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Based on interview and record review, the hospital failed to ensure one RN who floated to NICU met the basic requirements for the NICU RN. This failure posed the increased risk of substandard health outcomes to the patients cared for in the NICU.

Findings:

Review of the Hospital Plan for the Delivery of Care (Scope of Service) Department/Unit Plan dated 10/26/23, showed the Patient Care Department is the Neonatal Intensive Care Unit. The section of Scope of Service showed the ages of patients are the high-risk infants whose medical and/or nursing needs exceed the care given in a newborn nursery or acute care unit that have been continuously cared for in another nursery, NICU, or from home may be admitted into the hospital's NICU. The section of Qualifications of Staff showed the Registered Nurse is to oversee and participate in the successful delivery of quality patient care to the NICU patient by assessing, planning, implementing, and evaluating patient care. The RNs are NRP and PALS certified and perform all duties within the scope of licensure utilizing the nursing process.

On 12/4/24 at 1300 hours, review of NICU NOC (4 South) Patient Assignment Night Shift 7 pm to 7:30 am was conducted with the Director of NICU. The Director of NICU was asked for the RN who floated to the NICU (4 South) on 11/9/24. The Director of NICU stated RN 4 floated to the NICU from the 4th floor Medical Unit. The Director of NICU was asked for the patients to which RN 4 was assigned. The Director of NICU stated RN 4 floated to NICU was assigned to two patients.

On 12/4/24 at 1550 hours, an interview and concurrent record review of RN 4's certification or training record was conducted with the Director of Regulatory Affairs, Director of HR Compliance & Associate Relations, Senior Disability Case Manager, Nurse Manager 5, Nurse Manager 4, Nurse Manager 6, Nurse Educator 1, Nurse Educator 2, and HR Manager 3. The Director of HR Compliance & Associate Relations, Senior Disability Case Manager, Nurse Manager 5, Nurse Manager 4, Nurse Manager 6, Nurse Educator 1, Nurse Educator 2, and HR Manager 3 were asked to show the NRP certificate for RN 4. The Director of HR Compliance & Associate Relations, Senior Disability Case Manager, Nurse Manager 5, Nurse Manager 4, Nurse Manager 6, Nurse Educator 1, Nurse Educator 2, and HR Manager 3 could not show RN 4's certificate or training record for NRP.

The finding was shared with the Director of Regulatory Affairs and Director of NICU.