HospitalInspections.org

Based on documentation review it was determined the Hospital failed to ensure patient ' s were receiving care in a safe setting and that Hospital policies clearly addressed all requirements for labeling of breast milk.

Findings included:

The Hospital policy titled Feeding, Expressing Breast Milk/Use of Electric Breast Pump (policy # M, F-8) was reviewed. The Policy stated pour (expressed) milk into sterile container and label with infant ' s name, date of birth, date and time obtained.

Review of the Hospital policy titled Breast Milk, Identification, Fortification, Use and Storage of was reviewed. The Policy stated Mothers will collect breast milk per hospital policy (refer to policy #M, F-8). Every container must have a tamper proof label across the tip to prevent tampering. The policy did not clearly identify when or whose responsibility it was to place the tamper proof label on the expressed container of breast milk.

Based on documentation review it was determined the Hospital failed to ensure nursing staff consistently met all patients needs related to validation of patient ' s identification prior to breast milk feeding in four out of ten NICU patient ' s records reviewed.

Findings included:

The Breast Milk, Identification, Fortification, Use and Storage policy was reviewed. The policy stated prior to administering a feeding, two RN ' s will verify at the bedside the identification of the patient and the breast milk by matching the infant ' s name, medical record number and date of birth on the breast milk label to the information on the patient ' s identification bracelet and medical record. Both RN ' s must document this identification check for each feeding.

Review of Patient #2 ' s medical record documentation did not indicate the verification at the bedside, was performed by two RN ' s, as specified in Hospital policy, on 10/10/10 at 5:00 PM; 10/14/10 at 10:00 PM, on 10/15/10 at 12:40 AM, 3:30 AM, 6:15 AM; 10/18/10 at 5:00 PM; 10/22/10 at 8:30 PM; and 10/26/10 at 11:00 AM and 2:00 PM.

Review of Patient #4 ' s medical record documentation indicate the verification at the bedside, was not performed by two RN ' s, as specified in Hospital policy on 10/25/10 at 4:15 PM and 7:05 PM, 10/27/10 at 1:00 PM and 6:30 PM.

Review of Patient #8 ' s medical record documentation did not indicate the verification at the bedside, was performed by two RN ' s, as specified in Hospital policy on 10/25/10 at 12:00 AM, 3:30 AM and 6:45 AM.

Review of Patient #9 ' s medical record documentation did not indicated the verification at the bedside, was performed by two RN ' s, as specified in Hospital policy on 10/21/10 at 6:00 PM and 9:00 PM; on 10/22/10 at 6:00 PM; on 10/24/10 at 6:00 AM, 7:00 PM and 10:00 PM; on 10/25/10 at 6:00 PM and 9:00 PM; on 10/28/10 at midnight and 3:00 AM; on 10/29/10 at 3:00 AM, 5:57 AM, 9:00 AM and 12:00 PM and on 10/31/10 at 9:00 PM.