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Based on review of facility documentation and personnel files (PF), and staff interviews (EMP), it was determined that the facility failed to ensure that a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

Findings include:

Review of Policy MCH 1.1, Staffing Maternal Child Health, reviewed December 2, 2011, revealed, "... III. Procedure/Protocol: A. When preparing a schedule for MCH, the staffing goal is 1 RN for labor and delivery; 1 RN for nursery; and 1 RN or LPN for postpartum every shift, every day. In addition to full time and part time employees, float pool, cross-trained hospital employees, and on call staff is utilized as needed. B. AWHONN [Association of Women's Health, Obstetrics and Neonatal Nurses] guidelines and close evaluation of all factors involved in a specific case is essential in establishing an acceptable nurse/patient ratio. Variables such as birth weight, gestational age, and diagnosis of patients; patient turnover; acuity of patients' conditions; patient or parent education needs; bereavement care; mixture of skills of the staff; environment; types of deliveries; and use of anesthesia must be taken into account in determining appropriate nurse/patient ratios. C. In the event of significant changes in census, acuity, and/or staff availability the director or administrative supervisor will assess the necessity for adjustment in staffing pattern. D. In the event there is no patient census, one MCH nurse will available in house. ..."

Review of Policy MCH 1.2, Service Goals and Objectives for Maternal Child Health, reviewed June 2009, revealed, "... III. Text: A. Delivery Suite ... 2. Goal: To provide surveillance and quality care to all patients admitted to the delivery suite, with an established triage system for identifying high-risk/complicated patients who should be transferred to a facility that provides specialty or subspecialty care. 3. Objectives: To provide competent nursing staff 24 hours a day. To provide quality care per AWHONN Standards for Professional Nursing Practice in the Care of Women and Newborns. ... B. Postpartum/GYN Unit ... 2. Goal: To provide quality patient care that meets the normal physiologic and psychosocial needs of the antepartum, postpartum, or gynecological patient. 3. Objectives: To provide competent nursing staff 24 hours a day. To provide quality care per AWHONN Standards for Professional Nursing Practice in the Care of Women and newborns. ... C. Newborn Nursery ... 2. Goal: Surveillance and care of all newborns delivered, with stabilization and transfer of any newborn who on the basis of socioeconomic, genetic or pathophysiologic history prior to delivery or on the basis of findings in the neonate period, manifests or is likely to manifest persistent and significant signs of distress (high-risk neonates). 3. Objectives: To provide competent nursing staff 24 hours a day. To provide quality care to the apparently normal full-term or pre-term neonate who has demonstrated successful adaptation to extrauterine life. ..."

Review of "AWHONN Guidelines for Professional Registered Nurse Staffing for Perinatal Units, copyright 2010, revealed, "... Models of staffing that may be appropriate for medical-surgical units are not applicable to perinatal care. Staffing plans for perinatal units should include estimates of patient volume that count admissions, discharges, and 'less than full day' patients such as women that present for obstetric triage ... 'Hours per patient day' and/or 'midnight census' models are not applicable in planning perinatal nurse staffing, because they are not appropriately adjusted for risk and do not consider the dynamic nature of caring for women during labor and birth, the frequent admissions and discharges assigned to one nurse on a shift that influence workload, or the large volume of triage patients and outpatients who often present to the perinatal unit for care ... Adequate education and competence validation related to the care of such patient should be provided ... For the purposes of this document, the staffing ratios recommended assume that the nurse with primary responsibility for each type of patient and clinical situation listed has been adequately oriented to the clinical unit and has demonstrated at least entry-level competence in the area of practice ... Table 2 Summary of Guidelines for Professional Registered Nurse Staffing for Perinatal Units (See the full text for assumptions and conditions that may affect the stated ratios in each instance.)" Review of Table 2 revealed that for Antepartum, one to one staffing would be appropriate for a "woman presenting for initial obstetric triage; a woman with antepartum complications who is unstable; and ... continuous bedside attendance for woman receiving IV magnesium sulfate for the first hour of administration for preterm labor prophylaxis and no more than 1 additional couplet or woman for a nurse caring for a woman receiving IV magnesium sulfate in a maintenance dose". For Antepartum, staffing would be one to two/three for the following patients: "women during nonstress testing; women in obstetric triage after initial assessment and in stable condition; women with antepartum complications in stable condition; and women receiving pharmacologic agents for cervical ripening". For Intrapartum, staffing would call for one to one in the following instances: "woman with medical (such as diabetes, pulmonary or cardiac disease, or morbid obesity) or obstetric (such as preeclampsia, multiple gestation, fetal demise, indeterminate or abnormal FHR pattern, women having a trial of labor attempting vaginal birth after cesarean birth) complications during labor; woman receiving oxytocin during labor; woman laboring with minimal to no pain relief or medical interventions; woman whose fetus is being monitored via intermittent auscultation; continuous bedside nursing attendance to woman receiving IV magnesium sulfate for the first hour of administration; 1 nurse to 1 woman ratio during labor and until at least 2 hours postpartum and no more than 1 additional couplet or woman in the patient assignment for a nurse caring for a woman receiving IV magnesium sulfate during postpartum; continuous bedside nursing attendance during initiation of regional anesthesia until condition is stable (at least for the first 30 minutes after initial dose); continuous bedside nursing attendance to woman during the active pushing phase of second-stage labor". For Intrapartum, staffing calls for one to two for "women in labor without complications". For Intrapartum, staffing calls for two to one for "birth; 1 nurse responsible for the mother and 1 nurse whose sole responsibility is the baby". For Postpartum and Newborn Care, staffing would call for one to one for the following: "continuous bedside nursing attendance to woman in the immediate postoperative recovery period (for at least 2 hours); newborn boy undergoing circumcision or other surgical procedures during the immediate preoperative, intraoperative and immediate postoperative periods; newborn requiring multisystem support; unstable newborn requiring complex critical care". For the Postpartum and Newborn Care, staffing would call for one to two/three for the following: "mother-baby couplets after the 2-hour recovery period (with consideration for assignments with mixed acuity rather than all recent post-cesarean cases); women on the immediate postoperative day who are recovering from cesarean birth as part of the nurse to patient ratio of 1 nurse to 3 mother-baby couplets; women postpartum with complications who are stable; newborns requiring continuing care; newborns requiring intermediate care; newborns requiring intensive care". For the Postpartum and Newborn Care, staffing would call for one to five/six for the following: "women postpartum without complications (no more than 2-3 women on the immediate postoperative day who are recovering from cesarean birth as part of the nurse to patient ratio of 1 nurse to 5-6 women without complications); healthy newborns in the nursery requiring only routine care whose mothers cannot or do not desire to keep their baby in the postpartum room". For the Postpartum and Newborn Care, staffing calls for one nurse in the following: "at least 1 nurse physically present at all times in each occupied basic care nursery when babies are physically present in the nursery; at least 1 nurse available at all times with skills to care for newborns who may develop complications and/or need resuscitation".

1. Review of staffing sheets for the Maternal/Child Health unit failed to consistently designate which staff were on orientation and failed to consistently identify which section (post partum, nursery, and labor and delivery) of the Maternal/Child Health Unit each staff person was assigned to work. Twenty-eight of 36 shifts reviewed revealed the use of orientees to staff a particular section of the OB unit without proof of the orientee being "signed off" of orientation for that section or an explanation of how assignments were handled when there were only two nurses and three sections of the unit to be staffed. Examples include:

a) November 1, 2011, between 7:00 AM and 3:00 PM the staffing sheet revealed there were five moms, five babies, and two women in the labor and delivery area; the assignment sheet revealed one trained RN assigned to the nursery, a surgical RN (with no documentation of orientation to the OB unit) for post partum, and an orientee assigned to Labor and Delivery (L&D).

b) November 9, 2011, between 7:00 AM and 3:00 PM the staffing sheet revealed there were two moms, two babies, and two outpatients. By interview with staff, outpatients are placed in the Labor and Delivery area of the hospital. There were two trained RNs assigned, with an orientee assigned with no designation of what section they would work in. An orientee was listed as "on call."

c) November 9, 2011, between 3:00 PM and 11:00 PM an orientee was listed as working until 7:00 PM (replaced by a trained RN at 7:00 PM) one trained RN, and one orientee. There were two moms, two babies, and two outpatients during the shift. Specific assignments were not distinguishable on the assignment sheets. By interview with staff, the outpatients would be placed in the Labor and Delivery area. This would leave orientees in sections of the department without trained staff with them.

d) November 11, 2011, between 7:00 AM and 3:00 PM there were three patients in L&D, one patient in observation in the L&D, and one delivery; a trained RN was listed in L&D. One orientee, not marked as being on orientation, was assigned to the nursery and two orientees were assigned to the post partum section.

e) November 11, 2011, between 3:00 PM and 11:00 PM there were three patients in L&D, two outpatients, and one delivery; one orientee was listed as working part of the shift and being replaced by a trained RN the rest of the shift, and an orientee was assigned to the post partum section.

f) November 13, 2011, between 11:00 PM and 7:00 AM there were three moms, three babies and an outpatient, there were two trained RN's, one assigned to the post partum and L&D area, and one assigned to the nursery.

g) November 13, 2011, between 7:00 AM and 3:00 PM there were three moms, three babies, one gynecological patient, two in L&D, and one outpatient; a trained RN was assigned to the L&D, and one orientee presumably assigned to post partum. There was a note that a second RN was called in, but there was not a name of that person listed.

h) November 13, 2011, between 3:00 PM and 11:00 PM there was a trained RN and an orientee until 7:00 PM and a trained RN on call, the schedule reflected there was one mom, one baby, and one in L&D.

i) November 18, 2011, between 7:00 AM and 3:00 PM when there was one mom, one baby, and two in L&D; there were also two deliveries. The schedule reflected there were two trained RN's and an orientee assigned to work.

j) November 18, 2011, between 3:00 PM and 11:00 PM there was a discrepancy between the staffing sheet and the assignment sheet, making it unable to be determined if there were three trained RN's working for one mom, one baby, and one in L&D, or if there were two trained RN's and one trained RN on call.

k) November 23, 2011, between 7:00 AM and 3:00 PM there were five moms, five babies, and two in L&D; there were two trained RN's, an RN from surgery without documentation of orientation to the unit and two orientees.

l) November 23, 2011, between 3:00 PM and 11:00 PM there were five moms, five babies, and one in L&D, there were two trained RN's sharing a shift, one working from 3:00 to 7:00 PM and the other working 7:00 PM to 11:00 PM, an orientee sharing a shift with a trained RN, and 2 orientees. It was unclear if another person listed was pulled from another location in the hospital or if she had ever been oriented to the unit.

m) December 30, 2011, between 11:00 PM and 7:00 AM there were two moms, two babies, and one in L&D; there was a delivery during the shift. The schedule reflected there were two trained RN's to cover the three areas. One RN was assigned to post partum and the nursery, and one was assigned to L&D.

n) December 30, 2011, between 7:00 AM and 3:00 PM there were two moms, two babies, one L&D, four outpatients and one delivery. The schedules revealed there were three trained RN's and two orientees assigned to work. It was unable to be determined from the schedules which sections the nurses were assigned to work.

o) December 30, 2011, between 3:00 PM and 11:00 PM there were two moms, two babies, one in L&D, one in observation in L&D, and two outpatients for a trained RN working from 3:00 PM-7:00 PM, another trained RN working from 7:00PM to 11:00 PM, a trained RN working from 3:00 PM to 11:00 PM, and an orientee. It was unable to be determined from the schedule where each nurse was assigned to work.

p) January 18, 2012, between 11:00 PM and 7:00 AM there were four moms, four babies, and two in L&D with two trained RN's. One of the RN's was assigned to the post partum and L&D and the other to the nursery. A third trained RN was called in at 4:00 AM.

q) January 18, 2012, between 7:00 AM and 3:00 PM there were four moms, four babies, two in L&D, three outpatients and two deliveries. There was a trained RN assigned to L&D, a surgical nurse with no documentation of orientation to the unit, an orientee assigned to the nursery, and an additional trained RN position split between three RN's.

r) January 18, 2012, between 3:00 PM and 11:00 PM there were three moms, three babies, and one in L&D; the assignments showed there were two trained RN's and an orientee that was assigned to the nursery.

s) March 1, 2012, between 7:00 AM and 3:00 PM there were three moms, three babies, two gynecological patients, one L&D, one outpatient, and one delivery. The assignment reflected there were two trained RN's assigned to L&D and nursery and an orientee that was assigned to post partum.

t) March 1, 2012, between 3:00 PM and 11:00 PM there were four moms, four babies, one gynecological patient, one in L&D, one ambulatory surgical patient, and one outpatient; two trained RN's were assigned to L&D and nursery and an orientee was assigned to post partum.

u) March 4, 2012, between 7:00 AM and 3:00 PM there was one mom, one baby, and one outpatient; one trained RN was assigned to work post partum and L&D, and an orientee was assigned to work in the nursery.

v) March 4, 2012, between 3:00 PM and 11:00 PM there were no patients, the trained RN was pulled to work a unit in the hospital without documentation of orientation to that unit (SNF), an orientee remained on the unit from 3:00 PM until 7:00 PM, and a trained RN worked 7:00 PM to 11:00 PM. An orientee was listed on call.

w) March 14, 2012, between 11:00 PM and 7:00 AM there were two moms, two babies, and an outpatient; two trained RN's were assigned, one to post partum and one to nursery. There was no designation of who was responsible to take care of any outpatients that would be placed in L&D.

x) March 14, 2012, between 7:00 AM and 3:00 PM there were two moms, two babies, three gynecological patients, one outpatient that had not prenatal preventative care, and two deliveries, one of which had post partum hemorrhaging; there was one trained RN for L&D, one orientee assigned to the nursery, and one surgical RN with no documentation of orientation to the unit until 1:00 PM. A trained nurse came in at 1:00 PM and was available if needed while prepping for a class that evening.

y) March 14, 2012, between 3:00 PM and 11:00 PM there was one mom, one baby, and two gynecological patients; there were two trained RN's assigned to post partum and L&D, an orientee until 7:00 PM in the nursery, and an orientee assigned to post partum.

z) March 16, 2012, between 11:00 PM and 7:00 AM there were two moms, two babies, two gynecological patients, one L&D, and one outpatient; there were two trained nurses assigned, one to the nursery, and one to post partum and L&D.

aa) March 16, 2012, between 7:00 AM and 3:00 PM there were two moms, two babies, two gynecological patients, one outpatient, one patient in L&D, and another observation patient in L&D; there were two trained RN's, one assigned to L&D, and one to the nursery. An orientee was assigned to post partum.

2. Review of personnel files revealed PF4, PF6, PF7, and PF8 were hired July 2011. A blank orientation sheet to the Maternal/Child Health unit revealed specific duties for the post-partum section, the nursery section, and the Labor and Delivery section with a box. Some of the boxes contained initials with no dates or times. At the end of the form was a line for sign off when the person had completed orientation. Interviews with staff revealed inconsistent meaning to the initials in the boxes. Interview on April 30, 2012, at 3:45 PM with EMP10 revealed, "Each [orientee] has a sheet [for orientation] for sign off. We are supposed to sign off. We refuse. We are not comfortable with it. [EMP11] just decides when they are off orientation ... The initials may mean that they have observed it once or they might mean that they are competent to perform that task alone." Interview on May 1, 2012, at 8:35 AM with EMP5 revealed, "[EMP11] doesn't sign off on orientation."

3. Interviews conducted on April 30-May 2, 2012, between 8:15 AM and 4:35 PM with EMP7, EMP10, EMP12, and EMP14 confirmed that staff were sometimes assigned to work different sections of the unit before they were oriented or before the orientation was completed for that section.

4. Review of PF3 did not reveal a Unit Orientation Checklist. The facility failed to provide this documentation while the surveyors were onsite from April 30-May 2, 2012.

5. Review of PF6 and PF7 did not reveal a Unit Orientation Checklist. EMP11 stated that the employees are still in possession of these as they are still on orientation.

6. Review of PF12 did not reveal a job description for Maternal Child Health Nurse. Review did not reveal a unit orientation checklist for the Maternal Child Health Unit. Further review revealed an annual performance evaluation from November/December 2011, which revealed, "... Evaluator's Additional Comments: ... EMP16 is cross training to work in the OB department. ..."

7. At approximately 2:45 PM on May 1, 2012, when stated that from the staffing sheets, it is difficult to tell which nurses are responsible for what areas, EMP11 stated, "You're right ..."

8. Between 2:30 PM on April 30, 2012, and 3:15 PM on May 2, 2012, EMP7, EMP10, and EMP12 confirmed knowledge of circumstances where staffing on the Maternal Child Health Unit was insufficient. EMP12 further confirmed being given assignments on the medical floors that the employee did not feel he/she was adequately trained to provide care for such as cardiac monitored patients and patient receiving total parenteral nutrition, lipids, and/or blood products.

Review of Policy SSD 1.0, Staffing in the Operating Room, reviewed April 2012, revealed, "... 3. A surgical team will consist of a registered nurse (circulating nurse), a scrub nurse (either a surgical technician, or a licensed practical nurse or registered nurse with scrub experience) and an anesthesiologist and/or a certified registered nurse anesthetist (not required if local anesthesia). No cases will be done without a full surgical team in the operating rooms and endoscopy room. ... 5. ... Assignments will be based on patient requirements and staff expertise. ... 7. New orientees will not be included in the staffing pattern until the basic orientation period is completed and evaluated, or until basic competency for those scheduled procedures has been deemed adequate. ..."

1. Review of OR staffing assignment sheets from February 1, 2012-May 9, 2012, revealed that EMP25, an orientee, was assigned as scrub; and therefore, counted in staffing 53 of the 57 times that the orientee was working at the facility between February 1, 2012-May 9, 2012. Review further revealed that the orientee was assigned a student, OTH1, on February 21, 2012.

2. Review of the "Orientation Competency Skills Checklist" for PF22 revealed, "Period: ... 9. During the period of orientation, the orientee will not be counted in unit staffing patterns." Further review of the checklist revealed EMP25 to be on orientation. The following sections of the checklist were not complete as of May 10, 2012; Introduction to Unit Organization, Patient Entry Into designated Operating Room, Patient Equipment, Ophthalmology Equipment, Orthopedic, Dental, Vascular, ENT, Scopes, and General Surgery. Before the Operation was completed December 28, 2011. Room Readiness, Sterile Field, Opening Supplies, Patient Leaving The OR and Room Clean UP were signed off on May 2, 2012.

Based on review of facility documents, observation and staff interviews (EMP), it was determined that the facility failed to ensure drugs and biologicals be prepared in accordance with accepted standards of practice in the operative suite.

Findings include:

On May 10, 2012, at approximately 8:50 AM, EMP5 stated that the facility follows the AORN recommendations for the labeling of medications.

Review of facility policy SSD 3.1, revised June 2011 revealed, "III. Policy Statement: Grove City Medical Center believes the utilization of this cited text is a quality reference proving standards, recommended practices and guidelines. IV. Text A. The operating room staff member will utilize the following cited text as a guide regarding operating room procedures: Association of Perioperative Registered Nurses, Inc. 2011 standards, Recommended Practices, and Guidelines. ..."

Review of the 2012 edition of the Perioperative Standards and Recommended Practices utilized by the facility revealed, "RP: Medication Safety ... Recommendation ... VII.e.4. Medications should not be pre-drawn up and stored on the anesthesia cart or elsewhere unless the pre-filled syringes are supplied by the manufacturer or pharmacy VIII.f. Unless the medication is to be administered immediately, all medications removed from the original package and transferred to a secondary container should be clearly marked and easily identifiable ..."

Review of policy NURS1.0, revised November 2011 revealed, "I. Title: Reference Book for Fundamental Nursing Procedures ... Text: A. The Nursing department staff member will utilize the following cited text as a guide regarding fundamental nursing procedures: Smith, Sandra f., Duell J., and Martin, Barbara C. (2012) Clinical Nursing Skills: Basic to Advanced Skills 8th ed., Prentice Hall , New Jersey. ..."

Review of Clinical Nursing Skills: Basic to Advanced Skills 8th ed., Prentice Hall , New Jersey (Smith, Sandra f., Duell J., and Martin, Barbara C. (2012)) revealed, "Chapter 18 Medication Administration ... Preparing Injections ... 6. Unless administering immediately, apply identifying label to prepared syringe- Rationale: Lack of labeling has been cited as a major risk for medication administration errors. ..."

1. On May 9, 2012, at 1:35 PM, EMP23 opened the anesthesia cart in OR3 revealing a pre-drawn syringe of Lidocaine. The medication had no date, time or person who drew the medication written on the label. EMP23 stated, "I guess they are not dated." When asked how someone would know who drew the medication and when, EMP23 stated, "You can't. I just know I didn't do it. ... It's standard to date and time."

2. Tour of OR4 and OR1 from 1:40 PM to 1:50 PM on May 9, 2012, revealed pre-drawn syringes of Lidocaine and Zemuron (OR4) and pre-drawn syringes of Phenylephrine, Xylocaine, and Succinylcholine (OR1). None of the pre-drawn syringes were complete for date and time drawn and person who drew the medication. EMP23 confirmed the missing documentation on the pre-drawn syringes. When asked again how someone would know who drew the medication and when, EMP23 stated, "I don't know. Again, I didn't do it (draw the syringes)."

Based on tour of surgical suites, staff interview (EMP), and review of facility policy, it was determined that the facility failed to follow established policies regarding surgical environment of care for patients in three of five operating rooms (OR1, OR3, and OR4).

Findings Include:

Review of facility policy SSD 3.1, revised June 2011 revealed, "III. Policy Statement: Grove City Medical Center believes the utilization of this cited text is a quality reference proving standards, recommended practices and guidelines. IV. Text A. The operating room staff member will utilize the following cited text as a guide regarding operating room procedures: Association of Perioperative Registered Nurses, Inc. 2011 standards, Recommended Practices, and Guidelines. ..."

The Perioperative Standards and Recommended Practices, 2012 Edition, "Recommendation I, The patient should be provided a clean, safe environment. ... 1a. The perioperative registered nurse should assess the perioperative environment frequently for cleanliness and take action to implement cleaning and disinfection procedures if needed. Cleanliness means the absence of visible dust, debris, soil, or body substances. Environmental cleaning and disinfection is a team effort involving surgical personnel and environmental services personnel.

1. On May 9, 2012, from approximately 1:15 PM to 2:00 PM, heavy dust was found on the anesthesia carts and the radiance view monitors in OR1, OR3, and OR4. EMP32 verified the findings and stated, "Now I can see that dust."

2. At approximately 1:24 PM on May 9, 2012, EMP23 was asked who is responsible for cleaning the anesthesia carts, EMP23 replied, "They are wiped down every morning and between patients, but that is a lot of dust."

3. On May 10, 2012, at approximately 3:00 PM, an interview with EMP28 revealed, "I assumed that they were all being cleaned every night, I guess we will make sure they are cleaned every day."