HospitalInspections.org

Based on a review of facility policies and documents, and staff interview (EMP), it was determined that the facility failed to follow their established policy for labeling of breast milk for twelve of twelve packages of expressed mother's milk.

Findings include:

Review on April 17, 2023, at approximately 2:00 PM, of facility policy, "Breastfeeding Assisting the Mother with" dated December 5, 2022, indicated, "... General Guidelines ... 5. Seal the container tightly. Mother will apply breast milk label to container and complete the initial time and date of collection. Do not place label on the lid. ... Hospital personnel receiving the container of milk from the mother will verify the labeling information and then place container in an appropriate storage area. ..."

1. During a tour on April 17, 2023, at approximatley 11:55 AM, of the Blue Unit, revealed a refrigerator in the nutrition room, which contained 12 bags of expressed mother's milk. The patient's name was identifed on the label, but there was no collection date or time on the bag.

During an interview at the time of the tour EMP2 confirmed that the twelve containers of expressed mother's milk were not labeled with the date or time of collection as required by policy.

Based on a review of facility documents, medical records (MR), and staff interview (EMP), it was determined that Children's Home of Pittsburgh failed to ensure the necessary medical information accompanied four of five patients transferred to a higher level of care. (MR4, MR6, MR7,MR10).

Findings include:

Review of policy on April 17, 2023, at approximately 2:00 PM revealed, "... Policy: Transfer of a Patient ... Purpose: To provide Hospital staff with guidelines to be followed when the transfer of a patient back to a tertiary facility is necessary as determined by the Attending/on-call physician. Policy 200.18 ... Policy: ... A Copy of the medical chart will be sent with the patient to the tertiary facility. ..."

1. Review of MR4 on April 18, 2023, at approximately 10:30 AM, revealed that the patient was ordered to be transferred to an outside hospital. There was no documentation that the medical record accompanied the patient to the receiving hospital.

2. Review of MR6 on April 18, 2023, at approximately 12:00 PM, revealed that the patient was ordered to be transferred to an outside hospital. There was no documentation that the medical record accompanied the patient to the receiving hospital.

3. Review of MR7 on April 18, 2023, at approximately 12:15 PM, revealed that the patient was ordered to be transferred to an outside hospital. There was no documentation that the medical record accompanied the patient to the receiving hospital.

4. Review of MR10 on April 18, 2023, at approximately 12:20 PM, revealed that the patient was ordered to be transferred to an outside hospital. There was no documentation that the medical record accompanied the patient to the receiving hospital.

On April 19, 2023, at approximately 11:30 AM, EMP3 confirmed that there was no documentation in the medical record indicating that the clinical record contents were sent to the receiving facilities for MR4, MR6, MR7, and MR10.