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Based on record review and staff interview, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative to providing the necessary treatment and nursing services, consistent with professional standards of practice, and hospital policy relative to the administration of expressed human breast milk and patient identification verification practices.

Findings are as follows:

1. The hospital failed to follow their policy titled "Breast Milk Collection; Labeling; Storage; Handling; & Verification" relative to the verification of patient identification for the administration of human breast milk. (Refer to A-398)

Based on record review and staff interview, it was determined that the hospital failed to ensure licensed personnel followed hospital policies and procedures relative to patient identification practices for the administration of expressed human breast milk which resulted in the inadvertent administration of the incorrect breast milk to two premature infants who were admitted to the Neonatal Intensive Care Unit (NICU) for 2 of 5 infants reviewed, Patient ID #s 1 and 2.

Findings are as follows:

According to a report submitted on 8/21/2023 by the hospital to the Rhode Island Department of Health, a 26-week-old infant who was admitted to the Neonatal Intensive Care Unit (NICU) for prematurity received breast milk from another patients mother on 8/18/2023. An additional report submitted by the hospital on 8/21/2023 to the Rhode Island Department of Health indicated that a 33-week-old infant who was admitted to the NICU for prematurity received breast milk from another patient's mother on 8/19/2023.

According to the hospital's policy titled, "Breast Milk Collection; Labeling; Storage; Handling; & Verification" which had been in effect since 8/17/2021, states in part,

" ...D. Verification of Breast Milk

...2. Special considerations for NICU:

...Delivery of Breast Milk from Nutrition Preparation Room to Patient Room

...c. Upon delivery, containers of breast milk are verified with clinical staff or parent prior to placement in the locked in-room refrigerator.

...Verification of breast milk prior to feeding

a. Verify breast milk using two identifiers (name & [medical record number] MRN) and a two person check, one of which is a clinical staff member ..."

Record review for Patient ID #1 revealed she/he was admitted to the NICU after being born at 26 weeks gestation in August of 2023 with respiratory distress syndrome (breathing problem), apnea of prematurity (breathing pauses), and required gavage feeding (a way to provide nutrition to infants who cannot eat on their own).

Record review for Patient ID #2 revealed she/he was admitted to the NICU after being born at 33 weeks gestation in August of 2023 with respiratory distress syndrome and required gavage feeding.

During a surveyor interview on 8/25/2023 at 9:18 AM with the Clinical Effectiveness Manager, she explained that the NICU Care Assistant (NCA)/Nursing Assistant (NA), who takes care of the "milk room" where breast milk is stored in separate bins with patient labels, delivers breast milk to the unit. The Clinical Effectiveness Manager revealed that on 8/17/2023, Employee B, a Travel Nurse who was assigned to Patient ID #1, picked up two labeled human breast milk bottles from the "milk room" which were provided by Employee A, NCA/NA. The Clinical Effectiveness Manager stated that this was not the process, as it is the NCA/NA who delivers the human breast milk to the nurses at the patient bedside. The Clinical Effectiveness Manager further revealed that while in the "milk room," Employee A picked up human breast milk labeled with Patient ID #3's (ID #6's mother) name instead of Patient ID #1's name and documented in Patient ID #1's record that two people had verified patient identification at the bedside. The Clinical Effectiveness Manager further revealed that on 8/18/2023, as the day shift nurse was doing her safety checks, she found a milk bottle labeled with Patient ID #3's name inside Patient ID #1's in-room refrigerator with the amount of milk that was consistent with the feedings Patient ID #1 had received overnight. Additionally, the Clinical Effectiveness Manager revealed that when Employee A was interviewed regarding this error, Employee A stated that she did not have her glasses on when she gave Employee B the milk bottles.

During an additional surveyor interview on 8/25/2023 at approximately 10:10 AM with the Clinical Effectiveness Manager, when asked about the second incident involving Patient ID #2, the Clinical Effectiveness Manager revealed that on the evening of 8/18/2023, Employee C, NCA/NA, delivered three bottles of breast milk to Employee D, Registered Nurse. The Clinical Effectiveness Manager revealed that at approximately 2:00 PM on 8/19/2023, the day shift nurse found a bottle of milk labeled with Patient ID #1's name in Patient ID #2's in-room refrigerator. The Clinical Effectiveness Manager revealed that an interview was conducted with Employee C, where Employee C stated that Employee D requested milk for Patient ID #1 and patient verification was done in the hallway, off an elevator, outside of the patient's room. When asked if there was documentation in Patient ID #2's record that milk was delivered, the Clinical Effectiveness Manager indicated that there was not. The Clinical Effectiveness Manager indicated that patient identification is not supposed to happen in the hallway, but inside the patient's room. The Clinical Effectiveness Manager revealed that when Employee D was interviewed on 8/20/2023, he stated that he had requested milk for Patient ID #2 and indicated that both him and Employee C looked at the labels on the milk bottles and he verified the patient's name with the "blue card." The Clinical Effectiveness Manager revealed that Employee D stated he fed Patient ID #2 milk from all three bottles that Employee C had delivered. She further acknowledged that both employee statements did not align.

Record review for Patient ID #1 revealed that on 8/17/2023 at 10:48 PM, Employee A delivered two bottles of breast milk for Patient ID #1 to the nurse on duty and patient identification was completed in the patient's room. However, based on the interview with the Clinical Effectiveness Manager, patient identification verification was not done in the patient's room per hospital practice, and the incorrect breast milk was administered to Patient ID #1.

Additional record review for Patient ID #1 revealed that on 8/18/2023 at 10:51 PM, Employee C delivered 3 bottles of frozen breast milk to Employee D and patient identification was completed in the patient's room. However, based on the interview with the Clinical Effectiveness Manager, patient identification verification was not done inside the patient's room per hospital practice, and breast milk labeled for Patient ID #1, was administered to Patient ID #2 in error.