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Based on record review of 2 Newborns (Newborn #1 and #2) in a total sample of 12 patients, interviews and review of the Hospital policies titled 1.) Admission to the Nursery and 2.) Admission to the Level II (Special Care) Nursery and The Guidelines for Perinatal (Mother & Newborn) Care, the Medical Staff failed to ensure that Newborn Orders included guidelines for monitoring newborn vital signs.

Findings include:

1.) The Hospital policy titled Admission to the Nursery, dated 3/20/12, indicated that nursing staff should monitor newborn vital signs (temperature, heart and breathing rates) on admission to the Newborn Nursery and a second set of vital signs after the newborn's bath. The policy did not indicate when or how often nurses should monitor newborn vital signs during hospitalization through the time of discharge.

2.) The Hospital policy titled Admission to the Level II Nursery, dated 3/20/12, indicated that nursing staff should obtain a complete set of vital signs (temperature, heart and breathing rates). The policy did not indicate when or how often nurses should monitor vital signs.

3.) The Guidelines for Perinatal (Mother & Newborn) Care from the American Academy of Pediatrics and The American College of Obstetricians and Gynecologists (a well-recognized professional text and standard of care for maternal newborn care) indicated:

A.) The newborn should be carefully observed for the first 6-12 hours after birth,

B.) Temperature, heart and breathing rates, skin color, circulation, breathing pattern, level of consciousness, tone, and activity should be monitored and recorded at least once every 30 minutes until the neonate's condition has remained stable for 2 hours and

C.) The newborn's vital signs should be normal and stable for the 12 hours before discharge, including temperature, breathing and heart rate.

4.) Newborn #1.

Physician Orders, dated 6/25/14 at 0030 A.M., indicated hospital staff was to implement the Nursing Level 1 Protocol. Physician orders did not indicate guidelines (when or how often) to monitor newborn vital signs.

Nursing Level 1 Protocol (Patient Order List) dated 6/25, year and time not documented, did not indicate guidelines (when or how often) to monitor newborn vital signs. It referred hospital staff to the Newborn Protocol Kardex.

Newborn Protocol Kardex, dated 6/25, year and time not documented, did not indicate guidelines (when or how often) to monitor newborn vital signs.

Newborn Clinical Sheet, dated 6/25/14 indicated that staff monitored Newborn #1's vital signs at 12:50 A.M., 6:00 A.M. 7:30 A.M. and 2:00 A.M. on 6/25/14.

Newborn Clinical Sheet, dated 6/25/14 did not indicate staff monitored Newborn #1's vital signs at least once every 30 minutes, after birth, until the neonate's condition remained stable for 2 hours.

Newborn #2.

Physician Orders, dated 10/12/14 at 10:28 A.M., indicated that hospital staff was to implement the Level II Newborn Orders and monitor vital signs according to the Special Care Nursery (SCN) routine, Kardex.

Special Care Nursery (SCN) routine, Kardex, dated 10/12/14 at 10:28 A.M., indicated that staff was to monitor vital signs per the SCN routine.

Medical record review indicated Patient #2 was born on 10/12/14 at 9:18 A.M. and transported to a Neonatal Intensive Care Unit on 10/12/14 at 3:45 P.M.

The Newborn Clinical Sheet, dated 10/12/14 (time not documented) indicated heart and respiratory rates. The Newborn Clinical Sheet did not indicate a temperature.

The Special Care Nursery Record indicated on 10/12/14 at:
9:56 A.M. a heart rate and did not indicate a temperature or respiratory rate,
11:40 A.M. temperature, heart and respiratory rates,
1:30 P.M. Right arm and leg blood pressures and did not indicated temperature, heart and respiratory rates.
2:00 P.M., temperature, heart and respiratory rates,

The Infant Transport Data Record, dated 10/12/14 at 2:00 P.M. indicated temperature, heart and respiratory rates.

Newborn Clinical Sheet, Special Care Nursery Record and The Special Care Nursery Record, dated 10/12/14 did not indicate staff monitored Patient #2's vital signs at least once every 30 minutes, after birth, until Patient #2's condition remained stable for 2 hours.

Physician orders, Nursing Kardex and SCN policy did not indicate guidelines for monitoring newborn vital signs and the Hospital did not generate Newborn Nursing Care Plans that indicated guidelines for monitoring vital signs.

See TAG # A-0396 (Nursing Care Plan).

D.) The Surveyor interviewed the Nurse Manager at 10:00 A.M. on 10/21/14. The Nurse Manager said that it was her expectation that nurses monitor newborn vital signs every 4 hour for 24 hours after birth, then every 8 hours. The Nurse Manager said that these guidelines were not yet policy, the guidelines would be incorporated into a new policy and the policy was in committee review.

Based on record review of 2 Newborns (Newborn #1 and #2), in a total sample of 12 patients, interviews and review of the Hospital policy titled Care Planning Process, the Hospital failed to ensure that RNs developed and kept current a nursing care plan.

Findings include:

A. The Hospital policy titled Care Planning Process, dated 2/9/10, indicated that:

1.) Care was planned to response to each patient's assessment, data analysis, unique needs, expectations and characteristics with effective, efficient and individualized care and

2.) Nurses periodically assessed patient progress against care goals, the plan of care and when indicated, nurses revised the plan or goals.

B.) The Guidelines for Perinatal Care (a well-recognized professional text and standard of care for maternal newborn care) indicated in the chapter on Care of the Neonate that:

1.) Following an initial evaluation of the newborn's condition, a care plan should be established.

2.) If the newborn is healthy and stable, the care plan should allow ongoing contact of the mother and the infant during this period.


C.) Medical record review of Newborn #1 and #2 did not indicate that Registered Nurses:
-Initiated a nursing care plan at the time of admission (birth),
-Developed an individualized plan of care based on nursing assessment and newborn parent need(s),
-Developed appropriate nursing interventions in response to the identified nursing care needs,
-Developed patient care goals,
-Developed a plan of care for parent teaching or discharge of newborns or
-That a nursing care plan was part of a larger, coordinated interdisciplinary plan of care.

Review of Newborn #1 and #2s medical records did not indicate a nursing care plan.