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Based on policy review, record review and staff interviews it was determined the hospital failed to follow their own hourly rounding policy. This failure could potentially lead to infant death.

Findings include:

1. A review of the hospital policy entitled 'Hourly Rounding,' approved 2/2019, states in part: "Address the following as you make your hourly rounds: Safety and fall prevention efforts ... Hourly rounding is documented on the hourly rounding log maintained at each patients bedside."

2. A review of the medical record for patient #1 reveals a thirty-five (35) year old female that presented to the Labor and Delivery Unit at 1:38 a.m. on 1/13/20. She was thirty-seven (37) weeks and three (3) days pregnant with a history of drug abuse and was currently taking Methadone seventy (70) milligrams daily. Her urine drug screen tested positive for methadone, opiates and tetrahydrocannabinol (THC). She delivered a little boy (patient #2) at 2:16 a.m. on 1/13/20. Cord blood was obtained after delivery to be tested for drugs. The cord blood was positive for methadone, fentanyl, opiates and THC. Child Protective Services (CPS) was notified on 1/13/20 at 5:13 a.m. On 1/15/20 at 5:15 a.m. patient #2 was taken to patient #1's room to be fed. At 6:10 a.m. the post-partum nurse was in the room to do a safety check and take the vital signs of patient #1. At 6:42 a.m. patient #1 came out into the hall and handed the baby to the Certified Registered Nurse Anesthetist (CRNA) and asked, "Is my baby breathing?" The CRNA attempted to stimulate patient #2 while going to the nursing station. She informed post-partum nurse #1 that patient #2 wasn't breathing and the nurse immediately began chest compressions while running to the nursery with the patient.

3. An interview was conducted with the CRNA on 2/3/20 at approximately 12:45 p.m. She stated, "We to do a follow-up with our epidural people. I went over to Three (3) South to follow-up with my epidural patients and was walking out of another patient's room when patient #1 walked out of her room and said, "Is my baby breathing?" She shoved the baby in my chest and just walked back in her room." The CRNA stated the baby was warm but had a yellowish-gray color. She tried to stimulate him as she walked to the nursing desk where she handed the baby to post-partum nurse #1. She said the nurse immediately began chest compression while rushing the baby to the nursery. She stated, "He was hypoxic looking when given to me but he was warm." She stated, "Formula was coming out of the baby's nose and mouth and he was asystole."

4. An interview was conducted with post-partum nurse #1 on 2/3/20 at approximately 2:10 p.m. She stated, "I was just coming on shift when the CRNA handed me the baby saying he wasn't breathing. He was ashen and limp but warm. I began doing chest compressions while running to the nursery, the CRNA was right with me. I remember looking up at the clock when I came through the door and it was 6:43 a.m. I laid the baby down on the scale underneath the warmer and they began to bag him and continued doing chest compressions. I went out to let the mom know what was going on."

5. An interview was conducted with nursery nurse #2 on 2/4/20 at approximately 7:25 a.m. She stated, "I was working the nursery that night and took the baby to the mother's room at 5:15 a.m. to be fed." She stated she had taken care of him for the past two (2) days and the baby had no episodes of apnea and vital signs had been stable. She stated he had begun antibiotics as a precautionary measure for the elevated C-Reactive Protein (CRP). She stated that the post-partum nurse and the nursery nurse had good communication skills. If something was wrong with the baby or mother the post-partum nurse would call the nursery and notify the nursery nurse.

6. An interview was conducted with the Director of Women and Children's Services on 2/4/20 at approximately 10:00 a.m. She stated, "The baby is the responsibility of the nursery nurse." She stated that post-partum, nursery and labor and delivery all use the electronic health record (EHR) system in Centricity that is supposed to immediately pull into the Meditech system. She stated when the patient is discharged everything should then be found in ChartMax. She stated that in the Centricity system there is a place for the nursery nurse to check where the baby is every hour. She stated that patient #2 was taken to patient #1's room at 5:15 a.m. to be fed and was supposed to call the nursery nurse when he finished eating for the baby to be scored for the NAS scale. When questioned if it was unusual for the nursery nurse not to check on the baby every hour she stated, "It takes some babies longer to eat or the mother may not start feeding the baby as soon as you take the baby in the room." When asked if there was a specific policy for the nursery nurse on hourly rounding she stated, "No, they follow the post-partum policy."

7. An interview was conducted with nursery nurse #3 on 2/4/20 at approximately 2:00 p.m. She stated, "We do hourly rounding. A nurse has to be in the nursery at all times." She said if one of the nursery nurses are out on the floor checking on their patients the other nurse had to stay in the nursery until the other nurse returned. She stated that could make them late for doing hourly rounds. She stated in the past she has been told between the times of 6:00 a.m. to 8:00 a.m. and 6:00 p.m. to 8:00 p.m. it was the floor nurse's responsibility to check on the babies if they are in the room with the mothers. She stated that is when the nursery was giving report.

8. Another interview was conducted with the Director of Women and Children's Services on 2/4/20 at approximately 3:25 p.m. with the Chief Nursing Officer (CNO), Director of Risk Management and the Chief Executive Officer (CEO) present. During the interview when questioned about who is responsible for the baby when they are in the room with the mother between 6:00 a.m. to 8:00 a.m. and 6:00 p.m. to 8:00 p.m. she stated, "The nursery nurse is always responsible for the hourly checks on the baby and the post-partum nurse is responsible for the checks on the mother." When questioned about the forty-two (42) minute delay in the hourly check of patient #2 she stated, "I expect the nursery nurse to check on the baby hourly when in the room with the mother." She concurred the nursery nurse had not been in to check on patient #2 in one (1) hour and forty-two (42) minutes when patient #1 brought patient #2 into the hallway and handed the baby to the CRNA asking if he was breathing. During the interview, while discussing the conflicting information received by the nursery nurses and the post-partum nurses, it was agreed upon by the CEO and CNO that all babies would be brought to the nursery between 6-8 o'clock while nursery was receiving report so all babies would be in the nursery. The new process would be implemented during shift report that evening (2/4/20).

9. A second interview was conducted with nursery nurse #2 on 2/5/20 at approximately 7:55 a.m. She stated, "I never went back in the mother's room after I took her the baby at 5:15 a.m. to feed him." She stated, "The mom was supposed to call me so I could come and get him to do the NAS score and she had never called. I had other babies in the nursery I was getting lab work from and feeding another baby." She stated it could take the mother longer than an hour to get the baby fed.

10. In an interview with the CNO on 2/5/20 at approximately 9:00 a.m. she concurred nursery nurse #2 did not check on patient #2 for one (1) hour and forty-two (42) minutes.

Based on policy review, record review and staff interviews it was determined the hospital failed to follow their own policy on hourly rounding. This failure could potentially lead to infant death.

Findings include:


1. A review of the hospital policy entitled 'Hourly Rounding,' approved 2/2019, states in part: "Address the following as you make your hourly rounds: Safety and fall prevention efforts ... Hourly rounding is documented on the hourly rounding log maintained at each patients bedside."

2. A review of the medical record for patient #1 reveals a thirty-five (35) year old female that presented to the Labor and Delivery Unit at 1:38 a.m. on 1/13/20. She was thirty-seven (37) weeks and three (3) days pregnant with a history of drug abuse and was currently taking Methadone seventy (70) milligrams daily. Her urine drug screen tested positive for methadone, opiates and tetrahydrocannabinol (THC). She delivered a little boy (patient #2) at 2:16 a.m. on 1/13/20. Cord blood was obtained after delivery to be tested for drugs. The cord blood was positive for methadone, fentanyl, opiates and THC. Child Protective Services (CPS) was notified on 1/13/20 at 5:13 a.m. On 1/15/20 at 5:15 a.m. patient #2 was taken to patient #1's room to be fed. At 6:10 a.m. the post-partum nurse was in the room to do a safety check and take the vital signs of patient #1. At 6:42 a.m. patient #1 came out into the hall and handed the baby to the Certified Registered Nurse Anesthetist (CRNA) and asked, "Is my baby breathing?" The CRNA attempted to stimulate patient #2 while going to the nursing station. She informed post-partum nurse #1 that patient #2 wasn't breathing and the nurse immediately began chest compressions while running to the nursery with the patient.

3. An interview was conducted with the CRNA on 2/3/20 at approximately 12:45 p.m. She stated, "We to do a follow-up with our epidural people. I went over to Three (3) South to follow-up with my epidural patients and was walking out of another patient's room when patient #1 walked out of her room and said, "Is my baby breathing?" She shoved the baby in my chest and just walked back in her room." The CRNA stated the baby was warm but had a yellowish-gray color. She tried to stimulate him as she walked to the nursing desk where she handed the baby to post-partum nurse #1. She said the nurse immediately began chest compression while rushing the baby to the nursery. She stated, "He was hypoxic looking when given to me but he was warm." She stated, "Formula was coming out of the baby's nose and mouth and he was asystole."

4. An interview was conducted with post-partum nurse #1 on 2/3/20 at approximately 2:10 p.m. She stated, "I was just coming on shift when the CRNA handed me the baby saying he wasn't breathing. He was ashen and limp but warm. I began doing chest compressions while running to the nursery, the CRNA was right with me. I remember looking up at the clock when I came through the door and it was 6:43 a.m. I laid the baby down on the scale underneath the warmer and they began to bag him and continued doing chest compressions. I went out to let the mom know what was going on."

5. An interview was conducted with nursery nurse #2 on 2/4/20 at approximately 7:25 a.m. She stated, "I was working the nursery that night and took the baby to the mother's room at 5:15 a.m. to be fed." She stated she had taken care of him for the past two (2) days and the baby had no episodes of apnea and vital signs had been stable. She stated he had begun antibiotics as a precautionary measure for the elevated C-Reactive Protein (CRP). She stated that the post-partum nurse and the nursery nurse had good communication skills. If something was wrong with the baby or mother the post-partum nurse would call the nursery and notify the nursery nurse.

6. An interview was conducted with the Director of Women and Children's Services on 2/4/20 at approximately 10:00 a.m. She stated, "The baby is the responsibility of the nursery nurse." She stated that post-partum, nursery and labor and delivery all use the electronic health record (EHR) system in Centricity that is supposed to immediately pull into the Meditech system. She stated when the patient is discharged everything should then be found in ChartMax. She stated that in the Centricity system there is a place for the nursery nurse to check where the baby is every hour. She stated that patient #2 was taken to patient #1's room at 5:15 a.m. to be fed and was supposed to call the nursery nurse when he finished eating for the baby to be scored for the NAS scale. When questioned if it was unusual for the nursery nurse not to check on the baby every hour she stated, "It takes some babies longer to eat or the mother may not start feeding the baby as soon as you take the baby in the room." When asked if there was a specific policy for the nursery nurse on hourly rounding she stated, "No, they follow the post-partum policy."

7. An interview was conducted with nursery nurse #3 on 2/4/20 at approximately 2:00 p.m. She stated, "We do hourly rounding. A nurse has to be in the nursery at all times." She said if one of the nursery nurses are out on the floor checking on their patients the other nurse had to stay in the nursery until the other nurse returned. She stated that could make them late for doing hourly rounds. She stated in the past she has been told between the times of 6-8 it was the floor nurse's responsibility to check on the babies if they are in the room with the mothers. She stated that is when the nursery was giving report.

8. Another interview was conducted with the Director of Women and Children's Services on 2/4/20 at approximately 3:25 p.m. with the Chief Nursing Officer (CNO), Director of Risk Management and the Chief Executive Officer (CEO) present. During the interview when questioned about who is responsible for the baby when they are in the room with the mother between 6-8 she stated, "The nursery nurse is always responsible for the hourly checks on the baby and the post-partum nurse is responsible for the checks on the mother." When questioned about the forty-two (42) minute delay in the hourly check of patient #2 she stated, "I expect the nursery nurse to check on the baby hourly when in the room with the mother." She concurred the nursery nurse had not been in to check on patient #2 in one (1) hour and forty-two (42) minutes when patient #1 brought patient #2 into the hallway and handed the baby to the CRNA asking if he was breathing. During the interview, while discussing the conflicting information received by the nursery nurses and the post-partum nurses, it was agreed upon by the CEO and CNO that all babies would be brought to the nursery between 6-8 o'clock while nursery was receiving report so all babies would be in the nursery. The new process would be implemented during shift report that evening (2/4/20).

9. A second interview was conducted with nursery nurse #2 on 2/5/20 at approximately 7:55 a.m. She stated, "I never went back in the mother's room after I took her the baby at 5:15 a.m. to feed him." She stated, "The mom was supposed to call me so I could come and get him to do the NAS score and she had never called. I had other babies in the nursery I was getting lab work from and feeding another baby." She stated it could take the mother longer than an hour to get the baby fed.

10. In an interview with the CNO on 2/5/20 at approximately 9:00 a.m. she concurred nursery nurse #2 did not check on patient #2 for one (1) hour and forty-two (42) minutes.

Based on record review, staff interviews and policy review it was revealed the hospital failed to ensure the medical record of patient #1 was accurate. This failure has the potential to negatively impact patients receiving care from the hospital staff.

Findings include:

1. A review of the medical record for patient #1 from the ChartMax systems document entitled, 'LD Flowsheet' dated 1/14/20 at 7:00 a.m. states, "Pt crying and upset due to infant being coded."

2. An interview was conducted with the Director of Risk Management on 2/3/20 at approximately 3:50 p.m. When asked about the conflict in the medical record, he concurred the ChartMax record was inaccurate. The code did take place on 1/15/20.

3. An interview was conducted with the Director of Women and Children's Services on 2/4/20 at approximately 10:00 a.m. She stated, "The baby is the responsibility of the nursery nurse." She stated that post-partum, nursery and labor and delivery all use the electronic health record (EHR) system in Centricity that is supposed to immediately pull into the Meditech system. She stated when the patient is discharged everything should then be found in ChartMax. When questioned about the error in the medical record she was able to pull up the medical record of patient #1 in the Centricity system and show the nurse documented on the right day. She stated, "I am not sure why it isn't showing right in the other system."

4. A review of the hospital document entitled 'Audit Trail Print' dated 1/14/20 at 6:38 a.m. states: "Notified by staff nurse that patient walked out of her room holding baby and stated her baby was not breathing and was gray. And post-partum nurse #1 started chest compressions and rushed the infant to the nursery. Found mother crying in room." The record time indicates post-partum nurse #2 recorded the note at 1/15/20 at 9:45 a.m. The document further indicates the nurse corrected the date and time of the note on 1/15/20 at 9:46 a.m.

5. An interview was conducted with the Clinical Informatics Specialist on 2/4/20 at approximately 11:05 a.m. When asked why the conflict in the medical record she stated that it was a Centricity issue and they were not aware there had been a problem until it was brought to their attention on 2/3/20. She stated, "We have notified the people at Centricity and they are working on the problem now."

6. A review of the hospital policy entitled 'Legal Health Record,' approved 10/2018, states: "The Legal Health Record (LHR) at Raleigh General Hospital includes the documentation of health care services provided to an individual in all delivery settings by our clinical and professional staff. The LHR consists of individually identifiable data in any medium, collected, processed, stored, displayed and directly used in documenting health care delivery or health status.

7. In an interview with the Director of Risk Management on 2/4/20 at approximately 3:50 p.m. he concurred that the medical record in ChartMax was not accurate.

Based on a tour of Three (3) South it was revealed the facility and nursing staff failed to maintain a sanitary environment to avoid the transmission of infection and communicable diseases. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of Three (3) South was conducted on 2/3/20 at 10:10 a.m. The Director of Risk Management accompanied the surveyors on the tour. Upon entering the clean supply room located near the nurses station, two (2) outside contracted workers were sitting in the clean supply room. The contracted worker's supplies were sitting in boxes and tool bags on the floor of the clean supply room. Four (4) step ladders were located leaning against the walls of the clean supply room. Seasonal decorations were located in the clean supply room. A shelf of older books were located in the clean supply room on a book shelf. The Director of Women and Children Services stated the contracted workers are to fix the nurse's call system located in the electrical room. The access to the electrical room is through the clean supply room. The Director of Women and Children Services stated all the books were brand new and they took the plastic off the books before putting them on the shelf.

2. An interview was conducted with the Director of Risk Management on 2/3/20 at 10:45 a.m. He concurred there were old books located in the clean supply room.

3. An interview was conducted with the Chief Nursing Officer on 2/3/20 at approximately 11:30 a.m. She concurred the staff failed to maintain a sanitary environment.

4. A tour of the Three (3) South clean supply room was conducted on 2/4/20 at 8:15 a.m. The clean supply room was relocated to room 311 with only clean supplies. The general storage room, now located across from the nurse's station, revealed a bassinet located in the room with general supplies. During the tour the Director of Women and Children Services stated the bassinet was from a discharged patient and the staff placed the bassinet in the storage room prior to cleaning the bassinet. She stated the bassinet was dirty. She stated their normal procedure is for the staff to clean the bassinet after discharge, cover it with a bag and put it in clean storage.

5. A review of the policy titled "Routine Cleaning/Disinfection of Hospital Equipment," approved 11/2018, stated in part: "Upon discharge or discontinuation of use or when being taken out of a patient room/care area, non-critical patient care equipment shall be cleaned with a hospital-approved surface disinfectant. Cover the clean device with plastic bag. Store in the designated area for clean equipment."

6. An interview was conducted with the Director of Risk Management on 2/5/20 at approximately 11:00 a.m. He concurred the nursing staff failed to follow hospital policies and procedures for cleaning and disinfection of equipment.