HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined the Chief Executive Officer (CEO) failed to ensure the Intensive Care Unit inpatient beds were utilized to provide inpatient care.

Findings include:

Review on June 5, 2015, of the "Chief Executive Officer" job description, no review date, revealed "Position Purpose The Chief Executive Officer is responsible for the overall administrative management and operation of the hospital. The CEO has the authority to effect this responsibility ... General Duties ... Evaluates the effects of external forces on the hospital, recommends long-term plans that supports the hospital's mission and general objectives. Ensures compliance with regulations of hospital and the rules of accrediting bodies by continually monitoring the organization's service delivery and initiating changes as required. ..."

Review on June 5, 2015, of the facility's "Plan for Patient Care Services," revised April 2014, revealed "Berwick Hospital Center's Plan for Patient Services Preamble Berwick hospital is a full service acute care facility offering specialized services in the areas of skilled nursing care, and geriatric psychiatry. ... Intensive Care Services ... The ICU [Intensive Care Unit] serves primarily adult/geriatric patients with actual or potential life threatening conditions requiring an intensive level of care. The ICU is designated for inpatients, as well as patients requiring post anesthesia care after normal PACU hours. ..."

A request was made of EMP1, EMP5 and EMP6 for a facility policy or procedure addressing performing outpatient procedures in inpatient licensed beds. No policy/procedure was provided.

Interview with EMP9 and EMP10 on June 4, 2015, at approximately 10:15 AM revealed the facility performed cardioversions (a procedure using an electrical current to reset the heart rhythm back to a regular rhythm) and transesophageal echocardiography (TEE - a test using an ultrasound transducer positioned in the throat to assess the heart valves and chambers) on outpatients in the facility's inpatient Intensive Care Unit (ICU).

Review of MR1 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on May 19, 2015, in the facility's ICU unit.

Review of MR2 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on January 6, 2015, in the facility's ICU unit.

Review of MR3 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on April 20, 2015, in the facility's ICU unit.

Review of MR4 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on March 2, 2015, in the facility's ICU unit.

Review of MR5 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on January 9, 2015, in the facility's ICU unit.

Review of MR6 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on March 2, 2015, in the facility's ICU unit.

Review of MR7 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on May 1, 2015, in the facility's ICU unit.

Review of MR8 on June 4, 2015, revealed the facility performed a cardioversion on this outpatient on February 23, 2015, in the facility's ICU unit.

Review of MR9 on June 4, 2015, revealed the facility performed a TEE on this outpatient on January 28, 2015, in the facility's ICU unit.

Review of MR10 on June 4, 2015, revealed the facility performed a TEE on this outpatient on March 2, 2015, in the facility's ICU unit.

Review of MR11 on June 4, 2015, revealed the facility performed a TEE on this outpatient on January 6, 2015, in the facility's ICU unit.

Review of MR12 on June 4, 2015, revealed the facility performed a TEE on this outpatient on January 5, 2015, in the facility's ICU unit.

Interview with EMP1, EMP5, EMP8 and EMP19 on June 4, 2015, at approximately 1:50 PM confirmed the facility conducted outpatient cardioversions on MR1, MR2, MR3, MR4, MR5, MR6, MR7 and MR8 and outpatient TEE's on MR9, MR10, MR11 and MR12 in licensed inpatient ICU beds.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to follow the established Quality Improvement Program for data collection, totaling, analyzing, calculating and comparing the results of the Outpatient Rehabilitation Satisfaction Survey to show measurable improvement for 2014 and 2015.

Findings include:

Review on June 11, 2015, of the "Berwick Hospital Center Organization-wide Quality Improvement Program 2014" last revised March 2014, revealed "Berwick Hospital Center Mission Statement The mission of this organization is to provide a continuum of quality health care to the residents of the communities we serve in a compassionate, collaborative and cost-effective manner. ... II. Introduction/Philosophy: A. Purpose Berwick Hospital Center is an institution dedicated to meeting the needs of our patients in a manner which is consistent with our mission, vision and goal statements. The Organizational Quality Improvement plan is designed to provide a systematic and organized program for the promotion of safe, quality patient care and services. ... F. Scope of Activities The scope of the Organizational Quality Improvement Program encompasses measurement and assessment activities of the Medical Staff, Nursing and Ancillary or support services. Processes and outcomes of care are designed, measured and assessed by appropriate departments. Quality Improvement activities will address both clinical and organization functions. These activities are designed to assess key functions of patient care and to identify, study, and correct problems and improvement opportunities found in the processes of care delivery. ... Hospital Departments The Department Leaders are accountable to Administration, the Quality Improvement Council and the Board for the quality and safety of care/services and performance of their staff and departments. Department Directors and Managers are responsible for the systematic monitoring and analysis of the quality and safety of care provided in their departments. Directors will: Submit opportunities for improvement to the Quality Improvement Council for prioritization Promote the development of standards of care and criteria to objectively measure the quality and safety of care/services rendered in their departments. Monitor and analyze the processes in their areas that affect patient care, safety, outcomes and satisfaction. Design and redesign work processes to improve safety and quality. ... IV. Design - Quality Approach and Framework ... Data Collection The staff collects, organizes and analyzes data necessary to determined root causes, track performance, benchmarking, etc. Data is organized in such a manner as to facilitate comparison and trends. The data collection is conducted in a timely and efficient manner. Statistical techniques and data displaying 'tools' will be utilized. .. "

Review on June 10, 2015, of the facility's [Name of therapy contracted service] revealed this contract was signed effective July 1, 2013. Further review of this contract revealed "Therapy Services Under Arrangement Contractor Agreement ... Addendum IV Performance Criteria At the conclusion of the first six months and each successive three-month period, the Contractor shall monitor and report the following distinct performance criteria. ... Performance Measures: The following Performance measures shall be monitored by Contractor and submitted to the Hospital on a quarterly basis after the first six (6) months. Patient Satisfaction: Contractor will monitor patient satisfaction in a mutually agreed upon manner. The baseline shall be 95 [percent] patient satisfaction ..."

Review on June 10, 2015, of the facility's Outpatient Rehabilitation Satisfaction Survey, no review or revision date, revealed "I. Services I received (check all that apply) Physical therapy Occupational therapy Speech therapy II. Circle the item that best reflects your opinion: S=Strongly agree A=Agree SD Strongly disagree D=Disagree U=Undecided N/A-Not Applicable". The form then lists the following questions: "a) My central scheduling process was easy b) My registration process/time was easy. c) There was available parking for me. d) I did not have a long wait at my first therapy visit. e) My therapist was knowledgeable regarding my condition and care. f) The therapy facilities were adequate. g) I had privacy during my care when privacy was needed. h) I feel my pain was appropriate managed. i) I feel that I participated in establishing my goals." This was followed by three questions requiring a written response. "III. What I liked best about therapy was, followed by a line. IV. If I could suggest one change, it would be to, followed by a line and V. Comments: followed by a line. Name (optional):"

Interview with EMP46 and EMP47 on June 10, 2015, at approximately 2:00 PM revealed the Rehabilitation Department distributed the satisfaction surveys to patients on their last visit and instructed the patients to return them by mail. Further interview with EMP46 and EMP47 confirmed the Rehabilitation Department collected quality data on the Patient Satisfaction survey for 2014 and 2015. Continued interview with EMP46 and EMP47 confirmed the data collected on the Patient Satisfaction survey for 2014 and 2015 was not totaled, analyzed, calculated or compared to show measurable improvement.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to identify an area for improvement in environmental rounds and failed to measure the success and track the performance in the Outpatient Rehabilitation Department to ensure measurable improvement.

Findings include:

Review on June 11, 2015, of the "Berwick Hospital Center Organization-wide Quality Improvement Program 2014" last revised March 2014, revealed "... IV. Design - Quality Approach and Framework ... E. Improve Berwick Hospital Centerwill [sic] implement a hospital-wide approach to systematically improve quality utilizing the [name] method. Action is directed primarily at improving processes. Improvement opportunities are identified by departmental and organizational QI [Quality Improvement] activities, customer satisfactions surveys, sentinel events, hospital/medical staff committee structure, opportunity for improvement forms and through formal and informal networking of all Employees. Appropriate action will be recommended and implemented to eliminate or reduce variations identified or to improve quality of care. ..."

1) Review on June 10, 2015, of the facility's "Quarterly Grounds and Equipment Maintenance and Inspection Checklist EC.02.01.01.5a" last revised December 2009, revealed a section "... Dumpsters [and] Linen Area Inspection Item Dumpsters / Trash Disposal Areas Area Clean Dumpsters marked w/warning signs Units stable Hydraulic Controls secure, key required to operate Signage Other ..."

Observation on June 10, 2015, at approximately 8:30 AM revealed the hospital is a one-story building. There was a brick chimney on the hospital roof near the loading dock, dumpster and trash disposal area. Further observation revealed green vegetation growing from the top of the brick chimney. The green vegetation appeared to be 2-3' high. At the base, there were four metal doors. The top of the third door was missing a triangular piece, measuring approximately 7" at the top of the opening to approximately 1" on the bottom of the opening.

Interview with EMP5, EMP49 and EMP50 on June 10, 2015, at approximately 10:15 AM confirmed there was green vegetation growing from the brick chimney on the facility's roof and the missing portion on the third metal door. EMP50 revealed the brick chimney was a boiler stack which was not in use. EMP50 revealed the facility did not include this area on the environmental rounds form, and the facility did not identify this as an area for improvement during the environmental rounds.

2) Interview with EMP46 and EMP47 on June 10, 2015, at approximately 2:00 PM confirmed the data collected from the Outpatient Rehabilitation Satisfaction Surveys for 2014 and 2015 were not analyzed to identify areas for improvement or changes that would lead to improvement.

Cross reference:
482.21(a),(b)(1),(b)(2)(i),(b)(3) Data Collection and Analysis

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to develop and implement preventive actions to ensure contracted radiology physicians documented notification of critical results to the patient's ordering physician on the radiology report for three of four applicable medical record reviewed (MR15, MR17 and MR18).

Findings include:

Review on June 11, 2015, of the Berwick Imaging Department "Critical Results Reporting" policy, last approved February 12, 2015, revealed "Purpose: To provide a consistent means of reporting critical examination results from the Imaging Department to the physician. Documentation of these results will be maintained in the patient's medical record. ... Procedure: ... Unexpected abnormal results will be communicated to the caregiver at the time of dictation by the dictating physician. Results will be called directly to the patient's caregiver by the radiologist and documentation will be included in the report. ..."

Review on June 11, 2015, of the Critical Results Report [name of contracted radiology group] revealed an area for documenting compliance with notification of the critical results to the patient's ordering physician.

Review of MR15 on June 11, 2015, revealed the physician ordered a CT (Computerized tomography) scan on March 16, 2014, of the abdomen and pelvis with contrast for a diagnosis of lower abdominal pain and nausea. The reading radiologist documented "Impression: Prominent focal presumed sigmoid colon wall thickening, presumably diverticulitis with perforation and moderate extraluminal air tracking along the mesentery." Further review revealed no documentation on the radiology report indicating the results were discussed with the ordering physician, as required by facility policy.

Review of MR17 on June 11, 2015, revealed the physician ordered a CT scan on January 10, 2015, of the chest, abdomen and pelvis following a fall resulting in a complaint of left side rib pain. The reading radiologist documented "Impression: 1. Acute left-sided lateral 4th-8th rib fractures with mild displacement. No pneumothorax or chest wall hematoma. 2. Secretions in the carina and subsegmental lower lobe bronchi right greater than left with adjacent compressive atelectasis in the lung. Findings could be from aspiration. No pulmonary nodules or masses. No thoracic lymphadenopathy or pleural effusion. 3. Nonobstructing [sic] lower left renal calculus 2 to 3 mm. Nonspecific perinephric fat stranding bilaterally. 4. Cholecystectomy. No biliary ductal dilatation. Normal bowel including appendix." Further review revealed no documentation on the radiology report indicating the results were discussed with the ordering physician, as required by facility policy.

Review of MR18 on June 11, 2015, revealed the physician ordered an upper GI (gastrointestinal) study on February 23, 2015. The reading radiologist documented "Impression: 1. Large hiatal hernia, the stomach is intrathoracic. No obstruction. 2. Gastritis. 3. Mild gastroesophageal reflux. 4. Right pleural effusion." Further review revealed no documentation on the radiology report indicating the results were discussed with the ordering physician, as required by facility policy.

Interview with EMP51 on June 11, 2015, at approximately 2:15 PM confirmed there was no documentation on the radiology reports for MR15, MR17 and MR18 indicating the results of these patient's radiology tests were discussed with the ordering physician, as required by facility policy. Further interview revealed the facility did not develop, implement or evaluate a Quality Improvement program to review compliance with contracted radiology physicians and the documentation of notification of critical results to the patient's ordering physician on the radiology report.

Based on review of facility documents and staff interview (EMP), it was determined the Director of Nursing failed to ensure a registered nurse serving as a nursing supervisor was on the hospital premises 24 hours a day, 7 days a week; failed to ensure adequate nurse staffing in the Emergency Department, Intensive Care Unit and the Medical/Surgical department and failed to ensure staff were trained prior to working in other nursing departments (A392).

Findings include:

Review on June 5, 2015, of the "Chief Nursing Officer" job description, no review date, revealed "Position Purpose The Chief Nursing Officer is responsible for planning, coordinating, implementing and administering all nursing management activities. Organizes and administers areas of Patient Care Services to attain the hospital's objective established by the governing authority. ... General Duties Organizes, directs, and administers the Patient Care Services in order to provide the level of care required by current medical and nursing standards. Knows and practices the prescribed philosophy, purpose and standards of Patient Care Services and the Hospital. ... Develop organizational patient care programs, policies and procedures that describe how nursing care is assessed and evaluated. ... Recommends the modification, addition or deletion of personnel policies to ensure reasonable hours and acceptable working conditions to provide patient care coverage. Reviews and approves with Department Mangers the current staffing patterns and patient care needs of Nursing Services patients. ... Notifies the CEO and CFO concerning unusual situations, problems and/issues as necessary ... Performs additional duties as assigned."

Review on June 4, 2015, of the facility's "Staffing/Scheduling" policy, last revised July 2012, revealed "I. Scheduling: A. Method of Determining Personnel Required: The method of determining personnel required is determined by patient census and patient acuity. Patient acuity is determined by the director's or nursing supervisor's assessment while making rounds. ... II. Daily Staffing Guidelines: E. The Emergency Department for 7:00 a.m. - 3:30 p.m. is staffed as follows: Sunday, Monday, Friday and Saturday - 2 registered nurses 7:00 a.m. - 11:00 a.m., 3 registered nurses 11:00 a.m. - 3:30 p.m. Tuesday, Wednesday and Thursday - 2 registered nurses 7:00 a.m. - 3:30 p.m. Sunday through Saturday - 2 Registered Nurses, 1 LPN/RN 3:00 Pm - 11:30 PM Sunday through Saturday - 2 Registered Nurses, 11:00 PM - 7:30 AM Sunday through Saturday - Unit secretary 7:00 a.m. - 7:30 p.m. Extra staff is provided as needed for high acuity or high census periods. ..."

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 9, 2015, for the 11 - 7:30 AM shift revealed the ED was staffed with 1 RN and 1 LPN. The facility requirement was 2 RN's.

Review on June 4, 2015, of the Shift Supervisors report for May 9, 2015, for the 11 - 7:30 AM shift revealed EMP14 was scheduled as the nursing supervisor for the shift. Further review revealed EMP16 (LPN) was pulled to Obstetrics. Continued review revealed EMP14 was required to work in the ED as the second RN and function as the house nursing supervisor.

Review on June 4, 2015, of the Shift Supervisors report for May 15, 2015, for the 11 - 7:30 AM shift revealed EMP14 was scheduled as the nursing supervisor for the shift. Further review revealed an open shift in the ED. Continued review revealed EMP14 was required to work in the ED as the second RN and function as the house nursing supervisor.

Interview with EMP1 on June 4, 2015, at approximately 3:05 PM confirmed the ED staffing for May 9 and May 15, 2015. Further interview revealed EMP1 was aware EMP14 was required to work as the second RN in the ED on the 11 - 7:00 AM shift. Continued interview revealed EMP1 assumed the function of nursing supervisor, called into the facility and made phone rounds for the 11 - 7:00 AM shift on May 9 and May 15, 2015. EMP1 confirmed this employee was not on the hospital premises while performing the duties of nursing supervisor. EMP1 revealed this employee covered the nursing supervisor position from home by making phone rounds on at least two other occasions since taking the position of Chief Nursing Office in July 2014.

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

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure adequate staffing in the Intensive Care Unit, the Emergency Department, and the Medical/Surgical department for 19 of 33 days, May 1 thru June 2, 2015, and failed to ensure staff were trained prior to working in other nursing departments.

Findings include:

Observation on June 4, 2015, of the facility's open job opportunities dated May 29, 2015, posted outside the Human Resource office revealed the following positions: full time Registered Nurse (RN) positions for the first, second and third shift; a full time rotating RN position for M-Wing; an as needed (PRN) RN position for third shift and a part time RN rotating position for the Emergency Department (ED) and a PRN RN for the first shift and a full time RN for the first shift in the operating room.

Interview with EMP5 and EMP30 on June 4, 2015, at approximately 10:00 AM confirmed these open nursing positions.

Review on June 5, 2015, of the "Chief Nursing Officer" job description, no review date, revealed "Position Purpose The Chief Nursing Officer is responsible for planning, coordinating, implementing and administering all nursing management activities. Organizes and administers areas of Patient Care Services to attain the hospital's objective established by the governing authority. ... General Duties Organizes, directs, and administers the Patient Care Services in order to provide the level of care required by current medical and nursing standards .... Reviews and approves with Department managers the current staffing patterns and patient care needs of Nursing Service patients ..."

1) A request was made of EMP1 and EMP5 for the facility document identifying facility nursing staff and patient census.

On June 4, 2015, EMP1, EMP3, EMP5 and EMP8 provided the following documents for review:

1) The Daily Staffing sheets which captured patient names and staff assignments. The Daily Staffing sheets did not capture nursing staff that floated to the unit.

2) The Supervisor's shift report which captured only 3:00 PM - 11:30 PM and 11:00 PM -7:30 AM shift information.

3) The [brand name of staffing program] sheets which captured staffing and patient census. The document did not consistently capture staff reassignments. This document was provided at approximately 2:30 PM on June 4, 2015.

4) The Unit Based Assignment sheets which captured patient names and staff assignments. This document did not capture nursing staff that floated to the unit.

On June 5, 2015, at 2:30 PM EMP1 provided the Unit Schedule which captured the staff's home unit, requested time off, additional time worked and on-call time. This document did not capture patient census.

Interview with EMP1 and EMP5 on June 5, 2015, at approximately 3:00 PM revealed the [brand name of staffing program] sheets which captured staffing and patient census was the most accurate information to review for staffing and patient census.

Review on June 4, 2015, of the facility's "Staffing/Scheduling" policy, last revised July 2012, revealed "I. Scheduling: A. Method of Determining Personnel Required: The method of determining personnel required is determined by patient census and patient acuity. Patient acuity is determined by the director's or nursing supervisor's assessment while making rounds. ... II. Daily Staffing Guidelines: A. The Medical /Surgical unit is staffed utilizing the medical/surgical staffing guidelines. Patient acuity along with patient census is considered when determining staffing levels. Patient acuity is determined by the director or nursing supervisor assessment while making rounds. B. The Post-Partum unit is staffed with one registered nurse. When census is greater than five or a high-risk pregnancy patient is on OB, additional staff may be required. C. The Labor and Delivery unit is staffed with one registered nurse. Staff is either in house or on call depending upon the number of patients and the acuity of the patients. If post-partum is closed, two registered nurses will be staffed in Labor and Delivery. D. The Nursery is staffed with one registered nurse. When census is greater than five or high acuity infant is in the nursery, additional staff is required. E. The Emergency Department for 7:00 a.m. - 3:30 p.m. is staffed as follows: Sunday, Monday, Friday and Saturday - 2 registered nurses 7:00 a.m. - 11:00 a.m., 3 registered nurses 11:00 a.m. - 3:30 p.m. Tuesday, Wednesday and Thursday - 2 registered nurses 7:00 a.m. - 3:30 p.m. Sunday through Saturday - 2 Registered Nurses, 1 LPN/RN 3:00 PM - 11:30 PM Sunday through Saturday - 2 Registered Nurses, 11:00 PM - 7:30 AM Sunday through Saturday - Unit secretary 7:00 a.m. - 7:30 p.m. Extra staff is provided as needed for high acuity or high census periods. F. The CICU is staffed utilizing staffing guidelines. G. The Behavior Health Services unit is staffed according to census and patient acuity using BHS staffing guidelines. A minimum of one registered nurse along with other registered nurses, licensed practical nurses and nursing assistants will be staffed on each shift. ..."

Intensive Care Unit

Review on June 4, 2015, of the facility document "Intensive Care Unit Staffing Guidelines," no review date, revealed guidelines for staffing based on patient census. Further review revealed a patient census of 2, 3 and 4 the facility is to staff the ICU with 2 Registered Nurses (RNs) on the 7 - 3:30 PM shift, 3 - 11:30 PM shift and 11 - 7:30 AM shift; a patient census of 5 the facility is to staff the ICU with 2 RNs and a Unit Secretary (US) or an RN for four hours on the 7 - 3:30 PM shift and 2 RNs on the 3 - 11:30 PM shift and 11 - 7:30 AM shift, a patient census of 6 and 7 the facility is to staff the ICU with 3 RNs on the 7 - 3:30 PM shift, 3 - 11:30 PM shift and 11 - 7:30 AM shift; a patient census of 8 the facility is to staff the ICU with 4 RNs on the 7 - 3:30 PM shift and 3 - 11:30 PM shift and 3 RNs on the 11 - 7:30 AM shift; a patient census of 9 the facility is to staff the ICU with 4.5 RNs on the 7 - 3:30 PM and 4 RNs on the 3 - 11:30 PM shift and 3 RNs on the 11 - 7:30 AM shift; and a patient census of 10 the facility is to staff the ICU with 5 RNs on the 7 - 3:30 PM shift and 3 - 11:30 PM shift and 4 RNs on the 11 - 7:30 AM shift.

Interview with EMP3 and EMP5 on June 4, 2015, at approximately 1:15 PM revealed the facility's [brand name of staffing program] is what the facility utilizes to track patient census, staff scheduled shifts, awarded shifts, on call shifts, non-duty shifts, open shifts and requested shifts. Further interview with EMP3 and EMP5 revealed this report also identifies unfilled open shifts. Continued interview revealed this report also documented when an employee was pulled from one unit to another. EMP3 and EMP5 noted this report was not reliable if the employee did not change location using the time clock or submit a written notification changing unit location.

Review on June 4, 2015, of the Intensive Care Unit (ICU) [brand name of staffing program] sheet provided by EMP3 and EMP5 revealed staffing for day, evening and night shift and the census for each day and each shift for May 1, 2015, to June 4, 2015.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 6, 2015, for the 7 - 3:30 PM shift revealed the ICU had 6 patients and was staffed with 2 RNs. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 6, 2015, for the 3 - 11:30 PM shift revealed the ICU had 7 patients and was staffed with 1.5 RNs and 1 Licensed Practical Nurse (LPN). The facility requirement for 7 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 7, 2015, for the 7 - 3:30 PM shift revealed the ICU had 9 patients and was staffed with 4 RNs. The facility requirement for 9 patients was 4.5 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 7, 2015, for the 3 - 11:30 PM shift revealed the ICU had 8 patients and was staffed with 2 RNs and an LPN. The facility requirement for 8 patients was 4 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 7, 2015, for the 11:00 - 7:30 AM shift revealed the ICU had 9 patients and was staffed with 2 RNs and an LPN. The facility requirement for 9 patients was 4 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 8, 2015, for the 7 - 3:30 PM shift revealed the ICU had 9 patients and was staffed with 2.75 RNs and an LPN, the facility requirement for 9 patients was 4.5 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 9, 2015, for the 7 - 3:30 PM shift revealed the ICU had 5 patients and was staffed with 2 RNs. The facility requirement for 5 patients was 2.5 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 9, 2015, for the 3 - 11:30 PM shift revealed the ICU had 4 patients and was staffed with 1.5 RNs, the facility requirement for 4 patients was 2 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 12, 2015, for the 7 - 3:30 PM shift revealed the ICU had 6 patients and was staffed with 2 RNs and an LPN. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 12, 2015, for the 3 - 11:30 PM shift revealed the ICU had 6 patients and was staffed with 2 RNs. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 13, 2015, for the 11:00 - 7:30 AM shift revealed the ICU had 4 patients and was staffed with 1 RN and 1 LPN. The facility requirement for 4 patients was 2 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 15, 2015, for the 3 - 11:30 PM shift revealed the ICU had 7 patients and was staffed with 2 RNs. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 15, 2015, for the 11:00 - 7:30 AM shift revealed the ICU had 6 patients and was staffed with 1 RN and 1 LPN. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 16, 2015, for the 7 - 3:30 PM shift revealed the ICU had 6 patients and was staffed with 2.25 RNs. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 18, 2015, for the 7 - 3:30 PM shift revealed the ICU had 5 patients and was staffed with 2 RNs. The facility requirement for 5 patients was 2.5 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 18, 2015, for the 11:00 - 7:30 AM shift revealed the ICU had 6 patients and was staffed with 2.5 RNs. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 20, 2015, for the 7 - 3:30 PM shift revealed the ICU had 5 patients and was staffed with 2 RNs. The facility requirement for 5 patients was 2.5 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 20, 2015, for the 3 - 11:00 PM shift revealed the ICU had 6 patients and was staffed with 1.75 RNs. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 20, 2015, for the 11:00 - 7:30 AM shift revealed the ICU had 6 patients and was staffed with 2 RNs. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 21, 2015, for the 7 - 3:30 PM shift revealed the ICU had 6 patients and was staffed with 2 RNs and an LPN. The facility requirement for 6 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 23, 2015, for the 7 - 3:30 PM shift revealed the ICU had 7 patients and was staffed with 2 RNs. The facility requirement for 7 patients was 3 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 24, 2015, for the 7 - 3:30 PM shift revealed the ICU had 5 patients and was staffed with 2 RNs. The facility requirement for 5 patients was 2.5 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 26, 2015, for the 3 - 11:00 PM shift revealed the ICU had 4 patients and was staffed with 1 RN and 1 LPN. The facility requirement for 4 patients was 2 RNs.

Review on June 4, 2015, of the ICU's [brand name of staffing program] sheet for May 28, 2015, for the 3 - 11:00 PM shift revealed the ICU had 3 patients and was staffed with 1 RN and 1 LPN. The facility requirement for 3 patients was 2 RNs.

Interview with EMP1, EMP5 and EMP8 on June 5, 2015, at approximately 9:30 AM confirmed the facility did not staff the ICU on May 6, 7, 8, 9, 12, 13, 15, 16, 18, 20, 21, 23, 24, 26 and 28, 2015, as indicated by the facility established staffing guideline for the ICU, and the facility staffed the ICU with an LPN when an RN was required.

Emergency Department

Review on June 4, 2015, of the facility's "Staffing/Scheduling" policy, last revised July 2012, revealed "I. Scheduling: A. Method of Determining Personnel Required: The method of determining personnel required is determined by patient census and patient acuity. Patient acuity is determined by the director's or nursing supervisor's assessment while making rounds. ... II. Daily Staffing Guidelines: ... E. The Emergency Department for 7:00 a.m. - 3:30 p.m. is staffed as follows: Sunday, Monday, Friday and Saturday - 2 registered nurses 7:00 a.m. - 11:00 a.m., 3 registered nurses 11:00 a.m. - 3:30 p.m. Tuesday, Wednesday and Thursday - 2 registered nurses 7:00 a.m. - 3:30 p.m. Sunday through Saturday - 2 Registered Nurses, 1 LPN/RN 3:00 Pm - 11:30 PM Sunday through Saturday - 2 Registered Nurses, 11:00 PM - 7:30 AM Sunday through Saturday - Unit secretary 7:00 a.m. - 7:30 p.m. Extra staff is provided as needed for high acuity or high census periods. ..."

Review on June 4, 2015, of the Emergency Department's (ED) [brand name of staffing program] sheet for May 6, 2015, for the 7 - 3:30 PM shift revealed the ED was staffed with 1.5 RNs. The facility requirement was for 2 RNs.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 6, 2015, for the 3 - 11:30 PM shift revealed the ED was staffed with 2.38 RNs. The facility requirement was for 2 RNs and 1 LPN.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 8, 2015, for the 3 - 11:30 PM shift revealed the ED was staffed with 2 RNs. The facility requirement was for 2 RNs and 1 LPN.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 8, 2015, for the 11 - 7:30 AM shift revealed the ED was staffed with 1 RN and 1 LPN. The facility requirement was for 2 RNs.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 9, 2015, for the 11 - 7:30 AM shift revealed the ED was staffed with 1 RN and 1 LPN. The facility requirement was for 2 RNs.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 13, 2015, for the 3 - 11:30 PM shift revealed the ED was staffed with 2 RNs and 1 LPN until 7:00 PM then 1 RN and 1 LPN from 7:00 PM to 11:30 PM, the facility requirement was for 2 RNs and 1 LPN.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 19, 2015, for the 11 - 7:30 AM shift revealed the ED was staffed with 1 RN. The facility requirement was for 2 RNs.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 22, 2015, for the 3 - 11:30 PM shift revealed the ED was staffed with 2 RNs. The facility requirement was for 2 RNs and 1 LPN.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 23, 2015, for the 3 - 11:30 PM shift revealed the ED was staffed with 2 RNs. The facility requirement was for 2 RNs and 1 LPN.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for May 28, 2015, for the 11 - 7:30 AM shift revealed the ED was staffed with 1 RN and 1 LPN. The facility requirement was for 2 RNs.

Review on June 4, 2015, of the ED's [brand name of staffing program] sheet for June 2, 2015, for the 3 - 11:30 PM shift revealed the ED was staffed with 3 RNs unit 7:00 PM then 2 RNs from 7:00 PM to 11:00 PM. The facility requirement was for 2 RNs and 1 LPN.

Interview with EMP1, EMP4 and EMP5 on June 5, 2015, at approximately 10:30 AM confirmed the facility did not staff the ED on May 6, 8, 9, 13, 19, 22, 23 and 28, 2015 and on June 2, 2015, as indicated by facility policy.

Medical/Surgical (M-Wing)

Review on June 4, 2015, of the facility's "Staffing/Scheduling" policy, last revised July 2012, revealed "I. Scheduling: A. Method of Determining Personnel Required: The method of determining personnel required is determined by patient census and patient acuity. Patient acuity is determined by the director's or nursing supervisor's assessment while making rounds. ... II. Daily Staffing Guidelines: A. The Medical /Surgical unit is staffed utilizing the medical/surgical staffing guidelines. Patient acuity along with patient census is considered when determining staffing levels. Patient acuity is determined by the director or nursing supervisor assessment while making rounds. ... "

Review on June 4, 2015, of the facility document "Med/Surg" last revised January 2015, revealed guidelines for staffing based on patient census. Further review revealed for a patient census of 0 - 10 the facility is to staff the Medical/Surgical unit (M-Wing) with 2 RN/LPN and 1 Telemetry Tech on the 7 - 3:00 PM shift and 3 - 11:00 PM shift; a patient census of 11 - 15 the facility is to staff M-Wing with 3 RN/LPN, 1 Nursing Assistant (NA) and 1 Telemetry Tech on the 7 - 3:00 PM shift and the 3 - 11:00 PM shift; a patient census of 16 - 20 the facility is to staff M-Wing with 4 RN/LPN, 1 Nursing Assistant (NA) and 1 Telemetry Tech on the 7 - 3:00 PM shift and the 3 - 11:00 PM ..."

Review on June 4, 2015, of the facility document "Med/Surg" last revised January 2015, revealed guidelines for staffing based on patient census on the 11 - 7 AM shift. Further review revealed a patient census of 0 - 14 the facility is to staff M-Wing with 2 RN/LPN, no NA and 1 Telemetry Tech; for a patient census of 11 - 21 the facility is to staff M-Wing with 3 RN/LPN, no NA and 1 Telemetry Tech.

Review on June 4, 2015, of M-Wing's [brand name of staffing program] sheet for May 7, 2015, for the 3 - 11:00 PM shift revealed M-Wing was staffed with 2 RN/LPN. The facility requirement for 12 patients was for 3 RN/LPN and 1 NA.

Review on June 4, 2015, of M-Wing's [brand name of staffing program] sheet for May 14, 2015, for the 7 - 3:00 PM shift revealed M-Wing was staffed with 3 RNs. The facility requirement for 17 patients was 4 RN/LPN.

Review on June 4, 2015, of M-Wing's [brand name of staffing program] sheet for May 15, 2015, for the 7 - 3:00 PM shift revealed M-Wing was staffed with 3 RNs. The facility requirement for 17 patients was 4 RN/LPN.

Review on June 4, 2015, of M-Wing's [brand name of staffing program] sheet for May 20, 2015, for the 7 - 3:00 PM shift revealed M-Wing was staffed with 3 RNs. The facility requirement for 17 patients was 4 RN/LPN.

Review on June 4, 2015, of M-Wing's [brand name of staffing program] sheet for May 22, 2015, for the 7 - 3:00 PM shift revealed M-Wing was staffed with 3 RNs. The facility requirement for 18 patients was 4 RN/LPN and 1 NA.

Interview with EMP1, EMP5 and EMP11 on June 5, 2015, at approximately 11:30 AM confirmed the facility did not staff M-Wing on May 7, 14, 15, 20 and 22, 2015, as indicated by facility policy.

A request was made of EMP1 and EMP5 for documentation that nurse staffing was adjusted based on patient acuity. No documentation was provided that nurse staffing was adjusted based on patient acuity or that the facility's staffing matrix was not being met due to patient acuity.

The nursing staffing sheets for the Intensive Care Unit and M-Wing were reviewed with the department managers. The nursing staffing sheets for the Emergency Department were reviewed with the Chief Nursing Officer and the department manager. Each confirmed the patient care units were not staffed according to the facility's matrix and staffing policy.

2) Review on June 5, 2015, of the facility's "Plan for Patient Care Services," revised April 2014, revealed "Berwick Hospital Center's Plan for Patient Services Preamble Berwick Hospital is a full service acute care facility offering specialized services in the areas of skilled nursing care, and geriatric psychiatry. ... Staff Development and Education Each department director assumes responsibility for establishing an Orientation and Staff Development Plan. Each department director, in cooperation with the Human Resources staff, will evaluate the Orientation and Staff Development Plan annually in December. ... Each new employee will be required to attend a formal orientation program prior to their first day of work on their assigned unit. Orientation consists of two days of general hospital orientation, followed by unit/department orientation ranging from two days to four weeks. ... "

Review on June 5, 2015, of the facility's "Orientation/Reorientation" policy, effective February 2013, revealed "1.0 Purpose To specify the curriculum of orientation sessions for new employees, as well as for the annual reorientation of all employees. ... Orientation to individual and department job responsibilities must be conducted by the department head or designated department representative within five working days after the employee begins work in the department. See Sample Department Orientation Initial Competency Assessment (DOICA) (Form 22). Employees transferring from one Facility to another must attend or complete via a validated competency assessment or CBC, General Orientation. ... Nursing Skill Proficiency. All new nursing staff, including PRNs, will be required to demonstrate proficiency in nursing skills required for their unit. Nursing orientation to the unit must be individualized for each staff member by having the unit manager assign the new employee to a preceptor. ... The completed competency assessment must be returned to the Facility's Human Resources Department as soon as orientation is complete. ... "

Interview on June 4, 2015, in the AM with EMP4 revealed the nursing departments share staff. The facility completes cross training of the nursing staff and documents the training on a DOICA.

Interview on June 4, 2015, in the AM with EMP11 revealed nursing staff are shared by departments. Nursing staff could be pulled (reassigned to another department) to obstetrics, medical/surgical, behavioral health, emergency services or intensive care.

Interview on June 4, 2015, in the AM with EMP12 confirmed this employee was pulled to the Emergency Department, the Behavioral Health Unit and Intensive Care Unit. EMP12 stated they were never cross trained.

Interview on June 4, 2015, in the PM with EMP18 confirmed this employee was pulled to other units in the hospital to work. EMP18 confirmed they were not cross trained for the other departments.

On June 5, 2015, a request was made for EMP1 to provide a listing of staff pulled to work in alternate nursing departments for the month of May 2015. The listing was provided for May 2 thru May 20, 2015.

EMP13 was reassigned to the BHU on May 2, 2015, and May 3, 2015, and May 12, 2015.
EMP15 was reassigned to the BHU on May 3, 2015.
EMP20 was reassigned to the BHU on May 2, 2015, and May 3, 2015, and May 16, 2015.
EMP21 was reassigned to the Behavioral Health Unit (BHU) on May 4, 2015, May 11, 2015, and May 15, 2015.
EMP22 was reassigned to the ICU on May 4, 2015, and May 10, 2015.
EMP23 was reassigned to the ICU on May 7, 2015.
EMP24 was reassigned to the BHU on May 11, 2015.
EMP25 was reassigned to telemetry on May 11, 2015.
EMP26 was reassigned to the ICU on May 12, 2015.
EMP27 was reassigned to the Emergency Department (ED) on May 7, 2015, May 13, 2015, and May 15, 2015.
EMP28 was reassigned to the ICU on May 14, 2015.
EMP29 was reassigned to the ICU on May 6, 2015. The DOICA for this employee for the ICU noted the following areas as N/A [not applicable]: PCA [patient controlled analgesia] Pump, Constavac, Suction Machine, Feeding Pump, CPM [continuous passive motion] Machine. There was a note on page 6 of the DOICA which stated "N/A [equals] areas that this nurse does not perform. This nurse helps with medication passes, answering call bells, [and] ADLs [activities of daily living] when floats to ICU setting. [EMP] currently does not take a patient assignment."

Each of the personnel files for the employees noted above was reviewed. EMP30 was unable to provide documentation the employees were oriented to the alternate nursing units.

EMP5 and EMP6 also confirmed there was no documentation the employees noted above were oriented to the units to which they were reassigned prior to the dates they were pulled to the nursing units.