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PUTNAM COMMUNITY MEDICAL CENTER 611 ZEAGLER DR PALATKA, FL 32177 Oct. 9, 2014
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of the facility's Policies and Procedures, record review, and staff interviews revealed that the facility failed to provide care and services with supervision for 1 of 10 patients (Patient #1).


Findings:

1. Medical record review revealed that patient #1's mother that was 39 weeks and 3 days gestation, and in active labor, presented to the hospital labor and delivery (L&D) department on 08/28/2014 at 9:20 AM. The baby's mother stated that her membranes had ruptured the previous day at 3:00 AM, and she did not seek medical attention.

The baby's mother had been diagnosed on admission prolonged rupture of membranes at term, and she was started on Intravenous (IV) fluids and an external fetal monitor was placed. Intrauterine press catheter was placed along with a scalp electrode and internal monitors were applied. Patient #1 had a fetal heart rate of 140's and 150's. The uterine contractions were mild to moderate, and the patient (mother) was started on Pitocin. During the insertion of the pressure catheter, there was no fluid that could be seen, and when the applicator was removed, it was full of very thick meconium. Amnioinfusion (amnion is the innermost membrane that encloses the embryo) began with warm lactated ringers in order to decrease the thickness of the meconium and to improve anticipated variable decelerations with a patient with amniotic fluid, which according to the physicians (Obstetrician) progress notes was from rupture at least two or three days prior to admission.

2. Interview on 10/09/2014 at 9:45 AM in L&D with Charge Nurse, RN#B revealed that the nursing staff was extremely busy on the day that this mother in active labor arrived, and Charge Nurse #A was marked off the schedule, and at a classroom training, which left nursing staff short. The L&D Nursing Director left the L&D to go get RN#A to assist us and was gone for an hour.

Patient #1 was delivered vaginally at 5:02 PM, with an APGAR: score of 2, a Neonatal Code Blue was called, and resuscitation by the Obstetrician, nursing and Respiratory Therapist. Nursing staff failed to call Respiratory prior to the Code Blue.

3. Review of the hospital ' s Policy and Procedure titled " Newborn Assessment and Danger Signs in Newborn " dated effective 02/2008 revealed the following:

PURPOSE: Guidelines for nurses when assessing newborns. Nurses are to observe the newborn for danger signs. Notify the attending pediatrician when appropriate.

4. Record review of the Neonatal Code Blue Record dated 08/28/2014 revealed that there was no documentation that Respiratory therapy was present nor documentation of her role in the resuscitation. Nursing staff failed to have vital signs including heart rate documented. And further review of the Code Blue revealed Epinephrine 0.5 ml was administered at 5:05 PM. But there was no documentation of the person that administered the Epinephrine or the response to the medication.

Interview on 10/09/2014 at 9:30 AM of RN# B revealed that she had asked RT #1 to run the blood gases to the lab after they had been obtained by the physician from the cord, and that the RT felt that it was not a priority, and left to get the O2 Hood. By this time 30 minutes had lapsed and it was too late to obtain results from the lab for the blood gases.

5. Review of the hospital's Policy and Procedure titled " Code Blue: Adult & Pediatric Respiratory and/or Cardiac arrest dated effective date of 01/03/2011 revealed the following:

Putnam Community Medical Center has a process in place to respond to an adult or child, regardless of age, in acute or impending cardiopulmonary arrest.

" Pediatric Code Blue " for a child less than [AGE] years old, is the term used to differentiate a pediatric code from an adult " Code Blue ". The purpose of calling a code is to identify the location of the cardiopulmonary arrest.
Documentation: A code blue flow sheet, located at the top of the crash cart, will be utilized for documentation of assessments and interventions implemented during a cardiopulmonary arrest. Licensed personnel are to document on the Code Blue Record.

6. Interview on 10/12/2014 at 3:30 PM with RN, Director of Labor and Delivery (L&D), revealed that she had been concerned with the presence of the thick meconium, prolonged ruptured membranes, and suspected early chorea amnionitis, and had ordered on [DATE] at 3:45 PM that the Operating Room (OR) be opened and prep for an imminent C-section to be performed for patient#1 prior to the vaginal delivery. She was told by the physician that he did not want the Pediatrician on call to take care of the newborn, and that she had gotten in a heated argument with the Obstetrician by refusing to call another Pediatric Care group (Azalea Health). Further interview with the Director of the L&D revealed that she did not administer the epinephrine (Epi), but did order the oxygen hood for patient #1 in the nursery after this birth during the Code Blue.

Interview on 10/09/2014 at 1:30 PM with patient #1's Obstetrician providing care and services on 08/28/2014 revealed that he did not order epinephrine, an oxygen hood, and that he had drawn the blood gases from patient #1 after delivery and asked nursing staff to ensure that they were taken to the lab to obtain results, which the blood gases were not. This Obstetrician noticed a liquid when he was suctioning using the meconium aspirator, and he stated he was told by RN#B that it was the Epinephrine that had been administered.

7. Review of the hospital 's Policy and Procedure titled " Administrative Call (AOC) " approved on 06/2014 revealed the following:

POLICY: An Administrative representative shall be available 24 hours per day, seven days a week to assist and support hospital staff during off business hours. Administrative call for outside regular administrative office hours will be rotated between the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Chief Nursing Officer (CNO) and other directors as designated by the CEO. Immediate notification of the person on administrative call is required for: Any question of issue requiring administrative support.

Interview of the CNO on 10/09/2014 at 1:30 PM and record review revealed that the Director of Labor and Delivery or the Charge Nurse did not notify the Chief Nursing Officer (CNO) regarding any of these issues or concerns requiring Administrative support on 08/28/2014. The CNO or AOC was not informed of possible delivery of decompensated infant, and that the L&D Director had been told by the Obstetrician that he did not want the Pediatrician on call to take care of the newborn.

Patient #1 was transported to a Neonatal Hospital for a higher level of care on 08/28/2014 at 8:02 PM.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, review of Policy and Procedures, and interview revealed that Respiratory Services and Nursing Services failed to document and describe assessments and patients response to medications and service for a Neonatal Code Blue for 1 of 10 (patient #1) patients reviewed.

Findings:

1. Medical record review revealed that a Neonatal Code Blue was called for respiratory arrest of a newborn, (patient #1) on 08/28/2014 at 5:02 PM. Review of the call list revealed that respiratory paged at 5:07 PM on 08/28/2014.

Record review of the Neonatal Code Blue Record dated 08/28/2014 revealed that there was no documentation that Respiratory therapy was present or documentation of her role in the resuscitation.

Nursing staff failed to have vital signs including heart rate documented. And further review of the Code Blue revealed Epinephrine 0.5 ml was administered at 5:05 PM. But there was no documentation of the person that administered the Epinephrine nor the response to the medication.

2. Review of the hospital's Policy and Procedure titled " Code Blue: Adult & Pediatric Respiratory and/or Cardiac arrest dated effective date of 01/03/2011 revealed the following:

Putnam Community Medical Center has a process in place to respond to an adult or child, regardless of age, in acute or impending cardiopulmonary arrest.

" Pediatric Code Blue " for a child less than [AGE] years old, is the term used to differentiate a pediatric code from an adult " Code Blue ". The purpose of calling a code is to identify the location of the cardiopulmonary arrest.
Documentation: A code blue flow sheet, located at the top of the crash cart, will be utilized for documentation of assessments and interventions implemented during a cardiopulmonary arrest. Licensed personnel are to document on the Code Blue Record.

3. Interview with Respiratory Therapist #1 on 10/09/2014 at 3:20 PM revealed that she stated when she arrived at the Neonatal Code Blue the Labor and Delivery (L&D) Director asked her to get the Oxygen (O2) Hood, which is kept in the L&D but could not be found, so she had to go to the Respiratory Therapy Department next door across the hall to obtain a O2 Hood. She further stated that RN# B asked her to run the blood gases to the lab on her way to get the O2 Hood. She chose to go and get the O2 Hood without taking the blood gases to the lab. There was no documentation of RT #1 retrieving the O2 Hood, or failing to take the blood gases to the lab, or any of her presence or duties performed during her visit to the Nursery.

4. Interview of the CNO on 10/09/2014 at 1:30 PM and record review revealed that the Director of Labor and Delivery or the Charge Nurse did not notify the Chief Nursing Officer (CNO) regarding any of these issues or concerns requiring Administrative support on 08/28/2014. The CNO or AOC was not informed of possible delivery of decompensated infant, and that the L&D Director had been told by the Obstetrician that he did not want the Pediatrician on call to take care of the newborn.
VIOLATION: RESPIRATORY SERVICES Tag No: A1164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview revealed that respiratory services failed to follow the facility's Policy and Procedures and document in 1 of 10 (patient #1) patient records services provided in a Neonatal Code Blue Record.

Findings:

1. Medical record review revealed that a Neonatal Code Blue was called for respiratory arrest of a newborn, (patient #1) on 08/28/2014 at 5:02 PM. Review of the call list revealed that respiratory paged at 5:07 PM on 08/28/2014.

Record review of the Neonatal Code Blue Record dated 08/28/2014 revealed that there was not any documentation that Respiratory therapy was present or documentation of her role in the resuscitation. Respiratory Therapy and nursing staff failed to have vital signs including heart rate documented. And further review of the Code Blue revealed Epinephrine 0.5 ml was administered at 5:05 PM. But there was no documentation of the person that administered the Epinephrine or the response to the medication.

2. Review of the hospital's Policy and Procedure titled " Code Blue: Adult & Pediatric Respiratory and/or Cardiac arrest dated effective date of 01/03/2011 revealed the following:
Putnam Community Medical Center has a process in place to respond to an adult or child, regardless of age, in acute or impending cardiopulmonary arrest.

" Pediatric Code Blue " for a child less than [AGE] years old, is the term used to differentiate a pediatric code from an adult " Code Blue ". The purpose of calling a code is to identify the location of the cardiopulmonary arrest.
Documentation: A code blue flow sheet, located at the top of the crash cart, will be utilized for documentation of assessments and interventions implemented during a cardiopulmonary arrest. Licensed personnel are to document on the Code Blue Record.

3. Interview on 10/09/2014 at 1:30 PM with patient #1's Obstetrician providing care and services on 08/28/2014 revealed that he did not order an oxygen hood, and that he had drawn the blood gases from patient #1 after delivery and asked nursing staff to ensure that they were taken to the lab to obtain results, which the blood gases were not.

4. Interview with Respiratory Therapist #1 on 10/09/2014 at 3:20 PM revealed that she stated when she arrived a the Neonatal Code Blue the Labor and Delivery (L&D) Director asked her to get the Oxygen (O2) Hood, which is kept in the L&D but could not be found, so she had to go to the Respiratory Therapy Department next door across the hall to obtain a O2 Hood. She further stated that RN# B asked her to run the blood gases to the lab on her way to get the O2 Hood. She chose to go and get the O2 Hood without taking the blood gases to the lab. There was no documentation of RT #1 retrieving the O2 Hood, or failing to take the blood gases to the lab, or any of her presence or duties performed during her visit to the Nursery.

5. Interview on 10/09/2014 at 9:30 AM of RN# B revealed that she had asked RT #1 to run the blood gases to the lab after they had been obtained by the physician from the cord, and that the RT felt that it was not a priority, and left to get the O2 Hood. By this time 30 minutes had lapsed and it was too late to obtain results from the lab for the blood gases.