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Based on record review, interview and policy review, the facility failed to renew a physician's order for wrist restraint(s) for 1 of 30 patients (Patient # 25).

Findings include:

Patient #25

On 1/24/12, Patient #25 was admitted with diagnoses of hypertension, dyslipidemia, atrial fibrillation, cervical carotid atherosclerosis, and right hemispheric stroke.

On 1/24/12 at 8:05 PM, a nurse obtained an order for soft limb holders for the right wrist due to the patient "attempting to remove lines, tubes, equipment and/or dressings." The orders were subsequently renewed each day until 1/30/12. Documentation showed the application for the restraint at 8:00 PM on 1/30/12. The next physician's order for restraint renewal was dated 1/31/12.

On 1/31/12 at 4:15 PM, Employee #11 consulted with Employee #12 regarding the missing physician's order and concluded Patient #25's record lacked a physician's order for a restraint on 1/30/12.

According to the facility's policy, Management of Patients Requiring Restraint, effective 3/11, soft limb holders are considered restraints (4.13.2) and all patients requiring restraints should have an order from a licensed independent practitioner. The facility's restraint renewal forms indicated "renewal order required each calendar day."

Based on record review, interview and policy review, the facility failed to renew a physician's order for wrist restraint(s) according to its policy for 1 of 30 patients (Patient # 25).

Findings include:

Patient #25

On 1/24/12, Patient #25 was admitted with diagnoses of hypertension, dyslipidemia, atrial fibrillation, cervical carotid atherosclerosis, and right hemispheric stroke.

On 1/24/12 at 8:05 PM, a nurse obtained an order for soft limb holders for the right wrist due to the patient "attempting to remove lines, tubes, equipment and/or dressings." The orders were subsequently renewed each day until 1/30/12. Documentation showed the application for the restraint at 8:00 PM on 1/30/12. The next physician's order for restraint renewal was dated 1/31/12.

On 1/31/12 at 4:15 PM, Employee #11 consulted with Employee #12 regarding the missing physician's order and concluded Patient #25's record lacked a physician's order for a restraint on 1/30/12.

According to the facility's policy, Management of Patients Requiring Restraint effective 3/11, soft limb holders are considered restraints (4.13.2) and all patients requiring restraints should have an order from a licensed independent practitioner. The facility's restraint renewal forms indicated "renewal order required each calendar day."

Based on observation, interview, document and record review, the facility failed to demonstrate the Quality Assessment and Performance Improvement (QAPI) Program's involvement when multiple changes that were made with policies, environmental changes and the increase bed capacity in the Neonatal Intensive Care Unit (NICU). With multiple changes in the NICU, safety concerns, non-compliance with new policy changes and environmental hazards were identified without the knowledge of the facility staff including the QAPI department. The facility failed to ensure its quality assessment and performance improvement program identified and monitored the safety of services in its NICU (Tag A0285).

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 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 2/3/12 in the morning, the Director of Risk Management indicated she was not involved with the changes made to the Neonatal Intensive Care Unit (NICU) regarding the new policy on decompression for overcapacity in the NICU by increasing bed capacity from 15 licensed beds to 29 beds (14 unlicensed beds) and by placing curtains all around the unit dividing stations in half to accommodate the additional beds. The Director of Risk Management indicated she would have liked to been involved in the entire process.

1. On 2/1/12 in the afternoon, the Maternal Child and Pediatric Director indicated curtains were being placed in the NICU in April 2011 for privacy (to accommodate the additional beds).

Stations 1-11 and 13-15 which originally had one bed/isolette in each station was being divided to place two beds into each area. Station 12 was partly divided with one bed and a storage area. A floor-plan documenting how the 15 licensed and 14 unlicensed beds were situated to fit in the NICU was given to the surveyor on 2/1/12.

On 1/31/12 in the afternoon, sliding curtains that were hung from ceiling to floor that were being used to divide each one bed station in half to accommodate two beds in each Stations 1-6, Stations 8-11 and Stations 13-15.

Stations 1-6, Stations 8-11 and Stations 14-15 were similarly set up as follows:

-Each station was originally designed for one bed/patient.
-Each station was divided by curtains to place another patient into the same space (two beds).
-The facility's 29 designated (15 licensed and 14 unlicensed) care areas were for both Level III and Level II neonates were unapproved and not in compliance. The facility did not have a policy describing their intension for care in this area or the removal of equipment when there was a reduction in the number of neonates.
-The first bed in each station was closest to the back wall. The first curtain separated the first bed from the second bed.
-After the first curtain, which separated bed one and bed two, came the second bed in the station which was closest to the aisleway. There was a second curtain between the second bed and the aisleway.
-When closing the first curtain, the first bed was not visible from the hallway but the second bed would be visible.
-When closing the second curtain, both beds were not visible from the aisleway. Staff had to open the second curtain, pass the second bed and open the first curtain to obtain access to the baby located in the first bed.
-If the second curtain was closed, it would be difficult to visually assess who was working in the station. It would also be difficult to see if visitors or parents were entering other baby stations other than their own.

On 2/3/12 in the afternoon, a staff nurse indicated it was sometimes difficult to hear what type of alarm was going off and whose baby's alarm was going off when the curtains were closed and obstructed the view for bed one and bed two.

On 2/3/12 in the afternoon, another staff nurse indicated when the curtains were being used it would be difficult to see if other family members were going to the other baby's bassinet.

2. The facility's policy and procedure, dated 9/11, and titled, NICU Decompression for Overcapacity/Level II Lateral Transfers documented:

- " ...Scope - To define the process for managing patient overcapacity in the ...NICU ... "
- " ...Objective - To provide guidelines to identify and implement decompression strategies for high census and overcapacity in the NICU departments ... "
- " ...Decompression - is the process to alleviate overcapacity and /or high patient census in the NICU and includes the following strategies as ordered by the LIP (Licensed Independent Practitioner) ... "
- " ...Parents will be educated on the potential necessity for transfer of their infants beginning with the admission process and as the infant stabilizes and progresses toward discharge ... "

On 2/1/12 in the afternoon, the Interim NICU Manager indicated there was no documented evidence parents were asked if their infant could transfer to another facility due to over capacity at the facility.

3. On 2/1/12 in the afternoon, the Charge Nurse responsible for policies indicated the maximum capacity in the NICU interior was 20 beds.

On 2/1/12 in the afternoon, the Maternal Child and Pediatric Director confirmed the facility preferred a maximum of 20 patients in the NICU but there was no documented evidence in the policy for a maximum number. The Director indicated there were times when the census reached 29 patients.

A floor-plan documenting how the 29 beds were situated to fit in the NICU was given to the surveyor on 2/1/12. The floor-plan diagramed a bed blocking a sink and stations being divided in order to place two beds into one station. After measurements were made in the area by the surveyors and interviews were conducted with the staff it was concluded that there was insufficient space to provide care if 29 beds were placed in the NICU area. (Also see Tag A700.)

On 2/3/12 in the afternoon, staff nurses did not know the maximum amount of patients that could be admitted in the NICU.

On 1/31/12 in the afternoon, the Interim NICU (neonatal intensive care unit) Manager indicated the NICU was licensed for 15 beds (isolettes/bassinets). The NICU had 14 stations which originally held one bed for each station and one enclosed room which also originally had one bed designated to the room. The stations including the room were numbered from 1 to 15. These licensed beds were for Level III neonates (critical care babies), which could also accommodate Level II (less critical) neonates. The census for the NICU on 1/31/12 was 23 (15 licensed + 8 unlicensed beds) patients/babies.

The Interim NICU Manager indicated the NICU had been going over census for several months and the NICU could possibly hold up to 29 (15 licensed + 14 unlicensed beds) Level III (critical) and Level II (less critical) baby beds. She was not sure what the maximum capacity of NICU beds were and needed to clarify the number.

The NICU census during the survey was:

2/1/12 - 23 (15 licensed + 8 unlicensed beds)
2/2/12 - 20 (15 licensed + 5 unlicensed beds)
2/3/12 - 18 (15 licensed + 3 unlicensed beds)

Based on observation, interview, clinical record, and policy review, the facility failed to ensure the nurse evaluated the care for each patient upon admission and, when appropriate, on an ongoing basis in accordance with hospital policy for 4 of 30 sampled patients (Patients # 6, #13, #23, and #25).

Findings include:

Patient #6

Patient #6 was admitted to the facility on 2/2/12, with diagnosis including left shoulder osteoarthritis glenohumeral joint, rotator cuff tear and acromion fracture. The patient had a reverse total shoulder replacement on 2/2/12, and arrived on unit 1 W at 12:15 PM.

On 2/2/12 at 10:09 AM, Post Operation Orders were written for Intravenous fluid (IVF): current at 100 milliliters (ml) per hour. Convert to saline lock when awake and alert. Patient Controlled Analgesia (PCA) orders dated 2/2/12, documented Patient #6 had a loading dose of Morphine 2 milligram (mg), a patient bolus volume/dose of 1 mg and bolus interval/bolus per hour 6 minutes/10 per hours.

The facility's policy entitled, Patient Controlled Analgesia (PCA), dated effective 3/11, documented:
4.5 "At a minimum, the patient will be assessed for pain and level of sedation every hour for the first four (4) hours after the PCA is initiated or when the medication dosage is changed. 4.5.1 documented the patient will be reassessed every four (4) hours and as needed (prn) thereafter.
6.2 documented, "All patient assessments and reassessments will be documented in the patient's health record."

The medical record lacked documentation Patient #6 had been assessed for pain from 12:30 PM to 3:00 PM on 2/2/12.

On 2/3/12 at 9:15 AM, the Nurse Manager on unit 1 W stated the nurses should have assessed the patient's pain when the vitals were taken. The Nurse Manager stated the policy for pain assessment had not been followed.

On 2/3/12 at 10:10 AM, a Registered Nurse (RN) stated with any newly initiated PCA medications the patient was to be assessed for pain every hour for the first 4 hours and then every 4 hours. The RN was not able to locate documentation Patient #6 had been assessed every hour for the first 4 hours after the PCA had been initiated. The RN verbalized the policy for PCA medication had not been followed.

The medical record contained documentation on the nurse's flow sheets which indicated Patient #6 was receiving oxygen at 2 liters/per nasal cannula from 2/2/12 at 12:15 PM through 2/3/12 at 8:00 AM.

The medical record lacked documentation Patient #6 had a physician's order for oxygen use on the unit.

On 2/3/12 at 9:30 AM, the Nurse Manager on 1 W confirmed Patient #6 had oxygen on at 2 liters per minute via nasal cannula. The Nurse Manager was not able to locate documentation in the medical record oxygen had been ordered for Patient #6. The Nurse Manager on unit 1 W stated a physician's order was required for oxygen.

Post Operation Orders, dated 2/2/12, documented Patient #6 was to received Intravenous fluid (IVF): current at 100 milliliters (ml) her hour. Convert to saline lock when awake and alert. The physician's order was noted on 2/3/12 at 2:20 AM.

Nursing Progress notes, dated 2/2/12 at 12:15 PM, documented the patient was alert and orientated times 3. The documentation indicated Patient #6 had received IVF from 12:15 PM throughout the night and the IVF was running on 2/3/12 at 9:15 AM.

On 2/3/12 at 9:30 AM, Patient #6 was observed in bed with oxygen on, a Foley catheter in place and IVF fluid running at 100 ml per hour.

According to the medical record on 2/3/12 at 5:30 AM, a call was place to the physician for clarification of the IVF orders.

On 2/3/12 at 10:15 AM, a RN stated the nurse should check the IVF infusing from the Post Anesthesia unit and call for an order to clarify what solution the physician wanted. The facility's policy indicated the physician's orders need to name the solution to be given, so the physician's order for IVF current solution would need to be clarified. The RN verbalized if the patient was awake and alert the nurse should have followed the order to convert to a saline lock or call the physician for an order to continue the IVF at a keep open rate so the PCA could still be used. The RN stated the physician's orders had not been followed. The patient had received IVF at 100 ml per hour since she arrived on the unit. The RN verbalized she did not know why the staff waited until 5:30 AM on 2/3/12 to get the IVF orders clarified.

The facility's policy entitled, Indwelling Urinary Catheter and Maintenance, dated effective 9/10, documented a Licensed Independent Practitioners (LIP) order was required for the insertion and removal of an indwelling urinary catheter.

The medical record documented Patient #6 had a Foley Catheter in place when she arrived on 1 W at 12:15 PM on 2/2/12. The medical record lacked a current physician's order for the Foley Catheter.

Nursing Progress notes, dated 2/2/12 and 2/3/12, documented Patient #6 had a Foley Catheter in place.

On 2/3/12 at 9:30 AM, the Nurse Manager on 1 W stated a physician's order was required for a Foley Catheter. The Nurse Manager was not able to locate a physician's order for the Foley Catheter.

Patient #13

Patient #13 was admitted to the facility on 1/27/12, from the Emergency Room with diagnosis including vascular dementia, osteoarthritis and falls.

The facility's policy entitled, Interdisciplinary Pain Management, dated effective 7/9, documented:
We respect and support a patient's right to adequate pain management. Patients presenting to any setting will be assessed and treated for the presence of pain including the physical, emotional, spiritual, cultural and psychosocial aspects.
5.1 Pain assessment and Reassessment: An assessment and reassessment will be performed and documented: 5.1.1 Upon admission to the hospital or intake. 5.1.2 Pain reassessment occurs with every nursing assessment.
5.2 Pain assessment and reassessment will include patient's current pain intensity level and patient target intensity (goal) level using the appropriate pain scale tool.

The Pre-Hospital Care Report from the Ambulance Company documented Patient #13 complained for acute onset sharp hip/pelvic pain, provoked by movement with a severity of 10 on a scale of 10.

The Emergency Room documentation indicated Patient #13 entered the Emergency Room on 1/27/12 at 10:44 AM, via ambulance. The patient had fallen off her bed last night and now complained of right hip pain. The documentation indicated Patient #13 had a pain intensity of 10.

The Emergency Department Treatment Record lacked documentation the physician had ordered pain medication for Patient #13.

The medical record lacked documentation to explain why the patient had not received pain medication for a pain level of 10.

On 2/1/12 at 2:25 PM, the Nurse Manager on 1 W was not able to locate documentation Patient #13 had received pain medication for a pain level of 10. The Nurse Manager was not able to locate documentation to explain why the patient had not received pain medications.

On 1/29/12, physician's orders were written for Post Anesthesia Care Unit oxygen. The orders indicated Patient #13 was to receive oxygen at 3 liters per minute via nasal cannula for 24 hours.

Nursing Flow Sheets, dated 1/29/12, documented Patient #13 had received oxygen at 4 liters per minute via nasal cannula from 8:00 AM on 1/29/12 through 1/31/12 at 11:40 AM.

On 2/1/12 at 2:20 PM, Employee #9 confirmed the oxygen orders for Patient #13 had not been followed.


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Patient #23

On 6/26/11, Patient #23 was admitted with diagnoses of subacute stroke, hypertension, and hypothyroidism.

According to the facility's standards of care for intensive care patients with neurologic diagnosis, effective 6/10, under section 2.2.2.1: "Neurologic assessment will be completed every two (2) hours or as ordered by the LIP (licensed independent practitioner).

On 6/27/11 at 8:15 PM, a physician ordered "neuro checks ICU (intensive care unit) routine."

On 2/2/12 in the afternoon, Employee #12 indicated neuro checks were supposed to be done every two hours for Patient #23.

Patient #23's clinical record lacked additional orders denoting the frequency of neuro checks post 6/27/11.

Patient #23's clinical record showed nurses documented neuro checks every four hours throughout the patient's stay in the ICU.

On 7/4/11 during the day shift, Employee #14 left an 8 hour gap in neuro assessments between noon and 8:00 PM.

On 2/2/12 at 2:20 PM, Employee #14 indicated she did not know what happened regarding the lack of neurological assessment between noon and 8:00 PM on 7/4/11.

Patient #25

On 1/24/12, Patient #25 was admitted with diagnoses of hypertension, dyslipidemia, atrial fibrillation, cervical carotid atherosclerosis, and right hemispheric stroke.

On 1/24/12 at 5:45 PM, a physician ordered intravenous Cardene if needed to keep systolic blood pressure 150-180.

Pharmacy documentation showed nobody faxed the order to pharmacy until 7:41 PM. The pharmacy processed the order and dispensed the medication at 7:53 PM. A nurse did not document initiating the medication until 9:00 PM.

On 2/1/12 in the afternoon, Employees #15, #16, and #17 were interviewed separately. Employees #15, #16, and #17 indicated an acceptable turn around time for ordering medications to receiving them for administering was two hours. The facility lacked a policy regarding an acceptable turn around time for routine medication orders.

Patient #25's blood pressure was documented every 15 minutes from 5:45 PM through 9:00 PM on 1/24/12. Patient #25's systolic blood pressure exceeded 200 7 out of 13 possible times blood pressure was documented from 5:45 PM through 9:00 PM. Employee #23 indicated the physician was aware but kept the file until the end of the nurse's shift at 7:00 PM.

Based on observation, interview, clinical record review, and policy review, the facility failed to ensure drugs and biologicals were administered in accordance with approved medical staff polices and procedures for 4 of 30 sampled patients (Patients # 6, #12, #23, and #25).

Findings include:

Patient #12

Patient #12 was admitted to the facility on 1/29/12, with diagnosis including chronic obstructive pulmonary disease and intractable vomiting.

The facility's policy entitled, Medication Administration, dated effective 11/10, documented: ...medications ordered STAT (a medical term used to imply urgent or rush) will be administered within sixty (60) minutes of the order.

On 1/31/12 at 9:30 AM, a physician's order was received for Levaquin 750 milligram (mg) orally first dose now and Fentanyl patch 75 microgram (mcg) every 72 hours-first dose now.

On 1/31/12 at 12:30 PM, a Registered Nurse (RN) stated the physician's orders for the medications were not scanned to the pharmacy. The RN stated the policy for now (or STAT) medication was not followed.

On 2/3/12 at 1:25 PM, a Pharmacist stated the Specific Criteria Report documented the time the nurse removed the medication from the Omnicell System (automatic medication dispensing system).

The Specific Criteria Report documented the medication Levaquin had not been retrieved from the Omnicell System on 1/31/12 until 12:54 PM and the Fentanyl patch had not been removed from the system until 1:14 PM.


Patient #6

Patient #6 was admitted to the facility on 2/2/12, with diagnosis including left shoulder osteoarthritis glenohumeral joint, rotator cuff tear and acromion fracture. The patient had a reverse total shoulder replacement on 2/2/12 and arrived on unit 1 W at 12:15 PM.

Post Operation Orders dated 2/2/12, documented Patient #6 was to received Intravenous fluid (IVF): current at 100 milliliters (ml) her hour. Convert to saline lock when awake and alert. The physician's orders were noted on 2/3/12 at 2:20 AM.

Nursing Progress notes dated 2/2/12 at 12:15 PM, documented the patient was alert and orientated times 3. The documentation indicated Patient #6 had received IVF from 12:15 PM throughout the night and the IVF was still running on 2/3/12 at 9:15 AM.

On 2/3/12 at 9:30 AM, Patient #6 was observed in bed with IVF fluid running at 100 ml per hour.
According to the medical record on 2/3/12 at 5:30 AM, a call was place to the physician for clarification of the IVF orders.

On 2/3/12 at 10:15 AM, an RN stated the nurse should check the IVF infusing from the Post Anesthesia unit and call for an order to clarify what solution the physician wanted. The facility's policy indicated the physician's order need to name the solution to be given, so the physician's order for IVF current solution would need to be clarified. The RN verbalized if the patient was awake and alert the nurse should have followed the order to convert to a saline lock or call the physician for an order to continue the IVF at a keep open rate so the PCA could still be used. The RN stated the physician's order had not been followed. The patient had received IVF at 100 ml per hour since she arrived on the unit. The RN verbalized she did not know why the staff waited until 5:30 AM on 2/3/12 to get the IVF orders clarified.


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Patient #23

On 6/26/11, Patient #23 was admitted with diagnoses of subacute stroke, hypertension, and hypothyroidism.

On 6/26/11 at 11:25 AM, a physician ordered Neosynephrine drip to keep systolic blood pressure 170-200.

On 6/26/11 at 4:04 PM, a physician ordered Levophed drip to maintain systolic blood pressure 170-200.

Nursing documentation demonstrated initiation of the above medications without ordered initial doses/rates at 11:45 AM and 4:45 PM respectively.

According to the facility's policies, Medication Titration #4.1 (effective 9/09) and Medication Administration #4.18 (effective 11/10), orders for medications that require titration must include a start dose.

Patient #25

On 1/24/12, Patient #25 was admitted with diagnoses of hypertension, dyslipidemia, atrial fibrillation, cervical carotid atherosclerosis, and right hemispheric stroke.

On 1/24/12 at 5:45 PM, a physician ordered intravenous Cardene if needed to keep systolic blood pressure 150-180. The order lacked a starting dose/rate.

According to the facility's policies, Medication Titration #4.1 (effective 9/09) and Medication Administration #4.18 (effective 11/10), orders for medications that require titration must include a start dose.

Pharmacy documentation showed nobody faxed the order to pharmacy until 7:41 PM. The pharmacy processed the order and dispensed the medication at 7:53 PM. A nurse did not document initiating the medication until 9:00 PM.

On 2/1/12 in the afternoon, Employees #15, #16, and #17 were interviewed separately. Employees #15, #16, and #17 indicated an acceptable turn around time as two hours for ordering medications to receiving them for administering. The facility lacked a policy regarding an acceptable turn around time for routine medication orders.

Based on interview, and clinical record review, the facility failed to ensure patient's clinical records contained documentation to describe a patient's progress and response to services for 1 of 30 sampled patients (Patient #5).

Findings include:

Patient #5

Patient #5 was admitted to the facility on 1/29/12, with diagnosis including shingles and meningitis.

On 1/29/12, a physician's order was received for an International Normalized Ratio (INR, which measures blood clotting time) to be drawn at 2:00 AM on 1/30/12. If the INR was greater than 1.5 at 2:00 AM, give Vitamin K 10 milligram times 1 STAT (a medical term used to imply urgent or rush) and repeat INR at 6:00 AM.

The medical record lacked documentation the INR had been drawn at 2:00 AM on 1/30/12, in accordance with the physician's orders. There was no documentation in the medical record to indicate the test had been canceled, if the timing of the test had been changed or an explanation why the test was not completed.

On 2/2/12 at 1:50 PM, a Registered Nurse (RN) was not able to locate documentation the INR had been completed. The RN stated she was not able to locate documentation to indicate why the lab work had not been done.

On 1/30/12 at 7:10 AM, a telephone physician's order was obtained to insert a midline peripherally inserted catheter STAT.

On 1/30/12 at 7:50 AM, a telephone physician's order was obtained to insert a Peripherally Inserted Central Catheter (PICC) line, cancel midline peripherally inserted catheter STAT.

On 1/30/12 at 9:55 AM, a telephone physician's order was obtained to please change PICC line to midline PICC now (can be used line for blood draw).

On 1/30/12 at 12:20 PM, a physician's order was received to please PICC STAT.

The medical record indicated the PICC line had been placed on 1/30/12 at 3:00 PM and a chest x-ray was done at 3:40 PM to confirm placement.

The medical record lacked documentation to explain why the nursing staff called the physician to change the midline peripherally inserted catheter to a PICC line and back to a midline PICC line. The medical record lacked documentation to indicate why there had been delays with the insertion of the line

On 2/2/12 at 2:55 PM, Employee #13 stated there was definitely a delay in getting the PICC line inserted. The RN was not able to locate documentation to indicate why there was a delay in the patient getting the PICC line or why the changes in physician's orders were required.

Based on interview, clinical record review, and policy review, the facility failed to ensure 2 of 30 sampled patients' (Patient #6 and #13) clinical records contained all documentation and information necessary to monitor the patients' condition.

Findings include:

Patient #6

Patient #6 was admitted to the facility on 2/2/12, with diagnosis including left shoulder osteoarthritis glenohumeral joint, rotator cuff tear and acromion fracture. The patient had a reverse total shoulder replacement on 2/2/12, and arrived on unit 1 W at 12:15 PM.

Patient Controlled Analgesia (PCA) orders, dated 2/2/12, documented: Patient #6 had a loading dose of Morphine 2 milligram (mg), a patient bolus volume/dose of 1 mg and bolus interval/bolus per hour 6 minutes/10 per hours.

The facility's policy entitled, Patient Controlled Analgesia (PCA), dated effective 3/11, documented:
4.5 "At a minimum, the patient will be assessed for pain and level of sedation every hour for the first four (4) hours after the PCA is initiated or when the medication dosage is changed. 4.5.1 documented the patient will be reassessed every four (4) hours and as needed (prn) thereafter.
6.2 documented, "All patient assessments and reassessments will be documented in the patient's health record."

The medical record lacked documentation Patient #6 had been assessed for pain from 12:30 PM to 3:00 PM on 2/2/12.

On 2/3/12 at 10:10 AM, a Registered Nurse (RN) stated with any newly initiated PCA medications the patient was to be assessed for pain every hour for the first 4 hours and then every 4 hours. The RN was not able to locate documentation Patient #6 had been assessed every hour for the first 4 hours after the PCA had been initiated. The RN verbalized the policy for PCA medication had not been followed.


Patient #13

Patient #13 was admitted to the facility on 1/27/12, from the Emergency Room with diagnosis including vascular dementia, osteoarthritis and falls.

The Pre-Hospital Care Report from the Ambulance Company documented Patient #13 complained for acute onset sharp hip/pelvic pain, provoked by movement with a severity of 10 on a scale of 10.

The Emergency Room documentation indicated Patient #13 entered the Emergency Room on 1/27/12 at 10:44 AM, via ambulance. The patient had fallen off her bed last night and now complained of right hip pain. The documentation indicated Patient #13 had a pain intensity of 10.

The Emergency Department Treatment Record lacked documentation the physician had ordered pain medication for Patient #13.

The medical record lacked documentation to explain why the patient had not received pain medication for a pain level of 10.

On 2/1/12 at 2:25 PM, the Nurse Manager on 1 W was not able to locate documentation Patient #13 had received pain medication for a pain level of 10. The Nurse Manager was not able to locate documentation to explain why the patient had not received pain medications.

Based on record review, interview and policy review, the facility's pharmacy failed to ensure intravenous medications with titration orders were dispensed according to the facility's medication administration and medication titration policies for 2 of 30 patients (Patient #23 and Patient #25).

Findings include:

Patient #23

On 6/26/11, Patient #23 was admitted with diagnoses of subacute stroke, hypertension, and hypothyroidism.

On 6/26/11 at 11:25 AM, a physician ordered Neosynephrine drip to keep systolic blood pressure 170-200.

On 6/26/11 at 4:04 PM, a physician ordered Levophed drip to maintain systolic blood pressure 170-200.

Nursing documentation demonstrated initiation of the above medications without ordered initial doses/rates at 11:45 AM and 4:45 PM respectively.

According to the facility's policies, Medication Titration #4.1 (effective 9/09) and Medication Administration #4.18 (effective 11/10), orders for medications that require titration must include a start dose.

Patient #25

On 1/24/12, Patient #25 was admitted with diagnoses of hypertension, dyslipidemia, atrial fibrillation, cervical carotid atherosclerosis, and right hemispheric stroke.

On 1/24/12 at 5:45 PM, a physician ordered intravenous Cardene if needed to keep systolic blood pressure 150-180. The order lacked a starting dose/rate.

According to the facility's policies, Medication Titration #4.1 (effective 9/09) and Medication Administration #4.18 (effective 11/10), orders for medications that require titration must include a start dose.

Pharmacy documentation showed nobody faxed the order to pharmacy until 7:41 PM. The pharmacy processed the order and dispensed the medication at 7:53 PM. A nurse did not document initiating the medication until 9:00 PM.

On 2/1/12 in the afternoon, Employees #15, #16, and #17 were interviewed separately. Employees #15, #16, and #17 indicated an acceptable turn around time for ordering medications to receiving them for administering was two hours. The facility lacked a policy regarding an acceptable turn around time for routine medication orders.

Employee #16 and Employee #17 agreed intravenous medications with titration orders should have an ordered start dose/rate. Employee #16 indicated he would still dispense the medication if it were a life or death situation.

Based on document review and interview, the hospital failed to have a complete HIV/HCV Lookback policy, and failed to retain all documentation from a specific Lookback incident in the patient's medical record.

Findings include:

On 2/3/12 at approximately 10:00 AM, Employee #30 confirmed:

1. The Lookback policy did not make provision for record maintenance of 10 years, prompt retrieval of records, and a fully-funded plan to transfer the records to another hospital or entity should the hospital cease operation.

2. The Lookback policy did not make provision for the notification of a patient's relative.

3. The Lookback policy did not make provision for documenting in the patient's medical record the extenuating circumstances beyond the hospital's control that caused the notification timeframe to exceed twelve weeks, should such an instance occur.

On 2/3/12 at approximately 2:00 PM, Employee #30 confirmed:

The hospital did not maintain the complete documentation from Patient #35's Lookback incident in the patient's medical record.

Based on observation, interview, document and record review, the facility failed to provide and maintain a physical environment that was safe for neonatal patients as evidenced by:
1) providing care in unlicensed areas with insufficient space and infrastructure to support proper care;
2) obstructing visibility and preventing the ability to properly assess for safety of the neonates; and
3) improper storage of equipment in the patient care areas.

See Tags A722 and A725.

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 and staff interview, the facility was found not to be adequately designed and maintained to reflect the services it offered in accordance with accepted standards of practice. The Neonatal Intensive Care Unit (NICU) was licensed for 15 Level III (critical infant) beds and the census varied from 18 to 23 during the days of the survey. Room #301, licensed as a Labor Delivery Room, and had a census of 4 to 6, Level II, newborns during the days of the survey and Room #301 was not designed, nor constructed for Level II (less critical infants) neonates.

Findings include:

Interpretive Guidelines 482.41(c) Adequate facilities means the hospital has facilities that are: Designed and maintained in accordance with Federal, State, and local laws regulations and guidelines: and Designed and maintained to reflect the scope and complexity of the services it offers in accordance with accepted standards of practice.

State regulations requires the hospital to observe the American Institute of Architects, "Guidelines for Design and Construction of Health Care Facilities," (AIA Guidelines)concerning their physical plant's design and construction. The AIA Guidelines currently in effect in Nevada is the 2006 edition.

The pertinent AIA Guidelines sections the facility is deficient are listed below:

A) (Level III) NICU requirements per bassinet (2.1 General Hospitals, 3.4.6 Newborn Intensive Care Units) are:
-120 square feet clear floor space, excluding sinks and aisles,
- 4 ft. aisle adjacent to each infant care space,
- 8 ft. between infant care beds
B) The electrical outlet requirements (2.1-10.3.7(3)) are:
- 7 duplex outlets, 50% of which are on emergency system power.
C) Piped-in medical gas systems requirements (oxygen, vacuum and medical air) (2.1-10.1.4.1 and Table 2.1-5: Newborn Intensive Care) are:
- 3 oxygen, 3 vacuum, and 3 medical air
D) (Level II) NICU requirements per bassinet (2.1-3.4.7 Continuing Care Nursery) are:
-50 ft. per bassinet, exclusive of auxiliary work areas
- four feet between and at all sides of each bassinet

The facility presentation at the time of the survey and the deficient practices for the neonatal care areas are given below:

Issue 1 - Neonatal Intensive Care Unit (NICU): The commingling of space for licensed and unlicensed NICU beds (beds/isolettes/bassinets) and Level III (critical) and Level II (less critical) neonate beds.

On 2/1/12, nursing staff were interviewed to provide the surveyors with a diagram identifying the space configuration of their current NICU. The drawing showed 29 bassinets designated in the NICU in space only licensed for 15 bassinets. Later that day the NICU was observed with 21 infants and the facility indicated that they were Level II (less critical) and Level III (critical) neonates in the NICU. Each licensed care station was divided in two with a curtain. In some cases, drawn curtains would have concealed the babies from visual observation by the nursing staff. There were four specific locations of concern for possible visual concealment: Station 1 NW, Station 15 SW, Station 11 W, Station 10 W, Station 9 E, and Station 8 E.

Note: Less critical care patient (Level II) can be assigned into a vacant, more critical care (Level III) bed, provided that all care staff know each patient's critical care status.

There was no designated area for Level II babies within the NICU. The two Levels were intermixed throughout the NICU (licensed and unlicensed beds), requiring all stations to meet the more stringent Level III requirements of the AIA Guidelines. The facility reported the census as 23 for 2/1/12.

On 2/2/12 at 11:00 AM, 19 babies were observed in bassinets in the NICU. They were doubled-up in Stations #3, #4, #5 and #6. Each care station throughout the unit had curtains dividing the station in half. The facility reported the census as 20 for that day. In every instance where babies were doubled-up in a single care station, they had access to only half of the required space, and half of the required number of electrical outlets, and piped-in medical gas (oxygen, air, and vacuum) outlets. The care stations were measured with the divider curtains drawn, the two smallest ones (#8 West, and #9 East) measured only 32 square feet (120 square feet is required). Divider curtains were installed in 14 of 15 NICU care stations, Station #12 was the only exception.

In the morning of 2/3/12, babies were doubled-up in Stations #3, #4, #6, and #11. The facility reported the census as 18 for that day. The divider curtains in some care stations had been removed.


Issue 2 - Room #301: Being used as an unlicensed Level II NICU

Room #301 was licensed as a Labor Delivery Room. The bassinet alcove in Room #301 was provided with three sets of oxygen, vacuum and medical air outlets. It also had 16 duplex electrical outlets, 50% of which were connected to the emergency power system. The opposing wall, where the headboard of the mother's bed would normally be, had three sets of oxygen, vacuum and medical air outlets. It had eight duplex outlets, seven of which were connected to the emergency power system.

Room #301 was being used as an unapproved, NICU overflow room. On 2/1/12 nursing staff were asked to provide the surveyors with a drawing showing the space configuration of this overflow area. The diagram showed six bassinets. On 1/31/12 the facility reported a census of 6 newborns in this room. The usable space within this room measured approximately 225 square feet, and was used for only Level II babies. There was insufficient space for six Level II bassinets in this room (6 beds X 50' = 300 square feet). The bassinet configuration failed to provide four foot clearance on all sides of each bassinet.

The babies shared Room #301 with electronic servers and other hardware located in a closet concealed by a set of hollow-core, bi-fold doors which were locked. One bassinet was located directly in front of these closet doors. This baby was on oxygen, but not connected to a wall outlet, oxygen was provided from an "E" sized cylinder.

On 2/1/12, the surveyors went to this unlicensed NICU (Room #301) and counted five Level II newborns. On 2/2/12 at 11:00 AM, there were four babies in bassinets in Room #301. On the morning of 2/3/12, there were four babies in bassinets in Room #301.

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

Findings include:

Interpretive Guidelines 482.41(c) Adequate facilities means the hospital has facilities that are: Designed and maintained in accordance with Federal, State, and local laws regulations and guidelines: and Designed and maintained to reflect the scope and complexity of the services it offers in accordance with accepted standards of practice.

State regulations requires the hospital to observe the American Institute of Architects, "Guidelines for Design and Construction of Health Care Facilities," (AIA Guidelines)concerning their physical plant's design and construction. The AIA Guidelines currently in effect in Nevada is the 2006 edition.

The pertinent AIA Guidelines sections the facility is deficient are listed below:

A) (Level III) NICU requirements per bassinet (2.1 General Hospitals, 3.4.6 Newborn Intensive Care Units) are:
-120 square feet clear floor space, excluding sinks and aisles,
- 4 ft. aisle adjacent to each infant care space,
- 8 ft. between infant care beds
B) The electrical outlet requirements (2.1-10.3.7(3)) are:
- 7 duplex outlets, 50% of which are on emergency system power.
C) Piped-in medical gas systems requirements (oxygen, vacuum and medical air) (2.1-10.1.4.1 and Table 2.1-5: Newborn Intensive Care) are:
- 3 oxygen, 3 vacuum, and 3 medical air
D) (Level II) NICU requirements per bassinet (2.1-3.4.7 Continuing Care Nursery) are:
-50 ft. per bassinet, exclusive of auxiliary work areas
- four feet between and at all sides of each bassinet

The facility presentation at the time of the survey and the deficient practices for the neonatal care areas are given below:

On 1/31/12 in the afternoon, the Interim NICU (neonatal intensive care unit) Manager indicated the NICU was licensed for 15 beds (isolettes/bassinets). The NICU had 14 stations which originally held one bed for each station and one enclosed room (infection isolation room) which also originally had one bed designated to the room. The stations including the room were numbered from 1 to 15, and these licensed bed were for Level III (critical) neonates, which could accommodate Level II (less critical) neonates. The census for the NICU on 1/31/12 was 23 (15 licensed + 8 unlicensed beds) patients/babies. The Interim NICU Manager indicated the NICU had been going over census for several months and the NICU could possibly hold up to 29 (15 licensed + 14 unlicensed beds) Level II and Level III baby beds. She was not sure what the maximum capacity of NICU beds were and needed to clarify the number.

The NICU census during the survey was:

2/1/12 - 23 (15 licensed + 8 unlicensed beds)
2/2/12 - 20 (15 licensed + 5 unlicensed beds)
2/3/12 - 18 (15 licensed + 3 unlicensed beds)

Stations 1-11 and 13-15 which originally had one bed/isolette in each station was being divided to place two beds into each station. Station 12 was partly divided with one bed and a storage station. A floor-plan documenting how the 15 licensed and 14 unlicensed beds were situated to fit in the NICU was given to the surveyor on 2/1/12.

On 1/31/12 in the afternoon, sliding curtains that were hung from ceiling to floor that were being used to divide each one bed station in half to accommodate two beds in each Stations 1-6, Stations 8-11 and Stations 13-15.

Stations 1-6, Stations 8-11 and Station 14-15s were similarly set up as follows:

- Each station was originally designed for one bed/patient.
- Each station was divided by curtains to place another patient (two beds).
-The facility's 29 designated (15 licensed and 14 unlicensed) care areas were for both Level III and Level II neonates were unapproved and not in compliance. The facility did not have a policy describing their intension for care in this area or the removal of equipment when there was a reduction in the number of neonates.
-The first bed in each station was closest to the back wall. The first curtain separated the first bed from the second bed.
-After the first curtain, which separated bed one and bed two, came the second bed in the station which was closest to the aisleway. There was a second curtain between the second bed and the aisleway.
-When closing the first curtain, the first bed was not visible from the aisleway, but the second bed would be visible.
-When closing the second curtain, both beds were not visible from the aisleway. Staff had to open the second curtain, pass the second bed and open the first curtain to obtain access to the baby located in the first bed.
-If the second curtain was closed, it would be difficult to visually assess who was working in the station. It would also be difficult to see if visitors or parents were entering other baby areas other than their own.

On 2/3/12 in the afternoon, a staff nurse indicated it was sometimes difficult to hear what type of alarm was going off and whose baby's alarm was going off when the curtains were closed and obstructed the view for bed one and bed two.

On 2/3/12 in the afternoon, another staff nurse indicated when the curtains were being used it would be difficult to see if other family members were going to the other baby's bassinet.

Station 1

Station 1, which was originally used for one bed, was now separated into a two bed area by a curtain. The first bed in the station had a space of approximately 63 square feet. The second bed in Station 1 had approximately 56 square feet of space. In Station 1 bed 2, there was a bin full of cords and toys being stored on the floor. Also in the room was the emergency cart. On 2/3/12 in the afternoon, the interim unit manager indicated due to the limited space in the NICU the designated station for the emergency cart was in Station 1 bed 2's area. Having the emergency cart, bins of supplies, toys, isolette, medical equipment (such as a ventilator and intravenous pumps) in the 56 square foot area in Station 1 bed 2 did not have adequate space to provide care for the patient. The space would also need to accommodate staff and family members along with the equipment.

On 2/3/12 in the morning, a staff nurse indicated since the start of the survey equipment around the NICU was being stored somewhere else to clear the NICU area. The staff nurse indicated the NICU aisleways were being cleared of equipment just because the surveyors were in the facility. The staff nurse indicated when the survey was completed, the equipment would be returned to the NICU.

Station 2

Station 2, which was originally used for one bed, was now separated into a two bed station by a curtain. The station which the first bed was located had 63 square feet of space. The station which had the second bed had approximately 60 square feet of space. On 2/3/12 in the afternoon, family members were visiting the baby located in the first bed. Along with the crib being in the area there was also one chair in the first bed station. The chair limited the space in the area. On 2/3/12 in the afternoon, the interim unit manager indicated the policy for visitors was two family members for each baby. She also indicated that at some cases more family members were allowed into a station if a baby was declining rapidly.

Common to All Stations

There was no documented evidence a new policy was initiated regarding the number of visitors for each baby since the increase in the number of beds in the unit from 15 beds (licensed) to 29 beds (15 licensed + 14 unlicensed). Station 2 was similar to all the stations in the NICU. If the unit had a census of 29 babies there would be limited space in each station to provide care if two family members were visiting their baby within the unit. Family members and chairs used for nursing mothers would take up the available and limited space in the modified stations.

On 2/3/12 in the morning, a team of physicians, students and other hospital staff were seen rounding in Station 10. There were 8 people noted in the group.

On 2/3/12 in the morning, an Occupational Therapist was seen in Station 14 working with a baby.

On 2/3/12 in the afternoon, a staff nurse indicated when the census increases above the 15 licensed beds, it gets crowded in the NICU due to the extra equipment, family members, nursing staff, physicians, students, therapist and clerical staff. The staff nurse indicated there was limited space to move around in the rooms due to the people and the equipment. The increased equipment and staff increased the noise level and the amount of alarms going off in the unit. The staff nurse also indicated that the increased equipment posed a tripping hazard to staff and family members.

Station 3

Station 3, which was originally for one bed, was now separated into a two bed station by a curtain. The station which the first bed was located had 55 square feet of space. The station which had the second bed had approximately 48 square feet of space. One wall of the station had supplied oxygen, outlets, vacuum and air. The wall measured approximately 9 feet in length. Two beds were situated along the wall to access the supplied ports. The two beds were separated approximately 2 ? feet away from each other. Along with the beds each baby could possibly be on a ventilator, intravenous pump and a feeding pump.

The following equipment was measured:
-Isolette/bed (used mostly for level III babies) 40 inches x 25 inches.
-Bassinet/bed (used for level II babies) 34 inches x 21 inches.
-Intravenous IV pumps on a pole 24 inches in diameter.
-Ventilator 21 inches x 24 inches.

The first bed in Station 3 had approximately 5 feet of space to place the bed and equipment along the wall. If one IV pump on a pole, one bed/isolette and one ventilator was used for bed 1 station 3, the length needed would almost total 6 feet (for outlet access for equipment).

The second bed in Station 3 had approximately 4 feet of space to place the bed and equipment along the wall. If one IV pump on a pole, one bed/isolette and one ventilator was used for the bed two station, the length needed again would be almost 6 feet (for outlet access for equipment).

If Station 3 were to have one bed allocated to the area. There would be sufficient space for one bed and equipment to provide care for the baby.

Stations #1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #13, #14, and #15 were similar with Station #3, regarding the insufficient wall length needed to place beds and equipment when the stations were divided in two.

There was no documented evidence there was a policy in place for the unapproved NICU arrangement, discussing what type of baby bed or equipment could be placed together in a station that was divided for two babies. On 2/1/12 in the afternoon, the Interim NICU Manager indicated in any station in the NICU two level III babies could be placed in a single station that was separated by curtains and that there were no restrictions on what equipment could be placed in the station if the station had two beds in them.

On 2/3/12 in the afternoon, two staff nurses indicated when the census increases to over 20 babies in the NICU some staff had trouble going around the equipment due to the increased equipment used on the unit. The staff members indicated sometimes they would trip over the equipment.

Station 7

Station 7 was an enclosed room originally used as an infection isolation room for one bed. The facility floor plan diagrammed two beds in the room. The first bed was along the wall that supplied oxygen, air, vacuum and electrical outlets. The floor plan diagrammed the second bed blocking and preventing access to the sink. Also, this second bed did not have access to the piped-in medical gas systems and electrical outlets.

Upon entering the room on 2/2/12 in the afternoon, there was one isolette/bed in the room being used by a baby. Along with the bed was equipment being used for the patient. The bed and equipment used the entire head wall that supplied oxygen, electrical outlets and air. The second bed would have to be located in front of the hand sink as indicated on the floor plan to fit within the room. The Director of Quality Risk Services confirmed it was not acceptable to place the bed in front of the sink preventing access and to be without medical gas system and electrical outlet access.

Station 15

Station 15 was also divided to provide room for two beds in the station. Bed one in the station had 63 square feet of space and bed two also had 63 square feet of space.

On 2/3/12 in the morning, the hospital staff was performing a procedure on a baby in Station 15 bed one. There was no baby in the bed two area closest to the aisleway. The echocardiogram machine was inside the area and was very large. The charge nurse indicated if there was another baby in the second bed the machine would not be able to fit in the area. The nursing staff indicated the baby having the test would have to be moved somewhere else to perform the test, but there was no designated area to transfer the baby to perform the test. The Interim NICU Manager indicated x-rays were also performed at the bedside at times and confirmed that there would be no space available for the x-ray machine if two beds were in use in the same divided station. The Interim Unit Manager indicated there was no policy regarding what test could be done at the bed side, where the babies could be transferred, which babies could be transferred if there was no space available in the area to do the test or procedure due to the two beds into a single station designated for one bed.

Along the aisleway next to Station 15 were open shelving units that had medical supplies stored on the shelves. The shelf was approximately 12 feet long by 6 feet high. Anyone had easy access to the supplies (contamination, infection control and tamper concerns).

On 2/3/12 in the afternoon, the infection control director indicated the supplies that were stored on the shelves next to Station 15 was not acceptable and should be stored in a locked area.

Based on observation, interview, clinical record and policy review the facility failed to ensure their infections control polices were implemented.

Findings include:

1. The facility's policy entitled, Infection Control, Isolation-Contact Transmission Based Precautions, dated revised 11/08, documented:
... remove gloves before leaving the patient's room and wash hands immediately with an anti-microbial agent or a waterless antiseptic agent. Remove the gown before leaving the patient's environment.

The facility provided documentation entitled, Contact Isolation Precautions. The documentation indicated use hand hygiene-aseptic technique, gown and glove when entering the room, wear a regular surgical mask, if indicated, use dedicated patient equipment.

Patient #31 was admitted to the facility on 12/25/11, with diagnosis including anemia, urinary tract infection and hyponatremia.

A blood culture report, dated 1/21/12, documented Patient #31's gram stain tested positive for Gram Negative Rods. The culture showed Staphylococcus Epidermidis and Pseudomonas Aeruginosa.

A blood culture report dated 1/23/12, documented Patient #31's gram stain tested positive for Gram Positive Cocci-in clusters.

On 1/24/11, a physician's order was received for Patient #31 to remain in contact isolation

On 2/2/12 at 9:00 AM, Employee #1 exited a contact isolation room (Patients #31's) with a gown, mask and gloves on and removed them in the corridor.

On 2/2/12 at 9:03 AM, Employee #1 stated she was supposed to remove the equipment in the room not in the corridor. The Housekeeper stated she did not do it right.

On 2/2/12 at 9:10 AM, Patient #31's room had a sign posted outside the room to alert staff and visitors the patient was on contact isolation. Employee #2 entered the room with the a gown on untied in the back which hung down around his chest. Employee #2 put a pair of gloves on after entering the patient's room.

On 2/2/12 at 9:12 AM, Employee #3 entered the contact isolation room of Patient #31 and touched the door to close it. The employee did not put on a pair of gloves until after she had entered the patient room.

On 2/2/12 at 9:14 AM, Employee #1 exited Patient #31's room with a gown, mask and gloves on after mopping the floor. The employee removed the equipment in the corridor.

On 2/2/12 at 9:30 AM, Employee #3 stated for patients' on contact isolation a gown and gloves were to be put on before entering the patients' room. Employee #3 stated this rule applied to all staff and family members. The employee verbalized it was not appropriate to enter the room with the gown untied and no gloves. Employee #3 stated Personal Protective Equipment (PPE) was used to protect ourselves and other patients.

On 2/2/12 at 10:20 AM, the Director of Infection Control stated it was the facility's expectation all staff follow the policy and procedure for Isolation and PPE.


2. On 2/2/12 at 8:25 AM, the Intravenous (IV) fluid tubing and 3 secondary tubings in Room #474 contained orange stickers. The orange stickers lacked documentation of the date, time or initials of the person who initiated the use of the tubing.

On 2/2/12 at 8:55 AM, a Registered Nurse stated any time new IV tubing was hung it needed to be labeled with the dated, time and nurse's initials.

On 2/3/12 from 10:35 AM to 10:40 AM, a tour of 1 W was made with 2 facility staff members. The IV fluid tubing and secondary tubings contained an orange stickers in Patient Rooms #117, #118, #119 and #120. The orange stickers lacked documentation of the date, time or initials of the person who initiated the use of the tubing.

On 2/3/12 at 11:30 AM, an IV fluid tubing of Normal Saline and 2 secondary tubings in Room #385 contained orange stickers. The orange stickers did not contain documentation to indicate the date, time or initials of the person who initiated the use of the tubing.

The facility's policy entitled, Adult Vascular Access Devices-Insertion and Maintenance, dated effective 2/11, documented: All IV tubing, including secondary sets, will be labeled with time, date and clinical staff's initials to identify when the tubing was hung.


3. On 2/2/12 at 9:16 AM, Employee #4 was removing clean linen from a large bin and placing the linen in the clean linen cart on the unit. The clean linen was observed up against the employee's uniform. Employee #4 stated it was not appropriate for clean linen to be against his clothing.

On 2/2/12 at 10:20 AM, the Director of Infection Control stated linen was a potential carrier of infection. Clean linen should be kept away from the uniform.


4. Documentation provided by the facility entitled, Infection Prevention, documented:
Linen: Do not place on the floor.

On 2/2/12 between 1:05 and 1:08 PM, 2 bags were on the floor outside of Patient Room #356 in the corridor. One bag was clear plastic and the other was blue plastic. Four bags were on the floor outside Patient Room #354. Two bags were clear plastic and 2 were blue plastic bags.

On 2/2/12 at 1:10 PM, Employee # 8 stated the clear bags contained trash and the blue bags contained dirty linen. Employee #8 stated it was not okay for the bags to be sitting on the floor in the corridor. It was an infection control issue.

Based on record review and interview, two of eight respiratory department personnel did not meet the qualifications stated in their respective job descriptions.

Findings include:

On 2/2/12 at approximately 11:30 AM, Employee #25 confirmed the following data from employee files obtained from Human Resources:

1. Employee #26 did not have a Neonatal Advanced Life Support (NALS) certification, as required in the job description for Respiratory Department Supervisor.

2. Employee #28 did not have a Blood Gas General Supervisor license, as required in the job description for Pulmonary Function Test Technician.

Based on record review and interview, physician orders for Patient #34 were not delivered as written.

Findings include:

In an interview conducted on 2/3/12 at 12:00 PM, Employee #26, Employee #27 and Employee #25 confirmed that physician orders were not followed as written for Patient #34, as observed in the Physician's Orders, Medication Administration Record (MAR), St. Rose Respiratory Department PEDS/PICU Worksheet, and Patient #34's Interdisciplinary Progress Notes and Respiratory Record Sheets.

St. Rose Dominican Hospitals-Policy/Procedure # NS-M1.1000, 4.7 states: "All medications are to be administered within thirty (30) minutes prior to the scheduled time or thirty (30) minutes after the scheduled time."

Examples of orders not given as required include:

1. On 1/21/12 at 2:00 PM, an order was written for Pulmozyme every 6 hours. Ploy was given on 1/22/12 at 7:45 AM and then on 1/22/12 at 9:30 PM, which is a difference of 13 hours and 45 minutes. Pulmonzyme was given on 1/23/12 at 3:00 AM and next on 1/23/12 at 9:00 PM, which is a difference of 18 hours.

2. On 1/21/12 at 10:10 AM, an order for Albuterol every 6 hours, every 3 hours PRN, was written. Abuterol was given on 1/21/12 at 2:00 PM and next on 1/22/12 at 4:44 AM, which is a difference of 14 hours and 44 minutes. Abutter was next given on 1/22/12 at 6:30 AM, a which is a difference of fewer than 2 hours. Abutter was given on 1/24/12 at 1:00 AM and next on 1/24/12 at 12:00 PM, which is a difference of 11 hours.

Based on observation, interview, clinical record review, and policy review, the facility failed to ensure drugs and biologicals were administered in accordance with approved medical staff polices and procedures for 4 of 30 sampled patients (Patients # 6, #12, #23, and #25).

Findings include:

Patient #12

Patient #12 was admitted to the facility on 1/29/12, with diagnosis including chronic obstructive pulmonary disease and intractable vomiting.

The facility's policy entitled, Medication Administration, dated effective 11/10, documented: ...medications ordered STAT (a medical term used to imply urgent or rush) will be administered within sixty (60) minutes of the order.

On 1/31/12 at 9:30 AM, a physician's order was received for Levaquin 750 milligram (mg) orally first dose now and Fentanyl patch 75 microgram (mcg) every 72 hours-first dose now.

On 1/31/12 at 12:30 PM, a Registered Nurse (RN) stated the physician's orders for the medications were not scanned to the pharmacy. The RN stated the policy for now (or STAT) medication was not followed.

On 2/3/12 at 1:25 PM, a Pharmacist stated the Specific Criteria Report documented the time the nurse removed the medication from the Omnicell System (automatic medication dispensing system).

The Specific Criteria Report documented the medication Levaquin had not been retrieved from the Omnicell System on 1/31/12 until 12:54 PM and the Fentanyl patch had not been removed from the system until 1:14 PM.


Patient #6

Patient #6 was admitted to the facility on 2/2/12, with diagnosis including left shoulder osteoarthritis glenohumeral joint, rotator cuff tear and acromion fracture. The patient had a reverse total shoulder replacement on 2/2/12 and arrived on unit 1 W at 12:15 PM.

Post Operation Orders dated 2/2/12, documented Patient #6 was to received Intravenous fluid (IVF): current at 100 milliliters (ml) her hour. Convert to saline lock when awake and alert. The physician's orders were noted on 2/3/12 at 2:20 AM.

Nursing Progress notes dated 2/2/12 at 12:15 PM, documented the patient was alert and orientated times 3. The documentation indicated Patient #6 had received IVF from 12:15 PM throughout the night and the IVF was still running on 2/3/12 at 9:15 AM.

On 2/3/12 at 9:30 AM, Patient #6 was observed in bed with IVF fluid running at 100 ml per hour.
According to the medical record on 2/3/12 at 5:30 AM, a call was place to the physician for clarification of the IVF orders.

On 2/3/12 at 10:15 AM, an RN stated the nurse should check the IVF infusing from the Post Anesthesia unit and call for an order to clarify what solution the physician wanted. The facility's policy indicated the physician's order need to name the solution to be given, so the physician's order for IVF current solution would need to be clarified. The RN verbalized if the patient was awake and alert the nurse should have followed the order to convert to a saline lock or call the physician for an order to continue the IVF at a keep open rate so the PCA could still be used. The RN stated the physician's order had not been followed. The patient had received IVF at 100 ml per hour since she arrived on the unit. The RN verbalized she did not know why the staff waited until 5:30 AM on 2/3/12 to get the IVF orders clarified.


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Patient #23

On 6/26/11, Patient #23 was admitted with diagnoses of subacute stroke, hypertension, and hypothyroidism.

On 6/26/11 at 11:25 AM, a physician ordered Neosynephrine drip to keep systolic blood pressure 170-200.

On 6/26/11 at 4:04 PM, a physician ordered Levophed drip to maintain systolic blood pressure 170-200.

Nursing documentation demonstrated initiation of the above medications without ordered initial doses/rates at 11:45 AM and 4:45 PM respectively.

According to the facility's policies, Medication Titration #4.1 (effective 9/09) and Medication Administration #4.18 (effective 11/10), orders for medications that require titration must include a start dose.

Patient #25

On 1/24/12, Patient #25 was admitted with diagnoses of hypertension, dyslipidemia, atrial fibrillation, cervical carotid atherosclerosis, and right hemispheric stroke.

On 1/24/12 at 5:45 PM, a physician ordered intravenous Cardene if needed to keep systolic blood pressure 150-180. The order lacked a starting dose/rate.

According to the facility's policies, Medication Titration #4.1 (effective 9/09) and Medication Administration #4.18 (effective 11/10), orders for medications that require titration must include a start dose.

Pharmacy documentation showed nobody faxed the order to pharmacy until 7:41 PM. The pharmacy processed the order and dispensed the medication at 7:53 PM. A nurse did not document initiating the medication until 9:00 PM.

On 2/1/12 in the afternoon, Employees #15, #16, and #17 were interviewed separately. Employees #15, #16, and #17 indicated an acceptable turn around time as two hours for ordering medications to receiving them for administering. The facility lacked a policy regarding an acceptable turn around time for routine medication orders.

Based on observation, interview, clinical record, and policy review, the facility failed to ensure the nurse evaluated the care for each patient upon admission and, when appropriate, on an ongoing basis in accordance with hospital policy for 4 of 30 sampled patients (Patients # 6, #13, #23, and #25).

Findings include:

Patient #6

Patient #6 was admitted to the facility on 2/2/12, with diagnosis including left shoulder osteoarthritis glenohumeral joint, rotator cuff tear and acromion fracture. The patient had a reverse total shoulder replacement on 2/2/12, and arrived on unit 1 W at 12:15 PM.

On 2/2/12 at 10:09 AM, Post Operation Orders were written for Intravenous fluid (IVF): current at 100 milliliters (ml) per hour. Convert to saline lock when awake and alert. Patient Controlled Analgesia (PCA) orders dated 2/2/12, documented Patient #6 had a loading dose of Morphine 2 milligram (mg), a patient bolus volume/dose of 1 mg and bolus interval/bolus per hour 6 minutes/10 per hours.

The facility's policy entitled, Patient Controlled Analgesia (PCA), dated effective 3/11, documented:
4.5 "At a minimum, the patient will be assessed for pain and level of sedation every hour for the first four (4) hours after the PCA is initiated or when the medication dosage is changed. 4.5.1 documented the patient will be reassessed every four (4) hours and as needed (prn) thereafter.
6.2 documented, "All patient assessments and reassessments will be documented in the patient's health record."

The medical record lacked documentation Patient #6 had been assessed for pain from 12:30 PM to 3:00 PM on 2/2/12.

On 2/3/12 at 9:15 AM, the Nurse Manager on unit 1 W stated the nurses should have assessed the patient's pain when the vitals were taken. The Nurse Manager stated the policy for pain assessment had not been followed.

On 2/3/12 at 10:10 AM, a Registered Nurse (RN) stated with any newly initiated PCA medications the patient was to be assessed for pain every hour for the first 4 hours and then every 4 hours. The RN was not able to locate documentation Patient #6 had been assessed every hour for the first 4 hours after the PCA had been initiated. The RN verbalized the policy for PCA medication had not been followed.

The medical record contained documentation on the nurse's flow sheets which indicated Patient #6 was receiving oxygen at 2 liters/per nasal cannula from 2/2/12 at 12:15 PM through 2/3/12 at 8:00 AM.

The medical record lacked documentation Patient #6 had a physician's order for oxygen use on the unit.

On 2/3/12 at 9:30 AM, the Nurse Manager on 1 W confirmed Patient #6 had oxygen on at 2 liters per minute via nasal cannula. The Nurse Manager was not able to locate documentation in the medical record oxygen had been ordered for Patient #6. The Nurse Manager on unit 1 W stated a physician's order was required for oxygen.

Post Operation Orders, dated 2/2/12, documented Patient #6 was to received Intravenous fluid (IVF): current at 100 milliliters (ml) her hour. Convert to saline lock when awake and alert. The physician's order was noted on 2/3/12 at 2:20 AM.

Nursing Progress notes, dated 2/2/12 at 12:15 PM, documented the patient was alert and orientated times 3. The documentation indicated Patient #6 had received IVF from 12:15 PM throughout the night and the IVF was running on 2/3/12 at 9:15 AM.

On 2/3/12 at 9:30 AM, Patient #6 was observed in bed with oxygen on, a Foley catheter in place and IVF fluid running at 100 ml per hour.

According to the medical record on 2/3/12 at 5:30 AM, a call was place to the physician for clarification of the IVF orders.

On 2/3/12 at 10:15 AM, a RN stated the nurse should check the IVF infusing from the Post Anesthesia unit and call for an order to clarify what solution the physician wanted. The facility's policy indicated the physician's orders need to name the solution to be given, so the physician's order for IVF current solution would need to be clarified. The RN verbalized if the patient was awake and alert the nurse should have followed the order to convert to a saline lock or call the physician for an order to continue the IVF at a keep open rate so the PCA could still be used. The RN stated the physician's orders had not been followed. The patient had received IVF at 100 ml per hour since she arrived on the unit. The RN verbalized she did not know why the staff waited until 5:30 AM on 2/3/12 to get the IVF orders clarified.

The facility's policy entitled, Indwelling Urinary Catheter and Maintenance, dated effective 9/10, documented a Licensed Independent Practitioners (LIP) order was required for the insertion and removal of an indwelling urinary catheter.

The medical record documented Patient #6 had a Foley Catheter in place when she arrived on 1 W at 12:15 PM on 2/2/12. The medical record lacked a current physician's order for the Foley Catheter.

Nursing Progress notes, dated 2/2/12 and 2/3/12, documented Patient #6 had a Foley Catheter in place.

On 2/3/12 at 9:30 AM, the Nurse Manager on 1 W stated a physician's order was required for a Foley Catheter. The Nurse Manager was not able to locate a physician's order for the Foley Catheter.

Patient #13

Patient #13 was admitted to the facility on 1/27/12, from the Emergency Room with diagnosis including vascular dementia, osteoarthritis and falls.

The facility's policy entitled, Interdisciplinary Pain Management, dated effective 7/9, documented:
We respect and support a patient's right to adequate pain management. Patients presenting to any setting will be assessed and treated for the presence of pain including the physical, emotional, spiritual, cultural and psychosocial aspects.
5.1 Pain assessment and Reassessment: An assessment and reassessment will be performed and documented: 5.1.1 Upon admission to the hospital or intake. 5.1.2 Pain reassessment occurs with every nursing assessment.
5.2 Pain assessment and reassessment will include patient's current pain intensity level and patient target intensity (goal) level using the appropriate pain scale tool.

The Pre-Hospital Care Report from the Ambulance Company documented Patient #13 complained for acute onset sharp hip/pelvic pain, provoked by movement with a severity of 10 on a scale of 10.

The Emergency Room documentation indicated Patient #13 entered the Emergency Room on 1/27/12 at 10:44 AM, via ambulance. The patient had fallen off her bed last night and now complained of right hip pain. The documentation indicated Patient #13 had a pain intensity of 10.

The Emergency Department Treatment Record lacked documentation the physician had ordered pain medication for Patient #13.

The medical record lacked documentation to explain why the patient had not received pain medication for a pain level of 10.

On 2/1/12 at 2:25 PM, the Nurse Manager on 1 W was not able to locate documentation Patient #13 had received pain medication for a pain level of 10. The Nurse Manager was not able to locate documentation to explain why the patient had not received pain medications.

On 1/29/12, physician's orders were written for Post Anesthesia Care Unit oxygen. The orders indicated Patient #13 was to receive oxygen at 3 liters per minute via nasal cannula for 24 hours.

Nursing Flow Sheets, dated 1/29/12, documented Patient #13 had received oxygen at 4 liters per minute via nasal cannula from 8:00 AM on 1/29/12 through 1/31/12 at 11:40 AM.

On 2/1/12 at 2:20 PM, Employee #9 confirmed the oxygen orders for Patient #13 had not been followed.


26251



Patient #23

On 6/26/11, Patient #23 was admitted with diagnoses of subacute stroke, hypertension, and hypothyroidism.

According to the facility's standards of care for intensive care patients with neurologic diagnosis, effective 6/10, under section 2.2.2.1: "Neurologic assessment will be completed every two (2) hours or as ordered by the LIP (licensed independent practitioner).

On 6/27/11 at 8:15 PM, a physician ordered "neuro checks ICU (intensive care unit) routine."

On 2/2/12 in the afternoon, Employee #12 indicated neuro checks were supposed to be done every two hours for Patient #23.

Patient #23's clinical record lacked additional orde

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

Findings include:

Interpretive Guidelines 482.41(c) Adequate facilities means the hospital has facilities that are: Designed and maintained in accordance with Federal, State, and local laws regulations and guidelines: and Designed and maintained to reflect the scope and complexity of the services it offers in accordance with accepted standards of practice.

State regulations requires the hospital to observe the American Institute of Architects, "Guidelines for Design and Construction of Health Care Facilities," (AIA Guidelines)concerning their physical plant's design and construction. The AIA Guidelines currently in effect in Nevada is the 2006 edition.

The pertinent AIA Guidelines sections the facility is deficient are listed below:

A) (Level III) NICU requirements per bassinet (2.1 General Hospitals, 3.4.6 Newborn Intensive Care Units) are:
-120 square feet clear floor space, excluding sinks and aisles,
- 4 ft. aisle adjacent to each infant care space,
- 8 ft. between infant care beds
B) The electrical outlet requirements (2.1-10.3.7(3)) are:
- 7 duplex outlets, 50% of which are on emergency system power.
C) Piped-in medical gas systems requirements (oxygen, vacuum and medical air) (2.1-10.1.4.1 and Table 2.1-5: Newborn Intensive Care) are:
- 3 oxygen, 3 vacuum, and 3 medical air
D) (Level II) NICU requirements per bassinet (2.1-3.4.7 Continuing Care Nursery) are:
-50 ft. per bassinet, exclusive of auxiliary work areas
- four feet between and at all sides of each bassinet

The facility presentation at the time of the survey and the deficient practices for the neonatal care areas are given below:

On 1/31/12 in the afternoon, the Interim NICU (neonatal intensive care unit) Manager indicated the NICU was licensed for 15 beds (isolettes/bassinets). The NICU had 14 stations which originally held one bed for each station and one enclosed room (infection isolation room) which also originally had one bed designated to the room. The stations including the room were numbered from 1 to 15, and these licensed bed were for Level III (critical) neonates, which could accommodate Level II (less critical) neonates. The census for the NICU on 1/31/12 was 23 (15 licensed + 8 unlicensed beds) patients/babies. The Interim NICU Manager indicated the NICU had been going over census for several months and the NICU could possibly hold up to 29 (15 licensed + 14 unlicensed beds) Level II and Level III baby beds. She was not sure what the maximum capacity of NICU beds were and needed to clarify the number.

The NICU census during the survey was:

2/1/12 - 23 (15 licensed + 8 unlicensed beds)
2/2/12 - 20 (15 licensed + 5 unlicensed beds)
2/3/12 - 18 (15 licensed + 3 unlicensed beds)

Stations 1-11 and 13-15 which originally had one bed/isolette in each station was being divided to place two beds into each station. Station 12 was partly divided with one bed and a storage station. A floor-plan documenting how the 15 licensed and 14 unlicensed beds were situated to fit in the NICU was given to the surveyor on 2/1/12.

On 1/31/12 in the afternoon, sliding curtains that were hung from ceiling to floor that were being used to divide each one bed station in half to accommodate two beds in each Stations 1-6, Stations 8-11 and Stations 13-15.

Stations 1-6, Stations 8-11 and Station 14-15s were similarly set up as follows:

- Each station was originally designed for one bed/patient.
- Each station was divided by curtains to place another patient (two beds).
-The facility's 29 designated (15 licensed and 14 unlicensed) care areas were for both Level III and Level II neonates were unapproved and not in compliance. The facility did not have a policy describing their intension for care in this area or the removal of equipment when there was a reduction in the number of neonates.
-The first bed in each station was closest to the back wall. The first curtain separated the first bed from the second bed.
-After the first curtain, which separated bed one and bed two, came the second bed in the station which was closest to the aisleway. There was a second curtain between the second bed and the aisleway.
-When closing the first curtain, the first bed was not visible from the aisleway, but the second bed would be visible.
-When closing the second curtain, both beds were not visible from the aisleway. Staff had to open the second curtain, pass the second bed and open the first curtain to obtain access to the baby located in the first bed.
-If the second curtain was closed, it would be difficult to visually assess who was working in the station. It would also be difficult to see if visitors or parents were entering other baby areas other than their own.

On 2/3/12 in the afternoon, a staff nurse indicated it was sometimes difficult to hear what type of alarm was going off and whose baby's alarm was going off when the curtains were closed and obstructed the view for bed one and bed two.

On 2/3/12 in the afternoon, another staff nurse indicated when the curtains were being used it would be difficult to see if other family members were going to the other baby's bassinet.

Station 1

Station 1, which was originally used for one bed, was now separated into a two bed area by a curtain. The first bed in the station had a space of approximately 63 square feet. The second bed in Station 1 had approximately 56 square feet of space. In Station 1 bed 2, there was a bin full of cords and toys being stored on the floor. Also in the room was the emergency cart. On 2/3/12 in the afternoon, the interim unit manager indicated due to the limited space in the NICU the designated station for the emergency cart was in Station 1 bed 2's area. Having the emergency cart, bins of supplies, toys, isolette, medical equipment (such as a ventilator and intravenous pumps) in the 56 square foot area in Station 1 bed 2 did not have adequate space to provide care for the patient. The space would also need to accommodate staff and family members along with the equipment.

On 2/3/12 in the morning, a staff nurse indicated since the start of the survey equipment around the NICU was being stored somewhere else to clear the NICU area. The staff nurse indicated the NICU aisleways were being cleared of equipment just because the surveyors were in the facility. The staff nurse indicated when the survey was completed, the equipment would be returned to the NICU.

Station 2

Station 2, which was originally used for one bed, was now separated into a two bed station by a curtain. The station which the first bed was located had 63 square feet of space. The station which had the second bed had approximately 60 square feet of space. On 2/3/12 in the afternoon, family members were visiting the baby located in the first bed. Along with the crib being in the area there was also one chair in the first bed station. The chair limited the space in the area. On 2/3/12 in the afternoon, the interim unit manager indicated the policy for visitors was two family members for each baby. She also indicated that at some cases more family members were allowed into a station if a baby was declining rapidly.

Common to All Stations

There was no documented evidence a new policy was initiated regarding the number of visitors for each baby since the increase in the number of beds in the unit from 15 beds (licensed) to 29 beds (15 licensed + 14 unlicensed). Station 2 was similar to all the stations in the NICU. If the unit had a census of 29 babies there would be limited space in each station to provide care if two family members were visiting their baby within the unit. Family members and chairs used for nursing mothers would take up the available and limited space in the modified stations.

On 2/3/12 in the morning, a team of physicians, students and other hospital staff were seen rounding in Station 10. There were 8 people noted in the group.

On 2/3/12 in the morning, an Occupational Therapist was seen in Station 14 working with a baby.

On 2/3/12 in the aftern

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 2/3/12 in the morning, the Director of Risk Management indicated she was not involved with the changes made to the Neonatal Intensive Care Unit (NICU) regarding the new policy on decompression for overcapacity in the NICU by increasing bed capacity from 15 licensed beds to 29 beds (14 unlicensed beds) and by placing curtains all around the unit dividing stations in half to accommodate the additional beds. The Director of Risk Management indicated she would have liked to been involved in the entire process.

1. On 2/1/12 in the afternoon, the Maternal Child and Pediatric Director indicated curtains were being placed in the NICU in April 2011 for privacy (to accommodate the additional beds).

Stations 1-11 and 13-15 which originally had one bed/isolette in each station was being divided to place two beds into each area. Station 12 was partly divided with one bed and a storage area. A floor-plan documenting how the 15 licensed and 14 unlicensed beds were situated to fit in the NICU was given to the surveyor on 2/1/12.

On 1/31/12 in the afternoon, sliding curtains that were hung from ceiling to floor that were being used to divide each one bed station in half to accommodate two beds in each Stations 1-6, Stations 8-11 and Stations 13-15.

Stations 1-6, Stations 8-11 and Stations 14-15 were similarly set up as follows:

-Each station was originally designed for one bed/patient.
-Each station was divided by curtains to place another patient into the same space (two beds).
-The facility's 29 designated (15 licensed and 14 unlicensed) care areas were for both Level III and Level II neonates were unapproved and not in compliance. The facility did not have a policy describing their intension for care in this area or the removal of equipment when there was a reduction in the number of neonates.
-The first bed in each station was closest to the back wall. The first curtain separated the first bed from the second bed.
-After the first curtain, which separated bed one and bed two, came the second bed in the station which was closest to the aisleway. There was a second curtain between the second bed and the aisleway.
-When closing the first curtain, the first bed was not visible from the hallway but the second bed would be visible.
-When closing the second curtain, both beds were not visible from the aisleway. Staff had to open the second curtain, pass the second bed and open the first curtain to obtain access to the baby located in the first bed.
-If the second curtain was closed, it would be difficult to visually assess who was working in the station. It would also be difficult to see if visitors or parents were entering other baby stations other than their own.

On 2/3/12 in the afternoon, a staff nurse indicated it was sometimes difficult to hear what type of alarm was going off and whose baby's alarm was going off when the curtains were closed and obstructed the view for bed one and bed two.

On 2/3/12 in the afternoon, another staff nurse indicated when the curtains were being used it would be difficult to see if other family members were going to the other baby's bassinet.

2. The facility's policy and procedure, dated 9/11, and titled, NICU Decompression for Overcapacity/Level II Lateral Transfers documented:

- " ...Scope - To define the process for managing patient overcapacity in the ...NICU ... "
- " ...Objective - To provide guidelines to identify and implement decompression strategies for high census and overcapacity in the NICU departments ... "
- " ...Decompression - is the process to alleviate overcapacity and /or high patient census in the NICU and includes the following strategies as ordered by the LIP (Licensed Independent Practitioner) ... "
- " ...Parents will be educated on the potential necessity for transfer of their infants beginning with the admission process and as the infant stabilizes and progresses toward discharge ... "

On 2/1/12 in the afternoon, the Interim NICU Manager indicated there was no documented evidence parents were asked if their infant could transfer to another facility due to over capacity at the facility.

3. On 2/1/12 in the afternoon, the Charge Nurse responsible for policies indicated the maximum capacity in the NICU interior was 20 beds.

On 2/1/12 in the afternoon, the Maternal Child and Pediatric Director confirmed the facility preferred a maximum of 20 patients in the NICU but there was no documented evidence in the policy for a maximum number. The Director indicated there were times when the census reached 29 patients.

A floor-plan documenting how the 29 beds were situated to fit in the NICU was given to the surveyor on 2/1/12. The floor-plan diagramed a bed blocking a sink and stations being divided in order to place two beds into one station. After measurements were made in the area by the surveyors and interviews were conducted with the staff it was concluded that there was insufficient space to provide care if 29 beds were placed in the NICU area. (Also see Tag A700.)

On 2/3/12 in the afternoon, staff nurses did not know the maximum amount of patients that could be admitted in the NICU.

On 1/31/12 in the afternoon, the Interim NICU (neonatal intensive care unit) Manager indicated the NICU was licensed for 15 beds (isolettes/bassinets). The NICU had 14 stations which originally held one bed for each station and one enclosed room which also originally had one bed designated to the room. The stations including the room were numbered from 1 to 15. These licensed beds were for Level III neonates (critical care babies), which could also accommodate Level II (less critical) neonates. The census for the NICU on 1/31/12 was 23 (15 licensed + 8 unlicensed beds) patients/babies.

The Interim NICU Manager indicated the NICU had been going over census for several months and the NICU could possibly hold up to 29 (15 licensed + 14 unlicensed beds) Level III (critical) and Level II (less critical) baby beds. She was not sure what the maximum capacity of NICU beds were and needed to clarify the number.

The NICU census during the survey was:

2/1/12 - 23 (15 licensed + 8 unlicensed beds)
2/2/12 - 20 (15 licensed + 5 unlicensed beds)
2/3/12 - 18 (15 licensed + 3 unlicensed beds)