HospitalInspections.org

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Based on Medical Record review, document review and interviews, it was determined that the facility failed to meet the Condition of Participation for Patients' Rights as evidenced by the following:

The facility failed to provide care to infants in a safe environment.
(See Tag A 144)

The facility failed to ensure that patients were safe from physical and sexual abuse
(See A 145)
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Based on observation, staff interview, and review of procedures, it was determined that the facility failed to ensure a safe environment for infants and children. The facility failed to have a system in place for the protection of infants and children in order to minimize the potential risk for harm or abduction. This was based on two of two units.

The facility's failure placed all infants and children at risk for abduction.

Findings:

Observations in the facility's Maternity Units during a tour between 9:30AM and 10:15AM on 11/02/15 identified the following:

During an interview with Staff A (Nurse Manager), she explained that the "McRoberts" Prosec Electronic Transmitter System is used to augment safety and tracking of newborn infants. The transmitter is a clamp system placed on a patient's umbilical cord. A monitor on the Nursing Station telephone displays a picture of the person at the door.

The Unit is accessed via Employee Swipe Cards only, and anyone that comes to the Unit must be buzzed in by staff. However, the East Exit Door is unlocked and not alarmed, and leads directly to the Unit Lobby Elevators for anyone who wants to depart the Unit.

If the infant wearing the device gets within approximately two (2) feet of the Exit Doors to the Unit, the Door automatically locks except for the East Exit Door which does not have a locking mechanism when exiting into the Lobby. However, the Unit Lobby Elevators lock down when approached by an infant wearing the clamp transmitter. This was demonstrated with the use of a test mannequin baby by the staff. As per the Unit Nurse Manager, this doll is used for all "Code Pink" Abduction Drills.

The device is linked electronically to a Computer Tracking System which activates a Visual and Audible Electronic Alarm.

There are seven (7) Exits on the Maternity Units, which includes the Mother / Baby Unit and the Labor and Delivery (L&D) Unit.

An inspection of the facility's Electronic Infant Security System was conducted with Staff Members A and B (AVP Quality & Resource Management). Staff A stated that the umbilical clamp required a "special tool" to remove the clamp from the infant. An attempt to remove the clamp from the test doll was made by the Surveyor and took less than one (1) second to remove without the tool, using only fingers.

This was demonstrated in the presence of Staff Members A and B.

Due to the facility staffs' insistence that the clamp could be opened easily because it was on a thick foam umbilical cord, and not on an actual infant, the clamp was reclosed without the test doll and was able to be reopened in less than thirty (30) seconds with only the use of a paper clip. This was demonstrated in the presence of another Surveyor.

With the clamp removed it would be possible to remove an infant from the Unit through the unlocked Door (East Exit) into the Unit Lobby, and down the Elevators without setting off any Alarms.

Review of the Prosec Manufacturer's User Manual for the Infant Abduction System, dated 2003, revealed that there were two (2) types of Umbilical Transmitting "Tags"; one (1) which is "Non-Sensing" and does not transmit an Alarm when opened, and one (1) which initiates an Alarm when a clamp is opened or tampered with.

The facility's system is a "Non-Sensing" System, does not Alarm when removed, and therefore does not lock down the Unit.

This was confirmed in the presence of Staff Members A and B.

Additional observations in the facility's Pediatrics Unit during a tour between 10:20AM and 11:00AM on 11/02/15 identified the following:

The Unit is accessible through only one (1) door via Employee Swipe Cards, and anyone that comes to the Unit must be buzzed in and out by staff. However, there is one (1) Fire Door at the end of the Hallway that is unlocked, is supposed to alarm when opened, and leads directly to the outside of the hospital.

During an interview with Staff C (Nurse Manager Pediatrics), she explained that the "Cuddle" Accutech Electronic Transmitter System is used to augment safety and tracking of children through seventeen (17) years of age.

The White Plastic Band System has plastic snaps and Alarms when the band is cut. The band is not skin contact sensitive. If the child wearing the device gets within approximately two (2) feet of the Exit Doors to the Unit, the Door automatically locks.

As per Staff C, the device is linked electronically to a Computer Tracking System which activates a Visual and Audible Electronic Alarm.

An inspection of the facility's Electronic Child Security System was conducted with Staff C in the presence of Staff B.

Staff C stated that the transmitter "will Alarm within three to four (3-4) seconds" when removed from the child.

A transmitter and white plastic band was placed on the Surveyor and the system was set by Unit Staff. After the transmitter was slipped from the Surveyor, the system failed to Alarm even after over one (1) minute. The Alarm only sounded after the band was cut.

On 11/02/15 at 10:25AM Staff C stated "It's supposed to Alarm after three to four (3-4) seconds when removed, even when the band is not cut", and "I know that it should Alarm because we have had patients get them off before and the Alarms have gone off".

On the afternoon of 11/02/15 it was brought to the attention of the Surveyors by Unit Staff that the facility has two (2) types of pediatric transmitters.

The second transmitter is a Yellow Foam Band System placed on a children less than one (1) year of age, but may be used for children up to the age of two (2) at the discretion of the Nurse. The foam band is stretchable and works on a skin contact system while on the child. The band alarms when not in contact with the child's skin.

Three (3) new tests were conducted on the Pediatric Unit on 11/02/15 between 1:00PM and 2:00PM.

On the initial test, the "Skin Sensitive" Foam Band was placed on a Surveyor's wrist and when it was slipped off the wrist it did not "Alarm" for more than ninety (90) seconds. The Alarm was not an audible Alarm and only showed on a screen to the side of the Nurses' desk.

A second test of a second Foam Band also did not "Alarm" for twenty-five (25) seconds. This Alarm also only showed as "Alarming" on the screen. No audible Alarm was observed anywhere on the Unit.

The third test was of the Fire Door at the end of the Unit Hallway. Staff C stated that although the Door is not locked, it emits a very loud audible Alarm when open.

Due to the anticipated loudness of the Alarm, all patients were notified in advance and their Doors were closed in preparation for the test.

When the Fire Door was open, no sound was emitted. The Door was held open for more than one (1) minute but no Alarm sounded.

The Stairwell is a direct access to the street outside of the building, however, access can also be gained to the rest of the hospital through an unlocked / unalarmed Door to the Endoscopy Suite on the next level down.

With the lack of audible Alarms when the transmitters are slipped off of children, and the lack of a working Alarm on the Unit Stairwell Door, it would be possible to remove a child from the Unit through the Fire Door.

These tests and findings were conducted with Staff C in the presence of Staff B.

The facility failed to have working Redundant Security Systems for both the Maternity and the Pediatrics Units to prevent infant / child abductions.
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Based on record review and interview, the facility failed to investigate allegations of sexual and physical abuse in two (2) of two (2) Medical Records reviewed.

The facility's failure to investigate allegations place all patients at risk of sexual and physical abuse.

Findings:

Review of the facility's Occurrence Tracking Reports documented two (2) incidents of alleged abuse / assault of patients by staff which occurred on May 11, 2015 (MR #1) and October 2, 2015 (MR#2).

Review of Medical Record (MR) #1 on 11/03/15 revealed that this patient presented to the Emergency Department (ED) on 05/05/15 with a chief complaint of thoughts of wanting to hurt herself. The patient was admitted.

Review of the Medical Record documented that on 05/05/15 at approximately 6:30PM, the patient reported to a female Psychiatric Attendant that she flashed Staff D after he asked her to while he was sitting on safety watch. The patient also reported that she "flashed Staff D during a prior admission to D4 in November 2014". She also reports today that he gave her his cell phone so that she could look at pornography and that Staff D asked for oral sex and traditional sex.

Review of the Occurrence Report dated 05/11/15 at 6:35PM documented that the Registered Nurse received a Report by an Aide stating that the patient complained that an Aide made untoward advances. There is no evidence that a physician was notified of this occurrence.

The Report documented "See Attached" which documented an interview dated 05/11/15 at 6:35PM in which the patient stated she flashed the male Aide while on safety watch and informed the Nurse that this was not the first encounter with the identified staff member. She further verified the account which was documented in the Medical Record.

The Investigative File contained documentation indicating that Staff D was interviewed on 05/13/15, two (2) days after the allegation was made, regarding Patient #1. Staff D denied all the allegations. During the interview Staff D, he stated that he was later assigned to take vital signs on the unit which included Patient #1. Following the report of the allegation, Staff D remained and completed his shift on the Unit, as revealed by review of his time card.

Additionally, Staff D returned to work on 05/15/15 even though he was removed from the Unit where the allegation was reported to have occurred. The facility failed to remove Staff D from all Patient Care Areas.

On 11/03/15 at 9:35AM a request for the Policy and Procedure for Investigation of Allegations of Abuse was made. Staff B, AVP Quality and Resource Management, stated there was none.

Review of the Medical Record for Patient #2 documented that this patient, a 25-year-old, was admitted on 09/13/15.

Review of the Medical Record documented that on 10/02/15 at 5:00PM the patient reported to the Nurse Manager and Assistant Nurse Manager that earlier during visiting hours between 1:00PM and 1:30PM, as he was entering the Day Room three (3) Psych Attendants, Staff Members E, F and G would not let him in the Day Room. The patient indicated that Staff Members E, F and G were pushing hard on both shoulders and chest. Also, when a visitor was leaving, Staff Members E, F and G would not let him talk to the visitor as they were blocking him from the visitor with light touch.

Review of the Occurrence Tracking Report dated 10/02/15 describes the event and includes an examination by the Physician on 10/02/15 at 8:30. The Investigative Follow Up Section included documentation that an x-ray of the left shoulder was ordered and "investigation to follow".

Review of the Investigative File documented that on 10/06/15, four (4) days following the report of the occurrence, Staff Members F and G were interviewed. There was no documentation that Staff E was interviewed.

The patient remained on the Unit until discharge on 10/16/15. Review of the Time Records for Staff Members E, F, and G revealed the staff members also remained on the Unit.

On 11/03/15 at 9:35AM a request for the Policy and Procedure for Investigation of Allegations of Abuse was made. Staff B, AVP Quality and Resource Management, stated there was none.