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Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient's Rights as evidenced by the hospital failing to protect a NICU patient from neglect when providing the administration of intravenous intralipids by failing to ensure a 100 ml bag of intralipids was placed on a pump or any other device/system to ensure the patient received the prescribed dose at the prescribed rate for 1 (#2) of 5 patients sampled (see findings A-0145).

Based on record review and interview, the hospital failed to protect a NICU patient from neglect when providing the administration of intravenous intralipids by failing to ensure a 100 ml bag of intralipids was placed on a pump or any device/system to ensure the patient received the prescribed dose at the prescribed rate. The hospital also failed to ensure that an incident of neglect was reported to the Louisiana Department of Health within 24 hours of discovery in accordance with state law for 1 (#2) of 5 patients sampled.

Findings:

Review of the Louisiana R.S. 40:2009.20 revealed that "Neglect" is defined as the failure to provide the proper or necessary medical care, nutrition, or other care necessary for consumers' well-being; and that "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect."


Review of the hospital policy titled IV Therapy revealed in part:

E. Process: Labeling of IV fluid lines and Double Checking with Second Nurse

2. All IV rates and fluids must be double checked with a second nurse at the time of starting an infusion, at the time of any rate changes, at the time of any shift change and any time IV fluids are being restarted.

F. Documentation
2. Fluids, Medications, flushes, Boluses, blood products and hyperalimentation should be documented hourly in the NICU.


Review of Patient #2's medical record revealed, he had been born on 11/16/19 at 27 weeks and 5 days gestation. Further review revealed, he weighed 1260 grams (2 pounds 8 ounces) at birth. On 11/18/19, Patient #2 was on a high frequency oscillatory ventilator with nitric oxide, a Dopamine drip and an Epinephrine drip.

Review of Patient #2's physician's orders dated 11/18/19 at 9:00 a.m. revealed an order for Fat emulsion (intralipids) 100 ml @ 0.2 mls/hr (4.8 ml in 24 hours).


Review of Patient #2's NICU Follow-up note (Death Note) written by S5MD dated 11/19/19 at 4:28 a.m. revealed the following:

Patient started to deteriorate at mid-morning on 11/18/19. Oxygen desaturation and increase in the PCO2. BP was stable on Dopamine and Epinephrine. The CXR showed increased granularity. The ventilator settings were adjusted with improvements. At around 3:00 p.m., we realized the whole bag of intralipids of 100 cc had been infused by error. The blood was milky.


In an interview on 1/6/2020 at 2:50 p.m. with S5MD, he said Patient #2's lipid bag was not on a pump but should have been.


In an interview on 1/7/2020 at 9:15 a.m. with S3RN, she said she worked on 11/18/19 and was assigned Patient #2 with a preceptor (S4RN) and they had no other patients. She said, Patient #2 was just prescribed and started on Lipids that morning. She said, she spiked the bag and primed the IV tubing with the lipids. She said, she then hung the lipids on a pole and clamped the tubing. S3RN said, they needed to go get another pump so they left the lipids hanging on the pole until they could get one.

She then, said they did an assessment of Patient #2 and the preceptor showed her where the medications were attached on the IV line and they attached the lipids. S3RN said, she then unclamped the lipids and neither she or S4RN realized the lipids were not on a pump. She said, S4RN was supposed to check behind her when hanging fluids but she did not. She said, they both documented on the patient during the shift. She said they forgot to put the lipids on the nursing flowsheet.

She said around 3:00 p.m., the respiratory therapist drew some blood and said it looked milky. It was then discovered the whole bag (100 ml) of lipids had infused and had not been put on a pump or monitored (approximately 6 hours after the drip was started). She said, after the empty bag was discovered they realized the lipids had not been documented on the flowsheet the whole shift.


In an interview on 1/7/2020 at 5:35 p.m. with S1CNO, she said, they did not feel like the incident with Patient #2 was neglect so they did not report it to the state. She verified the staff did not follow the hospital's policy and procedure for IV fluids.

Based on record review and interview, the hospital failed to ensure all drugs and biologicals were administered in accordance with the hospital's policies and procedures. This deficient practice is evidenced by the nursing staff failing to connect the 100 ml bag of Fat emulsion (intralipids) to an IV pump in order to administer the prescribed dosage at the ordered rate of delivery, failed to transcribe an order for intralipids to the nursing flowsheet to document the hourly intake as per hospital policy and failed to ensure documentation was accurate for 1 (#2) of 5 patients sampled.

Findings:

Review of the hospital policy titled IV Therapy revealed in part:

F. Documentation
2. Fluids, Medications, flushes, Boluses, blood products and hyperalimentation should be documented hourly in the NICU.


Review of Patient #2's medical record revealed, he had been born on 11/16/19 at 27 weeks and 5 days gestation. Further review revealed, he weighed 1260 grams (2 pounds 8 ounces) at birth. On 11/18/19, Patient #2 was on a high frequency oscillatory ventilator with nitric oxide, a Dopamine drip, and an Epinephrine drip.

Review of Patient #2's physician's orders dated 11/18/19 at 9:00 a.m. revealed an order for Fat emulsion (intralipids) 100 ml @ 0.2 mls/hr (4.8 ml in 24 hours).

Review of Patient #2's MAR for 11/18/19 revealed, Fat Emulsion Intravenous (intralipids) at 0.2 ml/hr was documented as having been started at 8:28 a.m. by S4RN. The medication was documented as 0.2 ml infused every hour from 9:00 a.m. until 4:00 p.m.

Review of Patient #2's NICU Follow-up note (Death Note) written by S5MD dated 11/19/19 at 4:28 a.m. revealed the following:

Patient started to deteriorate at mid-morning on 11/18/19. Oxygen desaturation and increase in the PCO2. BP was stable on Dopamine and Epinephrine. The CXR showed increased granularity. The ventilator settings were adjusted with improvements. At around 3:00 p.m., we realized the whole bag of intralipids of 100 cc had been infused by error. The blood was milky.

In an interview on 1/6/2020 at 2:50 p.m. with S5MD, he said, Patient #2's lipid bag was not on a pump but should have been.

In an interview on 1/7/20 at 9:15 a.m. with S3RN, she said, she worked on 11/18/19 and was assigned Patient #2 with a preceptor (S4RN) and they had no other patients. She said, Patient #2 was just prescribed and started on Lipids that morning. She said, she spiked the bag and primed the IV tubing with the lipids. She said, she then hung the lipids on a pole and clamped the tubing. S3RN said, they needed to go get another pump so they left the lipids hanging on the pole until they could get one.

She then said, they did an assessment of Patient #2 and the preceptor showed her where the medications were attached on the IV line and they attached the lipids. S3RN said, she then unclamped the lipids and neither she nor S4RN realized the lipids were not on a pump. She said S4RN was supposed to check behind her when hanging fluids but she did not. She said they both documented on the patient during the shift but they forgot to put the lipids on the nursing flowsheet.

She said around 3:00 p.m., the respiratory therapist drew some blood and said it looked milky. It was then discovered the whole bag (100 ml) of lipids had infused and had not been put on a pump. She said, after the empty bag was discovered they realized the lipids had not been documented on the flowsheet the whole shift. S3RN said, she asked her preceptor what to do and S4RN went and talked to another RN. S3RN said, she was then told by S4RN to fill in the amounts in 0.2 ml/hr increments for the shift which was the original ordered rate. She said, she knew it was false documentation and felt it was wrong but because her preceptor told her to write it, she did.


In an interview on 1/7/20 at 1:31 p.m. with S1CNO, she said, the hospital did not identify the problem that Patient #2's medication, intralipids, was not added to the nursing flowsheet which would have prompted the nurse to check the rate of the lipids every hour. When asked if the transcription error was included in the root cause analysis the facility had conducted, she said, it had not been identified as a problem. She said, the computer program where medications are ordered and the nurse's flowsheet do not interface. She said, unrelated to this incident, they have been working on getting a system that does interface. S1CNO verified the nurses have to manually add a medication to the flowsheet.


In an interview on 1/7/20 at 1:45 p.m. with S2NICUMgr, she said, getting a new system that interfaced physician's orders with the nursing flowsheet was not in the action plan for the root cause analysis because they were working on getting a new system already. She also said, the hospital did not have a policy on how to ensure medications ordered are transcribed to the nursing flowsheet.


In an interview on 1/8/20 at 10:15 a.m. with S6Risk, she verified her department did an investigation of the incident from 11/18/19 where Patient #2 received 100 ml of lipids. She verified the incorrect documentation of the lipids infusing at 0.2 ml/hr on the flowsheet was not part of the root cause analysis.