HospitalInspections.org

Based on review of facility documention and interview with facility staff (EMP), it was determined that the facility failed to ensure that a sufficient number of nursing personnel were assigned to provide nursing care needs of patients by failing to follow adopted staffing guidelines and policies.


Findings Include:

Conemaugh Memorial Medical Center ... PolicyStat ID: 1970090 ... Policy Area: Organizational-Clinical ... Patient Rights policy and procedure dated December 2015 [March 2019 reviewed with no revision]. "Statement of Policy: It is the policy of Conemaugh Health System (CHS) to respect the rights of patients during their hospitalization and to recognize that each patient is an individual with unique health care needs. Staff will provide considerate, respectful care, incorporating personal values and belief systems and strive to protect each patient's dignity. ... A Statement of the Patient's Rights ... 9. You have the right to high quality care and professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid personal discomfort. ... 25. You have the right to voice questions, concerns, or comments to your health care provider, to the Patient Representative at the hospital or you may contact the Pennsylvania Department of Health, Acute and Ambulatory Care Services, ... ."
Attachment entitled, "A Statement of the Patient's Rights" revealed, "... 1. You have the right to respectful care given by skilled staff. ... 8. In case of emergency, you can expect emergency treatment without delay. ... 9. You have the right to quality care and high professional standards that are always kept and reviewed. ... 19. You have the right to expect good management techniques to be used, considering good use of your time and to avoid any personal discomfort. ... ."


Conemaugh Memorial Medical Center ... PolicyStat ID: 4871749 ... Policy Area: Maternity ... Obstetric Scope of Service, Standard of Practice and Staffing Plan-Maternity Department policy and procedure dated May 2018. "Purpose: A. To provide comprehensive services to assist patients and families in achieving and maintaining their highest level of physical, emotional, social and spiritual health. B. To attain optimal patient and family outcomes through collaboration of members of the multidisciplinary health care team. ... Staffing Plan A. Patient care assignments are made by the Nurse Manager or charge nurse on the basis of the clinical complexity and dynamics for the nursing care needed. Assignments are matched to the individual nurses ability to meet those needs. The nurse's experience level, competency level and individual capabilities should be taken into consideration. B. To enable nurses to focus on patient care, the following ancillary personnel should be available: Registration staff, environmental support, and patient care assistants. Unusual occurrences, such as higher than normal census/acuity, large numbers of 'call-ins,' or severe weather conditions, are covered by nurses in a variety of ways, including employing staff who volunteer to work extra, staff from other perinatal units within the site, and 'on-call' staff C. The obstetric core patient care team consists of perinatal providers, registered nurses, OB technicians, Clinical support associates (CSA), work under direct supervision of registered nurses. Registered nurses coordinate the multidisciplinary needs of the family unit in collaboration with the physician, perinatologist, and neonatologist, anesthesia personnel, advanced practice nurses, lactation consultants, pharmacist and dietician, as needed. ... ."


Conemaugh Health System Memorial Medical Center Human Resources Policy Manual Title: Excess Shift Work Hours policy and procedure dated January 2013. "Statement of Policy Memorial Medical Center generally will not require an employee, agency employee, or contracted personnel to work in excess of an agreed to regularly scheduled daily work shift unless an unforeseeable emergent circumstance or a patient care procedure causes necessary coverage. Requirements I. Covered Departments and Positions The guidelines apply to non-exempt employees who have direct patient care or work in a clinical care service position and work in the following department/areas: inpatient units (acute, rehabilitation, and long-term care), operating room, emergency medicine, diagnostic and treatment departments, home health and hospice. II. Unforeseeable Emergent Circumstances/Completion of a Patient Care Procedure The following unforeseeable emergency circumstances by virtue of their unpredictability may cause an employee to work beyond his regular scheduled shift: ... (C) unexpected absences discovered at or before the shift which could not be prudently planned for by a department and would significantly affect patient safety In addition to the above circumstances, an employee will be required to work additional hours beyond their scheduled shift in order to complete a patient care procedure that is already in progress if an employee's absence could have an adverse effect on the patient. This includes the completion of patient charting that is required before an individual concludes their shift. In addition, any individual who arrives on Memorial Medical Center's property for a scheduled service will be considered as a patient care procedure in progress. III. Procedure to Secure Coverage during Unforeseeable Emergent Circumstances The following steps must be followed in order following steps must be followed in order to provide staff coverage during any unforeseeable emergent event: (A) Request that employees who are presently working to volunteer for extra hours to be covered, (B) Contact all qualified employees who are not working and have made themselves available to work extra time, (C) Contact hourly employees, and (D) If necessary and approved by the department, utilize agency personnel. (E) If steps A-D were not successful in securing staff coverage, the employee will be expected to work as requested/needed. This will occur whenever all reasonable efforts to obtain staffing have been exhausted. The above steps do not have to be followed in the case of a patient procedure that is in progress. IV. General Guidelines (A) These guidelines do not apply to work hours associated with on-call. However, off-duty time as detailed in (B) is required (B) Employees who are required to work or volunteer to work more than twelve (12) hours will be granted at least 10 (ten) consecutive hours of off-duty time (unless voluntarily waived). If the employee is unable to work all or part of their next shift due to the need to have at least 10 (ten) consecutive hours off, they may request to be paid PTO time for the missed hours (not to exceed the total shift hours that were scheduled). If the employee does not elect PTO time, then the hours should be coded as 'UPM'-unpaid miscellaneous- in order that the scheduled hours can be documented in Kronos. The off-duty time also applies to an employee who works twelve (12) or more hours during on-call. (C) If an employee is required to work due to an unforeseeable emergent circumstance as detailed in Section II (A-C), the employee must be given up to 1 (one) hour to arrange for childcare, eldercare, and disabled family member care, if needed. (This time-up to one hour-is not compensated. Therefore, the employee must punch out of Kronos then punch back in upon resuming to work.) (D) If an employee is required to work hours in excess of his/her regularly scheduled shift, the manager must complete a PER-21, Excess Shift Work Hour Documentation Form (see Attachment A). The employee's signature is also required required. In the absence of the manager or charge person (e.g. off-shift), the employee will be responsible for completing the form and ensuring that is is received by the manager. The PER-21 should be maintained by the department for three years after the occurrence. (E) All worked hours will follow the current pay practices. (F) If the employee is mandated to work excess hours and refuses, he/she will be disciplined according to the process contained in Performance Improvement Policy (P-11). (G) Employees will not be disciplined against for refusing to work excess hours beyond their scheduled shift hours during non-emergent circumstances or times of patient care procedures that are not in progress. (H) Departments that utilize required excess shift work hours will be reviewed in order that staffing issues and and other contributing factors can be appropriately addressed. V. Attachment B, Department Specific Guidelines for Excess Shift Work Hours, includes a template that must be completed and modified appropriately for each department that has employees who are covered by this policy. These department-specific guidelines will supplement the organizational policy. Questions regarding provisions on this policy should be directed to the Human Resources Department. ... ."



1) Interview with EMP2 on March 26, 2019, at 9:15 AM revealed, "At times, yes, they are being mandated. We have several people that work hourly or part-time that may be assigned to work an extra shift. It is overtime for them because they are part-time and it takes them over 40 hours. ... We've had several resignations, well not so much resignations but staff going to physician offices. ... Staffing is tight right now in that area [Obstetrics]. ... We do have vacant positions, we do not have any agency nurses now, not to say that we would not entertain that. Sometimes that's not the answer as that period of request for nurses can sometimes take two to three months, sometimes they are out of state and may not be licensed in PA. We've had no recent changes in our staffing grid. ... A lot of nurses are phasing out. ... About four days a month we are busier than usual, we have on-call and use them a little bit. ... We are stretched right now, volumes have been up, capacity is at about 90%. We've had resignations and are relying on our new graduates to run the organization. ... We do not have a shortage of RNs right now. We are in a crunch. ... We've had 25 plus nursing and nursing assistant positions open since I've been here. We've also have Directors/Service Line Directors and Managers for each unit. ... If really in a crunch, we have challenged the Clinical Coordinators to go back into staffing if census went up and there is increase in volume. ... The trend has not changed since I have been here."

2) Interview with EMP3 on March 26, 2019, at 10:20 AM revealed, "Yes, I've been mandated recently. We have a book that lists who is mandated and when. Whoever is in charge mandates, the Supervisors or Managers. ... We have no bonus right now. ... It's hectic in the Labor and Delivery area. There are times that I've done 12 hour shifts and have not gotten any breaks. ... Staff is very unhappy right now, we're losing someone all the time. ... ."

3) Interview with EMP4 on March 26, 2019, at 10:35 AM revealed, "I've been here for 25 years. Mandating is happening. We are also on-call, we pick 12 hour shift and most likely we come in. I know that they just mandated two people on Friday night. If you are mandated, you have to be off work 10 hours between shifts before you can come back to work, so if your daylight the next day and just finished up at 11:00 PM, you can't come back to work until 9:00 AM, which then puts that shift behind. It's a vicious cycle. ... There were two RN's last week, we were full with 14 or 15 patients. ... People are working extra, they are scheduled extra and part-timers are working extra consistently. We have a mandate book. ... We don't eat sometimes, no relief to go to eat. Night shift is very busy, very rarely get relief on nights. This is the worst I've ever seen, people are very unhappy and looking for other jobs, changing status. I know they've gone and talked to someone about staffing. ... ."

4) Interview with EMP5 on March 26, 2019, at 10:50 AM revealed, "I've been here two and a half years today. Just Friday night I was mandated. I was scheduled 7A-7P, and worked until 11 AM, I was off the next day. ... A lot of people are leaving, there are a lot of holes in the schedule. The last person that left, maybe gave three weeks notice. I worked 40 plus hours last week, two twelves and two eights and sixteen hours of on-call I picked up. Most of us are doing that. ... We are mandated more and work on-call more. I work all of the areas, it can be frustrating. We work very well as a team, but I can't be in two places at once, it's not safe. ... Concerns were brought to EMP9. EMP10 talked to someone and hopefully something will be done. Since I've started here, it's amazing that so many have left, come back and left again."

5) Telephone interview with EMP7 on April 3, 2019, at 9:50 AM revealed, "... Staffing is a serious problem. Ultimately, it's left up to me, I'm responsible for the patient. Many nurses have left, they are being mandated, they are working over and doing extra call. It's not safe for the patients. Everybody used to want to work in OB, you couldn't get a job in this department. Now we can't even hire people. People are leaving. When they do come they are thrown into the mix because orientation time is cut in half. We are high risk, we're the only OB Unit in the area, we've outgrown our unit. They've been mandating nurses, making them work overtime, part-timers working overtime and getting nothing. The Director doesn't have a good handle on it, it's a safety issue. It's just a matter of time unit someone really gets hurt or we lose a baby. ... They're not even getting their lunches. ... ."

6) Interview with EMP10 on April 8, 2019, at 12:10 PM revealed, "It has been a struggle lately. I mentioned it to PI Committee. We've been noticing staff stretched to the max making nurse's feel overwhelmed and making them, good, experienced nurses wan to leave. Twenty nurses left in twelve months. I've been here twenty years and that's the way it was, you were here until you retire, we can't even bring any new nurses on because of the way staffing is. Some nurses are on maternity leave, others come in and fill in the open slots. The reason they are leaving is because they are working way more than they are supposed to do. They are being mandated and being called at home. Nurses are different than they were ten years ago. Some left because they were getting called in all of the time, other new nurses are trained then they leave, good nurses are overwhelmed, then they try to leave. I was talking to EMP9 and to administration, that we need more staff. Laborlytics-all this shows is that we have excess nurses. We want safety for patients. We deal with a lot of high risk mother and babies. We have a very good core of excellent nurses who go beyond. If census goes up, our satisfaction score go down. They are trying to do a new simulation and new staff simulation. Nurse's doing so much, don't want to see them getting burned out. They are working a significant amount of hours. It's been frustrating, of the twenty that we lost, only eight of them were replaced and two of them left."

7) Telephone interview with EMP11 revealed, "... Staffing, truly is a big problem. The staff are working 80, 90 100 hours a week sometimes, just as the midwives are. ... We don't have the staff. ... I'm there, I see what happens. They still have births in the Triage area. We deal with at the time, but it is so unsafe. So unsafe to have these patients deliver this way, we have too many patients on the floor. ... The [closure of another facility's OB Unit] pushed us over the edge. I don't know how staffing changed, but the acuity went up and we were never allowed to hire on. ... ."

Second interview with EMP11 on April 8, 2019, at 12:20 PM revealed, "We're all afraid of retaliation, ... Our ratio in L&D is one nurse to two patients but on many it should be one to one since many of our patients are high risk. I was just on call Saturday, the on call nurse was scheduled and we had four deliveries in the first eight hours of the shift, every bed was full throughout the night. We triage about 500 patients per month, that 500 is never counted in our staffing. We were thinking of starting evening hours to help keep our numbers down. We were told that we can't get approval for additional but did she even bother to ask? I think this just pushed everyone over the edge, starting mother/baby."

8) Review of Mother Baby Meeting dated March 18, 2019, at 7:30 AM revealed, "Staff involvement in committee to move forward with plan. Implementation date March 25th. Like to have input from staff working. PowerPoint reviewed with staff. What are we going to do about staffing, extra time, mandatory stay? Agency nurse? This is a last resort Hired 2 new nurses, one on orientation now Don't have enough staff r/t LOA's Can't hire to cover LOA's Constantly losing people-staff feels never going to catch up. Working on-call, not really using on call much 3 12's-have to work extra 8 because getting benefits RICN volume down Productivity-when you need help, you need to use the staff that you have. Utilize the staff being flexed Staff are concerned about how we are going to staff for mom/baby New thinking, about where to place patients the best Looking at more support staff Cross training staff-why have RICN not been trained? Need a plan for orientation? ... ."

9) Review of job description, Interim Chief Nursing Officer, revealed, "General Responsibilities: Clinical operational and financial review of new acquisition opportunities. Development of business models and action plans to achieve operating results post-transition ... Actively participates in the organization's Operational Assessment Teams with particular focus on process improvement, labor productivity, contract labor reduction, resource management initiatives, and quality assurance ... Assists in the development and maintenance of the company's productivity reporting system. ... ."
10) Review of job description, Director, Woman/Child Services Department: Patient Care Services revealed, "... Job Summary: Accountable for the overall operations, efficiency, quality and financial performance of assigned clinical areas in collaboration with the physician chairman and other key stakeholders ... Mission Responsibilities: Core Competencies: ... Continuous Improvement - Acts to constantly improve the level of clinical and non-clinical outcomes and level of customer satisfaction in both individual and team work processes ... Leadership Responsibilities: ... Recommends a sufficient number of qualified and competent persons to provide care/services; ...Continuously assesses and improves the performance of care and services provided; ...Supervisory Responsibilities: Participated to some degree in each of the following responsibilities: Hires and Transfers - Interviews, selects, and provides for training of employees ... Assigns and Directs - Work Grants overtime; assigns & schedules. Adjusts Grievances - Meets with employees to listen to and resolve employee issues and adjust grievances. Essential Responsibilities: ...Oversight of quality and safety initiatives for each department. Improvement initiatives for patient and staff satisfaction ... ."
11) Review of job description, Nurse Manager-RN Department: Obstetrics, revealed, "... Job Summary Responsible for managing, coordinating and evaluating all aspects of care and outcomes for a designated group of patients. Supervises the delivery of patient care. Practices to the fullest extent of license, certification, or registration in accordance with organizational policies and procedures. ... Job Specific Competencies Supervisory Responsibilities Participate to some degree in each of the following responsibilities: Hires and Transfers-Interviews, selects, and provides for training of employees. Layoff and Recall-Recommends reduction in employee complement and initiates action, notifies employee(s) if conditions meet specific criteria. Promotes and Evaluates-Independently evaluates and determines work assignments and evaluates job performance, recognizes performances ... Assigns and Directs Work-Grants overtime; assigns and schedules. ... Exercises Supervisory Authority-Develops and implements department and/or hospital policy; insures all employees are trained in policy; exercises discretion, independent of policy to insure proper function of department or subdepartment. Essential responsibilities ... 6. Assigns patients to appropriate caregiver according to acuity, patient needs and level of care, 7. Coordinates team's work schedule (including 'off' time ) and approves all records supporting compensation. ... 9. Follows established orientation programs and assures completion of appropriate forms. ... ."

12) Review of facility documentation Staffing Plan for Maternity/Pediatrics. "Purpose: To provide quality care and meet the patient safety requirements of Women Child services. The Charge nurses of the involved units will work together to assess the situation, staffing capabilities, and coordinate care to transfer or place patients appropriately. Procedures for each area of the service line is detailed below: General Information: 1. The patient and staffing needs of the department take priority over flexing. 2. Level of staffing (RN, OB Technician and Clinical Support Associate) needs to be evaluated when the decision to flex takes place. (Acuity will be considered when flexing up of down.) 3. A minimum of 3 registered nurses must be present on the department at all times (even at lowest census). At this point all ancillary staff will be flexed off. ... 5. When a staff member needs to be paid for no lunch, the staff member is to make the appropriate punch in kronos and complete a pink slip. The reason for 'no lunch' must be stated. Assignments: Patient Care assignments are made by the Nurse Manager, supervisor, or charge nurse on the basis of the clinical complexity and dynamics for the nursing care needed. Assignments are matched to the individual nurse's ability to meet those needs. When assignments are being made, the charge nurses will decide who is best suited to cover each area. Department need, safety and experience are to be considered. For competency purposes, OB nurses will not be assigned Pediatric patients and Pediatric nurses will not be assigned antepartum patients during fetal monitoring of labor patients. OB nurses may need to care for those in neonatal (0-30 days) period, for example NAS, hyperbilirubinemia, weight loss, and hypothermia. In the event that predetermined assignments need to be adjusted, for example flexing up or down or for call off coverage, the following steps are to be taken: OB staff member needs to cover Maternity/Pediatrics: 1. Determine if need is for an RN or ancillary staff member (CSA or OB Tech). 2. Experience level, competency level and individual capabilities are to be evaluated to determine the best staff member to cover the need, 3. In the event that several staff members on duty can cover the need, then refer to the list to determine whose turn it is to cover the need. Maternity/Pediatrics nurse needs to cover OB: 1. One pediatric nurse is to remain on-call in house and is to report to OB to assist the unit. This nurse will need to cover any Pediatrics admissions or outpatient procedures therefore assignment should be that of assistance and support rather than a full assignment. This nurse will be paid from the Pediatrics cost center under minimal staffing requirements. 2. Other Pediatrics staff is flexed on call if not needed to work on OB. In the event that a pediatrics patient arrives, the on call person for the unit will be utilized so both pediatrics nurses can care for the pediatric patient per hospital policy. Requested time off guidelines: 1. Each schedule there will be a sheet posted for staff to write their name in the time slot that they would like to be considered to be off in the event that flexing takes place. 2. Each time a schedule is released, both Maternity and Maternity/Pediatrics begin a new list of flexed staff. If the need to flex is present, the charge nurse can refer to the posted departments to see who wants time off and then determine whose turn it is based on review of the list of staff who were already flexed. The staff member with the least number of hours is the one to flex after both units lists have been assessed. This may mean that an OB nurse needs to cover a need on Maternity/Pediatrics or a nurse on Maternity/Pediatrics needs to cover a need on OB. ... Flexible Staffing 1. Refer to the Daily Staffing Personnel Guide (Laborlytics staffing grid) for recommended staffing every 4 hours. 2. These hours are defined as 0700-1100, 1100-1500, 1500-1900, 1900-2300, 2300-0300, and 0300-0700. 3. The table states how many staff members are to be staffing the unit based on the patient volume present on the unit during that 4 hour period. 4. The table is built to calculate the staffing needs based on the head in the bed count for the post-partum area only. Other volume in other units is accounted for in the staffing standards used to build the table. 5. Document the head in the bed for all units as well as the staffing on the form titled Daily Staffing Maternity/Nursery/L&D/Triage."

13) Review of facility documentation dated May 8, 2015. "How to determine who is to stay mandatory: General information about the law enacted July 1st, 2009 The Act does not apply to staff who volunteer to work extra or who come in from home to work. The Act does not apply to on call time-on call time is predetermined. The Act does apply to direct patient care givers; RN's, LPN's, and CST's and NA's. Does not apply to unit secretaries. Mandatory stay is expected and is not protected in the event of national, state, municipal emergencies, natural disasters, acts of terrorism, or any unexpected absence that could not be covered ahead of time. The act does not apply to nursing staff involved in a procedure that is in progress such as a delivery, surgical procedure as well as charting that is required before a caregiver can safely leave the unit. To complete these activities, it is expected that an employee will remain on the unit to finish the work for the day. Time exceeding 1 hour will require documentation on the PER-21-under comments document what patient activity was in progress that required the stay-delivery, OR, charting, etc. Steps that need to be taken to prevent a mandatory stay-these steps need to be completed and documented on PER-21 to be compliant with the law. Once these steps have been taken, an employee may be mandated to work and still be in compliance with the law. These steps may be taken by the Nurse Manager or a designee, such as the charge nurse. 1. Ask all currently punched in staff if they will voluntarily stay to cover the need. The PER-21 needs to be completed and signed and signed by the employee to prove the voluntary stay. This is not a mandatory stay for our log book purposes. 2. Contact staff members who have volunteered to pick up extra time. There is a list located in the schedule binder that lists these individuals. The PER-21 does not need to be completed. 3. Contact staff members who are off duty to see if they would like to come in, even if not on the list. Those on the list should be called first. Employee will be paid time and a half and should punch call in emergency. 4. Contact hourly employees to see if they would be willing to report to work. 5. Once these efforts have been exhausted and documented, an employee may be mandated to stay. This can be documented on the mandatory stay log. 6. Review the mandatory stay list located in the schedule binder. Both the OB staff list and the Peds staff list are to be reviewed to determine whose turn it is to stay. The employee who had the least recent stay will be mandated to stay. Document this on the log for future reference. This determination was made to minimize the risk of the same individual needing to stay several times in a row. 7. Mandatory stay cannot be assigned to staff who teach class or have volunteered to come in extra that shift. Mandatory stay will only be assigned to staff members who are scheduled to work that shift. 8. If you pick up time for another staff member, mandatory guidelines do not apply (except for extreme circumstances). In that case, the Nurse Manager should be contacted to assist with staffing. If Nurse Manager unavailable, the Director should be called. The individual will be required to stay only if all efforts fail to provide staff coverage. In addition, the employee who needs to stay may take one hour of time to make personal arrangements. This time may be forfeited by the employee. If taken, the employee must punch out and punch back in after the 1 hour or sooner if arrangements are made sooner. The punch back in is a routine punch, not an on call punch. Time an a half is accrued per routine pay practices. This is not required if staying to complete a patient procedure or documentation. Also, employees who are mandated to work may take 10 hours of off duty time between shifts. This may also be waived by the employee and documented on the PER-21. Picking up Extra Time: ... 3. If you pick up time on the day that coverage is needed, you may punch in emergency, which will give you time and a half. ... On-Call Policy: 1. The Maternity/Pediatric departments will be viewed as a closed unit. The unit will utilize On-Call to cover the units staffing needs. On-Call will be scheduled to cover 3-11 & 11-7 on weekdays and 24/7 on weekends. 2. The On-Call will be utilized for Sick call offs Recovery of any category of C-section as needed Flexing-up during busy times on the unit. 3. There is a designated rotation that is rolling for the year. 4. Staff will be paid the On-call rate (as defined in Conemaugh's On-call policy). 5. On-call hours can be traded or given away. Staff will be responsible to find coverage for their on-call hours. This change should be documented on the pink assignment sheet. 6. Calling to complete the on call schedule will begin after the schedule has been posted. 7. A designated staff member will call to obtain on call hours. This is done on a pre established rotation that is defined and available for all staff to see. When calls are placed, a call will be made to the staff member's home and cell. 2 hours will then be provided for a return call prior to moving to the next staff member. Passes Hourly employees (Per hospital policy) are not required to take on call. ... 8. If a staff member is flexed off a shift, the scheduled on-call person is to be taken off call. The flexed individual is then placed on-call, unless mandatorily flexed. In this particular case, the on call remains on call, and the one mandatorily flexed is not placed on call. ... 9. The original on-call staff member must be notified (between the hours of 8 AM and 11 PM that they are 'off call' or they may still be paid on-call time. Outside of notification hours, notification will not occur but staff will be taken off call and not paid for on-call time. (This is a courtesy to the individual on call). 10. Only 4 hours are to be given off at a time including night shift. This will hopefully avoid the department paying time and a half staff for a shift staff was scheduled to work. Time and a half will not be given unless called in during the 4 hours of on call time. For the next four hours regular pay will be given. 11. CSA's and OB Tech's are to be considered when making the decision to flex and call in. If the work can be covered by utilization of a CSA or OB Tech then they may stay to cover the need. CSA's and OB Tech's can also flex if there is no activity that requires their attendance."

14) Review of the "RN Mandatory Stay List" from January 1, 2018, through March 22, 2019, revealed 77 mandated occurrences when a staff member signed their name, date, time and total hours [inconsistently filled in] they were mandated. 67 of the 77 mandated occurrences were on the "off shift" or after 3:00 PM. There were nine mandated