DENCE Regional Medical Center Everett

Nursing Administration

1321 Colby Avenue

Everett, WA 98201

ph. 425-261-4047

December 28, 2020

Pursuant to the Nurse Staffing Law (Patient Safety Act.HB 1714), the following is provided to meet the

regulatory compliance Standard.

1. Matrix by Unit and Shift

2. Chief Executive Attestation Form

Please reach out to me if there are any questions, clarifications, or concerns. I am happy to respond and

clarify to the staffing plan for Providence Regional Medical Center.

Chief Nursing Officer

Providence Regional Medical Center Everett

T: 425.26 1.4077 I P : 425 .303.4849 I janine.holbrook@providence.org

DENCE Regional Medical Center Everett

DENCE Regional Medical Center Everett

DENCE Regional Medical Center Everett

Nurse Staffing Coalition

Jan1, 2021

I, the undersigned with responsibility y for Providence Regional Medical Center Everett, attest that the

attached staffing plan and matrix was developed in accordance with RCW70.41.420 for 2020 and

includes all units covered under our hospital license under RCW70.4 1. This plan was developed with

consideration given to the following elements (please check):

IXl Census, including total numbers of patients on the unit on each shift and activity such as

patient discharge, admissions, and transfers;

IXl Level of intensity of all patients and nature of the care to be delivered on each shift;

IXl Skill mix;

IXl Level of experience and specialty certification or training of nursing personnel providing care;

IXl The need for specialized or intensive equipment;

IXl The architecture and geography of the patient care unit, including but not limited to placement of

patient rooms, treatment areas, nursing stations, medication preparation areas, and equipment;

IXl Staffing guidelines adopted or published by national nursing professional associations, specialty

nursing organizations, and other health professional organizations;

IXI Availability of other personnel supporting nursing services on the patient care unit;

IXI Strategies to enable registered nurses to take meal and rest breaks as required by law or the terms

of an applicable collective bargaining agreement, if any, between the hospital and a representative of

the nursing staff

This staffing plan was adopted by the hospital on:

12/28/2020 As approved by Kim Williams, CEO

Kim E. Wi lliams, MS, RN, FA CH E

Chief Executive Officer Providence

Heath & Services

Northwest Washington Service Area

Nurse Staffing Plan Scope

The following areas of the hospital are covered by the nurse staffing plan:

• Emergency Department

• Cardiovascular Lab (CVL)

• Interventional Radiology (IR)

• Radiation Oncology

• Wound Ostomy Clinic

• Surgical Services

• Endoscopy

• Infusion Services

• Surgical Home

• Surgery Pre-op and PACU

• A - 3 Medical Unit

• A - 5 Medical Renal Unit

• A - 6 Med-Surg (Close Observation Unit)

• A - 7 General Medical Unit

• C - 3 Pediatric/Adult Med-Surg Unit

• C - 4 Clinical Evaluation Unit (CEU Observation)

• D - 6N Thoracic & Vascular Care Unit

• D – 6S Medical Intensive Care Unit (MICU)

• D – 7N Cardiac Telemetry Unit

• D – 7S Surgical Intensive Care Unit (SICU)

• D – 8N Neurosurgery Unit

• D – 8S Orthopedic Unit

• D – 9N Oncology Unit

• D- 9S Surgical Unit

• D –10N Medical Telemetry Unit

• D – 10S Telemetry Unit

• P – 1S Behavioral Health

• P – 2N Med-Surg Pacific

• P – 2S Inpatient Rehabilitation Facility (IRF) Pacific

• P – PAV Neonatal Intensive Care Unit (NICU) Pacific

• P – PAV Obstetrics Family Maternity Center (FMC) L&D, Ante-partum and Post-Partum Pacific

• P – PAV Post-partum Clinic Pacific

• P – 1N Maternal Fetal Medicine Pacific

• P – PAV Lactation Services Pacific

Unit

ED

Week Day Weekend

Census RN EDT HUC RN CNA HUC

7:00 12 4 1 12 4 1

8:00 12 4 1 12 4 1

9:00 18 5 1 19 4 1

10:00 18 5 1 19 4 1

11:00 26 6 1 25 6 1

12:00 26 6 1 25 6 1

13:00 32 7 1 28 6 1

14:00 32 7 1 28 6 1

15:00 33 8 1 28 6 1

16:00 33 8 1 28 6 1

17:00 33 8 1 28 6 1

18:00 33 8 1 28 6 1

19:00 33 7 1 28 6 1

20:00 33 7 1 28 6 1

21:00 32 7 1 28 6 1

22:00 32 7 1 28 6 1

23:00 28 5 1 27 6 1

12:00 28 5 1 27 5 1

1:00 22 5 1 22 5 1

2:00 22 5 1 22 5 1

3:00 17 5 1 17 4 1

4:00 17 5 1 17 4 1

5:00 13 3 1 13 4 1

6:00 13 3 1 13 4 1

Unit Radiation Oncology

CENSUS RN MA

90-100 2 2

60-79 2 1

Up to 59 2 0

Unit In Patient Wound Clinic M-F

Hours: 08:00 to 16:30

Provider 1

RN 2 to 3

CAN 1

Scheduler 1 to 2

Cumulative each hour

PACU PACU

Week Day Weekend

RNs HCNA On Call

RNs RNs HCNA

On Call RNs

midnight 1 0 2 1 0 2

1:00 1 0 2 1 0 2

2:00 1 0 2 1 0 2

3:00 1 0 2 1 0 2

4:00 1 0 2 1 0 2

5:00 1 0 2 1 0 2

6:00 1 0 2 1 0 2

7:00 2 0 0 0 0 2

8:00 6 1 0 2 0 0

9:00 12 2 0 2 0 0

10:00 14 2 0 3 0 0

11:00 16 2 0 3 0 0

Noon 16 2 0 3 0 0

13:00 16 2 0 3 0 0

14:00 16 2 0 3 0 0

15:00 16 2 0 3 0 0

16:00 16 2 0 3 0 0

17:00 15 2 0 3 0 0

18:00 9 2 0 3 0 2

19:00 6 1 0 2 0 2

20:00 4 0 0 2 0 2

21:00 3 0 2 1 0 2

22:00 1 0 2 1 0 2

23:00 1 0 2 1 0 2

Cumulative each hour

Admissions/Preop Admissions/Preop

Weekday Saturday

RNs HCNA MA's RNs HCNA MA's

midnight 3 0 0 3 0 0

1:00 3 0 0 3 0 0

2:00 3 0 0 3 0 0

3:00 3 0 0 3 0 0

4:00 3 0 0 3 0 0

5:00 3 6 0 3 0 0

6:00 20 6 2 3 1 0

7:00 27 9 2 3 1 0

8:00 30 9 2 4 1 0

9:00 34 10 2 4 1 0

10:00 36 11 2 4 1 0

11:00 38 11 2 4 1 0

Noon 38 11 2 4 1 0

13:00 38 12 2 4 1 0

14:00 38 12 2 4 1 0

15:00 38 12 2 4 1 0

16:00 21 6 2 4 1 0

17:00 16 3 2 4 1 0

18:00 12 3 0 2 0 0

19:00 12 2 0 2 0 0

20:00 9 1 0 0 0 0

21:00 5 1 0 0 0 0

22:00 3 1 0 0 0 0

23:00 3 1 0 0 0 0

Unit Name: Endoscopy

Unit Surgical Home

Core Staffing Monday-Friday

Advance Practice Caregivers 2

MA'S 3

Scheduler/Health Unit Coord 1

Admissions/Preop (2N + 3N) - Colby

A- 6A Medical Medical/Surgical (Close Observation)

A- 5A Medical Renal

A- 3A Medical

A- 7A- General Medical

Day NOC Day NOC Day 8Hr EVE 8Hr NOC

CENSUS Chg RN Chg RN RN RN HUC/CNA HUC/CNA HUC/CNA

13 1 1 3 3 1 1 0

12 1 1 3 3 1 1 0

11 1 1 3 2 1 1 0

10 1 1 2 2 1 1 0

9 1 1 2 2 1 0 0

8 1 0 2 2 1 0 0

7 0 0 2 2 1 0 0

6 0 0 2 2 0 0 0

5 0 0 2 2 0 0 0

4 0 0 2 2 0 0 0

3 0 0 2 2 0 0 0

2 0 0 2 2 0 0 0

1 0 0 2 2 0 0 0

C- 3C Pediatrics/Adult Med-Surg

C- 4C Close Observation Unit

D- 6N Thoracic Vascular

D-6S Medical ICU (MICU)

DAY SHIFT/NIGHT SHIFT

Patient

Census

Charge RN

Patient Care RN

Resource RN

CNA

Total # Staff

1 1 1 0 0 2

2 1 1 0 0 2

3 1 2 0 0 3

4 1 2 0 0 3

5 1 3 0 0 4

6 1 3 0 0 4

7 1 4 0 0 5

8 1 4 0 0 5

9 1 5 0 1 7

10 1 5 0 1 7

11 1 6 1 1 9

12 1 6 1 1 9

13 1 7 1 1 10

14 1 7 1 1 10

15 1 8 1 1 11

16 1 8 1 1 11

17 1 9 1 1 12

18 1 9 1 1 12

19 1 10 1 1 13

20 1 10 1 1 13

21 1 11 1 1 14

22 1 11 1 1 14

23 1 12 1 1 15

24 1 12 1 1 15

25 1 13 1 1 16

26 1 13 1 1 16

27 1 14 1 1 17

28 1 14 1 1 17

Day Eve 1 Eve 2 NOC Day Eve 1 Eve 2 NOC Day Eve 1 Eve 2

CENSUS RN RN RN RN NAC NAC NAC NAC HUC HUC HUC

32 10 10 10 10 4 3 3 3 1 1 1

31 10 10 10 10 4 3 3 3 1 1 1

30 10 10 10 10 3 3 3 2 1 1 1

29 10 10 10 10 3 2 2 2 1 1 1

28 10 10 9 9 3 2 2 2 1 1 1

27 9 9 9 9 2 2 2 2 1 1 1

26 9 9 9 9 2 2 2 2 1 1 1

25 9 9 8 8 2 2 2 2 1 1 1

24 8 8 8 8 2 2 2 2 1 1 1

23 8 8 7 7 2 2 2 1 1 1 1

22 8 8 7 7 2 1 1 1 1 1 1

21 7 7 7 7 2 1 1 1 1 1 1

20 7 7 6 6 2 1 1 1 1 1 1

19 7 7 6 6 2 1 1 1 1 1 1

18 7 7 6 6 2 1 1 0 1 1 1

17 6 6 6 6 1 1 1 0 1 1 1

16 6 6 5 5 1 1 1 0 1 1 1

15 6 6 5 5 1 0 0 0 1 1 1

14 5 5 5 5 1 0 0 0 1 1 1

13 5 5 5 5 0 0 0 0 1 1 1

12 5 5 4 4 0 0 0 0 1 1 1

11 4 4 4 4 0 0 0 0 1 0 0

10 4 4 3 3 0 0 0 0 1 0 0

9 4 4 3 3 0 0 0 0 1 0 0

D- 7N Cardiac Telemetry

D-7S Surgical ICU (SICU)

DAY SHIFT/NIGHT SHIFT

Patient

Census

Charge RN

Patient Care RN

RRT

Resource RN

CNA

Total # Staff

1 1 1 1 0 0 3

2 1 1 1 0 0 3

3 1 2 1 0 0 4

4 1 2 1 0 0 4

5 1 3 1 0 0 5

6 1 3 1 0 0 5

7 1 4 1 0 0 6

8 1 4 1 0 0 6

9 1 5 1 0 0 7

10 1 5 1 0 0 7

11 1 6 1 1 0 9

12 1 6 1 1 0 9

13 1 7 1 1 0 10

14 1 7 1 1 0 10

15 1 8 1 1 0 11

16 1 8 1 1 0 11

17 1 9 1 1 0 12

18 1 9 1 1 0 12

19 1 10 1 1 0 13

20 1 10 1 1 0 13

D-8N Neuro-Telemetry

D- 10N Medical-Telemetry

D- 10S Telemetry

D- 9N Oncology

D-8S Orthopedics

D- 9S Surgical

Unit P 1S-Behavioral Health DAY SHIFT NOC SHIFT

CENSUS RN CNA HUC RN CNA

14 2 0 1 2 0

13 2 0 1 2 0

12 2 0 1 2 0

11 2 0 1 2 0

10 2 0 1 2 0

9 2 0 1 2 0

8 2 0 1 2 0

7 2 0 1 2 0

6 2 0 1 2 0

5 2 0 1 2 0

4 2 0 1 2 0

3 2 0 1 2 0

2 2 0 1 2 0

1 2 0 1 2 0

Unit P-2N MedSurg

DAY SHIFT

EVENING 1

EVENING 2

NOC

CENSUS

RN

CNA

CNA

R N

CNA

CNA

RN

CNA

CNA

RN

CNA

CNA

19 3 3 *3 3 3 *3 3 3 *3 3 3 *3

18 3 3 *3 3 3 *3 3 3 *3 2 2 *3

17 3 3 *3 3 2 *3 3 2 *3 2 2

16 3 3 *3 3 2 *3 3 2 *3 2 2

15 2 2 2 2 2 2 2 2

14 2 2 2 2 2 2 2 2

13 2 2 2 2 2 2 2 2

12 2 2 2 2 2 2 1 2

11 1 2 1 2 1 2 1 2

10 1 2 1 2 1 2 1 2

9 1 2 1 2 1 2 1 2

8 1 2 1 2 1 2 1 2

Unit P-2S IRF

DAY SHIFT

EVENING 1

EVENING 2

NOC

CENSUS

RN

CNA

HUC

RN

CNA

HUC

RN

CNA

HUC

RN

CNA

19 4 3 0.5 4 3 0.5 4 3 0.5 4 2

18 4 2 0.5 4 2 0.5 4 2 0.5 3 2

17 4 2 0.5 4 2 0.5 4 2 0.5 3 2

16 4 2 0.5 4 2 0.5 4 2 0.5 3 2

15 3 2 0.5 3 2 0.5 3 2 0.5 3 2

14 3 2 0.5 3 2 0.5 3 2 0.5 3 1

13 3 2 0.5 3 2 0.5 3 2 0.5 3 1

12 3 1 0.5 3 2 0.5 3 2 0.5 2 1

11 3 1 0.5 3 1 0.5 3 1 0.5 2 1

10 2 1 0.5 2 1 0.5 2 1 0.5 2 1

9 2 1 0.5 2 1 0.5 2 1 0.5 2 1

8 2 1 0.5 2 1 0.5 2 1 0.5 2 0

7 2 0 0.5 2 1 0.5 2 1 0.5 2 0

6 2 0 0.5 2 0 0.5 2 0 0.5 2 0

5 2 0 0 2 0 0 2 0 0 2 0

4 2 0 0 2 0 0 2 0 0 2 0

3 2 0 0 2 0 0 2 0 0 2 0

2 2 0 0 2 0 0 2 0 0 2 0

1 2 0 0 2 0 0 2 0 0 2 0

Unit NICU

Shift

Nurse

NRRT

CNA

HUC

0630 to 1900

12

1

1

1

1830 to 0700

12

1

1

1

NICU Staffing Acuity

1:1 (1)

• Unstable and vulnerable infant requiring many simultaneous interventions more than every

hour

• Ventilated infant with complex respiratory status (HFOV, JET,INO)

• Multiple/Unstable chest tubes

• Multiple blood transfusions

• Exchange transfusion

• Hemodynamically unstable infant with multiple drips and frequent titrations

• Multiple central lines that requires frequent medications and fluid administrations

Unstable infant with seizures

• Complex IV fluid and medications administrations (i.e. multiple antibiotics, drips, severe

acid/base

or electrolytes corrections)

• Hemodynamically unstable (i.e. anuria, oliguria, severe adrenal insufficiency) requiring

close monitoring and intermittent treatment

1:2 (0.5)

Stable ventilated infants, CPAP, NIPPV, HFNC >2L

Frequent apnea and bradycardia spells requiring interventions > 5 times each shift (for possible

work-up)

Frequent apnea and bradycardia on babies who are already on caffeine and 02 but still having

events (8-10 times/24 hours that are needing interventions)

Multiple access sites: PICC/UVC, VAC/PAL

Seizure controlled by anticonvulsant but with Intermittent symptoms.

Unstable NAS, scoring above 10 even on treatment

Arrhythmias requiring IV meds

Stable chest tubes

Nursing interventions/assessment/family interactions every 1-2 hours

1:3 (0.33)

NC, HENC </= 2L

Seizures controlled by medications and /or weaning from medications

Captured NAS on medications, scores <8

Occasional apnea and bradycardia, spells not requiring interventions

Phototherapy

R/O sepsis on antibiotics

Resolving hypoglycemia, weaning from IV fluid and working up on po feeding

NG feeding

AD lib feeding

Patient being discharge

Formula= Multiply 1:1 patients xl

Multiply 1:2 patients x 0.5

Multiply 1:3 patients x 0.33

Add total to equal number of needed nurses. Always round up. Add 2 for charge and flex

NICU Staffing Plan

Daily staffing 24/7

• 1 HUC

• 1 CN

1 Flex RN (to do transports, PICCs and deliveries as able)

Unit Family Maternity

Day NOC Total

Fixed Numbers

L&D Charge RN 1 1 2

Postpartum Charge 1 1 2

Triage RN 3 3 6

Flex Nurse 2 2 4

Surgical Techs 8hr 1 1

Surgical Techs 12 hr 2 2 4

HUC/CNA 1 1 2

HUC 2 2 4

C.N.A 2 2 4

L&D

CENSUS DAY NOC TOTAL RN

L&D Pts.

0 1 1 2

1 2 2 4

2 3 3 6

3 3 3 6

4 4 4 8

5 5 5 10

6 6 6 12

7 7 7 14

8 8 8 16

9 9 9 18

10 10 10 20

INDUCTIONS DAY NOC TOTAL RN

1 1 1 2

2 2 2 4

3 3 3 6

4 4 4 8

5 5 5 10

6 6 6 12

SCHED. C-SEC. DAY NOC TOTAL RN

1 2 0 2

2 3 0 3

3 4 0 4

4 4 0 4

ANTEPARTUM DAY NOC TOTAL RN

3 1 1 2

4 2 2 4

5 2 2 4

6 2 2 4

7 3 3 6

8 3 3 6

9 3 3 6

10 4 4 8

PP COUPLETS 4TH FLOOR CNA

PP COUPLETS 4TH FLOOR

DAY

NOC

TOTAL RN

DAY

NOC

TOT. CNA

1 1 1 2 0 0 0

2 1 1 2 0 0 0

3 1 1 2 0 0 0

4 2 2 4 1 1 2

5 2 2 4 1 1 2

6 2 2 4 1 1 2

7 3 3 6 1 1 2

8 3 3 6 1 1 2

9 3 3 6 1 1 2

10 3 3 6 1 1 2

11 4 4 8 2 2 4

12 4 4 8 2 2 4

13 4 4 8 2 2 4

14 5 5 10 2 2 4

15 5 5 10 2 2 4

16 5 5 10 2 2 4

17 6 6 12 2 2 4

18 6 6 12 2 2 4

19 6 6 12 2 2 4

20 7 7 14 2 2 4

21 7 7 14 2 2 4

22 7 7 14 2 2 4

23 8 8 16 2 2 4

24 8 8 16 2 2 4

25 8 8 16 2 2 4

26 8 8 16 2 2 4

27 9 9 18 2 2 4

28 9 9 18 2 2 4

29 9 9 18 2 2 4

Post-Partum Outpatient Clinic:

Staff Hours

ARNP (1) Mon - Wed 0800-1700

RN (2) Sun - Sat 0830-1700

Scheduler (1) Sun - Sat

730-1600

Maternal Fetal Medicine:

Staff hours

MD (2) Mon – Fri 830-1700

ARNP (1) Mon, Tues, Thu, Fri 0830-1700

Genetic Counselor (1) Mon-Fri 0900-1600

Dietician (1) Mon, Tues, Thu, Friday 0800-1700

LCSW (1) Mon, Tue, Thu 0800-1630

RN (3) Mon - Fri 0700-1730

MA (3) Mon, Tue, Thu, Friday. 0700-1730

*On Wed there will be (2) MA 0730-1630

Ultra Sound Tech (5) Mon – Fri 0830-1700

Scheduler (4) Mon – Fri 0630-1700

Unit Lactation

Day

Night

RN

1

1