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.

CENTRAL CAROLINA HOSPITAL 1135 CARTHAGE ST SANFORD, NC 27330 June 25, 2020
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of facilty policy and procedures, medical record review, and interviews, the facility's nursing staff failed to supervise and evaluate patient care by failing to follow the facility's bottle feeding policy for 1 of 1 inpatient bottle fed infants (Patient #9) and failing to notify the physican of a change in a newborn's condition in a timely manner in 1 of 4 patients (Patient #7).

The findings include:

A. Review of facility policy "Bottle Feeding, 14-7-11" last revised 06/2017 revealed "SCOPE: OB (Obstetrical) Nurses ...PURPOSE: To provide a nutritional diet for the baby ...PROCEDURE: 1. Bottle fed infants should be fed every 3-4 hours, 10-30 mls on the first day of life, increasing to 75-90ml by day 4-5 ....METHOD: ...7. Discard bottle after feeding, record volume taken ..."

Review of the closed medical record of Patient # 9 revealed an infant born on 04/02/2020 at 0052. Record review on 04/03/2020 nursing documentation of "Nutritional ADLs- Newborn/Infant" revealed documented feeding times at 1430 "Feeding Method Newborn: Bottle; Feeding Type: Breast Milk: 30 ml; at 1710 (2 hours 40 minutes later) Feeding Method Newborn: Bottle; Feeding Type: Formula: 20 ml; at 2300 (5 hours and 50 minutes later) Feeding Method Newborn: Bottle; Feeding Type: Formula: 21ml and on 04/04/2020 at 0750 (8 hours and 50 minutes later) Feeding Method Newborn: Bottle; Feeding Type: Formula: 35 ml ..." Record review of "Intake and Output 4/3/2020-4/4/2020 1800- 0600" revealed "12 hour Total 21ml" documented. There was no further documentation of bottle feedings between 2300 and 0750.

Review of Physician Progress Notes on 4/4/2020 at 1449 revealed "Physical Exam: **On initial exam this morning infant was pale and "pasty", and very jittery. Blood sugar was "less than 20" Much improved after interventions: See Narrative below ...infant was pale and pasty- with dry mucous membranes ... Blood sugar was less than 20. Repeat was 22. 40% Glucose Gel given... Infant also fed 22 kcal formula ("sucked it down" per nurse) ..."

Telephone interview on 06/19/2020 at 2000 with RN #8 revealed she is a float pool nurse. Interview confirmed she was assigned to the OB unit on night shift 7pm -7am April 3, 2020. Interview revealed she can care for babies just not sick babies. Interview revealed she does not routinely work on the OB unit. Interview confirmed she only documented one newborn feeding for the patient during her shift. Interview revealed she documents feedings during her assessments if feedings were completed. Interview revealed she should have awakened the mother to feed the baby or to ensure the baby was fed.

B. Review on 06/16/2020 of the facility policy titled "Care of the Newborn in Delivery, 14-6-17" with a revision date of 01/2017 revealed "...1. The provider will perform the initial suctioning with a bulb syringe after delivery if appropriate. 2. If stable, baby will be placed skin-to-skin with mom for at least 20 min. preferably up to 1 hour. If breastfeeding skin-to-skin should be maintained until first feeding is complete. 3. A newborn requiring interventions will be placed in the warming table provided in the delivery room. Table will be pre-warmed prior to delivery for closer observation and possible resuscitation. 4. Dry infant immediately to prevent heat loss and provide stimulation and cover with dry blanket. Apply cap to aide in maintaining heat. 5. Score APGAR (appearance, pulse, grimace, activity, respiration - test used to check a baby's overall physical condition at birth): 1 minute from time of delivery and then 5 minutes after delivery. If apgar is less than 7 at 5 minutes, continue to assign an apgar score every 5 minutes until the score reaches 7 or up to 20 minutes. Follow NRP (Neonatal Resuscitation Program -program focuses on basic resuscitation skills for newly born infants) Guidelines."

Review on 06/16/2020 of the facility policy titled "Delivery Care of Patient, 14-6-12" with a revision date of 01/2017 revealed "...2. Upon delivery, provide newborn supportive/resuscitative measures as condition warrants ..."

Review of closed medical record of Patient # 7 revealed a term 37 week 6 day infant born on 01/06/2020 at 0505. Record review revealed on 1/06/2020 at 0530 nursing documentation revealed "Procedure: Resuscitation at Birth: Bag/PPV(Positive Pressure Ventilation) with pressure limiting device, Oxygen, Pulse Oximeter, Suction; Weak cry, hypoventilation, body pink, extremities blue ... ". Review of "Seizure Assessment" at 0550 revealed :Seizure Activity: New; Seizure Location: All extremities, eyes, General, Head, or Neck". Review of "Newborn Assessment" at 0550 revealed "Behavior Newborn: Lethargic" and "Respiratory Assessment: Respirations: Agonal; Respiratory Pattern ICU: Irregular, Bradypnea (slow rate). Record review revealed at 0550 "Oxygen Therapy & Oxygenation Information: Blow- by, Nasal Intermittent Positive Pressure Ventilation; Oxygen Flow Rate: 10 L/min. (liters/minute). Record review revealed on 1/06/2020 at 0600 MD # 11 was notified.

Record review revealed MD #11 at bedside at 0633. Review of "History and Physical" 1/06/2020 at 0835 revealed "called after infant delivered and told APGAR were 3,7,5. Infant received PPV at delivery and improved. She was placed on mother to do skin to skin and nurses noticed grunting, Infant taken back to warmer and PPV restarted ... RT called and placed infant on 1L via NC at 30 %. Once Peds arrived ...infant was noticed to be posturing ...Infant switched to PPV while RT prepared for CPAP (continuous positive airway pressure) Phenobarbital (seizure medication) 20mg/kg loading dose given ...Parents updated on infant and consent signed for transfer ... "

RN #6 assigned to Patient #7 is not available for interview.

Interview on 06/17/2020 at 1515 with MD #11 revealed she recalled Patient #7. Interview revealed she was already awake and up that morning. Interview revealed the nurses did recognize the changes in condition and began interventions. Interview revealed it is an expectation to notify her immediately of any change in patient condition. Interview revealed "they should have notified me sooner." Interview revealed the 30-minute timeframe notification did not meet her expectations. Interview revealed anyone can make a call to her to let her know a patient is in distress.

Interview on 06/17/2020 at 1120 with Director #3 revealed she was aware of the event with Patient #7 on 01/06/2020. Interview revealed RN #6 should have notified MD #11 when the baby needed PPV at 0530. Interview revealed "she should have called the doctor when the baby needed PPV. They should not have trialed skin to skin." Interview revealed that MD #11 should be notified as soon as possible which any change in patient condition. Interview revealed RN #6 was an agency nurse and no longer employed at the facility.

Interview on 06/18/2020 at 1445 with RN #7 revealed she was charge nurse on the night shift of 1/05/2020 and recalled Patient #7. Interview revealed she helped with the care of Patient #7 and then went to care for her patients and other duties. Interview revealed they recognized the change in condition immediately and began interventions. Interview revealed she could have called MD #11 for RN #6 but felt RN #6 should be the one to talk to the physician. Interview confirmed when a patient had a change in condition the physician needs to be notified immediately.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Medical Staff Bylaws, policy review, medical record review and provider and staff interviews, the hospital failed to ensure an accurate medical record by failing to record a nurse delivery in 1 of 2 nurse delivered records reviewed. (#8)

The findings included:

Review of Medical Staff Bylaws, dated December 2018, revealed "... CLINICAL ENTRIES/AUTHENTICATION All clinical entries to the patient's medical record....shall be accurately and promptly dated, timed, authenticated and legible. ..."

Review of policy "Water Birth, 14-6-96", last revised 01/2017, revealed "...All water births must be planned in advance of admission. Requests made on admission may be honored. All water birth deliveries must be performed by the provider (Physician or Certified Nurse Midwife [CNM]) in order for the water birth to occur. ..."

Medical record review for Patient #8 revealed a [AGE] year-old with an EDD (estimated delivery date) of 01/24/2020 arrived to Labor and Delivery on 01/28/2020 at 2100 with ruptured membranes. Review of the History and Physical revealed "...Patient would like water birth and limited intervention. ..." Review of a Progress Note, subject "Obstetrics Delivery Note", Service Date/Time 01/29/2020 at 0638, revealed "...Pt sitting in water for labor. Complete and pushing at 5:30 am Spontaneous delivery of viable female infant @ (at) 0607am .... Delivery Providers (Name of CNM)....Assessment/Plan ....SVD (spontaneous vaginal delivery) of viable female infant. ..." Review revealed the patient and newborn were discharged on [DATE]. Record review did not reveal documentation by the CNM or RN to indicate the RN delivered the infant.

Review of Patient #8's newborn record revealed a History and Physical, service date/time 01/29/2020 at 0840, which stated "...Term AGA (appropriate for gestational age) female ....APGAR 8.9. Waterbirth delivered by nurse....Infant well appearing on exam. ..." Review revealed Delivery Personnel listed included a CNM and two Registered Nurses. Review of the Discharge Summary, electronically signed 01/31/2020 at 1052, revealed "Term ...Female Infant born vaginally at 06:07 on 1/29/2020 ...Delivery was a water-birth - nurse delivered (CNM delayed). ..."

A request to interview RN #6, who delivered the infant, revealed the RN was no longer at the hospital and not available for interview.

Telephone interview with MD #26, an Obstetrician, on 06/18/2020 at 0800 revealed any nurse delivery was not an expected event and should be documented by the provider as a nurse delivery in the Delivery Note. Interview revealed the RN should document it as well.

Telephone interview, on 06/18/2020 at 1500, with RN #7 revealed neither this RN nor CNM # 27 were present at the actual birth. Interview revealed everything was set up for the delivery and the CNM was going to deliver the patient in the water. Interview revealed the CNM and RN #7 had stepped out of the room thinking it would be a little while before the patient delivered. Interview revealed they remained nearby. Interview revealed RN #6, who was in with the patient, called out and they immediately went in to the room, but the baby was already born. RN #7 stated the patient and baby were fine. The patient, RN #7 stated, was very happy with her birth, said it was a "wonderful" birth.

Telephone interview on 06/18/2020 at 1220 with CNM #27 revealed the CNM was on duty and expected to deliver Patient #8. Interview revealed the patient was in the tub planning for a water birth. Interview revealed RN #6, an agency RN, was in the room with the patient and said the patient was pushing. CNM #27 stated she went into the room to check on the patient and multiple support people were in the room surrounding the tub. The CNM further stated she stayed in the room and observed Patient #8 for about 15 minutes and could see that the patient was not pushing yet. Interview revealed CNM #27 then left the labor room and went to sit down for a minute. Interview revealed RN #6 called out and the CNM immediately went back in the room and the baby was lying on the mother's chest. Interview revealed the nurse told the CNM she should have been in the room. Interview revealed CNM #27 was upset. Interview revealed CNM #27 told the nurse she was sorry she was not there. Interview revealed the CNM did not expect the delivery to happen that quickly. Interview revealed the patient was not pushing when CNM #27 left the labor room. CNM #27 stated both mom and baby were fine. Interview revealed CNM #27 did not document the nurse delivered the baby. CNM #27 stated she documented she delivered the baby because she did not want the nurse to get in trouble.

NC 707