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Based on interview and document review that included review of child/patient #1's medical record and CSA-L's emergency department (ED) record from hospital #2, hospital #1 failed to protect the right of one child/patient (P1) to receive care in a safe setting, of eleven children/patients reviewed. It was determined that the hospital failed to appropriately supervise and keep child/patient #1 safe when CSA-L, who was providing 1:1 supervision to child/patient #1, was found sleeping and intoxicated (0.3 blood alcohol level) while providing care to (P1) in (P1's) room. The hospital was found not to be in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include:

The hospital failed to protect and promote the right to receive care in a safe setting for 1 of 11 children/patients reviewed, (P1). CSA-L failed to implement adequate monitoring and safety measures for (P1) who was to be receiving 1:1 monitoring related to his complex medical needs and special equipment (feeding tube) and his behaviors related to being cognitively delayed and non-verbal. Staff found CSA-L, who was assigned to provide 1:1 monitoring of (P1), unconscious and slumped over in a chair in P1's room. P1 was in his mesh bed and asleep when the incident occurred. After several unsuccessful attempts, staff were able to wake up CSA-L who was observed to be disoriented and confused. Another staff person was assigned to remain with (P1) and CSA-L was transported to hospital #2's ED for an evaluation. Laboratory tests conducted at hospital #2 indicated CSA-L had a blood alcohol level of .3.

Based on interview and document review, the hospital failed to promote one child/patient's right to receive care in a safe setting for 1 of 11 children/patients reviewed (P1). CSA-L failed to provide adequate supervision and a safe environment for (P1) when CSA-L was impaired due to alcohol consumption while she was providing 1:1 monitoring of (P1).

Findings include:

P1's hospital record was reviewed on 10/17/18 and indicated (P1) was admitted to the hospital's sixth floor from 10/2/18 to 10/11/18 due to pneumonia and increased behavioral problems. The patient has a complex medical history with prematurity at 28 weeks gestation, Down's syndrome, autism, neuro/cognitive delay, congenital heart, hydrocephalus, seizures, chronic lung disease, thyroid disease, self injurious behavior (hitting and biting himself) and oral motor dysfunction which requires (P1) to be fed via a gastrostomy tube. Due to (P1's) complex medical condition, required medical equipment and self injurious behaviors, he was assigned a CSA (clinical support associate) on a 1:1 and ongoing basis per the RN's discretion for the purpose of monitoring (P1) and keeping him safe.

A 10/10/18 Risk Management Investigative Report that pertained to a 10/6/18 incident involving (P1) and CSA-L was reviewed. The report indicated CSA-L was assigned to be (P1's) 1:1 sitter on the evening of 10/6/18. The report indicated CSA-H entered (P1's) room at 9:30 p.m. on 10/6/18 for the purpose of providing CSA-L a break. CSA-H found CSA-L slumped over in a chair and in an unconscious state. (P1) was asleep in his mesh bed. CSA-H and RN-I unsuccessfully attempted to wake up CSA-L several times. Eventually, they were able to wake-up CSA-L and observed that she was disoriented and confused. The report indicated they did not detect an odor of alcohol. CSA-H remained in the room with (P1) and CSA-L was transported via ambulance to hospital #2's ED for an evaluation of her condition.

CSA-L's 10/6/18 (admission at 10:47 p.m.) ED record from hospital #2 was reviewed. The record indicated that CSA-L's blood alcohol was 0.3 at the time of the visit to the ED. The record indicated CSA-L was not admitted to the hospital for further care.

An in person interview with Clinical Support Associate (CSA/H) was conducted on 10/17/18 at 2:45 p.m. She stated she was working the evening shift on 10/6/18. She was assigned to provide every two hour breaks for CSA-L who was P1's 1:1 sitter that evening. CSA-L took her thirty minute supper break at 5:50 p.m. and seemed to be fine following the break. Around 9:00 p.m., CSA-H went to P1's room to give CSA-L a break. The door was closed, and the feeding pump was ringing. CSA-H entered the room and saw CSA-L slumped over in a chair that was beside P1's bed. P1 was in his mesh bed and asleep. CSA-H tried to wake up CSA-L several times but was unsuccessful, so she asked Registered Nurse (RN/I) to come to P1's room. CSA-L eventually woke up, and CSA-H and RN/I observed that CSA-L was incoherent and unable to respond to questions. RN/I called the supervisor about the incident and CSA-L was removed from the P1's room and transported to the ED via ambulance.

An in person interview with RN/I was conducted on 10/17/18 at 3:45 p.m. She stated she was working the evening shift on 10/6/18. She stated she and CSA/H observed CSA-L sleeping in a chair beside P1's bed. She recalled that it was very difficult to wake up CSA-L and stated P1 was very confused and incoherent when she finally woke up. RN/I stated she thought CSA-L was experiencing a medical issue, so she contacted the supervisor and CSA-L was tranported via ambulance to hospital #2.

An in person interview with Risk and Compliance Officer (A) was conducted on 10/17/18 at 8:30 a.m. She stated CSA-L was not adequately supervising and monitoring P1 at the time of the 10/6/18 incident. She stated she was not aware that CSA-L's blood alcohol level was .3 when CSA-L was evaluated at hospital #2's ED on the evening of 10/6/18. She stated CSA-L is currently on a leave of absence.

A phone interview was conducted with CSA-L on 10/25/18 at 9:15 a.m. She stated she is a CNA (certified nursing assistant) as well as a CSA (clinical support associate). She stated she had been drinking heavily prior to the start of her afternoon shift on 10/6/18 and was very intoxicated. She stated she has medical/mental health issues and has a history of problems related to alcohol consumption. She stated she has not pursued chemical dependency treatment. Although she requested a leave of absence from hospital #1, she was not planning to return to work there and plans to resign. She stated she decided to leave the health care field as a result of the 10/6/18 incident. She admitted that on 10/6/18, she failed to provide adequate supervision and care for P1, due to being intoxicated.