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Based on interview, record review, and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. The governing body failed to ensure its quality assessment and performance improvement program identified and monitored the safety of services in its neonatal intensive care unit (NICU), and failed to: 1) ensure actions planned to address identified discrepancies in NICU isolation protocols were implemented (Tag A0285); 2) provide a safe physical environment to provide care for neonatal patients (Tag A0700, A0725); and 3) ensure the hospital maintained a sanitary environment to provide care for neonates (Tag A0747).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.

Based on observation, interview, and document review, the facility failed to ensure its quality assessment and performance improvement program identified and monitored the safety of services in its neonatal intensive care unit (NICU).

Findings include:

On 12/3/10, the following two deficiencies were cited at the facility by the Bureau of Health Care Quality and Compliance with regard to the NICU unit: 1) A sanitary environment to avoid sources of transmission of infection and safety hazards was not maintained; and 2) contact isolation protocols were not being followed for an infant colonized with clostridium difficile bacillus.

During subsequent tours of the NICU unit on 3/10/11 and 3/11/11, issues related to hazards, infection control, and physical environment were observed. In one of the overflow NICU rooms, which could hold up to 10 infants, there was shelving above the bassinets. On the shelves were loose objects, medical devices, and cords, which had the potential of falling onto the infants. The shelves had a layer of dust and debris, putting the infants with respiratory conditions at risk. Sharps containers were placed on the wall next to the bassinets, requiring staff to have to reach over infants to discard needles.

The space in this overflow room was inadequate to provide the required spacing between bassinets, and to provide adequate room for staff and visitors.

These findings pertaining to the overflow NICU room were brought to the attention of the Director of Nursing (DON), who agreed the current conditions of the room could jeopardize the safety and health of infants. When these findings were brought to the attention of Performance Improvement (PI) Committee members on 3/10/11 in the afternoon, including the Chief Executive Officer, the Quality Outcomes Officer, and the Risk Manager, the members acknowledged they were unaware of these problems. The members acknowledged the safety of services in the NICU unit, with regard to hazards, infection control, and physical environment, were not being monitored by the PI Committee. Performance improvement activities did not include identifying problems in the NICU unit to assure the safety of services in that high-risk, high-volume area.

Based on observation, interview, and document and record review, the facility failed to provide and maintain a physical environment that was safe for neonatal patients as evidenced by: providing care in unlicensed areas that had shelving constructed that posed hazards to neonates, neonatal areas that had insufficient space to provide proper care, hazard containers that were placed in areas that could harm neonates, and improperly stored equipment in patient care areas (Tag A0725).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated care to its patients.

Based on observation, interview, and record review, the facility failed to treat neonatal patients in an appropriately designed and safe environment.

Findings include:

To better understand the layout of the facility, the surveyor designated a number to each corresponding area:

#1. Neonatal Intensive Care Unit (NICU) State licensed to treat 19 neonates.
#2. First unlicensed overflow area assigned to treat 6 neonates in the first room.
#3. Attached to Area #2 - an unlicensed overflow area assigned to treat 4 neonates in the second room.
#4. Second unlicensed overflow area assigned to treat 5 neonates.
#5. Third unlicensed overflow area attached to the licensed NICU to treat 4 neonates.

On 3/10/2011 in the morning, an initial tour of the NICU (Area #1) on the third floor was completed. The census during the morning of 3/10/2011, was twenty neonates. The NICU (Area #1) was licensed by the State of Nevada to treat nineteen level 2 or level 3 neonates. During the initial tour, fourteen neonates were being treated in the State licensed nineteen neonate area (Area #1).

On 3/10/2011 in the morning, in a different area on the same floor as the NICU (Area #1), was the first secured and enclosed area which treated level 2 neonates (Area #2, #3). Area # 2 and #3 were considered an overflow area for the NICU (Area #1) and had 10 available spaces to treat level 2 neonates. Area #2 and #3 were not licensed by the State to treat any neonates but the areas were still labeled as an NICU by the staff.

On 3/10/2011 in the morning, six neonates were being treated in Area #2, the unlicensed area. In the licensed NICU (Area #1), there were still 5 available areas to treat neonates but 5 neonates were being treated in the overflow unlicensed NICU (Area #2).

On 3/10/2011 in the morning, on the same floor, Area #4 was located away from the licensed NICU (Area #1) and unlicensed Area #2 and #3. Area #4 was designated by the staff as another NICU over flow area to treat five level 2 neonates. The area was not licensed by the State to treat level 2 or level 3 neonates.

On 3/10/2011 in the morning, Area #5 was an area to treat 4 neonates. Area #5 was located in a back room of area #1. Area #5 was not visible from the nursing station and was not licensed to treat level 2 or level 3 neonates. On 3/10/2011 in the afternoon, the Director of Women Services indicated level 2 or 3 neonates could be treated in Area #5, which was unlicensed.

On 3/10/2011 in the morning, in Area #1 were two enclosed rooms that were used for neonatal care and isolation rooms. The nursing staff indicated that 2 neonates with no infections could be placed in one room. The enclosed room dimensions were 9.6 feet by 9.8 feet. If 2 additional neonates were placed into the isolation rooms the total number of neonates in Area #1 would be 21. Again, Area #1 was licensed for 19 level 2 or level 3 neonates.

The total number of unlicensed over flow neonate care areas were 21 and a total of licensed areas in Area #1 were 19, giving a total of 40 neonates being treated in the unlicensed and licensed areas on the third floor. On 3/11/2011 in the morning, the Director of Women Services indicated the neonate census had been up to 35 at one time.

Area #1

On 3/10/2011 and 3/11/2011 in the morning, several large medical equipment items, which were covered with plastic, were being stored in the aisles of the the licensed NICU area. There were three aisles which staff and family could pass to get to 4 neonate care areas at one side of the NICU (Area #1), but since equipment blocked 2 of the aisles, there was only one small area to pass.

Along with blocking the walkway to patient care areas, the equipment was stored next to cribs where neonates were being cared for, leaving only space for the nurse to provide care on one side of the crib.

Area #2

On 3/11/2011 in the morning, Area #2 (unlicensed overflow) had six neonates in their cribs along the wall of the area. Along the walls of the room, secured over 5 feet above the floor, were 15 inches wide (from the wall to the front edge of the shelf) continuous shelving that covered each wall from end-to-end. The shelves were cluttered with monitors, binders, papers, telemetry cords. electrical cord packs, flow meters. suction meters, extension poles, and other medical devices. Some areas of the shelf had items stacked on top of each other.

The patient monitors had the telemetry cords dangling over the shelves and were connected to the neonates. All the items on the shelves were not secured down with straps. Anyone could reach over above their heads, extend their arm and reach for an item on the shelf. It would also be difficult to see what was on the shelf if an individual was short in stature. There was a potential for items to fall off the shelf due to the stacking of the items or from pulling cords that were tangled with items on the shelf.

To see the top surface of the shelf, the surveyor who was 5 foot 8 inches tall, had to stand next to the shelving and extend his neck backwards. Without having to swipe his hands on the shelf, the surveyor noted a coating of dust and clumps of dust along the entire shelf. Trash items such as small pieces of papers and thermometer probes were also noted.

All six cribs were situated at an angle where the inside head area of the cribs were 2 to 2.5 feet directly under the front edge of the shelving. The cribs had no protective covering over the top of the crib and the top was open to air. If an item were to fall off directly from the front edge of the shelf, the item could possibly hit the neonates. Obtaining cords or items from the shelf could stir up dust, which could have fallen on top of the neonate.

Area #3

Area #3's (unlicensed overflow) dimensions were 10 feet by 9.8 feet (98 square feet). Along one wall of the area was the same 15 inch wide shelving that was secured to the entire 10 foot wall. The height of the shelves was greater than 5 feet above the floor. The same medical items were stored on the shelving. Dust and trash were noted on the top surface of the shelf.

On 3/10/2011 in the morning, the Director of Women Services indicated Area #3 (unlicensed area) could only hold up to 3 neonates in the area. Area #3 treated only level 2 neonates. She indicated only cribs - not the incubators - were placed in the overflow areas since the incubators were too large.

On 3/10/2011, in the morning, the staff Registered Nurse (RN) for Area #2 and #3 indicated Area #3 had 4 neonates three weeks before. This contradicted what the administrative staff indicated. The RN demonstrated how the cribs were placed. Three cribs were lined up against the wall where the shelf was located. The cribs were lined up just below the edge of the shelf. The cribs were parallel to the shelf, so if an item or dust were to fall, the item could possibly hit the top of the neonates head, thorax, legs or feet. Each crib had a one to two inch gap between them from the foot of one crib to the head of the other crib.

The way the cribs were situated, care for the neonate could only be accessed on one side of the crib. The second crib, next to the wall, had the sharps container located approximately 1 to 2 inches away from the side of the crib. If an individual were to use the sharps container, one would have to cross over the neonate's head or legs with a soiled glove and needle to open and dispose of the item.

The RN also indicated that incubators were used in the overflow area for photo therapy. The RN demonstrated how the fourth crib or incubator was situated in
Area #3.

Next to Area #3 was a short walkway, in which one side led to Area #2 and the other side lead to a secured door that exited the area. The walkway also lead to a small open room which stored supplies. Also in the walkway were two small black refrigerators. One held feeding supplies such as breast milk and the other stored patient medications. Both refrigerators were not locked and could be easily opened. The staff led the surveyor to the small open supply room where oral medications were being stored. The drawer was also left unlocked and stored with medication.

Area #4

On 3/11/2011 in the morning, Area #4 (unlicensed overflow) had the same 15 inch wide shelving that lined along the entire length of the wall. There were no neonates currently in the area. The Administrative staff indicated 5 neonates could be placed in the area. The cribs were placed under the shelving and the shelves could be stocked with unsecured monitors and medical equipment that could possibly fall directly into the crib.

Area #5

Area #5 (unlicensed overflow) was a room located in the back of the licensed NICU (Area #1). In order to get to the room, one had to pass the nurse's station and licensed care areas of the NICU (Area #1). One would turn a corner and go along a short hallway which passed an office, nurses break room, the respiratory room, and the supply room. The room was not visible from the nurse's station, and there was no video monitor noted in the room to watch from the nurse's station. The room had a door that could be shut and a bed that could be used for family members. The area was set up to care for four neonates. The administrative staff indicated the overflow area could be used for level 2 or level 3 neonates.

There was no policy regarding specifics to the overflow unlicensed areas. The administrative staff indicated the overflow areas were part of the NICU area and the overflow areas followed the licensed NICU policies. However, there were several verbal contradictions when obtaining information regarding care, acuity, staffing, and bed criteria between the licensed NICU and the unlicensed overflow units and between the unlicensed over flow units:

- Within the licensed NICU area, the area was licensed for 19 level 2 and level 3 neonates, but the Administrative staff indicated a total of 21 neonates could be placed in the area.

- Administrative staff indicated only level 2 trained nurses and level 2 neonates could be cared for in the unlicensed overflow areas, but in Area #5 (unlicensed over flow) neonates who were level 2 and level 3 care could be placed in the area.

- The Administrative staff indicated a total of 3 neonates could be placed in Area #3 (unlicensed over flow), but staff indicated 4 neonates were placed in the area just recently.

- The Administrative staff indicated no incubators were used in the overflow areas, but staff indicated incubators were used in the overflow areas for photo therapy.

- The Administrative staff indicated the NICU policy was to allow two family members per neonate to visit. According to this stated policy, there would be too many people allowed per square footage in Area #3. To illustrate, if there were four neonates and two family members per neonate allowed to visit, there would be too many people occupying this small area of 98 square foot room.

- The overflow unlicensed areas were being used, even though there was space available to treat neonates in the licensed NICU area.

Based on observation, interview, and record review, the facility failed to provide a sanitary environment in the neonate care areas.

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.

Findings include:

To better understand the layout of the facility, the surveyor designated a number to each corresponding area:

#1. Neonatal Intensive Care Unit (NICU) State licensed to treat 19 neonates.
#2. First unlicensed overflow area assigned to treat 6 neonates in the first room.
#3. Attached to Area #2 - an unlicensed overflow area assigned to treat 4 neonates in the second room.
#4. Second unlicensed overflow area assigned to treat 5 neonates.

Area #1

On 3/10/2011 and 3/11/2011 in the morning, several large medical equipment items, which were covered with plastic, were being stored in the aisles of the licensed NICU area. There were three aisles which staff and family could pass to get to 4 neonate care areas at one side of the NICU (Area #1), but since equipment blocked 2 of the aisles, there was only one small area to pass.

Along with blocking the walkway to patient care areas, the equipment was stored next to cribs where neonates were being cared for, leaving only space for the nurse to provide care on one side of the crib.

On 3/10/2011 in the morning, the supply room located in the licensed area of the NICU stored expired supplies:

- Pneumothorax procedure tray with an expiration date of January 2010.
- A box filled with autogaurd 22 gauge catheters with an expiration date of January 2011.
- A box of catheters with an expiration date of September 2010.

Area #2

On 3/11/2011 in the morning, Area #2 (unlicensed overflow) had six neonates in their cribs along the wall of the area. Along the walls of the room, secured over 5 feet above the floor, were 15 inches wide (from the wall to the front edge of the shelf) continuous shelving that covered each wall from end to end. The shelves were cluttered with monitors, binders, papers, telemetry cords. electrical cord packs, flow meters. suction meters, extension poles, and other medical devices. Some areas of the shelf had items stacked on top of each other.

The patient monitors had the telemetry cords dangling over the shelves and were connected to the neonates. All the items on the shelves were not secured down with straps. Anyone could reach over above their heads, extend their arm and reach for an item on the shelf. It would also be difficult to see what was on the shelf if an individual was short in stature. There was a potential for items to fall off the shelf due to the stacking of the items or from pulling cords that were tangled with items on the shelf.

To see the top surface of the shelf, the surveyor who was 5 foot 8 inches tall, had to stand next to the shelving and extend his neck backwards. Without having to swipe his hands on the shelf, the surveyor noted a coating of dust and clumps of dust along the entire shelf. Trash items such as small pieces of papers and thermometer probes were also noted.

All six cribs were situated at an angle where the inside head area of the cribs were 2 to 2.5 feet directly under the front edge of the shelving. The cribs had no protective covering over the top of the crib and the top was open to air. If an item were to fall off directly from the front edge of the shelf, the item could possibly hit the neonates. Obtaining cords or items from the shelf could stir up dust, which could have fallen on top of the neonate.

Area #3

Area #3's (unlicensed overflow) dimensions were 10 feet by 9.8 feet (98 square feet). Along one wall of the area was the same 15 inch wide shelving that was secured to the entire 10 foot wall. The height of the shelves was greater than 5 feet above the floor. The same medical items were stored on the shelving. Dust and trash were noted on the top surface of the shelf.

On 3/10/2011 in the morning, the Director of Women Services indicated Area #3 (unlicensed area) could only hold up to 3 neonates in the area. Area #3 treated only level 2 neonates. She indicated only cribs - not the incubators - were placed in the overflow areas since the incubators were too large.

On 3/10/2011, in the morning, the staff Registered Nurse (RN) for Area #2 and #3 indicated Area #3 had 4 neonates three weeks before. This contradicted what the administrative staff indicated. The RN demonstrated how the cribs were placed. Three cribs were lined up against the wall where the shelf was located. The cribs were lined up just below the edge of the shelf. The cribs were parallel to the shelf, so if an item or dust were to fall, the item could possibly hit the top of the neonates head, thorax, legs or feet. Each crib had a one to two inch gap between them from the foot of one crib to the head of the other crib.

The way the cribs were situated, care for the neonate could only be accessed on one side of the crib. The second crib, next to the wall, had the sharps container located approximately 1 to 2 inches away from the side of the crib. If an individual were to use the sharps container, one would have to cross over the neonate's head or legs a soiled glove and needle to open and dispose of the item.

The RN also indicated that incubators were used in the overflow area for photo therapy. The RN demonstrated how the fourth crib or incubator was situated in Area #3.

Next to Area #3 was a short walkway, in which one side led to Area #2 and the other side lead to a secured door that exited the area. The walkway also lead to a small open room which stored supplies. Also in the walkway were two small black refrigerators. One held feeding supplies such as breast milk and the other stored patient medications. Both refrigerators were not locked and could be easily opened. The staff led the surveyor to the small open supply room where oral medications were being stored. The drawer was also left unlocked with a medication in it.

The Administrative staff indicated the NICU policy was to allow two family members per neonate to visit. According to this stated policy, there would be too many people allowed per square footage in Area #3. To illustrate, if there were four neonates and two family members per neonate allowed to visit, there would be too many people occupying this small area of 98 square foot room.

Area #4

On 3/11/2011 in the morning, Area #4 (unlicensed overflow) had the same 15 inch wide shelving that lined along the entire length of the wall. There were no neonates currently in the area. The Administrative staff indicated 5 neonates could be placed in the area. The cribs were placed under the shelving and the shelves could be stocked with unsecured monitors and medical equipment that could possibly fall directly into the crib.

On 3/11/2011 in the afternoon, after the surveyor informed the Administrative staff regarding infection control and environmental concerns in the unlicensed neonate areas, the staff transferred all six neonates from the unlicensed Area #2 to the licensed NICU (Area #1) and proceeded to do a complete terminal cleaning of Areas #2, #3, and #4.