HospitalInspections.org

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure that: 1.) medical staff carry out its responsibilities of documenting in the progress notes after responding to issues raised by nursing concerning a patient's change in status; 2.) a transfer note is made in the medical record by the treating physician.

Findings include:

1. Reference: Facility's Medical Bylaws Rules and Regulations state, " ... Medical Records: ... 9. Daily visitations by physicians or licensed independent practitioner shall occur and will be documented in progress notes. A progress note shall be written each time the treating physician, or licensed independent practitioner visits the patient. If issues have been raised in the medical record by other disciplines, the treating physician shall provide an appropriate response. ... "

On 12/29/22, during a review of Patient #3's (P3) medical record, the following was revealed: at 12 midnight on 11/10/22, Staff #16 alerted Staff #17 concerning P3's abdomen appearing "more firm" and that 10 mL's (milliliters) of residual was aspirated from the feeding tube. According to the nurse's notes written by Staff #16, Staff #17 instructed to give the residual back and feed the next feeding as usual.

At 3:00 AM, Staff #16 documented, "Baby lethargic and RR [respiratory rate] down to 18 at times ... Baby's abd [abdomen] taut, suctioned thick formula from mouth. Aspirated 60 mL from OGT [orogastric tube]. [Staff #17] notified of changes." It further stated that blood work CBC (complete blood count) and CBG (capillary blood glucose) was sent, attending was made aware of the change in the patient. KUB [kidney, ureter, bladder diagnostic study] was done.

During the review of P3's medical record on 12/29/22, there was no corresponding progress note from Staff #17 concerning the events. At 4:16 PM, during a telephone interview, Staff #17 confirmed that there was no corresponding progress note in the medical record concerning the event when he/she responded to the call from Staff #16 concerning P3's condition that started at 12 midnight.

2. Reference: Facility's Medical Bylaws Rules and Regulations state, " ... Medical Records: ... 10. If the patient is transferred to another health care facility, that facility must have an accepting physician. A transfer note shall be made by the patient's treating physician to reflect the patient's immediate needs. ..."

On 12/29/23, during the review of P3's medical record there was no documented evidence of a transfer note by the treating physician that identified the accepting physician and reflecting the immediate needs of the patient being transferred.

At 4:25 PM, upon interview, Staff #3 stated that [the accepting facility] sends and coordinates the transfer of neonates. The facility's attending initiates the provider-to-provider call.

The above findings were confirmed with Staff #1, Staff #2, and Staff #3 upon discovery and during the exit conference.

Based on review of three of three medical records (Patient #1 (P1), Patient #2 (P2), and Patient #3 (P3) of patients receiving tube feedings, staff interviews, and review of facility documents, it was determined the facility failed to ensure a policy is created and implemented that guides the practice of all NICU (Neonatal Intensive Care Unit) nurses for neonates on enteral gastric tube feeding regimen.

Findings include:

On 12/29/22 at 10:21 AM, during a tour of the NICU, staff interviews were conducted on the care of neonates on tube feeds. During the interview with Staff #13, it was stated that assessments are conducted every 3 hours, this includes inspection of stomach and assessing if the baby is tolerating the [tube] feeds. Staff #13 added that the nurse will aspirate the OG (orogastric) tube for color and amount of aspirate. He/she looks for presence of blood or bile. If there are any concerns, Staff #13 stated that the APN (Advance Practice Nurse) or the neonatologist will be alerted of the findings. During the interview, Staff #13 added that babies on the vent (ventilator) are at high risk for aspiration, thus it is important to ensure that there is no air in the stomach by aspirating air every 4 hours if the neonate in on continuous feeds. According to Staff #13, if the patient is on an Q3Hour (every three hours) feed, then residual is checked every three hours. When questioned of the process, should there be an issue identified with feeding, Staff #13 stated that he/she will not always stop feeding, it's a nursing judgement. He/she will notify the provider and they will assess and give orders to stop or proceed with feeding. When questioned concerning the policy and procedure on enteral feeding for neonates, Staff #13 stated there is no policy,

On 12/29/22, during the medical record review for P1, P2, P3, the following was revealed:

At 11:05 AM, medical record review was conducted on P1, a 5 week old neonate on continuous tube feeds using donor breastmilk. Review of the flowsheet data for neonatal input/output indicated the following:

12/29/22 at 0100 (1:00 AM) and 0500 (5:00 AM) - there was no documentation of the abdominal girth and residual check.
12/28/22 at 2100 (9:00 PM) - there was no documented residual check.
12/28/22 at 1600 (4:00 PM) - there was no documented residual check.
12/28/22 at 1200 (12:00 PM) - there was no documented residual check.
12/28/22 at 0800 (8:00 AM) - there was no documented residual check.
The last documented residual was on 12/27/22 at 2100 (9:00 PM).

At 11:30 AM, during an interview with Staff #14, the nurse caring for P1, he/she stated that residuals might not be documented because there is no residual. Staff #14 added that if the residual is 2 mLs (milliliters), it is not considered a residual, as it will be the amount of formula left in the tube. When questioned if "zero" should be documented if there was no residual, Staff #14 stated that he/she documents "zero" if there is no residual however not everybody documents zero for no residual.

At 11:40 AM, during a review of P2's medical records, it was revealed that the tube feed residual check was not consistently checked and documented for the following dates and times:

12/23/22 from 0200 (2:00 AM) to 2100 (9:00 PM)
12/24/22 at 0100 (1:00 AM)
12/24/22 at 0500 (5:00 AM)
12/25/22 from 1300 to 2100 (1:00 PM to 9:00 PM)
12/26/22 at 0100
12/27/22 at 1700 and 2100 (5:00 PM)
12/28/22 at 0100

At 1:20 PM, during a review of P3's medical record for admission date 10/18/22, it was indicated that the patient was receiving bolus tube feeds every three hours. A review of the flowsheet for the following dates revealed that the tube feed residual was not consistently checked for the following dates:

11/8/22 at 2100
11/9/22 at 0000 (12:00 AM)
11/9/22 at 0300 (3:00 AM)
11/9/22 at 0600 (6:00 AM)

Upon request of the policy related to enteral tube feeding for neonates, Staff #1 provided the facility policy titled, "Care of Patient with Enteral Tube and Enteral Tube Feeding" which states, " ... D. Clinical Assessment: ... Pediatrics: Continuous feeding - GRV [Gastric Residual Volume] checked every 4 hours & held if volume is (greater than or equal to) the hourly rate. Bolus feeding - GRV may be checked before the next feeding & held if residual volume is more than half of previous feeding volume. ... V. Documentation Electronic Medical Record Patient Care flowsheet: GI assessment - Verification of correct placement prior to each feeding/medication administration (check mark) Gastric Residual Volume - amount, color ...Tolerance of feeding/GRV ..."

Upon interview at 1:15 PM, Staff #1 confirmed that the policy is for pediatric patients and not specific to neonates. It was confirmed that there is no policy for care of a patient with enteral tube feeding for neonates.

The above findings were confirmed with Staff #1 and Staff #6 upon discovery.