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Based on observation, interview, and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P on verifying the OG tube placement prior to the medication administration for one of three sampled patients (Patient 2). This failure posed the risk of adverse health outcomes to the patient.

Findings:

Review of the hospital's P&P titled Administration of Oral Medications (NICU and Perinatal) dated 7/2023 showed for NG/OG tube administration, verify tube placement prior to medication administration.

Patient 2's medical record showed the patient was admitted to the hospital on 11/13/24.

On 12/2/24 at 1050 hours, an observation of medication administration for Patient 2 by RN 2 was conducted, with the NICU Clinical Nurse Educator present.

RN 2 was observed administering 0.5 ml of Poly-Vi-Sol (multivitamin) via the OG tube without verifying the tube's placement beforehand. Both RN 2 and the NICU Clinical Nurse Educator acknowledged the findings. RN 2 and the NICU Clinical Nurse Educator stated the OG tube placement was verified by aspirating the tube to check for stomach contents, and if no stomach contents were aspirated, the staff was to auscultate the stomach.

Based on interview and record review, the hospital failed to ensure the nursing staff followed the hospital's P&P for Blood Product Administration in the NICU for one of three sampled patients (Patient 1) to assess and document the vital signs during the blood transfusion. This failure posed the risk for potential complications, including undetected changes in the patient's condition, delayed interventions, and overall compromised patient safety during the blood transfusion process.

Findings:

Review of the hospital's P&P titled Blood Product Administration in the NICU dated 10/2024 showed vital signs (temperature, blood pressure, heart rate, respiratory rate) must be taken within 30 minutes prior to starting the transfusion, then 15 minutes after the infusion has started, 1 hour after the start of the transfusion, every hour during administration, at the end of the infusion, and 1 hour after the end of the transfusion. Ensure all vital signs are entered into the electronic health record.

On 12/3/24 at 0923 hours, review of Patient 1's medical record was conducted with the NICU Clinical Nurse Specialist and Assistant Manager of Regulatory Affairs.

Patient 1's medical record showed the patient was admitted to the hospital on 5/18/24.

Review of the physician's order dated 6/4/24, showed to transfuse 17 ml of Neonatal FFP-Aliquot (fresh frozen plasma) over two hours, stat.

Review of Patient 1's medical record showed the fresh frozen plasma transfusion was started on 6/4/24 at 1224 hours and stopped at 1425 hours. However, there was no documented evidence the nurse had taken the patient's vital signs 15 minutes after the infusion was started.

On 12/3/24, during the record review, the NICU Clinical Nurse Specialist and Assistant Manager of Regulatory Affairs verified the findings.