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Based on record reviews, staff interviews and review of policies and procedures related to medication administration, the facility failed to ensure that nursing staff administered Poly-Vi-Sol (vitamins) as ordered for 1 of 1 (Patient 3) sampled breast fed newborns and for 42 of 42 facility identified breast fed newborns (admitted within the past 30 days) who had "Newborn Admission Orders" for Poly Vi Sol vitamins to be administered daily. The total sample size was 15. The facility census was 152.

Findings are:

A. Record review of the closed record for Patient 3 revealed the newborn was born on 2/5/14 and discharged 2/7/14. Record review of the "Newborn Care Flowsheet" documentation by nursing staff on 2/5/14 at 6:40 AM identified the baby was breast fed. Review of daily nursing staff documentation throughout the newborns stay identified the baby was breast fed. Record review of physician's orders revealed a standing order set titled "Newborn Admission Orders " (last revised date 1/19/11) dated 2/5/14 at 2:35 AM and signed by the practitioner. The order set included under the section titled "Medications" an "X" in the box indicating order to be implemented for "Poly-Vi-Sol 1 ml (milliliter) by mouth every day if mother is breastfeeding." Record review of the documentation on the "Newborn Admission MAR (Medication Administration Record)" found the Poly-Vi-Sol and dose as identified on the Newborn Admission Order set was printed on the MAR (Medication Administration Record). The MAR did not have any documentation that the Poly-Vi-Sol was administered to the baby between 2/5/14 through discharge on 2/7/2014.

B. Staff interview with LPN (Licensed Practical Nurse)-A on 4/1/14 at 10:00 AM revealed the LPN worked full time and had been assigned to mother/baby nursing cares. LPN-A was assigned to Patient 3 on the day of discharge 2/7/14. LPN-A stated "I never give newborn vitamins." The LPN identified the vitamins are ordered on the standard order set and printed on the MAR but "don't give" and have been doing this for "years." The LPN stated there are "no other orders on the standard order set that we routinely hold."

C. Staff interview on 4/2/14 with the Director of Quality and Risk at 12:30 PM revealed the facility had 42 newborns delivered in the last 30 days (from 3/3/14 - 4/1/14) who were breast fed and had orders for Poly-Vi-Sol that were checked on the Newborn Admission Orders and authorized by the practitioner. The Director confirmed that 100% (42 of 42) of the 42 newborns failed to be provided the Poly-Vi-Sol in accordance with physician orders.

D. Staff interview with the Nursing Director of Maternal Child Services on 4/1/14 at 9 AM revealed that the standard order set had been originally created without the "vitamins checked" and then later the facility automatically had it checked for medication administration with the intent to ensure that this order would pull forward electronically as part of the discharge orders. The practice of holding the vitamins went on "for a long time" because nurses would overhear the practitioners tell their patients not to give the vitamins until the mothers' milk came in. The Director met with members of the Medical Staff for the Maternal/Child Health Department Committee meeting on 4/1/14 in which the committee discussed the current newborn admission order set, specifically the prechecked medication order for "Poly-Vi-Sol 1 ml by mouth daily if the mother is breastfeeding" order.

E. Review of the Committee notes for 4/1/14 were reviewed. They discussed the importance of Vitamin D for newborns. The notes identified that The American Academy of Pediatrics recommended that "all infants should be given Vitamin D (Poly -Vi-Sol contains Vitamin D) regardless of breast feeding status." The medical staff recommended "to continue with Poly-Vi-Sol as the only choice listed on the order set as it is covered by Medicaid, making it more likely the prescription will be filled/refilled as needed." The order set was revised during the survey to remove the words "if mother is breastfeeding" so all newborns would receive daily vitamins.

F. Record review of facility policy titled "Standardized Order Sets" (revised 6/2012) stated "order sets will be implemented and used at GSH [Good Samaritan Hospital] as a guideline to provide care." Record review of the policy titled "Medication Administration and Medication Administration Record" (revised 11/2012) identified under the section titled "Policy" that Nursing staff are to practice safe medication administration stating: "The 5 rights for medication administration are followed: Right patient; Right medication; Right dosage; Right time; Right route. Medications administered are documented on the Medication Administration Record [MAR]."

Based on review of medication error reporting records from 11/11/13-3/28/14, hospital policy for reporting medication errors, patient records, and staff interviews; the facility failed to ensure that nursing staff caring for newborns reported medication omission errors related to Poly-Vi-Sol (vitamins) for 1 of 1 sampled (Patient 3) breastfed infants and for 42 of 42 other breastfed infants identified by the facility on 4/1/14. The total sample size was 15. The facility census was 152.

Findings are:

A. Record review of the closed record for Patient 3 revealed that the newborn was born on 2/5/14 and was discharged 2/7/14. Record review of the "Newborn Care Flowsheet" documentation by nursing staff on 2/5/14 at 6:40 AM identified that the baby was breast fed. Review of daily nursing staff documentation throughout the newborn's stay identified that the baby was breast fed. Record review of physicians orders revealed a standing order set titled "Newborn Admission Orders " (revised date 1/19/11) dated 2/5/14 at 2:35 AM, and signed by the practitioner. The order set included under the section titled "Medications" an "X" in the box indicating that the order was to be implemented for "Poly-Vi-Sol 1 ml (milliliter) by mouth every day if mother is breastfeeding." Record review of the documentation on the "Newborn Admission MAR (Medication Administration Record)" found the Poly-Vi-Sol and dose was identified on the Newborn Admission Order set and was printed on the MAR. The MAR did not have any documentation that the Poly-Vi-Sol was ever administered to the baby.

B. Staff interview with LPN (Licensed Practical Nurse)-A on 4/1/14 at 10 AM revealed the LPN worked full time and was assigned to mother/baby nursing cares. LPN-A had been assigned to Patient 3 on the day of discharge (2/7/14). LPN-A stated "I never give newborn vitamins." The LPN identified the vitamins were ordered on the standard order set and printed on the MAR but "don't give" and have been doing this for "years." The LPN stated there are "no other orders on the standard order set that we routinely hold."

C. Staff interview on 4/2/14 with the Director of Quality and Risk at 12:30 PM revealed that the facility had 42 newborns that had been delivered in the last 30 days (from 3/3/14 - 4/1/14) who were breast fed and who had orders for Poly-Vi-Sol checked on the Newborn Admission Orders authorized by the practitioner. The Director confirmed that 100% (42 of 42) newborns failed to be provided the Poly-Vi-Sol in accordance with practitioner orders.

D. Staff interview with the nursing Director of Maternal Child Services on 4/1/14 at 9 AM stated the practice of holding the vitamins went on "for a long time".

E. Record review of Medication errors from 11/11/14 through 3/28/14 (the day of entrance) failed to identify medication error reporting had been completed regarding the Poly-Vi-Sol omission for Patient 3 or any of the 42 patients identified by the facility who were admitted from 3/3/14 -4/1/14.

F. Interview with the Director of Quality and Risk on 4/2/14 at 12:30 PM confirmed that the omission errors were never reported by Maternal/Child staff and so the problem went undetected.

E. Record review of facility policy titled "Medication Errors" (revised 10/13) stated "The physician should be notified of all medication errors. Discuss error with charge nurse, department director or Administrative Associate to determine the significance of contacting the physician immediately. An occurrence report is to be made out on all medication errors and forwarded to Risk Manager as soon as possible."

Based on review of medication error reporting records from 11/11/13-3/28/14, hospital policy for reporting medication errors, patient records, and staff interviews; the facility failed to ensure that nursing staff caring for newborns reported medication omission errors related to Poly-Vi-Sol (vitamins) for 1 of 1 sampled (Patient 3) breastfed infants and for 42 of 42 other breastfed infants identified by the facility on 4/1/14. The attending physicians were not notified of the omission of the Poly-Vi -Sol by the nursing staff. The total sample size was 15. The facility census was 152.

Findings are:

A. Record review of the closed record for Patient 3 revealed that the newborn was born on 2/5/14 and was discharged 2/7/14. Record review of the "Newborn Care Flowsheet" documentation by nursing staff on 2/5/14 at 6:40 AM identified that the baby was breast fed. A Review of daily nursing staff documentation throughout the newborns stay identified the baby was breast fed. A record review of physicians orders revealed a standing order set titled "Newborn Admission Orders " (revised 1/19/11) dated 2/5/14 at 2:35 AM and signed by the practitioner. The order set included under the section titled "Medications" an "X" in the box indicating the order to be implemented for "Poly-Vi-Sol 1 ml (milliliter) by mouth every day if mother is breastfeeding." A record review of the documentation on the "Newborn Admission MAR (Medication Administration Record)" found the Poly-Vi-Sol and dose was identified on the Newborn Admission Order set and was printed on the MAR (Medication Administration Record). The MAR did not have any documentation that the Poly-Vi-Sol was ever administered to the baby. Review of physician orders failed to find any notification to the physician of the omission.

B. Staff interview with LPN (Licensed Practical Nurse)-A on 4/1/14 at 10 AM revealed that the LPN worked full time and was assigned to mother/baby nursing cares. LPN-A was assigned to Patient 3 on the day of discharge 2/7/14. LPN-A stated "I never give newborn vitamins." The LPN identified that the vitamins were ordered on the standard order set and printed on the MAR but "don't give" and have been doing this for "years." The LPN stated there are "no other orders on the standard order set that we routinely hold."

C. Staff interview on 4/2/14 with the Director of Quality and Risk at 12:30 PM, revealed that the facility had 42 newborns delivered in the last 30 days (from 3/3/14 - 4/1/14), who were breast fed, and who had orders for Poly-Vi-Sol checked on the Newborn Admission Orders authorized by the practitioner. The Director confirmed that 100% (42 of 42) of the newborns failed to be provided the Poly-Vi-Sol in accordance with physician orders. There was no evidence physicians were contacted regarding the errors.

D. Staff interview with the nursing Director of Maternal Child Services on 4/1/14 at 9 AM stated the practice of holding the vitamins went on "for a long time".

E. A record review of Medication errors from 11/11/14 through 3/28/14 (the day of entrance), failed to identify medication error reporting related to Poly-Vi-Sol omission for Patient 3 or for any of the 42 patients (who were admitted from 3/3/14 -4/1/14) identified by the facility that failed to receive the vitamins as ordered.

F. Interview with the Director of Quality and Risk on 4/2/14 at 12:30 PM confirmed that the omission errors were never reported by Maternal/Child staff and so the problem went undetected.

G. Record review of facility policy titled "Medication Errors" (revised 10/13) stated that "The physician should be notified of all medication errors. Discuss error with charge nurse, department director or Administrative Associate to determine the significance of contacting the physician immediately. An occurrence report is to be made out on all medication errors and forwarded to Risk Manager as soon as possible."