HospitalInspections.org

The Condition of Governing Body was not met based on medical record review of 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10), interviews, review of Hospital policies. documents, and accepted standards of Maternal Newborn Nursing practice, the Governing Body failed to consistently (24 hours a day and 7 days a week) staff the Continuing Care Nursery (CCN, a nursery specially equipped and staffed to provide specialized services to newborns) with qualified Registered Nurses (RN) on 2/16/16 and 3/7/16. The unacceptable management of staffing problems resulted in the Hospital activating a plan to divert their laboring maternity patients to area birthing hospitals. These diversions created an unsafe setting for pregnant women and newborns because the Governing Body failed to consistently staff the CCN with qualified RN's to provide care in accordance with the Hospital's policies, procedures and maternal newborn standards.

Findings include:

1.) The Governing Body failed to assure an adequate number of qualified RN's to consistently staff and meet patient care needs of newborns in the CCN on 2/16/16 and 3/7/16.

The document titled Hospital Licensure, dated 3/24/13, indicated the Commonwealth of Massachusetts Department of Public Health licensed the Hospital with Obstetric Services that included a Level IB Nursery (CCN).

Refer to A-0057

2.) The Governing Body failed to assure that the Nursing Services provided adequate types and numbers of nursing care personnel to staff the CCN on 2/16/16 and 3/7/16, a qualified Charge Nurse on the night shift of 2/16/16 and failed to assure nursing care plans were developed and updated for 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10).

Refer to TAG: A-0385, Condition of Participation: Nursing Services

Based on medical records reviewed, 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10), interviews, review of Hospital policies and documents, the Chief Executive Officer (CEO) failed to assure that qualified Registered Nurses (RN) consistently (24 hours a day, 7 days a week) staffed the Continuing Care Nursery (CCN, a nursery specially equipped and staffed to provide specialized services to newborns). This failure resulted in the Hospital diverting (temporarily closing) its Maternal Newborn Services (Birth Center, Labor & Delivery Unit, Postpartum Unit and CCN), once in February 2016 and once in March 2016.

Findings include:

1.) A Letter of Complaint, received by the Department of Public Health, dated 2/19/16, indicated the Hospital placed the Maternity Services on diversion sometime on 2/16/16 to the morning of 2/17/16, due to lack of experienced nurses to staff the nursery.

The Surveyor interviewed RN #1 at 10:00 A.M. on 3/3/16. RN #1 said that the Hospital diverted maternity patients once (2/16/16) because if a baby became sick and required the CCN and the Hospital did not have qualified staff to care for the CCN babies on the evening and night shifts of 2/16/16.

The Surveyor interviewed the Maternal Newborn Service Interim Nurse Director at 10:30 A.M. on 3/3/16. The Maternal Newborn Interim Nurse Director said the staff called in sick because they were unhappy and because of new Hospital management cross-training requirements. The Maternal Newborn Service Interim Nurse Director said that a nurse with CCN competency and qualifications called in sick on 2/16/16 and the Hospital could not replace her with a similarly qualified nurse with competency to care for a CCN baby; therefore, the Hospital was on diversion of maternity patients. The Maternal Newborn Service Interim Nurse Director said that the Hospital diverted maternity patients from 11:00 P.M. on 2/16/16 to 7:00 A.M. on 2/17/16, according to Hospital policy.

Hospital policy titled Code Pre-divert for Maternity Services, dated 9/20/12, indicated a process when the Hospital temporarily diverted (temporary closure of the maternity unit) maternity patients to another birthing hospital when the Hospital could not accept patients due to unexpected personnel shortage.

The Surveyor interviewed the Obstetrics and Gynecology (OBGYN) Chief at 9:15 A.M. on 3/7/16. The OBGYN Chief said the Hospital diverted a woman in labor with a full-term baby to another birthing hospital because of nurse staffing issues in the nursery on 2/16/16.


The Surveyor interviewed the Associate Chief Nurse Officer and Maternal Newborn Interim Nurse Director at 9:20 A.M. 3/8/16. The Associate Chief Nurse Officer and Maternal Newborn Interim Nurse Director said that the Hospital diverted maternity patients again at 7:00 P.M. on 3/7/16 to 7:00 A.M. on 3/8/16 because the Hospital could not staff the CCN due to a nurse sick call and this was an on-going problem.

2.) The document titled Hospital Licensure, dated 3/24/13, indicated the Hospital was licensed to provide Obstetric services that included a CCN.

Continuing Care Nursery policies titled 1.) Umbilical catheter line, insertion and maintenance, dated 3/15/14; 2.) Nasogastric, orogastric feeding catheter insertion and use in the neonate, dated 6/10/14; 3.) Blood sugar assessment in the newborn and management of hypoglycemia, dated 6/10/14; 4.) Oxygen therapy for the newborn, dated 6/10/14; 5.) Care of the substance (drug) exposed newborn, dated 7/15/14; and 6.) Care of the newborn with apnea (breathing problem), dated 6/15/14 indicated the Hospital cared for newborns in a CCN, specially equipped and staffed to provide specialized services to newborns.

However,
1.) The Chief of Pediatrics said that the Hospital did not care for substance (drug) exposed newborns because of a lack of staff competency and lack of support services to care for these babies.

2.) The Surveyor interviewed Clinical Nurse Educator #1 at 10:00 A.M. on 3/4/15. Clinical Nurse Educator #1 said the Hospital transferred Patient #2 because the baby had an NGT placed for feeding and nursing staff could not care for a baby with an NGT due to lack of staff competency.

The Medical Record, dated at 12:02 A.M. on 3/2/16, indicated a Pediatrician transferred Patient #2 to a higher level of care hospital for feeding immaturity and need for a nasogastric (nose to stomach) tube (NGT) feedings.

Refer to TAG: A-0385, Condition of Participation: Nursing Services

Based on medical record review of 1 of 10 sampled patients (Patient #1) and interviews the Hospital failed to assure that performance improvement activities thoroughly investigated that Registered Nurse (RN) #2 and Pediatrician #1 did not follow the Hospital's maternity diversion plan on 2/16/16 to transfer Patient #1 when Patient #1 became sick on 2/16/16.

Findings include:

The Surveyor interviewed the Maternal Newborn Service Interim Nurse Director at 10:30 A.M. on 3/3/16. The Maternal Newborn Service Interim Nurse Director said she did not know if RN #3 notified the Nurse Supervisor and did not know why there was a breakdown in communication about the diversion plan to transfer sick newborns while the Maternal Newborn Service was on diversion. The Maternal Newborn Service Interim Nurse Director said the plan was to transfer any newborn that became sick during the time of diversion on 2/16/16. The Maternal Newborn Service Interim Nurse Director said Pediatrician #1 knew the plan.

The Surveyor interviewed RN #3 at 2:45 P.M. on 3/3/16. RN #3 said the Hospital was on diversion from 11:00 P.M. on 2/16/16 to 7:00 A.M. the following morning because a qualified CCN Charge nurse called in sick and the Hospital was unable to replace her with another qualified CCN Charge Nurse. RN #3 said she was the Charge Nurse on the night shift of 2/16/16 and told the Nurse Supervisor she was uncomfortable with assuming the Charge Nurse role because she was not trained.

Hospital policy titled Code pre-divert for maternity services, dated 9/20/12, indicated that the Maternity Charge Nurse would contact the Director of Maternity to inform the Hospital of a critical situation that was occurring on the unit.

The History and Physical indicated that Patient #1 was born at 4:07 P.M. on 2/16/16. Nurses Notes indicated RN #4 cared for Patient #1 from 11:15 P.M. on 2/16/16 to 6:52 A.M. on 2/17/16 (during the time that the Maternal Newborn Service was on diversion). The medical record indicated the Pediatrician did not transfer Patient #1 to a higher level of care hospital until 8:00 P.M. on 2/17/15.

The Maternal Newborn Service Interim Nurse Director said RN #4 agreed to care for Patient #1 because RN #4 was the more experienced nurse, RN #4 did not have the qualifications to care for a CCN baby and she (the Maternal Newborn Service Interim Nurse Director) did not talk to RN #4 about the assignment because RN #4 was not her employee. The Maternal Newborn Service Interim Nurse Director said RN #4 was an employee of the Birth Center.

The Condition of Nursing Services was not met based on medical record review of 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10), Hospital policies and documents, and accepted standards of Maternal Newborn Nursing practice, Nursing Services failed to assure that adequate types and numbers of nursing care personnel were provided, a qualified Charge Nurse was provided and nursing care plans were developed and updated.

Findings include:

1.) The Hospital failed to assure an adequate number of qualified Registered Nurses (RN) to consistently (24 hours a day, 7 days a week) staff and meet patient care needs of newborns in the Continuing Care Nursery (CCN, a nursery specially equipped and staffed to provide specialized services to newborns) on 2/16/16 and 3/7/16.

Refer to A-0386

2.) The Hospital failed to provide an RN, with appropriate Charge Nurse qualifications, education and training to supervise nursing personnel, respond to nursing needs and care of the newborns in the CCN on 2/16/16.

Refer to A-0392

3.) The Hospital failed to assure an RN developed and kept current a nursing care plans for each newborn, in a sample of 10 of 10 patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) transferred from the Hospital to a hospital with a higher level of care nursery (Neonatal Intensive Care Unit, NICU).
Refer to A-0396
4.) The Hospital failed to assure that they assigned nursing personnel with the appropriate education, experience, competence and specialized qualifications provided nursing care for Patients #1 & #2 in accordance with the individual needs of the newborn.
Refer to A-0397

Based on medical records reviewed, 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10), interviews, review of Hospital policies and documents the Hospital failed to assure an adequate number of qualified Registered Nurses (RN) to consistently (24 hours a day, 7 days a week) staff the CCN (CCN, a nursery specially equipped and staffed to provide specialized services to newborns).

Findings include:

The Surveyor interviewed RN #1 at 10:00 A.M. on 3/3/16. RN #1 said that the Hospital diverted (temporarily closing the Maternity service) maternity patients once (2/16/16) because the Hospital did not have enough nurses competent to care for CCN babies. Registered Nurse RN #1 said that the postpartum unit did not have enough nurses competent to care for newborns in the CCN. RN #1 said that the Hospital did not use the CCN as a CCN because the Hospital did not have enough nurses competent to care for newborns in the CCN. RN #1 said that the CCN was a level 1B (Hospital licensure designation for Maternity Services with a CCN) and the Hospital did not admit retro-transferred infants (required transfer for a higher level of care, no longer required the high level of care, and transferred back to the Hospital) because the Hospital did not have enough nurses competent to care for the CCN babies.


The Surveyor interviewed the Associate Chief Nurse Officer at 11:30 A.M. on 3/3/16. The Associate Chief Nurse Officer said the Maternal Newborn service had many human resource issues, leadership changes, and staff schedule changes. The Associate Chief Nurse Officer said some staff did not support changes in staffing patterns and the cross-training (training to a different and related unit) program. The Associate Chief Nurse Officer said that the Hospital minimally scheduled the Maternal Newborn Service with 1 CCN qualified nurse. The Associate Chief Nurse Officer sait if there was a sick call and the Hospital could not find a qualified replacement, the Hospital would divert maternity patients.

The Surveyor interviewed the Associate Chief Nurse Officer and Maternal Newborn Interim Nurse Director, at 10:30 on 3/3/6. The Associate Chief Nurse Officer and Maternal Newborn Interim Nurse Director both said that they make the work schedule to core staffing and use the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, professional organization) Guidelines for Professional Registered Nurse Staffing for Perinatal Units, dated 2010. The Associate Chief Nurse Director and Maternal Newborn Interim Nurse Director both said the issue was managing covering nurse sick calls. The Associate Chief Nurse Officer and Maternal Newborn Interim Nurse Director both said that the Hospital made phone calls to staff with similar skills to staff the nurse sick call and if no nursing staff was available, they needed to close the service. The Associate Chief Nurse Officer and Maternal Newborn Service Interim Nurse Director said that it was their model of nursing care and the responsibility of the CCN nurse was to stabilize (care for) the baby until transport to the higher level of care hospital (Neonatal Intensive Care Nursery, NICU).

The Surveyor interviewed RN #2 (Nursery Clinical Nurse Educator) at 10:44 A.M. on 3/4/16. RN #2 said the Hospital at times required her to take a patient care assignment when the unit was short staffed taking her from educating the nursery staff. RN #2 said the Hospital transferred Patient #2 because the baby had a nasogastric (nose to stomach) tube (NGT) placed for feeding and nursing staff could not care for a baby with an NGT.

Hospital policy titled Nasogastric, orogastric feeding catheter insertion and use in the neonate, dated 6/10/14 indicated the Hospital cared for newborns in a CCN, specially equipped and staffed to provide specialized services to newborns.

The Medical Record, dated at 12:02 A.M. on 3/2/16, indicated a Pediatrician transferred Patient #2 to a higher level of care hospital for NGT feedings.

The document titled Hospital Licensure, dated 3/24/13, indicated the Commonwealth of Massachusetts Department of Public Health licensed the Hospital with Obstetric Services that included a Level IB Nursery (CCN).

Based on interview and a Post-partum Assignment Sheet the Hospital failed to provide RN #3 with appropriate Charge Nurse qualifications, education and training to supervise nursing personnel, respond to nursing needs, and care of the newborns in the Continuing Care Nursery (CCN).

Findings include:

The Surveyor interviewed RN #3 at 2:45 on 3/3/16. RN #3 said that she was the Charge Nurse on the night shift of 2/16/16 because the regular Charge Nurse called in sick and was unable to work. RN #3 said the Hospital did not provide her with education on the Charge Nurse Role and responsibilities.

The document titled Post-partum Assignment Sheet, dated 2/16/16, indicated RN #3 was the Charge Nurse on the night shift of 2/16/16.

The Surveyor interviewed the Associate Chief Nurse Officer at 11:30 A.M. on 3/3/16. The Associate Chief Nurse Officer said that RN #3 did not have Charge Nurse training and she (Associate Chief Nurse) needed to schedule RN #3 for Charge Nurse training.

Based on medical records, 10 of 10 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) the Hospital failed to assure an Registered Nurse (RN) developed and kept current a nursing care plan for each newborn.

Findings include:

The Medical Record, for Patient #1, dated 2/16/16 through 2/17/16, indicated that an RN did not develop a plan of care.

The Medical Record, dated 2/29/16, for Patient #2 indicated that an RN did not individualized a plan of care when Patient #2, required specialized care needs in the Continuing Care Nursery (CCN) and for transport to a higher level of care hospital.

The Medical Record, dated 3/3/16, for Patient #3, indicated that an RN did not develop a plan of care when Patient #3 required specialized care in the CCN and for transport to a higher level of care hospital.

The Medical Record, dated 8/31/15, for Patient #4, indicated that an RN did not develop an individualized a plan of care when Patient #4 required specialized care needs in the CCN and for transport to a higher level of care hospital.

The Medical Record, dated 7/8/15, for Patient #5, did not indicate that an RN developed an individualized plan of care when Patient #5 required specialized care in the CCN and for transport to a higher level of care hospital.

The Medical Record, dated 7/9/15 and 7/10/15, for Patient #6, did not indicate an RN developed a plan of care.

The Medical Record, dated 8/6/15 through 8/8/15, for Patient #7, did not indicate an RN developed a plan of care.

The Medical Record, dated 10/27/15, for Patient #8, did not indicate an RN developed a plan of care.

The Medical Record, dated 2/7/16, for Patient #9, did not indicate an RN developed a plan of care,

The Medical Record, dated 2/9/16, for Patient #10, did not indicate an RN individualized a plan of care, when Patient #10 required specialized care in the CCN and for transport to a higher level of care hospital.

Based on review of medical records, 2 of 10 sampled patients (Patients #1 and #2) and interviews the Hospital failed to assure that nursing personnel with the appropriate education, experience, competence and specialized qualifications were assigned to provide nursing care for Patients #1 and #2 in accordance with the individual needs the newborn.

Findings include:

The Surveyor interviewed the Maternal Newborn Service Interim Nurse Director at 10:30 A.M. on 3/3/16. The Maternal Newborn Service Interim Nurse Director said that if a baby become sick during the time of diversion the plan was for an RN and the pediatrician to stabilize and transfer the baby to a higher level of care hospital. The Maternal Newborn Service Interim Nurse Director said Patient #1 became ill during the time of diversion, Pediatrician #1 did not transfer the baby according to plan, RN #3 did not notify the Maternal Newborn Service Interim Nurse Director or the Nurse Supervisor and a Birth Center RN who did not have Continuing Care Nursery (CCN) competencies cared for the baby. The Maternal Newborn Service Interim Nurse Director said she did not know why RN #3 did not notify her or the Nursing Supervisor.

The Surveyor interviewed RN #3 at 2:45 P.M. on 3/3/16. RN #3 said she was the Charge Nurse on the night shift of 2/16/16. RN #3 said RN #4 was a nurse that floated (usually worked in the Birth Center) to the unit. RN #3 said RN #4 cared for Patient #1 on the night shift of 2/16/16. RN #3 said that she did not know if RN #4 was qualified, to care Patient #1 who was now a sick baby.

The Maternal Newborn Service Interim Nurse Director said that RN #4 agreed to care for Patient #1 because RN #4 was the more experienced nurse, RN #4 did not have the qualifications to care for a CCN baby.

A Physician Note, dated 2/16/16 at 11:09 P.M., indicated that Patient #1 was born at 4:07 P.M. on 2/16/16. Nursing Note, dated 2/16/16 at 11:15 P.M. and documented by RN #4, indicated Patient #1's breathing rate was 80 to 90 times per minute (normal newborn breathing rate, 30 to 60 breaths per minute) and the Pediatrician transferred the baby to the CCN for continuous monitoring. Nursing Note, dated 2/17/16 at 1:07 A.M. and documented by RN #4, indicated that the Pediatrician recommended ongoing monitoring in the CCN. The Medical Record indicated RN #4 cared for Patient #1 from 11:15 P.M. on 2/16/16 to 6:52 A.M. on 2/17/16 (during the time that the Maternal Newborn Service was on diversion due to a lack of qualified nursing staff to care for sick newborn). The medical record indicated the Pediatrician transferred Patient #1 to a higher level of care hospital at 8:00 P.M. on 2/17/15.

The Surveyor interviewed RN #2 at 10:44 P.M. on 3/4/15. RN #2 said the Hospital transferred Patient #2 because the baby had a nasogastric (nose to stomach) tube (NGT) placed for feeding and nursing staff could not care for a baby with an NGT.

The Discharge Summary, dated at 12:02 A.M. on 3/2/16, indicated a Pediatrician transferred Patient #2 to a higher level of care hospital for feeding and need for NGT feedings.

Hospital policy titled Nasogastric, orogastric feeding catheter insertion and use in the neonate, dated 6/10/14 indicated the Hospital cared for newborns in a CCN, specially equipped and staffed to provide specialized services to newborns.

The Surveyor interviewed RN #2 at 10:00 A.M. on 3/4/15. RN #2 said she had more than 10 years' experience caring for babies that required neonatal intensive care and the Hospital hired her as an educator. Clinical Nurse Educator #1 said she did not have nurse educator experience.