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Based on interviews and documentation review, the hospital failed to protect the rights of Patient #1, Patient #3 and their infants, Infant #2 and Infant #4, when Infant #4 was brought into Patient #1's room and improperly identified as her newborn. Patient #1 attempted to breastfeed Infant #4 and the infant latched on and began breastfeeding. Due to the seriousness of staff failing to follow procedures for identifying mother and newborns, the Condition of Participation of Patient Rights is out of compliance.

See documentation tag: A144

Based on interviews and documentation review, the hospital failed to provide 3 of 12 patients in the sample (Patient #1, Patient #3, and Infant #4) with adequate safety identification procedures to ensure that the correct newborn was transferred from the nursery and given to the correct parent.

Patient #3's medical record and hospital documentation was reviewed and revealed she was admitted to the hospital on 3/20/2012. Patient #3 had a cesarean section for the delivery of her baby, Infant #4, on 3/21/2012 at approximately 5:28 a.m. She transferred from room 226 to room 223 at approximately 12:06 a.m. on 3/21/2012 to open up a labor room.

Patient #1's medical record was reviewed and revealed she was admitted to the hospital on 3/21/2012 at approximately 7:28 p.m. Patient #1 gave birth to a baby boy on 3/22/2012 at approximately 12:31 a.m. in room 226.

Patient #1 was interviewed on April 27, 2012 at 1:06 p.m. and she stated was admitted to the hospital on March 21, 2012. The hospital staff did not put a hospital identification band on her until 3/23/2012 when someone from the lab came to draw blood and noticed she had no identification band. Patient #1 said her newborn, Infant #2, was delivered on March 22, 2012 at 12:31 a.m. Patient #1 nursed Infant #2 but he had a lot of mucous so he did not nurse very well. At approximately 2:30 a.m. the nurse took the newborn out of her room to get him cleaned up. The parents then tried to rest. At approximately 7:00 a.m. Patient #1 called the nursing station to request her newborn be brought back to her room. The nurse said her newborn was with the doctor at that time. Approximately 7:30 a.m. Nurse D brought a newborn into her room. Patient #1 read off her baby identification number to Nurse D. Patient #1 said Nurse D said, "OK, yep, here's your baby." Nurse D also said something about the newborn just being circumcised. Patient #1 said she thought that was a little odd because no consent for circumcision had been signed yet. Patient #1 stated the newborn was fussy so she attempted to breastfeed the newborn to comfort him. He latched onto the breast immediately and nursed for no more than 3-5 minutes. She felt the newborn felt heavier than earlier. She felt there was something strange and looked at the crib card. Patient #1 said the crib card had a different name on it. She told her husband that the newborn was not their baby. the husband took the newborn back to the nursery. She said Nurse D came in immediately. Both Patient #1 and Nurse D were crying. Patient #1 said Nurse D apologized for the mistake and said she had only read the first few numbers of the identification. Patient #1 also said it was dark in her room. Nurse D came back 3 or 4 more times. Nurse D brought her newborn, Infant #2, into Patient #1's room. Patient #1 kept Infant #2 with her after that until they discharged from the hospital on March 22, 2012. She said she did not want to leave him. Patient #1 also said she told a nurse in the evening and at night about what happened and that she had nursed the newborn brought in error to her room.

Nurse D was interviewed on April 19, 2012 at 11:15 a.m. She stated Patient #1 came to the nurse's station approximately 7:00 a.m. on March 22, 2012, and asked for her newborn baby, Infant #2, to be brought to her room. At approximately 7:30 a.m., Nurse D went into the nursery. Two baby boys were in the nursery. She checked the room number on their crib cards. Both newborns' crib cards noted the same room number. Employee stated she took one of the babies into Patient #1's room. The lighting in the room was dark. She asked Patient #1 to read her baby identification number. While Patient #1 did this, Nurse D looked at the identification number on the crib card, but did not read all of the numbers and did not look at the newborn's identification band. Nurse D handed Patient #1 a newborn and left the room. A few minutes later, Patient #1's spouse came to the nursery with a baby in the crib and stated it was the wrong baby. Nurse D went into Patient #1's room and apologized to Patient #1 for bringing the wrong baby to her. Nurse D acknowledged that she did not follow the hospital protocol for identifying newborns by looking at the baby's identification band number and matching it with the mother's identification band number. She did not also verify Patient #1's name or date of birth when she took the baby into Patient #1's room.

Employee B/administration was interviewed on April 18, 2012, at 2:22 p.m. She stated the hospital practice for identifying the correct baby with the correct mother is to match the newborn identifying band number on the mother with that of the newborn identification band on the baby's wrist and ankle. She verified this practice was not followed for Patient #1 and Infant #4, resulting in the wrong baby brought to the wrong mother.

The hospital policy and procedure for Infant Identification states "...the nurse will check the baby's identification bracelets every time, prior to leaving the nursery. There will be a match of the identification bracelet numbers every time the baby is brought to the mother and each time the baby is picked up from the nursery by the mother or other adult wearing (sic) identification bracelet. The hospital failed to follow their newborn security practice and the wrong baby, Infant #4, was brought to Patient #1's room and then breastfed by Patient #1.