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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure nursing staff followed established nursing policies and procedures for the treatment of an infant with a low body temperature of 35 degrees Celsius for one of one medical record reviewed (MR1).

Findings include:

Review on June 11, 2014, of the facility provided "Wong's Nursing Care of Infants and Children Eight Edition" manual, revealed "... Chapter 6 Communication and Physical and Developmental Assessment of the Child ... page 170 box 6.10 Normal Temperature Ranges Based on Measurement Method in Pediatrics Rectal - 36.6 degrees to 38 degrees Celsius (C ), (97.9 to 100.4 degrees Fahrenheit (F), Ear - 35.8 to 38 degrees C (96.4 to 100.4 degrees F, Oral - 35.5 to 37.5 degrees C (95.9 to 99.5 degrees F), Axillary - 34.7 to 37.3 degrees C (94.5 to 99.1 degrees F). ..."

Review on June 11, 2014, of the facility's "Radiant Warmer Use in the Nursery" policy, last revised April 2013, revealed "Purpose: to facilitate close observation of and easy access to neonates and to provide an adequately warmed and illuminated environment for performing procedures. ... Content: 1. Place baby on pre-heated radiant warmer ... if baby is hypothermic. ...3. Use Serocontrol with the abdominal skin sensor set at 36.5 to 37.0 degrees C. ..."

Review of MR1 on June 11, 2014, revealed EMP13 recorded this 3-day old infant patient rectal temperature on February 22, 2014, as 35 degrees C at 7:10 PM, 34.1 degrees C at 7:40 PM, as 34.9 degrees C at 8:10 PM and as 34.4 degrees C at 9:46 PM.

Review of MR1 on June 11, 2014, revealed no documentation CF1 or the ED nursing staff treated MR1's low body temperature.

Review of MR1 on June 11, 2014, revealed documentation on February 22, 2014, at 10:32 PM that the transporting emergency helicopter paramedic from the receiving hospital requested an isolette for MR1.

Interview with EMP10 on June 10, 2014, at approximately 12:15 PM revealed there was an incubator available in the trauma room for use with a newborn.

Observation of the trauma room on June 10, 2014, at approximately 12:15 PM revealed an incubator available and ready for use. EMP10 confirmed that a newborn with a temperature of 35 degrees Celsius would be placed in the incubator to be warmed. In addition, the staff could provide warm blankets and/or a cap.

Interview with CF3 on June 11 2014, at 9:30 AM, confirmed an isolette would be initiated if the neonate's body temperature was below 36.5 C.

Review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure nursing personnel had a valid and current license for one of four contracted nursing staff personnel files reviewed (PF1).

Findings include:

A request was made of EMP1, EMP2, EMP4 and EMP15 on June 11, 2014, for a policy or procedure for ensuring current licensure information for contracted nursing staff. No policy was provided.

Review of PF1 on June 11, 2014, revealed PF1 was a contracted registered nurse (RN) and began contracted employment on February 29, 2013, further review revealed PF1's nurses' license expired October 31, 2013.

Review on June 11, 2014, of the facility's staffing schedules for November 1, 2013, to April 3, 2014, revealed PF1 worked in the facility during this time.

Interview with EMP1 and EMP2 on June 11, 2014, at approximately 2:20 PM confirmed PF1 was a contracted RN, began contracted employment on February 29, 2013, and that PF1's nursing license expired October 31, 2013. Further interview with EMP1 and EMP2 confirmed PF1 worked in the facility during November 1, 2013, to April 3, 2014, without a current license.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure nursing staff documented the location of medication administered intramuscularly to one of one applicable medical record reviewed (MR9).

Findings include:

Review on June 11, 2014, of the facility's "Intramuscular Medication Administration" policy, last revised April 2014, revealed "Purpose To administer an aqueous suspended medication into the intramuscular tissue in a safe, accurate, and effective manner. ... Procedures ... R. document the injection on the MAR [Medication Administration Record] along with the site used ..."

Review of MR9 on June 11, 2014, revealed the patient was admitted to the emergency department (ED) on February 27, 2014. Further review revealed MR9's physician instructed nursing staff to administer Decadron (a steroid anti-inflammatory) 6 milligrams (mg) intramuscular (IM).

Review on June 11, 2014, of MR9's nursing documentation dated February 27, 2014, revealed nursing staff administered MR9's Decadron 6 mg IM in a split dose. Further review revealed no documentation of the sites nursing staff used to administer MR9's Decadron.

Interview with EMP3 and EMP14 on June 11, 2014, at approximately 1:30 PM confirmed MR9 was admitted to the emergency, MR9's physician instructed nursing staff to administer Decadron 6 mg IM to the patient, and nursing staff administered MR9's Decadron 6 mg IM in a split dose. Further interview with EMP3 and EMP14 confirmed there was no documentation of the sites nursing staff used to administer MR9's Decadron IM. EMP3 revealed a split dose was dividing the dose of medication into two equal syringes for administration at two different sites.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure laboratory results were part of a complete medical record for one of one applicable medical record reviewed (MR1).

Findings include:

Review on June 11, 2014, of the facility's "HIS/LIS Accuracy Checks" policy, last revised February 2014, revealed "Purpose To verify the accuracy of transmitted results across instrument interface and by manual entry to the patient report. To verify the accuracy of computer calculations involving reportable patient results. ..."

Review of MR1 on June 11, 2014, revealed CF1 ordered a magnesium level, a basic metabolic panel, and arterial blood gases for the patient. Further review revealed documentation on February 22, 2014, that the laboratory collected blood for the magnesium level at 7:45 PM and the basic metabolic panel at 8:32 PM. Respiratory services collected the arterial blood gases at 8:12 PM. Continued review of MR1 revealed no documentation of the laboratory results for the magnesium level, basic metabolic panel, and arterial blood gases.

Interview with EMP1 on June 11, 2014, at approximately 11:45 AM confirmed CF1 ordered a magnesium level, a basic metabolic panel, and arterial blood gases for the patient. EMP1 confirmed the laboratory collected blood for the magnesium level at 7:45 PM and the basic metabolic panel at 8:32 PM, and respiratory services collected the arterial blood gases at 8:12 PM. EMP1 confirmed there was no documentation in MR1 of the laboratory results for the patient's magnesium level, basic metabolic panel, or arterial blood gases.

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a safe medication process for mixing intravenous solutions for one of one medical record reviewed (MR1).

Findings include:

Review on June 10, 2014, of the facility's "TPN Compounding" policy, last revised April 2013, revealed "Purpose: To provide effective parenteral nutrition to all patients, who can not [sic] be fed enterally in a quality, cost effective manner. ... Neonatal Policy: Total parenteral nutrition is delivered through a 2:1 TPN [Total Parenteral Nutrition] solution prepared by pharmacy. ..."

Review on June 10, 2014, of the facility's "TPN/PPN Administration Management Protocol," last revised May 2014, revealed "... Neonatal Policy: Total Parenteral Nutrition or Peripheral Parenteral Nutrition will be provided as a 2 in 1 solution upon Pediatrician order to infants who are unable to meet their nutrition requirements via the oral or enteral route. ..."

Review on June 10, 2014, of the facility's "Neonatal Parenteral Nutrition" form, dated December 2009, revealed "... Route of Administration ... Peripheral line (Max dextrose conc [concentration] 12.5 [percent]. ..."

Review of MR1 on June 10, 2014, revealed this 3-day old infant patient was admitted to the facility's emergency department (ED) on February 22, 2014, with a chief complaint of trouble breathing. Further review of MR1 revealed CF1 ordered D-25 [Dextrose 25] percent intravenously (IV) 2 millimeters (ml) per Kilogram (kg) to be infused at 6 ml/kg/hr. Continued review of MR1 revealed CF2 would send the Dextrose -25 percent as soon as possible.

Review of MR1 on June 10, 2014, revealed nursing documentation that EMP13 started the intravenous solution bag of 250 ml of Dextrose - 25 percent at 6 ml/kg/hr.

Review of the facility provided "Pediatric Emergency Information Sheet (PEIS)," no review date, revealed "Emergency Medications ... Dextrose 50 [percent] = 0.5 g(Gram)/ml, 25 [percent] = 0.25 g/ml and 10 [percent] = 0.1 g/ml ... (max dose 2-4 ml/kg of 25 [percent] solution) ..."

Interview with EMP5 on June 10, 2104, at approximately 12:00 PM revealed this concentration of Dextrose was supplied in 10 ml syringes and was ready for use in the pediatric code cart located in the ED. Further interview revealed the Dextrose in the 10 ml syringes was used for intravenous (IV) push and not for a continuous IV drip.

Interview with EMP8 on June 13, 2014, at approximately 10:30 AM confirmed the pediatric code cart in the ED contained two 10 ml syringes of Dextrose 25 [percent]. Further interview with EMP8 revealed this Dextrose in 10 ml syringes was used for IV push and not for a continuous IV drip.

Review on June 10, 2014, of the facility's pharmacy charges for MR1 on February 22, 2014, revealed the patient was charged for 100 millimeters (ml) of sterile water and 50 grams in 100 ml of Dextrose 50 percent water.

Interview with EMP6 on June 11, 2014, at approximately 2:15 PM revealed in order for CF2 to make the Dextrose 25 percent, the pharmacist mixed 100 ml of the sterile water with 100 ml of Dextrose 50 percent. Further interview with EMP6 revealed by mixing the 100 ml of sterile water with the 100 ml of Dextrose 50 percent the solution would be diluted to the Dextrose 25 percent. Continued interview with EMP6 revealed the administration of the Dextrose 25 percent peripherally would cause burning and irritation to the intravenous insertion site.

Interview with EMP5 and EMP6 on June 10, 2014, at approximately 12:10 PM revealed the intravenous solution of Dextrose 25 percent did not exist in the Pharmacy. EMP5 and EMP6 confirmed this solution of Dextrose 25 percent was too concentrated for administration though a peripheral vein because it was double the concentration. EMP6 revealed the concentration of Dextrose 25 percent would only be administered through a central line. Further interview with EMP5 and EMP6 revealed there were no stops or flags in place in the pharmacy that would prevent a pharmacist from mixing medications that would potentially be harmful to the patient.