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Based on observation, interview, and record review the facility failed to ensure the Condition of Nursing Service(s) was not met in the Neonatal Intensive Care Unit (NICU) related to: 1) occurrences of patient care assignments which were not within the facility policy and procedure; in some of these instances medication errors occurred 2) occurrences of patient care assignments which were not within the facility policy and procedure 3) Lack of development of current nursing care plans for each patient and; 4) occurrences of nurses working excessive hours, in some cases exceeding 23 hours continuously.
See the findings under: A-0386 , A0392 , A0396 and A0405 .

Based on observation, interview, and record review the facility failed to have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care including having responsibility for the operation of the service, and determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all patients as needed in the Neonatal Intensive Care Unit (NICU) related to: 1) occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure 2) occurrences of nurses working excessive hours, exceeding 23 continuously hours .

The findings include:
1) Observation of the NICU on September 10, 2012 at approximately 11:52 AM; revealed There are a total of 3 rooms which are being utilized for patient care. Room 1 and Room 2 are observed for the higher acuity infants, while Room 4 is used for the lower acuity/healthier infants. The majority of the infants were observed to be on their own monitors which assesses the blood pressure, pulse rate, respiration rate, and in some cases the oxygen saturation.

Interview with the Assistant Nurse Manager on September 10, 2012 at approximately 11:52am revealed that the following are the Levels that are used for this NICU: 1) One to One (1:1) was the designation for infants who may be really sick. She reports that if a nurse is assigned a 1:1 baby, that nurse should not have any other patients; 2) Level 3 infants are typically sick infants that may need assistance with breathing - a nurse ought to be assigned up to 2 at any given time; 3) Level 2 - lowest acuity on the unit, usually easier for the nursing staff to care for these infants - a nurse can be assigned up to 4 of these infants. She reports that there is a charge nurse on each shift and they typically try not to assign this nurse to patient care. She reports that some of the responsibilities of the NICU charge nurse is to attend all caesarean sections and high risk deliveries in the facility. Additional duties of the charge nurse include assisting the nursing staff with starting their intravenous (IV) catheters, assisting with procedures. She reports that if the charge nurse has to the leave the unit, for any reason, the other nurses are responsible for taking on their patient assignment (should they have any). She confirms the implementation of a new staffing matrix for NICU which became effective in May 2012.

Review of the NICU Matrix, that is on the unit and is the document that staffing is planned from as it is documented in the " NICU Charge Nurse Book " reveals the following : A) 1:1 Criteria: Oscillator babies who are on life sustaining drips like Dopamine, Dobutamine, Priscoline, Prostaglandin will be assigned 1:1 status - or - babies having surgery pre and post-operatively - or - unstable babies requiring frequent assessment and interventions less than or equal to 1 hour; B) The ratio for Level III babies will be 2:1 (per left side of the form); C) The ratio for Level II babies will be 4:1 consistently; D) Unit Secretary/Patient Care Technician will work when the census is 10 and above; E) The Charge Nurse position remains intact; however, the charge nurse will be expected to take an assignment as needed.
Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure; in some of these instances, adverse incidents occurred: 6/1/2012: 2 Nurses were each assigned a total of 3 Level III infants. On 6/5/2012: a Nurse was assigned to Level III infant who was also in the Isolation room; she was also assigned to 3 infants in another room (room 4); additionally this nurse was typically did not work on NICU unit, she was from the Mother/Baby unit; the Charge nurse with no patient assignment(s); This staffing trend occurred on day and night shift this day. On 6/6/2012: A nurse, who normally work in another unit (Mother Baby Unit) was assigned to a Level III infant who was also in Isolation, which is a room away from the main 3 patient care rooms within the NICU; this nurse was also assigned to 3 other infants in another room (Room 4); On 6/11/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 6/21/2012: A nurse was not assigned to an infant for whom she set up an IV pump, with the settings on milliliters per minute rather than milliliters per hours; the patient inadvertently received approximately 5 hours of IV fluids (intralipids) in the space of 10-15 minutes. On 6/23/2012: A Nurse was staffed with 1:1 infant and had additional assignment (1 additional infant). On 7/1/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 7/9/2012: A nurse was assigned a total of 5 infants; one of which was a Level III; the charge nurse was not documented to have any patient assignment(s). On 7/13/2012: A Nurse was assigned to a 1:1 infant as well as 4 Level II from 7pm to 9:30pm; another nurse on the assignment sheet took on 3 patients from this nurse; still leaving that nurse with a 1:1 and 1 Level II infant; the Charge nurse was did not have any patient assignment(s). Another nurse was assigned a 1:1 as well as 1 Level II infant. On 7/20/2012: A nurse was assigned 5 patients at some point during her shift; and was assigned to prepare and assist in eye exams on 2 patients; the nurse subsequently realized that she dilated the wrong infant; the MD was notified and no harm came to the patient who was given eye medication in error.

2) Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of nurses working excessive hours, in some cases exceeding 23 hours continuously. On 7/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours. On 8/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 20 hours; this nurse assigned a total of 2 Level II infants on both shifts. Another nurse was assigned to come in at 3 am on Sunday (8/12) and worked until 7p on 8/13; according to the staffing sheet this nurse worked approximately 16 hours and was assigned 3 Level III infants and 1 Level II infant. On 8/19/2012 to 8/20/2012: 1 Nurse worked a total of 2 - 12 hour shifts; according to staffing sheet; total of approx. 24 hours; this nurse was assigned 3 Level II infants on both shifts; Charge Nurses on both shifts with no patient assignment(s), according to the NICU daily staffing sheet. On 8/21/2012: The above nurse: was off of work for approximately 12 hours, after working the above 24 hours; she then returned to the unit on 8/21/12 on the 7P shift - after having worked 2 - 12 hours shifts; she was off for a total of 12 hours and came back for another 12 hour shift. On 9/9/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours; this nurse assigned 1 Level III; and 2 Level II infants on both shifts; the charge nurse (on both shifts) with no patient assignment(s). Additional documentation reflect that this nurse worked straight through hours as written, with no breaks 7:00pm to 6: 24am (the next day).

Review of the facility Scope of Services Neonatal Intensive Care Unit, 2012; reveals the following: Section IV: Assignments: The department consists of four nurseries, which are arranged in a theater style to facilitate ongoing monitoring and observations of patients. Each nurse is assigned to a patient or group of patients and such assignments are recorded on the daily staffing sheet posted in the department. Assignments are based on assessment and documentation of competencies, educational preparation, skill level and experience of staff, also patient acuity and special needs. Staffing levels are based on patient census and level of care required, i.e., use of high frequency oscillators, conventional ventilators, central lines, etc. The charge registered nurse acts to ensure patient flow management, which includes making sure patients are assigned/seen, ensuring nursing coverage, overseeing hospital admissions, directing physicians and service as a role model for the NICU staff.

Based on observation, interview, and record review the facility failed to ensure they had an adequate number of license nurses to provide nursing care to all patients as needed in the Neonatal Intensive Care Unit (NICU) related to: 1) occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure in which in some of these instances medication errors occurred; 2) occurrences of nurses working excessive hours, exceeding 23 continuously hours .
The findings include:
1) Observation of the NICU on September 10, 2012 at approximately 11:52 AM; revealed There are a total of 3 rooms which are being utilized for patient care. Room 1 and Room 2 are observed for the higher acuity infants, while Room 4 is used for the lower acuity/healthier infants. The majority of the infants were observed to be on their own monitors which assesses the blood pressure, pulse rate, respiration rate, and in some cases the oxygen saturation.

Interview with the Assistant Nurse Manager on September 10, 2012 at approximately 11:52am revealed that the following are the Levels that are used for this NICU: 1) One to One (1:1) was the designation for infants who may be really sick. She reports that if a nurse is assigned a 1:1 baby, that nurse should not have any other patients; 2) Level 3 infants are typically sick infants that may need assistance with breathing - a nurse ought to be assigned up to 2 at any given time; 3) Level 2 - lowest acuity on the unit, usually easier for the nursing staff to care for these infants - a nurse can be assigned up to 4 of these infants. She reports that there is a charge nurse on each shift and they typically try not to assign this nurse to patient care. She reports that some of the responsibilities of the NICU charge nurse is to attend all caesarean sections and high risk deliveries in the facility. Additional duties of the charge nurse include assisting the nursing staff with starting their intravenous (IV) catheters, assisting with procedures. She reports that if the charge nurse has to the leave the unit, for any reason, the other nurses are responsible for taking on their patient assignment (should they have any). She confirms the implementation of a new staffing matrix for NICU which became effective in May 2012.

Review of the NICU Matrix, that is on the unit and is the document that staffing is planned from as it is documented in the " NICU Charge Nurse Book " reveals the following : A) 1:1 Criteria: Oscillator babies who are on life sustaining drips like Dopamine, Dobutamine, Priscoline, Prostaglandin will be assigned 1:1 status - or - babies having surgery pre and post-operatively - or - unstable babies requiring frequent assessment and interventions less than or equal to 1 hour; B) The ratio for Level III babies will be 2:1 (per left side of the form); C) The ratio for Level II babies will be 4:1 consistently; D) Unit Secretary/Patient Care Technician will work when the census is 10 and above; E) The Charge Nurse position remains intact; however, the charge nurse will be expected to take an assignment as needed.
Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure; in some of these instances, medication errors occurred: 6/1/2012: 2 Nurses were each assigned a total of 3 Level III infants. On 6/5/2012: a Nurse was assigned to Level III infant who was also in the Isolation room; she was also assigned to 3 infants in another room (room 4); additionally this nurse was typically did not work on NICU unit, she was from the Mother/Baby unit; the Charge nurse with no patient assignment(s); This staffing trend occurred on day and night shift this day. On 6/6/2012: A nurse, who normally work in another unit (Mother Baby Unit) was assigned to a Level III infant who was also in Isolation, which is a room away from the main 3 patient care rooms within the NICU; this nurse was also assigned to 3 other infants in another room (Room 4); . On 6/11/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 6/21/2012: A nurse was not assigned to an infant for whom she set up an IV pump, with the settings on milliliters per minute rather than milliliters per hours; the patient inadvertently received approximately 5 hours of IV fluids (intralipids) in the space of 10-15 minutes. On 6/23/2012: A Nurse was staffed with 1:1 infant and had additional assignment (1 additional infant). On 7/1/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 7/9/2012: A nurse was assigned a total of 5 infants; one of which was a Level III; ; the charge nurse was not documented to have any patient assignment(s). On 7/13/2012: A Nurse was assigned to a 1:1 infant as well as 4 Level II from 7pm to 9:30pm; another nurse on the assignment sheet took on 3 patients from this nurse; still leaving that nurse with a 1:1 and 1 Level II infant; the Charge nurse was did not have any patient assignment(s). Another nurse was assigned a 1:1 as well as 1 Level II infant. On 7/20/2012: A nurse was assigned 5 patients at some point during her shift; and was assigned to prepare and assist in eye exams on 2 patients; the nurse subsequently realized that she dilated the wrong infant; the MD was notified and no harm came to the patient who was given eye medication in error.

2) Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of nurses working excessive hours, in some cases exceeding 23 hours continuously. On 7/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours. On 8/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 20 hours; this nurse assigned a total of 2 Level II infants on both shifts. Another nurse was assigned to come in at 3 am on Sunday (8/12) and worked until 7p on 8/13; according to the staffing sheet this nurse worked approximately 16 hours and was assigned 3 Level III infants and 1 Level II infant. On 8/19/2012 to 8/20/2012: 1 Nurse worked a total of 2 - 12 hour shifts; according to staffing sheet; total of approx. 24 hours; this nurse was assigned 3 Level II infants on both shifts; Charge Nurses on both shifts with no patient assignment(s), according to the NICU daily staffing sheet. On 8/21/2012: The above nurse: was off of work for approximately 12 hours, after working the above 24 hours; she then returned to the unit on 8/21/12 on the 7P shift - after having worked 2 - 12 hours shifts; she was off for a total of 12 hours and came back for another 12 hour shift. On 9/9/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours; this nurse assigned 1 Level III; and 2 Level II infants on both shifts; the charge nurse (on both shifts) with no patient assignment(s). Additional documentation reflect that this nurse worked straight through hours as written, with no breaks 7:00pm to 6: 24am (the next day).

Review of the facility Scope of Services Neonatal Intensive Care Unit, 2012; reveals the following: Section IV: Assignments: The department consists of four nurseries, which are arranged in a theater style to facilitate ongoing monitoring and observations of patients. Each nurse is assigned to a patient or group of patients and such assignments are recorded on the daily staffing sheet posted in the department. Assignments are based on assessment and documentation of competencies, educational preparation, skill level and experience of staff, also patient acuity and special needs. Staffing levels are based on patient census and level of care required, i.e., use of high frequency oscillators, conventional ventilators, central lines, etc. The charge registered nurse acts to ensure patient flow management, which includes making sure patients are assigned/seen, ensuring nursing coverage, overseeing hospital admissions, directing physicians and service as a role model for the NICU staff.

Based on observation, interview, and record review the facility failed to ensure there was a comprehensive, current nursing care plan for 4 (Patient #2, #4, #5, and #7) out of 10 sampled patients who were admitted in the Neonatal Intensive Care Unit (NICU).
The findings include:
Observation of the NICU on September 10, 2012 at approximately 11:52 AM; revealed a very busy unit. There are a total of 3 rooms which are being utilized for patient care. Room 1 and Room 2 are observed for the higher acuity infants, while Room 4 is used for the lower acuity/healthier infants. The majority of the infants were observed to be on their own monitors which assesses the blood pressure, pulse rate, respiration rate, and in some cases the oxygen saturation.

Medical record review for Patient #2 revealed he was admitted to the NICU on 6/19/2012 and was discharged (expired) on 6/22/2012. His primary diagnoses (includes but is not limited to): single labor in-house, with caesarean section; respiratory distress; neonatal thrombocytopenia; neonatal neutropenia, newborn septicemia (sepsis); newborn pulmonary hemorrhage, primary apnea of newborn, anemia of prematurity, extreme prematurity: 500-749 grams; 25-26 weeks gestation. There was a nursing care plan developed but it was not updated, prioritized, nor were any implementation of interventions were documented throughout his length of stay.

Medical record review for Patient #4 revealed she was admitted on 8/12/2012 and was discharged (expired) on 8/14/2012. Her primary diagnoses (includes but it not limited to): respiratory distress syndrome, newborn pulmonary hemorrhage, anemia of prematurity, extreme prematurity less than 500 grams; less than 24 weeks gestations. There was no nursing care plan developed throughout her length of stay.

Medical record review for Patient #5 revealed he was admitted on 7/12/2012 and discharged (expired) on 7/14/2012. His primary diagnoses (includes but is not limited to): weakness, extreme prematurity, late metabolic acidosis, respiratory problem after birth, hypotension, less than 24 weeks gestation. There was a nursing care plan developed but it was not updated, prioritized, nor were any implementation of interventions were documented throughout his length of stay.

Medical record review for Patient #7 revealed he was admitted to the facility on 6/1/2012 and is currently still admitted in the facility. His diagnoses includes (but is not limited to): prematurity, respiratory distress, since birth; anemia, periventricular leukomalacia, bilateral inguinal hernia, retinopathy of prematurity stage 3. There was a nursing care plan developed but it was not updated, prioritized, nor were any implementation of interventions were documented throughout his length of stay.

Interview with the Director of Nursing Services on September 12, 2012 at 1:12pm; she confirms that nursing care plans are expected to be initiated on all patients in the facility.

Review of the facility Scope of Services Neonatal Intensive Care Unit, 2012; reveals the following: Section II. Scope: The NICU specializes in the comprehensive care of critically ill neonates. Infants include those with genetic and congenital abnormalities, prematurity, infants with respiratory distress syndrome, bronchopulmonary dysplasisa, meconium aspiration, shock, DIC, withdrawal symptoms, post-surgical infants, and others. Close observation telemetry monitoring and advanced technological services are offered per policy and procedure. NICU personnel demonstrate clinical competence in executing life-saving nursing and medical procedures. Staff promotes confidence in the patient ' s family by demonstrating advance knowledge and expertise in the field of neonatal care while respecting each patient as a unique individual and promoting the care-taking role and individual response of the parents.

Based on observation, interview, and record review the facility failed to ensure a vial of saline flush medication was prepared with a needle being left in the top of the unattended vial and not in accordance with accepted standards of practice in 1 out of 2 nursing units observed
The findings include:
Observation on September 9, 2012 at approximately 6:33am of the Neonatal Intensive Care Unit (NICU), room 2, revealed that there were 2 nurses assigned to the 5 infants in this room. Nurse A was observed attempting to insert an Intravenous (IV) catheter for 1 of her assigned patients. Observed near her work area was a vial of 10 milliliters (ML) of normal saline, there was gauged needle punctured through the top/rubber portion of the vial, there was no body of the syringe attached to this needle. The nurse was on the left side of the crib working on the infant, apparently looking for a suitable vein. The vial of saline was observed to be on the counter space, behind the crib and on the opposite side.
At this time the dayshift nurses were arriving and the unit appeared to be getting busier with staff passing through. The charge nurse entered the room and was observed to ask Nurse A why she left sharp items unattended. The charge nurse was then observed placing gloves on her hands, obtaining the vial of saline and discarding the sharp in the appropriate container. She was then observed throwing away the vial of saline.

Interview on September 9, 2012 at approximately 6:43am with the night Charge Nurse reveal that this is not the expectation of the staff in the NICU. She confirms that it is not the facility ' s policy and procedure to prepare medication vials in this way, as well as leaving them unattended.

Based on observation, interview, and record review the facility failed to ensure the Condition of Nursing Service(s) was not met in the Neonatal Intensive Care Unit (NICU) related to: 1) occurrences of patient care assignments which were not within the facility policy and procedure; in some of these instances medication errors occurred 2) occurrences of patient care assignments which were not within the facility policy and procedure 3) Lack of development of current nursing care plans for each patient and; 4) occurrences of nurses working excessive hours, in some cases exceeding 23 hours continuously.
See the findings under: A-0386 , A0392 , A0396 and A0405 .

Based on observation, interview, and record review the facility failed to have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care including having responsibility for the operation of the service, and determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all patients as needed in the Neonatal Intensive Care Unit (NICU) related to: 1) occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure 2) occurrences of nurses working excessive hours, exceeding 23 continuously hours .

The findings include:
1) Observation of the NICU on September 10, 2012 at approximately 11:52 AM; revealed There are a total of 3 rooms which are being utilized for patient care. Room 1 and Room 2 are observed for the higher acuity infants, while Room 4 is used for the lower acuity/healthier infants. The majority of the infants were observed to be on their own monitors which assesses the blood pressure, pulse rate, respiration rate, and in some cases the oxygen saturation.

Interview with the Assistant Nurse Manager on September 10, 2012 at approximately 11:52am revealed that the following are the Levels that are used for this NICU: 1) One to One (1:1) was the designation for infants who may be really sick. She reports that if a nurse is assigned a 1:1 baby, that nurse should not have any other patients; 2) Level 3 infants are typically sick infants that may need assistance with breathing - a nurse ought to be assigned up to 2 at any given time; 3) Level 2 - lowest acuity on the unit, usually easier for the nursing staff to care for these infants - a nurse can be assigned up to 4 of these infants. She reports that there is a charge nurse on each shift and they typically try not to assign this nurse to patient care. She reports that some of the responsibilities of the NICU charge nurse is to attend all caesarean sections and high risk deliveries in the facility. Additional duties of the charge nurse include assisting the nursing staff with starting their intravenous (IV) catheters, assisting with procedures. She reports that if the charge nurse has to the leave the unit, for any reason, the other nurses are responsible for taking on their patient assignment (should they have any). She confirms the implementation of a new staffing matrix for NICU which became effective in May 2012.

Review of the NICU Matrix, that is on the unit and is the document that staffing is planned from as it is documented in the " NICU Charge Nurse Book " reveals the following : A) 1:1 Criteria: Oscillator babies who are on life sustaining drips like Dopamine, Dobutamine, Priscoline, Prostaglandin will be assigned 1:1 status - or - babies having surgery pre and post-operatively - or - unstable babies requiring frequent assessment and interventions less than or equal to 1 hour; B) The ratio for Level III babies will be 2:1 (per left side of the form); C) The ratio for Level II babies will be 4:1 consistently; D) Unit Secretary/Patient Care Technician will work when the census is 10 and above; E) The Charge Nurse position remains intact; however, the charge nurse will be expected to take an assignment as needed.
Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure; in some of these instances, adverse incidents occurred: 6/1/2012: 2 Nurses were each assigned a total of 3 Level III infants. On 6/5/2012: a Nurse was assigned to Level III infant who was also in the Isolation room; she was also assigned to 3 infants in another room (room 4); additionally this nurse was typically did not work on NICU unit, she was from the Mother/Baby unit; the Charge nurse with no patient assignment(s); This staffing trend occurred on day and night shift this day. On 6/6/2012: A nurse, who normally work in another unit (Mother Baby Unit) was assigned to a Level III infant who was also in Isolation, which is a room away from the main 3 patient care rooms within the NICU; this nurse was also assigned to 3 other infants in another room (Room 4); On 6/11/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 6/21/2012: A nurse was not assigned to an infant for whom she set up an IV pump, with the settings on milliliters per minute rather than milliliters per hours; the patient inadvertently received approximately 5 hours of IV fluids (intralipids) in the space of 10-15 minutes. On 6/23/2012: A Nurse was staffed with 1:1 infant and had additional assignment (1 additional infant). On 7/1/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 7/9/2012: A nurse was assigned a total of 5 infants; one of which was a Level III; the charge nurse was not documented to have any patient assignment(s). On 7/13/2012: A Nurse was assigned to a 1:1 infant as well as 4 Level II from 7pm to 9:30pm; another nurse on the assignment sheet took on 3 patients from this nurse; still leaving that nurse with a 1:1 and 1 Level II infant; the Charge nurse was did not have any patient assignment(s). Another nurse was assigned a 1:1 as well as 1 Level II infant. On 7/20/2012: A nurse was assigned 5 patients at some point during her shift; and was assigned to prepare and assist in eye exams on 2 patients; the nurse subsequently realized that she dilated the wrong infant; the MD was notified and no harm came to the patient who was given eye medication in error.

2) Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of nurses working excessive hours, in some cases exceeding 23 hours continuously. On 7/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours. On 8/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 20 hours; this nurse assigned a total of 2 Level II infants on both shifts. Another nurse was assigned to come in at 3 am on Sunday (8/12) and worked until 7p on 8/13; according to the staffing sheet this nurse worked approximately 16 hours and was assigned 3 Level III infants and 1 Level II infant. On 8/19/2012 to 8/20/2012: 1 Nurse worked a total of 2 - 12 hour shifts; according to staffing sheet; total of approx. 24 hours; this nurse was assigned 3 Level II infants on both shifts; Charge Nurses on both shifts with no patient assignment(s), according to the NICU daily staffing sheet. On 8/21/2012: The above nurse: was off of work for approximately 12 hours, after working the above 24 hours; she then returned to the unit on 8/21/12 on the 7P shift - after having worked 2 - 12 hours shifts; she was off for a total of 12 hours and came back for another 12 hour shift. On 9/9/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours; this nurse assigned 1 Level III; and 2 Level II infants on both shifts; the charge nurse (on both shifts) with no patient assignment(s). Additional documentation reflect that this nurse worked straight through hours as written, with no breaks 7:00pm to 6: 24am (the next day).

Review of the facility Scope of Services Neonatal Intensive Care Unit, 2012; reveals the following: Section IV: Assignments: The department consists of four nurseries, which are arranged in a theater style to facilitate ongoing monitoring and observations of patients. Each nurse is assigned to a patient or group of patients and such assignments are recorded on the daily staffing sheet posted in the department. Assignments are based on assessment and documentation of competencies, educational preparation, skill level and experience of staff, also patient acuity and special needs. Staffing levels are based on patient census and level of care required, i.e., use of high frequency oscillators, conventional ventilators, central lines, etc. The charge registered nurse acts to ensure patient flow management, which includes making sure patients are assigned/seen, ensuring nursing coverage, overseeing hospital admissions, directing physicians and service as a role model for the NICU staff.

Based on observation, interview, and record review the facility failed to ensure they had an adequate number of license nurses to provide nursing care to all patients as needed in the Neonatal Intensive Care Unit (NICU) related to: 1) occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure in which in some of these instances medication errors occurred; 2) occurrences of nurses working excessive hours, exceeding 23 continuously hours .
The findings include:
1) Observation of the NICU on September 10, 2012 at approximately 11:52 AM; revealed There are a total of 3 rooms which are being utilized for patient care. Room 1 and Room 2 are observed for the higher acuity infants, while Room 4 is used for the lower acuity/healthier infants. The majority of the infants were observed to be on their own monitors which assesses the blood pressure, pulse rate, respiration rate, and in some cases the oxygen saturation.

Interview with the Assistant Nurse Manager on September 10, 2012 at approximately 11:52am revealed that the following are the Levels that are used for this NICU: 1) One to One (1:1) was the designation for infants who may be really sick. She reports that if a nurse is assigned a 1:1 baby, that nurse should not have any other patients; 2) Level 3 infants are typically sick infants that may need assistance with breathing - a nurse ought to be assigned up to 2 at any given time; 3) Level 2 - lowest acuity on the unit, usually easier for the nursing staff to care for these infants - a nurse can be assigned up to 4 of these infants. She reports that there is a charge nurse on each shift and they typically try not to assign this nurse to patient care. She reports that some of the responsibilities of the NICU charge nurse is to attend all caesarean sections and high risk deliveries in the facility. Additional duties of the charge nurse include assisting the nursing staff with starting their intravenous (IV) catheters, assisting with procedures. She reports that if the charge nurse has to the leave the unit, for any reason, the other nurses are responsible for taking on their patient assignment (should they have any). She confirms the implementation of a new staffing matrix for NICU which became effective in May 2012.

Review of the NICU Matrix, that is on the unit and is the document that staffing is planned from as it is documented in the " NICU Charge Nurse Book " reveals the following : A) 1:1 Criteria: Oscillator babies who are on life sustaining drips like Dopamine, Dobutamine, Priscoline, Prostaglandin will be assigned 1:1 status - or - babies having surgery pre and post-operatively - or - unstable babies requiring frequent assessment and interventions less than or equal to 1 hour; B) The ratio for Level III babies will be 2:1 (per left side of the form); C) The ratio for Level II babies will be 4:1 consistently; D) Unit Secretary/Patient Care Technician will work when the census is 10 and above; E) The Charge Nurse position remains intact; however, the charge nurse will be expected to take an assignment as needed.
Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of patient care assignments which were not within the facility NICU staffing policy and procedure; in some of these instances, medication errors occurred: 6/1/2012: 2 Nurses were each assigned a total of 3 Level III infants. On 6/5/2012: a Nurse was assigned to Level III infant who was also in the Isolation room; she was also assigned to 3 infants in another room (room 4); additionally this nurse was typically did not work on NICU unit, she was from the Mother/Baby unit; the Charge nurse with no patient assignment(s); This staffing trend occurred on day and night shift this day. On 6/6/2012: A nurse, who normally work in another unit (Mother Baby Unit) was assigned to a Level III infant who was also in Isolation, which is a room away from the main 3 patient care rooms within the NICU; this nurse was also assigned to 3 other infants in another room (Room 4); . On 6/11/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 6/21/2012: A nurse was not assigned to an infant for whom she set up an IV pump, with the settings on milliliters per minute rather than milliliters per hours; the patient inadvertently received approximately 5 hours of IV fluids (intralipids) in the space of 10-15 minutes. On 6/23/2012: A Nurse was staffed with 1:1 infant and had additional assignment (1 additional infant). On 7/1/2012: 1 Nurse assigned to a total of 3 Level III infants; Charge nurse with no patient assignments. On 7/9/2012: A nurse was assigned a total of 5 infants; one of which was a Level III; ; the charge nurse was not documented to have any patient assignment(s). On 7/13/2012: A Nurse was assigned to a 1:1 infant as well as 4 Level II from 7pm to 9:30pm; another nurse on the assignment sheet took on 3 patients from this nurse; still leaving that nurse with a 1:1 and 1 Level II infant; the Charge nurse was did not have any patient assignment(s). Another nurse was assigned a 1:1 as well as 1 Level II infant. On 7/20/2012: A nurse was assigned 5 patients at some point during her shift; and was assigned to prepare and assist in eye exams on 2 patients; the nurse subsequently realized that she dilated the wrong infant; the MD was notified and no harm came to the patient who was given eye medication in error.

2) Review of the Daily NICU Staffing Sheets from June 2012 to September 10, 2012 revealed the following occurrences of nurses working excessive hours, in some cases exceeding 23 hours continuously. On 7/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours. On 8/12/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 20 hours; this nurse assigned a total of 2 Level II infants on both shifts. Another nurse was assigned to come in at 3 am on Sunday (8/12) and worked until 7p on 8/13; according to the staffing sheet this nurse worked approximately 16 hours and was assigned 3 Level III infants and 1 Level II infant. On 8/19/2012 to 8/20/2012: 1 Nurse worked a total of 2 - 12 hour shifts; according to staffing sheet; total of approx. 24 hours; this nurse was assigned 3 Level II infants on both shifts; Charge Nurses on both shifts with no patient assignment(s), according to the NICU daily staffing sheet. On 8/21/2012: The above nurse: was off of work for approximately 12 hours, after working the above 24 hours; she then returned to the unit on 8/21/12 on the 7P shift - after having worked 2 - 12 hours shifts; she was off for a total of 12 hours and came back for another 12 hour shift. On 9/9/2012: 1 Nurse worked double shift; according to staffing sheet; total of approximately 23 hours; this nurse assigned 1 Level III; and 2 Level II infants on both shifts; the charge nurse (on both shifts) with no patient assignment(s). Additional documentation reflect that this nurse worked straight through hours as written, with no breaks 7:00pm to 6: 24am (the next day).

Review of the facility Scope of Services Neonatal Intensive Care Unit, 2012; reveals the following: Section IV: Assignments: The department consists of four nurseries, which are arranged in a theater style to facilitate ongoing monitoring and observations of patients. Each nurse is assigned to a patient or group of patients and such assignments are recorded on the daily staffing sheet posted in the department. Assignments are based on assessment and documentation of competencies, educational preparation, skill level and experience of staff, also patient acuity and special needs. Staffing levels are based on patient census and level of care required, i.e., use of high frequency oscillators, conventional ventilators, central lines, etc. The charge registered nurse acts to ensure patient flow management, which includes making sure patients are assigned/seen, ensuring nursing coverage, overseeing hospital admissions, directing physicians and service as a role model for the NICU staff.

Based on observation, interview, and record review the facility failed to ensure there was a comprehensive, current nursing care plan for 4 (Patient #2, #4, #5, and #7) out of 10 sampled patients who were admitted in the Neonatal Intensive Care Unit (NICU).
The findings include:
Observation of the NICU on September 10, 2012 at approximately 11:52 AM; revealed a very busy unit. There are a total of 3 rooms which are being utilized for patient care. Room 1 and Room 2 are observed for the higher acuity infants, while Room 4 is used for the lower acuity/healthier infants. The majority of the infants were observed to be on their own monitors which assesses the blood pressure, pulse rate, respiration rate, and in some cases the oxygen saturation.

Medical record review for Patient #2 revealed he was admitted to the NICU on 6/19/2012 and was discharged (expired) on 6/22/2012. His primary diagnoses (includes but is not limited to): single labor in-house, with caesarean section; respiratory distress; neonatal thrombocytopenia; neonatal neutropenia, newborn septicemia (sepsis); newborn pulmonary hemorrhage, primary apnea of newborn, anemia of prematurity, extreme prematurity: 500-749 grams; 25-26 weeks gestation. There was a nursing care plan developed but it was not updated, prioritized, nor were any implementation of interventions were documented throughout his length of stay.

Medical record review for Patient #4 revealed she was admitted on 8/12/2012 and was discharged (expired) on 8/14/2012. Her primary diagnoses (includes but it not limited to): respiratory distress syndrome, newborn pulmonary hemorrhage, anemia of prematurity, extreme prematurity less than 500 grams; less than 24 weeks gestations. There was no nursing care plan developed throughout her length of stay.

Medical record review for Patient #5 revealed he was admitted on 7/12/2012 and discharged (expired) on 7/14/2012. His primary diagnoses (includes but is not limited to): weakness, extreme prematurity, late metabolic acidosis, respiratory problem after birth, hypotension, less than 24 weeks gestation. There was a nursing care plan developed but it was not updated, prioritized, nor were any implementation of interventions were documented throughout his length of stay.

Medical record review for Patient #7 revealed he was admitted to the facility on 6/1/2012 and is currently still admitted in the facility. His diagnoses includes (but is not limited to): prematurity, respiratory distress, since birth; anemia, periventricular leukomalacia, bilateral inguinal hernia, retinopathy of prematurity stage 3. There was a nursing care plan developed but it was not updated, prioritized, nor were any implementation of interventions were documented throughout his length of stay.

Interview with the Director of Nursing Services on September 12, 2012 at 1:12pm; she confirms that nursing care plans are expected to be initiated on all patients in the facility.

Review of the facility Scope of Services Neonatal Intensive Care Unit, 2012; reveals the following: Section II. Scope: The NICU specializes in the comprehensive care of critically ill neonates. Infants include those with genetic and congenital abnormalities, prematurity, infants with respiratory distress syndrome, bronchopulmonary dysplasisa, meconium aspiration, shock, DIC, withdrawal symptoms, post-surgical infants, and others. Close observation telemetry monitoring and advanced technological services are offered per policy and procedure. NICU personnel demonstrate clinical competence in executing life-saving nursing and medical procedures. Staff promotes confidence in the patient ' s family by demonstrating advance knowledge and expertise in the field of neonatal care while respecting each patient as a unique individual and promoting the care-taking role and individual response of the parents.

Based on observation, interview, and record review the facility failed to ensure a vial of saline flush medication was prepared with a needle being left in the top of the unattended vial and not in accordance with accepted standards of practice in 1 out of 2 nursing units observed
The findings include:
Observation on September 9, 2012 at approximately 6:33am of the Neonatal Intensive Care Unit (NICU), room 2, revealed that there were 2 nurses assigned to the 5 infants in this room. Nurse A was observed attempting to insert an Intravenous (IV) catheter for 1 of her assigned patients. Observed near her work area was a vial of 10 milliliters (ML) of normal saline, there was gauged needle punctured through the top/rubber portion of the vial, there was no body of the syringe attached to this needle. The nurse was on the left side of the crib working on the infant, apparently looking for a suitable vein. The vial of saline was observed to be on the counter space, behind the crib and on the opposite side.
At this time the dayshift nurses were arriving and the unit appeared to be getting busier with staff passing through. The charge nurse entered the room and was observed to ask Nurse A why she left sharp items unattended. The charge nurse was then observed placing gloves on her hands, obtaining the vial of saline and discarding the sharp in the appropriate container. She was then observed throwing away the vial of saline.

Interview on September 9, 2012 at approximately 6:43am with the night Charge Nurse reveal that this is not the expectation of the staff in the NICU. She confirms that it is not the facility ' s policy and procedure to prepare medication vials in this way, as well as leaving them unattended.