A small, cliquish bevy of nurses was working their way through orientation in the NICU straight out of nursing school. They were happy and thrilled to be accepted into this specialized nursing unit: the NICU.

Practicing good hygiene, washing hands up to the elbows with soap each time one entered a baby’s cubicle, and gowning and gloving was a standard and mandatory protocol before touching the babies.

These were preemies in the NICU.

Molly and her friends felt privileged and honored to get this job straight out of nursing school.

It was a fast-paced NICU with levels 2-4. The higher the level, the higher the babies’ acuity. They were tiny and frail, with weak immune systems. Most were born prematurely. Others had defects, congenital anomalies, and immature lungs. Some babies had to be fed by a feeding tube. Some were on the ventilator.

This was the most sacred unit in the hospital because every nurse that came aboard knew they must always be meticulous in everything they did.

The basic cardinal rules, though, were to always wash your hands and keep your fingernails trimmed.

The new nurses were fashionable, pretty, and smart. But they refused to let a protocol like having short nails bother them. Management looked the other way when they saw the new grads parade in with their glossy, long stiletto-type nails. I guess if they just looked away, everything would be okay.

Baby Jessie was a level 2 baby in the NICU. Born prematurely, hypoglycemic, grossly underweight, and unable to feed without a feeding tube inserted through her nose into her stomach. She was frail but had big eyes and a hint of fine red hair. She was a beauty.

Her parents, washing their hands, gowning, and gloving, held their new baby close to them. Every day they’d come for a visit, hoping and praying for a progress report. Each day seemed to bring a new accomplishment.

Baby Jessie seemed to be progressing.

Then one day, her status was changing rapidly. Poor Jessie, with her rapid respirations, diarrhea, and a rash developed on her abdomen. Fever developed, lethargy, and Jessie was rapidly deteriorating. The sepsis protocol was initiated, stat labs drawn, ABGs, and an LP performed.

A code blue was called. The code team rushed in. CPR, ventilator support as baby Jessie rapidly went into asystole. Rounds of epinephrine, bicarb, but the code team couldn’t bring Jessie back.

After what seemed a lifetime, the NICU physicians pronounced her death and sadly met her devastated parents.

An autopsy was performed, and bacteria were found. E. coli. It was mandatory to report this to infection control and epidemiology. The CDC got involved. E. coli was found in Jessie’s bloodstream.

That new bevy of nurses – the fashionable ones with those long stiletto nails – the bacteria was traced back to their nails upon scraping and microscopic findings.

It was determined that two of these nurses contributed to the death of this neonatal premature NICU baby.

Beyond respecting and acknowledging the protocol on wearing short nails, of always washing your hands up to your elbows without fail each time a nurse entered a baby’s room in the NICU, because of these nurses who failed to honor this mandatory protocol, a death was pronounced of this small, innocent newborn baby.

Years of trying to finally get pregnant, yearning for that new baby, baby room decorated, crib with pink ruffles, baby showers, and happiness.

Endless tears as baby Jessie lay lifeless in her parent’s arms.

Debbie Moore-Black is a nurse who blogs at Do Not Resuscitate.