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.

MOSES TAYLOR HOSPITAL 700 QUINCY AVENUE SCRANTON, PA 18510 Oct. 7, 2015
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure there was a quality review for a newly instituted process for transferring neonates from the Neonatal Intensive Care Unit (NICU) to other patient care units in the hospital.

Findings include:

Review of the the facility's "Quality [and] Performance Improvement Plan," dated last reviewed June 2015 revealed "I. Introduction The Board of Directors, Medical Staff and Administration shall continue to provide quality care within the accepted standards of medical/professional care and provide for the optimal delivery of this care to the sick of every race, age, color, creed, national origin, and economic status, within the constraints of the available resources and consistent with the goals judged to be achievable by the institution. ... II. Purpose The purpose of the Quality [and] Performance Improvement Program is to ensure the organization's commitment to providing safe, competent, quality care. ... B. Performance Improvement Council The Performance Improvement Council provides oversight for Moses Taylor Hospital's performance improvement program. The council reports to the Board of Directors. Membership includes representatives from the Medical Staff, Administration and Management. The responsibilities of the Performance Improvement Council include: Develop, modify and approve the hospital's Quality and Performance Improvement Plan Prioritize performance improvement activities Select projects requiring multidisciplinary Performance Improvement Teams Assign teams with designated performance improvement projects Review reports and feedback from quality committees, performance improvement teams, patient satisfaction surveys, other executive level data, comparative data and information impacting on organizational performance Evaluate the effectiveness of the performance improvement activities of the hospital departments and teams. Determine the education and training needs of the organization related to performance improvement Determine budget implications of organization-wide performance improvement activities ..."

Review of the Quality Meeting Minutes for April 2015 to present revealed no discussion regarding the process for transferring a neonate from the NICU to other nursing care units. There were no quality monitors developed for this process.

Interview with EMP1 on October 6, 2015, confirmed there was no documentation of a quality monitor for the process of transferring neonates from the NICU to the Well Baby Nursery and/or to Pediatrics. EMP1 confirmed there was no documentation of discussion in the meeting minutes, April 2015 to present, related to this transferring process. EMP1 confirmed the facility had not evaluated the process for effectiveness.

Cross Reference:
482.22(b)(1), (2), (3) Medical Staff Organization and Accountability
482.42(a) Infection Control Program
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, medical records (MR), observation, and staff interview (EMP), it was determined the facility failed to ensure neonates once admitted to the Neonatal Intensive Care Unit (NICU) were provided with continuous care in the NICU for 19 of 24 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR17, MR18, MR20, MR21, MR22 and MR23) and failed to ensure there was a defined process in place for transferring neonates from the Neonatal Intensive Care Unit (NICU) to other nursing care units.

Findings include:

Review on September 30, 2015, of the 28 PA Code for Pennsylvania Hospitals revealed regulation 139.2. a. Definitions:

NICU - Neonatal intensive care unit - The term refers to an unit which is specifically equipped and staffed for the care and treatment of high-risk infants and those infants otherwise in need of intensive care.

Neonate - Patients treated in neonatal care units. The term is synonymous with baby or infant.

Review on September 30, 2015, of the "Guidelines for Perinatal Care," Seventh Edition revealed "Newborn Nursery. In most cases care for healthy term neonates can be provided in the mother's room. A separate newborn nursery is available for infants who require closer observation or whose mothers cannot care for them. In addition to providing care for healthy term infants, a level I neonatal unit can provide care for late preterm infants born at 35-37 weeks of gestation who are physiologically stable. These neonates are not ill but may require frequent feeding and more hours of nursing care than healthy term neonates. ..."

1) Review on September 30, 2015, of the facility's policy "Departmental Scope of Care and Services A. Department Name: Neonatal Intensive Care Unit," dated approved February 10, 2015, revealed " ... C. Overview: The Neonatal Intensive Care Unit (NICU) at Moses Taylor Hospital is a 20-bed, Level III unit specifically designed for the complex needs of critically-ill neonates. Our NICU is comprised of private rooms, offering a unique, family-centered approach for the delivery of developmentally-appropriate care. ... E. Population Served: The NICU is available to all pre-term and full-term infants born at Moses Taylor Hospital and outlying community hospitals who are in need of treatment for a variety of condition. ..."

Review on September 30, 2015 of the facility policy "Criteria for Admission to the Neonatal Intensive Care Unit Policy," last revised April 28 2015, revealed "Policy Newborns meeting any of the following criteria will be admitted to the NICU. Other newborns may be admitted to the NICU as deemed necessary by the neonatologist. Purpose to ensure safe, quality care to be given to the compromised neonate. Criteria I. Less than 2000 grams II. Any infants 25 weeks of gestation or greater up to and including 30 days of age. III. Any infant born less than 35 weeks, especially those exhibiting any symptoms of [DIAGNOSES REDACTED]. VI. Any infant requiring surgical interventions. VII. Any infant with strong suspicion or documentation of sepsis or meningitis. VIII. Any infant requiring the administration of IV [intravenous] fluids. IX. Any infant with feeding problems or [DIAGNOSES REDACTED], requiring close glucose monitoring or nasogastric feedings. X. Any infant with suspicion or documentation of seizure activity, or neurological problems, requiring therapy or evaluation. XI. Any infant with evidence of [DIAGNOSES REDACTED], requiring phototherapy or an exchange transfusion. XII. Any infant with evidence of perinatal asphyxia requiring close observation. XIII. Any infant with complex congenital anomalies. XIV. Any infant with complex or symptomatic cardiac anomalies will be evaluated by the Neonatologist for potential admission to the NICU. XV. Any other newborn requiring close observation or critical care as per neonatologist. XVI. Any infant exhibiting symptomatic drug withdrawal requiring medication therapy. ..."

Review on September 30, 2015 of the facility policy "Criteria for Admission of the Pediatric/Adolescent Patient," last revised February 2014, revealed "Purpose To establish appropriate criteria for the admission of a pediatric/adolescent patient to Moses Taylor Hospital. Policy 1. Any child or adolescent patient 18 years of younger will automatically admitted to the Pediatric/adolescent Unit. 2. Pending pediatric bed availability, any child [AGE] and older may be admitted to the Medical-Surgical department. 3. Any child under the age of 15 years admitted to a Medial-Surgical department will have a pediatric nurse assigned to care for him/her. 4. The pediatric/adolescent nurse manager or her designee may be consulted at any time to determine where a child should be admitted . 5. All appropriate resuscitation equipment should be made available on any unit where an adolescent patient is admitted . 6. The transmission of infectious disease will always be taken into consideration when room assignments are made. Utilize guidelines set forth in the Infection Control Manual."

Review on September 30, 2015, of the facility policy "Discharge Criteria for NICU Policy," dated last reviewed April 27, 2015, revealed "Policy An infant will be discharged after meeting the established criteria developed by the Neonatologist. Purpose To ensure safe discharge of an infant to a parent or guardian. Action I The infant will have a minimal discharge weight of of 1.8 kg. II. The infant will have the ability to nipple feed, retain adequate oral feeding, and demonstrate consistent weight gain for a period of 48 hours prior to discharge. If an infant is receiving gastrostomy tube feedings, the infant may be discharged if all the other parameters are met. III. There will have been no significant episodes of Apnea, Bradycardia or Oxygen Desaturation with Cyanosis for 48 hours prior to discharge. IV. Parents/caregivers of infants with diagnosis of [DIAGNOSES REDACTED]. VI. The infant will have the ability to maintain temperature, fully clothed in an open crib. ..."

Observation tour on September 30, 2015 at approximately 10:30 AM of the Pediatric Department revealed two neonates admitted to this department, MR4 and MR5. MR4's birth date was September 27, 2015. MR4 was transferred from the Well-Baby Nursery to the Pediatric Department on September 27, 2015, for phototherapy due to [DIAGNOSES REDACTED].

MR5's birth date was September 24, 2015. The neonate's diagnosis was poor feeder and temperature instability. There was a transfer order to Pediatrics under the care of OTH1, a neonatologist, on September 28, 2015, at 08:40 AM. Nursing documentation revealed MR5's temperature instability persisted with the temperature dropping as low as 95 when the neonate was out of the isolette. Feeding remained poor. A nasogastric tube was inserted on September 30, 2015. MR5 was transferred back to the NICU on September 30, 2015, at 10:30 PM.

Review on October 2, 2015, of MR1 revealed a birth date of June 19, 2015, with neonatal abstinence syndrome and poor feeder. The neonate required oral methadone in decreasing doses and Phenobarbital (an anti-convulsive) for tremors. There was a transfer order to Pediatrics on July 2, 2015. OTH1, a neonatologist, continued to follow the neonate on the Pediatrics unit.

Review on October 2, 2015, of MR2 revealed a birth date June 26, 2015. The neonate was a preterm twin with feeding issues and required total parenteral nutrition (TPN) until June 29, 2015, at which time a nasogastric tube was inserted. The neonate was transferred to Pediatrics on July 3, 2015. The nasogastric tube remained in place until July 8, 2015. The neonatologists continued to follow the baby in the Pediatric Department (OTH1 and OTH2).

Review on October 2, 2015, of MR3 revealed a birth date of June 26, 2015. The neonate was a preterm twin with feeding issues that required TPN. The neonate was transferred to Pediatrics on July 3, 2015, at 4:15 PM with a nasogastric tube in place for enteral feedings. The neonate was transferred back to the NICU on July 4, 2015, at 8:00 AM. There was no change in the neonate's condition documented prior to this transfer back to NICU. The transfer to Pediatrics was ordered by OTH2 on July 3, 2015. The transfer back to NICU was ordered by OTH1 on July 4, 2015.

Review on October 5, 2015, of MR6 revealed a birth date of August 16, 2015, with the diagnosis of [DIAGNOSES REDACTED]

Review on October 5, 2015 of MR7 revealed a birth date of August 20, 2015, with the diagnosis of [DIAGNOSES REDACTED]" Documentation revealed oral morphine continued in decreasing doses.

Review on October 5, 2015, of MR8 revealed a birth date of August 14, 2015, with the diagnosis of [DIAGNOSES REDACTED]" Documentation revealed oral morphine continued in decreasing doses.

Review on October 5, 2015, of MR9 revealed a birth date of August 18, 2015, with the diagnosis of [DIAGNOSES REDACTED]"Transfer to peds under neo care." Documentation revealed oral morphine continued in decreasing doses.

Review on October 5, 2015 of MR10 revealed a birth date of August 19, 2015, with the diagnosis of [DIAGNOSES REDACTED]

Review on October 5, 2015 of MR11 revealed a birth date of August 19, 2015, with the diagnosis of [DIAGNOSES REDACTED]

Review on October 5, 2015, of MR12 revealed a birth date of August 29, 2015, with the diagnosis of [DIAGNOSES REDACTED].

Review on October 5, 2015 of MR13 revealed a birth date of September 9, 2015, with the diagnosis of [DIAGNOSES REDACTED]

Review on October 5, 2015, of MR17, revealed a birth date of July 30, 2015, with admission to the NICU with symptoms of [DIAGNOSES REDACTED]. On August 1, 2015, the neonate experienced seizure-like activity and was transferred back to NICU. On August 2, 2015, the neonate was transferred back to the Well-Baby Nursery and rooming in with the parent.

Review on October 5, 2015, of MR18, revealed a birth date of September 9, 2015. The neonate was admitted to NICU with transient tachypnea. Oxygen saturations were in the low 90's and 80's. The neonate placed on continuous positive airway pressure (C-PAP). On September 10, 2015, the neonate discharged from NICU to the Well-Baby Nursery.

Review on October 5, 2015, of MR20 revealed a birth date of July 29, 2015. The neonate was admitted to NICU for early gestational age, possible Suboxone withdrawal, and drug testing. On July 31, 2015, the neonate was discharged from NICU to the Well-Baby Nursery.

Review on October 5, 2015, of MR21 revealed a birth date of September 28, 2015. The neonate was admitted to the NICU for monitoring of oxygen saturation, heart rate, and respiratory rate. The neonate discharged from NICU to the Well-Baby Nursery.

Review on October 5, 2015, of MR22 revealed a birth date of September 27, 2015. The neonate was admitted to the NICU for history of maternal fever, fetal tachycardia and rule out apnea. The neonate was discharged from NICU to the Well-Baby Nursery on September 29, 2015, under NICU care.

Review of on October 5, 2015, of MR23 revealed a birth date of July 30, 2015. The neonate was admitted to NICU on July 30, 2015, for crying, cyanosis and respiratory distress. The mother had a history of Suboxone use. The neonate transferred to the Well-Baby Nursery on July 31, 2015. On August 1, 2015, the neonate experienced seizure-like activity and was transferred back to NICU. On August 2, 2015, the neonate then transferred to the Well-Baby Nursery.

Interview on September 3, 2015, with EMP4 confirmed the Pediatric Department received transfers of neonates from the NICU, and they provided care to neonates with the diagnoses of [DIAGNOSES REDACTED].

Interview on September 30, 2015, at 3:00 PM with EMP1 confirmed there was no defined process in place for the transfer of the neonates from NICU to Pediatrics.

Interview on September 30, 2015, with OTH1 confirmed it was the facility process to transfer neonates from NICU to Pediatrics. OTH1 confirmed the transfers occurred when there was a need for a NICU bed, or in the case of MR5, due to a staffing issue in the NICU.

Telephone interview on October 5, 2015, with OTH2 confirmed that if a neonate was 12 hours old and was in need of intermediate care, it was the facility process to transfer the neonate to Pediatrics.

2) Review of the Medical Executive Committee meeting minutes dated August 13, 2015, revealed the facility implemented a competency program in the Pediatric Department to equip the nursing staff to care for the transfer of a stable, non-acute infant from the Nursery and or NICU.

The facility was unable to provide additional documentation regarding the transfer of neonates to other nursing care units. There was no documentation of a criteria for the transfer of a neonate from the NICU or Well-Baby Nursery to Pediatrics.

Interview on September 30, 2015, with EMP1 confirmed there was no defined process for the transfer of neonates out of the Well-Baby Nursery and NICU to the Pediatrics Department.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the medical records in the obstetrical unit, for the neonate, were complete and readily accessible for 12 of 24 records reviewed (MR3, MR4, MR11, MR14, MR15, MR16, MR17, MR18, MR19, MR20, MR21, and MR22).

Findings include:

Review of the facility's "Medical Staff Rules and Regulations," dated approved October 17, 2015, revealed "Section I: Purpose The Medical Staff shall adopt such Rules and Regulations as may be necessary to implement, more specifically, the general principles found within the Medical Staff Bylaws of the Moses Taylor Hospital subject to the approval of the Governing Body. These shall relate to the proper conduct of Medical Staff organization activities as well as embody the level of practice that is required of each licensed independent practitioner member of Moses Taylor Hospital's Medical Staff. ... Section III. Patient Management 1. All patients should/shall be seen at least every 24 hours by the attending physician of record, and an entry made in the Progress Note every forty-eight (48) hours, but preferably daily. Critically ill patients should be seen daily and an entry made in the Progress Notes. ... Section VII. Medical Records 1. General a. An adequate medical record shall be maintained for every patient treated or examined in any area of the hospital. The medical record shall contain sufficient information to identify the patient clearly, support the diagnosis, justify the treatment, document the course and results accurately and facilitate continuity of care among health providers. 2. History and Physical a. All patients admitted to the hospital shall be required to have a History and Physical Exam. b. ... The medical history and physical is to be completed within the first 24 hours of admission to inpatient services and must be performed prior to any operative procedure and/or invasive procedure. ..."

Review on October 8, 2015, of the facility policy "Medical Record Content Policy," dated reviewed April 17, 2015, revealed "i. Purpose To define the contents of patient medical record, whether in paper or electronic format, in such a way that it facilities communication, coordination and continuity of care and promotes efficiency and effectiveness of treatment. ... III. Procedure A. All medical record entries, including handwritten and electronic must be legible, complete, true and accurate, dated, timed and authenticated by the person responsible for providing or evaluating the services provided, consistent with hospital policies. ..."

Review of the facility policy "Admission [and] Immediate Care of a Normal Newborn," dated revised March 26, 2015, revealed "Procedure Ensure safe, effective care of the infant during the transition to extrauterine life. Policy All Infants born at Moses Taylor Hospital will have an initial nursing assessment performed by a RN. ... Guidelines ... XII Documentation ... D. Notify the attending physician of admission. Infants must be seen by a physician within 24 hours of birth and day of discharge. ... F. Mother-Baby Link A. Choose the mother/patient you wish to link to the baby or babies. B. Choose the Menu Bar/Patient Administration/Mother-Baby Link C. On pop up screen, choose Create Baby Record. D. Search for the infant by medical record number E. Choose infant by the medical record number and hit ok. ..."

Review of the facility policy "Nursing Care for a Mother and Newborn Policy," dated last revised May 1, 2015, revealed "Purpose Perform routine physical assessments of mother and infant for early detection of any health-threatening problem. To provide family centered care that optimizes learning through role modeling and use of the "teachable moment". To promote optimal parental competence and confidence related to care of their newborn prior to discharge. ... Guidelines ... III. Newborn assessments. A. Monitor vital signs every [half hour] x 4 after birth or more frequently as indicated until stable after birth, then every shift until time of discharge. B. Following the initial admission assessment, perform a newborn physical assessment every shift, including vital signs, color, bowel and bladder functions, cord condition, and feeding patterns. Document the findings. ..."

Review on October 2, 2015 of MR3 revealed the neonate was transferred from the Pediatric Department to the Neonatal Intensive Care Unit (NICU) on July 4, 2015. There was no documentation in MR3 regarding the transfer or documentation of a report given to the NICU.

Review on September 30, 2015, of MR4 revealed the neonate birth date was September 27, 2015, at 1314. The neonate was transferred from the Well-Baby Nursery to the Pediatric Department on September 29, 2015, at 22:10 for phototherapy treatment. There was no documentation of the RN to RN report from the Well-Baby Nursery to the Pediatric RN. The physician's telephone order was not part of MR4 when initially reviewed at approximately 09:00 on September 30, 2015. The physician's transfer order was presented on September 30, 2015, at approximately 14:30.

Interview on September 30, 2015 with EMP4, at approximately 10:00 AM confirmed there was no documentation of the physician's telephone order for MR4 for the transfer from Well-Baby Nursery to Pediatrics for photo therapy. EMP4 confirmed there was no documentation of the RN to RN report from the Well-Baby Nursery to the Pediatric RN.

Review on October 5, 2015 of MR11 revealed a birth date of August 19, 2015, at 18:52. Vital signs were documented at 18:52, 19:30, 20:00. There was not a fourth set of vital signs documented within thirty minutes.

Review on October 5, 2015 of MR14 revealed a birth date of September 26, 2015. The history and physical was completed on September 28, 2015. There were no progress notes for September 26, 2015 and September 27, 2015.

Review October 5, 2015, of MR15 revealed a birth date of September 27, 2015. The initial nursing assessment was completed at 17:06. The next nursing assessment was documented at 08:30, the following morning. Vital signs were completed post delivery at 17:06, 17:30, 18:15, and 19:45. The next set of vital signs were at 01:00.

Review October 5, 2015, of MR16 revealed a birth date of September 28, 2015, at 07:22. Vital signs were completed at 07:22, 08:15, and 09:10. The next set of vital signs were at 12:00.

Review on October 5, 2015, of MR17 revealed a birth date of July 29, 2015. The neonate was admitted to the NICU on July 29, 2015. There was no documentation of the last set of the 15-minute vital signs after the 4:00 AM set of vital signs on July 29, 2015.

Review on October 5, 2015, of MR18 revealed a birth date of September 27, 2015. The neonate was admitted to the NICU on September 27, 2015. There was no documentation of neonatal progress notes or vital signs every 15 minutes.

Review on October 5, 2015, of MR19 revealed a birth date of September 28, 2015. The neonate was admitted to the NICU at 16:18. The neonate was discharged from NICU and transferred to the Well-Baby Nursery on September 29, 2015, at 04:50. Vital signs were documented at 06:00 on September 29, 2015. There was no documentation of neonatal progress notes from 04:50 until 06:00 on September 29, 2015.

Review on October 5, 2015, of MR20 revealed a birth date of July 29, 2015. The neonate was admitted to the NICU for early gestational age, possible Suboxone withdrawal, and drug testing. Vital signs were taken at 3:35 AM, 3:45 AM and 4:00 AM. There was no documentation of the last set of the 15-minute sequential vital signs.

Review on October 5, 2015 of MR21 revealed a birth date of September 28, 2015. The neonate was admitted to the NICU for monitoring of oxygen saturation, heart rate, and respiratory rate. The neonate discharged from NICU to the Well-Baby Nursery. The neonate's blood glucose dropped to 27, (Normal Range 40-90). A second blood glucose check was 35. The neonate was transferred back to NICU. There was no documentation of progress notes for the neonate.

Review on October 5, 2015, of MR22 revealed a birth date of September 27, 2015. The neonate was admitted to the NICU for history of maternal fever, fetal tachycardia and rule out apnea. The neonate was discharged from NICU to the Well-Baby Nursery on September 29, 2015, under NICU care. There was no documented evidence of 15-minute vital signs or neonate progress notes.

Interview on October 5, 2015 with EMP13, at approximately 9:30 AM confirmed there was no documentation of progress notes for neonatal MR22.

The required medical record documentation was very difficult to locate. Navigating thru the electronic medical record required a minimum of two facility staff members. Both the mother and baby electronic medical records had to be reviewed to find all the required documentation, including vital signs and assessments.

Interview on October 5, 2015, with EMP6 confirmed there was no consistency in the required medical record documentation. EMP6 confirmed this issue was related to the requirement for staff to link the electronic medical record of the mother to the neonate. EMP6 confirmed the linking was not completed consistently by staff.

Interview on October 1, 2015, at 11:00 AM with EMP5 confirmed the documentation listed above was absent, and vital signs were not obtained, as required by facility policy. EMP5 confirmed the information in the electronic medical record was not readily accessible. EMP5 confirmed chart audits were not completed by the department managers on a regular bases. EMP5 was not aware the linking requirement for the electronic mom and baby medical records was not consistently completed. EMP5 was not aware the information from the mother's electronic medical record was not being pulled into the neonate's electronic medical record.

Interview on October 5, 2015, with EMP7 confirmed that the electronic medical records utilized in the Obstetrical Unit were reviewed randomly by the Medical Records Department for components, such as the history and physical and progress notes. EMP7 confirmed the electronic medical records were not reviewed for the actual department requirements. EMP7 stated that type of quality review would be the responsibility of the individual department.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure there were specific infection control guidelines when transferring neonates from the Neonatal Intensive Care Unit (NICU) to other patient care units in the hospital.

Findings include:

1) Review of the facility's "The Infection Control Program Policy," dated revised May 1, 2015, revealed "I. Introduction: Healthcare - associated infections can result in an increase in the duration of hospitalization , increased patient costs, and increased morbidity and mortality. To prevent the spread of communicable diseases and infections Moses Taylor Hospital will administer an effective infection prevention and control program. ... III. Scope of Care: The scope of infection prevention and control activities extends to all direct inpatient and outpatient services, ancillary services, support services, in-service education, and employee health. ..."

Interview on October 8, 2015, with EMP9 from Infection Control confirmed they were not aware of the process for transferring neonates from the NICU to other nursing care units in the hospital. EMP9 confirmed there were no Infection Control policies in place regarding this process.

Review on October 5, 2015, of MR17, revealed a birth date of July 30, 2015, with admission to the NICU with symptoms of Suboxone (medication used for the treatment of opioid dependence) withdrawal, respiratory distress, crying, and cyanosis. On July 31, 2015, the neonate was discharged from NICU and admitted to the Well-Baby Nursery and rooming in with the parent. On August 1, 2015, the neonate experienced seizure-like activity and was transferred back to NICU. On August 2, 2015, the neonate was transferred back to the Well-Baby Nursery and rooming in with the parent.

Review on October 5, 2015, of MR18, revealed a birth date of September 9, 2015. The neonate was admitted to NICU with transient tachypnea. Oxygen saturations were in the low 90's and 80's. The neonate placed on continuous positive airway pressure (C-PAP). On September 10, 2015, the neonate discharged from NICU to the Well-Baby Nursery.

Review on October 5, 2015, of MR20 revealed a birth date of July 29, 2015. The neonate was admitted to NICU for early gestational age, possible Suboxone withdrawal, and drug testing. On July 31, 2015, the neonate was discharged from NICU to the Well-Baby Nursery.

Review on October 5, 2015, of MR21 revealed a birth date of September 28, 2015. The neonate was admitted to the NICU for monitoring of oxygen saturation, heart rate, and respiratory rate. The neonate discharged from NICU to the Well-Baby Nursery.

Review on October 5, 2015, of MR22 revealed a birth date of September 27, 2015. The neonate was admitted to the NICU for history of maternal fever, fetal tachycardia and rule out apnea. The neonate was discharged from NICU to the Well-Baby Nursery on September 29, 2015, under NICU care.

Review of on October 5, 2015, of MR23 revealed a birth date of July 30, 2015. The neonate was admitted to NICU on July 30, 2015, for crying, cyanosis and respiratory distress. The mother had a history of Suboxone use. The neonate transferred to the Well-Baby Nursery on July 31, 2015. On August 1, 2015, the neonate experienced seizure-like activity and was transferred back to NICU. On August 2, 2015, the neonate then transferred to the Well-Baby Nursery.

2) Review on October 8, 2015, the facility's policy "Infection Control Dress Code for Mom/Baby [and] Nursery Staff Policy," dated revised May 14, 2015, revealed "Policy All personnel in the Nursery will be required to adhere to the appropriate dress code. Purpose To prevent the spread of infection between newborns, personnel, and ancillary personnel. Equipment Nursing staff: pre-approved uniform, Barrier (such as burp cloth or blanket) Guidelines I. Nursing staff will be required to wear pre-approved uniform. II. Nursing staff will be required to remove all hand and wrist jewelry, except wrist watch and a wedding band. III. Nursing staff will apply clean burp cloth or blanket to provide barrier between neonate and staff member when feeding or holding a neonate. Barriers are maintained for the exclusive use in the the care of the neonate and changed each shift. (Keep barriers in drawer of infant's crib). IV. Fingernails must be kept clean and trimmed to a short length. V. Artificial nails or wraps are not permitted. VI. Ancillary staff will don a clean cover gown when performing testing."

Review on October 8, 2015, of the facility's policy "Infection Control Dress Code for NICU Policy," dated last reviewed April 28, 2015, revealed "Policy All personnel in the NICU will be required to adhere to the appropriate dress code. Purpose To prevent the spread of infection between patients, personnel, and visitors. Equipment a) Nursing staff: pre-approved uniform, white lab coat or blue, pink or white warm-up jacket. Guidelines I. Nursing staff will be required to wear blue scrub pants with a matching blue, white or pink top. A blue, white or pink cover jacket is worn when off the department. II. Nursing staff will be required to wear a long sleeved, buttoned lab coat or warm up jacket or cover gown when leaving the NICU (during work hours). III Nursing staff will be required to remove all hand and wrist jewelry, except a wedding band while caring for infants in the NICU. IV. Nursing will don a clean long sleeved cover gown over their clothing prior to the handling of NICU patients. Cover gowns are maintained for exclusive use in the care of that neonate and changed when soiled, and with each shift change. V. Fingernails must be kept clean and trimmed to a short length. VI. Artificial nails or wraps for nails are not permitted."

Phone interview on October 8, 2015, with EMP3 confirmed the Pediatric Department staff gown only when they feed the neonates transferred to Pediatrics from the NICU.

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