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Based on interview, record review, and a review of the facility policies, it was determined the Governing Body failed to ensure that the facility Chief Executive Officer (CEO) effectively managed the facility related to promoting patient rights, preventing and protecting patients from abuse, and failed to ensure care was provided in a safe setting. Patient #2 gave birth to Patient #1 in the facility's Labor and Delivery Unit on 04/21/16. Patient #2 was observed upon admission to have "track marks" (evidence of intravenous drug use), and her Urine Drug Screen was positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug). The facility Social Worker (SW) evaluated Patient #2 on 04/21/16 and the patient informed the SW that she had lost custody of her other children. The SW failed to collaborate with the Department for Community Based Services (DCBS) to determine if Patient #2 had a history of abusing children in her custody, and failed to inform DCBS of the observed signs of intravenous drug use. Patient #1 was left in the room with Patient #2 and her significant other on 04/24/16 for approximately two (2) to three (3) hours. Staff failed to assess Patient #1's condition every hour as required by facility policy and at approximately 6:00 AM on 04/24/16 Patient #2 returned Patient #1 to the Nursery with abnormalities observed to Patient #1's head. Staff observed a "bulging suture line" on the right side of Patient #1's head, but failed to notify the patient's physician for three (3) hours. Patient #1 was diagnosed with an epidural hematoma and a mildly depressed skull fracture on 04/24/16 at 10:30 AM.

On 04/24/16, orders were received to transfer Patient #1 to another facility for further care/treatment. Staff was unsure how Patient #1's skull fracture occurred; however, staff permitted Patient #1 to go back into the room with Patient #2, unsupervised, for approximately one (1) hour prior to being transferred to another facility.

The DCBS worker stated staff informed her on 04/24/16, after the skull fracture occurred, that Patient #2 had "looked high" at times and that Patient #2's significant other had "looked drunk and the hospital room had smelled of alcohol" during their stay at the facility. Staff failed to inform DCBS of Patient #2's observed signs of intravenous drug use and that Patient #2 and her significant other had appeared impaired during the hospital stay. The DCBS worker stated that information would have changed the way the referral was addressed by the local DCBS office, and that supervised visits may have been initiated during the patient's hospital stay.

Interview with the Chief Executive Officer (CEO) of the facility on 05/10/16 at 2:00 PM revealed he was responsible for "everything" that occurred in the facility. The CEO further stated the governing board of the facility had met (date and time of the meeting unknown) and discussed that a high percentage of the babies delivered in the facility were born to drug addicted mothers and had discussed community services that could potentially be beneficial. However, the governing board and CEO took no action to ensure facility policies and procedures were reviewed/revised/developed to ensure the safety of the infants born to drug addicted mothers. (Refer to A0057.)

The Governing Body's failure to ensure the CEO effectively managed the facility placed patients at risk for serious injury, harm, impairment, or death. It was determined Immediate Jeopardy existed on 04/21/16 and is ongoing.

Based on interview, record review, and a review of the facility policies, it was determined the Chief Executive Officer failed to ensure patients received quality care in a safe environment and were free from abuse for one (1) of ten (10) sampled patients (Patient #1). Review of Patient #2's medical record revealed she gave birth to Patient #1 in the facility's Labor and Delivery Unit on 04/21/16. Patient #2 was observed upon admission to have "track marks" (evidence of intravenous drug use), and her Urine Drug Screen was positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug); therefore, the facility Social Worker (SW) was consulted. The SW saw Patient #2 on 04/21/16 and Patient #2 informed the SW that she had lost custody of her other children. The SW failed to collaborate with the local Department for Community Based Services (DCBS) to determine why Patient #2 had lost custody of her children, and failed to inform DCBS of the observed signs of intravenous drug use. On 04/24/16, Registered Nurse (RN) #1 allowed Patient #1 to be left in the room with Patient #2 and her significant other for approximately two (2) to three (3) hours, and the RN failed to assess Patient #1 every hour as required. At approximately 6:00 AM on 04/24/16, Patient #2 returned Patient #1 to the Nursery, and a "bulging suture line" was observed on the right side of Patient #1's head. Patient #1's physician was not notified of the abnormality for three (3) hours. Patient #1 was diagnosed with an epidural hematoma and a mildly depressed skull fracture on 04/24/16 at 10:30 AM.

The DCBS worker stated Physician #1 informed her on 04/24/16, after the skull fracture occurred, that Patient #2 had "looked high" at times, during her hospital stay. The DCBS worker also stated that Licensed Practical Nurse (LPN) #1 informed her on 04/24/16, after the skull fracture occurred, that Patient #2's significant other had "looked drunk and the hospital room had smelled of alcohol" during their stay at the facility. She stated staff should have informed DCBS of Patient #2's observed signs of intravenous drug use and that Patient #2 and her significant other had appeared impaired during the hospital stay. The DCBS worker stated that information would have changed the way the referral was addressed by the local DCBS office, and that supervised visits may have been initiated during the patient's hospital stay.

On 04/24/16, staff received orders to transfer Patient #1 to another facility for further care/treatment. Even though staff was unsure how Patient #1's skull fracture occurred, staff permitted Patient #1 to go back into the room with Patient #2, unsupervised, for approximately one (1) hour prior to being transferred to another facility.

(Refer to A0115, A0144, and A0145.)

The findings include:

Review of the job description for the Chief Executive Officer (CEO), not dated, revealed he/she was responsible for ensuring the facility maintained compliance with federal, state, and local codes and regulations, as they apply to the hospital setting.

Interview with the CEO on 05/10/16 at 2:00 PM revealed the facility had a "governing board," but did not have a policy related to the functions of the governing board. He also acknowledged that the facility had not developed any policies to ensure the safety of patients through collaboration with the Department for Community Based Services (DCBS), related to infants born in the facility to drug addicted mothers.

Review of the facility policy titled Abuse, Neglect, Prevention and Investigation, last revised January 2014, revealed patients would be free from abuse, neglect, and mistreatment. The policy stated staff was to deny unsupervised access to the patient, of which abuse is suspected, pending an investigation.

Review of the facility policy titled "Hourly Rounding for a Purpose," last revised January 2014, revealed nursing personnel were required to conduct rounds on facility patients every hour.
Review of Patient #2's medical record revealed the facility admitted the patient on 04/21/16 to the facility's Labor and Delivery Unit. Patient #2's record revealed, at the time of admission, that "track marks" (evidence of intravenous drug use) were observed on her arms, legs, feet, hands, abdomen, and chest. Patient #2 also tested positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug) on a Urine Drug Screen, conducted at the time the patient was admitted, and the facility SW was consulted.

Review of Patient #2's Social Services Progress note dated 04/21/16 at 2:05 PM revealed a report was made to the Department of Protection and Permanency (DPP) related to the patient's positive drug screen and that a confirmation had been made that the patient had a valid prescription for Subutex. The SW's documentation provided no evidence that she had collaborated with DCBS, related to Patient #2's loss of custody of her previous children, to ensure the patient did not have a history of abuse/neglect of children previously in her care. No evidence was provided in the patient's record that DCBS was notified that Patient #2 had signs of intravenous drug use.

Interview with SW #1 on 05/03/16 at 2:05 PM revealed Patient #2 had informed her that she had a closed case with DCBS, and had lost custody of her other two (2) children and a boyfriend was arrested at that time. SW #1 stated she made a referral to DCBS and informed them that Patient #2 had delivered a baby at their facility, and that she had a valid prescription for, and had tested positive for, Subutex. SW #1 had not informed DCBS that Patient #2 had "track marks" observed by staff, and had not requested any information related to Patient #2's previous case with DCBS, to ensure she had no history of abuse/neglect of children in her care.

Interview with Registered Nurse (RN) #1 on 05/06/16 at 8:00 PM revealed she was assigned to care for Patient #1 from 7:00 PM on 4/23/16 until 7:00 AM on 04/24/16. She stated Patient #2 had taken Patient #1 to her room at approximately 3:00 AM on 04/24/16, and the RN stated she had not evaluated Patient #1 every hour as required by the facility policy. The RN stated a head/toe assessment of Patient #1 was conducted at the beginning of her shift and no abnormalities were identified. Patient #2 had returned Patient #1 to the Nursery at approximately 6:00 AM and "pointed to" an area on Patient #1's head and said "is that ok." RN #1 stated she noticed the area "first thing and said what's wrong with" his/her "head." The RN stated because there was not any "obvious injury" to Patient #1's head, she passed the change in condition on to the next shift and did not contact Patient #1's physician.

Interview with LPN #1 on 05/04/16 at 1:20 PM revealed she had observed a "raised knot" across the front and the back of Patient #1's head at approximately 7:00 AM on 04/24/16. The LPN acknowledged she "knew it wasn't normal" for the patient's head to have the observed abnormality; however, she failed to contact the physician until 9:00 AM, two (2) hours after she had identified the abnormality. The LPN stated after the patient's epidural hematoma and depressed skull fracture had been identified, she permitted an unsupervised visit with Patient #2, even though she was not sure how the injury had occurred to Patient #1. LPN #1 stated she was unsure what the facility's abuse policy directed staff to do with allegations or suspicions of abuse/neglect, and stated, "I guess we didn't protect" the patient, by allowing an unsupervised visit after an injury had been observed and an investigation was ongoing. LPN #1 stated that Physician #1 and the DCBS social worker had given her permission to allow the unsupervised visit to occur. LPN #1 denied observing Patient #2 or her significant other under the influence of drugs or alcohol during their hospital stay.

Interview with Physician #1 on 05/04/16 at 2:00 PM revealed she expected staff to notify her immediately when a "true" change in a patient's condition was identified. Physician #1 stated she had evaluated Patient #1 on 04/24/16, when he/she was diagnosed with an epidural hematoma and a depressed skull fracture. She stated she was unaware how Patient #1's injury occurred, but felt it was not abuse. The Physician stated she had not permitted an unsupervised visit with Patient #1 and Patient #2 after the injury had been identified to Patient #1. The physician also stated she had not observed Patient #2 or her significant other to be under the influence of drugs/alcohol during their hospital stay.

Interview with the DCBS social worker on 05/05/16 at 9:20 AM revealed the initial referral DCBS had received from hospital staff was that Patient #2 was positive for Subutex and Marijuana at delivery, and that he/she had a valid prescription for Subutex. She stated they were not informed that track marks had been observed on Patient #2, and the worker stated "having a prescription and injecting something is different." The DCBS worker stated she was at the facility after Patient #1 had been diagnosed with a skull fracture, and LPN #1 stated that Patient #2's significant other had "looked drunk and the hospital room smelled of alcohol." She also stated that Physician #1 had stated to her that Patient #2 had "looked high and would leave the unit, and come back looking higher." The DCBS worker stated hospital staff had not informed DCBS that Patient #2 and her significant other, that had unsupervised access to Patient #1, were observed to be under the influence of drugs/alcohol during the hospital stay. The worker stated if staff had informed DCBS of their concerns with Patient #2 and her significant other, supervised visits may have been initiated during the patient's hospital stay. The worker stated she had directed staff to permit visitation between Patient #1 and Patient #2, after the skull fracture had been identified to Patient #1 on 04/24/16, but stated she was not informed the visit would be unsupervised and assumed staff would be present during the visitation.

Interview with Physician #2 on 05/05/16 at 11:40 AM revealed she was certified by the American Board of Pediatrics in General Pediatrics and Pediatric Child Abuse and was a physician at the hospital Patient #1 was transferred to for care. She stated she evaluated Patient #1 and in her opinion he/she had been "dropped or had sustained a blow to the head." She stated staff had informed her that the facility where the patient was transferred from stated in report at the time of transfer that Patient #1's mom/dad had been observed to be "impaired" during the hospital stay. She stated it was concerning that unsupervised visits had occurred with Patient #1 and parents that were suspected of being "impaired."

Interview with the Director of Nursing Operations (DON) on 05/03/16 at 2:35 PM revealed staff was required to observe patients in the facility every hour to evaluate and ensure patient safety. She stated staff had not evaluated Patient #1's status every hour as required during the timeframe the injury was identified on 04/24/16. She stated staff should not have permitted unsupervised contact between Patient #1 and Patient #2 while the investigation was ongoing. The DON stated staff was required to notify physicians of a change in a patient's condition in a timely manner, and stated Patient #1's physician should have been contacted sooner than a three (3) hour timeframe. The DON stated the facility had no policies related to ensuring the safety of infants born to drug addicted mothers.

Interview with the CEO on 05/10/16 at 2:00 PM revealed he was responsible for "everything" that occurs in the facility. He stated at an unknown date/time, the governing board of the facility had discussed how, at the time of their discussion, sixty to seventy percent of the babies delivered in the facility were delivered to drug addicted mothers. He stated the governing board had discussed community services that could potentially benefit the drug addicted mothers. However, no actions had been taken to ensure their hospital policies had been developed to ensure the needs and safety of infants born to drug addicted mothers in the facility were being met. He stated that because there had not been any "issues" on the Labor and Delivery Unit, which included the nursery area of the facility, they were "not on the radar screen."

Based on interview, record review, and a review of the facility policies it was determined the facility failed to ensure patient rights were protected and promoted for one (1) of ten (10) sampled patients (Patient #1). Patient #1 was admitted to the facility on 04/21/16 with diagnoses that included term birth, living child. Patient #2, which had given birth to Patient #1 at the facility on 04/21/16, was observed to have "track marks" (evidence of intravenous drug use) on her arms, legs, feet, hands, abdomen, and chest at the time of admission. Patient #2's Urine Drug Screen results were positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug), therefore the facility Social Worker (SW) was consulted. Patient #2 informed the facility Social Worker (SW) on 04/21/16 that she had a closed case with the Department for Community Based Services (DCBS) and had lost custody of her other children. The facility SW had not investigated or collaborated with the local DCBS office to find out why Patient #2 had lost custody of her children, to ensure it was not related to abuse/neglect. The SW had also failed to notify DCBS that Patient #2 had evidence of intravenous drug use upon admission.

Interview with Registered Nurse (RN) #1 revealed Patient #1 was left in the room with Patient #2 and her significant other for approximately two (2) to three (3) hours on 04/24/16, without being assessed every hour as required by facility policy. When Patient #2 returned Patient #1 to the Nursery, on 04/24/16, a "bulging suture line" was observed on the right side of Patient #1's head. Patient #1 was diagnosed with an epidural hematoma and a mildly depressed skull fracture on 04/24/16.

Staff received orders to transfer the patient to another facility for further care/treatment on 04/24/16, and even though staff was unsure how the patient's skull fracture occurred, staff permitted Patient #1 to go back into the room with Patient #2, unsupervised, for approximately one (1) hour prior to being transferred to another facility. Interview with the local DCBS worker revealed staff informed her on 04/24/16, after the skull fracture occurred, that Patient #2 had "looked high" and that her significant other had "looked drunk and the hospital room had smelled of alcohol" during their stay at the facility. The DCBS worker stated facility staff had not notified DCBS of Patient #2's track marks that were observed upon admission, or that she had appeared to be impaired during her hospital stay. The DCBS worker stated if staff had notified DCBS of the identified concerns for Patient #2, that information would have changed the way DCBS addressed the referral and that supervised visits may have been initiated during the patient's hospital stay.

The failure of the facility to identify and protect patients from abuse; failure to provide a safe environment; failure to conduct hourly rounds; and failure to ensure patients were protected from further potential abuse placed patients at risk for serious injury, harm, impairment, or death. It was determined that Immediate Jeopardy existed on 04/21/16 and is ongoing.

Based on interview, record review, and a review of the facility policy it was determined the facility failed to ensure newborn patients received care in a safe setting for one (1) of ten (10) sampled patients (Patient #1). Review of the medical record revealed Patient #2 gave birth to Patient #1 in the facility's Labor and Delivery Unit on 04/21/16. Upon admission into the facility's Labor and Delivery Unit on 04/21/16, Patient #2 was observed to have "track marks" (evidence of intravenous drug use) on her arms, legs, feet, hands, abdomen, and chest. Patient #2 received a Urine Drug Screen, and results were positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug). Patient #2 was evaluated by the facility Social Worker (SW) on 04/21/16, related to her positive drug screen, and Patient #2 informed the SW that she had lost custody of her other children and a "boyfriend" was arrested at the time she lost custody of the children. Interview with the facility SW revealed that although she informed the local Department for Community Based Services (DCBS) office that Patient #2 was positive for drugs upon admission to the hospital, she had not investigated or collaborated with DCBS to find out why Patient #2 had lost custody of her children, to ensure it was not related to abuse/neglect. Interview with the local Department for Community Based Services (DCBS) worker revealed staff informed her on 04/24/16, after the skull fracture occurred, that Patient #2 had "looked high" and that her significant other had "looked drunk and the hospital room had smelled of alcohol" during their stay at the facility. As a result of the facility's failure to provide care in a safe setting, Patient #2 was allowed unsupervised visits with Patient #1, and on 04/24/16 Patient #1 sustained an epidural hematoma and a depressed skull fracture that required treatment at a Neonatal Intensive Care Unit.

The findings include:

Review of the facility policy titled "Patient Rights and Responsibilities," last revised January 2012, revealed hospital staff allows for a family member, or other individual of the patient's choice, to be present with the patient for emotional support during the course of stay, unless the individual's presence infringed on others' rights or safety.

Review of the medical record for Patient #2 revealed the facility admitted the patient on 04/21/16 to the facility's Labor and Delivery Unit. Review of Patient #2's Ante/Intrapartum Flowsheet dated 04/21/16 revealed "track marks" (evidence of intravenous drug use) were observed on her arms, legs, feet, hands, abdomen, and chest. Further review of Patient #2's medical record revealed she received a Urine Drug Screen initially upon admission, and the results were positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug).

Review of Patient #2's Social Services Progress note dated 04/21/16 at 2:05 PM revealed the patient was evaluated by the facility SW on 04/21/16, related to her positive drug screen, and the SW's documentation revealed that nursing staff had observed track marks on Patient #2's abdomen. The SW's documentation revealed a report was made to DPP (Department of Protection and Permanency) related to the patient's positive drug screen and that a confirmation had been made that the patient had a valid prescription for Subutex. The SW's progress note provided no evidence that the SW collaborated with DCBS regarding Patient #2's loss of custody of her previous children, and a "boyfriend's arrest" to ensure Patient #2 did not have a history of abuse/neglect of children.

Review of Patient #1's medical record revealed the facility admitted the patient into the Newborn Nursery following his/her live birth on 04/21/16 at 7:00 AM. Review of Patient #1's urine drug screen, collected on 04/21/16, revealed the patient tested positive for Subutex (a medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug).

Interview with SW #1 on 05/03/16 at 2:05 PM revealed she had evaluated Patient #2 on 04/21/16. The SW stated Patient #2 had informed her that she had a closed case with DCBS, and had lost custody of her other two (2) children, and a boyfriend was arrested at that time. The SW stated she made a referral to DCBS and informed them that Patient #2 had delivered a baby at their facility, and that she had a positive drug screen for Subutex. The SW stated she had informed DCBS that the patient had a prescription for Subutex, but had not informed DCBS that Patient #2 had "track marks" observed by staff, and had not requested any information related to the patient's previous case with DCBS to ensure Patient #2 had no history of abuse/neglect of children in her care.

Interview with the DCBS social worker on 05/05/16 at 9:20 AM revealed the information received from hospital staff related to Patient #2 was that she had delivered a child at their facility, and that Patient #2 was positive for Subutex and Marijuana at delivery. The DCBS worker stated facility staff had also notified them that Patient #2 had a valid prescription for the Subutex. The DCBS worker further stated the facility had not provided her with information that track marks had been observed on Patient #2, and the worker stated "having a prescription and injecting something is different." The DCBS worker also stated that staff informed her on 04/24/16, after the skull fracture occurred, that Patient #2 had "looked high" and that her significant other had "looked drunk and the hospital room had smelled of alcohol" during their stay at the facility. The DCBS worker stated that hospital staff should have informed the local DCBS office that Patient #2 had track marks, and stated that information would have made a difference in the way the referral was addressed by the local DCBS office, and that supervised visits may have been initiated during the patient's hospital stay if all the information about Patient #2 was shared with the DCBS office.

Interview with Registered Nurse (RN) #1 on 05/06/16 at 8:00 PM revealed she was assigned to care for Patient #1 from 7:00 PM on 4/23/16 until 7:00 AM on 04/24/16. She stated Patient #2 had taken Patient #1 to her room at approximately 3:00 AM on 04/24/16. RN #1 stated she was the only nurse scheduled in the Nursery and had not evaluated Patient #1 every hour as required. She stated she had performed a head/toe assessment of Patient #1 at the beginning of her shift on 04/23/16, and no abnormalities had been identified. The RN stated Patient #2 had returned Patient #1 to the Nursery at approximately 6:00 AM and "pointed to" an area on Patient #1's head and said "is that ok." RN #1 stated she noticed the area "first thing and said what's wrong with [his/her] head." The RN stated Patient #1 "didn't act any different" and because there wasn't any "obvious injury" she passed the change in condition on to the next shift and did not contact Patient #1's physician.

Interview with LPN #1 on 05/04/16 at 1:20 PM revealed she was notified of Patient #1's bulging area at his/her suture line, and had observed a "raised knot" across the front and the back of the patient's head at approximately 7:00 AM on 04/24/16. LPN #1 acknowledged she "knew it wasn't normal" for the patient's head to have the observed abnormality; however, she failed to contact the physician until 9:00 AM, two (2) hours after she had identified the abnormality. The LPN stated Patient #1 was diagnosed with an epidural hematoma and depressed skull fracture after diagnostic tests were completed on 04/24/16. LPN #1 stated that even though she was unsure how the injury had occurred to Patient #1, she permitted an unsupervised visit with Patient #2. LPN #1 stated she was unsure what the facility's abuse policy directed staff to do with allegations or suspicions of abuse/neglect, and stated, "I guess we didn't protect" the patient, by allowing an unsupervised visit after an injury had been observed and an investigation was ongoing. She stated that Physician #1 and the DCBS social worker had given her permission to allow the unsupervised visit to occur. LPN #1 denied observing Patient #2 or her significant other under the influence of drugs or alcohol during their hospital stay.

Interview with Physician #2 on 05/05/16 at 11:40 AM revealed she was certified by the American Board of Pediatrics in General Pediatrics and Pediatric Child Abuse and was a physician at the hospital Patient #1 was transferred to for care. She stated she had evaluated Patient #1, and in her opinion he/she had been "dropped or had sustained a blow to the head." Physician #2 stated staff had informed her that the facility where the patient was transferred from stated in report at the time of transfer that Patient #1's mom/dad had been observed to be "impaired" during the hospital stay. She stated it was concerning that unsupervised visits had occurred with Patient #1 and parents that were suspected of being "impaired."

Interview with the Director of Nursing Operations (DON) on 05/03/16 at 2:35 PM revealed the facility had no policy or procedure for ensuring the safety of newborn patients, when a DCBS referral was warranted and until DCBS came to the facility and formulated a plan for a newborn's safety. The DON further stated when the facility social worker received information on 04/21/16 that Patient #2 had a history of children removed from her custody, an investigation should have been conducted to ensure Patient #2 had no history of abuse/neglect of children previously in her care before allowing unsupervised visits with Patient #1.

Based on interview, record review and a review of the facility policy, it was determined the facility failed to protect one (1) of ten (10) sampled patients from abuse (Patient #1). Review of the medical record revealed Patient #2 gave birth to Patient #1 in the facility's Labor and Delivery Unit on 04/21/16. Upon admission into the facility's Labor and Delivery Unit on 04/21/16, Patient #2 was observed to have "track marks" (evidence of intravenous drug use) on her arms, legs, feet, hands, abdomen, and chest. Patient #2 also received a Urine Drug Screen, which was positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug). Patient #2 was seen by the facility Social Worker (SW) on 04/21/16 because of her positive drug screen and informed the SW that she had lost custody of her other children. The facility SW failed to collaborate with the local Department for Community Based Services (DCBS) to determine if Patient #2 had a history of abusing children in her custody. Interview with staff revealed Patient #1 was left in the room with Patient #2 and her significant other for approximately two (2) to three (3) hours on 04/24/16, without being assessed every hour as required. When Patient #2 returned Patient #1 to the Nursery, on 04/24/16, a "bulging suture line" was observed on the right side of Patient #1's head. Patient #1 was diagnosed with an epidural hematoma and a mildly depressed skull fracture on 04/24/16. Staff received orders to transfer the patient to another facility for further care/treatment and even though staff was unsure how the patient's skull fracture occurred, staff permitted Patient #1 to go back into the room with Patient #2, unsupervised, for approximately one (1) hour prior to being transferred to another facility. Interview with the local Department for Community Based Services (DCBS) worker revealed staff informed her on 04/24/16, after the skull fracture occurred, that Patient #2 had "looked high" and that her significant other had "looked drunk and the hospital room had smelled of alcohol" during their stay at the facility.

The findings include:

Review of the facility policy titled "Abuse, Neglect, Prevention and Investigation," last revised January 2014, revealed staff would monitor patient care/treatment, on an ongoing basis, to ensure patients were free from abuse, neglect, or mistreatment. Further review of the policy revealed if the accused individual was not employed by the facility, staff was required to deny unsupervised access to the patient pending outcome of the investigation.

Review of the facility policy titled "Hourly Rounding for a Purpose," last revised January 2014, revealed nursing personnel were required to conduct rounds on facility patients every hour.

Review of Patient #2's medical record revealed the facility admitted the patient on 04/21/16 to the facility's Labor and Delivery Unit. Patient #2's Ante/Intrapartum Flowsheet dated 04/21/16 revealed "track marks" (evidence of intravenous drug use) were observed on her arms, legs, feet, hands, abdomen, and chest.

Further review of Patient #2's medical record revealed she received a Urine Drug Screen initially upon admission, and results were positive for Subutex (medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug).

Review of Patient #2's Social Services Progress note dated 04/21/16 at 2:05 PM revealed the patient was evaluated by the facility SW on 04/21/16, related to her positive drug screen. The SW's documentation revealed that nursing staff had observed "track marks" on Patient #2's abdomen. The SW's documentation further revealed a report was made to the Department of Protection and Permanency (DPP) related to the patient's positive drug screen and that a confirmation had been made that the patient had a valid prescription for Subutex. The SW's documentation provided no evidence that the SW discussed Patient #2's loss of custody of her previous children to ensure the patient did not have a history of abuse/neglect of children previously in her care.

Interview with SW #1 on 05/03/16 at 2:05 PM revealed Patient #2 had informed the SW that she had a closed case with DCBS and had lost custody of her other two (2) children and a boyfriend was arrested at that time. The SW stated she made a referral to DCBS and informed them that Patient #2 had delivered a baby at their facility, and that she had a positive drug screen for Subutex. The SW stated she had informed DCBS that the patient had a prescription for Subutex; however, she had not informed DCBS that Patient #2 had "track marks" observed by staff. The SW stated she had not requested any information related to Patient #2's previous case with DCBS, in which her custody was revoked, to ensure Patient #2 had no history of abuse/neglect of children in her care.

Interview with Physician #1 on 05/04/16 at 2:00 PM revealed she expected staff to notify her immediately when a "true" change in a patient's condition was identified. She stated she evaluated Patient #1 on 04/24/16, when he/she was diagnosed with an epidural hematoma and a depressed skull fracture. She stated she did not feel like it was abuse; however, she was unaware how Patient #1's injury had occurred. The Physician stated she had not permitted an unsupervised visit between Patient #1 and Patient #2 after the injury had been identified to Patient #1. The physician also stated she had not observed Patient #2 or her significant other to be under the influence of drugs/alcohol during their hospital stay.

Interview with the DCBS social worker on 05/05/16 at 9:20 AM revealed the information received from hospital staff related to Patient #2 was that Patient #2 was positive for Subutex and Marijuana at delivery. The DCBS worker stated facility staff had also notified them that Patient #2 had a valid prescription for the Subutex. However, the DCBS worker stated they had not received information that track marks had been observed to Patient #2, and the worker stated "having a prescription and injecting something is different." The DCBS worker stated she was at the facility after Patient #1 had been diagnosed with a skull fracture, and was notified by Licensed Practical Nurse (LPN) #1 that during the hospital stay Patient #2 had looked "impaired" and that the patient's significant other had "looked drunk and the hospital room smelled of alcohol." The DCBS worker also stated Physician #1 had stated to her that Patient #2 had "looked high and would leave the unit, and come back looking higher." The DCBS worker stated that hospital staff should have informed the local DCBS office that Patient #2 and her significant other, who had unsupervised access to Patient #1, were observed to be under the influence of drugs/alcohol during the hospital stay. The worker stated that staff should have informed the DCBS office that Patient #2 had track marks and stated that information would have changed the way the referral was addressed by the local DCBS office, and that supervised visits may have been initiated during the patient's hospital stay. The worker stated she had directed staff to permit visitation between Patient #1 and Patient #2 after the skull fracture had been identified to Patient #1 on 04/24/16, but stated she was not informed the visit would be unsupervised.

Interview with Registered Nurse (RN) #1 on 05/06/16 at 8:00 PM revealed she was assigned to care for Patient #1 from 7:00 PM on 4/23/16 until 7:00 AM on 04/24/16. She stated Patient #2 had taken Patient #1 to her room at approximately 3:00 AM on 04/24/16. The RN stated she was the only nurse scheduled in the Nursery and had not evaluated Patient #1 every hour as required by the facility policy. She stated she had performed a head/toe assessment of Patient #1 at the beginning of her shift and no abnormalities were identified at that time. She stated Patient #2 had returned Patient #1 to the Nursery at approximately 6:00 AM and "pointed to" an area on Patient #1's head and said "is that ok." RN #1 stated she noticed the area "first thing and said what's wrong with" his/her "head." The RN stated Patient #1 "didn't act any different" and because there wasn't any "obvious injury" she passed the change in condition on to the next shift and did not contact Patient #1's physician.

Interview with LPN #1 on 05/04/16 at 1:20 PM revealed she was notified of Patient #1's bulging area at his/her suture line, and had observed a "raised knot" across the front and the back of the patient's head at approximately 7:00 AM on 04/24/16. The LPN acknowledged she "knew it wasn't normal" for the patient's head to have the observed abnormality. However, the LPN failed to contact the physician until 9:00 AM, two (2) hours after she had identified the abnormality and stated she should have notified the physician "sooner." The LPN further stated after the patient's epidural hematoma and depressed skull fracture had been identified, she permitted an unsupervised visit with Patient #2, even though she was not sure how the injury had occurred to Patient #1. LPN #1 stated she was unsure what the facility's abuse policy directed staff to do with allegations or suspicions of abuse/neglect, and stated, "I guess we didn't protect" the patient by allowing an unsupervised visit after an injury had been observed and an investigation was ongoing. LPN #1 stated that Physician #1 and the DCBS social worker had given her permission to allow the unsupervised visit to occur. LPN #1 denied observing Patient #2 or her significant other under the influence of drugs or alcohol during their hospital stay.

Interview with Physician #2 on 05/05/16 at 11:40 AM revealed she was certified by the American Board of Pediatrics in General Pediatrics and Pediatric Child Abuse and was a physician at the hospital Patient #1 was transferred to for care. She stated she had evaluated Patient #1, and in her opinion he/she had been "dropped or had sustained a blow to the head." She stated staff had informed her that the facility where the patient was transferred from stated in report at the time of transfer that Patient #1's mom/dad had been observed to be "impaired" during the hospital stay. She stated it was concerning that unsupervised visits had occurred with Patient #1 and parents that were suspected of being "impaired."

Interview with the Director of Nursing Operations (DON) on 05/03/16 at 2:35 PM revealed staff was required to observe patients in the facility every hour to evaluate and ensure patients' safety. She stated she had determined through the investigation that staff had not evaluated Patient #1's status every hour as required, during the timeframe the injury was identified on 04/24/16. She had instructed staff since that time that Patient #1 should have been evaluated hourly or returned to the nursery care area. She also stated staff had been trained on the facility's abuse and neglect policy. She stated staff should not have permitted unsupervised contact between Patient #1 and Patient #2 while the investigation was ongoing. She stated staff was required to notify physicians of a change in a patient's condition in a timely manner, and stated Patient #1's physician should have been contacted sooner than a three (3) hour timeframe.

Based on interview, record review, and a review of the facility's policies it was determined the facility failed to ensure adequate nursing services were provided to meet the needs of patients for four (4) of ten (10) sampled patients (Patient #1, Patient #2, Patient #3, and Patient #4). Based on the survey findings it was determined the Conditions of Participation at 42 CFR 482.23 Nursing Services was not met. Registered Nurse (RN) #1 was assigned to care for Patient #1 from 7:00 PM on 04/23/16 until 7:00 AM on 04/24/16. The RN failed to evaluate Patient #1 every hour according to facility policy when Patient #1 was in the care of Patient #2 for approximately two (2) or three (3) hours. During the approximate two (2) to three (3) hours that Patient #1 was unsupervised by nursing staff, Patient #1 sustained an injury of unknown origin (epidural hematoma and mildly depressed skull fracture). At approximately 6:00 AM on 04/24/16, Patient #2 returned Patient #1 to the Newborn Nursery and "pointed to" an area on Patient #1's head and stated "is that ok." Nursing staff acknowledged that the area observed to Patient #1's head was abnormal; however, staff failed to notify Patient #1's physician of the change in the patient's condition, for a period of three (3) hours. Patient #1 was diagnosed with an epidural hematoma and a mildly depressed skull fracture at approximately 10:30 AM on 04/24/16.

Staff received orders to transfer Patient #1 to another facility for further care/treatment on 04/24/16. Even though staff was unsure how Patient #1's skull fracture occurred, staff permitted Patient #1 to go back into the room with Patient #2, unsupervised, for approximately one (1) hour prior to being transferred to another facility.

Furthermore, the facility failed to develop plans of care for four (4) of ten (10) sampled patients. Care Plans were not developed for newborn patients (Patient #1 and Patient #3) related to Neonatal Abstinence Syndrome (NAS), a term for a group of problems a baby experiences when withdrawing from exposure to narcotics, positive urine drug screens, and to address "Prevention Plans" developed by the Department for Community Based Services (DCBS) to ensure the safety of patients. Care Plans were also not developed for Patient #2 and Patient #4 related to drug abuse when the patients were admitted to the facility's Labor and Delivery Unit and had positive urine drug screens that indicated drug abuse.

The facility's failure to ensure patients were evaluated hourly; failure to ensure physicians were notified timely of changes in a patient's condition; and failure to provide adequate supervision to ensure patients were protected from further potential abuse during an investigation placed patients at risk for serious injury, harm, impairment, or death. It was determined that Immediate Jeopardy existed on 04/21/16 and is ongoing. Refer to A0395 and A0396.

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as outlined in the facility policy for one (1) of ten (10) sampled patients (Patient #1). Interview and record review revealed Registered Nurse (RN) #1 was assigned to care for Patient #1 from 7:00 PM on 04/23/16 until 7:00 AM on 04/24/16. The RN stated on 04/24/16 she had not evaluated Patient #1 every hour as required, and Patient #1 was in the care of Patient #2 for approximately two (2) or three (3) hours without being evaluated by nursing staff. The RN stated at approximately 6:00 AM on 04/24/16, Patient #2 returned Patient #1 to the Newborn Nursery and "pointed to" an area on Patient #1's head and stated "is that ok." RN #1 stated she identified the area and stated "what's wrong with [his/her] head." However, RN #1 stated she did not contact Patient #1's physician prior to leaving her shift on 04/24/16 because Patient #1 "didn't act any different" and because there was not any "obvious injury." Record review revealed Patient #1 was diagnosed with an epidural hematoma and a mildly depressed skull fracture at approximately 10:30 AM on 04/24/16, and was transferred to another facility for further care/treatment.

The findings include:

Review of the facility policy titled "Hourly Rounding for a Purpose," last revised January 2014, revealed nursing personnel were required to conduct rounds on facility patients every hour.

Review of the medical record for Patient #1 revealed the facility admitted him/her to the facility's Newborn Nursery on 04/21/16 at 7:00 AM. Patient #1's urine drug screen was positive for Subutex (a medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug) on 04/21/16. On 04/21/16, staff initiated monitoring of Patient #1 for signs and symptoms of neonatal abstinence syndrome (NAS), a term for a group of problems a baby experiences when withdrawing from exposure to narcotics.

Interview with Registered Nurse (RN) #1 on 05/06/16 at 8:00 PM revealed she was assigned to care for Patient #1 from 7:00 PM on 4/23/16 until 7:00 AM on 04/24/16. She stated Patient #2 had taken Patient #1 to her room at approximately 3:00 AM on 04/24/16. RN #1 stated she was the only nurse scheduled in the Nursery and had not evaluated Patient #1 every hour as required. She stated she had performed a head/toe assessment of Patient #1 at the beginning of her shift on 04/23/16, and no abnormalities had been identified. She stated Patient #2 had returned Patient #1 to the Nursery at approximately 6:00 AM and "pointed to" an area on Patient #1's head and stated "is that ok." RN #1 stated she noticed the area "first thing and said what's wrong with [his/her] head." She stated Patient #1 "didn't act any different" and because there wasn't any "obvious injury" she passed the change in condition on to the next shift and did not contact Patient #1's physician.

Interview with LPN #1 on 05/04/16 at 1:20 PM revealed she was notified of Patient #1's bulging area at his/her suture line and had observed a "raised knot" across the front and the back of the patient's head at approximately 7:00 AM on 04/24/16. The LPN acknowledged she "knew it wasn't normal" for the patient's head to have the observed abnormality; however, the LPN failed to contact the physician until 9:00 AM, two (2) hours after she had identified the abnormality and stated she should have notified the physician "sooner." The LPN further stated after the patient's epidural hematoma and depressed skull fracture had been identified, she permitted an unsupervised visit with Patient #2, even though she was not sure how the injury had occurred to Patient #1. LPN #1 stated she was unsure what the facility's abuse policy directed staff to do with allegations or suspicions of abuse/neglect, and stated, "I guess we didn't protect" the patient by allowing an unsupervised visit after an injury had been observed and an investigation was ongoing. LPN #1 stated that Physician #1 and the DCBS social worker had given her permission to allow the unsupervised visit to occur. LPN #1 denied observing Patient #2 or her significant other under the influence of drugs or alcohol during their hospital stay.

Interview with Physician #1 on 05/04/16 at 2:00 PM revealed she expected staff to notify her immediately when a "true" change in a patient's condition was identified. She stated she evaluated Patient #1 on 04/24/16, when he/she was diagnosed with an epidural hematoma and a depressed skull fracture. She stated she did not feel like it was abuse; however, Physician #1 was unaware how Patient #1's injury had occurred. The Physician stated she had not permitted an unsupervised visit between Patient #1 and Patient #2 after the injury had been identified to Patient #1. The physician also stated she had not observed Patient #2 or her significant other to be under the influence of drugs/alcohol during their hospital stay.

Interview with the Director of Nursing Operations (DON) on 05/03/16 at 2:35 PM revealed staff was required to observe patients in the facility every hour to evaluate and ensure patients' safety. The DON stated Patient #1's status had not been evaluated every hour as required on 04/24/16. She stated if Newborn Nursery staff was unable to make hourly rounds on 04/24/16, the RN should have contacted the House Supervisor or another staff member to evaluate the status of Patient #1. She further stated staff was required to notify physicians of a change in a patient's condition in a timely manner and stated Patient #1's physician should have been contacted sooner than a three (3) hour timeframe.

Based on interview, record review, and a review of the facility policy it was determined the facility failed to ensure a plan of care was developed for four (4) of ten (10) sampled patients (Patient #1, Patient #2, Patient #3, and Patient #4). Patient #1 and Patient #3 were newborn patients that had positive urine drug screens after birth and were being monitored for Neonatal Abstinence Syndrome (NAS), a term for a group of problems a baby experiences when withdrawing from exposure to narcotics. The facility failed to develop a plan of care to address Patient #1 and Patient #3's positive urine drug screens or the potential to develop NAS. Furthermore, the Department for Community Based Services (DCBS) developed a "Prevention Plan" to ensure the safety of Patient #3 during contact with his/her mother. The facility failed to develop a care plan to ensure the "Prevention Plan" was implemented to ensure the safety of Patient #3. Patient #2 and Patient #4 were admitted to the facility's Labor and Delivery Unit and had positive urine drug screens that indicated drug abuse. The facility failed to develop care plans for Patient #2 and Patient #4 related to the drug abuse and related to safety issues related to the care of their newborns.

The findings include:

Review of the facility policy titled "Nursing Care Plans," last revised January 2014, revealed staff would implement an individualized plan of care for each patient that was based on his/her problems and needs assessed by staff.

1. Review of Patient #2's record revealed she gave birth to Patient #1 in the facility on 04/21/16. Upon admission, staff observed "track marks" (evidence of intravenous drug use) on her arms, legs, feet, hands, abdomen, and chest. Patient #2's urine drug screen was positive for Subutex (a medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug) on 04/21/16. Further review of Patient #2's medical record revealed no evidence of a care plan that addressed Patient #2's drug abuse, which included the use of intravenous drugs during pregnancy, and any safety issues that could develop related to care of her newborn in the facility or when discharged.

2. Review of the record for Patient #1 revealed the facility admitted the patient into the facility's Newborn Nursery following his/her live birth on 04/21/16 at 7:00 AM. Review of Patient #1's urine drug screen, collected on 04/21/16, revealed Patient #1 tested positive for Subutex (a medication used to treat narcotic addiction) and Marijuana (an illegal Schedule 1 drug). Review of Patient #1's form titled "Neonatal Abstinence Scoring System," revealed on 04/21/16 staff was monitoring Patient #1 for signs and symptoms of neonatal abstinence syndrome (NAS), a term for a group of problems a baby experiences when withdrawing from exposure to narcotics. Patient #1's positive urine drug screen or the potential to develop NAS had not been included as a concern on the patient's plan of care.

3. Review of the record revealed the facility admitted Patient #4 on 04/11/16 with a diagnosis of induction of labor, and her urine drug screen results were positive for Opiates (narcotic pain medication) upon admission into the facility. A Social Services consultation was initiated as a result of the patient's positive drug screen. A social worker from the Department for Community Based Services (DCBS) visited the facility on 04/14/16 (two days after birth) and initiated a Prevention Plan that stated all contact between Patient #3 and Patient #4 was to be supervised by a family member at all times. Patient #4 continued to stay in the facility until 04/15/16 (one day later). Further review of the record revealed no evidence the facility developed a plan of care to address the supervised visitation as outlined in the "Prevention Plan" developed by DCBS on 04/14/16.

4. Review of Patient #3's record revealed the facility admitted the patient to the Newborn Nursery on 04/12/16. Patient #3's urine drug screen on 04/13/16 (one day following birth) was positive for medications, which included Opiates (narcotic pain medication), and a Social Services consultation was initiated for the patient as a result. The facility began evaluating Patient #3 for NAS on 04/13/16, but failed to develop a care plan for the identified concern. Patient #3's record further revealed a social worker from the local DCBS visited the facility on 04/14/16 (two days after birth) and initiated a "Prevention Plan" to ensure Patient #3's safety. The Prevention Plan stated that any contact between Patient #3 and Patient #4 was to be supervised by a family member at all times. Patient #3 continued to stay in the facility until 04/15/16 (one day later). Further review of the record revealed no evidence the facility developed a care plan to address the "Prevention Plan" that DCBS outlined to provide safety for the newborn.

Interview with Registered Nurse (RN) #3 on 05/06/16 at 5:40 PM revealed she provided care to patients on the facility's Labor/Delivery and Newborn Nursery units. She stated "we have a lot of patients admitted to the unit with drug use/abuse issues." She also stated "a lot of our babies require monitoring for NAS." However, RN #3 stated staff had not been trained to develop care plans for facility patients related to drug use/abuse, or any social services consultations or prevention plans that may be implemented by the local DCBS office.

Interview with the Director of Nursing Operations (DON) on 05/03/16 at 2:35 PM revealed staff had not been trained to develop care plans related to drug use/abuse or any of the potential effects that may develop as a result, for newborn patients. She stated DCBS was frequently involved in providing consultations and developing Prevention Plans for facility patients related to drug use and/or abuse for the patients cared for on the facility's Labor and Delivery Unit. The DON stated staff had not been directed to update, review, or revise patients' plans of care, to ensure safety Prevention Plans, that had been developed by DCBS for patients, were implemented in the facility.