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Based on observation, document review, and interview, it was determined that the Hospital failed to ensure that patient rights were protected. This potentially places current, and future infants admitted to the Hospital at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure care was provided in a safe setting by not following the Hospital's process during a code pink (infant abduction). See deficiency cited at A-144-A.

2. The Hospital failed to ensure that safety of an infant (Pt. #1) by not properly managing the use of MyChild alarm (electronic sensor to prevent infant abduction), therfore allowing for (Pt. #1) to be abducted from the unit and taken from the hospital. See A-0144 B.

The immediate jeopardy began on 7/10/2020, due to the Hospital's failure to ensure policy and process for infant/child security, management of My Child alarm, and infant abduction (Code Pink) policies were appropriately followed. This was identified on 7/16/2020 at 42 CFR 482.13, Patient Rights, and the IJ was announced on 7/16/2020 at 4:10 PM, during a meeting with the Chief Operating Officer and the Chief Quality Officer. The IJ was not removed by the survey exit date of 7/16/2020.

A. Based on document review, video surveillance review, observation, and interview it was determined that the Hospital failed to ensure care was provided in a safe setting by not following the Hospital's process during a code pink (infant abduction). This affects all current and future infant patients admitted to the Hospital for potential serious harm.

Findings include:

1. The Hospital's policy, "Infant-Pediatric Abduction-Code Pink" dated 08/2017 was reviewed and included, " ...to mobilize security and all hospital personnel in the event there is a kidnapping or missing infant or child ...all department play a significant role in the successful implementation of this policy ...an infant being carried- not transported in bassinet ...carrying large packages (e.g. gym bags) off maternity unit, especially if they are "cradling" or talking to the parcel ...immediately search the entire unit ... designate personnel to man the exits ..."

2. The Hospital's process for "Infant/Child Security" (undated) was reviewed and included, " ...7. A. While a code pink is in process: a. Patients and visitors may not enter or exit the (name of the unit); b. staff should try to prevent anyone leaving the hospital campus that has an infant/child with them ... 9. While working in the hallway you hear the door alarm ... You should ... b. Personally visualize ... to make sure that no one has exited ..."

3. On 07/14/2020 at approximately 1:00 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a newborn baby boy delivered on the Labor and Delivery Unit on 07/09/2020 at 12:33 AM.

4. On 7/14/2020 at approximately 1:30 PM, the clinical record of Pt. #2 (Pt. #1's mother) was reviewed. Pt. #2 was a 21-year-old female admitted to the Hospital on 7/8/2020.

5. On 7/14/2020 at approximately 1:35 PM, the Hospital's incident report written by E #7 (Manager, 2nd floor New Family Center (Labor and Delivery/Post-partum Unit, and Nursery) for Pt. #1, on 7/10/2020 at 3:30 PM was reviewed. The report included, " ... Mother (Pt. #2) of (Pt. #1) was to be discharged. (Pt. #1) was to remain in hospital for phototherapy (treatment to reduce yellowish skin discoloration) ... They (Pt. #1 and Pt. #2) left while the door was opened for a visitor. The elevator doors (elevators #3 and #4) were opened as they rounded the corner and proceeded to get on the elevator ... The staff identified who left the unit ... Code Pink was initiated. The front desk stated they had already pulled away (Pt. #1 and Pt. #2 have left the hospital) ..."

6. The Hospital's "Code Pink" report dated 7/10/2020 indicated that code pink was called at 3:33 PM and was canceled at 3:34 PM, although Pt. #1 have not been located by the Hospital staff. The document also indicated that code pink was initiated approximately 5 minutes after Pt. #1 and Pt. #2 have left the Hospital building.

7. On 7/15/2020 at approximately 9:00 AM, the video surveillance footage for the 2nd floor New Family Center and Hospital's main lobby , on 7/10/20, between 3:25 PM to 4:24 PM was reviewed. This was the timeframe when Pt. #1's abduction occurred. The surveillance video showed:

- At 3:26 PM, Pt #1 and Pt. #2 left the unit (secured/locked unit) through the unit's main entrance/exit door escorted by an unidentified male person.
- At 3:27 PM, Pt. #1, Pt. #2 entered the 2nd floor elevator (elevator #3 and #4).
- At 3:28 PM, Pt. #1 and Pt. #2 exited the Hospital's thru the main lobby.
- At 3:33 PM, Public Safety Officer (PSO) allowed 2 persons with bags to exit the building without checking their bags.
- Nobody was seen manning the 2nd floor elevator (elevator #3 and #4) during the code pink.

8. On 7/15/20 at approximately 9:30 AM, a video surveillance for 7/14/20 from 2:23 PM thru 2:27 PM was reviewed for staff response during a code pink. The video surveillance showed from 2:25 PM thru 2:26 PM, the 2nd floor elevator remained unsupervised (manning) during the code pink.

9. On 07/14/2020 between 2:00 PM and 2:30 PM, observation of staff's response to code pink at the Hospital's main lobby was conducted. During the observation, interviews were conducted with the Public Safety Officers (PSOs) E #4 and E #5. E#4 stated, that he identified two visitors with a backpack and a duffle bag, as construction workers, but did not check their bags before they left the Hospital building. E #5 stated, "We should have checked their bags as they can carry a baby in it."

10. On 7/15/2020 at approximately 9:30 AM, an interview was conducted with E #2 (Charge Nurse, 2nd floor New Family Center on 7/10/2020). E #2 stated that she (E #2) ordered the code pink to be cleared, although both Pt. #1 and Pt. #2 were not yet located by the Hospital.

11. On 07/15/2020 at approximately 10:20 AM, the Director of Public Safety Officer (E #10) was interviewed. E #10 stated, "Whenever there is a code pink we must be manning all the elevators and exits to the building. If any visitor is trying to leave the building, we must assess and check if they are carrying any bags."

B. Based on document review and interview, it was determined that the Hospital failed to ensure an infant's (Pt. #1) safety by not managing properly the use of My Child alarm (electronic sensor to prevent infant abduction), therefore allowing for (Pt. #1) to be abducted from the unit and taken from the Hospital. This potentially affects all current and future infant patients.

Findings include:

1. The Hospital's process for "Infant/Child Security" (undated) was reviewed and included, " ... 9. While working in the hallway you hear the door alarm ... You should ... b. Personally visualize ... to make sure that no one has exited ..."

2. On 07/14/2020 at approximately 1:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a newborn baby boy delivered on Labor and Delivery Unit on 07/09/2020 at 12:33 AM.

3. The Hospital's document titled, "My Child Sensor Tag # E20F42 (My Child alarm) - Tracking Log" dated 07/10/2020 was reviewed. The document included the tracking of sensor tag #E20F42 (fastened on Pt. #1's abdomen). The document indicated that Pt. #1 was by the unit's main entrance door from 3:25 PM until 3:27 PM. The document also indicated that the main entrance door of the unit was opened while the door was alarming.

4. The Hospital does not have a policy and procedure related to the My Child sensor tag that is used in the Hospital.

5. On 07/14/2020 at approximately 1:45 PM, the Supervisor of Clinical Engineering (E #3) was interviewed. E #3 stated, "...We are able to track the sensor tag location, alarm or alerts, and action by the staff. On 07/10/2020, our log indicates that while the tag #E20F42 was alarming, the Unit Secretary (E #11) opened the main lobby exit doors to the elevator..."

6. On 7/15/2020 at approximately 9:30 AM, an interview was conducted with E #2 (Charge Nurse, 2nd floor New Family Center on 7/10/2020). E #2 stated that she (E #2) heard the door alarm going off and saw people leaving the unit. E #2 said that E #11 (Unit Secretary) unlocked the main entrance door for these people to leave the unit while the My Child alarm was triggered. E #11 stated that staff should have checked the unidentified persons leaving the unit as the baby's security alarm was causing the door alarm to go off.

7. On 07/15/2020 at approximately 11:20 AM, the Unit Secretary (E #11) was interviewed. E #11 stated, " I saw a male person trying to open the main exit door, before I could let the visitor buzz out of the unit, the door alarm went off. I turned off the door alarm since it was a visitor. Instantly, when the visitor left the unit, the My Child Sensor tag alarm went off. Along with the visitor, there was a woman who went out of the main exit door. I did not see their faces ... I did not know it was mom (Pt. #2) and I did not see the baby (Pt. #1) that was on her chest." E #11 stated that she (E #11) did not personally visualize the unidentified persons who left the unit while the door alarm was going off as a result of the My Child sensor that had been triggered.

8. On 7/15/2020 at approximately 2:00 PM, an interview was conducted with E #9 (Chief Quality Officer). E #9 could not provide specific policy and procedure as well as training provided to staff related to the use of My Child alarm.