HospitalInspections.org

Based on record review and interview the facility failed to ensure prompt notification and involvement in care of parent/guardian of a suspicious bruise on an infant and failed to provide policy to staff to include prompt notification of parent/guardians when injuries on unknown origin were identified in 1 of 1 medical record reviewed (Patient #1).

Findings include:

The facility policy titled "Caregiver Misconduct Investigations and Reporting" #4.47, effective date October 1, 2016 was reviewed on 4/13/18 at 10:00 AM. Review of caregiver policy revealed no direction or protocol for notifying the family/guardian of minors identified to have injuries of unknown origin.

Patient #1's medical record was reviewed on 4/10/18 at 11:15 AM "Consult Note" dictated by Medical Director Child Protective Program K on 6/9/17 at 4:33 PM documented "Around 9:30 PM last evening, an area of slightly darkened skin on the left later back was noted and brought to the attention of the overnight NICU (neonatal intensive care unit) fellow, who left a note which states the size of the lesion was 2 cm x 3.5 cm and oval in shape. No active trauma has been witnessed during (Patient #1) stay at AFCH NICU (American Family Children's Hospital), and [he/she] has not had any monitors or procedures done in the area of question. [He/she] has not appeared in any distress to NICU staff."

An interview was conducted on 4/13/18 at 2:02 PM with Regulatory and Accreditation Specialist B in regards to delayed notification of parent of area on Patient #1's back stated "The bruise was noticed on 6/8/17-we had the nurse and physician come in an see the bruise right away. On 6/9 Medical Director Child Protective Program K and [his/her] team came in to do an investigation."

Per medical record review of nursing and physician notes, no documented notification of parent/guardian of area on Patient #1's back from the time of discovery on 6/8/17 at 9:33 PM until 6/10/17 at 7:07 AM.