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Based on interview, record review and review of the facility's Newborn Hypoglycemia Physician Orders (standing orders) it was determined the facility failed to ensure newborn infants at high risk of having Hypoglycemia (a decrease in blood sugar) were properly and adequately evaluated for one (1) of ten (10) sampled patients (Patient #3).
Patient #3's mother was admitted to the facility on 04/27/12 with diagnoses which included Gestational Diabetes, which was controlled with Glyburide. Patient #3 was delivered on 04/27/12 and was large for gestational age (LGA), weighing nine (9) pounds and five (5) ounces. Review of the facility's Newborn Hypoglycemia Physician's Orders, both factors put the infant at high risk for Hypoglycemia. The facility failed to identify Patient #3 as at risk for Hypoglycemia and failed to take appropriate action when Patient #3 exhibited abnormal behavior on 04/29/12. The facility failed to follow the standing Order Set for Newborn Hypoglycemia by failing to observe closely for these abnormal behaviors and failing to monitor the blood sugar levels after Patient #3 exhibited abnormal behaviors. On 04/29/12, Patient #3 required a transfer to a hospital with a neonatal intensive care unit due to low blood sugar and seizure like activities.
Those failures placed patients at risk for injury, harm, impairment or death. On 08/03/12, Immediate Jeopardy was identified and determined to exist related to Nursing Services. The facility initiated corrective actions on 08/03/12. It was determined the Jeopardy was abated on 08/06/12 prior to the survey exit.
Refer to A-395

Based on interview, record review and review of the facility's Newborn Hypoglycemia Physician's Orders, it was determined the facility failed to ensure newborn infants, at high risk for Hypoglycemia, were provided with nursing care to promote optimal health status for one (1) of ten (10) sampled patients (Patient #3). Patient #3's mother was admitted to the facility on 04/27/12 with diagnoses which included Gestational Diabetes and delivered Patient #3 on 04/27/12. The facility failed to ensure nursing services was provided to ensure Patient #3 was evaluated and appropriate nursing care was provided.

The findings include:

Review of the facility's Newborn Hypoglycemia Physician's Orders revealed infant's blood glucose was to be obtained if the infant's five (5) minute Apgar was less than or equal to seven (7), mother was diabetic, infant was small for gestational age (SGA) or large for gestational age (LGA) by weight, infant was jittery or lethargic or had respiratory distress. If the infant's blood glucose was below twenty five (25), staff would repeat centrally (laboratory blood draw), start intravenous line (IV) and give 2 milliliters/kilogram (ml/kg) of D10W (Glucose) then recheck glucose in fifteen (15) minutes after bolus was completed and call the Physician on call. If the blood glucose was twenty-five (25) to forty-five (45) and the infant was asymptomatic, staff was to give 10ml/kg of D5W or formula by mouth or by gavage (a tube inserted into the infant's stomach) and repeat the blood glucose test in fifteen (15) minutes. If the blood glucose was twenty-five (25) to forty-five (45) and the infant was symptomatic, staff would start an IV and give D10W at 5ml/kg per hour and repeat the blood glucose in fifteen (15) minutes after the IV was started and call the on-call Physician. If the infant's blood glucose was greater than forty-five (45) and the infant was symptomatic, the blood glucose was to be repeated in thirty (30) minutes and the infant was to be observed closely, and early feeding was to be encouraged. If the infant's blood glucose was greater than forty-five (45) and the infant was asymptomatic, the infant was to be observed closely.

Record review revealed the facility admitted Patient #3's mother on 04/27/12 and the mother gave birth to Patient #3 on 04/27/12. The infant's mother had Gestational Diabetes, which was controlled with Glyburide and the infant weighed nine (9) pounds five (5) ounces which was determined, by the facility, to be large for gestational age (LGA). According to the facility's Newborn Hypoglycemia Physician's Orders, both factors put the infant at high risk for Hypoglycemia. The high-risk infant's blood glucose was to be obtained and if the blood glucose was over 45 and the infant did not have symptoms of Hypoglycemia, the infant was to be monitored closely.

Record review revealed on 04/27/12, Patient #3's blood glucose was 47, the infant did not exhibit any symptoms of Hypoglycemia and the blood glucose was not obtained again.

Interview with Patient #3's mother, on 07/31/12 at 6:27 PM, revealed the infant roomed in with her. She stated that she reported to Registered Nurse (RN) #13 that Patient #3 was fussy the night of 04/28/12 and the next morning, on 04/29/12, the infant was not latching on well when breast feeding. She further stated she request "sugar water" for the infant and RN #13 told her to be careful because it might run Patient #3's sugar up.

Interview with RN #13, on 08/05/12 at 4:42 PM, revealed she cared for the mother on 04/29/12. She stated the infant was fussy and the mother was trying to breast feed.

Record review revealed the infant was to be discharged home on 04/29/12. According to the Nurses Notes, on 04/29/12 at 9:35 AM, Registered Nurse (RN) #1 observed the infant to roll his/her eyes and only the white was showing. The Physician performed a neurological exam and said everything was normal and proceeded to write the discharge order. At 11:00 AM, RN #1 was called to the room, by the infant's mother, and RN #1 noted the infant rolling his/her eyes and a startle type reflex was noted in Patient #3's arms; however, there was no documented evidence the facility re-checked Patient #3's blood glucose levels at that time. The mother requested for the Physician to re-evaluate the infant. Further record review revealed RN #1 called the Physician, who stated the newborn's neurological exam was normal but to ease the parent's concerns, he would cancel the discharge and perform tests on Patient #3 the following day. Continued record review revealed RN #1 documented at 11:48 AM, the infant was noted to roll his/her eyes again.

Interview with Patient #3's mother, on 07/31/12 at 6:27 PM, revealed she observed her infant's (Patient #3) eyes rolling back in his/her head and reported this to RN #2. Interview with RN #2, on 08/03/12 at 9:12 AM revealed she also observed Patient #3's eyes rolling at which time she took the infant back to the nursery.

Record review revealed RN #1 checked the blood glucose level at the mother's request and the infant's blood glucose level was less than 20 (the facility's glucometer only registered down to 20). The Physician was paged and at 11:52 AM, the blood glucose was still below 20. Per the record RN #1 attempted to place an intravenous line (IV) and another nurse attempted to feed the infant. At 12:16 PM, a possible seizure was noted, the infant drew his/her body to the left in a C-shape while he/she pulled his/her left arm inward and extended his/her right arm over his/her head. The infant drew his/her mouth to the left and his/her eyes rolled back and muscle rigidity was noted which lasted approximately 15 seconds. The nurses initiated blow by oxygen (O2). The on call Physician was called and a message was left requesting a return call, for an emergency in the nursery.

Further review of the Nurses Notes revealed at 12:17 PM, the infant had a second possible seizure with the same characteristics as the previous one which lasted approximately 15 seconds. At 12:20 PM, the Physician called with orders and he was notified of the attempts to start an IV and obtain the blood serum glucose (lab work), were unsuccessful. At that time, the patient's blood sugar was 27 (obtained by heel stick). The IV was started at 12:25 PM and the bolus of D10W 8 milliliters (ml) was given. At 12:36 PM, D10W IV drip was started at 20 ml per hour and the infant's blood glucose was 53. At 12:50 PM, the on-call Physician was at the bedside to evaluate the infant. At 1:03 PM, the labs were obtained. At 1:50 PM, the Physician contacted a local hospital with a neonatal intensive care unit and discussed with the parents the need to transfer the infant to a hospital with a neonatal intensive care unit. On 04/29/12 at 2:15 PM the infant was transferred to the hospital with the neonatal intensive care unit.

Interview, on 08/03/12 at 2:01 PM, with RN #1 revealed she was the charge nurse on 04/29/12 and she saw Patient #3 do something strange with his/her eyes. She informed Pediatrician #2 and he performed a neurological exam and wrote orders to discharge Patient #3. She stated, the Physician said the infant was normal so she took the infant to his/her mother's room. Interview further revealed later, she was called to the room and saw the infant do something with his/her eyes and arm, but the infant was easily soothed. She stated she notified the Physician and he stated it was immature eye movements; however, he stated to ease the parent's concerns, he would cancel the discharge. She further stated, another nurse checked the blood sugar of Patient #3 and it was low. Further interview revealed RN #12 attempted to feed the infant, while nurses (including the House Coordinator) were trying to obtain IV access. The House Coordinator eventually gained IV access and the bolus of glucose was given to the infant. She stated Patient #3 had a full blown seizure when the laboratory staff was in the room. Further interview revealed she thought the standing orders had something about gavage could be used, but she would have to look at the orders to be sure. She also stated she thought the infant got some formula down. Further interview revealed she did not recognize the episode as a sign of Hypoglycemia because seizures were not a typical sign of Hypoglycemia. She stated she was unsure if the standing orders reflected that blood sugar could be checked at any time, but knew the blood sugar could be checked if the infant was symptomatic.

Interview, on 08/02/12 at 4:50 PM, with Pediatrician #2 revealed he saw Patient #3 have the episode, in the nursery, on 04/29/12 and he thought it was a little unusual, but there was no shaking, atonia or postictal state, the infant was not flaccid or hypotonic. He stated Hypoglycemia was less likely the cause of seizures than other diagnoses. He stated the nurses should have been able to obtain IV access and because they were not able to gain IV access they should have used a gastric tube in order to get formula in the infant.

Interview, on 08/02/12 at 3:45 PM, with the Risk Manager revealed if nurses were unable to obtain IV access, the next step would be to give the formula by gavage. Further interview revealed she hoped the nurses and Physicians knew the signs of Hypoglycemia, and she believed the nurses trusted the Physician when he said the infant was normal. Interview, on 08/07/12 at 5:00 PM, with the Risk Manager revealed the nurses should have given the infant formula by gavage due to the difficulty with feeding the infant. She also stated she thought gavage should be on the standing orders and the orders should give specific steps, such as what to do until the nurses received new orders. She continued to say the facility had revise the standing orders after this incident occurred and removed the stipulation of providing feeding through gavage. The revised orders included to check the infant's blood sugar thirty (30) minutes after birth and every three (3) hours until two (2) consecutive readings were over forty-five (45), which could potentially end the monitoring for Hypoglycemia when the infant was just three and a half (3 1/2) hours old. She then stated the blood sugar would not be checked after that if there were no indications to do so.

Interview, on 08/03/12 at 10:30 AM, with Pediatrician #1 revealed the facility's newly revised protocol specified to obtain the blood glucose levels for infants at high risk for Hypoglycemia soon after birth. He stated infants at risk for Hypoglycemia could have a decrease in blood sugar up to forty-eight (48) hours after birth; however, the new protocol did not stipulate to monitor for that length of time. Further interview revealed, when he saw Patient #3, on 04/29/12, he wondered why the infant wasn't monitored, as the infant was LGA, his/her mother had Gestational Diabetes Mellitus, which was controlled by Glyburide (antidiabetic medication) and the infant had lost seven (7) ounces in less than twenty-four (24) hours, all of which were indicators of the risk for Hypoglycemia. He further stated he would expect the nurses to give formula by gavage to increase the blood glucose level, unless it was contraindicated and he didn't think it was contraindicated in Patient #3's case. He stated the facility nurses told him they didn't know Patient #3's mother had Gestational Diabetes.

Interview, on 08/02/12 at 9:00 AM, with the Director of the Women's Care Unit (DWCC) revealed Patient #3's blood sugar was forty-seven (47) and the infant was asymptomatic throughout the stay. The nurse noted the infant rolled his/her eyes but the Physician said it was normal and gave the discharge orders. The infant rolled his eyes again and the Physician cancelled the discharge orders. She stated Patient #3 appeared to have a seizure in the nursery and the blood sugar was less than twenty (20).

The facility failed to ensure newborn infants received nursing services to maintain optimal health. This failure placed patients at risk for injury, harm, impairment or death. On 08/03/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions. Those actions were as follows: The facility developed a committee to determine the root cause analysis of care for Patient #3 which identified opportunities for improvement. The facility revised the policy and order set for assessment and treatment for infants at high risk for hypoglycemia. Staff was educated and completed competency test related to infants at high risk for hypoglycemia. The Committee also reviewed all current standards and practices requiring at risk infants and care of hypoglycemia. The policy for Glucose testing and treatment for neonatal hypoglycemia and the Order Set for Newborn Hypoglycemia was revised by the Physician, a Registered Nurse and then review by a Pediatrician and approved by the Committee on 08/04/12. The Departmental Policy for Handoff Communication was developed to improve handoff communication between the labor nurse and nursery nurse. All staff was oriented to the new procedure during the inservice conducted on 08/05/12. An audit tool was developed to ensure compliance with policy, assessment for high risk, initiation of Physician's orders for newborn hypoglycemia, and appropriate handoff communication between the labor nurse and the nursery nurse. 100% of the newborn charts will be audited for ninety (90) days. Education Inservice and Competency Assessment was designed by the Committee and all nursing staff and House Coordinators attended mandatory training on 08/05/12. All staff who were on leave will be required to complete the training prior to returning to work. All current inhouse infants were screen for risk of Hypoglycemia as of 08/04/12. All Physicians with newborn nursery privileges received e-mail notification of the revisions to the policy and Order Set as of 08/05/12. All House Coordinators were instructed as to their role as scribes during intensive care of patients to achieve real time documentation. Interviews and record reviews were conducted which verified the corrective actions.

The Immediate Jeopardy was determined to be abated on 08/06/12 prior to the exit of the survey.