HospitalInspections.org

Based on document reviews, observations, and interviews, the hospital failed to properly label breast milk while feeding according to hospital policy.

The hospital's policy titled, "Breast Milk Collection, Storage, Administration and Exposure Procedures," last approved on 6/2023, states in part ... "When pouring the milk into the necessary feeding device/bottle, the nurse will label it with:
a. Correct patient's name and medical record number, b. Date and time of preparation, c. Preparer's initials."

During a tour of the NICU (Neonatal Intensive Care Unit), it was found that multiple patient's breast milk were not labeled according to policy.

At 10:12AM, room #3746, RN #5 verified that breast milk being administered was without a label.

At 10:40AM, room #3863, RN #6 verified that an empty breast milk syringe, which was attached to the baby, was without a label.

At 11:00AM, room #3831, RN#7 verified that a breast milk syringe was not labeled properly, missing date, time and preparer's initials.

Based on document reviews and interviews, the hospital failed to ensure medications were administered in accordance with the providers' orders for four (4) out of thirteen (13) patient medical records reviewed (Patients #1, #8, #11, & #12).

Findings:

The hospital's policy titled, "Administration of Medications," last approved on 05/22/2023 states in part, "...Medications will be administered only upon the order of providers..."

A review of thirteen (13) patients' medical records was conducted by the survey team on 12/15/2025 at 1:10 PM assisted by Clinical Informatics Specialist #1 and Clinical Informatics Specialist #2 which revealed the following:

-A review of Patient #1's medical record revealed the patient had an order for butalbital-acetaminophen-caffeine 50-325-40 mg tablet ordered as needed for, " ...headaches ..." The medical record revealed that on 10/23/2025 at 4:57 PM, RN #1 administered a dose of butalbital-acetaminophen-caffeine 50-325-40 mg. RN #1's documentation indicated that a pain scale of one-to-ten (1-10) was used to assess the patient's pain at the time of medication administration, however; RN #1 failed to document a pain score on the one-to-ten (1-10) scale. Clinical Informatics Specialist #1 was present for the medical record review and confirmed that no pain score was documented. Clinical Informatics Specialist #1 stated it is an expectation that a nurse would document a pain score.

-A review of Patient #8's medical record revealed the patient had an order for ibuprofen 200 mg tablet as needed for a pain score of one-to-three (1-3.) The medical record revealed that on 08/03/2025 at 6:04 AM ibuprofen 200 mg was administered by RN #2. RN #2's documentation indicated that a Pain Assessment in Advanced Dementia ("PAINAD") score was used to assess the patient's pain at the time of the ibuprofen administration. However, RN #2 failed to document a PAINAD score at this time. Clinical Informatics Specialist #1 was present for the record review and confirmed these findings.

-A review of Patient #11's medical record revealed the patient had an order for Acetaminophen 650 mg as needed for a pain score of one-to-three (1-3). The medical record revealed that on 07/12/2025 at 8:47 PM RN #3 administered 650 mg of acetaminophen to the patient but RN #3 failed to document a pain assessment with a numerical pain score for this administration. Clinical Informatics Specialist #2 was present for the record review and confirmed these findings.

-A review of Patient #12's medical record revealed the patient had an order for oxycodone 5 mg as needed for a pain score of four-to-six (4-6.) The medical record revealed that on 07/19/2025 at 4:16 PM, RN #4 documented the patient had a pain score of eight-out-of-ten (8/10) and the medical record revealed RN #4 administered 5 mg of oxycodone for the pain score of eight-out-of-ten (8/10). Clinical Informatics Specialist #2 confirmed was present for the record review and confirmed these findings.