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Based on newborn infant observations, reviews of the Hospital's license, 2 newborn infant medical records (Patients #2 and #6), in a total sample of 12 and interview, Medical Staff failed to transfer newborn infants with care requirements that exceeded the designated level of care allowed by the Hospital's license.

Findings include:

1.) The Hospital's Commonwealth of Massachusetts Department of Public Health License, issued 7/21/12, indicated the Hospital is licensed for a Level I-A/Well Infant Nursery.

2.) A Tour of the Hospital's Level I-A/Well Infant Nursery, conducted on 8/6/14, identified 2 Level I-B Nursery (a community-based newborn nursery with the capability of caring for newborns born at 35 weeks or more gestation that require more than Level I-A/Well Infant Nursery care, but do not require Level II Special Care Nursery or a higher level of care) infants (Patients #2 and #6).

3.) Patient #2 was being assessed for neonatal abstinence syndrome (NAS; a syndrome that occurs in newborns who were exposed to addictive opiate drugs while in the womb). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was born on 7/24/14 and was being treated for NAS with morphine sulfate (an opiate medication). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was on oxygen saturation and heart rate monitoring. Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

4.) Patient #6 had a nasogastric tube in place. Patient #6's Newborn Admission Note, dated 7/24/14, indicated he/she was born prematurely (at 34 weeks, 6 days gestation) on 7/24/14. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was receiving intermittent gavage (nasogastric tube) feedings. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

The Surveyor interviewed the Chief of Pediatrics at 7:55 A.M. on 8/7/14. The Chief of Pediatrics said the Hospital has pediatric physician coverage 24 hours/day, 7 days/week and the Pediatrician and Nursery Nursing Staff have been caring for NAS babies for a few years. The Chief of Pediatrics said the Pediatrician and Nursery Nursing Staff have also been ordering and administering gavage feeding for quite some time. The Chief of Pediatrics said she was familiar with the Commonwealth of Massachusetts Department of Public Health regulations related to maternal and newborn services, but did not understand that NAS assessment and treatment and gavage feeding were beyond the scope of a Level I-A/Well Infant Nursery.

Based on observations, reviews of the Hospital's license; Maternity standards of care; 3 newborn infant medical records (Patients #2, #4 and #6) in a total sample of 12 and interviews, Nursing Administration implemented standards of care for the care newborn infants that exceeded the designated level of care allowed by the Hospital's license.

Findings include:

1.) The Hospital's Commonwealth of Massachusetts Department of Public Health License, issued 7/21/12, indicated the Hospital is licensed for a Level I-A/Well Infant Nursery.

2.) A Tour of the Hospital's Level I-A/Well Infant Nursery, conducted on 8/6/14, identified 2 Level I-B Nursery (a community-based newborn nursery with the capability of caring for newborns born at 35 weeks or more gestation that require more than Level I-A/Well Infant Nursery care, but do not require Level II Special Care Nursery or a higher level of care) infants (Patients #2 and #6).

3.) Patient #2 was being assessed for neonatal abstinence syndrome (NAS; a syndrome that occurs in newborns who were exposed to addictive opiate drugs while in the womb). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was born on 7/24/14 and was being treated for NAS with morphine sulfate (an opiate medication). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was on oxygen saturation and heart rate monitoring. Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

4.) Patient #6 had a nasogastric tube in place. Patient #6's Newborn Admission Note, dated 7/24/14, indicated he/she was born prematurely (at 34 weeks, 6 days gestation) on 7/24/14. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was receiving intermittent gavage (nasogastric tube) feedings. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

5.) The Surveyor interviewed the Vice President (VP) of Patient Care Services/Chief Nursing Officer (CNO) and the Maternal Child Health (MCH) Nurse Manager at 2:30 P.M. on 8/6/14. The VP of Patient Care Services/CNO and the MCH Nurse Manager said the Hospital has pediatric physician coverage 24 hours/day, 7 days/week and the Pediatrician and Nursery Nursing Staff have been caring for NAS babies for a few years. The VP of Patient Care Services/CNO and the MCH Nurse Manager said the Pediatrician and Nursery Nursing Staff have also been ordering and administering gavage feeding for quite some time. The VP of Patient Care Services/CNO and the MCH Nurse Manager said they were familiar with the Commonwealth of Massachusetts Department of Public Health regulations related to maternal and newborn services, but did not understand that NAS assessment and treatment and gavage feeding were beyond the scope of a Level I-A/Well Infant Nursery.

6.) Patient #4's Newborn Admission Note, dated 7/29/14, indicated he/she was born on 7/29/14 and was being assessed for NAS. Patient #4's Newborn Flowsheet and Progress Notes, dated 7/29/14-8/6/14, indicated he/she was assessed for NAS in accordance with the Maternity Standard of Care titled "Care of the Substance Exposed Infant" and did not require the administration of morphine sulfate. Patient #4's Newborn Flowsheet and Progress Notes, dated 7/29/14-8/6/14, indicated he/she was in stable condition and progressing well.

7.) A review of Maternity Standards of Care identified standards related to the care Level 1-B Nursery (or higher level of care) newborns. The Maternity Standards of Care included standards titled "Care of the Substance Exposed Infant", "Gavage Feeding" and "Neonatal Oxygen Administration".

8.) A review of 3 nursing personnel files (RNs #1, #4 and #8's files) and nursing education programming and attendance records indicated Maternity Nursing Staff received education regarding care of the substance exposed infant, NAS, gavage feeding and neonatal oxygen administration.

Based on newborn infant observations, reviews of the Hospital's license, 2 newborn infant medical records (Patients #2 and #6), in a total sample of 12 and interview, Medical Staff failed to transfer newborn infants with care requirements that exceeded the designated level of care allowed by the Hospital's license.

Findings include:

1.) The Hospital's Commonwealth of Massachusetts Department of Public Health License, issued 7/21/12, indicated the Hospital is licensed for a Level I-A/Well Infant Nursery.

2.) A Tour of the Hospital's Level I-A/Well Infant Nursery, conducted on 8/6/14, identified 2 Level I-B Nursery (a community-based newborn nursery with the capability of caring for newborns born at 35 weeks or more gestation that require more than Level I-A/Well Infant Nursery care, but do not require Level II Special Care Nursery or a higher level of care) infants (Patients #2 and #6).

3.) Patient #2 was being assessed for neonatal abstinence syndrome (NAS; a syndrome that occurs in newborns who were exposed to addictive opiate drugs while in the womb). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was born on 7/24/14 and was being treated for NAS with morphine sulfate (an opiate medication). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was on oxygen saturation and heart rate monitoring. Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

4.) Patient #6 had a nasogastric tube in place. Patient #6's Newborn Admission Note, dated 7/24/14, indicated he/she was born prematurely (at 34 weeks, 6 days gestation) on 7/24/14. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was receiving intermittent gavage (nasogastric tube) feedings. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

The Surveyor interviewed the Chief of Pediatrics at 7:55 A.M. on 8/7/14. The Chief of Pediatrics said the Hospital has pediatric physician coverage 24 hours/day, 7 days/week and the Pediatrician and Nursery Nursing Staff have been caring for NAS babies for a few years. The Chief of Pediatrics said the Pediatrician and Nursery Nursing Staff have also been ordering and administering gavage feeding for quite some time. The Chief of Pediatrics said she was familiar with the Commonwealth of Massachusetts Department of Public Health regulations related to maternal and newborn services, but did not understand that NAS assessment and treatment and gavage feeding were beyond the scope of a Level I-A/Well Infant Nursery.

Based on observations, reviews of the Hospital's license; Maternity standards of care; 3 newborn infant medical records (Patients #2, #4 and #6) in a total sample of 12 and interviews, Nursing Administration implemented standards of care for the care newborn infants that exceeded the designated level of care allowed by the Hospital's license.

Findings include:

1.) The Hospital's Commonwealth of Massachusetts Department of Public Health License, issued 7/21/12, indicated the Hospital is licensed for a Level I-A/Well Infant Nursery.

2.) A Tour of the Hospital's Level I-A/Well Infant Nursery, conducted on 8/6/14, identified 2 Level I-B Nursery (a community-based newborn nursery with the capability of caring for newborns born at 35 weeks or more gestation that require more than Level I-A/Well Infant Nursery care, but do not require Level II Special Care Nursery or a higher level of care) infants (Patients #2 and #6).

3.) Patient #2 was being assessed for neonatal abstinence syndrome (NAS; a syndrome that occurs in newborns who were exposed to addictive opiate drugs while in the womb). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was born on 7/24/14 and was being treated for NAS with morphine sulfate (an opiate medication). Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was on oxygen saturation and heart rate monitoring. Patient #2's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

4.) Patient #6 had a nasogastric tube in place. Patient #6's Newborn Admission Note, dated 7/24/14, indicated he/she was born prematurely (at 34 weeks, 6 days gestation) on 7/24/14. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was receiving intermittent gavage (nasogastric tube) feedings. Patient #6's Newborn Flowsheet and Newborn Progress Notes, dated 7/24/14-8/6/14, indicated he/she was in stable condition and progressing well.

5.) The Surveyor interviewed the Vice President (VP) of Patient Care Services/Chief Nursing Officer (CNO) and the Maternal Child Health (MCH) Nurse Manager at 2:30 P.M. on 8/6/14. The VP of Patient Care Services/CNO and the MCH Nurse Manager said the Hospital has pediatric physician coverage 24 hours/day, 7 days/week and the Pediatrician and Nursery Nursing Staff have been caring for NAS babies for a few years. The VP of Patient Care Services/CNO and the MCH Nurse Manager said the Pediatrician and Nursery Nursing Staff have also been ordering and administering gavage feeding for quite some time. The VP of Patient Care Services/CNO and the MCH Nurse Manager said they were familiar with the Commonwealth of Massachusetts Department of Public Health regulations related to maternal and newborn services, but did not understand that NAS assessment and treatment and gavage feeding were beyond the scope of a Level I-A/Well Infant Nursery.

6.) Patient #4's Newborn Admission Note, dated 7/29/14, indicated he/she was born on 7/29/14 and was being assessed for NAS. Patient #4's Newborn Flowsheet and Progress Notes, dated 7/29/14-8/6/14, indicated he/she was assessed for NAS in accordance with the Maternity Standard of Care titled "Care of the Substance Exposed Infant" and did not require the administration of morphine sulfate. Patient #4's Newborn Flowsheet and Progress Notes, dated 7/29/14-8/6/14, indicated he/she was in stable condition and progressing well.

7.) A review of Maternity Standards of Care identified standards related to the care Level 1-B Nursery (or higher level of care) newborns. The Maternity Standards of Care included standards titled "Care of the Substance Exposed Infant", "Gavage Feeding" and "Neonatal Oxygen Administration".

8.) A review of 3 nursing personnel files (RNs #1, #4 and #8's files) and nursing education programming and attendance records indicated Maternity Nursing Staff received education regarding care of the substance exposed infant, NAS, gavage feeding and neonatal oxygen administration.