Women & Infants Hospital of Rhode Island

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43881 Based on review of hospital policies, medical records, labor and delivery staffing and census records, and interviews with nursing staff and hospital leadership, it was determined that the hospital failed to meet the requirements of CFR §482.23, Condition of Participation: Nursing Services, related to the provision of nursing services and staffing sufficient to meet the documented nursing care needs of patients on the Labor and Delivery unit. The hospital failed to ensure that nursing assignments and available nursing resources were sufficient to meet the documented care needs and required level of nursing observation of 14 patients receiving continuous infusion of Oxytocin on the Labor and Delivery unit during the 7:00 PM to 7:00 AM shift from 8/2/2026 through 8/3/2026, despite escalation of staffing concerns through the hospital’s established chain of command (A-0392). Findings are as follows: A CMS-authorized Substantial Allegation Survey was conducted at Women and Infants Hospital in response to an allegation of potential noncompliance. The survey included review of the requirements of CFR §482.23, Condition of Participation: Nursing Services. The investigation identified concerns regarding the hospital’s ability to provide nursing care consistent with the documented needs and acuity of patients receiving care on the Labor and Delivery unit during the 7:00 PM to 7:00 AM shift from 8/2/2026 through 8/3/2026. During the shift under investigation, staffing concerns were escalated through the hospital’s chain of command to the Nursing Supervisor, Nursing Director, and Physician Safety Officer. Despite escalation of the concerns, the hospital did not provide additional nursing resources during the period reviewed. Review of the medical records identified patients requiring continuous nursing observation and/or frequent nursing assessments. The investigation further identified missed nursing assessments and insufficient documentation to demonstrate that required patient monitoring was consistently performed in accordance with hospital policy. During the shift under review, 14 patients were receiving continuous infusions of intravenous Oxytocin. The presence of high-acuity patients (a patient, situation, or care setting that requires a high level of medical attention, monitoring, nursing care, or clinical intervention because of the severity or complexity of the condition), requiring frequent assessment and monitoring, combined with the missed documented assessments, demonstrated that the nursing resources available during the shift were not sufficient to consistently provide the nursing care required by the patients assigned to the unit. The hospital’s failure was further demonstrated by the escalation of staffing concerns through multiple levels of the hospital’s chain of command without provision of additional nursing resources and by the identification of missed patient assessments and monitoring during the same period. The deficient practice resulted in patients not receiving required nursing assessments and monitoring during a period in which staffing concerns had been escalated through the hospital’s chain of command and nursing resources had not been increased. The failure to provide the nursing care required by the patients’ documented needs placed affected patients at risk for serious harm. This noncompliance created the potential for an immediate threat to the health and safety of patients. On 8/13/2026, at approximately 1:50 PM, the survey team determined that the hospital’s deficient practice constituted Immediate Jeopardy (IJ) under §482.23 Nursing Services. On 8/13/2026, the hospital submitted an Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. The IPOC indicated that the following would be immediately implemented on 8/14/2026 at 3:00 PM: “1. The [Labor & Delivery] LDC Nurse Director provides a written staffing plan expected over the upcoming weekend to the Nurse Supervisor to include the Nurse Director’s contact information and, if necessary, to strategize staffing issues. 2. The Chain of Command algorithms are posted at the nursing station in the LDC [labor & delivery]. 3. Labor & Delivery nurses read and acknowledge understanding of applicable policies/guidelines listed below by signing an attestation prior to the start of their next shift. 4. All nurse supervisors will receive one-on-one retraining regarding escalating concerns using the Chain of Command policy prior to their next shift. Emphasis shall be placed upon circumstances involving throughput or staffing-related concerns that are unable to be resolved by either unit leadership or the Nurse Supervisor. In those circumstances, the Nurse Supervisor shall escalate the issue to the unit Director followed by the Administrator on Call. 5. Revise [policy] WIH-OB-IN-013 Oxytocin for Augmentation and/or Induction policy to prioritize patient care based on clinical acuity, huddle with the interdisciplinary team, and consider temporarily discontinuing IV oxytocin for an already-underway elective induction of labor. 6. At the start of the shift, two charge nurses will collaboratively review patient assignments to ensure assignments are appropriate for clinical complexity.” The IJ was abated on 8/14/2026, at approximately 3:00 PM, after the State Survey Agency verified that the hospital had implemented immediate corrective actions sufficient to remove the Immediate Jeopardy. 45769”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 43881 Based on review of hospital policies, medical records, interviews with nursing staff and hospital leadership, the hospital failed to ensure that licensed nursing personnel adhered to the hospital’s policy for assessment and monitoring of patients receiving Pitocin (oxytocin) (is a prescription uterotonic medication used to induce or strengthen labor contractions and to control postpartum bleeding, typically administered intravenously or intramuscularly in a hospital setting), as evidenced by 4 of 5 sampled patients whose medical records did not demonstrate that required maternal and fetal assessments and monitoring were performed and documented at the frequency required by hospital policy during the 7:00 PM to 7:00 AM shift from 8/2/2026 through 8/3/2026. Findings are as follows: According to a document titled, “Standards for Professional Registered Nurses Staffing for Perinatal units” as published by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), “Maternal and fetal status should be assessed every 15 minutes for patients receiving oxytocin for labor induction or augmentation as well as every time oxytocin dose is adjusted. This assessment includes determination of baseline rate; variability; presence or absence of accelerations; presence or absence of decelerations; contraction frequency, duration, and intensity; uterine resting tone, and the maternal-fetal response to the medication ...” The documents further states that, “Patient assignment for women receiving oxytocin for labor induction or augmentation should be 1 nurse to 1 woman to be able to assess maternal and fetal status every 15 minutes, consistent with safe care. If a nurse cannot clinically evaluate the effects of medication at least every 15 minutes, the oxytocin infusion should be discontinued until that level of maternal and fetal care can be provided ...1 nurse to 1 woman during the active pushing phase of the second stage of labor in continuous bedside attendance ...” The AWHONN guidance further identifies 1:1 nursing assignment for women receiving oxytocin as appropriate to permit the required maternal and fetal assessment. The AWHONN guidance is cited as supporting professional practice information; the regulatory deficiency is based on the hospital’s failure to follow its own established policy. The hospital’s policy titled, “Oxytocin for Augmentation and/or Induction” states in part, Documentation: Fetal heart rate (FHR) and uterine activity, maternal blood pressure, pulse, and respirations are assessed and documented every 15 minutes after every oxytocin infusion dose increase. Document FHR and uterine activity every 30 minutes when oxytocin is infused at a steady rate. Utilize annotation “strip reviewed by RN” at 15 minutes ... The above hospital policy lists the AWHONN. (2021). Fetal Heart Monitoring Principles and Practices (5th ed.) and AWHONN. (2020) Cervical Ripening and Labor Induction and Augmentation (5th ed). Review of the hospital’s policy titled, “Fetal Monitoring-Electrical Fetal Monitoring”, effective August 2024 states in part, ...Active phase of labor(6-9cm) every 15-minute review of strip by registered nurse... 1. Review of the medical record for Patient ID #1 revealed that vital signs were documented at 12:42 AM on 8/3/2026, with no subsequent vital signs documented until the patient entered the operating room at 1:50 AM, for a total of 1 hour and 8 minutes without documented vital-sign assessment. The medical record revealed that Patient ID #1 received a Pitocin infusion beginning at 1:56 PM. The record did not demonstrate that (Fetal Heart Rate) FHR and uterine activity were documented every 30 minutes while Pitocin was infusing, as required by hospital policy. There was no FHR or uterine activity documentation was identified from 1:00 AM until 2:11 AM, after delivery by cesarean section. 2. Review of the medical record for Patient ID #2 revealed that vital signs were documented at 2:18 AM on 8/3/2026, with no subsequent vital signs documented until 7:35 AM for a total of 5 hours and 17 minutes without documented vital-sign assessment. The record further revealed that Patient ID #2 received a Pitocin infusion beginning at 2:18 AM. The medical record did not demonstrate that FHR and uterine activity were documented every 30 minutes while Pitocin was infusing, as required by hospital policy. There was no documentation of FHR or uterine activity that was identified from 4:45 AM until 7:35 AM, representing approximately 2 hours and 50 minutes without the required documented assessment. 3. Review of the medical record for Patient ID #4 revealed documentation that the FHR strip was monitored at 12:44 AM and 12:56 AM. The record did not demonstrate subsequent FHR strip review at the required 15-minute interval until 2:02 AM. There was no documentation that was identified demonstrating the required 15-minute FHR strip review from 12:56 AM through 2:02 AM, a period of approximately 1 hour and 6 minutes. Additionally, the record did not demonstrate FHR strip review at the required intervals or completion of the required comprehensive fetal assessment from 3:45 AM through 6:33 AM, a period of approximately 2 hours and 48 minutes without the required documented assessment. The medical record did not demonstrate that the required FHR assessments and monitoring were performed and documented at the frequency established by hospital policy while Patient ID #4 was in active labor. 4. Review of the medical record for Patient ID #5 revealed that the FHR was last documented at 1:56 AM. The record did not demonstrate subsequent FHR strip review at the required 15-minute intervals or completion of the required comprehensive fetal assessment following the 1:56 AM assessment. The medical record documented delivery at 5:04 AM. Therefore, the record did not demonstrate that the FHR assessments and monitoring required by hospital policy were performed and documented from 1:56 AM through delivery for a total of 3 hours and 8 minutes. Interviews were conducted with several nursing staff on the Labor and Delivery unit on 8/12/2026. The staff interviewed included Employee N, Employee O, and Employee P, consistently indicated that nurses were being assigned two patients that required one-to-one monitoring. Staff indicated that staffing concerns had been communicated to nursing leadership, however, they reported that the response was generally to rearrange patient assignments to determine which nurses could be assigned two patients. Employee N indicated that patients receiving intravenous (IV) magnesium, patients undergoing a trial of labor after cesarean section (C-section), and patients who were actively pushing also required one-to-one nursing care, but reported that these patients were also being assigned to nurses who were also caring for another patient. Staff identified specific dates on which staffing was inadequate but were unable to provide specific patient names. Staff also voiced concerns regarding patients having to wait in the Emergency Department (ED) before being transferred to the Labor and Delivery Unit. Employee P indicated that staff discuss turning off or decreasing Pitocin with providers but reported that not all providers agree with doing so. Employee P further stated that the night shift was “scary” because “newer staff” were working this shift and there was not enough support available. During a surveyor interview on 8/12/2026 at 11:09 AM with (Employee Q), she stated that she had been a nurse on the Labor and Delivery Unit for 2 years. She confirmed that she reported to work on 8/2/2026 but left at 9:45 PM for personal/sick time. She explained that she had been assigned one patient in active labor who had begun pushing. She reported that her patient was subsequently assigned to another nurse, Employee Y, who already had another patient. She indicated that staffing on the unit was not adequate and observed that nurses were “doubled up” during the shift. She stated that the charge nurse asked her to remain on the unit for approximately 15 minutes so that patient assignments could be rearranged. She indicated that she did not see the Nursing Supervisor come to the unit during the time she was present. She revealed that she had previously been assigned two patients simultaneously who were receiving Pitocin, and that this had occurred more frequently recently. She stated that during orientation she was taught that patients receiving Pitocin require one-to-one nursing care, however, she reported that this had not been the practice, particularly during the summer. She stated that this had not happened to her frequently but that she had observed it occurring with newer nurses. Although assigning two patients receiving Pitocin to one nurse was not an appropriate assignment, she would not question the assignment. She stated that she had been taught to communicate staffing concerns to the charge nurse and, if the assignment could not be changed, to document the concern and submit an unsafe staffing report. She acknowledged that staff sometimes forgot to complete the report because the unit could become very busy. She also reported seeing several instances in which Pitocin was stopped after the provider was contacted but was unable to provide additional details. She stated that she had seen text messages sent to staff regarding opportunities for double-time pay and that staff generally responded to the “blast” pages. During an interview with the Labor and Delivery Nursing Director, (Employee A) on 8/5/2026, she stated that she was the Director on Call for 8/2/2026. She reported that two nurses called out for the 7:00 AM to 7:00 PM shift, reducing staffing to 13 nurses for patient care and one charge nurse. Overtime was offered, and two nurses accepted, restoring staffing to 15 nurses for patient care and one charge nurse. The Nursing Director reported that at approximately 4:00 PM, two additional nurses called out for the 7:00 PM to 7:00 AM shift. At that time, the previously held Emergency Department patients had been admitted to the Labor and Delivery unit. At approximately 5:00 PM, the Nursing Director was notified that the unit census was 17 patients, with two additional patients having delivered and one patient ready for transfer to the postpartum unit. She stated that the day charge nurse expressed concern that the upcoming shift would have 14 nurses available for patient care and one charge nurse for 17 patients. An overtime request had been issued. The Nursing Director further reported that the night charge nurse communicated that the unit was expected to be busy and that multiple patient assignments would need to be changed to accommodate changes in patient acuity. At approximately 9:30 PM, the Nursing Director communicated with the Nursing Supervisor and was informed that one nurse had left the unit at approximately 9:45 PM due to illness and that a replacement could not be obtained, leaving 13 nurses available for patient care and one charge nurse. During an interview on 8/11/2026, the Assistant Chief Nursing Officer, (Employee B) stated that she reviewed the Labor and Delivery patient census for 8/3/2026 and provided documentation showing a census of 19 patients between 12:01 AM and 2:00 AM. She stated that the patient board was very active and that nurses were frequently changing assignments to accommodate changing patient acuity. She confirmed that 13 nurses were providing patient care with one charge nurse during this period. During an interview on 8/11/2026, the Nursing Supervisor, (Employee S) stated that initial staffing consisted of 15 nurses, including one charge nurse who did not have a patient assignment, leaving 14 nurses available for patient care. She confirmed that after one nurse left at approximately 9:45 PM, 13 nurses remained available for patient care, in addition to the charge-nurse. The Nursing Supervisor was asked whether she was aware that the Labor and Delivery census was 19 patients at midnight. She stated that she was not aware and stated that there would not be 14 nurses caring for 19 patients and that management would have been called if that level of coverage was required. Based on review of hospital policies, medical records, Labor and Delivery staffing and census records, and interviews with nursing staff and hospital leadership, it was determined that the hospital failed to ensure that the nursing service had sufficient numbers of nursing personnel to meet the documented nursing care and monitoring needs of the patient population on the Labor and Delivery unit during the 7:00 PM to 7:00 AM shift from 8/2/2026 through 8/3/2026. 45769”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 43881 Based on record review and staff interviews, the hospital failed to ensure members of the medical staff accurately documented patient care and verified medication administration for 1 of 3 Rh-negative (a blood type that lacks lacks the Rh factor, a protein on red blood cells) patients reviewed, (Patient ID #1). This resulted in physician documentation indicating that Rhogam (a medication that helps prevent the patient’s immune system from developing antibodies that could harm a future Rh-positive pregnancy), had been administered when the medication had not been given. Findings are as follows: According to the hospital’s “Medical Staff Association Bylaws” last revised on 6/25/2025 states in part, “...All clinical entries in the patient’s medical record shall be authenticated...” Record review revealed that Patient ID #1 presented to the Emergency Department in June of 2026 for management of an ectopic pregnancy. The patient’s blood type was documented as O negative (Rh-negative), and an order for Rhogam was entered into the medical record on 6/29/2026 at 11:59 AM. Review of the Emergency Department provider note authored by Employee B, a first-year Obstetrics Resident, documented that Rhogam was “given in triage.” Review of the History and Physical completed by Employee C, a third-year Obstetrics Resident, also documented that Rhogam was “given in triage.” Record review of the Medication Administration Record failed to reveal evidence that Rhogam had been administered in the Emergency Department or at any time during the hospitalization. During a surveyor interview on 7/13/2026 at 2:36 PM with Employee G, Obstetrics and Gynecology Physician, she stated that Employee B reported documenting Rhogam as “given” because she believed that once the medication had been ordered, it had been administered. Employee G further stated that Employee C reported assuming Rhogam had been administered in the Emergency Department based on Employee B’s documentation that the medication had been given. During a surveyor interview on 7/10/2026 at 9:20 AM with the Clinical Effectiveness Manager, Employee I, she confirmed that, despite the patient’s Rh-negative status and the documented order, Rhogam was not administered before the patient was discharged from the hospital.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 43881 Based on record review and staff interviews, the hospital failed to ensure nursing staff supervised and evaluated the nursing care of 1 of 3 Rh-negative (a blood type that lacks the Rh factor, a protein on red blood cells) patients reviewed by failing to communicate changes in the patient’s plan of care during handoff and failing to administer an ordered medication prior to discharge, (Patient ID #1). Findings are as follows: The hospital’s policy titled, “Medication and Standardized Times” effective 10/3/2023 states in part, “...Review the Medication Administration Record, paying particular attention to the date and time the medication was last administered, as well as other medications ordered/administered...” Record review revealed Patient ID #1 presented to the Emergency Department in June of 2026 after an outpatient ultrasound identified an ectopic pregnancy. The patient’s blood type was documented as O negative (Rh-negative), and an order for Rhogam (a medication that helps prevent the patient’s immune system from developing antibodies that could harm a future Rh-positive pregnancy) was entered into the electronic medical record on 6/29/2026 at 11:59 AM. Record review revealed that at 12:53 PM, Employee D, Emergency Department Registered Nurse, provided handoff report to the Operating Room Charge Nurse. At 12:56 PM, Employee D documented in a Quick Update note that, per Employee E, a fourth-year Obstetrics Resident, Rhogam was to be administered in the Post Anesthesia Care Unit (PACU) following surgery. Record review failed to reveal evidence that the updated plan for postoperative administration of Rhogam was communicated to Operating Room or PACU staff. Review of the PACU nursing documentation, Medication Administration Record, and discharge documentation failed to reveal evidence that nursing staff identified the outstanding medication order or administered Rhogam prior to discharge. During a surveyor interview on 7/10/2026 at 2:00 PM with Employee D, Emergency Department Registered Nurse, she stated that she received instructions for Rhogam to be administered to the patient in the PACU after providing handoff to the Operating Room and did not call back to communicate the instructions because she believed staff could see the medication order in the electronic medical record. When asked what she would do differently, Employee D stated that, she would contact the Operating Room to communicate that Rhogam was to be administered following surgery. During a surveyor interview on 7/10/2026 at approximately 12:00 PM with Employee F, PACU Registered Nurse, she stated that if the patient’s Rh-negative blood type was not communicated during handoff, she would typically ask. When asked whether she would question the absence of a Rhogam order for an Rh-negative patient following surgical management of an ectopic pregnancy, Employee F stated that she typically would. During surveyor interviews on 7/13/2026 at 11:00 AM and 1:05 PM with Employee H, Nurse Director of Surgical Services, he stated that although the Rhogam order remained visible in the Medication Administration Record, it did not appear in the PACU nursing workflow because the order had been acknowledged in the Emergency Department. Employee H acknowledged that this contributed to nursing staff not identifying the medication for postoperative administration. During a surveyor interview on 7/10/2026 at 9:20 AM with the Clinical Effectiveness Manager, Employee I, she confirmed that, despite the patient’s Rh-negative status and the documented order, Rhogam was not administered before the patient was discharged from the hospital.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46539 Based on record review and staff interview, the hospital failed to ensure that 1 of 4 patients reviewed (Patient ID #1) was able to participate in the implementation of his/her plan of care when nursing staff failed to administer scheduled pain medication prior to discharge. This failure resulted in the patient experiencing unmanaged pain, inconsistent with the established pain management plan. Findings are as follows: Review of the hospital policy titled “Pain Management - Adult” stated, in part: “ ...Pain-related interventions ... Initiate pharmacological interventions in collaboration with the patient and family as ordered ...” A complaint submitted to the Rhode Island Department of Health in January 2026 alleged that, prior to discharge, the patient requested pain medication; however, it was not administered, and the patient described the ride home as “nearly unbearable.” Record review indicated that Patient ID #1 was admitted in January 2026 for a planned cesarean section. Review of the patient ’ s plan of care identified the following: Problem: Pain Goal: “Patient ’ s pain/discomfort is manageable” Interventions: Included assessing and monitoring pain using an appropriate scale and collaborating with the interdisciplinary team to implement interventions as ordered. Review of the Medication Administration Record (MAR) indicated the patient was scheduled to receive ibuprofen 800 mg at 6:30 PM. Further review of the MAR failed to demonstrate documentation that the medication was offered, administered, or refused. Record review indicated the patient was discharged at 7:25 PM, after the scheduled medication administration time. During an interview conducted on 03/12/2026, the Clinical Effectiveness Manager was unable to provide evidence that Patient ID #1 received the scheduled pain medication prior to discharge.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 43881 Based on record review and staff interview, the hospital failed to ensure that 1 of 4 patients reviewed (Patient ID#1) was able to participate in the implementation of his/her plan of care when a physician (Employee A) failed to respond to nursing staff’s repeated requests for pain management during labor. This failure resulted in the patient experiencing unmanaged labor pain, contrary to his/her expressed pain management plan. Findings are as follows: A complaint submitted to the Rhode Island Department of Health in September of 2025 alleged in part that during an induction of labor at the hospital, Patient ID #1 was “forced” to “endure unnecessary pain, suffering, and trauma.” The complaint further alleged that an epidural (anesthesia injection) was requested “again” for pain “when the pain became extremely tortuous,” but the patient was informed that there were no rooms available in the Labor and Delivery Unit. The complaint alleged that the nurse said she would page the doctor for the approval of morphine (medication used to treat pain), but an hour went by without response from the doctor. Patient ID #1 alleged that she/he experienced “uncontrollable body spasms without nothing to manage the pain.” Record review revealed that Patient ID#1 was admitted to the hospital in July of 2025 for an induction of labor. The record revealed a plan of care for the patient that stated the patient was to receive intravenous pain medications on an as needed basis while on the Antenatal Care Unit (ACU) and “per patient request,” the patient was to receive an epidural (anesthesia injection) and nitrous oxide (“laughing gas”) while on the Labor and Delivery Unit. At 10:32 PM on 7/26/2025, the patient rated his/her pain as 6 out of 10 and was administered morphine intravenously. At 12:03 AM on 7/27/2025, the patient’s contractions were described as “strong.” At 12:48 AM, the patient’s nurse (Employee B) paged the physician (Employee A) requesting assessment and “maybe” more intravenous pain medication. Employee A then assessed the patient at 1:10 AM, during which the patient requested an epidural. However, the epidural was not administered. At 1:30 AM, the patient rated his/her pain as 8 out of 10 and it was described as “intermittent,” “gradual,” and “cramping.” Another provider (Employee C) then assessed the patient at 1:47 AM and indicated that during the exam, pain management options were reviewed with the patient, however, no specific orders or plans were documented. At 1:47 AM, Employee B paged Employee A stating that the patient “would like morphine ordered.” However, the record failed to reveal evidence that a morphine order was placed or administered as outlined in the patient’s initial plan of care for as needed intravenous pain medication while in the ACU. At 1:59 AM the patient contractions continued and were described as “strong.” At 2:35 AM, a nursing progress note indicated that the patient’s significant other reported that the patient was “convulsing” with contractions. Employee B indicated in the note that she explained these “labor shakes” and again contacted the Charge Nurse on the Labor and Delivery Unit to report that the patient was “extremely uncomfortable.” At 2:39 AM, the nurse indicated in the record that she was “unable to get the nitrous to work” and spoke to the Charge Nurse in the Labor and Delivery Unit again to “get pt [patient] down ASAP [as soon as possible].” At 2:41 AM, Employee B paged Employee A again, stating that the patient was “super uncomfortable” and to “please put in morphine order.” Employee B further indicated that the nitrous oxide tank was not working because it was broken and to “please” order morphine because the patient was “in agony.” At 3:04 AM, the patient arrived on the Labor and Delivery Unit “very uncomfortable” requesting an epidural. The patient then delivered at 3:10 AM without receiving any pain medication despite his/her requested preferences or Employee B’s efforts to obtain an order for morphine. Additionally, the record failed to reveal evidence that Employee A responded to Employee B’s requests or ordered morphine or alternative analgesia prior to delivery. During a surveyor interview with the Clinical Effectiveness Manager on 7/26/2025, she was unable to provide evidence that Employee A responded to the pain medication requests sent by Employee B or that the patient’s pain was addressed in accordance with his/her plan of care and preferences.”

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 43881 Based on the review of hospital policies, Medical Staff Bylaws, patient records, and staff interviews, it has been determined that the hospital’s medical staff failed to adhere to the hospital’s bylaws as an infant received the incorrect amount of blood ordered for a double exchange transfusion (a procedure that removes toxic blood by replacing the baby’s total blood volume twice with donor blood) in the Neonatal Intensive Care Unit (NICU) (A-0353).”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43881 Based on a review of hospital policies, patient records, and staff interviews, it has been determined that the hospital failed to ensure a licensed nurse adhered to its policies and procedures regarding the administration of blood during an exchange transfusion (a procedure that removes and replaces one’s blood with donor blood) in the Neonatal Intensive Care Unit (NICU) (A-0398). Additionally, the nurse failed to verify the provider’s order for a double exchange transfusion (a procedure that removes toxic blood by replacing the baby’s total blood volume twice with donor blood) and failed to utilize the exchange transfusion document as required by hospital policy (A-0398). As a result, the infant received only half of the blood volume ordered by the physician (A-0398, A-0410).”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 43881 Based on the review of hospital policies, Medical Staff Bylaws, patient records, and staff interviews, it has been determined that the hospital’s medical staff failed to adhere to the hospital’s bylaws as an infant received the incorrect amount of blood ordered for a double exchange transfusion (a procedure that removes toxic blood by replacing the baby’s total blood volume twice with donor blood) in the Neonatal Intensive Care Unit (NICU) for 1 of 3 patients reviewed (Patient ID #1). Findings are as follows: According to the hospital’s policy titled “Blood Administration (NICU)”, the nurse “should verify provider order”. Additionally, the policy titled, “NICU Exchange Transfusion”, states that the “Provider determines a volume of blood to be removed and replaced every several minutes ...An entire cycle of removal of one aliquot [a portion of a larger whole] of blood and infusion of an equal volume of blood should occur over a 3 minute interval...Provider verbalizes ‘in’ and ‘out’ volumes” and the nurse “records all the volumes on the exchange transfusion document which comes in the exchange kit...” According to the hospital’s “Medical Staff Association Bylaws”, “An Attending Physician shall be responsible ultimately for the medical care and treatment of each patient in the Hospital...” Additionally, the bylaws state that “If any clinical caregiver has any reason to doubt or question the care provided to any patient...he or she shall call this to the attention of the supervisor, who in turn may refer the matter to the Chief Medical Officer and the Senior VP of Patient Care Services...” Record review revealed that Patient ID #1 was ordered 510 milliliters of blood to be administered over 153 minutes. The record indicated that during the exchange transfusion, the nurse (Employee A) failed to record the “in” and “out” blood volumes on the designated exchange transfusion document as required by hospital policy. Instead, Employee A recorded the volumes incorrectly on a blank sheet of paper. Employee A’s documentation indicated that 225 milliliters of blood was removed from the patient while only 225 milliliters of blood were administered over a period of 95 minutes. This indicates that the patient should have been transfused with an additional 285 milliliters of blood per the the physician’s order, and was not. Record review of the double exchange transfusion procedure note authored by Nurse Practitioner (Employee C), revealed that a total of 225 milliliters were exchanged during the procedure. This procedure note was then cosigned by the overnight Attending Physician (Employee F) who stated that he had supervised the procedure as the “attending physician on call.” During a surveyor interview on 9/5/2025 at 9:54 AM with Employee C, she explained that she was asked to relieve Employee B who had been performing the exchange transfusion. She stated that she and Employee B completed a “time out” where they verified the patient, confirmed the amount of blood to be removed and replaced, and the time it was to be infused over. Employee C then stated that she had asked the nurse that was recording the procedure, Employee A, if they were on the second bag of blood, to which Employee A replied that they were not. Employee C then stated that she stopped because “something didn’t sit right with me.” She then questioned Employee A again, and she indicated at that time that the blood had been ordered incorrectly. Employee C indicated that after the procedure was completed, she told the Fellow (Employee E) that they should have administered approximately 500 milliliters, but Employee E told her that what they administered was correct. Employee C stated that she did not question Employee E again because she is her “superior.” Employee C then explained that she went to document the procedure in the medical record and again confirmed with Employee E that they had performed a double volume exchange transfusion, and Employee E again indicated that the correct amount of blood had been infused. When asked if she had reviewed Employee A’s documentation for the exchange transfusion, Employee C confirmed that she had not. Upon reviewing Employee A’s documentation with Employee C, she immediately identified that the blood volumes were recorded incorrectly since it appeared that Employee A counted each volume “in” and each volume “out” individually when she should not have. During a surveyor interview on 9/5/2025 at 11:28 AM with the Fellow (Employee E), she explained that she received report from Attending Physician (Employee D). Upon arriving at the patient’s room, she observed Employee B performing the procedure and the nurse recording it. She stated that she did not speak to them because “they seemed to have a good handle on it.” She also stated that at one point, Employee B took over for Employee C during the procedure, but she did not hear what was discussed during their time-out. Employee E reported that when the nurse said the procedure was finished, she noticed “extra blood” but did not question it. She also indicated that during report, Employee D told her that they were performing a double exchange transfusion. However, she stated she was “under the impression it was a single exchange transfusion”, but was unable to explain why. When asked if she had reviewed the order to confirm the amount of blood to be administered to the patient, she stated that she had not. She also confirmed that she did not review Employee A’s documentation for the procedure. During a surveyor interview on 9/4/2025 at 2:40 PM with Employee D, he stated that he was present at the bedside when the exchange transfusion began and supervised Employee B during the initiation of the exchange transfusion. When asked if he had reviewed Employee A’s documentation during the exchange transfusion, he confirmed that he had not. Upon reviewing Employee A’s documentation with Employee D, he immediately identified that the volumes were recorded incorrectly since it appeared that Employee A counted each blood volume “in” and each volume “out” individually when she should not have. During a surveyor interview on 9/5/2025 at 9:14 AM with Employee F, he stated that he supervised the procedure but was not present the entire time. Employee F acknowledged that he cosigned the procedure note but “did not pay attention to the 225” because no concerns were reported to him. Additionally, he acknowledged that he did not review the order to confirm that the amount of blood administered was what was ordered. When asked if he had reviewed Employee A’s documentation when he supervised the exchange transfusion, he confirmed that he had not. Upon reviewing Employee A’s documentation with Employee F, he immediately identified that the volumes were recorded incorrectly since it appeared that Employee A counted each volume “in” and each volume “out” individually when she should not have.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 43881 Based on a review of hospital policies, patient records, and staff interviews, it was determined that the hospital failed to ensure a licensed nurse adhered to its policies and procedures regarding the administration of blood during an exchange transfusions (a procedure that removes and replaces blood with donor blood) in the Neonatal Intensive Care Unit (NICU) for 1 of 3 patients reviewed (Patient ID #1). Specifically, the nurse failed to verify the provider’s order for a double exchange transfusion (a procedure that removes and simultaneously replaces toxic blood from an infant with donor blood with twice their blood volume) and did not utilize the exchange transfusion document as required by hospital policy. As a result, the infant received approximately one half of the blood volume ordered by the physician. Findings are as follows: According to the hospital’s policy titled “Blood Administration (NICU)”, the nurse “should verify provider order”. Additionally, the policy titled, “NICU Exchange Transfusion”, states that the “Provider determines a volume of blood to be removed and replaced every several minutes ...An entire cycle of removal of one aliquot [a portion of a larger whole] of blood and infusion of an equal volume of blood should occur over a 3 minute interval...Provider verbalizes ‘in’ and ‘out’ volumes” and the nurse “records all the volumes on the exchange transfusion document which comes in the exchange kit...” Record review revealed that Patient ID #1 was ordered 510 milliliters of blood to be administered over 153 minutes. The record indicated that during the exchange transfusion, the nurse (Employee A) failed to record the “in” and “out” blood volumes on the designated exchange transfusion document as required by hospital policy. Instead, Employee A recorded the volumes incorrectly on a blank sheet of paper. Employee A’s documentation indicated that 225 milliliters of blood were removed from the patient while only 225 milliliters of blood were administered over a period of 95 minutes. This indicates that the patient should have been transfused with an additional 285 milliliters of blood per the the physician’s order, and was not. During a surveyor interview on 9/4/2025 at 2:10 PM with nurse (Employee A), she indicated that she reviewed the exchange transfusion order, but did not notice that the amount of blood transfused was not what the doctor had ordered. Additionally, Employee A acknowledged that she did not use the exchange transfusion document as required by hospital policy and instead made her own form that she used to document the procedure on. During a surveyor interview on 9/5/2025 at 9:54 AM with Nurse Practitioner (Employee C), she explained that she was asked to relieve Employee B who had been performing the exchange transfusion. She stated she and Employee B completed a “time out” where they verified the patient, confirmed the amount of blood to be removed and replaced, and the time it was to be infused over. Employee C then stated that she asked the nurse recording the procedure, Employee A, if they were on the second bag of blood, to which Employee A replied that they were not. Employee C then stated that she stopped because “something didn’t sit right with me.” She then questioned Employee A again and Employee A indicated at that time that the blood had been ordered incorrectly. Employee C indicated that after the procedure was completed, she told the Fellow (Employee E) that they should have given the patient approximately 500 milliliters, but Employee E told her that what they gave was correct. Employee C stated that she did not question Employee E again because she is her superior. Employee C then explained that she went to document the procedure in the medical record and again confirmed with Employee E that they had performed a double volume exchange transfusion, and Employee E again indicated they had infused the correct amount of blood. During a record review of Employee A’s documentation of the procedure with Employee C, Employee C immediately identified that the blood volumes were recorded incorrectly, as it appeared that Employee A counted each volume “in” and each volume “out” individually when she should not have. During a surveyor interview on 9/4/2025 at 2:40 PM with the Attending Physician (Employee D), he stated that he was present at the bedside when the exchange transfusion began and supervised Employee B during the initiation of the exchange transfusion. This surveyor presented Employee A’s recorded “in” and “out” blood volumes for the patient’s exchange transfusion. Upon reviewing the documentation with Employee D, he immediately identified that the volumes were recorded incorrectly as it appeared that Employee A counted each blood volume “in” and each volume “out” individually when she should not have.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 43881 Based on a review of hospital policies, patient records, and staff interviews, it has been determined that the hospital failed to ensure that the correct amount of blood was administered to an infant during a double exchange transfusion (a procedure that removes toxic blood by replacing the baby’s total blood volume twice with donor blood) in the Neonatal Intensive Care Unit (NICU), in accordance with hospital policy for 1 of 3 patients reviewed (Patient ID #1). As a result of this failure, the infant received approximately one half of the blood volume ordered by the physician. Findings are as follows: According to the hospital’s policy titled “NICU Exchange Transfusion”, a double exchange transfusion is defined as “A procedure to remove whole blood from an infant for the removal of toxic substances with the simultaneous replacement of an equal volume of whole blood lacking toxins. This procedure involves exchanging twice the infant’s calculated blood volume.” Record review revealed that Patient ID #1 was ordered 510 milliliters of blood to be administered over 153 minutes. The record indicated that during the exchange transfusion, 225 milliliters of blood were removed from the patient while only 225 milliliters of blood were administered over a period of 95 minutes. This indicates that the patient should have been transfused with an additional 285 milliliters of blood per the the physician’s order, and was not. During a surveyor interview on 9/4/2025 at 2:10 PM with the nurse (Employee A), she indicated that she reviewed the exchange transfusion order, but failed to identify that the amount of blood transfused was not what follow the doctor had ordered. During a surveyor interview on 9/4/2025 at 2:40 PM with the Attending Physician (Employee D), he acknowledged that the patient received half of the intended amount of blood.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 32374 Based on record review, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation for Emergency Services due to the hospital’s failure to follow their own policy and provide appropriate supervision for 1 of 1 patient being involuntarily detained under an emergency psychiatric certification, who was transferred to the Emergency Department (ED) and was at risk for elopement (Patient ID #1). Findings are as follows: The hospital failed to provide Patient ID #1, the appropriate supervision according to their policy. (A-1104)”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 32374 Based on policy review, record review, and staff interview, it has been determined that the hospital failed to prevent an elopement due to failure to follow their own policy related to “patient sitters” after receiving a report from the transferring facility informing that the patient sent to the emergency department (ED) was being involuntarily detained by an emergency psychiatric certification, for 1 of 1 patient reviewed at risk for elopement, Patient ID #1. Findings are as follows: A facility reported incident was submitted to the Rhode Island Department of Health on 6/27/2025, identifying that on 6/25/2025 at 10:56 PM, a patient that was transferred to the hospitals ED while being involuntarily detained at a psychiatric hospital, and was not provided appropriate supervision and eloped from the ED without being treated. Review of the hospital’s policy titled, “Patient Sitter Role/Constant Observation” last revised May 2023, states in part, ..III. Policy: ...patient sitter will be utilized to ensure patient safety in selected circumstances including but not limited to: Suicide precautions, Potential Elopements ... A review of the patient’s ED medical record revealed a transfer report was given to staff prior to the patient being transferred to the ED explaining that the patient was being sent to the hospital for an evaluation of a possible wound dehiscence (surgical complication in which a wound ruptures along a surgical incision) following a caesarian section on 6/17/2025. The transferring psychiatric facility identified that the patient was currently being involuntarily detained by a psychiatric emergency certification at their facility due to symptoms of postpartum psychosis. Review of the ED documentation reveals the patient arrived by ambulance and was brought to the triage area on 6/25/2025, at approximately 10:29 PM. A Nurse Progress note dated 6/25/2025, at 10:35 PM, indicated there was no bed available in the main ED area and the patient was placed in triage bay 3 to await an evaluation. At 10:38 PM, Staff B went to complete the triage assessment for this patient and noted the patient was missing. Security was notified of the elopement. At 10:40 PM, the ED received call from Security who notified that the patient was observed off hospital grounds, Police were then notified. During a surveyor interview with Employee A on 6/27/2025 at 2:00 PM, she stated that the hospital was informed by the transferring facility that the patient was being involuntarily detained by a psychiatric emergency certification. She acknowledged that both Staff B, and Staff C did not follow the hospital’s policy for “Patient sitters and/or Constant Observation” by their failure to assign Patient ID #1 a constant observation while in the ED.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 45769 Based on policy review, record review, and staff interview, it has been determined that the hospital failed to follow its policy titled, “Patient Discharge/Transfer Policy (Adult)-Inpatient and Outpatient Settings,” by discharging a patient home from the Post Anesthesia Care Unit (PACU), without a physician’s order for 1 of 6 patients reviewed, Patient ID #1. Findings are as follows: A community reported complaint submitted to the Rhode Island Department of Health on 1/3/2025, indicated that a patient was discharged home from the Post Anesthesia Care Unit, prematurely and was contacted by the hospital, the next day to return to the Emergency Room for blood work and further evaluation. Review of the hospital policy titled, “Patient Discharge/Transfer Policy (Adult)-Inpatient and Outpatient Settings” last reviewed 11/2023 states in part... “ ...Procedure 1. All discharges/transfers from the inpatient setting require a written order by the attending provider or designee ...” Review of Patient ID #1’s medical record revealed that the 27 year old, presented to the hospital’s emergency room (ED) on 10/27/2024, for heavy vaginal bleeding. It was also identified that the patient was currently 17 weeks pregnant. While in the ED, the patient continued with heavy bleeding. After physician evaluations and discussion with the patient and their family, it was determined that the only safe option was for the patient to undergo a dilation and evacuation (D&E), a procedure used to terminate a pregnancy in the second trimester (between 13 and 24 weeks). Review of the patient’s Operative Report, dated 10/27/2024 at 4:05 PM, documented that the patient was administered general anesthesia and a ultrasound guided, standard D&E was performed. Review of the patient’s Operating Room PACU Nursing Documentation, completed by Staff A, per diem Registered Nurse, on 10/27/2024, revealed that the patient entered the PACU at 3:50 PM and was discharged home from the PACU at 5:29 PM. Review of the patient’s Physician orders documented a physician order, entered at 4:04 PM by Staff B, 4th year Obstetrical (OB) Medical Resident, to admit the patient to the medical/surgical unit. Patient ID #1’s medical record failed to reveal any evidence of a physician order for the patient to be discharged home. During a surveyor interview on 1/30/2025 at 2:25 PM with Registered Nurse, Staff A, who discharged the patient home, she indicated that she not aware that the patient was going to be admitted to the hospital. She acknowledged that she did not see a discharge to home order. During a surveyor interview with the OB Physician, Staff B, on 1/30/2025, at 1:30 PM, he explained that he wrote an order for Patient ID #1, requesting an inpatient admission to the hospital’s medical surgical unit. Staff B indicated that he enters the admission order into the computer and the nurse is responsible to check the orders. During a surveyor interview with the PACU Anesthesia Physician, Staff C on 1/30/2025, at 2:00PM, he indicated that the PACU Physician is responsible for writing an order documenting that the patient may be discharged from the PACU level of care after they meet the Post Anesthesia Units discharge criteria. He then explained that each physician service is responsible to determine the patient’s next level of care, either an admission to the hospital, or to discharge home, entering an order into the patient’s medical record indicating the patient’s disposition when leaving the PACU. During a surveyor interview with the Assistant Nurse Manager of the PACU, Staff D, on 1/30/2025 at 2:45 PM she acknowledged that Staff A discharged Patient ID #1 from the PACU to home without a discharge order from the OB physician per the hospital’s policy.”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45769 43881 Based on review of medical records, review of facility documents, and staff and patient interviews, it was determined that the Hospital failed to meet CFR, 482.23 Condition of Participation: Nursing Services after the following was identified: - The Nursing Supervisor failed to follow the Chain of Command outlined in the Clinical Escalation of Concern policy to ensure the necessary personnel were available to provide nursing care in the Labor and Delivery unit (A-0386). - The hospital failed to ensure the Labor and Delivery unit had sufficient staff immediately available to provide nursing care to a patient who was induced for labor and had requested an epidural for pain control while on the Antepartum Care Unit, which resulted in the patient experiencing pain for an extended time period subsequently delivering an infant without pain medication as requested. (A-0392). These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients. Findings are as follows: A CMS authorized Substantial Allegation Survey was conducted from 11/4/2024 through 11/8/2024, at Woman and Infants Hospital to determine compliance with the requirements of CFR 482.23 Condition of Participation: Nursing Services following a community reported complaint in which a patient alleged that the hospital did not have sufficient personnel in the Labor and Delivery unit to accommodate the patient’s laboring process and pain control needs. On 11/7/2024, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 482.23 A-0385 Condition of Participation: Nursing Services, related to Patient ID #1 who underwent cervical ripening (the process of softening the opening of the cervix) for the induction of labor in the Antepartum Care Unit on 10/12/2024. During the evening, the patient experienced rapid labor progression and cervical changes which prompted the Midwife to request transfer to the Labor and Delivery Unit at 2:18 AM on 10/13/2024 for further management, comfort measures and/or an epidural. At the time of the request, it was identified that the Labor and Delivery Unit was not adequately staffed and although the unit had an available bed, the patient could not be transferred to the Labor and Delivery unit until 4:23 AM on 10/13/2024. As a result of the identified non-compliance, Patient ID #1 did not receive any additional pain medication after receiving pain medication at 11:29 PM on 10/12/2024. Patient ID #1 had ongoing communication of discomfort and repeated requests for pain medication/epidural from 2:02 AM on 10/13/2024 until 4:23 AM on the same day. The patient was then rushed to the Labor and Delivery Unit without receiving the epidural/pain medication she/he had requested to address his/her pain and subsequently delivered an infant without pain medication, as requested. The hospital’s Director of Risk Management and Professional Practice Specialist were informed of the Immediate Jeopardy, which was identified on 11/7/2024 and were provided with the Immediate Jeopardy template at approximately 11:15 AM on this date. On 11/7/2024, the hospital submitted the Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented: -The hospital created a guideline to clarify adjustment of nursing assignments due to critical level staffing and to support the accommodation of additional patients on the labor and delivery unit. -This guideline will be distributed to the labor and delivery unit nursing staff on November 7, 2024, by the Nurse Director and posted at the nursing station of the Labor and Delivery Unit. -The Labor and Delivery Nursing Director will provide a written staffing plan expected over the upcoming weekend to the Nursing Supervisor to include the Nursing Director’s contact information and, if necessary, to strategize staffing issues. -The Chain of Command algorithms will be posted at the nursing stations of the Labor and Delivery Unit and the Antenatal Care Unit (before birth) on Thursday, November 7, 2024. -Reinforcement of the chain of command with all nursing supervisors via email will be sent by the Chief Nursing Officer on November 7, 2024. On 11/8/2024, interviews with staff on duty on the Antenatal Care Unit and the Labor and Delivery Unit were conducted by the State surveyors and the IPOC was verified as being fully implemented by confirming that staff received and reviewed the escalation of care posting on both units and patient assignment guidelines in the Labor and Delivery Unit. As of 11/8/2024 the IJ was removed.”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 45769 Based on record review and staff interviews, it was determined that the hospital failed to ensure that the Nursing Supervisor followed the Chain of Command outlined in the Chain of Command-Escalation of Concern Policy to ensure the necessary personnel were available to provide nursing care in the Labor and Delivery Unit for 1 of 4 patients reviewed who were induced for labor, (Patient ID #1). Findings are as follows: The hospital’s policy titled, “Chain of Command, Escalation of Care” last revised on 9/2024 states in part... “ ...The Chain of Command is used when a clinical issue or concern arises that is unresolved at the staffing level ...” “ ...Involved parties will proceed to the next level on the chain of command until resolution is reached ...” During a surveyor interview on 11/4/2024 at approximately 10:50 AM with the Nursing Supervisor, Manager, Staff E, she explained that she thinks that on 10/12/2024 the units were “appropriately staffed because the manager wasn’t called.” When asked if she was made aware that the Nursing Supervisor, Staff F, was called by the nursing staff, she stated, “if she was, she did not tell me about it.” She explained that if the unit calls the Nursing Supervisor with a patient issue, the supervisor will usually go up to the unit, and she expects them to go up to the unit as she would do the same as Nursing Supervisor. During a surveyor interview on 11/4/2024 with Nursing Director, Staff I she stated that staffing was critical over the holiday weekend of 10/12 and 10/13. Double time was offered. She then stated that she was never called that night by the nursing supervisor or the labor and delivery room staff to come in and staff the unit. During a surveyor interview on 11/4/2024 at 11:59 AM, with Nursing Supervisor, Staff F, she stated her frustration over the holiday weekend staffing. She went on to say that the staffing throughout the hospital was a challenge due to the abundance of sick calls. At this time, she could not differentiate Saturday night from Sunday night. When asked if she notified the Administrator on call (AOC) of the situation she stated that they were not notified. During a surveyor interview on 11/6/2024, with Registered Nurse (RN) Staff L, when asked if the Nursing Director was called to discuss the staffing needs, she replied that she was so busy she did not have time to call the Director. 43881”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 45769 Based on record review and staff interview it has been determined that the hospital failed to ensure the Labor and Delivery unit had sufficient staff immediately available to provide nursing care to a patient who was induced for labor and had requested an epidural for pain control while on the Antenatal (before birth) Care Unit (ACU) , which resulted in the patient experiencing pain for an extended time period subsequently delivering an infant without pain medication for 1 of 4 patients who were induced for labor in the Antenatal Care Unit, Patient ID #1. Findings are as follows: Review of the medical record revealed that Patient ID #1 was a gravita 1(first pregnancy) Para 0 (birth history) at 41 weeks 2 days, who was a direct admission to the Antenatal Care Unit on 10/12/2024 at 11:38 AM for induction of labor. At 3:42 PM the patient received the first dose of 50 micrograms of Misoprostol (medication used to promote uterine contractions). Review of the patient’s flowsheet revealed that the patient began to complain of pain at 9:10 PM, identifying his/her pain score as a 7. The covering Midwife, Staff H, was paged by Nurse, Staff N to check the patient who was given 8 mg (milligrams) IV (into the vein) of Morphine for pain control and 10 mg of Prochlorperazine for nausea. The patient continued to report a pain level of 7 despite being medicated and at 10:32 PM, Staff H was repaged by Staff N to notify her that the patient was requesting a different pain medication because the Morphine did not help. At 11:29 PM, 57 minutes after the nurse notified Staff H, the patient was given 2 mg of Stadol IV (Narcotic used during labor). Prior to the administration of the Stadol the patient reported a pain level of 7. At 2:02 AM on 10/13/2024, the record revealed that Staff H was paged by Staff N again to come up and evaluate the patient, explaining that the patient remained very uncomfortable despite the Stadol that was given to him/her at 11:29 PM. At 2:15 AM the Charge Nurse, Staff O, documented in the patient’s record that the nursing supervisor was aware that the patient was uncomfortable. At 2:18 AM on 10/13/2024, a vaginal exam was performed by Staff H and the patient was now 5 cm (centimeters) dilated. At 2:21 AM on 10/13/2024, a nursing progress note authored by Staff O, revealed that the labor room was called and updated on the patient’s exam and that the patient was very uncomfortable. Review of the Obstetrics Progress Note authored by Staff H, revealed that given the progress of the patient’s cervical change and discomfort, will send the patient to the labor and delivery room for continue induction. The note also stated that the patient was “ok for comfort measures and or epidural as desired”. At 3:38 AM on 10/13/2024, a nursing progress note authored by Staff O revealed that a call was made to the Labor and Delivery Unit again for a bed and was informed they had no beds. At 3:42 AM on 10/13/2024, a nursing progress note authored by Staff N documented that the patient was very uncomfortable and was asking for an epidural. The note did not reveal any documentation of a pain assessment after 11:29 PM on 10/12/2024. At 3:48 AM on 10/13/2024, a nursing progress note authored by Staff N documented that the Nursing Supervisor was called to come up to talk to the patient and to check on the status of the Labor and Delivery room bed. At 4:05 AM on 10/13/2024, the record revealed a second vaginal exam documenting that the patient was now 8 cm dilated. At 4:20 AM on 10/13/2024, a nursing progress note authored by Staff O revealed that the Labor and Delivery Unit was called again and was notified that the patient had the urge to push. At 4:23 AM on 10/13/2024, the patient was assigned bed 14 on the Labor and Delivery Unit and arrived on the unit at 4:33 AM. At 4:37 AM on 10/13/2024, a vaginal exam revealed the patient was now 10 cm dilated, and 100% effaced. At 4:43 AM on 10/13/2024, review of the delivery room progress note authored by Staff J, revealed that the patient was requesting an epidural and anesthesia was made aware. The note also revealed that the patient was pushing involuntary. At 5:08 AM on 10/13/2024, Staff J documented that the patient was on his/her hands and knees pushing and bleeding was noted. At 5:09 AM on 10/13/2024, Certified Nurse Midwife, Staff D arrived to the room for delivery. The record revealed an OB Vaginal Delivery/Labor and Delivery Summary Note dated 10/13/2024 authored by Staff D which stated that the patient arrived from the Antepartum Care Unit to the Labor and Delivery Unit spontaneously pushing and an infant was born. The patient’s medical record revealed that the patient did not receive pain medication after 11:29 PM on 10/12/2024. The record also failed to reveal documentation that the Nursing Supervisor came to speak to the patient after being requested by the staff. During a surveyor interview on 11/6/2024 at 2:00 PM with Patient ID #1, she/he explained that on 10/12/2024 at approximately 4:30 PM, she/he received the first dose of an induction medication and described his/her response to the medication as, “fast and furious” as his/her body responded quickly. She/he indicated that at 8:30 PM, she/he received the second dose of the induction medication and by the time she/he was 5 centimeters dilated, she/he requested an epidural but was told by either the “nurse or the Midwife that a room was not available in the labor unit as there were no staff available.” She/he stated that staff told him/her, nothing could be done, and she/he would have to stay in ACU. The patient explained that she/he was checked again at some point by the Midwife who told her/her that she/he was now 8 centimeters dilated and staff began to “panic” that she/he was progressing quickly, and staff were eventually running him/her down the hall on a stretcher toward the labor room, with his/her spouse running behind. The patient stated that she/he was told not to push while in route, but his/her body was pushing on its own and she/he was 10 centimeters dilated by the time she/he arrived at the Labor room. The patient revealed she/he was told they had to “piece together staff” to accommodate delivery. During a surveyor interview with Staff H, Certified Nurse Midwife, on 11/4/2024 at 12:27 PM, she revealed that when she presented to her overnight shift on 10/12/2024 at 5:30 PM, Patient ID #1’s induction was already in process and explained that she “had to push very hard” to get Patient ID #1 to the Labor and Delivery Unit since she and other staff thought the patient would deliver his/her baby in the Antenatal Care Unit. Staff H stated that the Labor and Delivery Unit was going to take the patient when the patient was 5 centimeters dilated, but this did not happen. She revealed that when the patient was 8 centimeters dilated, the supervisor was notified, but the patient was still not transferred to the Labor and Delivery Unit. Staff H then stated that eventually, the Nursing Supervisor took the role of Charge Nurse on the Labor and Delivery Unit so that the nurse could take over the care of the patient. Staff H indicated that “the Labor and Delivery Unit had rooms available at the time, but not staff.” Review of email correspondence between the Risk Manager and the Certified Nurse Midwife Director, Staff B, dated 11/6/2024 at 6:12 PM revealed that she briefly reviewed this case with the Midwives on duty on 10/12/2024. Staff B stated in the email that the “primary issues” related to the patient’s care had to do with nurse staffing on the Labor and Delivery Unit “impacting patient flow rather than provider clinical decision-making” which caused “delays in transfer.” During a surveyor interview on 11/6/2024 with Registered Nurse (RN) Staff L, she stated that she was the dedicated Charge Nurse on the Labor and Delivery Unit on the night of 10/12/2024 from 7:00 PM to 7:00 AM. Staff L stated that she had voiced her concerns to the Nursing Director of the unit on 10/8/2024, regarding the number of RN vacancies on the night shift for the upcoming holiday weekend. She explained that at the time, there were 4 RNs out on a medical leave of absence, 2 RNs out on workmen’s compensation and 4 RNs with previously approved vacation requests. Staff L indicated that the previous shift had a total of 17 RNs, 16 RNs for patient care and 1 RN as Charge Nurse who does not take a patient assignment. She explained that the Labor and Delivery Unit has the capacity for 16 patients, along with a catch and recover c-section room and 1 alternative birthing room. Staff L stated that at 7:00 PM the staffing level of the Labor and Delivery Unit dropped down to 15 RNs, 14 RNs for patient care and 1 RN as Charge Nurse. At 11:00 PM, the staffing level dropped again to 10 nurses for the care of 12 patients. Staff L then explained that at 8:00 PM on 10/12/2024 the Nursing Director of the unit called her to check in and go over the board. At that time, there were 3 patients in the Emergency Department in labor and 4 patients on the Antenatal Care Unit who were undergoing IOL (induction of labor). Staff L stated that the advice that she received from the Director was not to take anyone to the unit unless they were ready to deliver or in need of an epidural. She went on to say that the Director was aware that the staffing numbers would decrease at 11:00 PM and she stated that she would call back prior to the shift to review the staffing plan. Staff L indicated that at 9:00 PM, the “patient board” was reviewed with the Maternal Fetal Medicine Attending Physician, herself, and the Nursing Supervisor. Staff L was then asked about her communication with the ACU Charge Nurse, Staff O, regarding Patient ID #1. She revealed that she remembered hearing about the patient when she was 5 cm dilated and at that time, she was told that the patient had been medicated with IV Morphine for pain. Staff L then stated that she was not made aware of the patient’s request for an epidural or her continued discomfort. The next call she received regarding Patient #1 was at 4:20 AM when the patient was 9 cm dilated and she immediately rearranged the staffing to accommodate the patient and notified the Nursing Supervisor to come up and assist. Staff L explained that the unit had an available bed, but not enough staff to cover all the rooms. When asked if the Nursing Director was called to discuss the staffing needs, she replied that the Director was going to call the unit back and at the time Staff L stated she was so busy she did not have time to call the Director. During a surveyor interview on 11/4/2024 at 11:59 AM with Nursing Supervisor, Staff F, she stated her frustration over the holiday weekend staffing. She went on to say that the staffing throughout the hospital was a challenge due to the abundance of sick calls. At this time, she could not differentiate Saturday night from Sunday night. She explained that the ED triage was busy and staffing was a challenge on all the units especially in the Labor and Delivery Unit, and she is only one person. She indicated that she did not recall going to the unit to speak to Patient ID #1 and stated that the staff often calls her when a patient is upset about not being able to be transferred to the Labor and Delivery Unit. In addition, Staff F stated that there are two issues that impact Labor and Delivery beds, adequate number of staff and bed availability. 43881”