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Based on observations, records reviewed and interviews, Hospital Quality Assessment & Performance Improvement (QAPI) activities failed to ensure: 1.) for seven patients (Patients #1, #3, #5, #6, #7, #8 & #9) of nine in a total sample of 10 newborn medical records reviewed, to thoroughly analyze cause(s), implement effective, preventive actions and monitor improvement activity effectiveness regarding newborn hypoglycemia (low blood sugar) events, after Patient #1's hypoglycemia event, 2.) the monitoring of the effectiveness of identified improvement activities of two events regarding Newborn Nursery coverage and 3.) the implementation of effective corrective actions after identifying that staff were not checking emergency carts in accordance with Hospital policy.

Findings included:

1.) The document titled Performance Improvement & Patient Safety Plan, dated 2017, indicated the Hospital's Quality Improvement Performance Improvement model. The Hospital used the model to identify, plan, implement and monitor continuous quality improvement efforts.

The policy titled Glucose Monitoring in Newborns, dated 5/20/14, indicated the Hospital screened all newborns for risk factors for early hypoglycemia and for signs and symptoms indicative of hypoglycemia.

The Nurse's Note, dated 8/3/17 at 4:53 A.M., indicated Patient #1 was jittery (shaky) in both hands and feet. The Nurse's note indicated Patient #1 met the criteria for blood sugar monitoring.

The policy titled Glucose Monitoring in Newborns indicated staff screened newborns for signs and symptoms indicative of hypoglycemia that included jitteriness.

The document titled Report, undated, indicated Patient #1 was jittery after birth and staff initiated the Newborn Glucose Monitoring policy and the jitteriness resolved. The Report indicated Registered Nurse (RN) #1, who was covering for RN #4, delegated the task of performing a blood sugar test to a nursing assistant who performed the test after Patient #1's mother requested the blood sugar test. The Report indicated the nursing assistant entered the result into Patient #1's medical record and did not verbally report the blood sugar result to RN #4, (the RN assigned to and responsible for providing Patient #1's nursing care).

The Surveyor interviewed the Special Care Nursery Medical Director, Quality Staff #1 and the Maternal Newborn Service Nurse Director at 2:00 P.M. on 11/21/17. The Special Care Nursery Medical Director, Quality Staff #1 and the Maternal Newborn Service Nurse Director said that corrective actions included clear written staff coverage for breaks and lunch, bedside report, use of bedside communication boards, and re-education of staff on required documentation. The Special Care Nursery Medical Director, Quality Staff #1 and the Maternal Newborn Service Nurse Director said that the Hospital had verbal confirmation that the Hospital implemented the corrective actions.

The Hospital provided no documentation to indicate that the Hospital implemented or monitored their identified corrective actions for effectiveness after Patient #1's hypoglycemia event.

Patients' #3, #5, #6, #7, #8 and #9's medical records indicated newborns that met the criteria for blood sugar monitoring and that staff did not monitor newborn blood sugars in accordance with the Hospital's policy titled Glucose Monitoring in Newborns.

Patient #3's medical record indicated the newborn was born on 11/15/17 at 2:16 P.M. to an insulin controlled diabetic mother. The medical record did not indicate documentation of the 11/14/17 at 5:01 P.M. feeding.

Patient #5's medical record indicated the newborn was born on 10/24/17 at 7:33 A.M. to an insulin dependent gestational (during the pregnancy) diabetic mother. The medical record did not indicate documentation of a pre-prandial (before feeding) blood sugar level for the 11:00 A.M. feeding on 10/24/17.

Patient #6's medical record indicated the newborn was born on 10/23/17 at 5:03 A.M. to an insulin controlled gestational diabetic mother. The medical record did not indicate documentation of a pre-prandial blood sugar level for the 11:30 A.M. feeding on 10/23/17.

Patient #7's medical record indicated the newborn was born on 10/16/17 at 2:34 A.M. to a mother with gestational diabetes. The medical record did not indicate documentation of the 10:30 A.M. feeding.

Patient #8's medical record indicated the newborn was born on 10/13/17 at 8:54 P.M. to a mother with gestational diabetes. The medical record did not indicate documentation of blood sugars in accordance with the Glucose Monitoring in Newborns Policy.

Patient #9's medical record indicated the newborn was born on 10/9/17 at 12:31 A.M. to a mother whose diabetes was diet controlled. The medical record did not indicate that staff obtained blood sugar levels before feedings in accordance with the Glucose Monitoring in Newborns Policy.

The Hospital provided no documentation to indicate the process improvement approach of sustainability through monitoring (auditing) corrective actions.

Reports, dated 8/1/17-11/20/17, indicated four events pertaining to newborns and monitoring of blood sugars.

Event #1, dated 8/13/17, indicated staff did not monitor a newborn's blood sugar level (Un-Sampled Patient #1) and that the mother birthed the newborn ten hours after she received terbutaline (a medication).

The policy titled Glucose Monitoring in Newborns, dated 5/20/14, indicated the Hospital screened all newborns of mothers treated with terbutaline in labor for early hypoglycemia and for signs and symptoms indicative of hypoglycemia.

Event #2, dated 10/9/17, indicated staff did not monitor blood sugars of a newborn born (Un-Sampled Patient #2) to an insulin dependent diabetic mother in accordance with the Glucose Monitoring in Newborns Policy.

The policy titled Glucose Monitoring in Newborns indicated the Hospital screened all newborns of diabetic mothers.

Event #3, 11/2/17, indicated that the mother was a gestational diabetic and Hospital staff did not initiate newborn (Un-Sampled Patient #3) blood sugar monitoring in accordance with the Glucose Monitoring in Newborns policy.

The policy titled Glucose Monitoring in Newborns indicated the Hospital screened all newborns of mothers with gestational diabetes.

Event #4, dated 11/16/17, (four days prior to the Survey and three months after Patient #1's low blood sugar event), indicated staff did not monitor blood sugars of a newborn (Un-Sampled Patient #4) born to an insulin dependent diabetic mother in accordance with the Glucose Monitoring in Newborns Policy.

The policy titled Glucose Monitoring in Newborns indicated the Hospital screened all newborns of diabetic mothers.

2.) The document titled Scope of Maternal Newborn Service, dated 10/2017, indicated that the Hospital staffed the newborn nursery with one (1) Registered Nurse at all times when a newborn(s) was physically present in the nursery.

Reports, dated 8/1/17-11/20/17, indicated two events pertained to newborns left alone in the Newborn Nursery occurring on 8/12/17 and 10/25/17.

The Surveyor interviewed RN #6, at 10:30 A.M. on 11/22/17. RN #6 said the Hospital had two events where staff left babies alone in the newborn nursery. RN #6 said she investigated both events and discovered the two events occurred at the change of shift with miscommunication of who was covering the newborn nursery. RN #6 said corrective actions after the events included staff re-education and assigning staff to newborn nursery coverage.

The Hospital provided no documentation to indicate the process improvement approach of sustainability through monitoring (auditing) that the corrective actions were effective.

3.) The Surveyor observed that the Code Cart Check Form did not indicate documentation that Hospital staff checked the Code Cart daily, on ten days from 4/2017 - 9/2017, in accordance with the Hospital's policy on Code Cart Checks.

The policy titled Code Cart Checks Replacement and Defibrillator Check, dated 12/16/16, indicated the Hospital checked code carts daily.

The Surveyor interviewed RN #6. RN #6 said corrective actions included speaking to the nurse assigned to checking the code cart on the days the nurse did not document the code cart check and reminding staff at staff huddles (report).

The Hospital provided no documentation to indicate the process improvement approach of sustainability through monitoring (auditing) that the corrective actions were effective.