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Based on interview and record review, the facility failed to ensure one of ten sampled employees (Registered Nurse - RN 8) was screened for a record of abuse or neglect prior to hire date and one of ten sampled employees (RN 9) had current abuse training, in accordance with local, state, federal and facility policies.

This deficient practice had the potential for lack of protection of patients against abuse.

Findings:

During a concurrent interview and record review on 7/28/2023, at 2:43 p.m., with human resources director (HR Dir.), clinical educator (Educator), and manager of labor and delivery (RN 12) a review of personnel files was conducted, HR Dir. stated RN 8 was hired 2/26/1996. HR Dir. said RN 8 had no background check done because the facility did not do background checks in 1996, for prospective employees, prior to being hired.

Concurrently, Educator stated RN 9 did not have current (2023) abuse training. Educator stated abuse training is done online and is an annual requirement for nursing employees.

A review of RN 9's personnel file indicated date of hire was on 3/02/2020.

A review of the facility's policy for Background Screening, dated 3/12/2020, indicated the following:
1. In accordance with applicable law, pre-placement background screening is done for pre-employment to provide a safe environment for patients, customers, and staff members.
2. All employment or placement offers are contingent upon successful completion of a background screening.
3. Background screening must be complete prior to the first day of work for employees and placement start date for student, volunteers, or other third parties (vendors - traveler, registry, temporary staffing agency), for whom the business may require a background screening.

A review of the facility's policy for Abuse, Neglect, and Violence - Patient Identification, Intervention, and Mandated Reporting, dated 2/24/2021, indicated in accordance with applicable laws, regulations and facility policies, all persons, on-site at the facility, will be protected from abuse, neglect, or violence.

Based on interview and record review, the facility failed to ensure Patient 1 had a comprehensive care plan (nursing care plan provides a framework for evaluating and providing patient care needs related to the nursing process) developed and implemented, after Patient 1 was transferred from the labor and delivery's operating room to the neonatal intensive care unit (NICU - hospital department equipped and staffed to provide intensive care to dangerously ill newborn babies), in accordance with the facility's policy and procedure regarding care plan.

This deficient practice resulted in Patient 1 getting transferred to the NICU without an individualized goal-oriented plan of care to provide a means for interdisciplinary communication for patient's care. This deficient practice also had the potential for Patient 1's needs and risks not addressed.

Findings:

A review of Patient 1's face sheet, dated 7/15/2023, indicated Patient 1 had a date of birth on 7/15/2023.

A review of Patient 1's history and physical (H&P), dated 7/16/2023, indicated the following:
1. Patient 1 was delivered by urgent cesarean section (the surgical delivery of a baby through a cut made in the mother's abdomen and uterus).
2. Patient 1's mother had ruptured membranes (when the water breaks for a pregnant woman and the amniotic fluid flows out from the mother's vagina) for twenty-two hours.
3. Amniotic fluid was stained with meconium (the first stool of the baby).
4. At delivery, Patient 1 was limp, pale, and not breathing on her own. Patient 1 was intubated (a process where a healthcare provider inserts a tube through the patient's mouth, then down into their windpipe) because patient was not breathing.
5. At delivery, Patient 1's heart rate was very slow and was provided cardiopulmonary resuscitation (CPR - lifesaving technique during an emergency in which someone's breathing, or heartbeat has stopped).
6. After Patient 1 was stabilized, Patient 1 was transferred to the NICU for further stabilization and care.
7. Plan for pain management - monitor and document pain level. For optimal pain control, give patient sucrose per protocol.

During a concurrent interview and record review on 7/27/2023, at 2 p.m., with Registered Nurse 11 (RN 11), Patient 1's medical record was reviewed. RN 11 stated Patient 1 had no care plan developed for pain management on admission in the NICU.

Concurrently, RN 11 stated a comprehensive care plan should have been initiated within eight hours, after Patient 1 was admitted to the neonatal intensive care unit (NICU) on 7/15/2023 at 9:10 p.m..

A review of Patient 1's discharge summary, dated 7/16/2023, indicated Patient 1 died at 12:23 p.m., when heart tones were not detected, when there was no spontaneous breathing, and when Patient 1's pupils were nonreactive.

A review of the facility's policy, Standards of Care in the neonatal intensive care unit (NICU), dated 2/2023, indicated the following:
1. Pain assessment using the Neonatal Pain and Sedation Scoring (N-PASS) tool.
2. Pain score will be obtained every time a complete set of vital signs (measurements of the body's most basic functions, including temperature, pulse rate, respiration rate, and blood pressure) is taken using N-PASS.
3. Individualized, interdisciplinary patient care plans, will be initiated within eight hours after admission.
4. Plan of care (POC) will be documented in the electronic health records.
5. Each active problem will be evaluated every shift.

A review of the facility's policy and procedure (P&P), titled "Interdisciplinary Care Planning," dated 2/2026, indicated the following:
1. Every patient will have a care plan initiated within 24 hours of admission.
2. The care plan shall be consistent with the medical plan of care.
3. At the time of transfer to another unit or service, the care plan will be updated.
4. The care plan will be reviewed to reflect only those problems requiring continued monitoring and interventions.
5. The nurse from the accepting unit validates the appropriateness for all problems on the care plan, during the handoff process.