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Based on document reviews, medical record reviews, and staff interviews, an Immediate Jeopardy ( IJ) to Nursing Services (failure to follow policy and procedures) was called on 10/20/21 at 8:50 a.m. Nursing failed to ensure a pediatric patient received the correct dosage of medication while in the Pediatric Unit. A pediatric patient received excessive dosage of medication, due to incorrect weight assessment. The pediatric patient weight was fifteen (15) pounds, but the patient received medication dosed for a patient weighing thirty (30) pounds. This excessive dose could result in serious adverse outcome.

A remedial plan of correction was received and sent to the State Agency Deputy Director. It was accepted and the facility abated the IJ on 10/20/21 at 4:28 p.m. A review of re-education for all employees revealed measures put in place for implementing weight measurements in the Emergency Department and Pediatric Unit, huddles with the staff on 10/5/21 to 10/8/21 and pharmacology re-education the staff received.

Based on document reviews, medical record reviews and staff interviews, it was determined the facility failed to ensure staff was obtaining an accurate weight for pediatric patients resulting in one (1) out of ten (10) medical records reviewed (patient #1) of administration of an incorrect dosage of medication due to an incorrect patient weight.

Findings include:

A review of the policy titled "Care and Triage of All Children in the Emergency Department," reviewed 09/2019, stated in part: "Record accurate weight in kilograms, with the exception of children who require emergent stabilization ... Obtain accurate assessment ..."

A review of the medical record for patient #1 revealed the patient was seen in the Emergency Department (ED) on 10/5/21. The patient's weight is documented as fifteen-point nine (15.9) kilograms (kg). The record does not specify if this was an actual or estimated weight. This weight of fifteen-point nine (15.9) kg was entered into the medical record during triage in the ED. Patient #1 is documented as an acuity of two (2), and the patient's oxygen saturation (O2 sats) was eighty-seven (87) percent upon triage. When placed on two (2) liters of supplemental oxygen in the ED, the patient's O2 sats was documented as ninety-five (95) percent.

A review of orders documented in the patient's medical record revealed an order was written in the ED for a sodium chloride bolus (a single dose of a drug or other medicinal preparation given at once) that stated: "Order: Sodium Chloride 0.9% (0.9% NaCL Fluid Bolus (PED mL/kg)-), Order Details: 318 mL, IVPB, 1x (once), Infuse over: 30 minute(s), STAT (immediately), 10/5/21, 5:01:00 AM EDT, Stop date 10/5/21 1:12:01 PM EDT." Documentation in the patient chart revealed the bolus was not administered in the ED, and the Pediatric Unit was notified due to the ED staff could not get an IV (intravenous) line started.

Further review revealed an order for admission to the Pediatric Unit was written on 10/5/21 at 5:46 a.m. It was aslo documented patient #1 weighed seven-point one (7.1) kg upon admission to the pediatric unit, with a weight of seven-point one (7.1) kg recorded. The above noted documentation revealed this is a discrepancy from the weight entered into the patient's medical record of fifteen-point nine (15.9) kg while in the ED.

Further review of patient #1's medical record revealed an order for Amoxicillin which stated: "Order: amoxicillin (amoxicillin (PED)), order details 715.5 mg (milligrams), = 14.31 mL, PO (liquid), q12h, Bilateral Otitis Media, NOW, 10/5/21 7:30:00 AM EDT (Amoxicillin 715.5 mg, = 14.31 mL, PO (by mouth), q12h (every twelve (12) hours), Otitis media bilateral (middle ear infection, both ears)." The medical record revealed that Amoxicillin 715 mg was given at 10:11 a.m. while patient was admitted to the Pediatric Unit. There is no documentation of an adverse medication reaction associated with administration of the first dose of Amoxicillin.

Review of the patient's medical record revealed that while admitted to the Pediatric Unit the patient was given one hundred forty (140) cc bolus of NaCL (Sodium Chloride) 0.9 %. The original order as documented above was for three hundred eighteen (318) cc bolus of sodium chloride. A review of the medication administration record for patient #1 revealed: "Sodium Chloride 0.9%, 140 mL to be given, Charted Date/Time: 10/5/21 13:12 EDT." Documentation revealed an IV was not started until the patient arrived on the Pediatric Unit and the initial order for sodium chloride was based on the ED weight of fifteen-point nine (15.9) kg.

Review of the patient's medical record revealed a second order for Amoxicillin which stated: "Order: amoxicillin (amoxicillin (PED)), Order Details: 315 mg, PO (liquid), q12h, Bilateral Otitis Media, NOW, 10/5/21 16:12:00 EDT. The second dose of Amoxicillin was not administered until 10/6/21 at 9:19 a.m. There is no documentation of Amoxicillin administration on 10/5/21 after the dose administered at 10:11 a.m.

Review of the medical record for patient #1 revealed the patient was discharged on 10/8/21.

An interview was conducted with the Pediatric Pharmacist on 10/19/21 at 8:21 a.m. When asked about pediatric dosage, the pharmacist stated, "It depends on the drug ... dosage is weight and age based." Amoxicillin is a weight-based medication and is divided into two (2) doses per day. After the incident with the large dose [double dosage for the weight of the patient] of Amoxicillin being given to the patient on 10/5/21, the physician and pharmacist conferred and decided to hold the next dose of Amoxicillin until the next day (10/6/21). The pharmacist stated they only see dosage, medication and weight when verifying an order for pediatric patients. When the pharmacist was asked about bolus medication dosage, the pharmacist stated, "All bolus dosages are verified by the pharmacy. Only when an order changes or a new order is written, does the pharmacist verify a new order." The pharmacist further stated they discovered the medication error when they were calculating a new medication order and saw it was not forty-five (45) mg/kg. They looked to see why there was a change in dosage, and once they realized it was an incorrect Amoxicillin dosage, they got in touch with the physician and discussed when the next dosage should be given.

An interview was conducted with Registered Nurse (RN) #1 on 10/19/21 at 9:10 a.m. When asked why a weight was not obtained, RN #1 stated, "The mother refused a weight. The mother had the baby covered up with a blanket and said the area wasn't sanitary. The mother allowed the cover to be raised so a pulse ox could be put on the patient's toe. The mother refused to undo the onesie so the staff could observe the patient's breathing by watching the abdomen. When the mother gave a weight, I asked if it was kilograms or pounds. The mother said kilograms. I asked if she was sure it was kilograms, and the mother said yes. A note was put on the nurse's board that an update weight was needed." When RN #1 was informed no additional weight measurement was obtained while patient #1 was in the ED, RN #1 stated, "Once a patient goes in a room I don't follow up." RN #1 stated, "The mother was more worried about sanitation than the patient's O2 sats." When asked if any re-education had been completed, RN #1 stated, "We only talked through email on 10/12/21 about proper weight measurements. The ED is implementing a change starting 10/18/21. ED staff will verify the weight a triage nurse has obtained, to prevent any issues." There is no documentation in the medical record during triage that the mother refused weighing of the patient or undoing patient clothing for a proper triage.

An interview was conducted with RN #2 on 10/19/21 at 10:54 a.m. When asked about the incident involving patient #1, RN #2 stated, "I admitted the baby to the floor, early morning after shift change. I got a weight and went through the history with the mom." The patient came to the floor without an IV (intravenous) line and Pediatric Intensive Care Unit (PICU) staff started the IV around 11:00 a.m. RN #2 stated they tried to start the IV once and couldn't get the IV started. When asked why it took so long to get the IV started, RN #2 stated the ultrasound machine had to be cleaned before it could be brought to the patient's room. RN #2 stated, "The admission weight in the pediatric unit was seven-point one (7.1) kg [actual weight], and the admission weight is used for dosage weight. I did not see the discrepancy with the patient's weight prior to giving the Amoxicillin." RN #2 concurred 715.5 mg, the wrong dosage, of Amoxicillin had been given to patient #1 before the discrepancy in weights were noted. RN #2 stated, "The patient had no issues after the Amoxicillin was given." RN #2 stated, "When starting to give the bolus, I realized the bolus was incorrect due to the weight obtained on admission. I looked on the computer, saw the discrepancy, and called the pharmacy and only gave one hundred forty (140) cc of the bolus fluids not the three hundred (300) cc. Due to the patient's weight I knew it was twenty (20) cc/kg." It should be noted this is the calculation for total amount of fluids to be given. RN #2 stated, "When the IV bag was hung, the mother was told the patient would only get part of the bolus, not all of it. The mother was apprehensive and concerned. The mother said 'this isn't going to drown her, is it?' " RN #2 stated, "I explained this was a bolus and going in the veins and it would not drown her." RN #2 stated, "The patient had congestion due to the Respiratory Syncytial Virus (RSV) and needed suctioning. There was nothing abnormal about the suctioning procedure, lubrication was used, but the patient did bleed more than normal. The patient did not fight the suctioning, just a little movement. The mother was crying with the bleeding and wanting to know why the patient was bleeding. The mother was very stressed, and the dad was frustrated with the IV." After the incident, RN #2 stated, "The Nurse Manager said to me it was my responsibility as part of the patient team to know what the med weight is. We had discussion in huddles about accurate weights. I had a one-to-one (1:1) discussion with the Nurse Manager. I normally don't pay attention to the ED weight. I knew all med dosage would come from the current floor weight." It should be noted the estimated weight of 15.9 kg given by the mother was used to calculate the dosage of Amoxicillin; the correct weight for calculation of the amoxicillin dosage should have been calculated using the actual weight of 7.1 kg. It should also be noted an IV was started with assistance of the ultrasound machine and the medication administration record reflected one hundred and forty (140) cc bolus to be given, dated 10/5/21 at 1:12 p.m. The original order for NaCL 0.9% bolus of three hundred eighteen (318) cc was stopped on 10/5/21 at 1:12 p.m. There was no documentation in the medical record concerning the patient bleeding after suctioning.

An interview was conducted with the attending physician on 10/19/21 at 5:01 p.m. When asked about the incident with the patient, the physician stated, "I did talk to the mother and the mother was happy, never had any more issues. Pharmacy suggested holding Amoxicillin until 10/6/21." The physician further stated it was a mistake, just not detrimental. When asked if the attending physician ever verifies weight before ordering medications, the physician stated, "At times I will verify weights if I question it as an actual weight or estimated weight. Patient #1 is hypotonic, floppy appearance which may have the appearance of weighing more, but not thirty (30) lbs. I wasn't sure she could tolerate oral fluids. Mom was concerned IV fluids had not started. Intern had talked to mom and said bolus was double for weight and was afraid to give IV. I talked to the Nurse Manager and was told the appropriate amount was given. Intern said mom would be happy getting maintenance fluids. Mom was really happy the next day." The attending physician stated this could have been a lot worse, really scary just thinking how scary this could be.

An interview was conducted with the Pediatric Resident on 10/19/21 at 12:21 p.m. When asked if they verify weights on pediatric patients before writing orders, the Resident stated, "No." The Resident stated, "I spoke to the supervisor before any orders went in the medical record." The Resident stated the computer will only flag any order that is over or under suggested dosage. The Resident stated, "I saw the patient in the ED, prior to admission to the floor."

An interview was conducted with the Director of the ED on 10/20/21 at 8:56 a.m. When asked about the incident involving no weight obtained on patient #1 in the ED, and patient #1 getting the wrong dose of medication, the Director of the ED stated, "The Clinical Coordinator is meeting one-to-one (1:1) with each shift prior to start of each shift, all staff, starting 10/18/21 about weighing patients. The Clinical Coordinator will audit effectiveness of five (5) charts per day. There is going to be an attestation form for the staff to sign of understanding for the ED and PICU." When asked about the expectations of re-education of the ED staff, the Director of the ED stated, "It should have occurred sooner." The Director concurred the ED staff did not follow policy.

A. Based on document review, medical record reviews, and staff interviews, it was determined nursing services failed to followed hospital policy and procedures. Nursing services failed to weigh a pediatric patient in the Emergency Department (ED) resulting in a pediatric patient receiving the wrong dose of medication after being admitted to the Pediatric Unit. This failure was identified in one (1) of ten (10) medical records reviewed (patient #1). The failure to provide a correct weight assessment can result in serious injury, serious harm, impairment, or death from the incorrect administration of medication.

Findings include:

A review of the policy titled "Care and Triage of All Children in the Emergency Department," reviewed 09/2019, stated in part: "Record accurate weight in kilograms, with the exception of children who require emergent stabilization ... Obtain accurate assessment ..."

A review of the medical record for patient #1 revealed the patient was seen in the ED on 10/5/21. The patient's weight is documented as fifteen-point nine (15.9) kilograms (kg). The record does not specify if this was an actual or estimated weight. This weight of fifteen-point nine (15.9) kg was entered into the medical record during triage in the ED.

Further review revealed an order for admission to the Pediatric Unit was written on 10/5/21 at 5:46 a.m. It is documented patient #1 weighed seven-point one (7.1) kg upon admission to the Pediatric Unit. It should be noted the patient's weight of seven-point one (7.1) kg is a discrepancy from the weight entered into the patient's medical record of fifteen-point nine (15.9) kg while in the ED.

Further review of the patient's medical record revealed an order for Amoxicillin which stated: "Order: amoxicillin (amoxicillin (PED)), Order Details: 715.5 mg, = 14.31 mL, PO (liquid), q12h, Bilateral Otitis Media, NOW, 10/5/21 7:30:00 AM EDT." (Amoxicillin 715.5 mg, = 14.31 mL, PO (by mouth), q12h (every twelve (12) hours), Otitis media bilateral (middle ear infection, both ears). The medical record revealed that Amoxicillin 715 milligrams (mg) was given at 10:11 a.m., while patient was on the Pediatric Unit. There is no documentation of an adverse medication reaction associated with administration of the first dose of Amoxicillin. It should be noted the dosage of Amoxicillin 715 mg is A double dosage for a patient weighing seven-point one (7.1) kg.

Further review of the medication orders for patient #1 revealed a discontinued order for Amoxicillin which stated: "Order: amoxicillin (amoxicillin (PED)), Order Details: 715.5 mg, = 14.31 mL, PO (liquid), q12h, Bilateral Otitis Media, NOW, 10/5/21 7:30:00 AM EDT. End Date & Time: 10/5/21 at 13:54 PM. Status: Discontinued." It is documented in the patient's medical record a second order for Amoxicillin which stated "Order: amoxicillin (amoxicillin (PED)), Order Details 315 mg, PO (liquid), q12h, Bilateral Otitis Media, Routine, 10/06/21 9:00:00 EDT." The second dose of Amoxicillin was not given until 10/6/21 at 9:19 a.m. and no Amoxicillin was given on 10/5/21 in the p.m. hours. The patient was discharged on 10/8/21.

An interview was conducted with the Pediatric Pharmacist on 10/19/21 at 8:21 a.m. When asked about pediatric dosage, the pharmacist stated, "It depends on the drug, dosage is weight and age based." Amoxicillin is a weight-based medication and is divided into two (2)doses per day. After the incident with the large dose of Amoxicillin [double dosage was given for the weight of the patient] being given to the patient on 10/5/21, a conversation occurred between the physician and the pharmacist, and it was decided to hold the next dose of Amoxicillin until the next day (10/6/21). The pharmacist stated they will only see dosage, medication and weight when verifying an order for pediatric patients. The pharmacist stated they only found out about the medication error when they were calculating a new medication order and saw it was not forty-five (45) mg/kg. They looked to see why there was a change in dosage, and once it was realized about the Amoxicillin dosage they got in touch with the physician and discussed when the next dosage of medication should be given.

An interview was conducted with Registered Nurse (RN) #1 on 10/19/21 at 9:10 a.m. When asked why a weight was not obtained, RN #1 stated, "The mother refused a weight. The mother had the baby covered up with a blanket, and said the area wasn't sanitary. The mother allowed the cover to be raised so a pulse ox could be put on the patient's toe. The mother refused to undo the onesie so the staff could observe the patient's breathing by watching the abdomen. When the mother gave a weight, I asked if it was kilograms (kg) or pounds (lbs.), the mother said kg. I asked if she was sure it was kg, and the mother said yes. A note was put on the nurse's board that an update weight was needed." When RN #1 was informed no additional weight measurement was obtained while patient #1 was in the ED, RN #1 stated, "Once a patient goes in a room I don't follow up."

An interview was conducted with RN #2 on 10/19/21 at 10:54 a.m. When asked about the incident involving patient #1, RN #2 stated, "I admitted the baby to the floor, early morning after shift change. I got a weight and went through the history with the mom." The patient came to the floor without an IV (intravenous) line. Pediatric Intensive Care Unit (PICU) staff started the IV around 11:00 a.m. RN #2 stated he/she tried to start the IV once and couldn't get the IV started. When asked why it took so long to get the IV started, RN #2 stated the ultrasound machine had to be cleaned before it could be brought to the patient's room. RN #2 stated, "The admission weight in the Pediatric Unit was seven-point one (7.1) kg [actual weight], and the admission weight is used for dosage weight." RN #2 stated, "I did not see the discrepancy with the patient's weight prior to giving the Amoxicillin." RN #2 concurred 715.5 mg of Amoxicillin, the wrong dosage, had been given to patient #1 before the discrepancy in weights were noted. RN #2 stated, "The patient had no issues after the Amoxicillin was given." After the incident of the wrong dose of medication given, RN #2 stated, "The Nurse Manager (NM) said to me it was my responsibility as part of the patient team to know what the med weight is. We had discussion in huddles about accurate weights. I had a one-to-one (1:1) discussion with the NM. I normally don't pay attention to the ED weight. I knew all medication dosage would come from the current floor weight." It should be noted the estimated weight of 15.9 kg given by the mother was used to calculate the dosage of Amoxicillin. The correct weight for calculation of the Amoxicillin dosage should have been the actual weight of 7.1kg.

B. Based on document review, observation, and staff interview, it was determined nursing services failed to follow hospital policy and procedures to maintain a clean and sanitary environment to avoid sources and transmission of infection. This failure has the potential to adversely affect all patients.

Findings include:

A review of the policy titled "Cleaning, Disinfection, and Sterilization Program," revised 2020, stated in part: "After cleaning and disinfecting, all patient care equipment will be identified as clean by use of an approved green twist tie. The twist tie should be applied around the electric cord, or in some way that it must be removed to use the equipment. All equipment stored in the Clean Storage area must have a green twist tie indicating it has been cleaned."

A tour of the Pediatric Unit was conducted on 10/18/21 at 12:04 p.m. with the Nurse Manager (NM) and Director of the Pediatric Unit. A tour of the clean supply room revealed there was one (1) bear hugger, one (1) percussion vest, three (3) breast pumps, one (1) adult blood pressure machine, one (1) tray, one (1) pediatric wheelchair and one (1) soother chair stored in the clean supply room which were not marked as clean.

During the tour of the Pediatric Unit on 10/18/21 at 12:04 p.m., the NM stated the equipment must be marked as clean to be stored in the clean supply room and concurred the equipment was not marked as clean.

C. Based on document review, observation, and staff interview, it was determined the nursing staff failed to follow hospital policy and procedures for patient food storage. Nursing staff failed to monitor the patient refrigerator for the correct temperature storage for patients' food and drinks. This failure has the potential to adversely affect all patients.

Findings include:

A review of the policy titled "Dietary Kitchen Food Storage," revised 12/2019, stated in part: "The designated staff member that is assigned to check and document daily refrigerator temperatures ... "

A tour of the Pediatric Unit was conducted on 10/18/21 at 12:04 p.m. with the Nurse Manager (NM) and the Director of the Pediatric Unit. A tour of the patient kitchen area revealed the refrigerator was not monitored for the correct temperature storage for patients' food and drinks.

A review of the temperature log checks for October 2021 revealed there were no temperature checks for 10/4, 10/8, 10/9 and 10/10/21.

An interview was conducted with the NM during the tour of the Pediatric Unit on 10/18/21 at 12:04 p.m. and concurred the refrigerator log had not been completed daily.

D. Based on document review, medical record reviews and staff interview, it was determined the nursing staff failed to provide care as ordered. Nursing staff failed to weigh pediatric patients as per physician's order. This failure was identified in four (4) of ten (10) medical records reviewed (patients #2, 3, 6, and 7). This failure has the potential to adversely affect all pediatric patients.

Findings include:

A review of the policy titled "Weight, Height/Length, and Head Circumference," revised 8/2013, stated in part: "Daily weights shall be obtained on all patients up to and including 6 months of age., Patients >6 months to 12 months of age shall be weighed every other day., Other weights as per physician order ..."

A review of the medical record for patient #3 revealed the patient was admitted on 10/2/21. An order for daily weights was ordered on 10/3/21 at 5:00 a.m. for every twenty-four (24) hour intervals, at the same time each day. Patient #3 had weights documented on 10/2/21 at 7:14 p.m. and 10/4/21 at 2:43 p.m. No other weight was documented. Patient #3 was discharged on 10/5/21.

A review of the medical record for patient #2 revealed the patient was admitted on 10/4/21. An order for daily weights was ordered on 10/5/21 at 5:00 a.m. for every twenty-four (24) hour intervals, at the same time each day. Patient #2 had a weight documented on 10/4/21 at 12:00 p.m. No other weight was documented. Patient #2 was discharged on 10/7/21.

A review of the medical record for patient #7 revealed the patient was admitted on 10/5/21. An order for daily weights was ordered on 10/6/21 at 5:00 a.m. for every twenty-four (24) hour intervals, at the same time each day. Patient #7 had no weights documented on 10/6/21, 10/7/21 or 10/8/21. Patient #7 was discharged on 10/8/21.

A review of the medical record for patient #6 revealed the patient was admitted on 10/9/21. An order for daily weights was ordered on 10/10/21 at 5:00 a.m. for every twenty-four (24) hour intervals, at the same time each day. Patient #6 had no weights documented on 10/10/21 or 10/11/21. Patient #6 was discharged on 10/11/21.

An interview was conducted with the NM of the Pediatric Unit on 10/20/21 at approximately 4:00 p.m. The Nurse Manager concurred patients #2, 3, 6 and 7 were not weighed every twenty-four (24) hours as ordered by the physician.