The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|SOUTHCOAST HOSPITALS GROUP||363 HIGHLAND AVENUE FALL RIVER, MA 02720||Jan. 13, 2011|
|VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES||Tag No: A0283|
|Based on interviews and documentation review, it was determined the Hospital had not (yet) completed 2 actions items called for by its Internal Investigation of Neonate #1's SRE/medication administration error.
A review of the Hospital Internal Investigation related to Neonate #1's SRE/medication administration error revealed it called for:
> Immediate identification banding of neonates with pre-registration information (until bracelets with birth information are available).
> Investigation of the possibility of decreasing the timeframe of availability of post-birth identification bracelets.
> Immediate cessation of the practice of bringing Terbutaline, oxytocin and/or other maternal medications into delivery rooms "just in case"/without a physician order.
> Immediate cessation of the practice of bringing neonatal medications into delivery rooms prior to birth.
> Placement of a second mobile computer with scanner in the labor & delivery room when delivery is imminent.
> Immediate and strict adherence to BMV policies/procedures.
> Formal re-education and counseling of Staff RN #1 regarding medication administration.
> Development of a Quality Monitoring Plan related to the neonatal medication administration process and Staff RN #1's medication administration practices.
> A RCA.
> A survey of medication administration practices throughout (all areas of) the Hospital.
A review of the implementation of the Corrective Action Plan associated with the Hospital Internal Investigation related to Neonate #1's SRE/medication administration error revealed all action items had been addressed except for the RCA and the Hospital-wide survey of medication administration practices.
At Exit Conference on 1/13/11, the Hospital-System Senior Vice President/Chief Nursing Officer said a RCA Team had been identified and a RCA meeting was in the process of being scheduled, and a plan for the Hospital-wide survey of medication administration practices was in the development phase.