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Based upon review of 1 of 10 medical records (#2), Continuous Quality Improvement (CQI) data and Meeting Minutes, Patient Safety and Quality Reports, and staff interviews, the hospital failed to analyze occurrences related to processes of care and hospital services as evidenced by failure of hospital personnel to report concerns of the Pediatric Intensivist Physician S9 relating to the transfer of a pediatric intensive care patient (#2) to another acute care hospital. Findings:

Review of pediatric patient #2's medical record revealed on 09/19/10 at 10:00 AM, the patient was transferred from the Pediatric Unit to the Pediatric Intensive Care Unit in severe septic shock. Review of the Physician Progress Notes completed by Pediatric Intensivist Physician S9 revealed the following "Transfer the child to (Hospital B). Spoke with (Physician S14) who I believe accepted the patient as per patient's aunt. Patient's aunt constantly interfered in the care provided to the child. This child was transferred from the floor approximately after 10:00 AM in severe Septic Shock. From the get go the aunt (not the mother) interfered constantly and persistently to transfer the patient to (Hospital B). In fact she gave me the card with (Hospital B Physician S14) number and told me that she has spoken to (Physician S14) and that she had accepted the patient and I should transfer this patient now as they're expecting it. I told her that we will transfer the patient to (Hospital B) when we feel it will be safe and right now we're working on different things to make the child stable for a safe transfer. When I called (Physician S14) I found out (patient's aunt) did not speak to her but to a resident in PICU at (Hospital B) who accepted the patient, however she has no information about this patient." "Full report given, Transferred arranged" "I'd spoken to nursing supervisor and raised my concern." "I will speak with administration."

Interview with Pediatric Intensivist Physician S9 on 07/27/11 at 11:05 AM, revealed when asked about his concerns identified in the Physician Progress Notes with patient #2, S9 stated soon after the patient was transferred to the PICU, the patient's aunt initially identified herself as the patient's mother and was demanding the patient be transferred to Hospital B immediately. After some confusion, Physician S9 stated he had to ask who had given birth to the child in order to find out who the actual mother was. When asked who he had reported his concerns to regarding the transfer of patient #2 to Hospital B, he replied Registered Nurse S17, the Pediatric Services Supervisor.

Review of the CQI data Patient Safety and Quality Reports revealed there failed to be evidence the concerns identified by Physician S9 were forwarded on and investigated through Patient Safety and Quality of the CQI Program. Interview on 07/28 /11 at 9:20 AM with Registered Nurse S2 with the CQI Department and the CQI Physician Director S4 revealed when asked if the incident with Patient #2 should have been reported and investigated through the CQI Program, they replied "yes".

Based upon review of 1 of 10 medical records (#2) and staff interviews, the Registered Nurse failed to conduct an on-going evaluation of patient #2 as evidenced by: 1) failure of RN S11 to document a continued evaluation from 8:35 AM, when the RN identified the infant's hands and feet were "cold and blue" until 10:00 AM when the infant was transferred to the Pediatric Intensive Care Unit, and 2) failure of RN S10 to obtain and document patient #2's vital signs every two hours while a patient in the Pediatric Intensive Care Unit. Findings:

Review of patient #2's medical record revealed the patient, a 1 month old male accompanied by his mother, presented to the hospital's Pediatric Emergency Department on 09/18/10 at 8:14 PM with the chief complaint "fever". The infant was examined by the ED Physician and admitted to the Pediatric Unit on 09/19/10 at 12:00 Midnight with the diagnosis of Pyelonephritis and Sepsis.

Review of the nursing notes revealed on 09/19/10 at 7:55 AM, RN S11 documented "Pt's (patient's) feet and hands cool. O2 (Oxygen) SAT (Saturation) 100%. Will cover Pt with blankets and assess in 20 minutes." "Pt sleeping prone in bassinet. Continuous Pulse Ox in place with limits set and functioning. O2 Sat 100% on room air. Feet and hands cool to touch. Will cover Pt with blankets and return to check on Pt in 20 minutes. PIV (Peripheral Intravenous) infusing to scalp IV without difficulty. No inflammation or irritation at site. Dressing C/D/I (Clean/Dry/Intact). Mother asleep in room. Will continue to monitor." The next documentation by RN S11 of the infant's condition was on 09/19/10 at 8:30 AM "Pt still asleep in bassinet. O2 Sat 100% on room air. Feet and hands still cool and bluish. Will notify (Physician S8) of concerns and continue to monitor." RN S11 identified she notified physician S8 in person on 09/19/10 at 8:45 AM with resolution to "Transfer to ICU". RN S11 further documented the patient was transferred to the Pediatric Intensive Care Unit (PICU) on 09/19/10 at 9:55 AM. There failed to be documented evidence RN S11 conducted an on-going assessment of patient #2 from 8:30 AM to 10:00 AM when the infant was transferred to the PICU. Review of the PICU Nursing Notes dated 09/19/10, 10:00 AM revealed "Received pt (patient) from peds floor. Pt in open bassinet accompanied by mom and RN's x2. Pt. placed in pedi crib placed on CRM (Continuous Respiratory Monitor) with pulse ox. Heart tones strong, pp (peripheral pulses) weak to palpation, skin cool and mottled, cap (capillary) refill sluggish at 4-5 seconds, pulse ox applied and reading 90% on RA (Room Air). Patient placed on 2L (liters) NC (Nasal Cannula), sat increased to 100%..."

Further review of patient #2's medical record revealed after the patient arrived in the PICU at 10:00 AM on 09/19/10 RN S10 documented the first set of vital signs were not obtained until 11:00 AM, an hour after the patient was admitted to the unit. The next set of vital signs were documented as obtained four hours later at 2:00 AM. Interview with RN S16 on 07/29/11 at 9:40 AM revealed when asked what the PICU's policy was on obtaining routine vital signs, S16 replied the PICU's standard of care was to obtain an initial set of vital signs when the patient was admitted to the unit then every two hours thereafter. S16 further stated if the child was on the ventilator or there were specific medications being administered to ensure hemodynamic stability, the vital signs were to be obtained at least every hour. After reviewing the medical record for patient #2, RN S16 confirmed there failed to be documented evidence RN S10 obtained the vital signs of the patient on admission to the PICU or evidence the vital signs were obtained at least every two hours.

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Based upon review of 1 of 10 medical records (Patient #2), and staff interviews, the Registered Nurse (RN) failed to administer a medication, per physician's order, to treat hypoglycemia (low blood sugar) in a one month old patient as evidenced by an order for Dextrose 10% to be administered without documentation to show it was administered. Findings:

Review of patient #2's medical record revealed S9 Pediatric Intensivist documented a physician's order, dated 09/19/11, 12:50pm, to administer "Dextrose 10% 5mL/Kg (milliliters/kilogram) 15 mL IV (intravenously) X (times) 1 for Hypoglycemia". Continued review of patient #2's medical record revealed there failed to be documentation on the Medication Administration Record (MAR) nor in the Nursing Notes that S10 RN administered the medication per physician's order.

Interview, on 07/28/2011 at 10:05am, with S10 RN revealed when he was questioned in regard to S9 Pediatric Intensivist's order for administration of Dextrose 10% for patient #2's hypoglycemia, S10 commented that he signed off the order but did not recall if he administered the medication. S10 RN reviewed the MAR and Nursing Notes and could not find documentation that the medication was administered. S10 RN confirmed that he was the RN assigned to care for patient #2 and he did not see documentation that he administered the dextrose 10% per physician S9's order.

Interview, on 07/28/2011 at 10:20am, with S2 RN Quality Improvement confirmed patient #2 did not receive the ordered medication as she had contacted Pharmacy and they confirmed patient #2 was not billed for Dextrose 10%; nor was there evidence in the Pyxis (automated medication dispensing machine) that the medication had been removed.