HospitalInspections.org

Based on review of a generally identified standard of practice, facility documents, medical records (MR), observation, and interview with staff (EMP), it was determined the facility failed to ensure the Neonatal Intensive Care Unit (NICU) was adequately staffed.

Findings include:

Review on August 22, 2013, of the generally identified standard of practice revealed "Neonatal Intensive Care Unit. Constant nursing and continuous cardiopulmonary and other support for severely ill newborns should be provided in the intensive care unit. ... The number of nursing, medical, and surgical personnel required in the neonatal intensive care area is greater than that required in less acute perinatal care areas. The nurse to patient ratio should be 1:2 or 1:1, depending on acuity. In some cases, such as extracorporeal life support, additional nursing personnel are required. In addition, the amount and complexity of equipment required also are considerably greater. In multipatient rooms, there should be at least 120 ft. of floor space for each neonate, beds should be separated by at least, 8 ft, and aisles should be 4 ft (1.22 m) wide. ... Each patient station needs at least 20 simultaneously accessible electrical outlets, 3-4 oxygen outlets, 3-4 compressed air outlets and 3-4 vacuum outlets. ..."

Review on August 22, 2013, of the facility policy "Staffing of the NICU," dated reviewed March 2, 2013, revealed "Policy Staffing shall be adequate to meet nursing goals, standards of nursing practice, and nursing care needs of patients. a. A minimum of two (2) RN's will be maintained in the NICU whenever occupied. b. Nurse/patient ratios: Newborns requiring continuing care: 1:3-4, b. Newborns requiring intermediate care 1:2-3 c. Newborns requiring intensive care 1:1-2 d. Newborns requiring multisystem support:1:1 e. Newborns requiring complex critical care:1:1 or greater."

Observation tour on August 22, 2013, of the NICU at 9:30 AM revealed six occupied bassinets in the NICU. The four bassinets on the right wall were approximately 1 foot apart. There were two registered nurses in the NICU at the beginning of the unannounced tour. Thirty minutes after the tour began a third nurse returned from the Cesarean section room where they were attending a delivery.

Review on August 22, 2013, of the medical records for the six patients in the NICU at the time of the observation tour revealed the following:

MR1 was admitted on August 17, 2013, for respiratory distress, requiring mechanical ventilation, anemia and hypovolemia, requiring transfusion. On August 22, 2013, the day of the observation tour, MR1 remained mechanically ventilated.

MR2 was admitted on July 17, 2013, for suspected sepsis. The patient was mechanically ventilated and had been exposed to intrauterine heroin with episodes of apnea. On August 22, 2013, the day of the observation tour, MR2 remained on oxygen. The patient was no longer ventilated. The patient was being observed for drug withdrawal symptoms and hypovolemia.

MR3 was admitted on August 20, 2013, for respiratory distress, possible sepsis, a very large PDA (patent ductus arteriosus), and possible chromosomal issues. On August 22, 2013, the day of the observation tour, MR3 was being weaned from mechanical ventilation, was ultimately extubated, was on continuous blood pressure and SAO2 (oxygen) monitoring, remained on antibiotics, and TPN (total parenteral nutrition) was started.

MR4 was admitted on August 17, 2013, for rule out sepsis diagnosis and an elevated white blood cell count. On August 22, 2013, the day of the observation tour, MR4 was being prepped for discharge.

MR5 was admitted on August 8, 2013, with the diagnosis of neonatal abstinence syndrome, requiring morphine, and exhibiting tremors when disturbed. On August 22, 2013, the day of the observation tour, MR5 was being weaned from Morphine and was being monitored.

MR6 was admitted on August 21, 2013, for respiratory distress and was mechanically ventilated. On the day of the observation tour, MR1 remained mechanically ventilated and on TPN.

Interview on August 22, 2013, with EMP4 confirmed that at times there were three to four patients on mechanical ventilation, and the NICU was staffed with three nursing staff members.

Review of the nursing staff schedule for June, July and August revealed the facility did not provide 1:1 or 1:2 staffing for these high census days. For example, on June 11, 2013, with a census at midnight of 10 and then nine throughout the day, there were four RNs on 7-3, 3.5 RNs on 3-11 and three RNs on 11-7. On July 30, 2013, with a census of 10 babies, the staffing was 3.3 RNs on 7-3 and three RNs on 11-7.

Interview on August 22, 2013, with EMP1 confirmed there was not a 1:1 or 1:2 ratio as required by the generally identified standard of practice. EMP1 stated the nurse staffing was based on acuity. EMP1 was unable to provide an acuity scale. EMP1 stated all the babies were not "true" NICU babies. EMP1 noted they were more intermediate care. EMP1 noted there was not another space to provide the intermediate care.

Interview with EMP5 on August 22, 2013, confirmed the NICU census was greater than four patients for the past two months.

Interview with EMP1 on August 22, 2013, confirmed that one NICU staff nurse would leave the NICU to go to Labor and Delivery after the incision was made to bring the baby to the nursery.

Based on review of Department of Health (Department) documents, facility documents, observation, and interview with facility staff (EMP), it was determined the facility exceeded the number of patients in the Neonatal Intensive Care Unit (NICU) and provided care to NICU patients in the well-baby overflow/isolation area.

Findings include:

1) Review of Department documents revealed an occupancy (JFYY11) for the NICU was completed on July 26, 2010. The occupancy was granted for four NICU beds based on the generally identified standard of practice in 2010. The area met the requirements for space, equipment and staffing for four NICU beds.

Observation tour on August 22, 2013, of the NICU at 9:30 AM revealed six occupied bassinets in the NICU. The four bassinets on the right wall were approximately 1 foot apart. There were two registered nurses in the NICU at the beginning of the unannounced tour. Thirty minutes after the tour began a third nurse returned from the Cesarean section room where they were attending a delivery.

Review of facility documents revealed the NICU census for every day of June 2013, exceeded four patients, with the exception of June 20, 2013. The census was as follows for:
June 1, 17, 18, 25 and 26, 2013, six babies.
June 2, 5, 6, 7,and 28, 2013, eight babies.
June 3, 4, 8, 9, 10, 12, 13, 14, 2013, nine babies.
June 11, 2013, 10 babies.
June 15, 16, 22, 23, 24, 27, 29 and 30, 2013, seven babies.
June 19 and 21, 2013, five babies.
July 2, 4, 5, 6, 7 and 15, 2013, six babies.
July 1, 3, 14 and 16, 2013, seven babies.
July 8, 9, 11, 12, 13, 17, 18, 19, 20, 21, 2013, eight babies.
July 10, 22, 23, 24, 25, and 26, 2013, nine babies.
July 10, 27, 28, 30, 31, 2013, 10 babies.
July 29, 2013, 12 babies.
August 1, 2013, 11 babies.
August 2 and 3, 2013, eight babies.
August 4, 5, and 6, 2013, seven babies.
August 7, 8, 9, 10, 11, 12, 20, and 21, 2013, five babies.
August 22, 2013, six babies.

2) Observation tour revealed another small room located outside of the NICU. This room was designated and granted occupancy as a well-baby overflow/isolation area. The room was set up for three bassinets. The room did not meet the NICU requirements for wall mounted oxygen outlets, compressed-air outlets and vacuum outlets.

Interview with EMP1 on August 22, 2013, confirmed the room, designed and granted occupancy as a well-baby overflow/isolation area, was also used for NICU babies. There were no NICU babies in this room at the time of the tour.

Interview with EMP2 on August 22, 2013, confirmed the days the NICU had a census exceeding nine, NICU babies would be placed in the well-baby overflow/isolation area.

Interview with EMP3 confirmed during the last two months the census in the NICU exceeded four babies.

Based on review of facility policy and procedure, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure patients admitted to the Neonatal Intensive Care Unit (NICU) from home were admitted into an isolation area for five of five discharged medical records reviewed (MR7, MR8, MR9, MR10, and MR11).

Findings include:

Review on August 22, 2013, of the "NICU Admission Criteria," dated approved March 7, 2013, revealed "Policy ... It is the policy of Pocono Medical Center to provide every newborn with a complete assessment and determination of health status to designate an appropriate level of care. ... Criteria for Admission to Level III Neonatal Unit ... A. Admission to Level III NICU will be: ... d. From home, into an isolation area, following consult from Pediatrician/Primary Care Physician due to issues developed after discharge and before 28 days of age ... "

Review on August 22, 2013, of MR7 revealed the patient was admitted from the pediatrician's office to the well-baby overflow/isolation area on April 4, 2013, at nine days of life with the diagnoses of preterm infant at 35 weeks, transient hypothermia, and feeding issues. The baby was discharged to home on April 5, 2013. The well-baby overflow/isolation area to which the baby was admitted did not meet the requirements for wall-mounted oxygen, compressed air and vacuum, as there were only two wall mounts per patient area and not the three required.

Review on August 22, 2013, of MR8 revealed the patient was admitted through the Emergency Department to the well-baby overflow/isolation area on April 17, 2013, at 14 days of life with an elevated temperature and presumed sepsis. The baby was discharged on April 24, 2013. The well-baby overflow/isolation area to which the baby was admitted did not meet the requirements for wall-mounted oxygen, compressed air and vacuum, as there were only two wall mounts per patient area and not the three required.

Review on August 22, 2013, of MR9 revealed the patient was admitted from the Emergency Department to the well-baby overflow/isolation area on May 16, 2013, at nine days of life with an elevated bilirubin level and dehydration. The baby was discharged on May 18, 2013. The well-baby overflow/isolation area to which the baby was admitted did not meet the requirements for wall-mounted oxygen, compressed air and vacuum, as there were only two wall mounts per patient area and not the three required.

Review on August 22, 2013, of MR10 revealed the patient was admitted from the Emergency Department to the well-baby overflow/isolation area on June 7, 2013, at 17 days of life with sepsis, dehydration, and apnea. The baby was discharged on June 17, 2013. The well-baby overflow/isolation area to which the baby was admitted did not meet the requirements for wall-mounted oxygen, compressed air and vacuum, as there were only two wall mounts per patient area and not the three required.

Review on August 22, 2013 of MR11 revealed the patient had been admitted from the Emergency Department to the well-baby overflow/isolation area on August 9, 2013 at 5 days of life with an elevated bilirubin and sodium levels. The baby was discharged on August 11, 2013. The well-baby overflow/isolation area to which the baby was admitted did not meet the requirements for wall-mounted oxygen, compressed air and vacuum, as there were only two wall mounts per patient area and not the three required.

Interview on August 22, 2013, with EMP1 at approximately 2:15 PM confirmed the well-baby overflow/isolation area did not meet the requirements for vacuum, suction and oxygen as there were only 2 wall mounts per patient area and not the 3 required.

Interview with EMP6 on August 22, 2013, confirmed infection control was not aware these babies were discharged and brought back into the NICU with elevated white counts and possible infections.