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Based on observation, record review, and interview, it was determined that the hospital failed to protect and promote each patient's right to receive treatment in a safe setting by properly responding to baby alarms and safety systems to secure the unit from unauthorized person and testing of the systems to protect the Family Place unit.

Findings include:

Refer to A144 (Patient Rights: Care in a Safe Setting):

1. By failing to response correctly to the baby alarm,

2. By failing to bring the baby to the correct parents,

3. By failing to do monthly testing of the safety system,

4. By failing to assess all door openings for security of the unit.

Based on interview, observation, and record review, it was determined that the hospital failed to ensure that patients in the Family Place unit received care in a safe setting for 1 of 6 patients reviewed (Patient identifier is #1),

1. By failing to response correctly to the baby alarm,

2. By failing to bring the baby to the correct parents,

3. By failing to do monthly testing of the safety system,

4. By failing to assess all door openings for security of the unit.

Findings include:

Interview on 9/20/19 at 9:40 a.m. with Staff A (Director of the Family Place) revealed the following: On 9/8/19 at approximately 5:40 a.m., an infant (Patient #1) from room 404 was brought to room 419 by Staff B (Registered Nurse). Staff B did not verify the number on the mother's and Patient #1's band. The "wrong mother" alarm sounded at 5:44 a.m. (The alarm for "wrong mother" is the sound of a baby crying.) Staff B then checked Patient #1's alarm bracelet and adjusted it. (The sound of the alarm for "band detached" is a siren.) Staff C (Unit Coordinator) silenced the alarm at the nurse's station and sent a text message to Staff B via the hospital's communication system to determine the cause of the alarm. Staff B had the hospital's communication device located in their pocket and did not respond to the message. Staff B gave Patient #1 back to the parents in room 419 and the alarm sounded again and Staff C cleared the alarm again. The patient remained in room 419 for approximately 10 minutes and was fed approximately 5 milliliters of formula (prescribed to Patient #1) by the wrong parent. As Staff B was leaving room 419 (Staff B had remained in the room since she brought Patient #1 there), Staff B noticed the crib card that showed the infant belonging to the parents in room 404 and immediately removed Patient #1 from 419.

Phone interview on 10/3/19 at 12:15 p.m. with Staff B, revealed that on 9/8/19 at approximately 5:40 a.m. Patient #1 from room 404 was brought to room 419 by Staff B. Staff B did not verify the number on the mother's and Patient #1's band. The father of Patient #1( which also had a bracelet) was sitting on the couch in the room and Staff B gave Patient #1 to the father. The "wrong mother" alarm began to sound in hallway but not in the room. (Each alarm has it's own sound. The sound for wrong mother is a crying baby while the loose bracelet is a siren.) Staff B's hospital communication device was not clipped to the lapel of their shirt but in Staff B's pocket because Staff B could not find a clip. Staff C (Unit Coordinator) sent a text to determine the cause of a wrong mother alarm which Staff B did not respond to this message. Staff B checked the alarm bracelet and adjusted it and the alarm stopped. Staff B continued to set up the father of Patient #1 to help facilitate the feeding of Patient #1 with the bottle with formula. Patient #1 remained in the room approximately 5-10 minutes and was fed approximately 5 milliliters of formula (prescribed) by the wrong parent. Staff B turned around to leave room 419, Staff B noticed the name on the crib card and realized the names and room number did not match and went to the nursery and confirmed that infant belonging in room 419 was still in the nursery and immediately removed Patient #1 from room 419 and brought the correct infant to the room 419.

Phone interview on 10/4/19 at 7:45 a.m. with Staff C, (Unit Coordinator) revealed on 9/8/19 at approximately 5:40 a.m. an alarm "wrong mother" was sounding. Staff C sent a text message and cleared the alarm. Staff C did not physically check on mother and baby before clearing the alarm. Staff C is not sure if anyone physically checked on mother and baby before clearing the alarm.
Staff C revealed that all staff members that have the hospital communication devices and should be worn on the lapel of your shirt. When a wrong mother alarm sounds the unit coordinator is to verbally call the nurse responsible for that patient and tell them that a wrong mother wrong baby is occurring; not use a text message. Staff C revealed that Staff C sent a text message and not a verbal communication and has no way to verify that the nurse received the message; only that the message was sent.
Staff C revealed that the alarms have two different sounds "wrong mother wrong baby is a baby crying and a band loose is a beeping sound."


Review on 9/20/19 of the hospital's policy titled "Identification of Newborn", dated 2/11/14, revealed the following: "4.6 Presentation of the baby to the mother: On presentation of infant to mother, the nurse will say the baby's name and ask the mother for the number on her band. The nurse will read the number printed on the newborn's band back to the mother. These numbers must match for the baby to be released to the mother. This procedure is to be done each time the baby is given to the mother. 4.7 Presentation of the baby to significant others: 4.7.1 Hand washing should be done upon entering the nursery and before contact with babies. 4.7.2 The person designated to wear the fourth band [designated for the significant other] will show the number to the nursery or mother-baby nurse. These numbers must match for the baby to be released to the significant other. This procedure is done each time the baby is taken out of the nursery by a significant other."

Review on 9/20/19 of the hospital's policy titled "Hugs Infant Protection System", dated 5/27/16, revealed the following; "4.3 Procedure during Kisses alarm. 4.3.1 In the event that a Hugs alarms "wrong mother" in the presence of a mother's Kisses band, a staff member will immediately investigate the cause of the alarm. If a baby has been separated from its mother and is being brought back into a room, the nurse will double check the identification bands on both mother and baby before leaving the infant with the parent. If the baby is safely with the correct mother, then the alarm can be cleared. If the medical record numbers for mom and baby do NOT match, the staff member will immediately bring the infant to the nursery."

Observation on 9/20/19 at approximately 10:15 a.m. revealed when the doors to the South side of the Family Place were opened, the doors remained opened for approximately 20 to 25 seconds.

Interview on 9/20/19 at approximately 10:15 a.m. with Staff A revealed that the hospital had identified the length of time it took for the doors of the Family Place to completely close and the magnets to activate to secure the unit. Staff A also confirmed that they had developed a solution and would be implementing it soon.

Interview on 9/20/19 at 10:20 a.m. with Staff D (Unit Coordinator) revealed that Staff D would not clear a "wrong mother" alarm without verifying the cause with a nurse.

Interview on 9/20/19 at 11:30 a.m. with Staff E (Registered Nurse) confirmed that a "wrong mother" alarm would sound as a crying baby and a "band detached" alarm would sound as a siren.

Review on 9/20/19 of the Hugs User Guide's Instruction and Maintenance, p A-8, revealed the following: "Check the tag's warranty date on the front of the Hugs tag. The tag may have many months of use after this date, but you should exercise caution when using a tag out of warranty. Always listen for the battery status chime, and check that the tag has Auto Admitted in the Hugs system software."

Observation on 9/20/19 at approximately 11:35 a.m. of a Hugs tag not currently in use revealed that the "warranty expiration" date was 8/28/19. Interview with Staff E revealed that they were unaware of what the date indicated.

Review on 9/20/19 of an audit performed on 9/20/19 of the warranty expiration dates currently in use on infants revealed that 3 of the 12 Hugs tags currently in use were past their warranty expiration dates (two were dated 6/19/19, one was dated 8/28/19).

Observation on 9/20/19 at 1:00 p.m. while on the Family Place unit revealed that every time the nursing staff passed the stairwell doors a green light indicator would light up showing that the door security alarm magnet was deactivated. It was observed with Staff A that a staff member entered the stairwell while another staff member passed the door sensor more than 5 feet away. This unlocked the door giving the first staff member direct access to the unit from the stairwell. Staff A at the time of observation confirmed the failure in their security system.

Review on 9/20/19 of the Hugs User Guide's Instruction and Maintenance, p 7-4, revealed the following: The following should be tested "at least monthly": Tag at an open exit/elevator, tag at a closed exit/elevator, band is cut, tag is shielded, Are there any gaps in the exciter field?, are cameras in sync with Hugs, are sounds audible/visible. "Failure to undertake regular testing and maintenance will increase the risk of system failure and false reports."

Review on 9/20/19 of alarm testing at the Family Place revealed there was no evidence of the above monthly testing.

Interview on 9/20/19 at approximately 1:30 p.m. with Staff A confirmed that the hospital did not perform the above testing monthly.