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Based on review and interview the facility failed to follow the policy and procedure for resuscitation of an infant with appropriate documentation in 1 of 1 (#2) patient chart reviewed.

Refer to Tag A0144

Based on review and interview the facility failed to follow the policy and procedure for resuscitation of an infant with appropriate documentation in 1 of 1 (#2) patient chart reviewed. The facility failed to ensure the assigned code blue team responded to all code blue events, and complete the required code blue form.

A review of patient #2's chart revealed he was born on 5/7/23 at 2:56 p.m. at 25 weeks gestation and weighed 1 lb. and 9 oz.

A review of Staff #8's written "Death Summary" Date of Service May-07-2023 1634 stated, "He arrived at the nursery by 1457. PPV started with 100% Fi02. No HR palpated and monitors placed without any HR noted on monitors. Saturations initially around 60-70 with PPV. Within 30 seconds chest compressions were started and these were continued throughout the entire resuscitation apart from brief pauses to assess whether infant had any HR.
First intubation attempt at 1459 and yellow change of the cap gas monitor noted on third attempt at 1503. PPV continued with ET tube. ET initially deep but pulled back to appropriate depth. 1504 surfactant given via ET tube. 1505 epi give via ET tube. No heart rate noted.

1510 UVC placed on second attempt. XRAY noted slightly deep for low lying, so it was pulled back. 1512 first dose of EPI given with 3 ml normal saline flush. No HR heard/felt/on monitor. A total of 4 doses of EPI were given with 3 ml every 3-5 minutes without any HR in infant. In between doses he was on D10 at 1OO mg/kg/day. Glucose 155.

PPV with ET in place was continued, but saturations progressively decreased to around 1530 where he was saturating at a max of 20 even with 100% oxygen and appropriate seal. CXR reviewed and sent to radiologist for review. Severe haziness no bilateral lungs. Later radiologist informed us that the right side had a pneumothorax with appropriate positioning of the ET Tube.

Team debriefed and a final call made to NICU. Decision was made to stop resuscitation and call time of death at 1545. No HR or spontaneous respirations never noted despite PPV, chest compressions, and umbilical line EPI x4. He had no tone or spontaneous movements noted during entire resuscitation. Apgars 0,0,0."

A review of the staff #13 RN's nurses notes dated 5/7/23 at 15:40 stated, "all resuscitation team members at bedside, cpr remains in progress. Discussed plans, infant stats, what has worked, what has not, infant stats, etc. Reviewed NPR guidelines as far as resuscitation measures and discontinuation measures with micropremies. Risks vs benefits, parent's plans. ____ (Staff #8), ____(#12), and ____( #10) have spoken with parents regarding status of the infant so far, and parents are in understanding. Cpr continues at this time. "

A review patient #2's chart revealed there was no documentation of who the resuscitation team members were. There was no found "code sheet" or documented evidence on what members of the code team responded, what actions each person performed at the code, and who was the assigned recorder.

The nurse documented on 5/7/23 at 15:05, "epi 0.1 mg down the ET tube." There was no further documentation on who administered the epi. 15:12 ...epi administered down UVC." There was no clear documentation on who administered the epi.

An interview was conducted with staff # 7 on 10/19/23. Staff #7 stated he was the house supervisor for today on 10/19/23. Staff #7 stated at the beginning of each shift, he makes code blue assignments. Staff #7 stated, that assigned staff responds to all codes if the code was called overhead. Staff #7 stated that sometimes Code Blue was not called overhead for neonates (newborns). Staff #7 stated that there has been instances where OB nurses code the neonates without calling a code overhead. Staff #7 stated the house supervisor should be notified of all codes performed in the hospital. Staff # 7 provided a daily staffing report for 5/7/23 that revealed an assignment for a hospital wide code blue team. Staff #7 confirmed that a code blue sheet should be used during a code blue that revealed who attended the code and the procedures they performed. A review of the code blue assignment for 5/7/23 revealed Staff # 6 RN was assigned to the team.

An interview was conducted with Staff #6 on 10/19/23. Staff #6 stated that she was on the code team that day (5/7/23) but does not have any memory of working with a deceased infant. Staff #6 stated that there was a code sheet that was used on all codes, and it should be in the chart.

An interview was conducted with staff # 2 on 10/19/23. Staff #2 stated a code sheet should have been in the chart. Staff #2 provided an example of a blank delivery record sheet that had a section for resuscitation of an infant. Staff #2 reviewed and confirmed there was no delivery record that included the code sheet in patient #2's chart.

A review of the policy and procedure Cardiopulmonary Arrest Response Team (Code Blue Team) stated, " POLICY
A. At the beginning of each shift, the house supervisor will make assignments to the Code Team on the Shift Scheduling Sheet. Each nurse assigned to the code team will have a current ACLS and BLS card. The Shift Scheduling Sheet will be placed at each time clock before the start of each shift.

B. A "Code Blue" will be called on all arrests unless a "No Code" or "DNR" order has been written in advance ...
... F. Code Team members who will respond to a "Code Blue" situation are the following:

a. Emergency Department Physician
b. Attending Physician (may or may not)
c. House Supervisor
d. Nurse with BLS/ACLS from Critical Care Unit if available or 2 ER nurses.
e. Nurse with BLS/ ACLS & ENPC or PALS from the Emergency Department
f. Respiratory Therapists
g. Charge Nurse (RN) on the Unit where the patient is located.
h. Nurse assigned to patient."

Review of the policy Neonatal Resuscitation stated,
"A. All nurses employed in labor and delivery and nursery units will be certified in CPR and NRP

B. Each L&D room will be equipped with resuscitation equipment. Emergency boxes with medications and airway supplies will be maintained in nursery and on the infant scale that will be taken to each delivery. Unit personnel will be responsible for checking emergency equipment prior to each delivery to ensure preparedness.

C. Resuscitative measures will be initiated by RN present at delivery and performed according to current American Heart Association NRP guidelines and shall be continued until the infant is stable. If the infant is stable and no further efforts are necessary, the infant can remain in the room with mom skin-to-skin or under close observation with frequent checks by neonatal nurse.

D. The infant will be transported to the special care nursery if:

1. Further resuscitative measures are necessary including but not limited to umbilical lines or airway management

2. Cardiac or apnea monitoring is required

3. Gestation is less than 35 weeks and transport is expected."

The facility failed to develop, adopt, implement, and enforce a staffing level for the nursery through the Nurse Staffing Effectiveness Committee, failed to provide a plan for staff and patient safety when a minimum of 1 nurse is assigned to a nursing unit with multiple patients, and failed to distinguish between a Registered Nurse (RN) and a Licensed Vocational Nurse (LVN) on the staffing grid.

Refer to Tag A0392

The facility failed to develop, adopt, implement, and enforce a staffing level for the nursery through the Nurse Staffing Effectiveness Committee, failed to provide a plan for staff and patient safety when a minimum of 1 nurse is assigned to a nursing unit with multiple patients, and failed to distinguish between a Registered Nurse (RN) and a Licensed Vocational Nurse (LVN) on the staffing grid.

A review of patient #2's chart revealed he was born on 5/7/23 at 2:56 p.m. at 25 weeks gestation and weighed 1 lb. and 9 oz. patient #2 was born without a pulse and CPR was initiated at birth.

A review of Staff #8's written "Death Summary" Date of Service May-07-2023 1634 stated, "He arrived at the nursery by 1457. PPV started with 100% Fi02. No HR palpated and monitors placed without any HR noted on monitors. Saturations initially around 60-70 with PPV. Within 30 seconds chest compressions were started and these were continued throughout the entire resuscitation apart from brief pauses to assess whether infant had any HR."
A review of the nurse notes dated 5/7/23 at 14:56 (2:56 p.m.) revealed staff # 13 RN documented, "delivered in ldr4 via svd ( labor and delivery room #4 via standard vaginal delivery) from spontaneous labor at 25 weeks and transferred to special care nursery to prewarmed radiant warmer where Dr. ______ (staff # 8) and resuscitation team awaits."

A review of the staffing grid revealed no nursery listed or nursery staff. Staffing grids are planning tools that assign the appropriate number of staff to care for the number of patients on the unit per the hospital's Nurse Staffing Effectiveness Committee. The grid only showed a staffing level for "mother-baby 606" unit. Staff # 3 confirmed on 10/19/23 that this was for the post-partum area. A notation at the top of the grid stated, "Labor & Delivery- 2 Rn's at all times."

An interview was conducted with Staff # 3 on 10/19/23. Staff #3 stated the postpartum floor is not always used because the rooms used for labor and delivery was also converted into a postpartum room. The mothers stay in the same delivery room and the baby stays with the mother after delivery until discharge. The babies do not go to the nursery because the nursery was closed.

A review of patient #2's chart revealed staff #13 RN documented the entire code process from 2:56 p.m. until 4:20 p.m. Staff #13 documented on 5/7/23 at 4:20 p.m. "infant cleaned, weighed, measured, printed, banded, swaddled, hat placed. To mothers' room for a time of grieving ..." Staff # 13 was scheduled to work labor and delivery as the charge RN and moved to the nursery when the patient #2 was coded on 5/7/23 at 2:57 p.m.

A review of the staffing sheet and the staffing grid for 5/7/23 revealed there were no patients on the 606 unit (postpartum). There were no comments about the nursery closed and there was no nursing staff assigned to the nursery. There was no documentation that anyone was on call for the nursery. The charge nurse (staff #13) had to leave her assignment on the L&D unit to provide care for patient #2 during the code blue.

An interview was conducted with Staff #1 and #3 on 10/19/23. Staff #1 stated the nursery unit had been closed for over a year. Staff # 1 stated that it was not needed since the babies were roomed with their mothers and did not need to go to the nursery. Staff #1 stated there was no process in place on how to close, monitor,or reopen the unit when an infant needed close monitoring or had complications. There was no process for how the unit would be staffed. Staff #1 stated there was no need for the unit. Staff #1 was made aware of the infant's death on 5/7/23 and that the nursery was used for resuscitation efforts. Staff #1 stated that it was not cost-effective to have the unit open. Staff #1 nor staff #2 was able to provide a plan or process for how to safely open, close, and staff the nursery unit.

A review of the policy and procedure "Neonatal Resuscitation" last revised 2018 stated., "Statement of Guideline D. The infant will be transported to the special care nursery if:
1. Further resuscitative measures are necessary including but not limited to umbilical lines or airway management.
2. Cardiac or apnea monitoring is required.
3. Gestation is less than 35 weeks and transport is expected."

A review of the staffing grid revealed there was only a grid for unit 606. The grid revealed at a minimum that 1 nurse could be left alone on the floor with up to 5 patients with no tech or unit clerk. There was no further evidence that any other staff member would be available to assist in case of an emergency. There was no process for when the nurse would be allowed breaks, or who, with obstetric training, would relieve the nurse.


The grid revealed that the Registered Nurse (RN) and Licensed Vocational Nurse (LVN) were listed as the same discipline and counted as the same on the grid. An LVN must have supervision by an RN and cannot be scheduled as an RN. The grid did not clarify if an RN was to be scheduled or an LVN. Staff #3 confirmed on 10/19/23 that an LVN could be assigned to the 606 department according to the current grid.

According to the Texas State Board of Nursing, " The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, physician, dentist, or podiatrist."

A review of the Nurse Staffing Plan stated under purpose, "The goal of this policy is to create a healthy environment for nurses and appropriate care for patients by establishing a Nurse Staffing Effectiveness Committee whereby nurses and hospital management shall participate in a joint process regarding decisions about nurse staffing ... The plan will set minimum staffing levels for patient care units, will include a contingency plan when patient care needs unexpectedly exceed direct patient care staff resources, and will include a method for adjusting the staffing plan for each patient care unit to provide staffing flexibility to meet patient needs."

An interview was conducted with Staff # 3 on 10/19/23. Staff #3 confirmed that the Nurse Staffing Effectiveness Committee meets quarterly, and the last meeting was held on 9/6/23. Staff #3 was unable to provide any documentation that the staffing grid for the women's care unit was evaluated for safe staffing levels and the closing of the nursery with staffing levels was ever discussed.