to be NRP certified.

a. Staff Member (SM) #6 stated house supervisors were asked to cover for the NICU nurses when they needed to leave the unit. They stated this was unacceptable because the house supervisors were not NRP certified and were not trained to resuscitate a neonate. Also, SM #6 stated babies in the NICU were fragile and at times required specialized equipment to breathe. Further, they said NICU nurses needed to be competent because they had a baby's life in their hands.

b. Staff Member (SM) #7 stated NICU nurses were required to leave the NICU to attend high-risk deliveries. They stated when they were away from the NICU, the department director or a nursing supervisor would watch the NICU babies. SM #7 stated they were concerned when non-NRP certified staff watched NICU babies.

c. On 5/7/24 at 2:30 p.m., an interview was conducted with advanced practice provider (APP) #5. APP #5 stated they were NRP certified, as were all of the NICU providers at the facility. APP #5 said NRP was important training that provided the knowledge needed to resuscitate newborn babies. APP #5 also stated if a NICU nurse was not NRP certified they would not be able to provide the nursing care newborn babies in the NICU required. Additionally, they stated nurses not trained in neonatal resuscitation could cause further harm to a neonatal patient in distress.

According to APP #5, nurses without NRP certification would not have the knowledge and training needed to resuscitate a neonatal patient. Additionally, interviews revealed it was important to continuously monitor neonatal patients because neonates could experience a change in condition and stop breathing within minutes, which put them at risk of death.

d. On 5/07/24 at 12:03 p.m., an interview was conducted with chief nursing officer (CNO) #1. CNO #1 stated after the plan of correction had been implemented in June of 2022, the facility had not implemented further staffing changes to ensure a NICU RN was present in the NICU. CNO #1 stated they were not aware the CCR 1011-1 Chapter Four, Part 14 Nursing Services regulations were updated on 6/14/23.

2. The facility failed to ensure staff were trained and qualified to perform specialized care for patients in the Labor, Delivery, Recovery, and Postpartum (LDRP) unit. Specifically, the facility failed to ensure the director of acute care nursing was competent to provide patient care to patients on the LDRP unit.

A. Document Review

i. A review of the 3/18/24 day shift (7:00 a.m. to 7:00 p.m.) staffing sheet revealed one LDRP nurse worked in the unit with a medical surgical RN who had been re-assigned to the LDRP unit as "helping hands" (an RN sent from a different patient care unit to assist). (Cross-reference A-0392)

ii. A review of the 3/29/24 LDRP night shift (7:00 p.m. to 7:00 a.m.) staffing assignment sheet revealed one LDRP nurse worked in the unit with a medical surgical RN who had been re-assigned to the LDRP unit as "helping hands." (Cross-reference A-0392)

iii. Review of the medical surgical unit competency grid revealed medical surgical nursing staff were not required to have NRP certification.

This was in contrast to the LDRP staffing grid which stated for one LDRP patient two LDRP nurses were required to be staffed at all times.

This was also in contrast to AWHONN guidelines which read a minimum of two LDRP-trained nurses should be in the hospital as minimum staffing, even when there were no perinatal patients. Two nurses were needed to safely care for a woman who presented with an obstetric emergency. Also, adding assistive staff to the staffing numbers did not replace the required RN staffing standards. Furthermore, the AWHONN guidelines read, adequate staffing was critical to provide safe, high-quality nursing care for all those who gave birth and their babies.

iii. Further review of the staffing assignment sheets for 3/18/24 and 3/29/24 revealed the director of acute care nursing (Director) #2 was on duty as a backup LDRP nurse from 7:15 p.m. to 7:00 a.m. (Cross-reference A-0392)

a. Review of Director #2's personnel file and clinical competencies revealed no evidence of annual practice updates for LDRP patient care competencies.

iv. Job descriptions for the director of nursing services and registered nurses were reviewed.

a. The facility registered nurse (RN) job description read the RN was responsible for the physical needs of the patient and promoted the safety and well-being of the patient. Also, the RN was expected to demonstrate competency in a variety of therapeutic /diagnostic interventions.

b. The facility director of acute care nursing job description read the director was to provide leadership for the daily operations of the clinical service. Also, the director oversaw the delivery of patient care. Furthermore, the director's job description did not state the director was expected to demonstrate competency or was responsible for the physical needs of patients.

B. Interviews

i. Interviews conducted with nursing staff between 4/29/24 and 5/14/24 revealed Director #2 had been on duty as the backup for LDRP nurses when there was a shortage of qualified nursing staff.

a. SM #7 stated Director #2 had volunteered to be the backup LDRP nurse on the night shift a few times. They stated Director #2 would have been able to function as helping hands on LDRP. They also stated Director #2 had not practiced bedside LDRP care for over 20 years and did not have completed competencies, so they were not qualified to be the second LDRP nurse.

Further, SM #7 stated Director #2 could not have been the second LDRP nurse because they were unable to perform LDRP nursing tasks like a vaginal exam to check a cervix, run equipment for an epidural (an injection in the back to stop the feeling of pain in part of the body), and was unable to pull medications from the PYXIS (automated medication storage and dispensing system).

b. SM #8 stated they discovered Director #2 did not have PYXIS access. SM #8 also stated Director #2 documented fetal heart monitor strips (used to assess a baby's heartbeat) upside down and gave insufficient hand off to other nurses.

c. On 5/7/24 at 1:11 p.m., an interview was conducted with Director #2. Director #2 stated when the nursing assignment sheet listed them as in-house, that meant they were there as a backup to read monitor strips, do labor exams, and be the second LDRP nurse. Director #2 stated they had been trained on these LDRP skills when they first started LDRP nursing care and had not completed the LDRP competencies at this facility. Also, they stated they were usually in the director role and had not often worked as a staff nurse on the LDRP unit.

Additionally, Director #2 explained new nurses were required to complete the LDRP competencies and attended an annual skills lab. Director #2 stated the LDRP nurses had a passport competency which included the skills labs and annual on-line assignments. They stated core LDRP staff were not allowed to care for patients unless they had completed all of the required competencies. Further, Director #2 stated they did not complete all of the required LDRP competencies because they were in the director role.

This was in contrast to the facility's scope of services which read, required competencies for the care of patients were completed annually and as needed.

Lastly, Director #2 stated competencies were important for LDRP nurses to know how to handle clinical situations for LDRP patients, such as, cesearean sections, postpartum hemorrhages, breech (bottom or feet first) babies, and shoulder dystocias (medical emergency that occurs when the baby's shoulder gets stuck behind the mother's pubic bone during childbirth, delaying the delivery of the baby's body). They stated, an LDRP nurse without the required competencies would not have had the knowledge and training needed to provide proper care to patients.

This was in contrast to the staffing assignment sheets, interviews, and Director #2's competency review, which revealed Director #2 had served as a backup LDRP nurse without being deemed competent to provide care to LDRP patients.