HospitalInspections.org

Based on interview and record review, the hospital failed to ensure there were two nurses physically in the PICU at all times when a patient was present as per the hospital's P&P. This failure had the risk to cause adverse patient outcomes.

Findings:

Review of the hospital's P&P titled Admission, Discharge, Transfer Criteria PICU dated July 2023 showed there shall be no less than two nurses physically present in the PICU at all times when a patient is present.

On 9/11/24 at 1504 hours, an interview and concurrent record review was conducted with the PICU Manager. The PICU Manager was asked about PICU staffing on 8/20/24. The PICU Manager reviewed the lunch break book and stated she covered the lunch breaks for two PICU nurses on the day shift at 1300 hours. The PICU Manager stated there were only two patients in the PICU at the time, so she sent the two PICU nurses on break at the same time, leaving her as the only nurse in the PICU.

On 9/12/24 at 0933 hours, an interview and concurrent record review was conducted with the PICU Manager and the Director, Maternal Health. The PICU Manager was asked about PICU staffing on 9/10/24 on the overnight shift. The PICU Manager reviewed the staffing and transport log. The PICU Manager stated there was one patient in the PICU and only one nurse on the unit from 0420 to 0648 hours. The PICU Manager stated that was not normal practice and there should be two nurses in the PICU when they had a patient.