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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A0392 STAFFING AND DELIVERY OF CARE The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on interviews and document review, the facility failed to ensure department qualified registered nurses were immediately available in the facility's Neonatal Intensive Care Unit (NICU) at all times. This failure was found in one of one medical records reviewed of a patient in active labor with no NICU nurse on site (Patient #6).

A0397 PATIENT CARE ASSIGNMENTS A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. Based on interviews and document review, the facility failed to ensure staff were trained and qualified to perform specialized care for patients in the Labor, Delivery, Postpartum and Recovery unit. This failure was found in one of two medical records reviewed of patients receiving phototherapy in the postpartum unit (Patient #3).

Based on interviews and document review, the facility failed to ensure department qualified registered nurses were immediately available in the facility's Neonatal Intensive Care Unit (NICU) at all times. This failure was found in one of one medical records reviewed of a patient in active labor with no NICU nurse on site (Patient #6).

Findings include:

References:

According to the facility's BirthPlace Scope of Services, the BirthPlace serves the following patient population: newborns beginning at 34 weeks gestational age (GA) or earlier if approved by pediatrician and primary care, and pregnant women greater than or equal to 34 weeks GA in all stages of labor. A registered nurse (RN) will be immediately available to assist and supervise patient care as well as to respond to emergency situations. NICU care will be given by a qualified NICU RN as defined by skills checklist. This includes utilization of the nursing process, performing all tasks and responsibilities related to care of newborns (normal and Level II special needs) and evaluating the effectiveness of both medical and nursing interventions.

According to the facility's Health Staffing Guideline, the department leadership must plan adequate coverage for individual unit staffing 24 hours a day, seven (7) days a week.

American Academy of Pediatrics and American College of Obstetrics and Gynecology (2017) Guidelines for Perinatal Care, p. 30, retrieved from: https://www.acog.org/clinical-information/physician-faqs/-/media/3a22e153b67446a6b31fb051e469187c.ashx
According to the American Academy of Pediatrics (AAP) and the American College of Obstetrics and Gynecology (ACOG) Guidelines for Perinatal Care, 32 weeks gestation would be considered moderately-preterm and a higher level of care (level 2 NICU) should be reserved for these newborns.

1. The facility failed to ensure a qualified Neonatal Intensive Care Unit (NICU) Registered Nurse (RN) was immediately available to assist and supervise patient care as well as to respond to emergency situations.

a. Review of the BirthPlace Census Acuity Staff Log from 1/1/22 to 6/1/22 revealed instances where a qualified NICU registered nurse (RN) was not staffed to be on duty. Examples include:

i. On 5/13/22, there was no NICU RN on the schedule to be immediately available during the 7:00 p.m. to 7:00 a.m. shift.

ii. During the 7:00 p.m. to 7:00 a.m. shift on 5/14/22, there was no NICU RN on the schedule to be immediately available in the unit.

iii. On 5/15/22 during the 7:00 a.m. to 7:00 p.m. shift, there was no NICU RN on the schedule to be immediately available in the unit. In addition, there was not a NICU RN immediately available on the unit from 7:00 p.m. until the following day when the nurse manager came into the unit at 5:00 a.m.

iv. On 5/19/22, during the 7:00 p.m. to 7:00 a.m. shift, there was no NICU RN on the schedule to be immediately available in the unit.

v. During the 7:00 p.m. to 7:00 a.m. shift on 5/20/22, there was no NICU RN on the schedule to be immediately available in the unit.

b. A medical record review of Patient #6 was conducted and revealed the patient presented to the facility on 5/15/22 at 7:25 p.m. Patient #6's pregnancy was estimated to be 32 weeks gestation and she was admitted to the facility for observation of preterm labor.

According to the BirthPlace Census Acuity Staff Log, there was no evidence of the facility having a NICU nurse present in the facility from 7:25 p.m. until 5:00 a.m on 5/16/22 while the mother labored in case the baby was born.

This was in contrast to the BirthPlace Scope of Services which stated, an RN would be immediately available to assist and supervise patient care as well as to respond to emergency situations. The scope of services further stated, NICU care would be given by a qualified NICU RN as defined by skills checklist.

In a Labor Progress Note on 5/16/22 at 9:07 a.m., approximately 14 hours after the patient arrived to the facility, the physician documented it was determined Patient #6 was unstable to transfer to a higher level of NICU care. The physician documented the facility was an appropriate location for delivery. However, the progress note continued to document the newborn would need to be transferred to a higher level of care due to staffing limitations at the facility. The baby was born on 5/16/22 at 1:03 p.m., however the baby was not transferred to a higher level of care facility until 12:48 a.m. on 5/17/22.

b. Interviews with RN #1 were conducted on 5/31/22 at 1:01 p.m. and on 6/1/22 at 11:25 a.m. RN #1 stated she worked as a NICU RN. RN #1 stated in addition to taking care of newborns in the NICU and postpartum units, her role was to attend all deliveries as the primary RN for the newborn. RN #1 reported this role was referred to as the catcher role. She reported there should always be a NICU RN on duty.

RN #1 additionally stated there had been shifts when there was not a NICU RN on site, or there was the potential for no NICU RN to be on site. When this occurred, RN #1 stated the plan was for the nurse manager to put herself on call, but the manager would not be present in the facility.

This was in contrast to the BirthPlace Scope of Services which stated, an RN would be immediately available to assist and supervise patient care as well as to respond to emergency situations. The scope of services further stated, NICU care will be given by a qualified NICU RN as defined by skills checklist.

RN #1 stated if she had newborns in the NICU and had to attend a birth, she could call the Neonatal Nurse Practitioner (NNP) to see if she was available to come and watch the NICU patients. RN #1 stated an NNP was always on duty, twenty-four hours a day, seven days a week and whose role included attending all high risk deliveries. However, RN #1 stated although an NNP was always on duty, the NNP would not perform the role as the NICU RN and would not act in a dual role as the NNP and NICU RN. RN #1 stated if the NNP or Manager #6 was not available, she would call the house supervisor to "babysit" the NICU newborns.

c. An interview was conducted with House Supervisor (Supervisor) #7 on 6/2/22 at 2:44 p.m. Supervisor #7 stated if there was no NICU RN on duty when a newborn delivered, it was hard to say if there would be a risk to the newborn. Supervisor #7 additionally stated she was not aware of a back up plan to have the house supervisors monitor newborns in the NICU. Supervisor #7 further reported she was not trained to care for patients in the NICU. Supervisor #7 stated she was not aware of any of the current house supervisors being trained to care for patients in the NICU.

d. An interview with the L&D and NICU nurse manager (manager) #6 was conducted on 6/2/22 at 9:48 a.m. Manager #6 reported if there was no NICU RN on duty and if an imminent delivery of a preterm newborn occurred, it could be an extremely high risk situation. She additionally stated while there was an NNP available in house at all times, a preterm newborn would require more than one NICU trained staff member to provide care. Manager #6 further stated a situation with an imminent delivery of a preterm newborn and no NICU RN on duty would be a concerning situation.

Manager #6 stated the goal was to always have a NICU trained RN in house twenty four hours a day, seven days per week. Manager #6 stated if a NICU RN was not available in house, she as the nurse manager was available on call, but not always onsite. She stated, if newborns were in the NICU and the NICU RN and NNP were called to attend a delivery, a house supervisor could be called in to monitor the newborns in the NICU. However, Manager #6 stated the current mix of house supervisors on staff were not trained in providing care to patients in the NICU. Additionally, Manager #6 stated there was a concern with a staff member who was not NICU trained caring for a newborn in the NICU. She further stated depending on the condition of the newborn, there was a potential for harm to the newborn if untrained staff were monitoring them.

e. An interview with chief nursing officer (CNO) #5 was conducted on 6/2/22 at 8:41 a.m. CNO #5 verified there were days when a NICU RN was not staffed on the unit. She further stated on these days, the unit nurse manager was on call but not always in the facility.

CNO #5 stated the facility had NICU trained travel RNs scheduled to start on 6/13/22. CNO #5 reported a decision was made on 5/16/22 to temporarily lower the NICU services from level 2 to level 1 and reduce the acuity of newborns being cared for. CNO #5 reported in the interim, while the unit operated at a lower NICU level and awaited the start of travel NICU RNs, the nurse manager had committed to being on call during the shifts when there was not a NICU RN, but the nurse manager would not always be in the facility.

This was in contrast to the facility's Health Staffing Guidelines which stated the department leadership must provide adequate coverage for individual unit staffing 24 hours a day, seven (7) days a week. Additionally, this was in contrast to the BirthPlace Scope of Services, which stated, an RN would be immediately available to assist and supervise patient care as well as to respond to emergency situations. Additionally, the scope of services stated, NICU care will be given by a qualified NICU RN as defined by skills checklist.

Based on interviews and document review, the facility failed to ensure staff were trained and qualified to perform specialized care for patients in the Labor, Delivery, Postpartum and Recovery unit. This failure was found in one of two medical records reviewed of patients receiving phototherapy in the postpartum unit (Patient #3).
Findings include:

Reference:

According to the BirthPlace Scope of Services, neonatal intensive care unit (NICU) care will be given by a qualified NICU RN as defined by skills checklist. This includes utilization of the nursing process, performing all tasks and responsibilities related to care of newborns (normal and Level II special needs) and evaluating the effectiveness of both medical and nursing interventions.

1. The facility failed to ensure the nursing staff on the postpartum unit were trained to perform specialized patient care duties.

a. According to a medical record review, on 5/20/22, during the 7:00 a.m. to 7:00 p.m. shift, RN #4, who was a labor and delivery (L&D) RN, had cared for a newborn (Patient #3). Further review of the medical record revealed Patient #3 had a diagnosis of hyperbilirubinemia (high levels of the by-product after red blood cells had broken down) and was undergoing phototherapy (light therapy used to break down bilirubin) for the treatment of hyperbilirubinemia.

i. A review of the BirthPlace Census Acuity Staff Log revealed during the 7:00 p.m. to 7:00 a.m. shift on 5/19/22, RN #4 was assigned as the primary RN for patient #3 and there was no NICU RN on duty in the facility.

ii According to a review of RN #4's personnel file, there was no evidence RN #4 received training and confirmation to be able to administer phototherapy or to supervise a newborn receiving phototherapy.

b. An interview with RN #4 was conducted on 6/1/22 at 4:03 p.m. RN #4 stated she worked as a labor and delivery (L&D) nurse at the facility. RN #4 reported it was rare for her to take care of newborns because her background was with taking care of mothers and she did not have a background in newborn care. RN #4 reported she had taken care of Patient #3, who was undergoing phototherapy during the night shift. RN #4 reported the only training with phototherapy she received was the night she provided care for Patient #3. RN #4 stated the day shift NICU RN showed her how to administer phototherapy during change of shift.

c. An interview with RN #3 was conducted on 6/1/22 at 10:36 a.m., who worked as an L&D nurse. RN #3 stated if there was a stable newborn who needed phototherapy, ideally this newborn would be cared for by a NICU RN. RN #3 reported, if a NICU RN was not on duty, the care of the newborn would fall on the L&D nurse. RN #3 further stated not all L&D nurses were trained to care for a newborn receiving phototherapy. RN #3 stated she did not recall having been provided specific training on administering or monitoring phototherapy for newborn.

d. An interview with the labor and delivery and NICU manager (manager) #6 was conducted on 6/2/22 at 9:48 a.m. Manager #6 stated phototherapy was used to decrease the amount of bilirubin in a newborn's body. Manager #6 further explained if a newborn's bilirubin was high and remained untreated, it could result in damage to the brain. Manager #6 stated if a well newborn in the postpartum unit required phototherapy, the goal was for a NICU trained RN to care for that newborn. Manager #6 further stated if there were newborns in the NICU when a well newborn required phototherapy in the postpartum area, the NICU RN was expected to go to the postpartum area and conduct a full assessment on the newborn receiving phototherapy every six hours.

This was in contrast to the medical record review of Patient #3 who received phototherapy, however, there was no evidence of a NICU nurse providing care for or conducting assessments every six hours during the night shift on 5/19/22.

Manager #6 further explained labor, delivery and postpartum RNs were expected to be trained to provide care for newborns on phototherapy, but she did not know if this training was part of the competency checklist for labor and delivery nurses.

This was in contrast to the personnel file review of RN #4 which showed no evidence of training for providing phototherapy to newborns. This was also in contrast to the interview conducted with RN #3 who stated she did not recall receiving training on phototherapy.

e. An interview with the RN Educator (Educator) #8 was conducted on 6/2/22 at 3:30 p.m. Educator #8 stated all staff who received postpartum training also completed training for administering and supervising phototherapy and hyperbilirubinemia. Educator #8 reported if a well newborn needed phototherapy, the goal was to assign the newborn to a NICU RN. She further explained if a NICU RN was not available, the plan was to assign the newborn to a L&D RN who had received phototherapy training.

This was in contrast with the interview with RN #3 who stated she did not recall receiving training on phototherapy. This was also in contrast with the interview with RN #4 who stated the only training she received was from the day shift nurse showing her how to provide phototherapy.

2. The facility failed to ensure a qualified staff member performed the role of an obstetrical scrub technician (OB tech).

a. Review of the BirthPlace Census Acuity Staff Log revealed multiple instances from 2/12/22 to 5/28/22, where RN #4 performed the role of the OB tech. These instances occurred during the 7:00 p.m. to 7:00 a.m. shifts on 2/12/22, 2/17/22, 3/7/22, 3/14/22, 4/2/22, 4/7/22, 4/9/22, 4/10/22, 4/14/22, 4/15/22, 4/23/22, 4/28/22, 4/29/22, 4/30/22, 5/1/22, 5/8/22, 5/15/22, 5/20/22, 5/21/22, 5/22/22, 5/27/22, and 5/28/22.

b. According to a personnel file review of the RN Core Competency checklist, there was no evidence RN #4 completed cross-training or an orientation to perform the OB tech role.

According to the BirthPlace Scope of Services, OB scrub techs were immediately available to act as scrub tech for cesarean section, tubal ligations (surgical procedure to prevent pregnancy), dilation and curettage (procedure to remove tissue from inside the uterus), or any other OB/Gyn procedure.

c. An interview with RN #4 was conducted on 6/1/22 at 4:03 p.m., who worked as a labor and delivery nurse. RN #4 stated she did not consider herself an OB scrub tech, but if there was not an OB tech on shift, she had filled in and performed the role.

d. An interview with Educator #8 was conducted on 6/2/22 at 3:30 p.m. Educator #8 stated the duties of the OB scrub tech included keeping the unit stocked with supplies, scrubbing in and assisting with surgical procedures, and setting out surgical instruments. She further stated the unit had completed cross training for RNs to fill the role of an OB tech. Educator #8 stated if RN wanted to be cross trained to also work in the role of an OB tech, the RN would spend a shift with an OB tech and complete the OB tech competency checklist. Educator #8 stated she would be involved in the cross training plan.

Educator #8 further stated to her knowledge Manager #6 was currently the only RN who was cross-trained to perform the role of an OB tech. Educator #8 further stated she was not aware of any additional RNs or travel RNs who served in the OB tech role at the time of the interview.