HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure nursing staff followed the hospital policy and procedure (P&P) when:

1. Security devices (a tag that was attached to a(n) infant/child to prevent infant/child abduction) were not applied to four of 27 patients (Patients 18, 21, 23, 24) and security device documentation was inconsistent for eight of 27 patients (Patients 1, 2, 3, 9, 11, 14, 19, 20);

2. Education on infant/pediatric abduction was not provided to two of three Registered Nurses.

These failures had the potential to place patients' safety at risk.

Findings:

Review of Patient 1's Admission Exam/Note, dated 11/5/23 indicated she was admitted on 11/5/23 for brief resolved unexplained event (BRUE, when an infant stops breathing, turns pale or blue in color, or becomes unresponsive).

During a concurrent interview and record review on 12/28/23 at 4 p.m. with the Director of Perinatal Services (DPS), Patient 1's Nursing note log was reviewed. The log indicated Patient 1 was discharged on 11/6/23 at 1:27 p.m. and there was no documentation that her security device was in place during the morning shift (shift that starts at 7 a.m. and ends at 7 p.m.) of 11/6/23. The DPS stated there should have been documentation at the beginning of the shift on 11/6/23.

Review of Patient 3's Newborn Report, dated 11/13/23 indicated she was born on 11/13/23 at 5:13 a.m.

During a concurrent interview and record review on 12/28/23 at 4:05 p.m. with the DPS, Patient 3's Nursing note log was reviewed. The log indicated there was no documentation that Patient 3's security device was in place during the evening shift (shift that starts at 7 p.m. and ends at 7 a.m.) of 11/14/23. The DPS stated nurses should have documented that the security device was in place every shift.

Review of Patient 9's Newborn Report, dated 9/22/23 indicated she was born on 9/21/23 at 10:14 p.m.

During a concurrent interview and record review on 12/28/23 at 4:10 p.m. with the DPS, Patient 9's Newborn Report and Nursing note log was reviewed. The Newborn Report indicated there was no documentation regarding Patient 9's security device. The log indicated the first time Patient 9's security device was in place was on 9/22/23 at 7:25 p.m. There was no documentation that indicated her security device was in place on 9/21/23 evening shift and 9/22/23 morning shift. The DPS confirmed Patient 9's security device documentation was missing

Review of Patient 11's Newborn Report, dated 12/15/23 indicated he was born on 12/15/23 at 11:53 a.m.

During a concurrent interview and record review on 12/28/23 at 4:10 p.m. with the DPS, Patient 11's Nursing note log was reviewed. The log indicated there was no documentation that Patient 11's security device was in place on 12/17/23 evening shift. The DPS confirmed Patient 11's security device documentation was missing

Review of Patient 19's Pediatric History and Physical, dated 12/24/23 indicated she was admitted on 12/26/23 at 7:16 a.m. for dehydration and influenza A (type of virus that causes influenza [flu] a respiratory illness).

Review of Patient 19's clinical record indicated there was no documentation regarding Patient 19's security device until she was discharged on 12/26/23 at 1:30 p.m.

During an interview on 12/26/23 at 3:34 p.m., Registered Nurse A (RN A) stated there was no documentation regarding Patient 19's security device when Patient 19 was admitted.

During an interview on 12/28/23 at 2:40 p.m., the Nurse Manager (NM) stated there should have been documentation of the security device on admission.

Review of Patient 21's Pediatric Admission History and Physical, dated 12/25/23 indicated she was nine years old and was admitted on 12/25/23 for dehydration and influenza A.

During a concurrent observation and interview on 12/26/23 at 11:48 a.m. Patient 21 did not have a security device on. RN A stated Patient 21 should have a security device on. She also stated all pediatric patients should get a security device on admission.

During an interview on 12/28/23 at 2:40 p.m., the NM stated she would expect a nine year old to have a security device. She also stated the security device application date and time should be documented.

Review of Patient 23's Pediatric History and Physical, dated 12/4/23 indicated she was admitted on 12/4/23 for Coronavirus Disease 2019 (COVID-19, a contagious respiratory disease) and was discharged on 12/7/23.


During an interview on 12/28/23 at 2:45 p.m., the NM stated Patient 23 should have had a security device but it was not there.


44577


During a review of Patient 2's medical record, dated 11/15/23, the physician's history and physical (H&P) note indicated Patient 2 was a single liveborn infant delivered on 11/15/23 at 5:50 p.m., Patient 2 was discharged 11/17/23 at 5:30 p.m.

During a concurrent interview and record review on 12/28/23 at 4:05 p.m. with the Director of Perinatal Services (DPS) Patient 2's Nursing note log dated 11/16/23 at 8:15 p.m. was reviewed. The log indicated, "security device ( radio frequency identification tags that provides alerts with location & movement of infants and children in healthcare facilities): device in place/location umbilical/number 24786. There was no evidence documented of a security device in place on 11/17/23. Patient 2's nursing log note indicated at 11/17/23 at 5:28 p.m., "security device: device removed". The DPS indicated "Ideally" 11/17/23 would have documentation of the "security device in place".

During a review of Patient 14's medical record, dated 11/4/23, the physician's H&P note indicated Patient 14 was an infant female born 11/4/23 at 4:13 p.m., Patient 14 was discharged 11/13/23 at 10:35 a.m.

During a concurrent interview and record review on 12/28/23 at 4:17 p.m. with the DPS, Patient 14's Nursing note log dated 11/10/23 was reviewed. There was no documentation that indicated the security device was in place on 11/10/23 for 7 a.m. to 7 p.m. shift and no documentation on 11/13/23. The DPS indicated documentation was expected every shift, including the day of discharge.

During a review of Patient 18's medical record dated 11/13/23, the physician's H&P note indicated Patient 18 was a one-year-old, admitted 11/13/23 with a diagnosis of community acquired pneumonia(lung infection) and left acute otitis media (ear infection). Patient 18 was discharged on 11/16/23. There is no documentation that indicated a security device was applied.

During an interview on 12/28/23 at 2:35 p.m. with the Nurse Manager (NM), the NM confirmed there was no documentation that indicated Patient 18 had a security device placed or was being monitored. The NM indicated the security devices are applied on admission with a tag number, date and time documented in chart.

During a review of Patient 20's medical record dated 10/3/23, the physician's H&P note indicated Patient 20 was an 8-year-old, admitted 10/3/23 with a diagnosis of acute appendicitis (Appendicitis is an inflammation of the appendix. The appendix was a finger-shaped pouch that sticks out from the colon on the lower right side of the belly). Patient 20 was discharged 10/4/23. There was no documentation that indicated a security device was applied on admission or was being monitored.

During an interview on 12/28/23 at 2:35 p.m. with the NM, the NM confirmed there was no documentation that indicated Patient 20 had a security device placed or monitored on admission.

During a review of Patient 24's medical record dated 11/16/23, the physicians H&P note indicated Patient 24 was an 8-year-old, admitted 11/16/23 with a diagnosis of abdominal pain ( pain in the belly). Patient 24 was discharged 11/17/23. There was no documentation that indicated a security device was applied or was being monitored.

During an interview on 12/28/23 at 2:55 p.m. with the NM, the NM confirmed there was no documentation that indicated Patient 24 had a security device placed or was monitored, NM indicated documentation was "not found".

During a review of the facility's policy and procedure (P&P) titled, "Infant/Child Security" dated 12/8/20, the P&P indicated, "Ensure a safe and secure environment for all infants born at Watsonville Community Hospital, infants admitted to the IICN, and children admitted to the pediatric area". "Pediatric Area: Upon admission RN or Unit clerk would register the patient and apply the security tag within 15 minutes. ...Perinatal Unit: Upon admission RN or unit clerk will register the patient and apply security tag within 15 minutes ..." " ...place tot tag in security band. Note serial number." "Pediatric and Perinatal Communication/Documentation: ...The Primary Care RN will record the number of the transponder and tag location in the medical record at each shift assessment; another RN will verify transponder number on patient. This process will occur at the same time."



During a review of Registered Nurse (RN) A's employee file, dated 1/20/17, there was no documentation that indicated RN A received annual review on the "Infant Pediatric Abduction Prevention Plan"

During a review of RN B's employee file, dated 3/6/17, there was no documentation that indicated RN B received annual review on the "Infant Pediatric Abduction Prevention Plan"

During an interview on 12/28/23 at 12:38 p.m.with the Director of Education (DEd), the DEd was not able to provide documentation of annual review.

During a review of the facility's policy and procedure titled, "Infant Pediatric Abduction Prevention Plan" dated 12/1/23, the P&P indicated, "Staff will receive instruction in the security issues and procedure as part of their department specific orientation process and will be reviewed at least annually thereafter. "

Based on interview and record review, the hospital failed to ensure medications were administered as ordered and in accordance with hospital policies for four of five patients (Patients 17, 18, 20, and 23) when:

1. Patient 23 received 10 times the ordered dose of intravenous (IV, administration of medication or fluids into a vein) vancomycin (antibiotic used to treat infections);
2. There was no documention of a second nurse verification for IV medication administration for Patients 17, 18, 20, and 23.
3. There was no documentation Patient 17 received a daily dose of IV antibiotic medication.

These failures had the potential to result in health complications. For Patient 23, the failures resulted in a medication error.

Findings:

Review of Patient 23's Pediatric History and Physical, dated 12/4/23 indicated she was a 12-day-old infant admitted on 12/4/23 for Coronavirus Disease 2019 (COVID-19, a contagious respiratory disease).

Review of Patient 23's All Orders History 12/4/23 thru 12/27/23 indicated a physician order for vancomycin 56 milligrams (mg, unit of measurement) in sodium chloride 0.9% solution (NS) 10 millilters (ml, unit of measurement) IV at 6.66 ml per hour (rate of infusion) every 8 hours.

Review of Patient 23's Medication Administration Record (MAR, record of medications given) indicated a dose of vancomycin 56 mg IV was administered on 12/6/23 at 3:02 p.m. The record indicated another dose of vancomycin was administered by Registered Nurse C (RN C) at 12/6/23 at 8:45 p.m., five hours after the previous dose. The record also indicated there was no second nurse verification for administration of the vancomycin on 12/6/23 at 8:45 p.m.

Review of Patient 23's Pediatric Discharge Summary, dated 12/7/23 indicated, "The first dose of vancomycin was given at 1500 [3 p.m.] as ordered (56 mg = 15 mg/kg [kilogram]/dose). The second dose of vancomycin was given at 2045 [8:45 p.m.] and given at a dose of 500 mg, infused in 50 ml of NS [normal saline] over 4-5 hours. Per nursing report, the entire bag was given. When it was discovered that patient received approximately 10x [10 times] the ordered dose of vancomycin ... Family was notified of the incident and [Patient 23] was prepared for transport to ICU [intensive care unit] level care at [Hospital B]."

During an interview on 12/28/23 at 1:35 p.m with the Director of Quality & Risk (DQR) and Risk Manager (RM), the DQR stated RN C did not perform a double check with another RN prior to administering the vancomycin to Patient 23.

During an interview on 12/28/23 at 1:56 p.m., the Nurse Manager (NM) stated she spoke to RN C. The NM stated RN C told NM when she pulled the medication from the Pyxis (medication dispensing cabinet), a drawer containing a 500 mg bag of vancomycin opened up and RN C was confused on how to mix the medication. The NM stated RN C did not know there was a pharmacy-prepared 10 ml syringe containing Patient 23's 56 mg dose of vancomycin available in the pyxis refrigerator. The NM stated RN C hung the 500 mg bag of vancomycin and set it at 6.66 ml/hr. The NM stated RN C should have used the pharmacy-prepared syringe and not the bag. The NM also stated the 8:45 p.m dose of vanco was given early and RN C should have retimed the medication so that it would have been given 8 hours after the previous dose.

Review of Patient 17's Pediatric History and Physical, dated 10/23/23 indicated she was admitted on 10/30/23 for continuation of IV antibiotic administration for Fusiform (type of bacteria) sepsis (the body's extreme response to an infection that could lead to organ failure, tissue damage and death).

Review of Patient 17's All Orders History 10/30/23 thru 12/27/23 indicated she had a physician order for ceftriaxone (Rocephin, antibiotic) 2000 mg in NS 100 ml IV at 100 ml/hr every 24 hours.

Review of Patient 17's MAR 10/30/23 through 12/27/23 indicated Patient 17 did not receive Rocephin 2000 mg IV on 11/5/23. The record also indicated there was no second nurse verification for administration of Rocephin 2000 mg IV from 10/31/23 to 11/9/23.

During an interview on 12/28/23 at 1:05 p.m., the DQR stated she was not able to find any documentation that indicated the reason Patient 17 did not receive Rocephin 2000 mg IV on 11/5/23.



44577

During a review of Patient 18's medical record, dated 11/16/23, the Physicians Transfer Summary dated 11/16/23 indicated Resident 18 was a 14-month-old admitted 11/13/23 with community acquired pneumonia (lung infection)

Review of Patient 18's Medication Administration Record (MAR, record of medications given) indicated a physician order for Omni pen (ampicillin -an antibiotic (medication used to treat an infection) 580 milligrams (mg -a unit of measure) intravenous (IV) every six hours. The medication was administered on 11/13/23 at 7:54 p.m., 11/14/23 at 1:12 a.m., 11/14/23 at 7:58 a.m., 11/14/23 at 2:37 p.m., 11/14/23 at 7:48 p.m. and 11/15/23 at 2:08 a.m., there was no evidence that indicated a double check of the medication was completed, no evidence of two care provider documentation on the MAR.

During a review of Patient 20's medical record, dated 10/3/23, the Physicians History and Physical (H&P) indicated Patient 20 was an 8-year-old admitted 10/3/23 with abdominal pain.

Review of Patient 20's MAR indicated a physician order for Zosyn (an antibiotic) 2.67 grams (gm- a unit of measure) IV every eight hours. The medication was administered on 10/3/23 at 8:25, 10/4/23 at 4:13 a.m., and 10/4/23 at 12:31 p.m., there was no evidence that indicated a double check of the medication was completed, no evidence of two care provider documentation on the MAR.

During an interview on 12/28/23 at 10:34 p.m. with RN B, RN B indicated another nurse checks all pediatric medication prior to administration and a second nurse checked the sign off. The name of the second nurse was entered in the MAR.

Review of the hospital's policy and procedure, "Administration of Medication," revised 5/2021 indicated the following:
"Verification process to assure accuracy of medication administation:
a. Read medication label at least three (3) times: i. When obtaining (removing) from Pyxix. ii. When checking against the MAR (ie, compare with medication order) iii. Prior to administration to the patient.
b. Mentally review five (5) rights of medication administation: i. Right patient ii. Right drug iii. Right dose iv Right route v. Right time
c. If there was a question regarding the medication, dosage, calculation, or any of the five rights, consult reference materials, another nurse, physician, or a pharmacist ... Administer medication as ordered."

Review of the hospital's policy, "High Alert Medications," revised 12/14/2020 indicated pediatric doses are considered high alert medications and require a double check. The policy indicated, "Two care providers (i.e. two nurses, or a nurse and a pharmacist of physician) may be required to double check certain orders (pump settings) and/or dose prior to administration ... Both persons will document their initials and signature on the MAR."