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Based on interview and record review the facility failed to comply with all of the requirements at 42 CFR 489.24 for one of ten sampled patients .

The Findings include:

1. Based on medical record reviews, policy and procedure, Lippincott Nursing Manual and interview, the facility failed to provide appropriate treatment and services as required to stabilize the medical condition of 1 of 21 sampled patients (#1) that was within the capability and capacity of the hospital. Refer to findings in A 2407.

Based on medical record reviews, policy and procedure, Lippincott Nursing Manual and interview, the facility failed to provide appropriate treatment and services as required to stabilize the medical condition in 1 of 21 sampled patients (#1) within the capability and capacity of the hospital.

The findings include:

Record review of sample patient # 1 revealed a 24 day old neonate/infant presented to the emergency department with the mother of the neonate stating she has concerns with breathing and low temperature on 9/2/12 at 6:01 a.m. Documentation revealed, at 6:15 a.m., the physician wrote the mother stated that the patient's axillary temperature was cold so she was told to bring the baby to the emergency department. The physician documented, the patient was "feeding well at the breast," with no fever, rash, cough, vomiting or level of consciousness changes. The patient ' s vital signs were recorded at 6:03 am as Pulse oximetry 99%, rectal temperature 96.7, (Lippincott Manual of Nursing Practice, Ninth Edition, documents a neonate has the age birth of birth to 1 month and a normal pediatric temperature ranges from 97-100 Fahreinheit(F) pulse 157 and respirations 32. The physical assessment noted well appearing, no apparent distress, alert, active and vigorous, not lethargic and not irritable. At 6:10 a.m., the vital signs were recorded as pulse oximetry 99%, rectal temperature 96.7, pulse 157 and respirations 32. Documentation revealed, at 6:10 a.m. the patient urinated well in the diaper and stool was on the diaper, patient was calm, abdomen was soft and bowel sounds were present. The nurse documented there was no nasal flaring or shortness of breath from sample patient #1. Vital signs documented at 7:14 a.m are temperature 96.7, pulse 148, respirations 32 and pulse oximetry 99%. The discharge documentation dated 09/2/12 revealed Your discharge instructions/diagnoses was "well child (normal exam)" was documented. The discharge instructions read, "The doctor in the emergency department examined your child and did not see any major abnormality or signs of injury at the present time. Some medical problems can be clinically identified only at a later time even though a thorough evaluation has been done. Not all problems are elicited at the time of evaluation. However, the doctor feels it is safe to send your child home now and if you notice any abnormal behaviors or complaints, please contact your Dr. [doctor] or return to the ED of Hospital #2 [emergency department]. " Furthermore, the doctor ' s orders state " Follow-Up: Physician: Take to [ hospital #2] if changes. Follow-up when: and have recheck with pediatrician this week." The patient was discharged at 7:04 a.m. and the mother was informed " if anything changes alertness feeding -anything- to take immediately to hosp[hospital #2]. " All discharge instructions are signed by sample patient #1's mother.
The facility failed to provide stabilizing treatment and services as required by not providing ancillary services such as laboratory tests or diagnostic procedures to SP#1, a neonate with persistent hypothermia on 9/2/2012.

Review of (SP)#1 medical record Discharge Summary from hospital #2 dated 10/22/2012 specified in part, " HISTORY OF PRESENT ILLNESS: 3 week old female with no past medical hx (History) who was irritable overnight with a " funny cry. " Around 4:30 am, Mom was breastfeeding and noticed that baby wasn ' t eating will and felt cold. Dad took to the bathroom in the light and the baby had acrocyanosis (a persistent blue or cyanotic discoloration of the extremities, most commonly occurring in the hands). Also (right) arm R was colder that left. No shaking of extremities or eyes rolling back. Mom took temperature at that time orally and was 91F. Called PCP (Primary Care Physician) after hour line and spoke with nurse who told to take orally and was 95F. At that time, told to wrap baby and take directly to the ER. Prior to last night,(baby ' s name) was acting well. Eating well with breastmilk. Stooling and urinating normally. Never had felt cold in the past. Parents had never heard a cry like this. Has been afebrile. Parents took to Mercy Hospital (where____was born), they evaluated ___after listening to mom ' s complaint and discharged them around 7:10 am saying was nothing wrong with the baby. They did not do any interventions including labs. On the way home, mom reached back to touch ___and noticed she felt cold again. She woke up dad (who was in the passenger seat) and had him look at the baby, and he noticed ___ was not breathing. They took her directly to (an acute care hospital). She arrive at the acute care hospital at approx. (approximately) 7:32 am and ___ was limp and not breathing. CPR (cardio pulmonary Resuscitation- an emergency measure to revive a patient ' s heart who has stopped beating) was initiated. Interosseous (Is a process of injecting directly into the marrow of a bone to provide non-collapsible entry point into the systemic venous system. This technique is used in emergency situations to provide fluids and medications when intravenous access is available or feasible) placed in right lower leg. Compressions and bagging initiated with eventual intubation (insertion of a tube into the trachea for airway maintenance, lung ventilation) . . . PICU Perinatal intensive care unit (unit designed with special equipment to care for seriously ill newborns) was called to help in resuscitation. 1 dose of Rocephin (antibiotic) given ... and CBC (Complete Blood count), CMP (Comprehensive Metabolic Panel), blood culture, type and cross match drawn, In total ___ was pulseless for about 30 minutes, and CPR was continued for about 45 minutes. ___ arrived to the PICU after intubation and stabilization. " Diagnoses at hospital #2 included: acute Respiratory Failure, Cardiac Arrest, Dyspnea and Volvulus.


Interview with MD #1 responsible for care of sample patient #1 revealed, he remembers seeing the patient on 9/2/12. The physician stated, sample patient #1 was brought to the emergency department by her mother for what her mother reported was shortness of breath. The physician stated, he examined the infant and found the vital signs to be stable and no signs of shortness of breath. The physician requested the mother to breast feed the infant so that he could observe the infant's latch and ability to suck. The physician stated, the infant latched to the mother's breast without difficulty and the mother told him that sample patient #1 was sucking strong. The physician stated, the abdomen was soft and bowel sounds were heard in all four quadrants. The physician stated, there were no indications that the infant was ill but that sample patient #1 was kept in the emergency department for an hour for observation and the mother was told to call for the nurse if she noted any changes. After one hour of no changes, the vital signs were reassessed and sample patient was discharged. The physician stated, instructions were given to go to the nearest emergency department if there were any changes. The physician stated the reason he instructed the mother to take sample patient #1 to another hospital (#2) if needed is because there is a closer hospital to their home and where the pediatrician is located. The physician stated, the reason the mother came to this facility was because the patient was delivered here. The surveyor questioned the physician on the temperature of sample patient #1 and he stated, while the temperature was 96.7 it remained stable and was not a concern. Furthermore, the physician stated that he had no indications that sample patient #1 could be suffering from mal-rotation of the intestine, a birth defect involving a malformation of the intestinal tract. The physician reiterated, he did an abdominal exam on sample patient #1 and his assessment was normal and the infant was not fussy on exam.

Review of policy, "Pediatric Assessment and Reassessment Policy" revealed, the facility uses the age categories of the American Academy of Pediatrics to define pediatric groups. The policy revealed that a pediatric patient less than 30 days old is a neonate. Sample patient #1 was under 30 days old.



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