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Based on review of hospital policies and procedures, medical records, staff and physician interviews and review of EEG video, the hospital's governing body failed to
ensure a safe environment for patients by failing to prevent abuse to a suspected abuse patient admitted to the Pediatric Intensive Care Unit (PICU).

The finding include:

1. The hospital staff failed to provide a safe environment for patient care in the Pediatric Intensive Care Unit (PICU) by failing to prevent physical abuse to a suspected abuse patient admitted to the PICU.
In summary, facility staff failed to implement hospital polices to ensure a suspected abuse patient was adequately monitored, supervised and rendered care in a safe environment. As a result a 2 year old ventilator dependent patient in bilateral wrist restraints and left leg restrained with a blood pressure cuff was physically abused multiple times.

~cross refer to 482.13 Patients' Rights, Condition Tag A0115

2. The hospital's nursing staff failed to ensure a safe environment for patients by failing to prevent abuse to a 2 year old suspected abuse patient admitted to the Pediatric Intensive Care Unit (PICU).

In summary, facility staff failed to implement hospital polices to ensure a suspected abuse pateint was adequately monitored, supervised and rendered care in a safe environment. As a result a 2 year old ventilator dependent patient in bilateral wrist restraints and left leg restrained with a blood pressure cuff was physically abused multiple times.

~cross refer to 482.23 Nursing Services, Condition Tag A0385

Based on review of hospital policies and procedures, medical records, staff and physician interviews and review of EEG video, the hospital staff failed to provide a safe environment for patient care by failing to prevent abuse to a suspected abuse patient admitted to the Pediatric Intensive Care Unit (PICU).

The finding include:

1. The hospital staff failed to provide a safe environment for patient care in the Pediatric Intensive Care Unit (PICU) by failing to prevent physical abuse to a suspected abuse pediatric patient in the PICU.

In summary, facility staff failed to implement hospital polices to ensure a suspected abuse pateint was adequately monitored, supervised and rendered care in a safe environment. As a result a 2 year old ventilator dependent patient in bilateral wrist restraints and left leg restrained with a blood pressure cuff was physically abused multiple times.


~cross refer to 482.13(c)(2) Patients' Rights, Standard Tag A0144

Based on policy and procedure review, medical record review, staff and physician interviews and review of EEG video, the hospital staff failed to provide a safe environment for patient care in the Pediatric Intensive Care Unit (PICU) by failing to prevent physical abuse to a suspected abuse patient admitted to the PICU in 1 of 1 patients reviewed (#1).

The findings include:

Review of the hospital policy and procedure on 4/1/2011 "PPB-NCBH-43 Suspected Victims of Abuse and Neglect" revised 10/09 revealed "PURPOSE: To provide guidelines for the identification, notification, reporting, management, and documentation of all patients who are possible victims of abuse or neglect...PROCEDURES: Abuse or Neglect Prior to Admission A. Identification...2. Any child under the age of 18 years with a recurrent illness or serious physical injury that appears to be the result of non-accidental trauma...B. Notification 1. Any report or concern of abuse or neglect should be reported to the patient's nurse or the staff member's immediate supervisor...notify the patient's physician...The Department of Care Coordination will notify the Department of Social Services in the county where the patient resides or is found and other authorities as needed...A report to (Name of City Police) is required for any child under the age of 18 years with...or serious physical injury that appears to be the result of non-accidental trauma...Appendix I Required Reporting for Recurrent Illness or Serious Physical Injury in Children...Head Injury...Appendix II House Bill 2338...(c) In addition to the reporting requirements...cases involving...serious physical injury to any child under the age of 18 years where the illness or injury appears, in the physician's professional judgement to be the result of non-accidental trauma shall be reported by the physician as soon as it becomes practicable before, during, or after completion of treatment."

Medical record review on 4/1/2011 from Hospital B (transferring hospital) for patient #1, revealed the patient presented to Hospital B's Emergency Department on 3/26/2011 at 1512 with a chief complaint of questionable seizure. Record review revealed the patient was carried in by the mother. Record review revealed documentation by the physician "Differential Diagnosis abuse, head bleed...CT of head/brain reveals moderate sized right subdural hematoma (blood clot in the brain)of mixed densities, suspect acute on chronic, with mass effect". Record review revealed the patient was placed on a ventilator. Record review revealed the patient was transferred to Hospital A (receiving hospital) via helicopter at 1635 for a higher level of care.

Medical record review on 4/1/2011 revealed patient #1 arrived via helicopter to Emergency Department (ED) at 1719. Record review revealed patient #1 was a 2 year old child transferred from Hospital B to Hospital A. Record review revealed patient #1 had a chief complaint of seizure, subdural hematoma and ventilator dependence. Review of the ED trauma Flowsheet revealed for documentation of the mechanism of injury "Question abuse" written by nurse #1. Further review revealed "Found subdural (blood presence in the brain) via CT at xxx (name of transferring hospital) no hx (history) of injury per parents. Review revealed documentation by nurse #1 "Eccymo (bruise) R (right) forehead." ED record review revealed documentation indicating the patient had an injury/bruise near the right eye/forehead area by written notation on a picture of the human body. Review of the ED trauma consult record revealed the consult was started at 1717. Review of the consult revealed the physician documented "headbleed> acute on chronic bleeding in head." Review of the ED "Physician Clinical Report" completed by resident #1 and signed by physician #1 revealed "...seen recently by a health care provider (A head CT was obtained and showed a large intracranial bleed with shifting.)...Small facial abrasions present on the forehead. Ecchymosis in the right frontal region...Head CT with large intracranial bleed and shifting. Transferred to zzz (Hospital A, receiving hospital) for definitive treatment...significant for Ecchymosis on right forehead with small abrasion...Trauma (trauma team) to obtain CT of chest/abdomen given possibility of NAT (non-accidental trauma)...Clinical impression...acute subdural hematoma...Intracranial hemorrhage."

Medical record review revealed nursing documentation by nurse #2 at 1833 that the patient was transferred from the ED to the PICU. Review of the PICU Assessment Sheet dated 3/26/11 (no time noted) revealed "Per Mom > Pt (patient) went to PCP(primary care physician) one week ago for R(right) ear infection. PCP called DSS (Department of Social Services) and social work for old bruises noted and Bump to forehead, Mom states Dept Social Services made home visit x 1 week ago." Review of nursing documentation at 2000 revealed on admission the patient had a 1/2 inch "tiny scratch healed" on the right forehead. Further record review revealed nursing documentation at 2000 "Conflict between mother & father is evident. Individually they have stated "we don't get along we don't talk to each other." Continued documentation revealed "Mother was aggressive & angry when approached about NAT investigating Mother & her boyfriend. was vocal throughout unit "We cannot belive this, this is ***" (explicative).

Review of PICU accept note at 2207 completed by the resident and cosigned by physician #2 revealed the patient's diagnosis was cranial fracture and "Concern for non-accidental trauma...CT head demonstrated subdural hematoma...Mom reports that she has been investigated by DSS once before, regarding injuries aaa (name of patient) had sustained, and no intervention was recommended...plans:...NAT workup to include skeletal survey, ophthalmology. DSS notified."

Further review revealed documentation titled "Attestation note creation date: 26MAR2011 2207...Late entry for: 26Mar2011" by physician #3. Review of the documentation revealed physician #3 had examined patient #1 with physician #2. Review revealed physician #3 agreed with findings, exam, assessment and plans in the resident's note at 2207. Further review revealed "SDH (subdural hematoma)/skull fracture suspicious for NAT (non-accidental trauma)...Proceed with NAT workup...will call Abuse Team in the morning." Documentation revealed the plan was discussed with the Pediatric Trauma Team, parents and consultants.

Review of the history and physical exam revealed no family was currently available to confirm patient information. Review revealed review the CT scan revealed a subdural hematoma and an "old healing fracture of the superior orbital rim on the right that extends into the right frontal bone...As there is concern for nonaccidental trauma, a nonaccidental workup will be initiated."

Review of documentation by Nurse #2 revealed on 3/27/11 at 2400 the boyfriend of the mother was pacing around patient #1's room and "I went out of room, came back in room ten minutes later and white EKG lead wire was torn into." At 0100 the nurse documented the ventilator was alarming and when she went into the room a ventilator monitor was disconnected from the patient. Nurse #2 documented at 0130 the boyfriend was "pacing in pt's (patient) room. Noted to walk out of room and slowly walk up and down PICU hall, looking into other pat's room. I told pt he could not be looking into pt's rooms, if he wanted to walk around he needed to go outside the unit. Notified charge nurse with boyfriend's walking back & forth. Notified (name of physician #2) of the boyfriend walking back & forth." At 0215 nurse #2 documented when the boyfriend went outside the patient's room "I entered room, 2 of the EEG monitor leads were detached from pt's head. Pt's eyes noted to be swollen and bruised bilaterally. Dr. (name of physician #2) made aware of pt's eyes and EEG leads being off pt. Charge nurse notified." At 0400 the nurse documented Respiratory Therapy checked on the ventilator and the end tidal carbon dioxide monitor was detached. The nurse documented at 0500 the patient's neurological exam was decreased (worse) and she notified the physician. At 0600 the physician was at the patient's bedside and the patient's neurological exam was better. The nurse also documented "Pt now opens eyes to pain. Bilateral eyes noted to be increasingly swollen. Knot to r (right) forehead much larger than earlier in the night". Record review revealed nurse #2 at 0705 gave report to the oncoming nurse. While in report the EEG technician informed the "PICU team including attending Dr. (name of physician #3) aware that a man was punching and suffocating baby on the continuous video recording of the EEG monitor. Name of physician #3 and I went with the EEG tech to view video. Security notified, as well as Risk Management, (name of City) police department and unit manager."

Medical record review revealed the EEG monitoring machine was applied on the patient on 3/26/2011 at 2325. Record review revealed documentation by physician #4 of the EEG recordings. Review of the documentation revealed "A Caucasian individual wearing a brown-gray hoodie with a black baseball cap with "D" and a design on the from of the cap is noted to forcibly pinch baby's toes at 01:38:10. At 01:38:54, the same individual is noted to slap the child. At 01:39:31, he tries to close the child's airway with his hand. The____ sounds shortly thereafter and he backs off. At 01:40:02, he is noted to be pulling the IV line out. At 01:40:51, he proceeds to remove the EKG leads. At 01:40:34, he again tries to forcibly close the child's airway. He then subsequently goes to twist the child's feet at 01:40:05, hit the baby in the stomach at 01:41:13. At 02:43:50, the mother is seen at the child's bedside and is noted to acknowledge loudly the presence of a camcorder towards it. The individual is in the room with her and hears the statement. At 03:07:41, the individual is noted to be pulling the child's hair out. At 03:09:06, he is noted to be pinching the kid's toes which he repeatedly does a few times. At 03:09:17 he bends the child's legs again. At 03:10:09 he puts a finger down the throat. At 03:30:40, he is seen trying to smother the child again by pinching her nose. AT 05:29:18, he faces and looks at directly at the camera and proceeds to hit the baby repeatedly on the nose and face and hit the baby directly with his hand on the face."

Review of the neuro surgery incident note dated 3/27/11 at 0835 revealed "The pediatric team alerted me this morning regarding abuse of (Name of Patient #1) by her mother's boyfriend. Multiple bouts of assault were caught on the continuous EEG camera...During my exam, her nurse brought it to my attention that the boyfriend was acting "strange". She responded to this by remaining within eyesight of (Name of patient) bed at all times except for very short periods of time when she had to care for her other patient. She left (name of patient) bedside only when she thought the boyfriend was not on the unit. She made these changes as soon as she noticed any abnormal behavior regarding the boyfriend. We immediately discussed talking to security and keeping the boyfriend out of the room until the issue could be resolved. This never became an issue from that point forward as the video evidence was reviewed and the appropriate authorities were notified shortly thereafter."

Interview with administrative ED nursing staff on 4/1/2011 at 0950 revealed she thought the ED had a written policy if a patient presented with suspected abuse, security would be called to the bedside to ensure safety. The interview revealed if there was not a written policy it was the standard of practice in the ED to call security to the bedside for suspected abuse patients.

Interview with the medical director of the child abuse team and executive medical director of the children's hospital on 4/1/2011 at 1000 revealed the staff did not follow the hospital policy for victims of suspected abuse and neglect. The interview revealed the physician was assessing further to decide if there was nonaccidental trauma.

Interview with administrative children's hospital staff on 4/1/2011 1015 revealed the PICU was considered a safe unit because entry was by badge only. Interview revealed the physician had given the child's mother a warning on admission to the PICU regarding her language and anger. The interview revealed parents are allowed to stay with children in the PICU.

Interview with nurse #1 on 4/1/2011 at 1050 revealed she was assigned the care of patient #1 on admission to the ED. The interview revealed she documented "question abuse" in the ED record because the ED physician (physician #1) had recommended to document this because of the presenting injury. The interview revealed any time a patient presents with a closed head injury with bleeding and shift, possible abuse is a concern. The interview revealed the standard of practice in the ED for the types of injuries and possible abuse, is to call security to the bedside. The interview revealed patient #1 did not have any family with her so she told security they were not needed and if any one showed up she would let them know. The interview revealed she did not know how security knew patient #1 was a suspected abuse.

Telephone interview with security officer #1 on 4/1/2011 at 1145 revealed he was at the helipad to assist with the transport of Patient #1 to the ED. The interview revealed he understood in conversation during the transport patient #1 was a suspected domestic abuse. The interview revealed he asked the ED nursing staff if security was needed at bedside due to suspected abuse. The interview revealed any time there is suspected abuse security is to stay at the patient's bedside to keep the patient safe from an abuser.

Telephone interview with ED physician (physician #1) on 4/1/2011 at 1210 revealed he was the ED attending physician for patient #1. The interview revealed he discussed with the ED physician at Hospital B (transferring hospital) if there were concerns with suspected abuse. The interview revealed he was notified of the CT results of blood in the head prior to the patient leaving Hospital B. The interview revealed with a 2 year old having a head injury with bleeding and unknown cause suspected abuse would "definitely" be a concern. The interview revealed he thought the trauma team and the neuro surgery team "all were working under assumption of abuse." The interview revealed he told the ED charge nurse to not let any family in because of suspected abuse. The interview revealed physician #1 was "surprised" the PICU staff did not pick up on suspected abuse. The interview revealed on 3/26/2011 his shift ended at 1800 and he reported off to the incoming physician. The interview revealed if he had stayed longer he would have called the social worker.

Interview on 4/1/2011 at 1505 with the EEG technician revealed "I came in at 0600 began review of all patients. I got to (Pt #1) started seeing questionable artifact high amplitude artifact. I knew it was not the ventilator or IV machine. Curious what was causing. I hit play and I saw it . He was flicking head and face and hit her so hard it moved her and the ventilator. He moved patient and tubing to center of bed alarms go off and nurse came in. I annotated all of it on video. He would do something else every time they (staff) left the room." Further interview revealed " I told (name of epilepsy team nurse) to call security to room 616 and meet me there. I went straight up and requested nurse for (name of patient #1). I told nurse man in room is abusing her. Nurse said "I knew it. I suspected it all night"."

Interview with the EEG technician and administrative staff on 4/1/2011 at 1600 revealed the male with the cap on observed in the video is the "mother's boyfriend". Review on 4/1/2011 at 1600 of the EEG video with audio for 3/27/2011 for patient #1 revealed the following at the respective times:

0139 Boyfriend forcibly slaps child in head;
0140 Boyfriend pulls EKG lead off;
0142 Nurse puts new lead on patient;
0244 Mother telling boyfriend there is camera and mother points directly into camera view;
0307 Boyfriend pulled out child's hair;
0308 Nurse telling boyfriend to stop trying to arouse child and she is going into the next room.
0309 Boyfriend forcibly slapping child's toes and twisting toes;
0310 Boyfriend putting his fingers down child's throat;
0310 Boyfriend thumping forcibly the child' head and eyes;
0311 Boyfriend forcibly slapping and thumping child's head and upper body;
0325 Boyfriend pinching child's nose, stops and Respiratory Therapy coming to the bedside;
0330 Boyfriend pinching nose;
0331 Boyfriend forcibly slapping and pinching child;
0523 Boyfriend pinching, pressing forcibly downward with hands onto child's chest and slapping child;
0529 Boyfriend forcibly slapping and thumping the child in head.
Review of the video revealed a 2 minute plus timeframe in which alarms were heard and there was no response by staff.

Telephone interview on 4/4/2011 at 1110 with nurse #3 revealed the nurse was the charge nurse for the shift from 1900 through 0700 in the PICU on 3/26-27/2011. The interview revealed the nurses in the PICU generally have 2 patients per one nurse unless the patient is a high acuity level requiring one nurse to one patient. The interview revealed nurse #2 was assigned to patient #1 and another patient. The interview revealed nurse #2 had informed her of things being altered in the room and the ventilator alarming. The interview revealed she told nurse #1 at approximately 0300 to stay close by the room or stay with in the cubicle outside of the room. The interview revealed she had concerns with the Boyfriend walking around in the unit and she reminded him to stay in the patient room. The interview revealed she had noticed that the Boyfriend was using different doors when he exited the unit. The interview revealed when she went into patient #1's room she noticed the EEG lead was off the patient's head. The interview revealed she questioned how the lead had come off the patient. Nurse #2 did not know how the lead came off and the mother had her head hanging down stating she had a "migraine". The interview revealed she suspected abuse because the mother and boyfriend's explanations of injury did not match with a closed head injury without a cause. The interview revealed nurse #2 voiced concerns about the ventilator tubing disconnected and leads off. The interview revealed she told nurse #2 to stay at the cubicle unless she was in the other patient's room and she would cover for her if needed. The interview revealed she did not remember hearing sounds coming from patient #1's room. The interview revealed when DSS is involved with a patient due to abuse, DSS decides visitation restrictions. The interview revealed in the past nursing staff had been told to be careful about identifying an abuser. The interview revealed without seeing the Boyfriend do something she could not restrict him from the room.

Telephone interview on 4/4/2011 at 1320 with nurse #2 revealed she was assigned to provide care for patient #1 and one other patient on 3/26-27/2011 from 1900 until 0700. The interview revealed when she arrived on the unit around 1830 the patient had not arrived. The interview revealed she was told her admission was a transfer from an outside hospital with a questionable skull fracture and blood in the brain. The interview revealed upon admission she noted patient #1 had "tiny scratch with a knot under the scratch" (forehead). The interview revealed the knot kept getting bigger through the shift. The interview revealed the ED nurse that accompanied the patient to the unit told her the nature of the injury and the patient would have to be worked up for nonaccidental trauma (NAT). The interview revealed physician #2 and #3 talked with the mother and Boyfriend about the work up for NAT and the mother "stormed in the room" angry and yelling at the maternal grandmother. The interview revealed the mother told the grandmother they were going to "blame her again." The interview revealed she asked the mother to leave the room because of over stimulation for the patient. The interview revealed the Boyfriend took the mother out of the room to "calm her down" for approximately 45 minutes. The interview revealed during the initial assessment she was told a couple of weeks prior to this admission the patient fell down hitting her head on an edge of a building. The interview revealed the grandmother told her"yes this happened at my house". The interview revealed about one week after the fall the patient was taken to her Primary Care Physician (PCP) The interview revealed the PCP sent DSS to the home for concerns of abuse. The interview revealed she alerted the charge nurse (nurse #3) about her concerns with the leads off, CO2 monitor off the ventilator, the Boyfriend stepping in and out of the room. The interview revealed she told the charge nurse "3" different times she did not "trust him(boyfriend), I had a sick feeling". The interview revealed she was told the charge nurse she thought the Boyfriend had "blood shot eyes". The interview revealed the charge nurse told her two previous families in which nursing staff had pointed a finger the" nurses got in trouble" and she could not point a finger at him without him doing something. The interview revealed she told the charge nurse and physician about her concerns with the Boyfriend. The interview revealed she talked with physician #3 about her feelings regarding the Boyfriend near the end of shift. The interview revealed she "wanted the Boyfriend thrown out". The interview revealed she was told to watch the patient closely.

Telephone with physician #3 on 4/4/2011 at 1400 revealed he did not notify DSS as documented in the medical record. The interview revealed physician #2 documented he notified DSS and he would check with him. The interview revealed he did not alert DSS because he thought the mother, grandmother's and Boyfriend's story was plausible. The interview revealed "I did not raise alarm because of doubt." The interview revealed "we believed the PICU was a safe place, now we know". Physician #3 returned call after talking with physician #2 to validate the notification of DSS. The interview revealed physician #2 did not notify DSS. The interview revealed physician #2 "assumed" DSS was already involved due to the visit that was made weeks before this admission. The interview revealed no one had contacted DSS prior to the EEG video review on 3/27/2011.

In summary, facility staff failed to implement hospital polices to ensure a suspected abuse patient was adequately monitored, supervised and rendered care in a safe environment. As a result a 2 year old ventilator dependent patient in bilateral wrist restraints and left leg restrained with a blood pressure cuff was physically abused multiple times.

Based on review of hospital policies and procedures, medical records, staff and physician interviews and review of EEG video, the hospital's nursing staff failed to ensure a safe environment for patients by failing to prevent abuse to a suspected abuse patient admitted to the Pediatric Intensive Care Unit (PICU).

The finding include:

1. The hospital's nursing staff failed to provide a safe environment for patient care in the Pediatric Intensive Care Unit (PICU) by failing to prevent physical abuse to a 2 year old suspected abuse patient admitted to the PICU.

In summary, facility staff failed to implement hospital polices to ensure a suspected abuse pateint was adequately monitored, supervised and rendered care in a safe environment. As a result a 2 year old ventilator dependent patient in bilateral wrist restraints and left leg restrained with a blood pressure cuff was physically abused multiple times.


~cross refer to 482.23(b)(3) Nursing Services, Standard Tag A0395

Based on policy and procedure review, medical record review, staff and physician interviews and review of EEG video the hospital's nursing staff failed to provide a safe environment for patient care in the Pediatric Intensive Care Unit (PICU) by failing to prevent physical abuse to a 2 year old suspected abuse patient admitted to the PICU in 1 of 1 patients reviewed (#1).

The Findings include:

Review of the hospital policy and procedure on 4/1/2011 "PPB-NCBH-43 Suspected Victims of Abuse and Neglect" revised 10/09 revealed "PURPOSE: To provide guidelines for the identification, notification, reporting, management, and documentation of all patients who are possible victims of abuse or neglect...PROCEDURES: Abuse or Neglect Prior to Admission A. Identification...2. Any child under the age of 18 years with a recurrent illness or serious physical injury that appears to be the result of non-accidental trauma...B. Notification 1. Any report or concern of abuse or neglect should be reported to the patient's nurse or the staff member's immediate supervisor...notify the patient's physician...The Department of Care Coordination will notify the Department of Social Services in the county where the patient resides or is found and other authorities as needed...A report to (Name of City Police) is required for any child under the age of 18 years with...or serious physical injury that appears to be the result of non-accidental trauma...Appendix I Required Reporting for Recurrent Illness or Serious Physical Injury in Children...Head Injury...Appendix II House Bill 2338...(c) In addition to the reporting requirements...cases involving...serious physical injury to any child under the age of 18 years where the illness or injury appears, in the physician's professional judgement to be the result of non-accidental trauma shall be reported by the physician as soon as it becomes practicable before, during, or after completion of treatment."

Medical record review on 4/1/2011 from Hospital B (transferring hospital) for patient #1, revealed the patient presented to Hospital B's Emergency Department on 3/26/2011 at 1512 with a chief complaint of questionable seizure. Record review revealed the patient was carried in by the mother. Record review revealed documentation by the physician "Differential Diagnosis abuse, head bleed...CT of head/brain reveals moderate sized right subdural hematoma (blood clot in the brain)of mixed densities, suspect acute on chronic, with mass effect". Record review revealed the patient was placed on a ventilator. Record review revealed the patient was transferred to Hospital A (receiving hospital) via helicopter at 1635 for a higher level of care.

Medical record review on 4/1/2011 revealed patient #1 arrived via helicopter to Emergency Department (ED) at 1719. Record review revealed patient #1 was a 2 year old child transferred from Hospital B to Hospital A. Record review revealed patient #1 had a chief complaint of seizure, subdural hematoma and ventilator dependence. Review of the ED trauma Flowsheet revealed for documentation of the mechanism of injury "Question abuse" written by nurse #1. Further review revealed "Found subdural (blood presence in the brain) via CT at xxx (name of transferring hospital) no hx (history) of injury per parents. Review revealed documentation by nurse #1 "Eccymo (bruise) R (right) forehead." ED record review revealed documentation indicating the patient had an injury/bruise near the right eye/forehead area by written notation on a picture of the human body. Review of the ED trauma consult record revealed the consult was started at 1717. Review of the consult revealed the physician documented "headbleed> acute on chronic bleeding in head." Review of the ED "Physician Clinical Report" completed by resident #1 and signed by physician #1 revealed "...seen recently by a health care provider (A head CT was obtained and showed a large intracranial bleed with shifting.)...Small facial abrasions present on the forehead. Ecchymosis in the right frontal region...Head CT with large intracranial bleed and shifting. Transferred to zzz (Hospital A, receiving hospital) for definitive treatment...significant for Ecchymosis on right forehead with small abrasion...Trauma (trauma team) to obtain CT of chest/abdomen given possibility of NAT (non-accidental trauma)...Clinical impression...acute subdural hematoma...Intracranial hemorrhage."

Medical record review revealed nursing documentation by nurse #2 at 1833 that the patient was transferred from the ED to the PICU. Review of the PICU Assessment Sheet dated 3/26/11 (no time noted) revealed "Per Mom > Pt (patient) went to PCP(primary care physician) one week ago for R(right) ear infection. PCP called DSS (Department of Social Services) and social work for old bruises noted and Bump to forehead, Mom states Dept Social Services made home visit x 1 week ago." Review of nursing documentation at 2000 revealed on admission the patient had a 1/2 inch "tiny scratch healed" on the right forehead. Further record review revealed nursing documentation at 2000 "Conflict between mother & father is evident. Individually they have stated "we don't get along we don't talk to each other." Continued documentation revealed "Mother was aggressive & angry when approached about NAT investigating Mother & her boyfriend. was vocal throughout unit "We cannot belive this, this is ***" (explicative).

Review of PICU accept note at 2207 completed by the resident and cosigned by physician #2 revealed the patient's diagnosis was cranial fracture and "Concern for non-accidental trauma...CT head demonstrated subdural hematoma...Mom reports that she has been investigated by DSS once before, regarding injuries aaa (name of patient) had sustained, and no intervention was recommended...plans:...NAT workup to include skeletal survey, ophthalmology. DSS notified."

Further review revealed documentation titled "Attestation note creation date: 26MAR2011 2207...Late entry for: 26Mar2011" by physician #3. Review of the documentation revealed physician #3 had examined patient #1 with physician #2. Review revealed physician #3 agreed with findings, exam, assessment and plans in the resident's note at 2207. Further review revealed "SDH (subdural hematoma)/skull fracture suspicious for NAT (non-accidental trauma)...Proceed with NAT workup...will call Abuse Team in the morning." Documentation revealed the plan was discussed with the Pediatric Trauma Team, parents and consultants.

Review of the history and physical exam revealed no family was currently available to confirm patient information. Review revealed review the CT scan revealed a subdural hematoma and an "old healing fracture of the superior orbital rim on the right that extends into the right frontal bone...As there is concern for nonaccidental trauma, a nonaccidental workup will be initiated."

Review of documentation by Nurse #2 revealed on 3/27/11 at 2400 the boyfriend of the mother was pacing around patient #1's room and "I went out of room, came back in room ten minutes later and white EKG lead wire was torn into." At 0100 the nurse documented the ventilator was alarming and when she went into the room a ventilator monitor was disconnected from the patient. Nurse #2 documented at 0130 the boyfriend was "pacing in pt's (patient) room. Noted to walk out of room and slowly walk up and down PICU hall, looking into other pat's room. I told pt he could not be looking into pt's rooms, if he wanted to walk around he needed to go outside the unit. Notified charge nurse with boyfriend's walking back & forth. Notified (name of physician #2) of the boyfriend walking back & forth." At 0215 nurse #2 documented when the boyfriend went outside the patient's room "I entered room, 2 of the EEG monitor leads were detached from pt's head. Pt's eyes noted to be swollen and bruised bilaterally. Dr. (name of physician #2) made aware of pt's eyes and EEG leads being off pt. Charge nurse notified." At 0400 the nurse documented Respiratory Therapy checked on the ventilator and the end tidal carbon dioxide monitor was detached. The nurse documented at 0500 the patient's neurological exam was decreased (worse) and she notified the physician. At 0600 the physician was at the patient's bedside and the patient's neurological exam was better. The nurse also documented "Pt now opens eyes to pain. Bilateral eyes noted to be increasingly swollen. Knot to r (right) forehead much larger than earlier in the night". Record review revealed nurse #2 at 0705 gave report to the oncoming nurse. While in report the EEG technician informed the "PICU team including attending Dr. (name of physician #3) aware that a man was punching and suffocating baby on the continuous video recording of the EEG monitor. Name of physician #3 and I went with the EEG tech to view video. Security notified, as well as Risk Management, (name of City) police department and unit manager."

Medical record review revealed the EEG monitoring machine was applied on the patient on 3/26/2011 at 2325. Record review revealed documentation by physician #4 of the EEG recordings. Review of the documentation revealed "A Caucasian individual wearing a brown-gray hoodie with a black baseball cap with "D" and a design on the from of the cap is noted to forcibly pinch baby's toes at 01:38:10. At 01:38:54, the same individual is noted to slap the child. At 01:39:31, he tries to close the child's airway with his hand. The____ sounds shortly thereafter and he backs off. At 01:40:02, he is noted to be pulling the IV line out. At 01:40:51, he proceeds to remove the EKG leads. At 01:40:34, he again tries to forcibly close the child's airway. He then subsequently goes to twist the child's feet at 01:40:05, hit the baby in the stomach at 01:41:13. At 02:43:50, the mother is seen at the child's bedside and is noted to acknowledge loudly the presence of a camcorder towards it. The individual is in the room with her and hears the statement. At 03:07:41, the individual is noted to be pulling the child's hair out. At 03:09:06, he is noted to be pinching the kid's toes which he repeatedly does a few times. At 03:09:17 he bends the child's legs again. At 03:10:09 he puts a finger down the throat. At 03:30:40, he is seen trying to smother the child again by pinching her nose. AT 05:29:18, he faces and looks at directly at the camera and proceeds to hit the baby repeatedly on the nose and face and hit the baby directly with his hand on the face."

Review of the neuro surgery incident note dated 3/27/11 at 0835 revealed "The pediatric team alerted me this morning regarding abuse of (Name of Patient #1) by her mother's boyfriend. Multiple bouts of assault were caught on the continuous EEG camera...During my exam, her nurse brought it to my attention that the boyfriend was acting "strange". She responded to this by remaining within eyesight of (Name of patient) bed at all times except for very short periods of time when she had to care for her other patient. She left (name of patient) bedside only when she thought the boyfriend was not on the unit. She made these changes as soon as she noticed any abnormal behavior regarding the boyfriend. We immediately discussed talking to security and keeping the boyfriend out of the room until the issue could be resolved. This never became an issue from that point forward as the video evidence was reviewed and the appropriate authorities were notified shortly thereafter."

Interview with administrative ED nursing staff on 4/1/2011 at 0950 revealed she thought the ED had a written policy if a patient presented with suspected abuse, security would be called to the bedside to ensure safety. The interview revealed if there was not a written policy it was the standard of practice in the ED to call security to the bedside for suspected abuse patients.

Interview with the medical director of the child abuse team and executive medical director of the children's hospital on 4/1/2011 at 1000 revealed the staff did not follow the hospital policy for victims of suspected abuse and neglect. The interview revealed the physician was assessing further to decide if there was nonaccidental trauma.

Interview with administrative children's hospital staff on 4/1/2011 1015 revealed the PICU was considered a safe unit because entry was by badge only. Interview revealed the physician had given the child's mother a warning on admission to the PICU regarding her language and anger. The interview revealed parents are allowed to stay with children in the PICU.

Interview with nurse #1 on 4/1/2011 at 1050 revealed she was assigned the care of patient #1 on admission to the ED. The interview revealed she documented "question abuse" in the ED record because the ED physician (physician #1) had recommended to document this because of the presenting injury. The interview revealed any time a patient presents with a closed head injury with bleeding and shift, possible abuse is a concern. The interview revealed the standard of practice in the ED for the types of injuries and possible abuse, is to call security to the bedside. The interview revealed patient #1 did not have any family with her so she told security they were not needed and if any one showed up she would let them know. The interview revealed she did not know how security knew patient #1 was a suspected abuse.

Telephone interview with security officer #1 on 4/1/2011 at 1145 revealed he was at the helipad to assist with the transport of Patient #1 to the ED. The interview revealed he understood in conversation during the transport patient #1 was a suspected domestic abuse. The interview revealed he asked the ED nursing staff if security was needed at bedside due to suspected abuse. The interview revealed any time there is suspected abuse security is to stay at the patient's bedside to keep the patient safe from an abuser.

Telephone interview with ED physician (physician #1) on 4/1/2011 at 1210 revealed he was the ED attending physician for patient #1. The interview revealed he discussed with the ED physician at Hospital B (transferring hospital) if there were concerns with suspected abuse. The interview revealed he was notified of the CT results of blood in the head prior to the patient leaving Hospital B. The interview revealed with a 2 year old having a head injury with bleeding and unknown cause suspected abuse would "definitely" be a concern. The interview revealed he thought the trauma team and the neuro surgery team "all were working under assumption of abuse." The interview revealed he told the ED charge nurse to not let any family in because of suspected abuse. The interview revealed physician #1 was "surprised" the PICU staff did not pick up on suspected abuse. The interview revealed on 3/26/2011 his shift ended at 1800 and he reported off to the incoming physician. The interview revealed if he had stayed longer he would have called the social worker.

Interview on 4/1/2011 at 1505 with the EEG technician revealed "I came in at 0600 began review of all patients. I got to (Pt #1) started seeing questionable artifact high amplitude artifact. I knew it was not the ventilator or IV machine. Curious what was causing. I hit play and I saw it . He was flicking head and face and hit her so hard it moved her and the ventilator. He moved patient and tubing to center of bed alarms go off and nurse came in. I annotated all of it on video. He would do something else every time they (staff) left the room." Further interview revealed " I told (name of epilepsy team nurse) to call security to room 616 and meet me there. I went straight up and requested nurse for (name of patient #1). I told nurse man in room is abusing her. Nurse said "I knew it. I suspected it all night"."

Interview with the EEG technician and administrative staff on 4/1/2011 at 1600 revealed the male with the cap on observed in the video is the "mother's boyfriend". Review on 4/1/2011 at 1600 of the EEG video with audio for 3/27/2011 for patient #1 revealed the following at the respective times:

0139 Boyfriend forcibly slaps child in head;
0140 Boyfriend pulls EKG lead off;
0142 Nurse puts new lead on patient;
0244 Mother telling boyfriend there is camera and mother points directly into camera view;
0307 Boyfriend pulled out child's hair;
0308 Nurse telling boyfriend to stop trying to arouse child and she is going into the next room.
0309 Boyfriend forcibly slapping child's toes and twisting toes;
0310 Boyfriend putting his fingers down child's throat;
0310 Boyfriend thumping forcibly the child' head and eyes;
0311 Boyfriend forcibly slapping and thumping child's head and upper body;
0325 Boyfriend pinching child's nose, stops and Respiratory Therapy coming to the bedside;
0330 Boyfriend pinching nose;
0331 Boyfriend forcibly slapping and pinching child;
0523 Boyfriend pinching, pressing forcibly downward with hands onto child's chest and slapping child;
0529 Boyfriend forcibly slapping and thumping the child in head.
Review of the video revealed a 2 minute plus timeframe in which alarms were heard and there was no response by staff.

Telephone interview on 4/4/2011 at 1110 with nurse #3 revealed the nurse was the charge nurse for the shift from 1900 through 0700 in the PICU on 3/26-27/2011. The interview revealed the nurses in the PICU generally have 2 patients per one nurse unless the patient is a high acuity level requiring one nurse to one patient. The interview revealed nurse #2 was assigned to patient #1 and another patient. The interview revealed nurse #2 had informed her of things being altered in the room and the ventilator alarming. The interview revealed she told nurse #1 at approximately 0300 to stay close by the room or stay with in the cubicle outside of the room. The interview revealed she had concerns with the Boyfriend walking around in the unit and she reminded him to stay in the patient room. The interview revealed she had noticed that the Boyfriend was using different doors when he exited the unit. The interview revealed when she went into patient #1's room she noticed the EEG lead was off the patient's head. The interview revealed she questioned how the lead had come off the patient. Nurse #2 did not know how the lead came off and the mother had her head hanging down stating she had a "migraine". The interview revealed she suspected abuse because the mother and boyfriend's explanations of injury did not match with a closed head injury without a cause. The interview revealed nurse #2 voiced concerns about the ventilator tubing disconnected and leads off. The interview revealed she told nurse #2 to stay at the cubicle unless she was in the other patient's room and she would cover for her if needed. The interview revealed she did not remember hearing sounds coming from patient #1's room. The interview revealed when DSS is involved with a patient due to abuse, DSS decides visitation restrictions. The interview revealed in the past nursing staff had been told to be careful about identifying an abuser. The interview revealed without seeing the Boyfriend do something she could not restrict him from the room.

Telephone interview on 4/4/2011 at 1320 with nurse #2 revealed she was assigned to provide care for patient #1 and one other patient on 3/26-27/2011 from 1900 until 0700. The interview revealed when she arrived on the unit around 1830 the patient had not arrived. The interview revealed she was told her admission was a transfer from an outside hospital with a questionable skull fracture and blood in the brain. The interview revealed upon admission she noted patient #1 had "tiny scratch with a knot under the scratch" (forehead). The interview revealed the knot kept getting bigger through the shift. The interview revealed the ED nurse that accompanied the patient to the unit told her the nature of the injury and the patient would have to be worked up for nonaccidental trauma (NAT). The interview revealed physician #2 and #3 talked with the mother and Boyfriend about the work up for NAT and the mother "stormed in the room" angry and yelling at the maternal grandmother. The interview revealed the mother told the grandmother they were going to "blame her again." The interview revealed she asked the mother to leave the room because of over stimulation for the patient. The interview revealed the Boyfriend took the mother out of the room to "calm her down" for approximately 45 minutes. The interview revealed during the initial assessment she was told a couple of weeks prior to this admission the patient fell down hitting her head on an edge of a building. The interview revealed the grandmother told her"yes this happened at my house". The interview revealed about one week after the fall the patient was taken to her Primary Care Physician (PCP) The interview revealed the PCP sent DSS to the home for concerns of abuse. The interview revealed she alerted the charge nurse (nurse #3) about her concerns with the leads off, CO2 monitor off the ventilator, the Boyfriend stepping in and out of the room. The interview revealed she told the charge nurse "3" different times she did not "trust him(boyfriend), I had a sick feeling". The interview revealed she was told the charge nurse she thought the Boyfriend had "blood shot eyes". The interview revealed the charge nurse told her two previous families in which nursing staff had pointed a finger the" nurses got in trouble" and she could not point a finger at him without him doing something. The interview revealed she told the charge nurse and physician about her concerns with the Boyfriend. The interview revealed she talked with physician #3 about her feelings regarding the Boyfriend near the end of shift. The interview revealed she "wanted the Boyfriend thrown out". The interview revealed she was told to watch the patient closely.

Telephone with physician #3 on 4/4/2011 at 1400 revealed he did not notify DSS as documented in the medical record. The interview revealed physician #2 documented he notified DSS and he would check with him. The interview revealed he did not alert DSS because he thought the mother, grandmother's and Boyfriend's story was plausible. The interview revealed "I did not raise alarm because of doubt." The interview revealed "we believed the PICU was a safe place, now we know". Physician #3 returned call after talking with physician #2 to validate the notification of DSS. The interview revealed physician #2 did not notify DSS. The interview revealed physician #2 "assumed" DSS was already involved due to the visit that was made weeks before this admission. The interview revealed no one had contacted DSS prior to the EEG video review on 3/27/2011.

In summary, facility staff failed to implement hospital polices to ensure a suspected abuse patient was adequately monitored, supervised and rendered care in a safe environment. As a result a 2 year old ventilator dependent patient in bilateral wrist restraints and left leg restrained with a blood pressure cuff was physically abused multiple times.

NC00071490