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Based on administrative record review and staff interview, the facility failed to ensure there is a sufficient number of licensed nursing staff based on census and needs of the patients. The facility failed to adhere to the established recommended standards for patient to nurse ratio in the Neonatal Intensive Care Unit for 26 of 28 shifts reviewed.

The findings included:

Review of the facility's license revealed the facility offers NICU (Neonatal Intensive Care Unit) Level 2 (25 beds) and Level 3 (20 beds).

The facility adheres to the RPICC (Regional Perinatal Intensive Care Center) guidelines for staffing the Neonatal Intensive Care Unit. The RPICC staffing guidelines document the following:
"RPICC Level II Neonatal Intensive Care Bed" - A patient care station in a RPICC with the capability of delivering special care to newborns including oxygen therapy, supplemental parenteral alimentation, constant electronic monitoring of vital signs, and with a minimum ratio of one member of the nursing staff to four patients.
"RPICC Level III Neonatal Intensive Care Bed" - A patient care station with the capability of delivering total intensive care to newborns including total respiratory support, supplemental parenteral alimentation, constant electronic monitoring of vital signs, long term arterial catherization, and with a minimum ratio of one member of the nursing staff to two patients, at all times, for the critical care of unstable neonates."

The facility failed to adhere to the minimum requirements outlined by RPICC for the care of the special needs of this vulnerable population of neonates for 26 of 28 shifts during a two-week period of 10/13/19 - 10/26/19, as noted on the NICU Assignment Sheet as follows:

1. On 10/13/19, 7 AM - 7 PM, the facility documented a census of 28 Level 3 patients, requiring 14 Registered Nurses (RNs), and a census of 23 level 2 patients, requiring 6 RNs plus 1 RN for additional transport/acuity; for a total of 21 RNs needed. The unit had 19 RNs documented as scheduled to work this tour.

2. On 10/13/19, 7 PM - 7 AP, Level 3 census of 29, requiring 14 RNs; Level 2 census 23, requiring 6 RNs plus 1; requiring a total of 21 nurses. The facility had 18 scheduled nurses.

3. On 10/14/19, 7 AM - 7 PM, Level 3 census 32, requiring 15 RNs; Level 2 census 20, requiring 6 RNs plus 1; requiring a total of 22 nurses. The facility documented 16 scheduled nurses.

4. On 10/14/19, 7 PM - 7AM, Level 3 census 33, requiring 16 RNs; Level 2 census 19, requiring 5 RNs plus 1; requiring a total of 22 nurses. The facility documented 18 scheduled nurses.

5. On 10/15/19, 7 AM - 7 PM, Level 3 census 34, requiring 16 RNs (the shift initially had a census of 32, then 33 and eventually 34); Level 2 census 16, requiring 5 RNs (the shift initially had a census of 20, then 19 and eventually noted 16) plus 1; requiring a total of 22 nurses. The facility documented 15 1/2 scheduled nurses.

6. On 10/15/19, 7 PM - 7 AM, Level 3 census 34, requiring 17 nurses; Level 2 census 16, requiring 4 nurses plus 1; requiring a total of 22 nurses. The facility documented 17 scheduled nurses.

7. On 10/16/19, 7 AM - 7 PM, Level 3 census 36, requiring 18 RNs; Level 2 census 16, requiring 4 RNs plus 1; requiring a total of 23 nurses. The facility documented 17 scheduled nurses.

8. On 10/17/19, 7 AM - 7 PM, Level 3 census 31, requiring 15 RNs; Level 2 census 20, requiring 5 RNs plus 1; requiring a total of 21 nurses. The facility documented 18 scheduled nurses.

9. On 10/17/19, 7 PM - 7 AM, Level 3 census 32, requiring 15 RNs; Level 2 census 19, requiring 5 RNs plus 1; requiring a total of 21 nurses. The facility documented 18 scheduled nurses.

10. On 10/18/19, 7 AM - 7 PM, Level 3 census 31, requiring 15 RNs; Level 2 census 20, requiring 5 RNs plus 1; requiring a total of 22 nurses. The facility documented 16 scheduled nurses.

11. On 10/18/19, 7 PM - 7 AM, Level 3 census 32, requriing 15 RNs; Level 2 census 20, requiring 5 RNs plus 1; requiring a total of 21 nurses. The facility documented 18 scheduled nurses.

12. On 10/19/19, 7 AM - 7 PM, Level 3 census 33, requiring 16 RNs; Level 2 census 20, requiring 5 RNs (census went down to 18) plus 1; requiring a total of 22 nurses. The facility documented 21 scheduled nurses.

13. On 10/19/19, 7 PM - 7AM, Level 3 census 33, requiring 16 RNs; Level 2 census 19, requiring 5 RNs plus 1; requiring a total of 22 nurses. The facility documented 18 scheduled nurses.

14. On 10/20/19, 7 AM - 7 PM, Level 3 census 32, requiring 16 RNs; Level 2 census 18, requiring 5 RNs (census decreased to 17) plus 1; requiring a total of 22 nurses. The facility documented 19 scheduled nurses.

15. On 10/20/19, 7 PM - 7 AM, Level 3 census 32, requiring 16 RNs; Level 2 census 17, requiring 5 RNs plus 1; requiring a total of 22 nurses (19 ventilators). The facility documented 21 scheduled nurses.

16. On 10/21/19, 7 AM - 7 PM, Level 3 census 32, requiring 16 RNs; Level 2 census 17, requiring 5 RNs plus 1; requiring a total of 22 nurses (19 ventilators). The facility documented 16 scheduled nurses.

17. On 10/21/19, 7 PM - 7 AM, Level 3 census 32 , requiring 16 RNs (census increased to 34); Level 2 census 19, requiring 5 RNs plus 1; requiring a total of 22 nurses; (19 ventilators). The facility documented 17 scheduled nurses.

18. On 10/22/19, 7 AM - 7 PM, Level 3 census 32, requiring 15 RNs; Level 2 census 20, requiring 6 RNs plus 1; requiring a total of 22 nurses. The facility documented 16 scheduled nurses.

19. On 10/22/19, 7 PM - 7 AM, Level 3 census 32, requiring 16 RNs; Level 2 census 24, requiring 6 RNs plus 1; requiring a total of 23 nurses (22 ventilators). The facility documented 18 scheduled nurses.

20. On 10/23/19, 7 AM - 7 PM, Level 3 census 30, requiring 15 RNs; Level 2 census 26, requiring 7 RNs plus 1; requiring a total of 23 nurses. The facility documented 20 scheduled nurses.

21. On 10/23/19, 7 PM - 7 AM, Level 3 census 32, requiring 16 RNs; Level 2 census 25, requiring 7 RNs plus 1; requiring a total of 24 nurses. The facility documented 21 scheduled nurses.

22. On 10/24/19, 7 AM - 7 PM, Level 3 census 32, requiring 16 RNs (census decreased to 30); Level 2 census 26, requiring 7 RNs (census increased to 28) plus 1; requiring 24 nurses. The facility documented 23 scheduled nurses.

23. On 10/24/19, 7 PM - 7 AM, Level 3 census 30, requiring 15 RNs; Level 2 census 28, requiring 7 RNs plus 1; requiring a total of 23 nurses. The facility documented 18 scheduled nurses.

24. On 10/25/19, 7 AM - 7 PM, Level 3 census 31, requiring 15 RNs; Level 2 census 28, requiring 7 RNs plus 1; requiring a total of 23 nurses. The facility documented 19.5 scheduled nurses.

25. On 10/25/19, 7 PM - 7 AM, Level 3 census 32, requiring 15 RNs; Level 2 census 28, requiring 7 RNs plus 1; requiring a total of 23 nurses. The facility documented 20 scheduled nurses.

26. On 10/26/19, 7 PM - 7 AM, Level 3 census 30, requiring 15 RNs; Level 2 census 29, requiring 8 RNs plus 1; requiring a total of 24 nurses. The facility documented 21 scheduled nurses.

An interview was conducted on 10/29/19 beginning at 1:10 PM with the Administrator of the Children's Hospital and Women's Services, the Chief Nursing Officer and the Patient Safety Officer/Risk Manager. The Administrator reported that the facility is experiencing an increase in their census with the number of babies being born in the facility. The facility's Neonatal Intensive Care Unit (NICU) is licensed for 45 (25 Level 2 and 20 Level 3) but now the census is averaging 55. The facility has to utilize the far side nursery to accommodate the overflow. She further reported they received correspondence, dated February 5, 2019 from the agency regarding the occupancy of the facility's Level III NICU. They responded to this letter addressing the concerns of overcapacity and the possible plan to resolve but not implemented. However, as of October 2019, the facility now has staffing issues as well. The administrative staff acknowledged that there is a persistent issue with the staffing, complicated by staff absences / call-outs, and they are attempting to get staff hired and trained to care for these specialized patients but have been unable to meet the minimum standards for the staffing ratio established by RPICC as noted above.