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.

BAPTIST HEALTH CORBIN ONE TRILLIUM WAY CORBIN, KY 40701 April 10, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interviews, record review, and facility policy review, it was determined the facility failed to have an effective Governing Body responsible for the conduct of the facility. The Governing Body and Chief Executive Officer failed to ensure the facility's policy and procedures for obtaining capillary blood samples (heel sticks) were safe. The facility's policy for obtaining a capillary blood specimen (heel stick) indicated staff should use warm, wet towels/washcloths (not to exceed 107 degree Fahrenheit) to warm the heel area prior to obtaining the specimen to increase blood flow to the area. Although the facility's policy directed staff not to utilize a microwave to heat towels/washcloths due to the increased potential for thermal injury, the policy did not address heating water in the microwave, or utilizing a disposable diaper as a method to apply the water to the infant's heel. Subsequently, on 03/26/18, Registered Nurse (RN) #1 placed a disposable diaper that contained microwaved water on Patient #1's (a newborn) left foot/leg, prior to obtaining a blood specimen in the newborn's heel. As a result, the newborn sustained a second degree burn to the left foot/leg and possible permanent tissue damage (refer to A057, A0115, A0144, A0385, and A0395).
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on interview, record review, and facility policy review, it was determined the Chief Executive Officer failed to effectively manage the hospital and ensure the facility's policies were implemented. The facility's policy for obtaining a capillary blood specimen (heel stick) indicated staff should use warm, wet towels/washcloths to warm the heel area prior to obtaining the specimen to increase blood flow to the area. Further review of the policy revealed utilizing a microwave to heat the towels/washcloths was prohibited due to the increased potential for thermal injury. However, on 03/26/18, Registered Nurse (RN) #1 placed a "Pampers" (brand name) disposable diaper that contained microwaved water on Patient #1's (a newborn) left foot/leg, prior to obtaining a blood specimen in the newborn's heel. As a result, the newborn sustained a second degree burn to the left foot/leg and possible permanent tissue damage (refer to A057, A0115, A0144, A0385, and A0395).

The findings include:

Review of the facility's "By Laws" dated 08/29/17, revealed the Board of Directors was responsible for overseeing the quality of care and services provided to patients...and ensuring compliance with Medicare Conditions of Participation. According to the By Laws, the Board of Directors selected and employed a Chief Executive Officer (CEO), who was charged with the responsibility and given the authority to see that the aims and objectives of the facility were carried out.

Review of the facility's policy titled, "Capillary Specimen Collection," last revised on 05/25/17, revealed prior to obtaining a blood specimen from an infant's heel, a warm, wet towel or washcloth should be placed to the heel for three (3) to five (5) minutes to improve blood flow to the area. The policy instructed staff not to warm towels or washcloths in the microwave and warned that if the temperature used to warm the infant's heel was too high there was risk of thermal injury to the baby. However, the policy did not address utilizing disposable diapers, (which contained an absorbent gel and plastic lining that promoted heat retention) or warming water in a microwave.

However, an interview with Physician #1 revealed utilizing a washcloth/towel was no longer the standard of practice since the introduction of heel warmers. Despite the facility having heel warmers available for use to warm the newborn's heel (specifically designed for this purpose), and a policy directing staff never to microwave towels/washcloths, on 03/26/18 RN #1 microwaved water, poured the water into a disposable diaper, and placed the diaper on Patient #1's (a two-day-old baby) left foot resulting in the newborn receiving a second degree burn to the foot/leg. In addition, interviews on 04/03/18 with RN #2 at 2:43 PM, RN #3 at 2:59 PM, and RN #4 at 3:06 PM, and interviews on 04/04/18 with RN #5 at 2:30 PM, RN #6 at 2:50 PM, RN #7 at 3:27 PM, and RN #8 at 3:38 PM, revealed the continued practice at the facility was to use a disposable diaper saturated with warm water, instead of towels/washcloths as directed by the policy. Interview with the Pampers representative on 04/09/18 at 3:40 PM, revealed that was not an acceptable use for the diaper.

Interviews with the facility's Director of Women's Health and Children on 04/03/18 at 3:17 PM, revealed it was also her understanding that it was acceptable for nursing staff to utilize disposable diapers filled with warm water for use as heel warmers prior to a heel stick. Further interview revealed monitoring of nursing staff for laboratory collection was not routinely conducted.

Interview with the facility's President (CEO) on 04/10/18 at 1:19 PM revealed he was responsible for ensuring that all policies and procedures were implemented. Further interview revealed he was aware of the incident and expected all nursing staff to follow facility policy and procedures. The interview revealed there was no evidence the CEO had identified that the facility was not utilizing safe practices for obtaining blood specimens in infants.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review, and review of facility policy it was determined the facility failed to protect and promote the rights of one (1) of ten (10) patients (Patient #1). Review of the facility's Capillary Specimen Collection policy revealed prior to obtaining a capillary blood sample (heel stick) from an infant's heel, staff should "prewarm" a towel or washcloth to a temperature no higher than 107 degrees Fahrenheit (F) to improve blood flow to the area. However, the policy did not direct staff not to utilize a microwave to heat the water. In addition, staff interviews revealed they did not use a towel or washcloth, but routinely utilized a disposable diaper to pour the warm water into, which was not identified as an acceptable practice in the facility's policy.

On 03/26/18, Registered Nurse (RN) #1 placed water in a microwave when the tap water was not warm enough, poured the microwaved water into a disposable diaper, and placed the diaper on Patient #1's left foot. As a result, Patient #1 sustained a superficial partial-thickness (second degree) burn to the left foot/leg, and potentially permanent damage to the foot (refer to A0043, A0057, A0144, A0385, and A0395).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of facility policy it was determined the facility failed to ensure one (1) of ten (10) patients (Patient #1) received care in a safe setting. Review of the facility's Capillary Specimen Collection policy revealed prior to obtaining a capillary blood sample (heel stick) from an infant's heel, staff should "prewarm" a towel or washcloth to a temperature no higher than 107 degrees Fahrenheit (F) with a warm wet towel or washcloth to improve blood flow to the area. However, on 03/26/18, Registered Nurse (RN) #1 placed water in a microwave when the tap water was not warm enough, poured the microwaved water into a disposable diaper, and placed the diaper on Patient #1's left foot. Subsequently, Patient #1 sustained a superficial partial-thickness (second degree) burn to the left foot/leg, and suffered potentially permanent damage to the foot (refer to A0043, A0057, A0115, A0385, and A0395).

The findings include:

Review of the facility policy titled, "Patient's Rights and Responsibilities," last revised 11/06/17, revealed patients had the right to receive fair and compassionate care at all times and under all circumstances.

Review of the facility's policy titled, "Capillary Specimen Collection," last revised on 05/25/17, revealed capillary blood specimen collection was accomplished by puncturing the skin. The policy stated heel stick puncture was the choice collection method for infants less than twenty (20) pounds. The policy further stated to improve blood flow to the area, a warm wet towel or washcloth not exceeding 107 degrees Fahrenheit should be placed on the infant's heel for three (3) to five (5) minutes prior to performing the heel stick. However, the policy did not address utilizing disposable diapers instead of towels/washcloths. Further review of the policy revealed if the temperature used to warm the infant's heel was too high, there was risk of thermal injury to the infant. Although the policy instructed staff "DO NOT warm towels or washcloths in microwave.", the policy failed to direct staff not to heat the water to be used to warm the infant's heel in the microwave.

Observation on 04/04/18 at 3:10 PM, revealed "Medline" (brand) heel warmers were available for patient use in the nursery. Review of the heel warmer package revealed the product was a specifically designed gel pack which conformed to the infant's heel to increase blood flow to the area and was manufactured not to exceed a temperature of 105 degrees Fahrenheit.

Review of Patient #1's medical record revealed Patient #1 was born at the facility on 03/24/18. Review of a Physician's Progress Note, dated 03/26/18, revealed Registered Nurse (RN) #1 notified the physician of the need to assess Patient #1's left foot. The Physician's Progress Note stated the nurse placed a warmed diaper over the newborn's left ankle for approximately five (5) minutes prior to obtaining laboratory tests, and then noticed an [DIAGNOSES REDACTED]tous desquamation (reddened area with the skin peeled back) after removing the diaper. Further review of the progress note revealed the newborn sustained a partial thickness (second degree) burn due to the contact with the warmed diaper. Patient #1 was transferred to a higher level of care hospital (Facility #2) for assessment by Pediatric Plastic Surgery.

Review of Patient #1's History and Physical from Facility #2, dated 03/26/18, revealed the patient had a 4 cm (centimeter) by 3 cm partial thickness burn to the left heel extending to the back of the leg caused by a diaper filled with water that was heated in a microwave and used as a heel warmer. Further review revealed the "baby appears to have significant pain."

Interview with Physician Assistant (PA) #1 on 04/09/18 at 4:17 PM revealed she conducted a plastic surgery consultation for Patient #1 at Facility #2 on 03/26/18. The PA stated the patient sustained a second degree burn from the microwaved diaper. The PA stated the newborn continued to receive treatment for the burn, which could potentially cause permanent damage to the newborn.

Interviews with the facility's Director of Women's Health and Children on 04/03/18 at 3:17 PM, with RN #2 at 2:43 PM, RN #3 at 2:59 PM, and RN #4 at 3:06 PM, and interviews on 04/04/18 with RN #5 at 2:30 PM, RN #6 at 2:50 PM, RN #7 at 3:27 PM, and RN #8 at 3:38 PM revealed that although heel warmers were readily available, they did not routinely utilize the heel warmers. Continued interview revealed they preferred applying a disposable diaper to the heel that contained warm tap water. Interviews with the nurses further revealed the only measure used to check the temperature of the water that was being placed in the diaper was to place a small amount of the water on their wrist/arm and judge if it "felt too hot."

Interview with RN #1 on 04/03/18 at 2:20 PM revealed it was her practice to routinely place warm water in a diaper and secure it around the infant's heel to warm the area prior to obtaining a blood sample. However, on the morning of 03/26/18, the nurse stated that the tap water did not feel to her as though it was warm enough to be effective. Therefore, the RN heated water in the microwave, poured the heated water into a disposable diaper, and secured the diaper around the infant's heel without ascertaining the temperature of the water.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation of video footage, interviews, record review, and review of facility policy and state laws, it was determined the facility failed to ensure nursing services were supervised. The facility's policy instructed staff not to warm towels or washcloths in a microwave prior to utilizing them to warm an infant's heels before obtaining a capillary blood specimen (heel stick). However, the policy did not address utilizing disposable diapers as heel warmers or warming water in a microwave for use on a newborn. Subsequently, on 03/26/18, RN #1 microwaved water, placed the water in a "Pampers" (brand name) disposable diaper, and wrapped the diaper around Patient #1's left heel. As a result, Patient #1 sustained a partial thickness (second degree) burn to the left heel that extended to the back of the infant's leg. Interviews with the Director of Women's Health and Children on 04/03/18 at 3:17 PM revealed she had not identified that the facility's nursing practice regarding utilizing hot water in disposable diapers for use as a heel warmer was not in accordance with the facility's policy. Further interview revealed the facility had no system in place to monitor to ensure staff were not utilizing unsafe practices when obtaining blood specimens from infants (refer to A0043, A0057, A0115, A0144, and A0395).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation of video footage of the facility's nursery, interview, record review, and review of facility policy and state laws, it was determined the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for one (1) of ten (10) sampled patients (Patient #1). The facility's policy instructed staff not to warm towels or washcloths in a microwave prior to utilizing them to warm an infant's heels before obtaining a capillary blood specimen (heel stick). However, the policy did not address utilizing water heated in a microwave on a newborn or utilizing a wet disposable diaper as a means to warm the heel area.

Subsequently, on 03/26/18, RN #1 microwaved water, poured the heated water into a disposable diaper, and wrapped the diaper around Patient #1's left heel. As a result, Patient #1 sustained a partial thickness (second degree) burn to the left heel that extended to the back of the infant's leg (refer to A0043, A0057, A0115, A0144, and A0385).

The findings include:

Review of Kentucky Revised Statute (KRS) 214.155 and Kentucky Administrative Regulation (KAR) 4:030 revealed all babies were required to undergo a newborn screening before leaving the hospital after birth. The screening included testing for [DIAGNOSES REDACTED] (PKU).

Review of the facility's policy titled, "Capillary Specimen Collection," last revised on 05/25/17, revealed a capillary blood specimen (to test for PKU) was collected by puncturing an infant's heel to obtain a blood specimen. The policy further stated the infant's heel should be warmed to improve blood flow to the area by applying a warm wet towel or washcloth with a water temperature that did not exceed 107 degrees Fahrenheit for three (3) to five (5) minutes. The policy instructed staff, "DO NOT warm towels or washcloths in microwave." However, the policy did not address heating the water in a microwave or utilizing disposable diapers as a method to apply the warm water to the infant's heel. Further review revealed if the temperature used to warm the infant's heel was too high, there was risk of thermal injury to the baby.

Review of a Physician's Progress Note, dated 03/26/18, revealed RN #1 secured a disposable diaper containing warmed water to Patient #1's left ankle for approximately five (5) minutes, before sticking the patient to obtain blood for the PKU testing. The Note stated the nurse then noticed an [DIAGNOSES REDACTED]tous desquamation (reddened area with the skin peeled back) after removing the disposable diaper. Further review of the progress note revealed the newborn sustained a partial thickness (second degree) burn.

Interview with Registered Nurse (RN) #1 on 04/03/18 at 2:20 PM revealed on the morning of 03/26/18, she heated a Styrofoam cup of water in the microwave for approximately 2 seconds and tested the water with her finger. The RN stated the water did not feel any warmer than tap water; therefore, she microwaved the water for another 7-8 seconds and again tested the water on her palm/wrist, and stated the water did not feel too warm. However, the RN made no attempt to obtain a thermometer and take the actual temperature of the microwaved water. The RN stated she then poured the water into a disposable diaper and fastened the diaper around Patient #1's foot. Further interview with RN #1 and review of video footage of the nursery recorded on 03/26/18, revealed after leaving the disposable diaper on the newborn for approximately five (5) minutes, she removed the diaper and attempted to obtain a blood specimen for the newborn's PKU test. However, the RN stated she squeezed the area to promote the blood flow and Patient #1's heel had "blood was under the skin" and the skin on the heel "peeled back."

Interview with the Director of Women's Health and Children on 04/03/18 at 3:17 PM revealed she had not identified that the facility's policy did not specifically address heating water in the microwave to facilitate warming an infant's heel to obtain a blood specimen, or the nurses' practice of utilizing a disposable diaper as the means to apply the warm water to the infant's heel. In addition the Director stated the facility had no system in place to monitor to ensure staff were not utilizing unsafe practices when obtaining blood specimens from newborns.

Review of Patient #1's History and Physical from Facility #2, dated 03/26/18, revealed the patient had a 4 centimeter (cm) by 3 cm partial thickness burn (second degree burn) to the left heel extending to the back of the leg related to a diaper filled with water that was heated in a microwave and used as a heel warmer. Further review revealed the "baby appears to have significant pain."

Interview with Family Member #1 and Family Member #2 on 04/07/18 at 7:50 PM revealed Patient #1 continued to be treated for the burn to the left foot/leg. Patient #1 was receiving wound care and being followed by a plastic surgeon. Further interview revealed the physician was concerned that the patient had potential nerve damage to the burned area.

Interview with Physician Assistant (PA) #1 on 04/09/18 at 4:17 PM, who worked in Plastic Surgery, revealed Patient #1's second degree burn could potentially lead to permanent damage.