HospitalInspections.org

Based on medical record review and staff interview, the facility failed to ensure staff nurses followed a physician order to notify for low oxygen saturation levels. This affected Patient #2. A total of 10 medical records were reviewed.


Findings include:


The medical record of Patient #6 was reviewed on 12/21/15. Patient #6, a Gravida 5 Para 3 at 37.3 weeks gestation, was admitted to the Labor and Delivery unit on 10/01/15 at 01:28 PM for a scheduled repeat cesarean section. The Obstetric Physician's History and Physical revealed the patient had a history of two prior cesarean sections, was positive for Hepatitis C, and had a history of heroin abuse. It was further noted that an ultrasound revealed the fetus had intrauterine growth restriction (IUGR). IUGR refers to a condition in which a fetus is smaller than it should be because it is not growing at a normal rate inside the womb. The Delivery Summary revealed the infant was delivered on 10/01/15 at 06:18 PM. The infant, weighing 2276 grams (approximately 5 pounds) was noted to be in a breech position and the Apgars were 8 and 9 at 1 and 5 minutes of life.
The medical record of Patient #2, the infant of Patient #6, was reviewed on 12/22/15. According to the Neonatologist's Discharge Summary, the infant required continuous positive airway pressure (CPAP) with fraction of inspired oxygen (FiO2) for approximately 10-15 minutes in the delivery room. It was further noted the infant was transferred to the regular newborn nursery when he/she was able to be weaned to room air and oxygen saturations remained greater than 90-95%. A Nursing Note at 09:28 PM revealed the infant appeared dusky with intercostal and supraclavicular retractions. The infant's oxygen saturations were also noted to be in the mid 80's. The infant was transferred to the NICU on 10/01/15 at 10:47 PM when he/she continued to exhibit these signs of respiratory distress which required supplemental oxygen. A stat chest x-ray was ordered on 10/01/15 and showed low lung volumes with a hazy appearance. On 10/01/15 at 10:57 PM a neonatologist ordered staff to maintain oxygen saturations above 90%. The Medication Administration Record noted the infant was medicated with Gentamicin and Ampicillin (antibiotics) and continued on CPAP. By 10/03/15, the infant's oxygen saturations remained between 90% and 93% requiring increasing FiO2 needs. The infant was intubated and given Survanta 4 mL/kg (used to treat or prevent respiratory distress syndrome in premature infants whose lungs have not fully developed). The infant was then extubated and placed back on CPAP. The infant was weaned off of CPAP on 10/05/15 and given 1/16 of a liter of oxygen per nasal cannula. A neonatologist modified the order for goal oxygen saturations on 10/08/15 at 01:25 AM. The new order instructed staff to notify a physician or NNP if the infant's oxygen saturations were less than 95%.
The NICU Flowsheet revealed the infant's oxygen saturation at 08:00 PM on 10/10/15 was 92%. One hour later, at 09:00 PM the saturations remained below 95% at 91%. The oxygen saturations at 10:00 PM and at 11:00 PM were 93% and 91%. The medical record lacked documentation a physician or NNP was notified. An NNP was noted to be at the bedside of the infant at 01:00 AM when the infant's oxygen saturation was noted to be 88%. No new orders were received. The oxygen saturations at 01:15 AM and 02:00 AM were both 93%.
The NICU flowsheet revealed the infant's oxygen saturation on 10/17/15 at 09:00 AM was 93%. At 10:02 AM the infant's oxygen saturation remained low at 91%. At 10:30 AM the saturation was 89%. Thirty minutes later, at 11:00 AM, the infant's oxygen saturation was 92%. At 11:50 AM the patient's oxygen saturation was 90%. The oxygen saturations remained below 95% at 93% at 12:00 PM, 92% at 01:30 PM, 94% at 03:00 PM and 04:00 PM, 93% at 05:00 PM and 92% at 07:00 PM. As on 10/10/15, the medical record lacked documentation a physician or NNP was notified, as ordered.
Staff A was interviewed on 12/22/15 at 03:15 PM. It was verified that the medical record lacked documentation the physician's order to notify a physician or NNP if the infant's oxygen saturations were less than 95% had been followed as the infant's oxygen saturations were consistently below 95% on 10/10/15 and 10/17/15. It was verified that it is the facility policy to follow physician's orders and the physician/NNP should've been notified.