HospitalInspections.org

Based on interview and record review, the facility failed to ensure an organized nursing service was provided to all patients by failing:

1. To ensure one sampled patient (Patient 8), who was receiving treatment for hyperbilirubinemia (a condition of newborns when red blood cells break down causing an excess of bilirubin in the blood that can lead to severely disabling brain damage or death), was transported to a higher level of care in a safe manner. (Refer to A392);

2. To ensure the staff recognized the newborns bilirubin fell in the "High Risk" and/or "High Intermediate Risk" Zones, and the physician was informed of the risk zone associated with the bilirubin level for two sampled patients (Patients 3 and 9). (Refer to A392);

3. To ensure the newborns discharge instructions and follow-up care were appropriate based on the facility's policy and procedure and the American Academy of Pediatrics (AAP) guidelines for two sampled patients (Patients 3 and 9). (Refer to A392);

4. To ensure laboratory tests were not drawn without a physician's order for one sampled patient (Patient 3). (Refer to A392);

5. To ensure an individualized plan of care was developed and maintained for one sampled patient (Patient 8) who developed hyperbilirubinemia (a condition of newborns when red blood cells break down causing an excess of bilirubin in the blood that can lead to severely disabling brain damage or death). (Refer to A396).

The cumulative effects of these systemic problems resulted in the failure of nursing services to ensure care was being provided in a safe and effective manner.

Based on interview and record review, the facility failed:

1. To ensure one sampled patient (Patient 8), who was receiving treatment for hyperbilirubinemia (a condition of newborns when red blood cells break down causing an excess of bilirubin in the blood that can lead to severely disabling brain damage or death), was transported to a higher level of care in a safe manner. This resulted in Patient 8 being transported via private vehicle to Facility B's Neonatal Intensive Care Unit (NICU).

2. To ensure the staff recognized the newborns bilirubin fell in the "High Risk" and/or "High Intermediate Risk" Zones, and the physician was informed of the risk zone associated with the bilirubin level for two sampled patients (Patients 3 and 9); and

3. To ensure the newborns discharge instructions and follow-up care were appropriate based on the facility's policy and procedure and the American Academy of Pediatrics (AAP) guidelines for two sampled patients (Patients 3 and 9).

This had the potential to result in a delay in follow-up care and treatment.

4. To ensure laboratory tests were not drawn without a physician's order for one sampled patient (Patient 3). This resulted in Patient 3 having a blood draw and laboratory tests done without a physician's order.

Findings:

1. On June 11, 2013, the record for Patient 8 was reviewed. Patient 8 was admitted to the facility on May 2, 2013, at 1:11 p.m.,with a diagnosis of newborn infant.

Patient 8's "Total Bilirubin" on May 4, 2013, at 5:15 a.m., was 12.1 milligrams per deciliter (mg/dL).

The "BiliTool (designed to help clinicians assess the risks toward the development of hyperbilirubinemia or "jaundice" in newborns)" used by the facility indicated Patient 8 was "High Intermediate Risk" for developing severe hyperbilirubinemia based on a "Total Bilirubin" of 12.1 mg/dL at 40 hours of age.

The "Physicians Orders" dated May 4, 2013, at 11 a.m., indicated "Initiate double light phototherapy (treatment of hyperbilirubinemia through light exposure) for 6 hours. Recheck bilirubin."

Patient 8's "Total Bilirubin" on May 4, 2013, at 6 p.m., was 14.8 mg/dL.

The "BiliTool" used by the facility indicated Patient 8 was "High Risk" for developing severe hyperbilirubinemia based on a "Total Bilirubin" of 14.8 mg/dL at 53 hours of age.

The "Physicians Orders" dated May 4, 2013, at 6:50 p.m., indicated "Re-start double phototherapy. Re draw baby Q (every) 12? (hours)."

The "Newborn - Nursing Comments" dated May 4, 2013, at 7:25 p.m., indicated the physician had arranged admission to Facility B's NICU and had spoken with the accepting physician. Patient 8 was to be discharged home with parents "with strict instructions to drive directly over to [Facility B] NICU ... for admission."

The "Patient Discharge Instructions" dated May 4, 2013, indicated "Discharge to [Facility B] NICU ... Upon departure from [Facility A] drive infant to [Facility B] and check in to NICU."

Patient 8 left Facility A on May 4, 2013, at 8:10 p.m., and arrived at Facility B on May 4, 2013, at 9 p.m., for admission to Facility B's NICU.

During an interview with the Director Obstetrical Services (DOS) on June 11, 2013, at 2:35 p.m., she stated it was not the facility's practice to send patients to another facility via private vehicle. The DOS stated Patient 8 should have been transferred to a higher level of care via an ambulance.

The facility policy and procedure titled "Transfer of Patients to Other Facilities" last reviewed November 2011, revealed "To provide timely, safe and efficient transfer of patients to other health care facilities to maintain continuity of care."

2a. On June 10, 2013, the record for Patient 3 was reviewed. Patient 3 was admitted to the facility on June 9, 2013, at 2:50 a.m., with a diagnosis of term newborn infant.

Patient 3's "Total Bilirubin" on June 10, 2013, at 2 a.m., was 7.4 milligrams per deciliter (mg/dL).

The "BiliTool (designed to help clinicians assess the risks toward the development of hyperbilirubinemia or "jaundice" in newborns)" used by the facility indicated Patient 3 was "High Intermediate Risk" for developing severe hyperbilirubinemia based on a "Total Bilirubin" of 7.4 mg/dL at 23 hours of age... "recommended follow-up visit and/or a recheck bilirubin value is recommended within 24-48 hours."

There was no indication in the record the staff recognized the "Total Bilirubin" for Patient 3 was in the "High Intermediate Risk" zone. There was no indication in the record the physician was informed of the risk zone associated with the bilirubin level for Patient 3.

During an interview with Licensed Vocational Nurse (LVN) 1, Patient 3's nurse, on June 10, 2013, at 3 p.m., she stated she did not do a "BiliTool" for Patient 3. LVN 1 stated she thought Patient 3 was two days old not one day old, and she misread the laboratory results when she documented the "Total Bilirubin" was 7.0 mg/dL rather than 7.4 mg/dL. LVN 1 stated she should have accessed the "BiliTool" to determine Patient 3's risk for developing hyperbilirubinemia, and she should have told Patient 3's mother that the infant needed to be seen by the pediatrician within two days based on the "Total Bilirubin" results and the facility's policy and procedure.

The facility policy and procedure titled "Hyperbilirubinemia, Management of" last reviewed August 2012, revealed " ... Risk assessment, management, documentation and follow-up are key elements in recognition and treatment of this condition. ... Any newborn discharged in less than 48 hours after birth will be referred for follow-up by a health care professional in an office, clinic or at home within 2 days of discharge."

b. On June 11, 2013, the record for Patient 9 was reviewed. Patient 9 was admitted to the facility on May 21, 2013, at 1:07 p.m., with a diagnosis of term newborn infant.

Patient 9's "Total Bilirubin" on May 22, 2013, at 2 p.m., was 8.3 milligrams per deciliter (mg/dL).

The "BiliTool (designed to help clinicians assess the risks toward the development of hyperbilirubinemia or "jaundice" in newborns)" used by the facility indicated Patient 9 was "High Risk" for developing severe hyperbilirubinemia based on a "Total Bilirubin" of 8.3 mg/dL at 25 hours of age..."recommended follow-up bilirubin is recommended in 6-12 hours if known hemolysis by direct Coomb's or ETCO (end-tidal carbon monoxide) and otherwise recommended within 24 hours (high risk)."

There was no indication in the record the staff recognized the "Total Bilirubin" for Patient 9 was in the "High Risk" zone. There was no indication in the record the physician was notified of the risk zone associated with the bilirubin level for Patient 9.

The "Patient Discharge Instructions" dated May 22, 2013, indicated the "Total Bilirubin" was 8.3 mg/dL, and "Follow Up Appointment - 1 week - Make appt. (appointment) for Friday (May 24, 2013 - 48 hours after discharge).

During an interview with Registered Nurse (RN) 4, on June 12, 2013, at 9:15 a.m., she stated the physician was given the "Total Bilirubin" results as a number and the staff do not report a "Risk Zone." When RN 4 was asked which "Risk Zone" a "Total Bilirubin" of 8.3 mg/dL would be associated with, she stated a "Total Bilirubin" of 8.3 mg/dL was within parameters, the patient could go home, and the result was in the "Intermediate Risk" zone. RN 4 did not utilize the "BiliTool" to reach this conclusion. When RN 4 was told the "Total Bilirubin" of 8.3 mg/dL indicated Patient 9 was "High Risk" for developing severe hyperbilirubinemia, she stated she was surprised the "Risk Zone" was so high. RN 4 stated if Patient 9's "Total Bilirubin" was in the "High Risk" zone, the patient should have been seen/re-evaluated within 24 hours. In addition, RN 4 stated she had not had any ongoing education with regards to hyperbilirubinemia.

3a. On June 10, 2013, the record for Patient 3 was reviewed. Patient 3 was admitted to the facility on June 9, 2013, at 2:50 a.m., with a diagnosis of term newborn infant.

Patient 3's "Total Bilirubin" on June 10, 2013, at 2 a.m., was 7.4 milligrams per deciliter (mg/dL).

The "BiliTool (designed to help clinicians assess the ris