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Based on interview and record review, the facility failed to ensure adequate numbers of registered nurses (RN) and other personnel to provide nursing care to patients in the neonatal intensive care unit (NICU) during the months of June, July, and August 2015.

The facility failed to provide adequate nursing staffing in the NICU :

8 of 30 days in June 2015
13 of 31 days in July 2015
7 of 31 days in August 2015

Findings include:

TX 00224969

Record review of complaint intake # TX 00224969 (anonymous letter dated August, 2015) read: "..the NICU..has been working with dangerously low numbers of RNs for many months...In house 'Safe Harbor' has been called multiple time by numerous shifts...no measures put forth to correct...Many times, the nurses in Level II have 5 sometimes 6 patients... "

Interview on 11-18-15 at 9:15 a.m. with NICU Director # 13 she stated staffing was as follows : "Level II acuity babies: maximum assignment for 1 nurse was four(4) Level II patients. Acuity level III babies were more critical (on ventilators, pressor drugs, etc) maximum assignment per nurse was two(2) Level III patients. NICU Director # 13 went on to say the facility based its staffing on AWHONN guidelines (Association of Women's Health, Obstetric and Neonatal Nurses).

Record review of NICU staffing assignments; patient census and acuity ( day and night shifts) were reviewed for the months of June, July, and August, 2015. These same records were discussed and verified with NICU Director # 13 and Charge Nurse # 10.

Based on this review, the following staffing deficits were identified:

JUNE 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 06/20/15 and 06/21/15,
*Two (2) nurses were assigned three (3) Level III babies on 6/26/15.
*One (1) nurse was assigned three (3) Level III babies on 6/19/15 and 06/27/15.

Night shift:

* Two(2) nurses were assigned three (3) Level III babies on 6/28/15 and 6/29/15.
*One (1) nurse was assigned three (3) Level III babies on and 06/14/15.

JUNE 2015 LEVEL II babies ( maximum 4 patients):

Day shift:

*Three (3) nurses assigned five (5) Level II babies on 6/21/15 ; one (1) nurses was assigned six(6) level II babies that same day.
* One (1) nurse was assigned five(5) Level II babies on 06/15/15 and 06/20/15.

Night shift:

*Three (3) nurses assigned five (5) Level II babies on 6/29/15
One (1) nurse was assigned five(5) Level II babies on 06/14/15 and 06/20/15.

JULY 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 07/01/15,
*Two (2) nurses were assigned three (3) Level III babies on 07/05/15 and 07/25/15**.
*One (1) nurse was assigned three (3) Level III babies on 07/03/15; 07/04/15; 07/06/15; and 07/19/15.

** Of note, on 07/25/15: charge nurse and transport nurse were each assigned two (2) Level III babies. Interview with Charge Nurse # 10 on 11-18-15 at 10:15 a.m., she said had either the charge nurse or transport nurse been needed for critical duties/needs on 07/25/15 ; their patients would have been assigned to nurses already caring for an over maximum patient load.

Night shift:

* Two(2) nurses were assigned three (3) Level III babies on 7/15/15 and 07/26/15.
*One (1) nurse was assigned three (3) Level III babies on 07/02/15; 07/04/15; 07/05/15; 07/06/15; 07/17/15; 07/29/15; and 07/23/15.


JULY 2015: LEVEL II babies ( maximum 4 patients):

Day shift:

*Two nurses were assigned six (6) Level II babies on 07/25/15 ;two(2) nurses were assigned five (5) level II babies that same day.
* Two(2) nurses were assigned five(5) Level II babies ; one (1) nurse was assigned six(6) Level II babies on 07/01/15.
*Two (2) nurses were assigned five(5) level II babies on 07/02/15 and 07/03/15.
*One (1) nurse was assigned five (5) Level II babies on 07/19/15 and 07/20/15

Night shift:

*Four (4) nurses were assigned five (5) Level II babies on 7/23/15.
*Two (2) nurses were assigned five(5) Level II babies on 07/06/15 and 07/22/15.
*One (1) nurse was assigned five (5) Level II babies on 07/19/15 and 07/26/15.

AUGUST 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 08/15/15 and 08/16/15.
*Two (2) nurses were assigned three (3) Level III babies on 08/21/15.
*One (1) nurse was assigned three (3) Level III babies on 08/06/15.

Night shift:

*Three (3) nurses were assigned three (3) Level III babies on 08/06/15.
*Two(2) nurses were assigned three (3) Level III babies on 08/07/15; 08//24/15; and 08/25/15.
*One (1) nurse was assigned three (3) Level III babies on 08/09/15; 08/10/15; 08/11/15; 08/12/15; 08/20/15; and 08/23/15.

AUGUST 2015: LEVEL II babies ( maximum 4 patients):

Day shift:

*Three (3) nurses were assigned five(5) Level II babies on 08/15/15 and 08/21/15.
*One (1) nurse was assigned five (5) Level II babies on 08/16/15.

Night shift:

*Three (3) nurses were assigned five (5) Level II babies on 08/24/15 and 08/25/15.
*Two (2) nurses were assigned five(5) Level II babies on 08/07/15 and 08/20/15.
_____________________________

On 11-17-15, between 9:45 a.m. and 2 p.m., nine (9) NICU registered nurses were interviewed ( Staff # 4, 5, 6, 7, 8, 9, 10, 11, 12). Interviews revealed the following:

1. All nine (9) RN's stated the NICU was short staffed for both shifts during the summer. Several RNs gave exampled of "unsafe staffing situations:"

RN # 4: "Beginning of August (2015) , I had 3 Level III babies; my podmate had 2 Level III babies that were very sick. the charge nurse had a full assignment. When my podmate went to lunch, I was caring for 5 babies with multiple alarms sounding. This was not a safe situation..."

RN # 5: " In August (2015) , I had three (3) Level III babies and I was the assigned transport nurse. If I had to go to a delivery or to a transport; these babies would be assigned to other staff who already had a full assignment. I didn't feel this was safe..."

RN # 6: "In the summer we were extremely short staffed. Once, I had 2 very sick Level III babies; my podmate also had 2 very sick Level III babies, plus a new orientee. We are supposed to have a float charge nurse but the charge nurse had 2 babies in Intensive transition ;the transport nurse had a full assignment as well. This was not a safe situation for the patients. This did not happen every day but it also was not a rare occurrence.."

RN # 8: " A few weeks ago, I had four (4) Level II babies; my podmate had four (4) level II babies. The transport nurse called in sick; so the charge nurse had babies assigned and acted as transport nurse. I had to take a baby to get an MRI ( magnetic resonance imaging) ; which left my podmate watching over seven (7) level II babies...not safe...."

2. All nine (9) nurses said they were aware several staff completed "Safe Harbor" forms multiple times during the summer because they felt the staffing was unsafe. None of the staff could offer feedback or changes made based on Safe Harbor reporting.

3. All nine(9) nurses said the facility made some attempts to address the nursing staffing shortage; but most felt the efforts were not effective. The NICU nurses interviewed said:

The facility assigned task nurses to help feed and change the babies. NICU staff said this was of minimal help; as the task nurses were not trained to provided critical care to these sick babies.

Facility offered bonuses to the regular NICU staff to work extra shifts; however, they often waited until an hour before a shift started to offer the bonus. Staff said many of them have small children and needed to make plans prior to an hour before start of shift.

Five (5) of the 9 RNs interviewed said they worked as many extra shifts as they safely could. Many said they were exhausted, both mentally and physically.

4. All nine(9) nurses said the staffing was acceptable at the present time; but felt it was only because the patient census was low. All expressed concerns over being short staffed when the census increases.
___________________________

Interview on 11-18-15 at 9:15 .a.m.. with NICU Director # 13 she stated the staffing situation began in May 2015 when the average daily census (ADC) rose from 20 to 40. It happened all of a sudden,over 2 to 3 weeks ( fluctuated week to week). She went on to say the facility addressed the staffing situation in several ways:

a. Human Resources Director called all hospitals with NICUs corporation-wide. We offered pay bonuses and housing. None of the hospitals with NICUs could send nurses, as they were busy as well.

b. "Division" approved increasing agency nurses pay rates and also offered completion bonuses.

c. Facility offered current NICU staff bonuses: sometimes up to a quadruple bonuses. This was decided day by day. NICU Director acknowledged sometimes bonus approval was received immediately prior to shift.

d. Did not accept transfers to NICU from outside hospitals during this time period, with the exception of Mainland, "sister hospital."

NICU Director # 13 went on to say she reviewed the NICU staffing in May 2015, based on an ADC of 30. She identified the need for 20 additional FTE ( full time equivalents). At the time; there were only 7 or 8 NICU positions open. NICU Director said she began requesting approval for additional FTEs, four (4) at a time. She currently had 15 open positions; and had hired six (6) new graduate nurses who were in various stages of orientation. In addition, she hired two(2) experienced part time nurses.

NICU Director # 13 said she also had requested the extension of three (3) contract nurses and asked for an additional five (5) contract nurses.
_________________________________

Interview on 11-18-15 at 2:30 p.m. with Chief Nursing Officer (CNO) # 14 she stated that in May 2015 the NICU ADC went from 28 to 50 babies; heavy in the Level III area. CNO said it was an "all hands on deck situation." Facility assigned 'task nurses' to assist in feeding babies. HR Director offered triple bonuses to staff to work extra shifts. In addition, facility reached out to the North Texas Division ( NICUs) : offered travel and housing; no one available. Facility increased agency pay rate and offered completion bonuses. Chief Executive Officer (CEO) and Medical Director in daily contact regarding babies for possible early but safe discharge. CNO # 14 went on to say the facility was now being more proactive with respect to staffing for known high risk OB patients.

Based on interview and record review, the facility failed to ensure adequate numbers of registered nurses (RN) and other personnel to provide nursing care to patients in the neonatal intensive care unit (NICU) during the months of June, July, and August 2015.

The facility failed to provide adequate nursing staffing in the NICU :

8 of 30 days in June 2015
13 of 31 days in July 2015
7 of 31 days in August 2015

Findings include:

TX 00224969

Record review of complaint intake # TX 00224969 (anonymous letter dated August, 2015) read: "..the NICU..has been working with dangerously low numbers of RNs for many months...In house 'Safe Harbor' has been called multiple time by numerous shifts...no measures put forth to correct...Many times, the nurses in Level II have 5 sometimes 6 patients... "

Interview on 11-18-15 at 9:15 a.m. with NICU Director # 13 she stated staffing was as follows : "Level II acuity babies: maximum assignment for 1 nurse was four(4) Level II patients. Acuity level III babies were more critical (on ventilators, pressor drugs, etc) maximum assignment per nurse was two(2) Level III patients. NICU Director # 13 went on to say the facility based its staffing on AWHONN guidelines (Association of Women's Health, Obstetric and Neonatal Nurses).

Record review of NICU staffing assignments; patient census and acuity ( day and night shifts) were reviewed for the months of June, July, and August, 2015. These same records were discussed and verified with NICU Director # 13 and Charge Nurse # 10.

Based on this review, the following staffing deficits were identified:

JUNE 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 06/20/15 and 06/21/15,
*Two (2) nurses were assigned three (3) Level III babies on 6/26/15.
*One (1) nurse was assigned three (3) Level III babies on 6/19/15 and 06/27/15.

Night shift:

* Two(2) nurses were assigned three (3) Level III babies on 6/28/15 and 6/29/15.
*One (1) nurse was assigned three (3) Level III babies on and 06/14/15.

JUNE 2015 LEVEL II babies ( maximum 4 patients):

Day shift:

*Three (3) nurses assigned five (5) Level II babies on 6/21/15 ; one (1) nurses was assigned six(6) level II babies that same day.
* One (1) nurse was assigned five(5) Level II babies on 06/15/15 and 06/20/15.

Night shift:

*Three (3) nurses assigned five (5) Level II babies on 6/29/15
One (1) nurse was assigned five(5) Level II babies on 06/14/15 and 06/20/15.

JULY 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 07/01/15,
*Two (2) nurses were assigned three (3) Level III babies on 07/05/15 and 07/25/15**.
*One (1) nurse was assigned three (3) Level III babies on 07/03/15; 07/04/15; 07/06/15; and 07/19/15.

** Of note, on 07/25/15: charge nurse and transport nurse were each assigned two (2) Level III babies. Interview with Charge Nurse # 10 on 11-18-15 at 10:15 a.m., she said had either the charge nurse or transport nurse been needed for critical duties/needs on 07/25/15 ; their patients would have been assigned to nurses already caring for an over maximum patient load.

Night shift:

* Two(2) nurses were assigned three (3) Level III babies on 7/15/15 and 07/26/15.
*One (1) nurse was assigned three (3) Level III babies on 07/02/15; 07/04/15; 07/05/15; 07/06/15; 07/17/15; 07/29/15; and 07/23/15.


JULY 2015: LEVEL II babies ( maximum 4 patients):

Day shift:

*Two nurses were assigned six (6) Level II babies on 07/25/15 ;two(2) nurses were assigned five (5) level II babies that same day.
* Two(2) nurses were assigned five(5) Level II babies ; one (1) nurse was assigned six(6) Level II babies on 07/01/15.
*Two (2) nurses were assigned five(5) level II babies on 07/02/15 and 07/03/15.
*One (1) nurse was assigned five (5) Level II babies on 07/19/15 and 07/20/15

Night shift:

*Four (4) nurses were assigned five (5) Level II babies on 7/23/15.
*Two (2) nurses were assigned five(5) Level II babies on 07/06/15 and 07/22/15.
*One (1) nurse was assigned five (5) Level II babies on 07/19/15 and 07/26/15.

AUGUST 2015: LEVEL III babies ( maximum 2 patients):

Day shift:

*Three (3) nurses were assigned three (3) Level III babies on 08/15/15 and 08/16/15.
*Two (2) nurses were assigned three (3) Level III babies on 08/21/15.
*One (1) nurse was assigned three (3) Level III babies on 08/06/15.

Night shift:

*Three (3) nurses were assigned three (3) Level III babies on 08/06/15.
*Two(2) nurses were assigned three (3) Level III babies on 08/07/15; 08//24/15; and 08/25/15.
*One (1) nurse was assigned three (3) Level III babies on 08/09/15; 08/10/15; 08/11/15; 08/12/15; 08/20/15; and 08/23/15.

AUGUST 2015: LEVEL II babies ( maximum 4 patients):

Day shift:

*Three (3) nurses were assigned five(5) Level II babies on 08/15/15 and 08/21/15.
*One (1) nurse was assigned five (5) Level II babies on 08/16/15.

Night shift:

*Three (3) nurses were assigned five (5) Level II babies on 08/24/15 and 08/25/15.
*Two (2) nurses were assigned five(5) Level II babies on 08/07/15 and 08/20/15.
_____________________________

On 11-17-15, between 9:45 a.m. and 2 p.m., nine (9) NICU registered nurses were interviewed ( Staff # 4, 5, 6, 7, 8, 9, 10, 11, 12). Interviews revealed the following:

1. All nine (9) RN's stated the NICU was short staffed for both shifts during the summer. Several RNs gave exampled of "unsafe staffing situations:"

RN # 4: "Beginning of August (2015) , I had 3 Level III babies; my podmate had 2 Level III babies that were very sick. the charge nurse had a full assignment. When my podmate went to lunch, I was caring for 5 babies with multiple alarms sounding. This was not a safe situation..."

RN # 5: " In August (2015) , I had three (3) Level III babies and I was the assigned transport nurse. If I had to go to a delivery or to a transport; these babies would be assigned to other staff who already had a full assignment. I didn't feel this was safe..."

RN # 6: "In the summer we were extremely short staffed. Once, I had 2 very sick Level III babies; my podmate also had 2 very sick Level III babies, plus a new orientee. We are supposed to have a float charge nurse but the charge nurse had 2 babies in Intensive transition ;the transport nurse had a full assignment as well. This was not a safe situation for the patients. This did not happen every day but it also was not a rare occurrence.."

RN # 8: " A few weeks ago, I had four (4) Level II babies; my podmate had four (4) level II babies. The transport nurse called in sick; so the charge nurse had babies assigned and acted as transport nurse. I had to take a baby to get an MRI ( magnetic resonance imaging) ; which left my podmate watching over seven (7) level II babies...not safe...."

2. All nine (9) nurses said they were aware several staff completed "Safe Harbor" forms multiple times during the summer because they felt the staffing was unsafe. None of the staff could offer feedback or changes made based on Safe Harbor reporting.

3. All nine(9) nurses said the facility made some attempts to address the nursing staffing shortage; but most felt the efforts were not effective. The NICU nurses interviewed said:

The facility assigned task nurses to help feed and change the babies. NICU staff said this was of minimal help; as the task nurses were not trained to provided critical care to these sick babies.

Facility offered bonuses to the regular NICU staff to work extra shifts; however, they often waited until an hour before a shift started to offer the bonus. Staff said many of them have small children and needed to make plans prior to an hour before start of shift.

Five (5) of the 9 RNs interviewed said they worked as many extra shifts as they safely could. Many said they were exhausted, both mentally and physically.

4. All nine(9) nurses said the staffing was acceptable at the present time; but felt it was only because the patient census was low. All expressed concerns over being short staffed when the census increases.
___________________________

Interview on 11-18-15 a