HospitalInspections.org

Based on interview and record review, the facility failed to promptly report or investigate an allegation of mistreatment/abuse for 1 (#4) of 2 pediatric allegations of abuse reviewed, resulting in the potential for less-than-optimal patient care outcomes. Findings include:

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A-118 Failure to promptly report or investigate an allegation of pediatric abuse

Based on interview and record review, the facility failed to promptly report and/or investigate an allegation of neonate mistreatment/abuse for 1 (#4) of 2 pediatric allegations of abuse, resulting in the potential for less-than-optimal patient outcomes. Findings include:

Medical record review revealed patient #4 was a premature infant born at 26 weeks and was hospitalized in the neonatal intensive care unit (NICU) from 9/12/24 - 11/21/24. On 6/20/25 at 1300, interview with Confidential Informant P revealed that on the night of 10/13/24 - 10/14/24 Nurse N mistreated the baby (tossed baby harshly on his side twice) and they reported it to Social Worker M and said the mother did not want Nurse N to take care of the baby anymore. However, Nurse N took care of the baby again later in the infant's stay. This was verified in the Nurses' Notes dated 10/27/24 - 10/28/24.

On 10/14/2024, the Social Work note documented that the mom had concerns related to care of her baby at the bedside by Nurse N. Phone interview with Social Worker, on 6/25/25 at approximately 1200, revealed that she did not report the issue to the nurse manager or anyone else because she thought it was just a clash of personalities and "it's not our protocol."

On 6/23/24 at approximately 1130, interview with Nurse Manager C revealed that she was unaware of any issues of staff mistreating babies and/or any issue with Nurse N. On 6/24/25 at 1030, interview with Patient Relations Manager G revealed that she was not aware of this allegation of baby mistreatment/abuse. On 6/24/25 at approximately 1130, interview with NICU Risk Manager I revealed she was unaware of the allegation of baby mistreatment/abuse. On 6/25/25 at 1345, phone interview with Nurse N revealed that she did not recall the neonate or the mother and this was the first she had heard about an issue.

Review of the facility policy titled "If a Physical Assault or Other Allegations of Misconduct Involving Patient-Investigating Allegation and Notification, dated 3/25/22" documented, "Inpatient and outpatient allegations of physical or other misconduct will immediately be reported to the entity leader as defined for the area where the allegation is made... An investigation should be initiated when: An allegation of physical or other misconduct involving a patient is made..." This had not been done.