Maternity Staff Shortage Found at St. Joseph

St. Joseph Hospital of Orange has consistently failed to keep enough nurses on duty in the maternity ward where a series of baby mix-ups culminated with an infant taken home by the wrong parents on Valentine’s Day, according to a state investigation made public Thursday.

Staffing problems over the past year continued into January and February of this year, state inspectors found, though they did not specifically blame insufficient staffing for the baby mix-ups.

Investigators cite the hospital for failing to comply with its own staff requirements and found that maternity nurses at St. Joseph on occasion handled twice as many patients as hospital policy allows. But they also conclude the hospital has since proposed adequate steps to correct the problems.

“Their plan of correction has been accepted,” said state Department of Health Services spokeswoman Lea Brooks.

Among the solutions planned for the maternity unit are shifting personnel so that more registered nurses are available during peak admission and discharge times, and adjusting staffing every four hours based on patient levels, said Diane Wynn, the hospital’s executive director of nursing services.

The steps come in addition to measures announced by the hospital last month, including a $500,000 system that will electronically encode matching wristbands for each baby and mother.

State inspectors went to St. Joseph on Feb. 16 after news reports that the wrong infant had been sent home on Valentine’s Day with a Tustin couple. Health officials returned to the hospital a week later to investigate additional complaints that on at least three other occasions nurses had mixed up babies at the hospital. Those errors were corrected while the infants were still in the hospital.

The hospital’s shortcomings are documented in Health Department findings that are highly critical of staffing in the maternity unit. Investigators concluded that the hospital failed to demonstrate that it followed “generally accepted standards of nursing practice.”

The investigators say the hospital consistently failed to meet its own staffing requirements in September and December 1998 and in January and February of this year.

Investigators also found that the hospital on several occasions fell far short of nursing levels recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The guideline calls for one licensed nurse for every “three to four normal mother-newborn couplets,” equivalent to one registered nurse per six to eight patients.

On June 11, for instance, one registered nurse was responsible for 14 and another for 16 patients, according to investigators. That was the day that two infants were mixed up and one was breast fed by the wrong mother, said Brooks.

St. Joseph CEO Larry Ainsworth acknowledged some of the staffing problems in an interview Thursday during which the hospital released a preliminary version of the state report in an effort to demonstrate their aggressive efforts to solve the problem. A final report was later released by the health department.

“We did blow it on staffing” on two of the occasions cited by inspectors, he said. But the maternity unit now has an adequate number of nurses, he said.

He said the hospital last year responded to the problem on its own by hiring 17 registered nurses for the maternity unit, which has an RN staff of about 65.

Ainsworth, however, criticized the state agency for not taking into account “the real-world exigencies hospitals have to manage.” These include a statewide nursing shortage and a 1997 law that required health insurers to pay for a minimum of two days in the hospital after delivery, he said.

Currently, the hospital staffing policy requires one registered nurse and one nurse assistant per six mother-newborn couplets, which is still below the staffing level favored by the state reports. Ainsworth, however, said the hospital did not have to meet those recommendations. California sets minimum nursing ratios only in its intensive care units.

While there is no regulation setting the minimum number of nurses in a maternity unit, hospitals must have a plan for determining staffing levels that is based on the kind and type of patients it is treating, as well as their acuity or condition. Those plans must be reasonable and responsible, said regulatory officials.

St. Joseph staffing policies take into account the pediatrician and obstetrician groups’ guidelines, but also factor in the recommendations of hospital nursing managers, the medical director and “what the community practice is,” said Ainsworth. The hospital runs the largest maternity unit in the county, delivering 5,500 babies a year.

St. Joseph uses nursing assistants to augment registered nurses to do routine work such as changing diapers and moving patients, he said. “That is reasonable because much of the care for patients doesn’t require the expertise or education of registered nurses,” he said.

“We are very much in the mainstream,” he added. “Frankly, given the nursing shortage, we couldn’t keep up with [physician groups’ guidelines] even if we wanted to.”

Maternity unit staffing levels at Hoag Memorial Hospital Presbyterian in Newport Beach are one registered nurse to three or four mother-newborn couplets, said spokeswoman Maureen Mazzatenta. The hospital does use nursing assistants to help an RN when a fifth or sixth couplet is assigned to that registered nurse, she said.

In addition to the Health Department investigation, the Joint Commission of Accreditation of Health Care Organizations also inspected St. Joseph last month as a result of Valentine’s Day mix-up. The group is responsible for accreditation of most hospitals in the country.

It will issue its finding May 6, said spokeswoman Julie Roberts. The committee could vote to continue accreditation, downgrade it or make recommendations for improvements, she said. As with the state, the joint commission has no minimum staffing requirements for maternity units.