The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PENN HIGHLANDS DUBOIS 100 HOSPITAL AVENUE DUBOIS, PA 15801 May 18, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility documents, and staff interviews (EMP), it was determined that the Governing Body failed to ensure that Nursing Services maintained an effective process to resolve/address staffing concerns of employees, failed to ensure that Nursing Services consistently assessed and analyzed compliance with adopted staffing grids, failed to ensure that Nursing Services analyzed patient events and patient related complaints which may have been associated with insufficient staffing (A0283), failed to ensure that Nursing Services documented that the supervision of all patients is by a Registered Nurse (A0395), failed to ensure that Nursing Services staffing schedules and staff grids contained consistent categories of nursing personnel (A0386), failed to ensure Nursing Services provided sufficient numbers of Registered Nurses and/or auxiliary staff for all shifts (A0392), failed to ensure that Nursing Services executed patient care assignments that were commensurate with the qualifications of nursing staff assigned to patients (A0397).

Findings include:

A review of Penn Highlands DuBois Plan for The Provision of Patient Care, 2015/2016, approved December 15, 2015, revealed, "... This framework allows for defining timely and clear goals as well as allocating adequate human, space, and other resources and appropriately directing activities to achieve these goals with the intent of responding to community and patient needs ... PH DuBois leadership assures that as part of the annual budget process, the necessary components are considered to ensure that appropriate financial support and resources are allocated to satisfy the Plan ... Customer Service Excellence ... Collaboration--Developing a sense of ownership within the organization and a commitment to co-workers to focus on patient care quality, providing a safe environment for patients and staff and to deliver an exceptional level of service ... The following strategies describe how PH DuBois works to achieve its vision ... 4. Employee/Employer Problem Resolution Program: An effective process is maintained to resolve employee problems and issues, starting with leadership intervention and ultimately use of "Problem Solving Procedures", when needed ... VI. Planning and Design for Provision of Patient Care ... Sources of Information used for determining the organization's priorities include, but are not limited to ... Employee and physician satisfaction data (AHRQ Staff Patient Safety Survey) ... B. Planning and Resource Allocation. The strategic plan, operating and capital budget, and programmatic plans are reviewed at least annually to assure that the organization's mission is consistently supported over time. Priorities are determined and resources are allocated during the annual budgeting process to support these priorities. The Board approves the annual operating budget and capital expenditure plan. The following factors are considered when formulating departmental/organization budgets to assure that the Plan for the Provision of Patient Care is satisfied: 1. The needs of the various patient populations and their implications for staffing. 2. The organization's ability to recruit and retain appropriate staff. 3. Departmental staffing variance reports. 4. Performance improvement data and outcomes. 5. The need to provide one level of care to patients through the organization. 6. Opportunities to improve patient care quality, service delivery, or systems and processes based on input from patient satisfaction data, physicians, employees, and other constituencies. 7. Other factors that may be identified on an ongoing basis. 8. Patient safety improvement activities ... D. Uniform Patient Care Processes. PH DuBois ability to provide uniform patient care processes is achieved by a systematic approach to performance improvement (described in the Performance Improvement Plan), consistency in plans, policies and procedures throughout the organization, staff competencies and planning for their learning needs (described in the Human Resources Plan), and the medical staff credentialing mechanisms (described in the Medical Staff Bylaws). PH DuBois believes that patients with the same health problems and care needs have a right to the same level and quality of care throughout the organization ... Acuity of the patients condition determines the resources allocated to meet the patients needs. Each department has a written defined scope of service and provides patient care in accordance with their scope of service ... E. Consistency in Plan, Policies, Procedures ... Patient care policies and procedures describe how the care needs for patient populations are assessed and met, address the care provided to patients/families, and show consideration of: Type (s) of age (s) of patients served. The scope of complexity of the patients care needs. The extent to which the level of care or service provided meets the patients needs. The appropriateness, clinical necessity, and timeliness of support service provided directly by PH DuBois or through referral contracts. The availability of necessary staff. Recognized standards or guidelines for practice, when available. Methods that are used to assess and meet patient care needs. Methods that are used to assess and meet patient safety needs. F. Investment in PH DuBois Workforce. For the last 5 years, PH DuBois has invested in workforce development in a planned way. Staffing capability in all services is evaluated on an ongoing basis to determine whether it is sufficient to meet the needs of the growing organization. 1. Registered Nurse hiring is a top priority due to increasing patient volumes and acuity, and to support the arrival of new physicians/ start of new services that require nursing services ... 2. Support caregivers such as Patient Care Tech and Unit Secretary positions have been added in many clinical patient care departments to support the growth of and complexity in the work requirements ... G. Staffing Effectiveness and Competencies. PH DuBois ability to provide for the needs of its patients as defined in the hospital's mission and the Plan for the Provision of Patient Care is directly related to the ability to recruit and retain the number and type of qualified, competent staff needed to provide safe and effective patient care ... H. Staffing Effectiveness. The staffing effectiveness plan covers direct care providers for PH DuBois inpatient services. Those inpatient services include: At PH DuBois West Unit: Cardiovascular Unit. Rehabilitation Unit. Joint Center of Excellence. Pediatrics Unit. Third Floor Medical/Surgical Unit. Progressive Care Unit. Intensive Care Unit. Obstetrics (Maternity & Nursery). Neonatal Intensive Care Unit. At PH DuBois East Unit: Adolescent Behavioral Health Unit. Adult Behavioral Health Unit. Flex Behavioral Health Unit. Objectives: 1. To assess staffing effectiveness defined as the number, competency, and skill mix of staff related to the provision of needed services. 2. To identify potential areas for improvement. Plan: The leaders of PH DuBois have identified staffing effectiveness as one of the performance improvement priorities ... The department managers are responsible for managing their staffing effectiveness on an ongoing basis ... VIII. Definition of Patient Services/Patient Care/Patient Support ... Patient care services are planned, coordinated, provided, delegated, and supervised by health care professionals who possess the knowledge and skills to identify and meet the individual's needs ... X. Scopes of Service/Staffing Plans ... The staffing plans for patient care/service departments have been developed based on the level of scope of care, the frequency and complexity of care, the patient population, and the education and skill level of the staff needed to provide such care. Each patient care/service department has a base staffing plan based on average daily census, volume, hours per patient day or departmental specific measure. Support departments staffing plans are based upon departmental responsibilities and hours of operation. Staffing plans are reviewed at least annually during the budget process giving consideration to utilization, performance improvement activities, employee turnover, changes in customer needs/expectations, and anticipated changes in actual service. XI. Responsibilities of Leadership. PH DuBois leadership, defined by the Board of Directors, Senior Management, physician leadership, and departmental leaders, is responsible for: ... 5. Establishment of standards of care that all patients can expect and which are monitored through the organization's Performance Improvement Plan. The Performance Improvement Plan is designed to provide a systematic way to continually improve PH DuBois services. 6. Ensure uniform delivery of care throughout the organization, in any department providing services. 7. Providing opportunities for staff development and increased staff satisfaction to promote retention of staff and promote excellence in care delivery and support services ... 9. Ensuring adequate competency staffing resources to meet the needs of the patients served ... XVIII. Review of Plan. The Hospital Plan for the Provision of Patient Care is reviewed annually and revised in response to: Priority patient care/community needs ... Staffing needs. Budget variance information ... ."
Attached to above was the "Addendum D Penn Highlands DuBois Plan for the Provision of Nursing Care 2015/2016" approved December 15, 2015, revealed "... II. Organization. The department of nursing is organized to meet the nursing care needs of patients and to maintain the established standards of practice. The structure is designed to provide delineation of responsibility that assures patients with similar nursing care needs receive the same level of nursing care throughout the hospital and that the patient care at the unit level is under the direction of an RN ... The Plan for the Provision of Nursing Care is reviewed annually and revised as necessary. Review of resource requirements is done as part of the annual budget process and is evidenced by budget requests/changes in those resources. Consideration is given to the following elements: ... Patient requirements for nursing care ... Existing and proposed patient care programs ... Changes in patient populations, acuity, and other clinical factors ... Review of staffing effectiveness and productivity data ... ."

1. A review of the Board Quality Oversight Committee meeting Minutes dated December 11, 2015, revealed the 2015/2016 Plan for Provision Of Pateint Care was presented and approved.

2. A review of Governing Body Meeting Minutes revealed the following:

November 17, 2015. ... Finance/Audit and Compliance Committee, ... Salaries: Continues very close scrutiny of requests for new or replacement staffing along with tight control over overtime use. FTEs continue to be under budget by a sizeable amount. ... .

December 15, 2015. ... Finance/Audit and Compliance Committee, ... Salaries: Staffing levels continue to be monitored very closely and FTE levels are under budget by a sizable amount. ... .

January 19, 2016. ... Finance/Audit and Compliance Committee, ... Salaries: Continues to be under budget by a large amount as our FTE count is under budget by 140. ... Professional Fees: Locum fees are increased in several areas including Hospitalists, Emergency Department, Neonatology and GI. Also, Agency Nursing is over budget due to the need for additional RNs. ...

February 16, 2016. ... Finance/Audit and Compliance Committee, ... Professional Fees: Primarily from the use of locum physicians in the following clinical settings: Hospitalist, Emergency Department, Neurology and General Surgery. Also, the need for Agency Nursing continues as we have open RN positions in numerous departments. ...

April 19, 2016. ... Salaries: RNs under budget by nearly $200,000, we were over budget in professional positions (Pharmacy and CRNAs) as well as physicians salaries netting to a slight variance from the budget. Professional Fees: use of locum physicians in the Emergency Department, Neurology and Hospitalist program along with continued use of Nursing Agency contributed to this variance.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of facilty documents and staff interviews (EMP) it was determined that Penn Highlands DuBois failed to follow their adopted Plan for the Provision of Patient Care, failed to follow their adopted Quality Assessment Improvement Plan, failed to follow their adopted Patient Rights Policy, and other facility policies, by failing to maintain an effective process to resolve staffing concerns by failing to analyze and address concerns of employees related to staffing, by limiting hospital staff access to the event reporting process and Administrator On Call, with concerns related to insufficient staffing, by failing to consistently meet their adopted staffing grids, and by failing to analyze patient events and patient related complaints which may have been associated with insufficient staffing.

Findings include:

A review of the facility policy entitled Rights & Responsibilities-Patient, dated February 2015, "... The patient has the right to good quality care and high professional standards that are continually maintained and reviewed ... The patient has the right to expect good management techniques to be implemented within the hospital considering effective use of the time of the patient and to avoid the personal discomfort of the patient ... ."

A review of facility Quality Assessment Performance Improvement Plan FY 2016, revealed, "... The Quality Assessment and Performance Improvement Plan (QAPI) provides a framework for promoting and sustaining performance improvement at Penn Highlands DuBois in order to achieve excellent, safe, patient centered, cost effective care ... The QAPI Plan has been designed as a mechanism to assure : ... Patient care is objectively and systematically monitored and evaluated in relation to current standards of care ... Opportunities to continuously improve patient care and services are pursued ... Identified problems are systematically investigated and resolved ... The Board of Directors has the ultimate responsibility for performance improvement and for assuring quality patient care. To fulfill this commitment, the Board relies on the support and collaboration of senior/executive leadership, directors, medical staff and employees. The Board of Directors ensures the following ... That clear expectations for safety are established. That adequate resources are allocated for measuring, assessing, improving and sustaining the hospitals performance and reducing risk to patients ... Patient Services: The Chief Nursing Officer or designee, together with the Patient Services Team, has the ultimate responsibility for advancing those aspects of patient experience ... and healthcare associated adverse events ... The Nursing Director/Executive Council is comprised of the Chief Nursing Officer, Nursing Directors, and Ancillary Directors/ Council Chairs, is responsible for ... 3. Development, implementation, and monitoring of plans to address QAPI opportunities ... 5. Reviewing events for patterns and trends including the impact of staffing effectiveness. 6. Reviews results of QAPI Teams such as Falls ... The Nursing Practice Quality Council (NPQC) is comprised of bedside patient cares, along with some Patient Services leaders who function in the role of council advisors, brings the perspective of the practicing patient care nurse. NPQC reports up to the Nursing Executive Council. NPQC performs the following as it relates to quality: 1. Reviews results of nursing sensitive indicators. Develops strategies to improve performance. 2. Identifies Performance Improvement opportunities and develops and implements plans to improved. Examples include: patient handoff, patient flow, etc ... Performance Improvement Priorities ... Priorities are based on the Mission, Vision and Strategic Plan for Penn Highlands DuBois. During planning, the following are given priority consideration: Processes that affect a large percentage of Penn Highlands DuBois patients. Processes that place patients at risk if not performed well, if performed when not indicated or if not performed when they are indicated. Processes that have been or are likely to be problem-prone ... Because Penn Highlands DuBois is sensitive to the ever changing needs of the organization, priorities may be changed or re-prioritized due to: Identified needs from data collection and analysis. Unanticipated adverse occurrences affecting patients ... Significant needs of patients and/or staff. Changes in the environment of care ... ."

A review of Penn Highlands DuBois Plan for The Provision of Patient Care 2015/2016, approved December 15, 2015, revealed, "... This framework allows for defining timely and clear goals as well as allocating adequate human, space, and other resources and appropriately directing activities to achieve these goals with the intent of responding to community and patient needs ... PH DuBois leadership assures that as part of the annual budget process, the necessary components are considered to ensure that appropriate financial support and resources are allocated to satisfy the Plan ... Customer Service Excellence ... Collaboration--Developing a sense of ownership within the organization and a commitment to co-workers to focus on patient care quality, providing a safe environment for patients and staff and to deliver an exceptional level of service ... The following strategies describe how PH DuBois works to achieve its vision ... 4. Employee/Employer Problem Resolution Program: An effective process is maintained to resolve employee problems and issues, starting with leadership intervention and ultimately use of "Problem Solving Procedures", when needed ... The following factors are considered when formulating departmental/organization budgets to assure that the Plan for the Provision of Patient Care is satisfied: 1. The needs of the various patient populations and their implications for staffing. 2. The organization's ability to to recruit and retain appropriate staff. 3. Departmental staffing variance reports. 4. Performance improvement data and outcomes. 5. The need to provide one level of care to patients through the organization. 6. Opportunities to improve patient care quality, service delivery, or systems and processes based on input from patient satisfaction data, physicians, employees, and other constituencies. 7. Other factors that may be identified on an ongoing basis. 8. Patient safety improvement activities ... PH DuBois believes that patients with the same health problems and care needs have a right to the same level and quality of care throughout the organization ... Acuity of the patient's condition determines the resources allocated to meet the patient's needs. Each department has a written defined scope of service and provides patient care in accordance with their scope of service ... E. Consistency in Plan, Policies, Procedures ... Patient care policies and procedures describe how the care needs for patient populations are assessed and met, address the care provided to patients/families, and show consideration of: Type (s) of age (s) of patients served. The scope of complexity of the patients care needs. The extent to which the level of care or service provided meets the patients needs ... Staffing capability in all services is evaluated on an ongoing basis to determine whether it is sufficient to meet the needs of the growing organization ... G. Staffing Effectiveness and Competencies. PH DuBois ability to provide for the needs of its patients as defined in the hospital's mission and the Plan for the Provision of Patient Care is directly related to the ability to recruit and retain the number and type of qualified, competent staff needed to provide safe and effective patient care ... H. Staffing Effectiveness. The staffing effectiveness plan covers direct care providers for PH DuBois inpatient services ... Objectives: 1. To assess staffing effectiveness defined as the number, competency, and skill mix of staff related to the provision of needed services. 2. To identify potential areas for improvement. Plan: The leaders of PH DuBois have identified staffing effectiveness as one of the performance improvement priorities ... The Department Managers are responsible for managing their staffing effectiveness on an ongoing basis ... X. Scopes of Service/Staffing Plans ... The staffing plans for patient care/service departments have been developed based on the level of scope of care, the frequency and complexity of care, the patient population, and the education and skill level of the staff needed to provide such care. Each patient care/service department has a base staffing plan based on average daily census, volume, hours per patient day or departmental specific measure ... Staffing plans are reviewed at least annually during the budget process giving consideration to utilization, performance improvement activities, employee turnover, changes in customer needs/expectations, and anticipated changes in actual service. XI. Responsibilities of Leadership. PH DuBois leadership, defined by the Board of Directors, Senior Management, physician leadership, and departmental leaders, is responsible for: ... 5. Establishment of standards of care that all patients can expect and which are monitored through the organization's Performance Improvement Plan ... Ensure uniform delivery of care throughout the organization, in any department providing services ... 9. Ensuring adequate competency staffing resources to meet the needs of the patients served ... XVIII. Review of Plan. The Hospital Plan for the Provision of Patient Care is reviewed annually and revised in response to: Priority patient care/community needs ... Staffing needs. Budget variance information ... ."

Attached to above was Addendum D, Penn Highlands DuBois Plan for the Provision of Nursing Care 2015/2016, approved December 15, 2015, revealed, "... II. Organization. The department of nursing is organized to meet the nursing care needs of patients and to maintain the established standards of practice. The structure is designed to provide delineation of responsibility that assures patients with similar nursing care needs receive the same level of nursing care throughout the hospital and that the patient care at the unit level is under the direction of an RN ... The Plan for the Provision of Nursing Care is reviewed annually and revised as necessary. Review of resource requirements is done as part of the annual budget process and is evidenced by budget requests/changes in those resources. Consideration is given to the following elements: ... Patient requirements for nursing care ... Changes in patient populations, acuity, and other clinical factors ... Review of staffing effectiveness and productivity data ... ."
A review of the facility policy entitled Staffing Concern Notification, dated November 2015. "Purpose: To provide a mechanism for Patient Services staff to communicate staffing concerns to Nursing Administration. Policy: 1. Employees may communicate staffing concerns of any kind to Nursing Administration on the "Staffing Concern Notification Form" ... 2. The Department Director discusses the staffing concern with the employee, including their ideas for solutions, and evaluates the situation that occurred. 3. The Department Director takes appropriate action as needed to respond to the staffing concern, with the focus on achieving long term solutions. 4. All "Staffing Concern Notification" forms are reviewed by the Vice President/Chief Nursing Officer for trending analysis and need for further action. Additionally, this information is analyzed as needed as part of the "Staffing Effectiveness Plan. ... ."

A review of the facility policy entitled Patient Safety-Event Reporting System, reviewed October 2015, was conducted and revealed, "Purpose: ... To promote open channels of communication throughout all levels within the organization on an as needed basis ... ."

A review of the facility policy entitled Patient Safety-Event Reporting System, reviewed April 2016, revealed, "Purpose: To enhance the quality of patient care, To promote a safe (risk-reduced) environment for that care ... To achieve consistency in the method of reporting, To serve as an information base for devising corrective measures to preclude reoccurrence, To target problem prone areas through effective trend analysis, to promote open channels of communication throughout all levels within the organization on an as needed basis ... ."
A review of the facility policy entitled Administrative Call Coverage, dated February 2015, revealed, "Purpose: To provide hospital staff, physicians and others access to administrative support at all times. Policy: During routine hours and days of operations, the organizational chain of command is followed in matters requiring administrative and management support. Support after hours, on weekends and holidays, and at any other time when on-site administrative resources are not available, the Administrator-on-Call is contacted an utilized. ... All calls to the Administrator-on-Call are first placed to the Nursing Supervisor who determines if the matter requires administrative intervention. If the Nursing Supervisor determines that the Administrator-on-Call should be contacted, he/she advised the hospital's Switchboard Operator to contact the Administrator-on-Call. The Nursing Supervisor may all contact the Administrator-on-Call directly ... ."
A review of the facility Memo dated January 18, 2016, related to 'Post Fall Huddle' revealed "... The Fall Team has been reviewing the recommendations and determined an area of opportunity is our current post fall management. The Post Fall Huddle was designed to allow transparent reporting and trending analysis of falls which in turn help make process improvements. The huddle form is a real time assessment of the fall and circumstances surrounding the event. Our goal is to have the huddle conducted by the Shift Supervisor or Clinical Manager with staff members involved in the patient's care ... ."

A review of The Huddle Report revealed this is the reporting of an inpatient fall, unit, date, time, assessment and action. It also includes a series of questions, was call light on, was safety-fall initiated, bed/chair alarm set, any items out of reach, was patient trying to get to bathroom, anxiety medication, BP Meds, diuretics, narcotics, sleepers, family notified and Provider notified.

1. A review of approximately 16 Staffing Concern Notification Forms, dated January 2, 2016-April 16, 2016, which were provided to surveyors was completed. It was noted that 14 of the 16 forms did not document current/immediate action related to the staffing/patient safety concerns, which were received by staff. The forms revealed the following:

Staffing Concern: 1-2-15 (2016 written in) ... Department: 3rd Flr. Shift: 7P-7:30AM, "... Came on with 4 RN - 1 PCT- No Charge Nurse- 4 admits on Board, when we walked on ... Communicated Staffing Concern To: ... House Supervisors ... Response to Staffing Concern. Department Director Assessment/Action: Starting Census 16 ...Staffing Model calls for 3RN/ (no) PCA. Staffing @ 20 pts = 4 RNs & 1 PCA. Additional PCA position added to unit start date 3/21/16. Staff encouraged to work together as a team to deliver patient care ... ." It was noted that this form was signed by the Department Director on March 17, 2016, Assistant VP, Patient Services on March 17, 2016, and by the VP Patient Services on March 21, 2016.
Staffing Concern: 3/7/16 ... Department: PCU. Shift: 7A-7P ... 9 pt - with 4 pt by self (No PCT) and orientee - unsafe ... Response to Staffing Concern. Department Manager Assessment/Action: Unit Director worked as Chg RN/assisting patients , families, & staff all day. Department Manager Follow-Up with Employee: All staff called & texted (without) success." It was noted that the Department Director signed the form on March 7, 2016, the Assistant VP Patient Services signed the form on March 14, 2016, and the VP Patient Services signed the form on March 15, 2016.
Staffing Concern: 3/3/16 ... Department: 3rd Floor. Shift: 7P-7A ... The floor had 3 nurses for 23 pts. The one nurse was not a base nurse. Providing care was maxed. You can't meet all pts needs. One aid (sic) is new and never oriented to Night shift. I had 2 pts that required 2 full bed changes along with bed baths. Pts had multiple wounds that needed to be changed and they didn't get done on time ... Department Director Assessment/Action: LPN call off ... PCA had orientation to night shift for one night and was sick ... other scheduled orientation days. Orientor felt ... would be ok (with) guidance. Department Director Follow-Up with Employee: Based staffing for 23 pts 4RN's 2 PCA. 7-11p 3 RNs 1 LPN (OB) 2 PCA. 11p-7a 3 RN's 2 PCA. All calls, texts, & alerts sent out. Actively hiring nurses this has been communicated to staff. The form was noted to be signed by the Department Director on March 17, 2016, the Assistant VP Patient Services on March 17, 2016, and the VP of Patient Services on March 21, 2016.
Staffing Concern: 3/7/16. Department: PCU. Shift 7A ... 8-9 patients per RN today (with) one PCT 2 of my patients are having acute MI's ... Two families very upset (with) how things are being done here, doctors, etc. Make that 3 pts. have to Life Flight a pericardial effusion out today. GI bleed patient that's been receiving (sic) blood & having low BPs. Absolutely unsafe for all employees & patients ... Sentinel event just waiting to happen ... Department Manager Assessment/Action: Department Manager on floor all day & Charge RN and assisting patients & family members. Department Manager Follow-Up with Employee: All staff called/texted. The form was noted to be signed by the Department Director on March 7, 2016, the Assistant VP Patient Services on March 14, 2016, and by the VP Patient Services on March 15, 2016.
Staffing Concern: 1900-0730 ... Department: 3rd floor ... 3/2/2016 ... Started (with) 9 patients then received (sic) 2 stroke admission. Ended (with) 10 pts. High acuity patients ... Patients not receiving the care they deserve... 3 new nurses running night shift ... Department Director Assessment/Action: Calls, texts & alerts sent out. Active recruitment of nurses occuring. Agency staff is being utilized. Spoke with ... about this night as ... said it was very busy but everything was under control and staff worked together. The form was noted to be signed by the Department Director on March 17, 2016, the Assistant VP Patient Services on March 17, 2016, and the VP of Patient Services on March 21, 2016.
Staffing Concern: 3rd Floor ... Date of Staffing Concern: 1/8/16 to 1/9/16. Department: Nursing Float Pool. Shift: 19:00 to 07:30 ... I started with 20 pts when I came in and got 6 admissions. I can't take care of that many pts by myself. I did receive help at approx 0000 ... Department Director Assessment/Action: Additional PCA positions have been added to the unit (3 new hires started) All PCA's positions are filled ... Department Director Follow-Up with Employee: PCA assignments have been decreased to 15/PCA. RN's/LPN's provide primary care to other patients. The form was noted to be signed by the Department Director on March 17, 2016, the Assistant VP Patient Services on March 17, 2016, and the VP of Patient Services on March 21, 2016.
Staffing concern: 2-1 (to) 2-2. Department: PCU. Shift: Night ... Only aide for 32 people with 5 RNs. Very busy patients ... Department Manager Assessment/Action: All attempts made to find additional staff (without) success. The form was noted to be signed by the Department Manager on March 3, 2016, the Assistant VP Patient Services on March 14, 2016, and by the VP Patient Services on March 15, 2016.
Staffing concern: 3/11/16/3/12/16 7P-7A. Department PCU ... Started with 6 pts with one being a CVU transfer. Got a 7th patient by 8pm. One patient receiving blood during by shift. Had a pt w/extensive wound care. Meds being given late and having to wake patients up to assess & give meds. Worried I would be unable to get to bed alarms in time and have an increased safety risk. I feel surveys will go down in satisfaction because of not receiving as thorough care and call bells taking extra time to be answered. Worried if a code or RRT & only 3 nurses on the floor ... Department Manager Assessment/Action: Aware of staffing needs-have made CNO & VP PCS aware of staffing concerns ... It was noted the form was signed by the Department Manager and Assistant VP Patient Services on March 14, 2016, and the VP Patient Services on March 15, 2016.
Staffing Concern: 1/30/16. Department: PCU. Shift: 7A-7P ... Having 7 patients when I have been on Dayshift for a week and a half. I am afraid if bed alarms are going off, I won't be able to get to them in time. I have a dialysis pt which I have to transport myself ... I am still learning this shift and feel this is a safety concern ... Department Manager Assessment Action: ... First day scheduled for Dayshift ... very busy but not unsafe. These days are very overwhelming for staff on PCU. Department Manager Follow-Up with Employee: The following staff voiced their concerns for staffing over the weekend ... Director review their concern with each one. The form was noted to be signed by the Department Director on February 3, 2016, the Assistant VP Patient Services on February 3, 2016, and by the VP of Patient Services on February 8, 2016.
Staffing Concern: 3/1/16. Department 2nd Floor. Shift 7P-7A ... not able to answer call bells in a timely manner, medications were given late ... Department Director ... All calls made-unable to meet base staffing ... ." The form was noted to signed by the Department Director on March 3, 2016, the Assistant VP Patient Services on March 14, 2016, and the VP Patient Services on March 15, 2016.
Staffing Concern: March 11, 2016: ... PCU. Shift: 7p-7a. Census 23 ... 7 pt run. 1 pt non-compliant-trying to leave, get OOB. Needed 1:1. Another pt needing wound care (extensive). 1 pt HR ... 160. An admission. Too many pts for 1 nurse. Unsafe-unable to get to pts in a timely manner. Unable ... to pass meds on time. Delay in pt care. Unable to get pt's pain meds in timely manner. Pt satisfaction (down) when aren't able to answer call bells/fulfill needs/pass meds in timely manner ... You also don't have enough time to ambulate pt's or provide all the care you want to because by the time you are done assessing & passing meds it's 12AM & pt's are sleeping ... Aware of current staffing situation, all call, texts and alerts sent to attempt to get additional staff. No success. VP PCS & CNO aware of current staffing situation." The form was noted to be signed by Department Director on March 14, 2016, the Assistant VP Patient Services on March 14, 2016, and the VP Patient Services on March 15, 2016.
Staffing Concern: March 11, 2016: ... 3rd Floor. Shift 7P-7A. Census: 23 ... Went to 3rd floor had 2 RN and 1 LPN for a total of 23 pts. 8 for 1 RN, 8 for LPN, & 7 for 1 RN ... Response to Staffing Concerns ... 3F had 2 agency RNs call off at 1700 pm for 3F. Had to make the best of a bad situation ... ." The form was noted to be signed by the Department Director of March 14, 2016, the Assistant VP Patient Services on March 14, 2016, and the VP Patient Services on March 15, 2016.
Staffing Concern: April 8, 2016: ... PCU. Shift 7A-3P ... 4 RNs for 26 patients ... unsafe nurse to patient ratio ... Response to Staffing Concerns ... All attempts made to acquire additional staff. No success ... Required: 5 RNs-5th RN in at 11AM. 2PCAs-had 2 PCAs. 1US-had 1, 1 MT-had 1. This form was noted to be signed by the Department Director on April 11, 2016, the Assistant VP Patient Services on April 22, 2016, and the VP Patient Services on April 29, 2016.
Staffing Concern: April 8, 2016: ... PCU. Shift 7A-7P ... 4 RNs (with) 26 pts (6-7) 2 PCT's originally (1 rehab, 1 reg staff) ... PCT (rehab-orientee- pulled to OA ... Response to Staffing Concern ... All attempts made to acquire additional staff (without) success ... Required: 5 RNs-5th RN in at 11AM. 2PCAs-had 2 PCAs. 1US-had 1, 1 MT-had 1. This form was noted to be signed by the Department Director on April 11, 2016, the Assistant VP Patient Services on April 22, 2016, and the VP Patient Services on April 29, 2016.
2. A review of a Memorandum, revealed, "To: Clinical Managers CC: ... From EMP5 Date: 10/10/2014. Re: Staffing and Beds. This memo is to provide clear understanding on how communication regarding staffing needs is to be handled. There has been a long standing practice of notifying the Administrator on Call of tight staffing situations. This practice is now to be discontinued. When a Unit requires additional staff due to high patient census or staff vacancies that cannot be met by re-assigning staff from an area that has more than sufficient staff scheduled, the Unit Director is to be notified. If needed, the Unit Director may have to come in to cover his/her Unit. If the staffing situation is believed to still be critical, then the appropriate Assistant Vice President is to be notified, and the CNO. Nurse staffing is nursing's responsibility. The Administrator on Call is not in a position to provide a solution. The solutions come from Nursing Leadership. Communication to nursing staff regarding staffing needs should be handled in as positive a manner as possible. Comments such as, "you'll need to hold admissions tonight," are not appropriate. If asked, please reply with something like, beds are tight, I'm sure we will work something out. Since the creation of the Penn Highlands Healthcare System, we have realized an increasing number of referrals for inpatient admission. At times this presents challenges in managing the increasing patient census and staffing. By working together, we are able to manage this and present it in a positive manner to our nursing staff. If you have any questions, please feel free to contact me."

An interview was conducted with EMP37. "... we're not allowed to call the Administrator On Call with staffing issues ... ."

3. A review of Events/Incidents dated January 1, 2016, through present was conducted. Topics of discussion included but were not limited to: Medication Errors, Falls, Transfers, Skin Integrity and Unsafe Staffing. During review, it was noted staff filed 3 Event Reports in March 2016, related to 'Unsafe Condition' of staffing on Units.

An interview with EMP18 revealed, "Staff are not supposed to enter staffing issues in the RL system (event reporting) as per EMP5 ... They (staff) were directed to put their staffing concerns on paper Staff Concern form."

3. Following review of approximately 146 shift increments (which included Assignment Sheets, Staffing Documents, and Staffing Grids) for the West Campus Nursing Units (Progressive Care Unit, Third Floor Medical/Surgical, Intensive Care Unit, Neonatal Intensive Care Unit, Obstetrics, Cardiovascular Unit, Rehab, Joint Center, Emergency Department, and Pediatrics), with representatives from Patient Services, it was noted that approximately 77 of the 146 shifts did not meet their adopted staffing grid for RN's and/or PCA's, and/or Unit Secretaries.

4. A review of Nursing Practice Quality Council Meeting Minutes dated December 17, 2015, January 21, 2016, March 17, 2016, and April 21, 2016, was completed, and revealed that the minutes did not reflect any assessment related to the Staffing Concerns received by employees or of failing to consistently meet adopted staffing grids.

5. A review of Patient Care Operations Council Meeting Minutes, dated November 11, 2015, January 13, 2016, March 9, 2016, and revealed the minutes did not reflect any assessment related to the Staffing Concerns received by employees or of failing to consistently meet adopted staffing grids.
6. A review of facility Huddle Reports dated January 26, 2016 to March 31, 2016, was conducted. The review revealed a "Huddle Report" dated January 30, 2016, that a patient fall occurred on Unit 3 at 13:50. Assessment revealed the bed alarm had been on earlier in the day and was turned off somehow. The action revealed, 'need better staffing both RNs and HCAs/continue fall precautions'."

A review of a facility document dated January 30, 2016, revealed the patient was found on the floor beside bed laying on left side. Contributing factors reported included insufficient staff, and that there was one Patient Care Assistant on the floor for 24 patients. Documentation indicated that staffing guidelines were not met for this day.

An interview with EMP18 confirmed that the fall noted above to have occurred on January 30, 2016, was discussed at the February 9, 2016, Fall Team Meeting. The minutes stated, "... January Fall Review... Med/Surg. Patient was found on floor beside bed lying on side. The patient had a small abrasion on knee but did not need treatment of any kind and was placed back into bed. It is unclear what caused the fall ... ." There was no discussion related to insufficient staffing.

A review of a facility document, dated April 10, 2016, revealed that the patient was ordered an observation assistant (one on one). Documentation indicated that multiple admissions were occurring and the Observation Assistant left the patient's room to answer the phone, and the patient flung self over bed rail and landed on the floor. Documentation indicated that the remainder of the staff were assisting with the intubation in another room, and getting an admission settled. Surveyors subsequently requested the Fall Huddle Form, and one was not received.

A review of the ICU Staff Assignment Sheet for April 10, 2016, was reviewed with EMP22, and revealed that for the shift 7P-7A, the shift was short a Patient Care Assistant, and EMP22 confirmed that no one was at the desk. EMP22 also confirmed that there should have been a Huddle form completed.

8. A review of the Grievance Log for Quarter 1, 2016, was completed. It was noted that there were three patient related Grievances related to staffing.
A review of the Grievance filed on February 8, 2016, related to the Progressive Care Nursing Unit and Staffing Levels, was completed. It was noted that this Grievance was forwarded to Patient Services staff for review. There was no documented investigation by Patient Services Staff, related to the allegations of insufficient nursing staff.
9. An interview was conducted with EMP5, "... We've received 10 Staffing Concern forms in the last three months ... we have seen more falls. The census has been up in the last two months. We have had more patient complaints on the 2nd and 3rd floor ... ."

10. An interview was conducted with EMP5. "Regarding the staffing concern forms, Staff can fill them out. Sometimes, they do them the day their concern occurred. They don't always come in real time. They're forwarded to the Director and then they come to us ... There is no Quality related to not being able to meet staffing grids being done ... ."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on a review of facility documents, medical records (MR) and staff interviews (EMP), it was determined that Penn Highlands DuBois failed to follow adopted policies by failing to document the supervision of all patients is by a Registered Nurse (A0395), by failing to ensure consistent categories of nursing personnel for their staffing grids and schedules (A0386), by failing to schedule sufficient numbers of Registered Professional Nurses and/or auxiliary nursing staff on duty for all shifts, according to adopted staffing guidelines for approximately 77 of 146 shift increments for the West Campus Nursing Units reviewed (A0392), by failing to follow adopted policies by ensuring that patient care assignments were commensurate with the qualifications of nursing staff assigned to patients, and by failing to document that nurses that were re-assigned to a specialty area were under the direction of a specialty nurse for that area. (A0397)

Findings include:

A review of the facility policy entitled Assignments, dated November 2015. "Purpose: To assure nurse-patient assignments are completed each day. Policy: A Registered Nurse is assigned to care for all patients. Licensed Practical Nurses and Patient Care Assistants function under the direction of the Registered Nurse. Patient care assignments are made for each shift by an RN who is competent in making appropriate assignments. Procedure: 1. When making patient care assignments on the Patient Services Departments, the RN (in collaboration with Department Director (or designee), Supervisor or Patient Services Clinical Manager when necessary) take the following factors into consideration: level/mix of staff available and staff competence ... patients need for nursing care/complexity of care and technology needed ... relevant infection control and safety factors ... availability of support services or supervision required ... unit geography. 2. Staff must report off to the RN during breaks, meal times or any other absence from the (sic) 3. The RN delegates specific patient responsibilities of other RNs, LPNs, therapy staff, and patient care assistants in accordance with appropriate Nurse Practice Acts, licensing requirements, and Penn Highlands DuBois policy ... ."

A review of the facility's policy entitled Staffing for Nursing in Patient Care Units, dated November 2015. "Purpose: To provide safe patient care with appropriate number of nursing staff. Policy: The patient care Units are appropriately staffed based upon the number of patients and the type of patient needs. Staffing is adjusted per shift based on these changing factors. Nurse staffing and the provision of nursing care are based on the unique needs of the patient population and the scope of care provided on each clinical nursing unit. Consideration is given to each patient diagnosis, and individualized needs, as well as specific unit characteristics such as the census, hours of operation, and patient turnover (admission, turnover, and discharge). Staffing guidelines are reviewed on an annual basis during the budgeting process, and more frequently as new programs are implemented, and unit characteristics and other variables would change. Variables considered when determining staffing guidelines include staffing mix (RN, LPN, and PCA), level of nurse experience, and experience with the population being served. Specific guides for each patient care unit are developed to assist with daily staffing determinations. These tools are used as a guideline. The Department Director, or designee, has the authority to adjust the staffing on a shift-to-shift based upon the patient census and patient care needs. This adjustment may include additional or fewer staff based on the patient care needs and activities ... 14. Supervisors ... may be assigned to nursing units to assist with patient flow and serve as a nursing resource. When patient care needs do not permit the presence of a Charge Nurse, the role is not replaced ... Nurses will have the competency to practice within the patient care areas they are assigned. If a nurse is re-assigned to a specialty area for which he/she does not have the specific competencies, that nurse will be assigned under the direction of an experienced specialty nurse who has demonstrated the needed competencies for that area. The re-assigned nurse will practice within the limits of his/her competencies. Registered nurses will complete an orientation to their assigned area and function under the direction of a Registered Nurse Preceptor. Orientation is considered completed when the specific competencies have been documented."

A review of facility policy entitled Schedules, dated November 2015. "Purpose: To assure adequate staffing levels on Units. Policy: Patient Services personnel schedules are developed by either the Department Director/Supervisor or by staff self-scheduling ... All schedules are reviewed and approved by the Department Director or designee before posting ... ."

A review of Penn Highlands DuBois, Plan for The Provision of Patient Care 2015/2016, approved December 15, 2015, revealed, "... This framework allows for defining timely and clear goals as well as allocating adequate human, space, and other resources and appropriately directing activities to achieve these goals with the intent of responding to community and patient needs ... PH DuBois leadership assures that as part of the annual budget process, the necessary components are considered to ensure that appropriate financial support and resources are allocated to satisfy the Plan ... Customer Service Excellence ... Collaboration--Developing a sense of ownership within the organization and a commitment to co-workers to focus on patient care quality, providing a safe environment for patients and staff and to deliver an exceptional level of service ... The following strategies describe how PH DuBois works to achieve its vision ... VI. Planning and Design for Provision of Patient Care ... B. Planning and Resource Allocation. The strategic plan, operating and capital budget, and programmatic plans are reviewed at least annually to assure that the organization's mission is consistently supported over time. Priorities are determined and resources are allocated during the annual budgeting process to support these priorities. The Board approves the annual operating budget and capital expenditure plan. The following factors are considered when formulating departmental/organization budgets to assure that the Plan for the Provision of Patient Care is satisfied: 1. The needs of the various patient populations and their implications for staffing. 2. The organization's ability to to recruit and retain appropriate staff. 3. Departmental staffing variance reports. 4. Performance improvement data and outcomes. 5. The need to provide one level of care to patients through the organization ... 7. Other factors that may be identified on an ongoing basis. 8. Patient safety improvement activities ... D. Uniform Patient Care Processes ... PH DuBois believes that patients with the same health problems and care needs have a right to the same level and quality of care throughout the organization ... Acuity of the patient's condition determines the resources allocated to meet the patient's needs. Each department has a written defined scope of service and provides patient care in accordance with their scope of service ... E. Consistency in Plan, Policies, Procedures ... Patient care policies and procedures describe how the care needs for patient populations are assessed and met, address the care provided to patients/families, and show consideration of: Type (s) of age (s) of patients served. The scope of complexity of the patients care needs ... The availability of necessary staff. Recognized standards or guidelines for practice, when available. Methods that are used to assess and meet patient care needs. Methods that are used to assess and meet patient safety needs ... G. Staffing Effectiveness and Competencies. PH DuBois ability to provide for the needs of its patients as defined in the hospital's mission and the Plan for the Provision of Patient Care is directly related to the ability to recruit and retain the number and type of qualified, competent staff needed to provide safe and effective patient care ... H. Staffing Effectiveness. The staffing effectiveness plan covers direct care providers for PH DuBois inpatient services ... Objectives: 1. To assess staffing effectiveness defined as the number, competency, and skill mix of staff related to the provision of needed services. 2. To identify potential areas for improvement. Plan: The leaders of PH DuBois have identified staffing effectiveness as one of the performance improvement priorities ... The Department Managers are responsible for managing their staffing effectiveness on an ongoing basis ... VIII. Definition of Patient Services/Patient Care/Patient Support ... Patient care services are planned, coordinated, provided, delegated, and supervised by health care professionals who possess the knowledge and skills to identify and meet the individual's needs ... X. Scopes of Service/Staffing Plans ... The staffing plans for patient care/service departments have been developed based on the level of scope of care, the frequency and complexity of care, the patient population, and the education and skill level of the staff needed to provide such care. Each patient care/service department has a base staffing plan based on average daily census, volume, hours per patient day or departmental specific measure ... Staffing plans are reviewed at least annually during the budget process giving consideration to utilization, performance improvement activities, employee turnover, changes in customer needs/expectations, and anticipated changes in actual service. XI. Responsibilities of Leadership. PH DuBois leadership, defined by the Board of Directors, Senior Management, physician leadership, and departmental leaders, is responsible for: ... 5. Establishment of standards of care that all patients can expect and which are monitored through the organization's Performance Improvement Plan ... 9. Ensuring adequate competency staffing resources to meet the needs of the patients served ... ."
Attached to above was Addendum D, Penn Highlands DuBois Plan for the Provision of Nursing Care, 2015/2016, approved December 15, 2015, revealed, "... II. Organization. The Department of Nursing is organized to meet the nursing care needs of patients and to maintain the established standards of practice. The structure is designed to provide delineation of responsibility that assures patients with similar nursing care needs receive the same level of nursing care throughout the hospital and that the patient care at the unit level is under the direction of an RN ... The Plan for the Provision of Nursing Care is reviewed annually and revised as necessary. Review of resource requirements is done as part of the annual budget process and is evidenced by budget requests/changes in those resources. Consideration is given to the following elements: ... Patient requirements for nursing care ... Existing and proposed patient care programs ... Changes in patient populations, acuity, and other clinical factors ... Review of staffing effectiveness and productivity data ... ."
A review of the Job Description and Performance Appraisal for a Registered Nurse/Neonatal Intensive Care Unit, dated February 2015, revealed, "... Position Summary. The Registered Nurse is responsible to the Department Director, and is to be clinically competent; delivers care to patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; and effectively interacts with patients, significant others, and other health care team members while maintaining standards of professional nursing ... Essential Job Requirements ... Experience: Previous neonatal experience preferred. Required skills: Healthcare Provider (CPR) within 6 months and NRP and Stable within 12 months of start date in position/department ... Requirements are representative of minimum levels of knowledge, skills, and/or abilities. To perform this job successfully, the employee must possess the abilities or aptitudes to perform each duty proficiently ... ."
A review of the Job Description and Performance Appraisal for a Registered Nurse/Cardiovascular Unit, dated February 2015, revealed, "... Position Summary. The Registered Nurse is responsible to the Department Director, and is to be clinically competent; delivers care to patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation; and effectively interacts with patients, significant others, and other health care team members while maintaining standards of professional nursing ... Essential Job Requirements ... Experience: Previous critical care or cardiovascular experience preferred. Required skills: Healthcare Provider (CPR) within 6 months and ACLS within 12 months of start date in position/department ... Requirements are representative of minimum levels of knowledge, skills, and/or abilities. To perform this job successfully, the employee must possess the abilities or aptitudes to perform each duty proficiently ... ."
A review of Penn Highlands DuBois Department/Position Competency Form for NICU/Registered Nurse, noted Transporter (High Frequency Ventilation, Conventional Ventilation, Monitor and Alarms), Critical Thinking (Present Case Study at least once per year, Model: Problem, Action, Reasoning, Changes/Outcome), and Accu-Check, as all essential to the job. In addition, attached was a NICU RN Procedure Competency which included Intubation/ETT Suction, UAV/UVC Insertion, Needle Aspiration, Oscillator, Long Line, Nitric oxide, Code Pink, Life flight Training, and Congenital Heart Disease Screening Test.
A review of Penn Highlands DuBois Department/Position Competency Form for CVU/Registered Nurse, noted Extravasation (Displays knowledge regarding care of the patient experiencing extravasation of an intravenous catheter), Care of the Complicated Patient (Demonstrates proper care of the patient who experiences deterioration/complications in condition), and Restraint (Displays knowledge regarding care of the restrained patient), as all essential to the job.
A review of facility policy entitled Assessment & Treatment of Neonates From Drug Dependent Mother, dated September 2015, revealed, "Purpose: Identify infants for increase medical risk because of drug exposure during pregnancy. To improve health outcomes and provide safe and effective care for infants suffering from Neonatal Abstinence Syndrome (NAS) ... Procedure: ... 4. If an infant has scores of greater than or equal to (8) eight for (3) consecutive times or scores greater than or equal to (12) twelve for (2) consecutive times the physician is notified to begin medical management and transferred to the NICU if a patient is in the nursery. 5. When the physician has diagnosed Drug Dependency Syndrome, it is recommended that the infant be transferred to the Neonatal Intensive Care Unit for further observation and management ... ."
A review of facility Neonatal Intensive Care policy entitled Staffing and Assignments, dated September 2015, revealed, "Purpose: To provide appropriate patient care using available staff. Policy: Nursing personnel in the department are prepared for their responsibilities through appropriate training and educational programs. Nurses working in this department receive an extensive orientation that prepares them to be competent in the care of the neonate. Staffing: The department is staffed by qualified registered nurses 24 hours a day. Other nurses and health care personnel may service as backup under the direct supervision of the qualified registered nurse ... ."
A review of Penn Highlands NICU Purpose, dated January 2015, revealed, "Based on an awareness of the singular characteristics of neonatal disorders, the function of this unit is to provide those newborns, who are critically or seriously ill, or who need special care or closer observation than a well baby, with the care necessary to bring about their survival ... ."
A review of the Neonatal Intensive Care policy entitled Neonatal Abstinence Management in the NICU, dated September 2015, revealed, "Purpose: To improve health outcomes and provide safe and effective care for infants suffering from Neonatal Abstinence Syndrome (NAS). Policy ... 4. If an infant scores of greater than or equal to (8) eight for (3) consecutive times or scores greater than or equal to (12) twelve for (2) two consecutive times the physician is notified to begin medical management and transferred to the NICU if a patient is in the nursery ... Procedure: Nursing staff and parents are directly involved in the care of each infant suffering from NAS. 1. Upon admission to the NICU, the infant is placed in a quiet, dark environment with definitive boundaries away from premature neonates in the unit to decrease stimulation ... 4. The infant is given frequent feedings to replace calories used for excessive crying and agitation. 5. Adequate nutrition is provided to meet increased metabolic demand ... Documentation: 1. Neonatal abstinence scoring utilizing the Finnegan score is documented in computer every (4) hours. If scores increase as per protocol, the Doctor is notified to begin medical treatment .. Safety: ... 2. Infant is not be placed on abdomen for sleeping purposes at any time, unless it is for prematurity, respiratory, or digestion issues. Safe sleep practices are followed ... ."
A review of the CVICU policy entitled Introduction and Purpose, dated December 1, 2015, revealed, "The Intensive Care Unit of Penn Highlands DuBois is 15 bed multipurpose unit specializing in the treatment of patients requiring extraordinary care on a concentrated and continuous basis. This specialized or intensive care is provided twenty-four hours a day. Admission policy is the same as the stated medical center admission policy. The Cardiovascular Unit of Penn Highlands Healthcare DuBois is a 12 bed critical care unit providing quality care and specializing in the treatment and care of the adult and geriatric patient population requiring cardiovascular surgery, thoracic surgery, and cardiac interventions. This specialized or intensive care is provided twenty-four hours a day. Admission policy is the same as the stated medical center admission policy. The Cardiovascular Unit is well organized and integrated with other units, departments, and services in the medical center ... ."
A review of the CVICU policy entitled ICU/CVU Philosophy, dated December 1, 2015, revealed, "... 8. Ensures delivery of competent quality patient care by completing yearly population specific competencies and mandatory continuing education requirements ... ."
A review of the CVICU policy entitled Penn Highlands DuBois Scope of Service Cardiovascular Unit, dated December 1, 2015, revealed, "... III. Level of Care: Patient care is based on a nurse to patient ratio. Staffing guides reflect nurse to patient ratio but patient acuity is considered in assignment of staff. Patient assessment/evaluation is completed per policy. Nursing staff is required to complete annual age specific competency, attend/complete mandatory education to meet patient needs ... ."
A review of the CVICU policy entitled Scope of Service Intensive Care Unit, dated December 1, 2015, revealed, "... III. Level of Care: Patient care is based on staffing guidelines. Nursing staff is required to complete annual age specific competency, department and hospital mandatory education programs and obtain 10 contact hours of continuing clinical education. The nurses are required to complete a basic dysrhythmia course, critical care course, and obtain/maintain ACLS and PALS certification ... ."
A review of the CVICU policy entitled Education and Competency, dated December 1, 2015, revealed, "Purpose: To establish a standardized orientation, competency validation and continuing education requirement for the RN working in ICU/CVICU. Policy: All professional registered critical care nurses are prepared for their responsibilities and validate competency in the Critical Care Units through appropriate orientation, inservice training, continuing education programs, and completion of competency validation process. The registered nurse practicing in the ICU/CVICU completes an individualized orientation program. Documentation of the completed orientation program is placed in the employee's personnel file. The orientation program is acceptable to the Director of the Critical Care Units and to the Patient Services Departments and is of sufficient duration and substance to cover all nursing responsibilities related to a nurse's level of participation in the Critical Care Unit. The orientation program prepares the nurse to be competent in the following: 1. The knowledge and skills required to competently assess and /or reassess patients admitted to, and treated in the unit. 2. Recognizing, interpreting and recording of the patient's signs and symptoms, particularly those signs and symptoms that require the notification and/or intervention of a physician. 3. Initiation of cardiopulmonary resuscitation and other patient safety requirements as defined by hospital policy. 4. Parenteral administration of electrolytes, fluids, blood and blood components. 5. Administration of emergency medications and routinely used medications as authorized. 6. Effective and safe use of electrical and electronic life-support equipment or other equipment in the unit. 7. Prevention of contamination and transfer of infection. 8. Recognizing and attending to the psychosocial needs of patients and those persons significant to the patient. 9. Recognizing and applying therapeutic measures in the psychological, social, spiritual, and rehabilitative aspects of the critically ill patient ... Registered critical care nurses and medical staff who provide care in the ICU/CVICU participate in relevant educational programs on a regular basis ... ."
A review of Penn Highlands Dubois Maternity - Child Policy / Procedure Title: Staff Education and Training for the Registered & Licence(sic) Practical Nurse, revealed, " ... Neonatal Intensive Care The unit orientation for the nurse working in the Neonatal Intensive Care Unit is individualized and will typically last 3 months to 6 months, depending on experience. Extension of orientation is considered if the employee demonstrates the ability to progress. Courses and clinical-orientation days are scheduled to provide experience with emergency procedures, skills, and ventilator care. The following courses will be provided within the first 12 months: Neonatal Resuscitation Program 1. Newborn Assessment 2. Gestational Age Assessment and APGAR scoring 3. STABLE (classroom course) 4. Scenario and simulation based skills performance components are provided. Annual Education and Competency Assessment 1. Ongoing education and competency assessment occurs annually 2. Annual unit-specific topics are chosen based on staff-member needs, new products/guidelines/procedures, findings from quality review surveys, new patient populations, or changes in evidenced-based practice. 3. All nurses are required to remain current with every-2-year courses in Basic Life Support, the Neonatal Resuscitation Program 4. Labor & Delivery nurses are required to remain current with ACLS every 2 years. 5. Recommend NICU nurses complete S.T.A.B.L.E. program every 2 years 6. Recommend Labor & Delivery nurses attend an AWHONN Fetal Monitoring class every 3 years ... . "
A review of Penn Highlands Dubois Scope of Service Neonatal Intensive Care Unit, revealed, "I. Introduction and Purpose: The Neonatal Intensive Care Unit provides 24 hours quality care for the critically ill neonate, intermediate neonates and forms of extended care. Transport services are also available 24 hours a day to bring infants from referring hospitals to our unit. The department embraces family centered developmental care and provides emotional support, education and discharge planning for patients, families and whose infants require specialized care and monitoring at a more intensive level than is available in Level I and II nurseries ... III. Level of Care: Patient care is provided to the newborn requiring intensive care and continuing care in the NICU. Patient care is based on a nurse patient ratio. Staffing guidelines reflect nurse to patient ratio but patient acuity is considered in assignment of staff ... Nursing staff is required to complete annual age specific competency and attend/complete mandatory education to meet patient needs ... Revised ... 1/15."

1. A review of a Staffing Concern Notification, dated March 11, 2016, revealed, "... 3rd Floor. Shift 7P-7A. Census: 23 ... Went to 3rd floor had 2 RN and 1 LPN for a total of 23 pts. 8 for 1 RN, 8 for LPN, & 7 for 1 RN ... Response to Staffing Concerns ... 3F had 2 Agency RNs call off at 1700 pm for 3F. Had to make the best of a bad situation ... ." The form was noted to be signed by the Department Director of March 14, 2016, the Assistant VP Patient Services on March 14, 2016, and the VP Patient Services on March 15, 2016.

A review of an Assignment Sheet for the Third Floor Nursing Unit, dated March 11, 2016, for the 7P-7A shift was completed. During review, it was noted that EMP67 had a patient assignment. Surveyors received confirmation on May 9, 2016, that EMP67 was identified as an Licensed Practical Nurse. The assignment sheet did not reflect that the patients assigned to a Licensed Practical Nurse were co-assigned to an RN.

2. A review of the Third Floor (Med-Surg) Schedules dated 2/14/2016-3/26/2016 and 3/27/4/9/2016, revealed that the staffing mix included Licensed Practical Nurses.

A review of the Third Floor (Med-Surg) Staffing Grids dated June 26, 2015 and March 14, 2016, revealed that Licensed Practical Nurses are not included in the staffing mix.

3. A review of the nursing schedules dated February 14, 2016-March 26, 2016, and March 27, 2016-April 9, 2016, for the Neonatal Intensive Care Unit, Joint Center, Third Floor, Rehab 5th Floor, Pediatrics, Obstetrics, Short Stay, Intensive Care Unit, Progressive Care Unit, and Cardiovascular Unit revealed a total of approximately 735, open opportunities. Of these open opportunities, approximately 526 were for RN's, 21 were for RN/LPN's, 181 were for Patient Care Assistants, and 7 were for LPNs.
An interview with EMP49, and EMP14 revealed that at the time the schedules are printed, the open opportunities that are listed, are the gaps in the schedule that need filled.

4. Following review of approximately 146 shift increments (which included Assignment Sheets, Staffing Documents, and Staffing Grids) for the West Campus Nursing Units (Progressive Care Unit, Third Floor Medical/Surgical, Intensive Care Unit, Neonatal Intensive Care Unit, Obstetrics, Cardiovascular Unit, Rehab, Joint Center, Emergency Department, and Pediatrics), with representatives from Patient Services, it was noted that approximately 77 of the 146 shifts did not meet their adopted staffing grid for RN's and/or PCA's, and or Unit Secretaries.

5. An interview was conducted with EMP4. "There are not enough staff to cover the load. We have 7 to 8 patients a piece, there's not enough aides. It's a big safety concern and concern for our nursing license. There's a lot of Agency people and a lot of staff are leaving. They're tired of having too many patients with no Health Care Aides ... I don't fill the forms out as much as I should. We're too busy to fill them out. Sometimes if there are only four RN's, we should all fill them out. During the shift, we make our needs known. On Night shift, the Supervisor comes up at 9PM. At 5:00AM, they bring the staffing paper. We know the patient ratio and the acuity is not safe. The House Supervisor makes the decision. The Supervisors fax it to us most of the time, they know what is going on in the entire hospital. If there is a call on the 3rd floor, and they have more patients than us, they pull us. They pull all over the place ... Sometimes the patients we have are a lot of work. We take dialysis patients all the time ... They're trialing LPN's on the 3rd floor, I think. I don't know if that will work. Half of the patients on the floor would've been in ICU years ago ... Medications are being given late. They want us to do charting right after we assess the patient. They say it will help us with staffing issues. Phone calls are horrible until a Secretary gets there. Sometimes the Supervisor will also have a 7 patient run ... If you have 7 patients, you don't have time to read the notes ... ."

6. An interview was conducted with EMP1. "We had four nurses and one got sick. The House Supervisor did everything they could ... The LPN's are taking patients, too ... ."

7. An interview was conducted with EMP16. "... There are staffing guidelines in the office. We have new staffing guidelines ... The numbers fluctuate, now there's minimum and maximum. A lot of times you can't adhere to the guidelines ... This is the worse morale it's ever been. They feel dumped on, overworked, and underpaid ... ."

8. An interview was conducted with EMP11. "... There are open holes most of the time that no one picks up. A lot of times there's open opportunities ... most of the time we're short staffed. They need more Nurse Aides to be support staff. Some patients might not be seen for awhile ... If the ER is busy, they will institute their Capacity Management protocol. If people are waiting to be seen, they want to get patients out of the ER, and up to the floors ... The ED calls the floor, we tell them to hold the patient there until the floor can handle an admission. They don't listen ... Agency nurses even say they're not coming back here, because they get pulled to other assignments ... ."

9. An interview was conducted with EMP9. "Sometimes, there's only one Aide on the floor. On the 3rd floor, I've had 29 patients to myself. On the 2nd floor we get big chunks of patients, and it's still not safe. There's not enough staff, I think there has been an increase in falls ... I can't get all the baths done. It's not fair to them. Sometimes people can bath themselves, sometimes not ... We have been voicing our concerns ... If you need a lift, you have to try to find someone to help you. Patients are complaining, we can't get to their call bells. Vital signs are getting done, but it takes awhile ... We need more staff right now. A couple of nights ago ... It was all Agency and this newer nurse who was in Charge, and (they) had a patient assignment. One night, they had 10 patients a piece. Sometimes they'll hold admits to Dayshift, but usually they just send them ... ."

10. An interview was conducted with EMP2. "Staffing has been a huge concern. We get seven to eight patients with more admissions to come. Sometimes there's no Aide. Answering call bells is hard, there's no safe way to handle that. The Administration is trying to do silly things, like pulling people off desk jobs. Those nurses can't really help with RN things. It's causing more dissatisfaction, their solutions aren't solving anything ... There's no relationship with upper Management. The changes aren't for the better. Everyone's beyond burnt out, we're angry ... They call you to come in at 5AM, but you don't get premium pay, because there's so many stipulations. The premium pay looks good on paper, but it's so dysfunctional. We don't have enough people to even train new nurse ... Med/Surg floats are being pulled into Critical Care, and they say if you have ACLS it's okay ... on Friday staffing was a disaster ... The 3rd floor had a new Charge Nurse with nine or ten patients. I don't pay attention to who shows up for RRTs ... Nurses are being pulled off orientation early and there are so many holes in the schedule ... The Agency nurses don't want to renew because of no-pull clauses in their contracts ... It's a mess ... ER has a policy that from the time they call report, you have a half hour to take the patient. Sometimes we have to retrieve the patients. 6:00PM happens and ED docs have sat on patients all day and all of a sudden they want them on the floors ... ."

11. An interview was conducted with EMP27. "... We called the RRT ... All the nurses were with me, so all the other patients were neglected for two hours. Our ty