HospitalInspections.org

Based on document review and interview, the hospital failed to ensure an adequate number of nursing coverage in the Neonatal Intensive Care Unit (NICU) during staff breaks.

Findings Include:

Review of facility policy titled "Plan for Provision of Nursing Care," last reviewed on 8/14/19, states: The practice of nursing by a Registered Professional Nurse at Jamaica Hospital Medical Center will mean assuming responsibility and accountability for the provision of nursing care ...The Department of Nursing aims to provide an acceptable number and mix of nursing personnel to produce a desired level of care that meets patient care needs. The allocation of nursing personnel to patient care areas is determined by multiple variables such as: Goals to meet acuity levels; Nursing department standards; Medical service requirements; Services provided by the multi-disciplinary team, and Patient and family satisfaction. The most important variable considered is patient care outcome.

Review of the facility's staffing ratio for the NICU stepdown on 3/16/20 as determined by the Optilink, revealed 1:2.26 (one nurse to two patients).
The staffing ratio did not address staffing coverage for breaks.

Review of the facility's staffing assignment in the NICU on 3/16/20 revealed three (3) nurses were assigned two (2) babies each. Additional assignments included crash cart check, glucometer check, equipment check, breast milk fridge and warmers temperature check, medication fridge and pantry fridge check, and charge nurse.
There was no coverage assigned for lunch or other breaks.

The adequacy of staffing ratio was broken on 3/16/20, when one of the nurses went on break and a second nurse went to the lab or pharmacy.

Review of the medical record for Patient #2 identified: On 3/16/20 at 10:35 AM, Neurologist documented: "four (4) day old baby with history of TTN. He is full term (FT) newborn. He fell off the incubator. He was still crying. This happened at around 9:55 AM. Assessment and plan: FT baby with TTN, History of fall. Rule out head injury, neuro exam is normal. Plan: MRI of brain. Follow-up after MRI of brain continue to observe.
At 4:10 PM, neurologist documented: " Patient was seen today because of fall from incubator. MRI showed parietal bone (behind the ear) fracture and subdural. Plan: As discussed by neurosurgery (surgeons that operate on the brain) continue to observe. No need for neurosurgical intervention. Continue neuro check (reflexes, muscle strength, sensory function, alertness, posture, eye movement).

During interview on 10/1/20 at 2:40 PM, Staff O, NICU RN stated: " ...Yes I am alone in the room. I was covering six (6) babies there. One nurse went to the lab or pharmacy, I told the other I can relieve her."
Staff O, RN NICU, stated: " ......The baby was crying so I stood up and approached the baby and changed his diaper and gave the pacifier. Then I think I sat down again, and I approached again. I opened the isolette and saw nothing wrong. I repositioned the baby, put baby on the stomach and put the pacifier back. The baby kept quiet. I sat back with my computer again. As I was typing the baby started to cry again after about 10 minutes. I heard a big bang like something exploded. I traced where the sound was coming from. I saw the baby on the floor....."

During interview on 10/1/20 at 3:16 PM, Staff X Clinical Nurse Manager of NICU, acknowledged the newborn's fall. Staff X stated: "They called and said the baby fell. I asked how the baby fell and Staff O said she was covering Staff Bb, Nurse Practitioner (was RN at the time of incident). She was on her WOW (a computer on wheels) and she heard a loud noise and she went and looked, and the baby was on the floor."

During interview on 10/1/20 at 3:16 PM, Staff B, Clinical Nurse Manager stated: "The day started with 12 patients and six (6) nurses. Two (2) patients in Continuing Care, four (4) in the main NICU. The NICU stepdown had six (6) infants and three (3) nurses. The primary nurse for the patient was Staff D."
Staff B could not name the third nurse in the NICU or knew why she left the assigned area.

At interview on 10/5/20 at 10:41 AM, Staff C, Director of Nursing for Maternal Child stated: "Staffing is based on patient care needs and staff in the area most often are 1:2 (one nurse to two babies). Surveyor asked what is the expectation for replacement coverage and for escalation up to a supervisor, when an assigned nurse leaves the area during breaks. Staff C replied: "The expectation is the nurse would say I am leaving for the bathroom and hand off ...My expectation is that they are aware of the situation and they give a handoff and they work together as a team."

Review of the facility's escalation policy titled "Chain of Command & Escalation" last reviewed 3/17/20, revealed the escalation policy does not address nursing coverage during breaks.

Based on document review and interview, the facility failed to maintain an adequate number of Registered Nurses to supervise the care and safety of infants in the Neonatal Intensive Care Unit (NICU) during staffing breaks.

Findings Include:

Review of facility policy titled "Plan for Provision of Nursing Care" last reviewed on 8/14/19, states: Scope of Nursing in terms of operating and managing ...Staffing; Scheduling ...The Supervisor and the Clinical Nurse Manager in the daily allocation of nursing personnel take into consideration using the Kronos and Optilink system the following: Changes in census; Changes in patient needs; Capabilities of staff on duty; Staff fluctuation; Staff education and Community activities. These variables influence staffing adjustments on a daily and shift by shift basis.

Review of the facility's staffing ratio for the NICU stepdown on 3/16/20 as determined by the Optilink and corroborated by the nursing supervisor, revealed 1:2.26 (one nurse to two patients).
The staffing ratio did not address staffing adjustments/coverage for breaks.

Review of the facility's staffing assignment in the NICU on 3/16/20 revealed three (3) Registered Nurses were assigned to six (6) babies, (two babies each). Additional assignments included crash cart check, glucometer check, equipment check, breast milk fridge and warmers temperature check, medication fridge and pantry fridge check, and charge nurse.

There was no coverage assignment for lunch or other breaks.

On 3/16/20 at 9:30 AM, the adequacy of staffing ratio was broken when the first nurse went on her morning break and shortly after, a second nurse left the unit.

Review of the medical record for Patient #2 identified: On 3/16/20 at 10:35 AM, Neurologist documented: "four (4) day old baby with history of TTN. He is full term (FT) newborn. He fell off the incubator. He was still crying. This happened at around 9:55 AM. Assessment and plan: FT baby with TTN, History of fall. Rule out head injury, neuro exam is normal. Plan: MRI of brain. Follow-up after MRI of brain continue to observe.
At 4:10 PM, neurologist documented: " Patient was seen today because of fall from incubator. MRI showed parietal bone (behind the ear) fracture and subdural. Plan: As discussed by neurosurgery (surgeons that operate on the brain) continue to observe. No need for neurosurgical intervention. Continue neuro check (reflexes, muscle strength, sensory function, alertness, posture, eye movement).

During interview on 10/1/20 at 2:40 PM, Staff O, NICU RN stated: " ...Yes I am alone in the room. I was covering six (6) babies there. One nurse went to the lab or pharmacy, I told the other I can relieve her." Staff O, RN NICU, stated: " ......The baby was crying so I stood up and approached the baby and changed his diaper and gave the pacifier. Then I think I sat down again, and I approached again. I opened the isolette and saw nothing wrong. I repositioned the baby, put baby on the stomach and put the pacifier back. The baby kept quiet. I sat back with my computer again. As I was typing the baby started to cry again after about 10 minutes. I heard a big bang like something exploded. I traced where the sound was coming from. I saw the baby on the floor....."

During interview on 10/1/20 at 3:16 PM, Staff X Clinical Nurse Manager of NICU, acknowledged the newborn's fall. Staff X stated: "They called and said the baby fell. I asked how the baby fell and Staff O said she was covering Staff Bb, Nurse Practitioner (was RN at the time of incident). She was on her WOW (a computer on wheels) and she heard a loud noise and she went and looked, and the baby was on the floor."

During interview on 10/1/20 at 3:16 PM, Staff B, Clinical Nurse Manager when asked by surveyor why the second nurse that was assigned to the NICU left the area and who she was, Staff B acknowledged she did not know who she was or where the second nurse went. Staff B later returned and told surveyor who was the second nurse and stated that the nurse went to the bathroom.

At interview on 10/5/20 at 10:41 AM, Staff C, Director of Nursing for Maternal Child stated: "Staffing is based on patient care needs and staff in the area most often are 1:2 (one nurse to two babies). Surveyor asked what is the expectation for replacement coverage and for escalation up to a supervisor when an assigned nurse leaves the area during breaks. Staff C replied: "The expectation is the nurse would say I am leaving for the bathroom and hand off ...My expectation is that they are aware of the situation and they give a handoff and they work together as a team."