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Based on medical record review, review of policy and procedure, and staff interview, the hospital failed to ensure that staff implemented an identified action plan to improve performance and increase patient safety in a high-risk area (Neonatal Intensive Care Unit) for 2 of 7 patient records reviewed (Patients #6 and #7).

Failure to monitor planned actions to improve patient safety and staff performance risked the health and well-being of patients.

Findings:

Patient #1 was born prematurely on 10/23/2008 and was intubated for respiratory distress syndrome. A catheter used by Respiratory Therapists to administer a surfactant medication (Curosurf) to help the infant breathe inadvertently broke off and was left in the infant's lung. The infant was eventually transferred to another hospital (higher level of care) for removal of the catheter and discharged to home 3 days later.

Per staff interviews on 6/1-2/2011, the hospital conducted an internal investigation following the incident. An action plan was formulated which included revising the Curosurf Administration procedure and adding a directive to staff to verify and document that the catheter was removed intact following administration of the Curosurf.

Review of the current revised procedure, "Curosurf Administration" No. 28.09.00 dated as last reviewed 7/2010 (more than 1 year after the incident) did not include a directive to staff to document observation of an intact catheter. It directed staff in item 5b: "Surfactant administration catheter should be retracted from the endotracheal tube following every surfactant dose delivery, to aid in optimal mechanical ventilation, surfactant distribution and to insure the catheter is intact."

The procedure lacked the planned directive that staff were to document that the catheter was removed intact.

Record review was conducted for 7 patients. Two were infants in the Neonatal Intensive Care Unit who had received the surfactant Curosurf (Patients #6 and #7). Review of the respiratory therapy documentation evidenced that of 6 doses of Curosurf administered from 5/31-6/1/2011, 2 administered doses did not include documentation by respiratory staff that the catheter was removed intact.

Staff verified on 6/2/2011 that there was no current procedural requirement that staff document that the catheter was observed to be intact following administration of the drug as determined by the internal action plan. In addition, there was no evidence that internal auditing had been done to ensure that staff were documenting their observations of intact Curosurf catheters.

The hospital failed to implement their action plan and failed to conduct an audit to monitor that the required action to improve performance had been implemented and sustained to improve patient safety and quality of care.