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Based on surveyor observation, record review, and staff interviews, it has been determined that the hospital failed to protect the rights of newborn patients whose identifiable information was visible in a patient care area and whose safety was jeopardized when security measures were not followed.

Findings are as follows:

1. The hospital failed to ensure privacy and safety requirements were met relative to newborn patients whose privacy and safety were/was jeopardized when an unauthorized person was allowed to enter the hospital nursery, (Refer to 0142).

2. The hospital failed to ensure newborn patients receive care in a setting that a reasonable person would consider safe relative to an unauthorized person who was allowed to enter a hospital nursery and handled a newborn patient, (Refer to 0144).

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to ensure newborns receive care in a setting that a reasonable person would consider safe relative to an unauthorized person who was allowed to enter a hospital nursery and handled a newborn patient.

Findings are as follows:

An anonymous complaint submitted to the Rhode Island Department of Health alleged that a nurse manager brought her mother into the nursery and was allowed to feed a baby. Additionally, the complainant alleged that the mother's vaccination status was unknown, and she did not have a medical background.

An interview conducted with the Nurse Director's mother on 4/10/2023 by the hospital revealed that on 3/23/2023, she followed her daughter, the Nurse Director, to the nursery, but she stayed at the door. In the interview the mother stated that "this would be her dream job" and a nurse said to her "come on in and grab a baby, any one you want." The mother then stated in her interview that "she went to a bassinette and took a baby out and went to a rocker ..." Additionally, the mother indicated during the interview that she knew the newborn's gender as she had been present during a diaper change and then revealed that she also "unsaddled the baby, took the old diaper off and put a new diaper on ..." During the interview she also shared that she had a conversation with the volunteer who was in the nursery at the time.

An interview conducted with Employee A, Registered Nurse, on 4/10/2023 by the hospital revealed that on 3/23/2023 she was assigned to four newborn patients who were in the nursery. During the interview, she indicated that the Nurse Director arrived at the nursery with her mother standing beside her and introduced her. Employee A revealed that the Nurse Director's mother "was walking around looking at the babies" and denied inviting her to hold one.

During a surveyor interview on 4/26/2023 at 12:53 PM with the Nurse Director of the Mother Baby Unit, she revealed that her mother "tailed behind" her when her presence was requested at the 5 East nursery. The Nurse Director stated that she had opened the door to the nursery with her badge to have a conversation with Employee A, who was holding a newborn patient at the time. The Nurse Director stated that she motioned her mother to come into the nursery. She stated Employee A said to her mother to come on in and hold a baby, but she did not think anything of it. The Nurse Director stated that she was gone for approximately 20 minutes and returned to the nursery "for a few minutes" and watched her mother place the newborn patient back in the pram. The Nurse Director was asked if her mother had completed a specialized training to care for newborn patients, or a health screening clearance including the required vaccinations to care for patients in a healthcare setting. She indicated her mother had not completed this.

During a surveyor interview on 4/27/2023 at 9:46 AM with the volunteer present on the day on the incident, she remembers there being many babies in the nursery on 3/23/2023 when a woman came in with her mother and said her mother was visiting. She believes the woman was Nurse Director and she explained to her mother that this was the nursery. The volunteer stated that the Director's mother approached her and said something along the lines of "what a dream it would be to work here." She stated that the Nurse Director then said to her mother if she would like to hold a baby but did not question this as it was not her place to question it. She indicated that some of the babies require special care and attention and she had to complete specialized training to be able to care for the babies. She stated that the Nurse Director did not ask the nurses if it would be okay for her mother to hold a baby and gave her mother permission to hold one. Additionally, she described the situation as inappropriate and disturbing.

During a surveyor interview on 4/26/2023 at 12:41 PM with the Chief Nursing Officer, she indicated that she expects the Nurse Director to ensure that anyone who is not a hospital employee or a volunteer "cuddler" has been approved prior to entering the nursery.

Based on record review and staff interview, the hospital failed to ensure nursing services provided in the Mother/Baby Unit of the hospital adhered to hospital policies, procedures, and/or protocols and were supervised by a Registered Nurse relative to an unauthorized visitor who was allowed to enter a locked hospital nursery and handle a newborn patient.

Findings are as follows:

1. The hospital failed to ensure services provided on the Mother/Baby Unit were supervised by a Registered Nurse who allowed an unauthorized visitor into the hospital nursery, (Refer to A-0395).

2. The hospital failed to ensure services provided to patients adhered to hospital policies, procedures, and/or protocols relative to unauthorized visitors entering a locked hospital nursery and handling a newborn patient, (Refer to A-0398).

Based on record review and staff interviews, it was determined that the hospital failed to ensure services provided in the Mother/Baby Unit were supervised by the Registered Nurse relative to an unauthorized visitor who was allowed to enter a locked patient care area, a hospital nursery.

Findings are as follows:

An anonymous complaint submitted to the Rhode Island Department of Health alleged that a nurse manager brought her mother into the nursery and was allowed to feed a baby. Additionally, the complainant alleged that the mother's vaccination status was unknown, and she did not have a medical background.

An interview conducted by the hospital's Director of Labor Relations with Employee A, Registered Nurse (RN), on 4/10/2023 revealed that on 3/23/2023, Employee A was assigned to four newborn patients who were in the nursery. During the interview, Employee A indicated that the Nurse Director of the Mother/Baby Unit arrived at the nursery with her mother, an unauthorized visitor (UV), who was standing beside the Nurse Director. Employee A revealed that the unauthorized visitor "was walking around looking at the babies." Employee A stated in her interview that she did not speak up as she "didn't want to alienate her boss" by asking the unauthorized visitor to leave.

An interview conducted by the hospital's Director of Labor Relations with the unauthorized visitor (UV) on 4/10/2023, revealed that on 3/23/2023, the UV followed the Nurse Director to the nursery. The UV revealed in the interview that an unknown nurse in the nursery said to her "come on in and grab a baby, any one you want." The UV then stated, "she went to a bassinette and took a baby out and went to a rocker ..." Additionally, the UV revealed she "unswaddled the baby, took the old diaper off and put a new diaper on ..."

During a surveyor interview on 4/26/2023 at 9:37 AM with Employee B, RN, she indicated that she did not question the presence of the UV in nursery since she assumed the Nurse Director had approval to do this as she is the boss. Employee B indicated that since the UV was already in the nursery holding a baby when she entered the nursery, someone would have cleared the UV to enter. Additionally, Employee B stated she would have expected Employee A to ask about the UV's clearance as Employee A was assigned to the nursery.

During a surveyor interview on 4/25/2023 at 1:04 PM with Employee C, RN, she revealed that on 3/23/2023 she was the Charge Nurse. Employee C indicated that the nursery was very busy that day and she was helping in the nursery at times. Employee C revealed that that she had never met the UV before and was hesitant to question the UV's presence in the nursery as the Nurse Director is her boss.

During a surveyor interview on 4/26/2023 at 12:53 PM with the Nurse Director of the Mother/Baby Unit, in the presence of the Director of Risk Management and the Clinical Effectiveness Manager, the Nurse Director revealed that the UV "tailed behind" her when her presence was requested at the 5 East nursery. The Nurse Director stated that she had opened the door to the nursery on 5 East with her badge to have a conversation with Employee A, who was holding a newborn patient at the time. The Nurse Director stated that she motioned the UV to come into the nursery and Employee A said to the UV to come on in and hold a baby, but the Nurse Director "did not think anything of it". The Nurse Director stated that she was gone for approximately 20 minutes leaving the UV in the 5 East Nursery. The Nurse Director indicated she then returned to the nursery "for a few minutes" and watched the UV place the newborn patient back in a pram. The Nurse Director stated that she did not lead by example and as the Nurse Director, she should have known better not to allow her mother, an unauthorized visitor, in the nursery. When the Nurse Director was asked about the unit's policy for allowing visitors into the nursery, the Nurse Director stated she "imagines it says that no unauthorized visitors are allowed" but the Director of Risk Management stated that there is no hospital policy about this regarding the hospital nursery. The Nurse Director was asked if the UV had completed any specialized training to care for newborn patients at the hospital, or a health screening clearance including the required vaccinations to care for patients in a healthcare setting, she indicated the UV had not completed this.

During a surveyor interview on 4/27/2023 at 9:46 AM with a volunteer "cuddler," a hospital trained volunteer "cuddler," who was present on the day of the incident, she indicated that remembers that there were many babies in the nursery on 3/23/2023 when a woman came in with their mother (the unauthorized visitor, UV) and said the UV was visiting. The "cuddler" stated that she believes the woman was the Nurse Director who explained to the UV that this was the nursery. The "cuddler" stated that the UV approached her and said something along the lines of "what a dream it would be to work here." The "cuddler" stated that the Nurse Director then said to the UV if the UV would like to hold a baby. The "cuddler" stated that she did not question this as it was not her place. The "cuddler" indicated that some of the babies require special care and attention and she had to complete specialized training to be able to care for the babies. The "cuddler" stated that the Nurse Director did not ask the nurses in the nursery if it would be okay for the UV to hold a baby and the Nurse Director gave the UV permission to hold one.

During a surveyor interview on 4/26/2023 at 12:41 PM with the Chief Nursing Officer, she indicated that she expects the Nurse Director to ensure that anyone who is not a hospital employee or a volunteer "cuddler" for the nursery has been approved to enter the nursery.

Based on record review and staff interviews, it was determined that the hospital failed to ensure hospital procedures and/or protocols were followed relative to unauthorized visitors entering a locked hospital nursery and handling a newborn patient.

Findings are as follows:

An anonymous complaint submitted to the Rhode Island Department of Health alleged that a nurse manager brought her mother into the nursery and was allowed to feed a baby. Additionally, the complainant alleged that the mother's vaccination status was unknown, and she did not have a medical background.

An interview conducted by the hospital with Employee A, Registered Nurse (RN), on 4/10/2023 revealed that on 3/23/2023, Employee A was assigned to four newborn patients who were in the nursery. During the interview, Employee A indicated that the Nurse Director of the Mother Baby Unit arrived at the nursery with her mother who was standing beside her and introduced her. Employee A revealed that the Nurse Director's mother "was walking around looking at the babies." Employee A stated in her interview that she did not speak up as she "didn't want to alienate her boss" by asking the mother to leave.

An interview conducted by the hospital's Director of Labor Relations with the unauthorized visitor (UV) on 4/10/2023, revealed that on 3/23/2023, the UV followed the Nurse Director to the nursery. The UV revealed in the interview that an unknown nurse in the nursery said to her "come on in and grab a baby, any one you want." The UV then stated, "she went to a bassinette and took a baby out and went to a rocker ..." Additionally, the UV revealed she "unswaddled the baby, took the old diaper off and put a new diaper on ..."

During a surveyor interview on 4/26/2023 at 9:37 AM with Employee B, RN, she indicated that she did not question the presence of the UV in nursery since she assumed the Nurse Director had approval to do this as she is the boss. Employee B indicated that since the UV was already in the nursery holding a baby when she entered the nursery, someone would have cleared the UV to enter. Additionally, Employee B stated she would have expected Employee A to ask about the UV's clearance as Employee A was assigned to the nursery.

During a surveyor interview on 4/26/2023 at 12:53 PM with the Nurse Director of the Mother/Baby Unit, in the presence of the Director of Risk Management and the Clinical Effectiveness Manager, the Nurse Director revealed that the UV "tailed behind" her when her presence was requested at the 5 East nursery. The Nurse Director stated that she had opened the door to the nursery on 5 East with her badge to have a conversation with Employee A, who was holding a newborn patient at the time. The Nurse Director stated that she motioned the UV to come into the nursery and Employee A said to the UV to come on in and hold a baby, but the Nurse Director "did not think anything of it". The Nurse Director stated that she was gone for approximately 20 minutes leaving the UV in the 5 East Nursery. The Nurse Director indicated she then returned to the nursery "for a few minutes" and watched the UV place the newborn patient back in a pram. The Nurse Director stated that she did not lead by example and as the Nurse Director, she should have known better not to allow her mother, an unauthorized visitor, in the nursery. When the Nurse Director was asked about the unit's policy for allowing visitors into the nursery, the Nurse Director stated she "imagines it says that no unauthorized visitors are allowed" but the Director of Risk Management stated that there is no hospital policy about this regarding the hospital nursery. Additionally, when the Nurse Director was asked how she ensured that the newborn patient was placed in the right pram, she indicated that she saw a pram in front of where the her mother (the UV) was sitting, but was unable to explain how she confirmed this.

During a surveyor interview on 4/27/2023 at 9:46 AM with a volunteer "cuddler," a hospital trained volunteer "cuddler," who was present on the day of the incident, she indicated that remembers that there were many babies in the nursery on 3/23/2023 when a woman came in with their mother (the unauthorized visitor, UV) and said the UV was visiting. The "cuddler" stated that she believes the woman was the Nurse Director who explained to the UV that this was the nursery. The "cuddler" stated that the UV approached her and said something along the lines of "what a dream it would be to work here." The "cuddler" stated that the Nurse Director then said to the UV if the UV would like to hold a baby. The "cuddler" stated that she did not question this as it was not her place. The "cuddler" indicated that some of the babies require special care and attention and she had to complete specialized training to be able to care for the babies. The "cuddler" stated that the Nurse Director did not ask the nurses in the nursery if it would be okay for the UV to hold a baby and the Nurse Director gave the UV permission to hold one.

Review of email correspondence dated 4/11/2023 from the Vice President of Chief Compliance/Privacy Officer sent to the Chief Nursing Officer and the Chief Executive Officer states in part that, "after conducting several interviews, reviewing policies, and discussing security protocols with security, we have concluded that [the unauthorized visitor] should not have been allowed in the nursery ..."

During a surveyor interview on 4/26/2023 at 12:41 PM with the Chief Nursing Officer, she indicated that she expects the Nurse Director to ensure that anyone who is not a hospital employee or a volunteer "cuddler" for the nursery has been approved to enter the nursery.