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Based upon review of the Pediatric Intensive Care Unit (PICU) staffing schedules, 3 of 6 medical records (#4, #5, #6), policy and procedures, Employee Cross Training Records, and staff interviews, the hospital failed to ensure the PICU patient received care in a safe setting by failing to follow PICU Policy and Procedure related to providing nursing support staff members. This was evidenced by: 1) Failing to ensure minimum PICU staffing was one (1) RN and a nursing support staff member on 09/26/12 when S21 RN was assigned to care for one PICU patient and then admitted another PICU patient who required an emergency CT Scan with no documented staff available to accompany patient #4 to the radiology department per hospital PICU policy, and 2) Failing to ensure adequate nursing staff was available in the PICU by assigning S20 RN the care of a PICU patient and an Adult Intensive Care Unit patient simultaneously. Findings:

Review of the medical record for patient #6 revealed this 2 week old male was admitted to the PICU on 09/22/12 with the diagnosis of Respiratory Syncytial Virus (RSV). According to the PICU Staff Assignments, S21 RN was listed as the only RN on the 7PM-7AM shift of 09/26/12 and was assigned to care for patient #6 with no other RN identified for lunch and break relief or as a "shift buddy". Further review of the PICU Staff Assignments revealed at 9:45 PM, S21 RN received a second admission into PICU, patient #4, a 13 year old male who was admitted from the Operating Room post Appendectomy with new onset of seizure activity. According to the nursing notes, documented by S21 RN, patient #4 required an emergency Computerized Tomography (CT) Scan and was taken to the radiology department by a "nurse"; however, there failed to be documentation what nurse accompanied this patient to radiology since S21 RN was in the PICU by herself with patients #4 and #6.

Further review of the medical records of patients #4 and #6 revealed S21 RN was the only RN who documented on these patients during the 7PM-7AM shift of 09/26/12. There failed to be documented evidence the PICU was staffed with a second RN to either assist with the transfer of patient #4 to the radiology department or provide care to the remaining PICU patient (#6). There also failed to be documentation an RN was provided for S21 RN's lunch and break relief. According to the lower portion of the PICU Staff Assignment form, it was identified S22, a PICU RN was reassigned from the PICU to work in the Adult ICU leaving S21 RN alone in the PICU.

Review of the policy titled "Pediatric Intensive Care Unit Specific Structure Standards" revealed: IV. Administration/Organization, C. b. The Director of Pediatric Services assigns a charge nurse each shift to oversee the 12 hour shift for the purpose of facilitating unit communication, coordination and delivery of patient care. VII. Staffing, B. Levels: 2. The minimum staffing pattern will be one (1) RN and a nursing support staff member...". Review of PICU policy #OMC-NS: PICU-041 titled "Transportation of PICU Patients" revealed "II. ...To ensure patients are safely transported other departments with appropriate equipment and monitoring by a PICU nurse" "...C. Transport patient to other department: PICU patients must be accompanied by a PICU staff RN." There failed to be documented evidence the hospital followed policy and procedure and assigned a nursing support staff member to the PICU on 09/26/12 or that a PICU staff RN accompanied patient #5 to the radiology department.

Further review of the PICU Staff Assignments revealed on 10/02/12, the 7PM-7AM PICU Nursing Staff was identified as S19 RN, in PICU orientation, and S20 RN with documentation out to the side "ICU Pt (patient)".

Review of the medical record for patient #5 revealed this 17 year old female was admitted on 10/02/12 at 6:15 PM to the PICU under a Physician Emergency Certificate after an attempted overdose. Review of the nursing notes dated 10/02/12, 7:30 PM, revealed S20 RN documented the initial shift assessment and the RN orienting to the PICU, S19 RN, was assigned to provide one-on-one sitter services to patient #5 and documented on the patient every 15 minutes from 7:00 PM on 10/02/12 to 7:00 AM on 10/03/12. Review of the "sitter" sheet revealed the following: "Sitter: See Guide to Risk Sitting-Information for Sitter. Sitter/staff member will maintain visual contact with the patient at all times. Movement from the designated room will require staff escort and close follow up when not in room. When toileting, the bathroom door should be kept ajar to allow for safety and privacy." Review of the nursing notes dated 10/02/12, 7:30 PM, revealed S20 RN documented the initial shift assessment. At 9:30 PM, PICU S19 RN completed the documentation on patient #5 at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM as the PICU RN for the patient. There failed to be any further documentation from PICU S20 RN after the initial shift assessment at 7:30 PM. Based upon documentation on the PICU Staff Assignments on 10/02/12 and the medical record of patient #5, PICU S19 RN, who was in PICU orientation, was alone in the PICU providing one-on-one sitter duties and acting as the PICU RN.

Interview with S3 RN, S4 RN, and S7 RN, on 10/12/12 at 8:45 AM, revealed when asked who was the PICU Charge Nurse, S7 RN replied S20 RN. When asked why ICU was written in next to S20 RN's name, S7 RN replied this nurse was also assigned to care for an Adult ICU patient. According to S3 RN, patient #5, a 17 year old who had overdosed, was admitted to the PICU under a Physician Emergency Certificate and S19 RN, who was orienting to the PICU, was placed one on one with the patient. According to S7 RN, there were two PICU RN's; however, the pediatric unit was short of nursing staff and so the other PICU nurse was reassigned to work in the pediatric department. The Adult ICU was also short of nursing staff so PICU RN S20 was assigned to take care of the PICU patient and also care for an Adult ICU patient. Observations of the Adult ICU and the PICU units on 10/10/12 at 3:40 PM, revealed the PICU and Adult ICU were separated by an electronic door and there is no direct visualization from one unit into the other unit.

Review of policy #OHS.NURS.019 titled "Staffing Assignments" revealed the following: IV. Procedures/Standards and Roles and Responsibilities, A. Assignments are formulated according to the patient's needs as determined by the nursing process. The following factors related to the patient are taken into consideration. #5. the degree of supervision required by each nursing staff member (e.g., #of orientees) based on his/her previously assessed level of competence and current competence in relation to the nursing care needs of the patient; #6. the availability of supervision appropriate to the assessed and current competence of the nursing staff members being assigned responsibility for providing nursing care to patients. B. The CC, OC, or Charge Nurse will consider the following factors related to the employee in the assignment process. #1. documented competence in at least the clinical knowledge, skills, and technology ordinarily employed in the care of patients in the unit, area or department.

Interview with S3 RN and S4 RN on 10/12/12 at 8:50 AM, revealed when the competencies for PICU was requested for S19 RN, their reply was this RN had her competency check list with her and it was not available for review nor was a copy maintained in the RN's personnel file.

Further review of the PICU Staff Assignments revealed the following:

On 09/01/12, 7PM-7AM shift: 2 PICU nurses, with 2 PICU patients and 2 overflow pediatric patients. According to the area for "Shift Buddy" and "Lunch Times" one nurse was scheduled for lunch at 11:00 PM and the other nurse was scheduled for 11:30 PM and "ICU Backup for Breaks".

On 09/25/12, 7PM-7AM shift: 1 RN in the PICU with one PICU patient. This same RN was documented as the "Shift Buddy" and no nursing staff was identified for break or lunch relief.

09/26/12, 7PM-7AM shift: 1 RN to 2 PICU patients. This same RN was documented as the "Shift Buddy" and no nursing staff was identified for break or lunch relief.

09/27/12, 7PM-7AM shift: 1 RN to 2 PICU patients. "0" was documented for Shift Buddy and "ICU Backup" was documented.

09/29/12, 7PM-7AM shift: 1 RN to 1 PICU patient. No Shift Buddy or back up for break or lunch relief was identified.

09/30/12, 7AM-7PM shift: 1 RN with 1 PICU patient until the patient was discharged at 4:35 PM. There was no documentation of a back-up for breaks and lunch relief.

10/02/12, 7PM-7AM shift: 1 RN (S19 RN) identified as in orientation and S20 RN identified as assigned to an Adult ICU patient. Interview with S3 RN on 10/12/12 at 9:20 AM revealed when asked who the PICU charge nurse, S3 RN identified S20 RN and confirmed this nurse was assigned to simultaneously care for a patient in the PICU and the Adult ICU during the 7PM-7AM shift of 10/02/12.

10/05/12, 7PM-7AM shift: 1 RN and 2 PICU patients. It was identified there was no back up and no shift buddy.

10/06/12, 7AM-7PM shift: 1 RN and two PICU patients. No back up and no shift buddy was identified.

10/06/12, 7PM-7AM shift: 1 RN and 1 PICU patient. No back up and no shift buddy was identified.

10/07/12, 7AM-7PM shift: 1 RN and 1 PICU patient. No back up and no shift buddy was identified.

10/07/12, 7PM-7AM shift: 1 RN and 1 PICU patient. for Shift Buddy and Lunch Times "NONE" was written in.

10/08/12, 7AM-7PM shift: 1 RN and 1 PICU patient. For Lunch Times and Shift Buddy the same RN was listed with the documentation for relief as "Me, Myself, and I".

10/09/12, 7AM-7PM shift: 2 RN's and 3 PICU patients with documentation "ICU charge back up for lunch"

10/09/12, 7PM-7AM shift: 2 RN's and 4 PICU patients with documentation these two RN's were responsible for each others lunch and breaks.

10/10/12, 7PM-7AM shift: 2 RN's and 4 PICU patients with documentation these two RN's were responsible for each others lunch and breaks.

Interview with S12 RN, the Adult ICU Charge Nurse, on 10/12/12 10:20 AM, revealed when asked about providing back up to the PICU staff, S12 RN replied they are usually just asked to watch the PICU patient monitors while the staff take their restroom breaks and lunch breaks on the unit and they do not provide actual PICU patient care.

Review of policy #OHS.NURS.020 titled "Staffing Guidelines" revealed the following: IV. Procedures/Standards and Roles and Responsibilities, E. Floating of Staff, #4. If a designated staff member will be floating to another unit frequently, a department orientation checklist (DOC) for the receiving unit will be completed by the floating staff member.

Interview with S12 RN, ICU Charge Nurse, on 10/12/12 10:20 AM, revealed when asked about providing back up to the PICU staff, S12 RN replied they are usually just asked to watch the PICU patient monitors while the staff take their restroom breaks and lunch breaks on the unit and they do not provide actual PICU patient care.

Based on review of hospital policies, nurse staffing schedules, personnel folders and staff interviews, the hospital failed to meet the Conditions of Participation related to Nursing Services to ensure the Registered Nurse assigned the nursing care of each patient in accordance with the patient's individual needs and specialized qualifications of the Registered Nurse as evidenced by:

1) assigning the Pediatric Intensive Care Unit Registered Nurse (S16 RN) to the Post-Partum Unit when the RN failed to have the specialized training and verified competencies to care for the post-partum patient and (A397)

2) assigning the Registered Nurse from the Adult Intensive Care Unit (S9 RN, S10 RN, S11, RN, S12, RN, S13RN S14 RN) to cover the Pediatric Intensive Care unit for lunch and breaks without the Adult ICU RN having the documented experience and competencies to care for the Pediatric Intensive Care patient. (A397)

Based upon review of personnel folders, nurse staffing schedules, and staff interviews, the hospital failed to ensure the Registered Nurse assigned the nursing care of each patient was in accordance with the patients individual needs and the specialized qualifications of the Registered Nurse. This was evidenced by: 1) assigning the Pediatric Intensive Care Unit Registered Nurse to the Post-Partum Unit when the RN failed to have the specialized training and verified competencies to care for the post-partum patient (S16 RN), 2) assigning the Registered Nurse from the Adult Intensive Care Unit (ICU) (S9 RN, S10 RN, S11 RN, S12 RN, S13 RN, S14 RN) to cover the Pediatric Intensive Care Unit for lunch and breaks without the Adult ICU RN having the documented experience and competencies to care for the Pediatric Intensive Care patient. Findings:

Interview with S16 RN on 10/11/12, 10:05 AM, revealed when the census in the PICU was low, the RN was re-assigned to different nursing areas in the hospital. According to S16 RN, there was an occurrence where there were no patients in the PICU and she was directed, by the House Supervisor, to go to the post-partum unit to work. S16 RN stated she told the House Supervisor she was not familiar with this unit or how to take care of the post-partum patient and the House Supervisor responded she was a nurse and should be able to work anywhere in the hospital. According to S16 RN, she was assigned to a post-partum Cesarean Section patient who developed bleeding complications due to high blood pressure, and the patient had to return to the operating room for an emergency hysterectomy. S16 RN further stated there were two other nurses on the post-partum; however, they were very busy and could not help her. According to S16 RN, the only person to assist her was a nursing instructor who was on the unit with her students.

Review of the personnel file for S16 RN and review of the Employee Cross-Training Record revealed there failed to be documented evidence the RN was experienced, cross-trained or had received an orientation to the post partum unit prior to being assigned to care for the post partum patient. According to the last paragraph of the Employee Cross-Training Record, it was identified "I understand if I staff a unit outside of my regularly scheduled department, I will be provided an assignment reflective of my current skills or receive an orientation to those skills that are new to me. If I have questions regarding an assignment on a cross-trained unit, I may call to discuss with House Supervisor...". It was confirmed through interview with S16 RN she had received no orientation to the post-partum unit prior to her assignment to the unit and added if you questioned the House Supervisor about unit re-assignment the nurse would be written up regardless if concerns were voiced by the nurse that she was not familiar with the unit or how to take care of the patients.

Interview with S6 RN on 10/11/12 at 1:00 PM revealed when asked if she had ever been assigned to the PICU by herself with the Adult ICU Charge Nurse as back-up, S6 RN replied "yes" and added "the ICU becomes understaffed so it is difficult for them to provide back up, especially when the Adult ICU Charge Nurse also has to take patients". When asked about the concerns of assigning nurses to units they were not familiar with, S6 RN replied "If you say anything to the House Supervisor he will blow up at you and tell you 'when I make a decision that is the end' ".

Review of policy #OHS.NURS.019 titled "Staffing Assignments" revealed the following: IV. Procedures/Standards and Roles and Responsibilities, B. The CC, OC or Charge Nurse will consider the following factors related to the employee in the assignment process. 1. documented competence in at least the clinical knowledge, skills, and technology ordinarily employed in the care of patients in the unit, area or department; C. It is the responsibility of the staff nurse to come forward with any concerns about their patient assignment and communicate these concerns to the CC (Clinical Coordinator), OC (Operations Coordinator) or charge nurse so that adjustments can be made if warranted.

Interview with House Supervisor S7 RN on 10/11/12, 2:10 PM, revealed when asked about the hospital's staffing assignments, S7 RN replied in conjunction with each shift a "bed huddle" was done where it would be determined "what staff go where". When asked how it was determined where staff would be placed, S7 RN replied the House Supervisors have a book which contains the cross training record of the employees for each department of the hospital.

Review of the PICU staff assignment sheets from 09/01/2012 through 10/10/2012 revealed documentation the Adult ICU staff would provide back up for the PICU staff for lunch and breaks. Interview with S3 RN and S4 RN on 10/12/12 at 10:20 AM, confirmed the Adult ICU Charge Nurse would provide back up and lunch and break relief for the PICU nurse.

Interview with S12 RN, Adult ICU Charge Nurse on 10/12/12 at 10:20 AM revealed when asked about providing back up for the PICU nurse, S12 RN replied they were usually asked to "watch the monitor (cardiac)" and the PICU RN would take their breaks or have lunch on the PICU unit.

Review of the personnel files for the Adult ICU charge nurses (S9 RN, S10 RN, S11 RN, S12 RN, S13 RN, and S14 RN) revealed there failed to be documented evidence these nurses had the specialized training and evaluation to ensure they were competent to care for the PICU patient. Review of the Employee Cross-Training Records, used by the House Supervisor for scheduling, revealed for Adult ICU Charge Nurses S9 RN and S12 RN, it was not identified for "Units/Departments with experience and/or cross training: (Check if experienced or cross trained)" that either nurse was experienced or cross trained in PICU or had Pediatric Advanced Life Support, a requirement for the PICU nurse. For S10 RN, the employee cross-training record identified she had experience in PICU; however, it was not identified this nurse had been cross trained in this area.

Review of policy #OMC-NS:6040-004 titled "Pediatric Intensive Care Unit Specific Structure Standards", IV. Administration/Organization: C. Direction of the Pediatric Intensive Care Unit 1. Patient Care Direction: b. The Director of Pediatric Services assigns a charge nurse each shift to oversee the 12 hour shift for the purpose of facilitating unit communication, coordination and delivery of patient care.