HospitalInspections.org

Based on interviews, and document review, it was determined the facility staff failed to report suspicion of abuse for four (4) premature infants in the Neonatal Intensive Care Unit (NICU) within twenty-four (24) hours of having reason to suspect a reportable offense of child abuse, as per the facility's policy and the state law.

Findings:

On 9/21/2023 at 10:36 a.m., the surveyors entered the facility to investigate facility reported incidents (FRI) of bone fractures among four (4) premature infants in the facility's Neonatal Intensive Care Unit (NICU) from 8/5/2023 through 9/5/2023.

On 9/21/2023 at 11:22 a.m., Staff Member (SM) 2 (Vice President of Quality) stated that the facility considered the discovery of bone fractures in four (4) premature infants in the NICU, between 8/5/2023 and 9/5/2023, a "safety event" and made two (2) telephone calls and sent one (1) email to the Department of Social Services (DSS) on 9/20/2023 to report the possibility of abuse. SM2 stated the facility also notified The Joint Commission "simply because of what happened." During an interview on 9/21/2023 at 11:22 a.m., SM2 stated the staff became aware of Patient #3's fracture, a "closed displaced transverse fracture of the shaft of left radius" on 8/5/2023. SM2 stated the fracture was an "incidental finding" on a "babygram (skeletal x-ray of an infant)." Patient #2 had a "fracture of the right radius and ulna" on imaging from 8/16/2023, a "6th right rib fracture" on imaging from 8/29/2023, and "minimally displaced fx [fracture] of left femoral metaphysis [the wide portions of long bones and the regions of the bone where growth occurs in the upper part of the leg (www.radiopaedia.org/articles/metaphysis)]" on imaging from 8/29/2023. Patient #1 had a "nondisplaced physeal fracture [involves the growth plate (www.radiopaedia.org/articles/physeal-fracture)] of the left tibia [larger long bone in the lower leg]" on imaging from 9/3/2023. Patient #4 had a "left radial [larger bone in lower arm that connects your forearm to your wrist (www.clevelandclinic.org)] buckle fracture [incomplete shaft of a long bone characterized by bulging; a compression fracture caused by sudden pressure on a bone (www.clevelandclinic.org)] on imaging from 9/5/2023.

During an interview on 9/26/2023 at 11:08 a.m., SM2 confirmed that DSS and the Virginia Department of Health (VDH) were notified of the multiple NICU babies with fractures on 9/20/2023. The surveyor asked SM2 why there was a delay in reporting the fractures to DSS and SM2 stated that they conducted interviews and had "outside experts" including consults with a radiologist, a geneticist, and a Neonatologist, and they retained a pediatric radiologist and a pediatric orthopedist, to investigate.

During an interview and review of x-ray imaging of Patient's #1, #2, #3, and #4's fractures on 9/22/2023 at 1:45 p.m., SM24 (Radiologist) stated that all fractures documented on the imaging reports were in fact fractures as per SM24's review. SM24 stated that one patient with fractures could be related to genetic or medical concerns, but having three (3) patient's with fractures would be a concern for trauma.

A review of the x-ray report for Patient #1 from 9/5/2023 contained the documentation "There is mild angulation and bands of increased density within the distal left radius with adjacent periosteal reaction consistent with a "buckle" fracture. There is mild angulation of the distal ulnar metaphysis as well. Concern for nonaccidental trauma is raised."

A review of the Orthopedic Physician's Consult note from 9/6/2023 contained the documentation "We have discussed with the NICU team that non accidental trauma needs to be considered. Treatment will be okay and sufficient with the AFO [ankle and foot orthoses] type splint that has been made by occupational therapy. I recommend a skeletal survey [x-ray of entire skeleton] to ensure that there are no other issues identified. We will repeat x-rays of the left lower extremity at three weeks and it may take longer given [the baby's] prematurity."

A review of the spreadsheet documenting information related to the patients' fractures from SM2 contained the documentation for Patient#1 "healing fx [fracture], pattern remains concerning for nonaccidental trauma until proven otherwise."

The concern about the delay in reporting suspected abuse to the local DSS was discussed with SM1, SM2, SM3, SM23, and Legal Council at the exit conference on 9/26/2023 at 2:45 p.m. SM1 stated that they were unsure whether or not they needed to report the above cases to DSS. Legal Council clarified that the surveyors were stating that for mandated reporting, the mandated reporters are required to report suspicion of abuse to DSS within twenty-four (24) hours and not notify VDH.

A review of the facility's policy titled "Abuse and Neglect" states in part:
... Responsible Persons: All health care professionals are legally responsible for reporting all suspected child or adult/elder abuse neglect and exploitation and certain injuries from domestic violence. This includes the following persons:
A. Any person licensed to practice medicine or any of the healing arts,
B. Any hospital resident or intern,
C. Any person employed in the nursing profession,
D. Any person employed as a social worker,
E. Any mental health professional, and
...
A. Reporting
1. Reporting Child and incapacitated Adult/Elder Abuse, Neglect or Exploitation. Mandated reporters directly involved in the care of the patient must report all suspect abuse, neglect, and exploitation of adults and children within [twenty-four] 24 hours, to the local welfare/social services agency of the county or city where the individual resides, or where it is believed to have occurred....

A review of the Code of Virginia "§ 63.2-1509. Requirement that certain injuries to children be reported by physicians, nurses, teachers, etc.; penalty for failure to report." stated in part:

A. The following persons who, in their professional or official capacity, have reason to suspect that a child is an abused or neglected child, shall report the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Department's toll-free child abuse and neglect hotline:
1. Any person licensed to practice medicine or any of the healing arts;
2. Any hospital resident or intern, and any person employed in the nursing profession;
3. Any person employed as a social worker or family-services specialist;
...
If neither the locality in which the child resides nor where the abuse or neglect is believed to have occurred is known, then such report shall be made to the local department of the county or city where the abuse or neglect was discovered or to the Department's toll-free child abuse and neglect hotline.
...
If the information is received by a teacher, staff member, resident, intern or nurse in the course of professional services in a hospital, school or similar institution, such person may, in place of said report, immediately notify the person in charge of the institution or department, or his designee, who shall make such report forthwith. If the initial report of suspected abuse or neglect is made to the person in charge of the institution or department, or his designee, pursuant to this subsection, such person shall notify the teacher, staff member, resident, intern or nurse who made the initial report when the report of suspected child abuse or neglect is made to the local department or to the Department's toll-free child abuse and neglect hotline, and of the name of the individual receiving the report, and shall forward any communication resulting from the report, including any information about any actions taken regarding the report, to the person who made the initial report.
...
D. Any person required to file a report pursuant to this section who fails to do so as soon as possible, but not longer than 24 hours after having reason to suspect a reportable offense of child abuse or neglect, shall be fined not more than $500 for the first failure and for any subsequent failures not less than $1,000. In cases evidencing acts of rape, sodomy, or object sexual penetration as defined in Article 7 (§ 18.2-61 et seq.) of Chapter 4 of Title 18.2, a person who knowingly and intentionally fails to make the report required pursuant to this section shall be guilty of a Class 1 misdemeanor.

Based on interviews and document review, it was determined the facility staff failed to adhere to the facility's policies and procedures, specifically related to documentation of obtaining labs.

Findings:

On 9/21/2023 at 10:36 a.m., the surveyors entered the facility to investigate a complaint involving the Neonatal Intensive Care Unit (NICU) from 8/5/2023 through 9/5/2023.

During an interview on 9/22/2023 at 9:46 a.m., while discussing lab draw or intravenous (IV) catheter insertion procedures, Staff Member (SM) 6 stated that staff are unable to determine who obtains labs from the patients and they do not have a way to "track that piece." SM6 stated that the staff does not necessarily document who drew the labs, because one staff member may print the labels and another staff member may perform the procedure.

During an interview on 9/26/2023 at 10:17 a.m., SM22 stated that the facility's lab verification system, called Mobilab (barcode specimen collection system), documents the staff member that printed the patient lab labels but does not document the staff member that performed the procedure. SM22 stated that the staff members use Mobilab to scan the patients' identification band and to print the lab labels. SM22 stated that sometimes the staff will use a patient label to label the lab specimens, instead of printing from Mobilab, and then put their initials on that label. SM2 stated that the nurses would document the details of the lab draw in the nursing notes, but SM2 was unable to locate that documentation in the medical records. SM22 showed the surveyor the instructions for Mobilab on SM22's laptop, but SM22 stated that SM22 was unable to print that document for the surveyor. The document stated that for documentation of the procedure to refer to the facility's policy. SM2 and SM22 were unable to locate where the lab draw information is documented as per the facility's policy titled "Blood Collection: Infants" which states in part "... Venipuncture ... Double check lab label with second nurse in NICU for correct patient and specimen.... Label specimen with date, time, initials ([two] 2 RN's for NICU) .... Document procedure, site and pain scale in nurses notes ... Capillary Puncture ... Double check lab label with second nurse for correct patient and specimen ... Label specimen with date, time, initials ... Document procedure, site and pain scale in nurses note ..."

During an interview on 9/26/2023 at 10:40 a.m., SM18 stated that the staff sign in to the Mobilab system and Mobilab recognizes that specific staff member for documentation. SM18 stated that "all blood draws are assumed to be venipuncture," but if it's a blood culture then a source will be listed, and if it's umbilical cord blood it will be ordered as "cord blood." SM18 stated that Mobilab takes into account the two (2) RNs confirming the patient's identity. SM18 then stated that SM18 does not know if the nursing staff is using the second RN verification in the NICU as per the facility's policy, but that the second RN verification is "not happening with Mobilab." SM18 stated that if the nursing staff is not using Mobilab then they must enter their facility identification (ID) number and initials, and the lab will document "collected by nurse (CBN)." SM18 stated that Mobilab documents the staff that is logged in to the system. SM18 stated that Mobilab went live on 6/6/23. SM18 stated that the lab draw is not documented anywhere unless the nursing staff are documenting it in the nursing flow sheets or nursing notes. SM18 stated that if "CBN" is documented, then there is no way to distinguish who drew the labs. SM18 stated that there have been times when the lab received multiple hemolyzed specimens on one shift, for example. The lab had to determine who drew the labs by looking at the initials on the lab specimens, so that they could reeducate the staff member. SM18 stated to ask the NICU director to determine which lab draw supplies the nurses were using on NICU babies and if they were using any new or different supplies.

During an interview on 9/26/2023 at 11:04 a.m., SM21 (NICU Manager) stated that two (2) RNs initial on the lab label for patient identification. SM6 (NICU Director of Nursing) stated that Mobilab checks the two (2) patient identifiers and SM6 was told that the nurses "don't have to sign anything anymore." SM6 stated that "I don't know that I document anything in the chart, just what Mobi" documents. SM6 stated that Mobilab has no place to document the site where the blood was obtained or if it was venipuncture or capillary. SM21 stated that the lab result report does not state the location on the body or type of blood vessel accessed, and it is "not necessarily documented in CPN (the facility's obstetrics and baby documentation system). SM6 stated that the nursing staff rotate heel stick sites, but you would only know which foot was stuck last based on which foot the Band-Aid was located on the patient. SM6 stated there would be no documentation in the medical record.

A review of the facility's policy titled "Testing Blood Glucose in Newborns at the Bedside" states in part:
... Documentation: Update patient's plan of care and medical record, as appropriate. Include: Date/time of blood glucose measurement ... Procedure description, including device used and puncture site location ...

A review of the facility's policy titled "PH-37 Mobilab Positive Patient Identification for Specimen Collection" states in part:
... Identify according to hospital policy using two identifiers... SM22 stated that SM22 was unable to print this document.

A review of the facility's policy titled "Blood Collection: Infants" which states in part:
... Procedure: A. Venipuncture: ... 2. Procedure: ... c. Double check lab label with second nurse in NICU for correct patient and specimen.... r. Label specimen with date, time, initials ([two] 2 RN's for NICU) and place in biohazard bag.... t. Document procedure, site and pain scale in nurses notes.... B. Capillary Puncture: ... 2. Procedure: ... b. Double check lab label with second nurse for correct patient and specimen.... k. Label specimen with date, time, initials and place in biohazard specimen bag... m. Document procedure, site and pain scale in nurses note....