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Based on review of facility policy, medical record review (MR) , and interview with staff, it was determined that the facility failed to ensure that medication was administered in accordance with the practitioners order for 1 out of 12 patients (Patient # 2) reviewed in the sample. Findings include:

Review of facility policy "Management of the Patient with Altered State of Comfort: Pain", no date, stated, " ...FLACC pain scale (behavioral): Children 2 months or older who are non-verbal and/or cognitively impaired ...Pain intensity is identified by the provider based on patient behavior. Five variables are assessed and assigned a numeric score; scores are then added to obtain a total. Total score range is from 0-10 ...Interpreting this Behavioral Score ...0= Relaxed and comfortable ..."

Review of medical record revealed a physicians order for morphine 0.56 mg intravenous every two (2) hours as needed for pain.

Review of patient's medication administration record revealed a dose of morphine was administered on August 30, 2024 at 9:05 AM.

Review of documented pain assessments on August 30, 2024 revealed pain was assessed at 8:00 AM using the FLACC pain scale. Total FLACC score was recorded as "0" which indicated the patient was relaxed and comfortable. The next documented pain assessment was at 10:00 AM and also reflected a score of "0". No evidence was found that indicated the patient required medication for pain at the time of the morphine administration.

The above finding was confirmed on February 18, 2024 with EMP6 at 1:09 PM

Based on observation, staff interview, and hospital policy and document review, it was determined that staff failed to follow the hospital's infection control policies potentially affecting 33 of 33 NICU (Neonatal Intensive Care Unit) inpatients. Findings include:


Hospital policy "Hand Hygiene Policy", effective 8/23/2023, stated, "...Procedure...1. Follow the World Health Organization's 5 Moments for Hand Hygiene...a) Moment 1: Before Touching the Patient...b) Moment 2: Before a Clean/Aseptic Task...c) Moment 3: After Body Fluid Exposure...d) Moment 4: After Touching a Patient...e) Moment 5: After Touching a Patient's Environment...Gloves are not a replacement for hand washing. Hand hygiene should be performed before donning and after removing gloves..."

Hospital document "Medication Administration and Monitoring", effective 7/23/2024, stated, "...IV Medications via Syringe Module of Infusion Device: 1. Perform hand hygiene...2. Attach syringe with medication to appropriate tubing and prime tubing with fluid/medication to eliminate air from tubing. 3. Load syringe into infusion device. 4. Program the electronic infusion device, confirm settings and start infusion. 5. Perform hand hygiene. 6. Scrub administration port with antiseptic wipe or swab, using a 5 second friction rub...7. Connect tubing to administration port. 8. Perform hand hygiene. 9. After medication syringe has infused, attach syringe with 0.9% saline (or compatible solution) to flush tubing. 10. Place this flush syringe on pump and infuse flush at same rate as medication..."


During a tour of the Neonatal Intensive Care Unit (NICU) on 2/18/25 from 10:11 to 10:50 AM, the following was observed during the care of Patient #13:

- EMP13, Registered Nurse (RN), picked up and discarded used gauze from bassinet without gloves, placed one glove partially on right hand, opened drawer of supply cart with partially gloved hand, used ungloved left hand to obtain supplies from cart, and brought supplies to bedside of patient.
- EMP13 failed to perform hand hygiene after going from dirty to clean task and before donning a glove.

This finding was confirmed at the time of observation by EMP6.

- EMP9, RN, in preparation to administer a PRN (as needed) medication intravenously (IV) using a syringe pump/module, performed hand hygiene using alcohol based hand rub, donned gloves, picked up medication syringe from computer table, sanitized IV port with alcohol, attached syringe module tubing to port, programmed the pump, charted on bedside computer using keyboard, replaced medication syringe with flush syringe, programmed pump, discarded used supplies after administration to include tubing and syringes, discarded gloves, performed hand hygiene.
- EMP9 failed to perform hand hygiene and replace gloves after programming syringe pump and charting on computer, after connecting tubing to IV port, and before replacing medication syringe with flush syringe.

EMP6 observed this finding at the time of discovery, and it was confirmed by EMP4, Director of Infection Control, during an interview on 2/18/25 from 11:06 AM to 11:24 AM.