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Based on medical record review, document review and interview, the hospital failed to ensure facility specific nursing policies and procedures are in place and adhered to in accordance with acceptable standards of nursing practice.

See Tag A395

Based on document review, observation and interview the facility does not ensure policies and procedures are in place and adhered to in accordance with acceptable standards of nursing practice for 2 of 2 patients. (Patient #1 and 5). Failure to develop facility specific policies and ensure adherence has the potential to result in an adverse patient event.

Findings Include:

Patient #1:

Review of physician orders dated 11/28/16 at 1:53pm revealed an order for newborn radiant warmer.

Review of physician orders dated 11/30/16 at 3:41pm revealed an order for bili lights. On 11/30/16 at 2:43pm an order for dual phototherapy and Wallaby (bili blanket) was entered.

Review of nurses note dated 12/1/16 at 8:23pm revealed that after consulting with the neonatal intensive care (NICU) nurse earlier that morning, they suggested changing the light system being used on the patient. The change included removing the Wallaby, starting a third overhead light and placing aluminum foil around the side rails of the warmer. It was recommended that the warmer not be turned on while using this therapy.

Interview with Staff P on 12/15/16 at 3:30pm revealed that although he knew the patient was on lights, he was unable to recall whether an order for the use of aluminum foil was entered. The warmer status would be left up to nursing.

Review of nursing note dated 12/1/16 at 4:40pm revealed the warmer began to alarm. The mother removed the infant from the warmer and went into the hallway where she met the nurse who took the infant to the nursery. The infant was noted with eyes open, floppy and ruddy in color. Temperature was 98.2F axillary and 98.9 rectally.

Interview with Staff R on 12/16/16 at 11:30am revealed that the infant's temperature was close to normal, but when she re-created the scene in an empty bed, the surface temperature was 113 degrees F when measured with an infrared thermometer and that the room air temperature was 98 degrees F. The infant was transferred to the NICU for observation, fluids and continued phototherapy.

Telephone interview with Staff O on 12/16/16 at 1:30pm revealed the nurse asked her to put the infant back in the warmer on 12/1/16 after he finished feeding. She placed the infant in the warmer and proceeded to turn it on. The patient's mother told her it was supposed to be off and she thought she turned it off. Since she thought it was off, a temperature sensor was not placed on the infant. Staff O stated that when she placed the infant under the warmer, the rails were wrapped in foil and the lights were closer than usual. It was stated that the nursing staff would routinely ask the Clinical Assistant's (CA) to set the warmers up and to take infants in and out of the beds.

Review of personnel file for Staff O revealed no evidence of orientation to infant warming or phototherapy equipment.

Interview with Staff E and Q on 12/15/16 and 12/16/16 respectively revealed neither had used foil with phototherapy in the newborn area.

Review of nursing policies and procedures revealed the infant phototherapy and thermoregulation policies are standard procedures obtained from the Lippincott manual. The phototherapy procedure includes checking the physician order to initiate therapy with a caution that if the lights are too close, the neonate may become overheated. The policies are general in nature and not facility specific as to the ordering of phototherapy, staff responsible for the initiation and ongoing administration of phototherapy, the positioning of the lights or the use of foil.


Patient #5:

Review of medical record dated 7/22/16 revealed the patient was admitted with leg pain and increasing difficulty with ambulation. Skin was noted to be intact.

Review of physician notes dated 7/25/16 revealed a Stage II decubiti on the right ischium.

Review of nursing documentation dated 7/26/16 revealed skin is clean, dry and intact.

Review of wound consult dated 7/27/16 revealed the patient had developed a full thickness stage III decubitus on right and left buttocks and the sacrum and coccyx.

Review of facility policy Skin Assessment/Pressure Ulcer Prevention and Management indicates the patient will be repositioned every 1- 2 hours unless contraindicated.

Review of the medical record dated 7/22/16 to 7/28/16 revealed inconsistent documentation related to patient turning and positioning.

Interview with Staff B on 12/16/16 verified the failure to adequately assess the patient and document preventive measures.

Based on document review and interview, the nursing staff did not ensure that a nursing care plan was kept current for 2 of 2 patients. (Patient #2 and 18)

Findings Include:

Review of the medical record for Patient #2 revealed the patient was transferred from another hospital on 12/7/16. Review of the nursing care plan revealed the patient's safety and wound care needs were not addressed despite documentation of a wound consult for a stage II decubitus of the left buttock on 12/12/16 and the implementation of wrist restraints on 12/13/16.

Review of the medical record for Patient #18 on 12/16/16 revealed the patient was admitted to the obstetric service on 12/13/16. Review of the patient's paper binder revealed an undated and incomplete nursing care plan.

During interview with Staff N on 12/16/16 it was stated that "We don't use those (paper nursing care plans) anymore, they would be on the electronic record." Review of the electronic medical record for Patient #18 revealed no evidence to indicate a nursing care plan was developed and implemented.

Interview with Staff C on 12/16/16 verified the above findings.