HospitalInspections.org

Based on staff interviews, medical record review, and review of facility documents, it was determined that the facility failed to ensure the covering practitioner enters a progress note into the medical record describing the findings about a patient's condition in one of two medical records reviewed (Patient (P)1).

Findings include:

On 07/17/25, P1's medical record was reviewed with Staff (S)15, in the presence of S1, S4, S12, S16 and S20, and the following was revealed:

P1 was a normal spontaneous vaginal birth on 07/01/25 at 1:50 PM and admitted to the normal newborn nursery.

The "Newborn Flowsheet" dated 07/02/25 at 4:30 AM stated, "... Heart Rate 163 ... Infant brought to wbn [well baby nursery] ... by PCT [Patient Care Technician] ... Per PCT ... MOI [mother of infant] stated infant 'breathing funny' and 'not waking up to feed.' Infant placed under radiant warmer. Infant's oxygen saturation 100%. No retractions or nasal flaring noted. Infant noted to make intermittent subtle moan with exhalation. Lungs clear upon auscultation. NICU [Neonatal Intensive Care Unit] RN [Registered Nurse] ... made aware of infant's intermittent noise with exhalation. 4:35 AM NICU RN ... in wbn assessing infant's lungs sounds. RN stated infant's lung sounds clear, respirations unlabored bilaterally. ... 5:30 AM ... Heart Rate 171 ... No retractions, nasal flaring noted. Intermittent subtle moan made by infant upon exhalation. Infant placed on continuous O2 [oxygen] monitoring. ... 6:20 AM ... Continuous O2 saturation monitoring removed. ... Heart rate fluctuating from 160 to 171. ... Infant continued to make intermittent subtle moan upon exhalation. ... 6:23 AM MD [Medical Doctor] ... made aware of infant's intermittent subtle moan upon exhalation by RN ... MD ... called WBN and instructed RN ... to notify PA [Physician Assistant] ... of infant's status. 6:30 AM PA ... made aware of infant's intermittent subtle moan upon exhalation. PA made aware infant's O2 saturation ... HR fluctuating from 160 to 171. ... PA on [his/her] way to assess infant in WBN. ... 6:35 AM PA ... in wbn, assessing infant in crib. As per PA, 'infant transitioning' no new orders received at this time. ... 7:00 AM RN ... received report on infant in wbn. RN ...and RN... noted at this time infant nasal flaring/retractions. Oncoming RN resumed care of infant. 7:15 MD called to assess newborn in nursery for mild retractions and grunting. ... Heart was noted to be in the 180s. 7:20 AM Dr. ... in the nursery assessing baby. ... 7:30 AM MD stated that newborn may be transferred to NICU for further monitoring ..."

P1 was admitted to the NICU on 07/02/25 at 8:05 AM.

Upon further review of the medical record, there was no documented evidence of a progress note completed by the PA (S23), following the 6:35 AM assessment of P1 on 07/02/25.

During an interview on 07/17/25 at 9:50 AM, S20 confirmed that following P1's assessment on 07/02/25 at 6:35 AM, S23 should have entered a progress note into P1's medical record.

Facility document titled, "Medical Staff Rules and Regulation" stated, "... Article III Medical Records 3.1. (a) The attending physician will be responsible for the timely, complete, accurate, and legible completion of the portions of the medical record that pertain to the care he or she provides. ... 3.3. Content of Record: ... (a) Medical records will contain information ... and describe the patient's progress and response ... 3.5. Progress Notes: (a) Progress notes will be written by the attending physician, his or her covering practitioner, and allied health professionals as permitted by their clinical privileges or scope of practice. (b) When appropriate, each of the patient's clinical problems should be clearly identified in the progress notes ..."