HospitalInspections.org

Based on document review and interview, nursing staff in the neonatal intensive care unit (NICU) providing nursing care to babies on ventilators lacked evidence of ventilator training in 3 of 3 NICU nurses personnel files reviewed.

Findings include:

-- Per review of Staff A, B, and C's personnel files, they lacked evidence of training on ventilators.

-- Per interview of Staff C on 1/14/2025 at 9:16 am, the NICU can keep ventilated babies for up at 72 hours. Staff C recalled providing care to a baby on a ventilator. Staff C indicated they would like education related to taking care of babies on ventilators.

-- Per interview of Staff D on 1/14/2025 at 9:42 am, the NICU can keep ventilated babies up to 3 days. Staff D stated they are not trained to take care of ventilators.

-- Per interview of Staff E on 1/14/2025 at 10:34 am, if a baby is ventilated, respiratory therapy (RT) manages the ventilator and nursing cares for the baby.

-- Per interview of Staff F on 1/15/2025 at 2:45 pm, some nurses are very comfortable taking care of ventilated babies and some are not.

-- Per interview of Staff B on 1/15/2025 at 9:30 am, they described an instance of multiple births that occurred. The babies were on ventilators for approximately 6 hours. Respiratory therapy (RT) managed the ventilators and nursing staff monitored the babies. Staff B is not trained on ventilators.

-- Per interview of Staff A, on 1/15/2025 at 10:40 am, they feel staff are not adequately trained to take care of ventilated babies.

-- Per interview of Staff G and Staff H on 1/16/2025 at 8:55 am, there is no policy and procedure for ventilators specific to the NICU, additionally the NICU nurses do not receive ventilator training.

Based on document review, medical record review, and interview in 4 of 11 medical records reviewed, Patient #1, Patient #6, Patient #7, and Patient #11, the facilty failed to ensure properly executed informed consent forms were completed. Specifically, anesthesia consent forms lacked required information.

Findings include:

-- Review of the facility's policy and procedure titled, "Advanced Directives, Consents and Medical Decisions Management Plan," dated 10/17/2024, indicated "written consent document form must contain at least the following: if the procedure if non-emergent, and is expected to involve either local or general anesthesia, the name of all physician(s), dentist(s), and podiatrist(s) who are reasonably expected to be involved in the procedure(s) ... name, signature, and date of provider(s) performing the procedure ... every blank should be filled in before the patient or responsible person signs and it is witnessed".

-- Review of Patient # 1's medical record, revealed a Consent for Anesthesia Services Form signed by the patient on 12/24/2024. This form indicated the patient would receive monitored anesthesia care (a form of anesthesia).
The consent form provided an area for a provider signature. It stated "I consent to the anesthesia service checked above and authorize that it be administered by _____". The space for the provider name was left blank.

-- Review of Patient # 1's medical record, revealed a Consent for Anesthesia Services Form signed by the patient on 12/26/2024. This form indicated the patient would receive monitored anesthesia care. The consent form provided an area for a provider signature "I consent to the anesthesia service checked above and authorize that it be administered by _____". The space for the provider name was left blank.

-- Review of Patient # 6's medical record, revealed a Consent for Anesthesia Services Form signed by the patient on 12/24/2024. This form indicated the patient would receive general anesthesia, post op (operative) ventilator (a device that assists in breathing) support, and invasive monitoring via an arterial line (catheter inserted into an artery that provides continuous blood pressure monitoring). The consent form provided an area for a provider signature. It stated "I consent to the anesthesia service checked above and authorize that it be administered by _____". The space for the provider name was left blank.

-- Review of Patient # 7's medical record, revealed a Consent for Anesthesia Services Form signed by the patient on 12/26/2024. This form indicated the patient would receive general anesthesia and invasive monitoring via an arterial line. The consent form provided an area for a provider signature. It stated "I consent to the anesthesia service checked above and authorize that it be administered by _____". The space for the provider name was left blank.

-- Review of Patient # 11's medical record, revealed a Consent for Anesthesia Services Form signed by the patient's sibling (authorized by the patient) on 1/10/2025. This form indicated the patient would receive general anesthesia. The consent form provided an area for a provider signature. It stated "I consent to the anesthesia service checked above and authorize that it be administered by _____". The space for the provider name was left blank.

-- Per interview of Staff G, on 1/16/2025 at 9:00 am, they acknowledged the above findings.