HospitalInspections.org

Based on review of facility documents, observations, and staff interview (EMP), it was determined the facility failed to provide a safe environment for a patient's emotional health and safety for four of four patients (MR1, MR3, MR4, and MR8).

Findings include:

Review of a copy of the UPMC Horizon "Your Rights as a Patient," no date provided, revealed, "... Regarding our staff and environment, you have the right: - to receive respectful care given by competent personnel in a setting that: -is safe and promotes your dignity, positive self image, and comfort; ... -is free from all forms of ... neglect; ... "

Review of a copy of "Caring for Your New Baby" information that is provided to all patients admitted to the Obstetrics unit revealed, "While your baby is in your room, mothers must take the responsibility to keep record of diaper changes and feedings after being shown by the nurse. Only normal health newborns are permitted to be rooming in with the mother. Daily, after morning care and physician visits, the baby will be brought to the mother's room for the day. If you would prefer your baby in the nursery between feeding, please communicate this to your nurse."

Review of the "Surge Capacity Plan for Obstetric, Infant, and Gynecologic Care" revision date November 11, 2014, revealed, "Scope: Womancare Birth Place, Nursery, IMCU Overflow Unit [crossed out and inserted] Mother-Baby/Women's Health Unit, and Operating Room Shenango Campus... Procedure A: The decision regarding patient placement may be modified based on patient needs and patient flow... 1. In order to promote patient flow and safety within the Womancare Birthplace, all stable post-partum patients [inserted] and/or clean gyne/surg patients may be assigned to beds on IMCU Overflow [crossed out with the following inserted] the 3rd floor Women's Health Unit ... Procedure B: 1. Every effort will be made to perform scheduled and unscheduled C-Sections in the operating room located within the Womancare Birth Place... Procedure C: 1. Newborns requiring Level I care will be accommodated in the Womancare Birth Place nursery [second floor] or newborn may accompany mother to Overflow [removed and inserted] Mother-Baby Unit utilizing couplet nursing care delivery..."

1. Review of complaint information (MR1) received by this office revealed the patient had a C-section delivery, was taken to the 3rd floor, and later requested nursing staff to take her baby to the nursery so she could rest. According to the complaint, she was told that that could not be done because, "We don't do that anymore."

2. Observations on December 29, 2014, between 9:40 and 2:30 PM on the 3rd floor revealed there was no nursery on the third floor [IMCU Overflow/Mother-Baby/Women's Health Unit].
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3. On December 29, 2014, at approximately 10:30 AM, an interview was held with the patient of MR3, who had been admitted to a room on the third floor IMCU Overflow/Mother-Baby/Women's Health Unit. When asked the process for when the baby is taken to the nursery the patient responded, "One nurse said that they encouraged rooming in. It is my fault. I should have napped when my mother in law was here..."

4. When asked the process for when the baby is taken to the nursery on December 29, 2014, at approximately 10:30 AM, the patient to MR4, also a patient on the third floor, indicated, "Oh I don't think the baby can be taken to the nursery..."

5. During an interview on December 29, 2014, at approximately 10:35 AM, OTH1 indicated, "I thought about it last night [asking for twin babies to be taken back to nursery]. We needed some rest, but we were told there was no nursery..."

6. When asked the process for when the baby is taken to the nursery on December 29, 2014, at approximately 1:30 PM, the patient to MR8, also a patient on the third floor, responded, "...I was told there is no nursery..."

7. Interview on December 29, 2014, at 3:15 PM with EMP11, when asked if there was ever a time when patients on the third floor [IMCU Overflow/Mother-Baby/Women's Health Unit] requested their baby be taken to the Newborn Nursery on the second floor, EMP11 revealed, "I took a baby one morning about 5:00 AM to the nurses' station." When asked if it was taken to the nursery, EMP11 said, "No I just brought [baby] back to where I was sitting ... 45 minutes." When asked if that was documented, EMP11 replied, "I didn't. It was not significant." When asked again if babies were ever taken to the Newborn Nursery, EMP11 said, "Almost never. Let me clarify. I can't think of a time when I have [taken a baby from the third floor to the second floor nursery.] When asked if Moms were ever allowed to request babies be taken to the nursery EMP11 said, "It's more of a staffing thing. You can't take someone from the third floor. There would have to be someone in the nursery." When asked if Moms had ever requested to have the baby taken to the nursery, EMP11 said, "Yeah, we used to. It was not an issue. We were taking the babies to the nurses' station until it became an issue with the rooming in." EMP11 further indicated that babies were not allowed to go to the 2nd floor nursery from the third floor.


Cross reference with:
482.23(b) Staffing and Delivery of Care

Based on review of documents, observations and staff interviews (EMP), it was determined the facility failed to ensure adequate nursing staff to provide nursing care to all patients as needed.

Findings include:

Review of the Obstetrics "Surge Capacity Plan for Obstetric, Infant, and Gynecologic Care policy revised November 11, 2014, revealed, "Definition: Identifiers may include high census, high acuity, and staff indicators for women/infant services to include obstetrics, newborn and gynecologic care. The following criteria may indicate the need to activate the policy: 1. Increased volume of laboring patients 2. Increased volume of postpartum patients 3. Unanticipated and/or emergency C-section 4. Increased volume of newborns requiring isolation related to airborne infectious disease ... The decision for any bed assignment or reassignment will be made collaboratively between the Unit Director of Inpatient Obstetrics and CNO (or designee e.g. shift supervisor). 1. In order to promote patient flow and safety within the Womancare Birthplace [second floor], all stable post-partum patients and/or clean gyne/surg patients may be assigned to beds on ... the 3rd floor Women's Health Unit ... Procedure C: 1. Newborns requiring Level I care will be accommodated in the Womancare Birth Place nursery or newborn may accompany mother to ... Mother-Baby Unit utilizing couplet nursing care delivery... Procedure D. 1. See appropriate staffing plans/grid for 2nd floor LDR and 3rd floor Mother-Baby Unit and Women's Health Unit overflow..."

1. Review of the Birthplace Staff Nurse/Patient Ratio, no date provided, revealed a grid with the number and skill mix of personnel notes that were to be used "as Guidelines." On day turn shift and afternoon shift if there were 1-3 "Couplets" the guidelines recommended 3 RNs and a Unit Clerk. On night turn, the staffing was the same except there was no Unit Clerk. For 4-6 Couplets for day shift and afternoon shift, the guidelines recommended 4 RNs and a Unit Clerk. Night shift recommended 4 RNs. For 7-11 couplets for the day and afternoon shift, the guidelines recommended 5 RNs and a Unit Clerk. Night turn shift recommended five RNs. Additionally it was noted, "Numbers above do not include Unit Director who is available for staffing as the need arises. Numbers above do not include Resource Nurse For census 0-2 in department RNs, and one Float RN Census 1-3 will have 2 RNs on call Census 4-6 will have 1 RN on call" Handwritten was "4 couplets/1 RN".

2. Review of the information packet provided to every new mom revealed a pamphlet "UPMC Horizon ... Caring for Your New Baby" HRZ.0238 revised May 2005 revealed, "While your baby is in your room, mothers must take the responsibility to keep record of diaper changes and feedings after being shown by the nurse... Daily, after morning care and physician visits, the baby will be brought to the mother's room for the day. If you would prefer your baby in the nursery between feedings, please communicate this to your nurse... - Never leave your baby out of your direct line of sight, even when you go to the bathroom. Never leave your baby alone in the room while you shower or go for a walk..."

3. Observations on December 29, 2014, at 9:35 AM revealed an RN in the nursery on the second floor and two babies. Observations at the same time on the third floor revealed there was no nursery on that floor. Babies on the third floor were observed rooming in with moms. Additional observations on December 29, 2014, at 1:25 PM revealed no babies or RN in the second floor nursery. Interview at that time with EMP5 revealed there were currently three moms and babies and the babies were all with the moms at that time.

4. Review of complaint information received by this office revealed the patient (MR1) had a C-section delivery, was taken to the 3rd floor, and later requested nursing staff to take her baby to the nursery so she could rest. According to the complaint, she was told that that could not be done because, "We don't do that anymore."

5. Review of staffing for December 29, 2014, revealed patients assigned for both the second and the third floor overflow unit. The schedules listed patient names with initials beside them of the staff assigned to the patient. On the second floor schedule there were five nurses listed including a charge nurse and 6 patient names plus one baby. One of the patients was scheduled for a C-section. Two nurses' initials were listed by the C-section patient. An additional nurse was listed as a scrub nurse. The third floor overflow unit revealed three moms and three babies (Couplets). Two nurses were assigned.

6. Interview on December 29, 2014, at 10:55 AM with EMP5 when asked if there was a separate nursery schedule revealed that the person assigned to the nursery, if there was a baby in the nursery, was one of the nurses assigned to the scheduled C-section patient.

7. Interview on December 29, 2014, at 3:15 PM with EMP11 when asked if there was ever anyone kind enough to take the baby when a new mom on the third floor overflow unit required rest, revealed, "I took a baby about 5:00 AM to the nurses' station ... about 45 minutes." When asked if moms on the third floor overflow unit were allowed to request babies be taken to the nursery [on second floor] EMP11 said, "Not to the actual nursery... It's more of a staffing thing. You can't take someone from the third floor. There would have to be someone in the nursery [on the second floor]..."

Cross reference with:
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on review of facility documents, medical records and staff interview (EMP), it was determined the facility failed to ensure documentation of pertinent information to contribute to the continuity of patient care for two of two medical records, one mother and one baby medical record. (MR5 and MR8).
Findings Include:

Review of the facility policy and procedure on December 30, 2014, at 2:00 PM revealed, "Documenation on the Medical Record/Charting..." Revised on October 2014, revealed, "...Purpose: To establish an effective interdisciplinary documentation system that will enhance communication among members of the health care team through organized Documenation of the patient's clinical information...1. To define the role and responsibility of nursing personnel in Documenation. 2. To identify essential aspects of documentation which facilitates communication between nurses and other members of the health care deliver team...3. To standardize documentation guidelines for collection of nursing date for a 24-hour period..."

1. Review of MR5 and MR8 on December 29, 2014, at approximately 10:00 AM revealed no documentation that the baby of MR5 was taken from the mother's room to the nurses' station to provide respite for the mother.

2. During an interview on December 29, 2014, at approximately 10:00 AM, EMP2 confirmed that there was no documentation in either the mother's or the baby's medical record [MR5 and MR8] indicating that the baby was taken out of the mother's room to the nurses' station.

3. Interview of the patient of MR5, when asked the process for when the baby was taken from her room for respite revealed, "The nurse took the baby out of the room from about 5:00 to 5:45 AM."

4. Telephone interview on December 29, 2014, at 3:15 PM with EMP11 when asked if someone was kind enough to take the baby so the mom could rest, responded, "I took a baby about 5:00 AM to the nurses' station. [Nursery?] No. I just brought him back to where I was sitting... for about 45 minutes. [Was it documented?] I didn't..."