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Based on medical record review, and staff interviews the hospital failed to protect the rights of Patient #1, Patient #2 and their infants, when Baby #2 was brought into Patient #1's room and improperly identified as her child. This failure places the Condition of Participation of Patient Rights out of compliance.

See documentation tags: A144, A122

Based on interview and documentation review, the facility failed to ensure that a grievance filed was resolved within a reasonable time frame.

On 6/20/2011, at 12:45 a.m., Baby #2 was brought into Baby #1's mother (Patient #1) to nurse. The proper procedure for identification was not followed by staff, and baby #2 was incorrectly identified as baby #1. Patient #1 attempted to nurse baby #2, but baby #2 would not latch on, so Patient #1 began to change her diaper. Patient #1 then noticed that the name and room number on the bassinet was not their room number, or their baby's correct identification. She alerted staff, and baby #2 was removed from her room.

Individual (L) was interviewed on 12/16/2011 at 10:57 a.m. and stated that within the first week after discharge, he made several requests for a meeting with the administration of the hospital regarding the incident. He stated that they met with hospital administrative staff on 6/28/2011, (eight days after the incident). Individual (L) stated that at the meeting, he requested written information that assured them that their daughter did not leave the nursery on 6/19/2011, and requested an internal investigation of the incident, and measures the hospital put in place to assure that an incident like this would not occur again. He stated that they received a letter on 10/24/2011 documenting security improvements to the Birthplace Unit, but did not receive a summary of the internal investigation. He stated that they received this information only after they requested the information on 10/18/2011.

Individual (M) was interviewed on 12/22/2011 at 7:17 a.m. and stated that on 6/19/2011, Baby #2 was brought into Patient #2's room at approximately 1:20-1:30 a.m., and Patient #2 was told that Baby #2 needed to nurse, and was also told that Baby #2 had been taken into the wrong room, and after approximately 10-15 minutes, was wheeled back out of the room after discovering the error. On 6/20/2011, Employee (B) came into Patient #2's room prior to discharge, and wanted to make sure that she was "OK" about the incident the previous night. He stated that they were not told by Employee (B) that the nurse left the baby in the room with Patient #1, or that she had attempted to nurse Baby #2. He stated that they were contacted by Physician (N) and Employee (A) four days after discharge, and explained that Baby #2 was left in Patient #1's room for 10-15 minutes, and Patient #1 had attempted to breastfeed Baby #2. A few weeks went by, and he stated he continued to call Employee (A), and Physician (N) for more information regarding the incident. They met with hospital staff, a few weeks after discharge (unsure of exact date), and at that time asked to receive a copy of the final report, and measures put in place to ensure that a similiar incident does not happen to another family. They were then told that the hospital didn't have an action plan in place yet, but they were "working on it." Following this meeting, he did not have any contact with the hospital for approximately two months. He stated that they still have not received a final report in writing, or any action plan in writing. He stated that they had requested the report and action plan at their initial meeting.

The policy entitled Patient Rights and Organizational Ethics documents that "if resolution of a complaint will extend beyond 7 days, the hospital should inform the patient/patient representative and give them a time frame of when they will receive a written response. The investigation and resolution process should not exceed 30 days for a concern or grievance/complaint, unless the patient and /or their representative and the site grievance/complaint contact agree upon a different time frame. The resolution of the grievance/complaint should be provided in writing to the patient as soon as reasonably possible, but in any envent, no later than 30 days after resolution of grievance/complaint."

Based on interviews and documentation review, the facility failed to provide 3 of 11 patients in the sample (Patient #1 and Patient #2, and Baby #2) with adequate safety identification procedures to ensure that the right baby was transferred from the nursery to the right family room.

Patient #1's medical record was reviewed and revealed that she was admitted to the hospital on 6/19/2011 at approximately 3:30 a.m., and gave birth on 6/19/2011 at 11:27 a.m. to a baby girl (Baby #1). Following the delivery, they were transferred to the post partum unit of the hospital.

Patient #2's medical record was reviewed and revealed that she was admitted to the hospital on 6/17/2011 at approximately 12:24 p.m., and had a c-section birth of a baby girl (Baby #2) on 6/17/2011 at approximately 3:00 p.m. Following the procedure, they were transferred to the post partum unit of the hospital.

Employee (B)/Administrative Staff was interviewed on 12/12/2011 at 12:43 p.m. and stated that when a baby is born, two pediatric bands are placed on each ankle, and one placed on the wrist of the mother and one on the father/significant other. The band is labeled wtih the mother's name, the medical record number, and the date of admission. The baby will have a band on his/her ankle with the same information, and is also badged with a HUG electronic security band which identifies the baby by badge number and room number. The HUG system will alarm if the baby gets to close to the security doors. Following delivery, the labor and delivery nurse will transport baby and mother up to postpartum unit, and will do a band identification check with the Post Partum staff, to ensure that the baby and mother have the correct and matching bands. Following any transfer of a baby on the post partum unit, the protocol for staff to follow, is to have the mother read the number on her band and state her last name, and the staff person will verify that the numbers match the babies numbers on their identification band.

On 6/20/2011, Baby #2 was in the nursery, and was transported to Patient #1's room by Employee (J)/Nursing Assistant (NA) to have Patient #1 nurse. Employee (J) did have Patient #1 read the identification numbers on the bands, but Patient #1 did not have on her glasses. Employee (J) did not verify or read the numbers back to the mother, or verify the last name of the mother on the identification band. Employee (J) handed Baby #2 to Patient #1. Patient #1 attempted to nurse Baby #2, but she would not latch on, so she went to change her diaper. Patient #1 put on her glasses and noticed that the baby identification did not match her number. Patient #1 alerted staff that she had the wrong baby in her room.

Individual (L) was interviewed on 12/16/2011 at 10:51 a.m. and stated that Patient #1 had been awake for approximately 48 hours straight, so Baby #1 was transferred to the nursery on 6/19/2011 at approximately 10:30-11:00 p.m., so Patient #1 could get some rest. He left for the night, and at approximately 1:10 a.m., he received a text from Patient #1 stating that a "strange baby" was brought into the room, but Baby #1 was fine. The next morning Patient #1 told him that at approximately 12:45 a.m., Employee (J) brought Baby #2 into the room in a bassinet, and stated that she needed to be fed. Employee (J) asked Patient #1 for the serial number on her ID tag, to confirm a match with the numbers on the baby's ID tag. Patient #1 was "half asleep" and did not have her glasses on. Patient #1 gave her arm to Employee (J) who stated that the numbers matched, and handed her Baby #2. Patient #1 attempted to nurse Baby #2 for approximately twelve minutes, but Baby #2 would not latch on, so she went to change her diaper, and noticed that the nametag on the bassinet was not the name of her baby. She put on her glasses, and verified that the serial numbers on Baby #2's band did not match her baby's serial numbers. She put on her call light and stated that the baby in her room was not her baby.

Employee (J) was interviewed on 12/13/2011 at 10:15 a.m. and stated that on 6/20/2011, she brought Baby #2 to Patient #1. She woke Patient #1, and stated that she needed to read the number on her band. Patient #1 held out her arm, and Employee (J) read the number on the babies band, and Patient #1 stated "correct." She did not verify the name, or have the mother read the number on her band to verify the correct numbers on the baby's band. She handed Baby #2 to Patient #1. She stated that approximately five minutes later, Patient #1 put on her call light, and stated that she had the wrong baby. Employee (J) stated that Patient #1 was tired and sleepy, and didn't look at the numbers correctly. She stated that the protocol is for the mother to read the numbers to staff, and Employee (J) stated that she read the numbers to Patient #1 on the night of 6/20/2011.

Employee (K)/nurse was interviewed on 12/13/2011 at 11:04 a.m. and stated that she was notified on 6/20/2011 that a baby was brought into the wrong room. She asked Patient #1 what had occurred, and was told that Baby #2 was brought into her room, and Employee (J) asked Patient #1 what numbers were on the bracelet. Patient #1 stated she couldn't see the numbers, and it was dark, so Employee (J) read the numbers to Patient #1, and Patient #1 agreed that they were the numbers that Employee (J) read to her. Patient #1 stated to her that she went to change the diaper of Baby #2, and noticed the wrong last name on the bassinet.

Individual (M) was interviewed on 12/22/2011 at 7:17 a.m. and stated that on 6/20/2011 at approximately 11:00 p.m., he left the hospital, and Baby #2 was transferred to the nursery. Approximately 45 minutes later, Baby #2 was brought into Patient #2's room to nurse, and was told that Baby #2 was just brought into another patient's room for approximately 5-10 minutes, and they wheeled her back out of the room when they realized that it was the wrong room. The following day, Employee (B) came into their room, and asked if they were "OK" with the incident the previous night. He stated that they were not told, until four days after they left the hospital, that Employee (J) left Baby #2 in the room with Patient #1, or that she had attempted to nurse Baby #2. They were told, at this time, that Employee (J) did read the identification number to Patient #1, but when she read the number, she was "one digit off" and Patient #1 repeated the wrong number back to her. When they were admitted to the post partum unit, they were informed of the system for baby transfers to the nursery or to tests. The procedure consisted of the mother/father reading the patient identification number from their identification band on their wrist to the staff person, and verbalize the name on the band. The staff person will verify the number and name on the baby's identification band with the number and name verbalized by the mother/father.

The policy entitled Identification of Newborn Infants, dated 8/10/2011, documents "when infant is brought to the mother/mother's designated person, the mother/mother's designated person will read the identification band number and last name to the nurse or designee. The nurse or designee will verify that the information matches the name and identification band number on the infant's identification band. If the mother/mother's designated person is unable to read the information, one nurse or designee will read the name and identification band number to another nurse or designee to verify the information.

Corrective action was initiated by the facility following the incident included a safety alert email sent on 6/24/2011 to all members of the Obstetrics staff outlining the correct procedure of the Mother/Infant identification process, management staff met one-to-one with every nursing assistant who works in Obstetrics to review the correct procedure policy. The information was reviewed at staff meetings. An additional infant security system will be implemented following staff training. The system will include a tag worn by the mother, and will chime if right baby/mother. The tag will not chime if not right mother/baby. The new infant security system was being installed, and tested at the time of the visit, and training was in process, but the system had not been implemented.