HospitalInspections.org

Based on review of facility policy and medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that staff followed the established policy for parent instruction for circumcision care, and infant care, including cord care for three of 10 medical records. (MR8, MR10, and MR12)

Findings include:

Review on April 10, 2014, at approximately 2:00 PM, of facility policy, "Discharge of Mother and Infant" revised August 2013, revealed, "Guidelines. 1. The registered nurse is responsible for coordination of mother/infant discharge which includes the identification verification of the mother and infant, patient teaching and nursing assessment on discharge...Procedure: D. Mother and/or significant other will verbalize understanding of the following skills and ability with:..2. Infant care, including cord care...8. Document on the electronic medical record...A. Mother's understanding of discharge instructions..."

Review on April 10, 2014, at approximately 2:15 PM of facility policy, "Newborn Circumcision" reviewed by facility on August 2013, revealed, "...Policy:...The registered nurse or clincal technician will identify the infant and assist the physician as needed...17. Document on the electronic medical record...K. Parent instruction on care of circumcision..."

1. Review of MR8 on April 10, 2014, at approximately 1:40 PM revealed that there was no documentation of cord care education to the parent of the newborn.

2. Review of MR10 on April 10, 2014, at approximately 1:50 PM revealed that there was no documentation that cord care education or circumcision care education was provided to the parents of the newborn.

3. Review of MR12 on April 10, 2014, at approximately 1:45 PM revealed that the medical record did not include any documentation of education provided to mother of the newborn.

4. During an interview on April 10, 2014, at approximately 1:50 PM, EMP3 confirmed that there was no documentaion of of the education for cord care for MR8, for cord care and circumcision care education for MR10. EMP3 confirmed that there was no documentation for any education for MR12.

5. During an interview on April 10, 2014, at approximately 1:50 PM, EMP4 confirmed that there was no documentaion of the education for cord care for MR8, for cord care and circumcision care education for MR10, and confirmed that there was no documentation for any education for MR12.