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Based on document review and interview it was determined for 1 of 1 (Pt #1) pediatric sleep study patient, the hospital failed to ensure the sleep study electrodes were safely removed per policy. This has the potential to affect all pediatric sleep study patients of one per month, as evidenced by:



1. On 3/8/2022 at approximately 12:00 PM-1:00 PM, the record of Pt #1 was reviewed. The record stated that: Pt #1 is a pediatric patient who was admitted to the sleep disorder center on 2/9/2022 at 8:30 PM. The sleep study was ordered due to Pt #1's snoring and sleep issues. The record states that Pt #1 was accompanied by the parents. According to the sleep study technician (E #2) progress note: "the process was explained to the parents followed by the placement of the electrodes and nasal cannula for oxygen and lights were turned out at 9:19 PM .... Patient only slept for 35 minutes. Patient could not tolerate the set up. Patient repeatedly removed the nasal cannula. parent stated this was a typical night for Pt #1. Parent stated that patient will not be able to fall back asleep or keep nasal cannula on. Parents wanted to end test."


2. On 3/8/2022 at 3:30 PM, the grievance and complaint log dated 6/2021-current was reviewed. The log noted a complaint concerning the event of 2/9/2022 with Pt #1 was entered on 2/11/2022. No other complaints concerning the sleep disorder center was noted. The hospital began the investigation on 2/11/2022 and the conclusion letter was sent to the complainant on 3/4/2022.


3. On 3/8/2022 at 2:00 PM, the hospital grievance investigation form was reviewed, According to the Hospitals investigation document into the complaint: Pt #1's parent and E #2 were interviewed, and Pt #2's sleep study video recording was viewed. The report states the parent stated that E #2: "grabbed the leads and yanked up ...and this action jerked and lifted Pt #1's body, then E #2 performed the same action again without success ...then E #2 allowed the parent to remove the leads ..." The report states that E #2 was interviewed and stated "We agreed to stop the test. I removed the leads/electrodes with one big pull. I warned the parent that it would be one big pull and they would be off. I assured the parent they were not glued on, they are held with sticky paste, which is water soluble and paper tape ... ...For uncooperative patients who want the electrodes off quickly, this is how I was taught. We place 15 electrodes to the head, in this case 13. and to remove them one by one can take 5-10 minutes and upset the patient more ... " E #2 stated in the report that E #2 "could have done things differently ...E #2 could have offered to have the parents remove the leads one at a time ..."The report states that: The sleep study video was reviewed, and the allegations of abuse could not be substantiated. "The parent was holding the patient when E #2 removed the electrodes. The conclusion was that it appeared the electrodes came away easily and E #2 did pull the electrodes from the patients' head but did not cause harm. E #2 did not restrain or pull on the patient. "No aggressive actions from the tech to the patient .... Conclusion of the report was:" ...all stakeholders determined no patient safety issues identified. No ill intent to harm patient. Video did not support or refute mothers' claims".

4. On 3/8/2022 at 2:30 PM, the video recording of Pt #1's sleep study was viewed with sleep study lab coordinator (E #5) and patient safety coordinator (E #4). E #2's actions and care were appropriate prior to removing the electrodes from Pt #1's head. The mother was holding Pt #1 when the electrodes were removed. E #2 pulled on the electrodes, and they released without any hesitation. As the electrodes were being removed the parent was lifting Pt #1 upwards towards E #2. Prior to removing the electrodes Pt #1 was crying and E #5 did not soak each electrode site with warm water, per policy. E #2 did not restrain Pt #1 during the sleep study. Pt #1's record lacked any mention of any injuries to Pt #1.


5. On 3/8/2022 at 3:40 PM, the policy titled "Pediatric Polysomnography Protocol" (dated by the facility March 2021) was reviewed. The policy required that "End of sleep study: ...carefully and diligently soak each electrode site with warm water until the electrode gently lifts away from the patient's skin".


6. On 3/8/2022 at 2:15 PM, the sleep lab coordinator (E #5) viewed the video of Pt #1's sleep study and stated that E #5 would expect E #2 to follow the policy on removing electrodes in the Pediatric Polysomnography Protocol policy.

7. On 3/9/2022 at 9:25 AM, the policy titled Patient Rights and Responsibilities (dated May 2021) required that: "Patient Rights ...to receive safe, considerate, and respectful care

8. On 3/9/2022 at 9:00 AM, the personnel files for sleep disorder unit technicians (E #2, E #3, E #6) were conducted. All files were up to date and no deficiencies in training noted. No disciplinary actions noted.