HospitalInspections.org

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Based on observation, record review and staff interview in three (3) of three (3) Units, the facility failed to have a functioning Infant Abduction Alarm System in place.

This places all newborn patients at potential risk for abduction.

Findings:

See Tag A 144
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Based on observation, staff interview and review of procedures, it was determined that the facility failed to ensure a safe environment for infants. The facility failed to have a system in place for the protection of infants in order to minimize the potential risk for harm or abduction on three (3) of three (3) Units housing infants.

The facility's failure placed all infants at risk for abduction.

Findings:

Observations in the facility's 3 Katz Mother Baby Unit during a tour between 10:00AM and 1:00PM on 10/29/15 identified the following:

An interview on 10/29/15 at 10:30AM on the 3 Katz Mother Baby Unit with Staff Members D, O, E and F revealed that the facility has three (3) Mother Baby Units and Nurseries. All Units are Secured Units requiring visitors to be identified and buzzed in by staff. Staff assigned to the Unit can access the Units via Employee Swipe Cards. There is a Staff Service Elevator with access to and from Labor & Delivery (L & D) on Level 3, to Levels 4 and 5 only. The 3 Katz Mother Baby Unit has ten (10) multiple Entrances and Exits to and from the Unit.

All Units utilize the "Safe Place Smart Sense Technology" Alarm System to protect and track newborn infants. Staff F stated that this system has been around for about five (5) years. A transmitter and band are placed around an infant's ankle. The transmitters are electronically linked to a computer tracking system which activates Alarms. The Alarms are heard throughout the Unit where it originates, but can be visualized on the monitors on all three (3) Mother Baby Nurses' Stations and at the Security Station where there is a slave monitor. The Unit's Alarm Monitors are observed by the CSS Staff (Unit Secretary). If an infant is brought too close to an Entrance or Exit Door, the transmitter will cause that door to automatically lock on approach, and a Low Chirping Alarm will sound to notify staff to check the immediate area.

The door will remain locked unless consistent pressure is applied for 15 (fifteen) seconds, after which time the door will open. On 10/29/15, Staff P stated "Delayed Egress" is a requirement within the Fire Life Safety Code. If the door is opened after the pressure is applied for fifteen (15) seconds, the Chirping Alarm will immediately change to a Loud Consistent Alarm to signify a "Door Breech". A Red Alarm Notice will display on the Alarm's Monitor at the three (3) Nursing Stations and in Security. Security will respond to the Door Breech Alarm by immediately dispatching an Officer and placing a phone call to the Unit.

Staff F explained the Alarm System also has 2 (two) other Alarms. A Chirping Alarm will sound to signify the transmitter is losing contact with the infant's skin and displays as a Yellow Alarm on the Alarm's monitor. This Chirping Alarm is meant for the staff to check the band on the infant and make any necessary adjustments. If the band is not adjusted, loses complete contact with the skin, or is cut, then a loud Siren Alarm will sound and display as a Red Alarm on the Alarm's monitor. Staff F stated Security does not respond to the Yellow Chirping or Red Siren Band Alarms unless the Alarms are not addressed by staff and continue to ring or a pattern is noticed.

Inspection of the facility's Infant Security System was conducted with Staff Members D, O, E and F.

The first simulation test on 3 Katz was performed at 12:25PM. Staff O placed the transmitter on her finger. When the transmitter was completely removed, it did not alarm for forty-eight (48) seconds, although it had lost contact with the skin. The Alarm registered as a Yellow "Check Band" Alarm and a chirping sound was heard. The Alarm never escalated to a Red Alarm "Band Off".

The second simulation test was performed at 12:32PM. Staff O again placed the transmitter on her finger. When the transmitter was slid completely off, it did not alarm for seventeen (17) seconds. At seventeen (17) seconds, the chirping sound could be heard and a Yellow "Check Band" Alarm was displayed on the monitor. The Yellow "Check Band" Alarm failed to escalate to a Red "Band Off" Alarm for four (4) minutes and forty-five (45) seconds after the transmitter had been removed. The Doors and Elevators did not lock.

The third simulation test was performed at 12:55PM. The transmitter band was cut from Staff O's finger. After two (2) seconds, the Red Loud Siren was heard. The Doors and Elevators did not lock. Staff F stated "The Doors are not going to lock with this Alarm. Only the tag [transmitter] will activate a Door lock down". When asked if it were possible for someone to slide off an infant's transmitter, leave it in a room, and walk through any Entrance or Exit Door with an infant, Staff F replied "Yes, I suppose that may be possible".

Interview on 10/29/15 at 1:10PM with Staff A revealed that CSS staff observe the Alarm Monitors and notify the Nursing Staff when an Alarm is received. She advised that the Nurse or the Aide would be notified when she receives an Alarm. When asked if she would call Security for an Alarm, she stated "Not always because Security calls if the Alarm keeps going". This was validated by Staff Members O and D.

Observations on the facility's 4 Katz Mother Baby Unit during a tour between 2:00PM and 3:00PM on 10/29/15 identified the following:

The simulation test on 4 Katz was performed at 2:22PM. Staff placed the transmitter on their finger. When the transmitter was completely slid off, it did not alarm for thirty-one (31) seconds. After thirty-one (31) seconds, the Chirping Alarm was heard, but at a very low volume and it was inaudible at the far ends of the hallway. The Alarm Chirping Sound did not escalate to a loud Red Siren Alarm for five (5) minutes and thirty (30) seconds and all of the Doors remained unlocked.

On 10/29/15 at 2:35PM Staff G stated that if an Alarm is received she would "Look to see who is alarming and find the Nurse to check the baby and if the band is on the baby". When asked if the Nurse cannot be found or isn't available, Staff G stated she would look for the PCA (Aide) or "Get up and check myself". When asked what she would do if there was no baby found, Staff G replied "I would check the Nursery and then call Security".

When asked if she had any responsibilities that may take her away from her desk, Staff G stated "I usually stay at the desk...I may go to the Nursery to drop off papers or get supplies, but sometimes the Charge Nurse or another Nurse may cover". Later in the interview, she stated "Sometimes I have to leave the desk unmanned". This was confirmed by Staff Members Q and R.

An interview conducted with the CSS on Level 5 on 10/29/15 at 1:30PM revealed that the Unit Secretaries are responsible for viewing the Alarm System as they are sitting at the Nurses' Station where the monitors alarm. We were further advised that at night there is one (1) Unit Secretary that is split between two (2) Units; either 5 Katz and 4 Katz and 3 Katz and 3 Katz North

Observations were conducted on the facility's 5 Katz Mother Baby Unit during a tour between 2:00PM and 3:00PM on 10/29/15 and similar findings were identified when the band was removed / cut during simulations.

A review of the Quick Reference Guide for the "Safe Place Infant Child Security System" documents, under "How to Respond", to "Always follow your facility's Policies / Procedures to ensure patient safety and secure the area". The Manual lacks specific timeframes for the activation and escalation of the Alarms.

The facility lacks a Policy and Procedure to define the timeframes at which the Alarms will be activated. The facility's Policy titled "Security in the Nurseries" last revised 2013, states "An audible sound is heard when an Alarm is activated. The Door alarming will be shown on corresponding video monitors on the Nursing Units and in Security. Nursing Staff should respond to the alarming Door when heard, secure all Exits, locate all newborns, notify Security and implement the Infant Abduction Policy...". There is no documentation of the timeframes for the activation and escalation of the Alarms.

Interview on 10/29/15 at 2:50PM with Staff F revealed Internal Alarm Tag Checks are performed quarterly. He tests the tags by taking a tag to a door and ensuring that the door locks. If it locks, he checks the egress delayed release (of fifteen {15} seconds). He performs random Unit Door checks but each Unit is not checked every quarter. As per Staff Q these safety checks are documented and reported to the Safety Committee.

An interview with Staff F on 10/30/15 in the afternoon revealed that the time parameters of the Baby Monitors have not been checked in years. The facility only checks whether the Doors lock.

The Preventive Maintenance and the Quarterly Internal Alarm Check Logs for the last five (5) years stating that the Baby Monitoring System was in place were requested from Staff Members R and S on 10/29/15 at 10:00AM and again on 10/30/15 at 10:00AM. The Contract for the Monitoring System and the Purchase Agreement were also requested. This information was not received by the time the survey ended on 11/02/15.