HospitalInspections.org

Based on observation, review of facility documents, and staff interviews, it was determined that the hospital failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to ensure that each patient on the Mother/Baby unit received care in a safe setting. (Cross Refer to tag 144)

Based on observation, review of facility documents, and staff interview, it was determined that the facility failed to ensure that each patient on the Mother/Baby unit received care in a safe setting following one (1) out of one (1) incidence of an unauthorized person gaining entry to the secured unit.

Findings include:

Reference: Facility policy and procedure titled, Security Management Plan, states, "... C. The Hospital controls access to and from areas it identifies as security sensitive. 1. Security Sensitive areas are identified based on the potential for violence or use of weapons, vulnerable patient populations (e.g. infants, children and behavioral health) and the availability of medications, money, unsecured personal property, equipment, and supplies. These areas include Mother/Baby Unit, Pediatrics Unit, Patient Care Areas, Health Information Systems, the Emergency Department, Behavioral Health Units, Pharmacy, Materials Management, medication rooms, and cash areas. ..."

1. During an interview on 11/23/21 at approximately 10:00 AM, Staff #2 described an incident that occurred on 11/9/21. As per Staff #2, a postpartum patient's (Patient #1) estranged mother learned that Patient #1 was on the Mother/Baby Unit through a family friend who worked for Environmental Services (EVS). The unauthorized visitor was able to enter the Mother/Baby unit without identification and entered Patient #1's room before leaving when Patient #1 screamed.

2. An "L&D/M/B Weekly Update 11/7-11/13 2021" states, "... Safety Concern: We had a visitor wearing blue scrubs and no badge walk into the Center for Childbirth, proceed to the elevators, and arrive on one of our floors. She pushed the doorbell, and was let into the unit, and proceeded to a patient room. This unauthorized visitor was estranged from her daughter, has a psychiatric history, and has threatened the patient with a weapon in the past. ... The significant other who was also in the room, never met the mother, and stated that she thought the visitor was a nurse. If the patient was in the bathroom and the visitor had said she wanted to take the baby, the significant other would have handed over the baby. ..."

3. During a tour of the Mother/Baby unit conducted on 11/23/21, Staff #2 identified an area of the nurse's station where a technician would normally sit to answer the unit doorbell. There were no staff members present in the area at the time and Staff #2 stated that the technician has other responsibilities that can take them from the desk. At 10:24 AM, this surveyor then exited the Mother/Baby unit and the rang the doorbell for entry. A staff member spoke to the surveyor via the intercom and did not allow the surveyor entry to the unit. Staff #15 then approached the surveyor outside of the unit and asked if the surveyor needed to go onto the unit. Staff #15 then used his/her identification badge to open the door without asking the surveyor for identification or checking for a band. Upon entering the unit, the surveyor introduced himself/herself to Staff #15 and asked how staff identifies individuals permitted entry to the unit. Staff #15 stated that usually visitors who are allowed onto the unit are wearing a band. Staff #15 stated that he/she did not ask to see a band because he/she thought the surveyor worked for DYFS (Division of Youth and Family Services) and that is why he/she was escorting the surveyor onto the unit.

a. The above was confirmed with Staff #2.

4. A review of education provided to Center for Childbirth staff on unit security included the following education:

"- Must check all visitors on arrival to unit
- Support people should have a blue band and baby band (if baby is born)
- Ask anyone you do not know to be a part of the unit who they are and why they are here
- Staff from other units should not be here without proper reasoning
- Remind all staff badges must be worn visible and above waist."

a. A review of the staff sign-in sheet for the above education indicated that Staff #15 had received education on 11/23/21.

b. During an interview on 11/24/21 at 11:34 AM, Staff #24 stated that Staff #15 had received the above education on 11/23/21 at 8:00 AM, prior to allowing the surveyor onto the unit without identification.

5. Upon request for evidence that security personnel had received education regarding the above incident that occurred on 11/9/21, Staff #7 provided email communication that indicated that security staff would receive education but did not indicate how or when the education would be received. Upon request, the facility could not provide evidence that security personnel had received the education. Staff #7 stated that the education was conducted "verbally".

The above findings resulted in an Immediate Jeopardy (IJ) on 11/23/21. The IJ template was provided to Staff #6 at 4:10 PM, and a removal plan was requested. An IJ removal plan was provided by the facility on 11/24/21 at 10:25 AM and was accepted.

On 11/24/21, it was determined that the facility took the following steps to remove the immediacy of the IJ: a 24/7 security post established outside of the Mother/Baby unit, enhanced video surveillance of the Mainland lobbies and doors outside the Mother/Baby unit, a modified route of transit so all visitors enter through the front door of the Mother/Baby unit, enhanced visitor screening process, education to all staff prior to start of shift, leadership rounding to reinforce safety practices, education to all security and patient experience staff regarding visitor "vetting", infant abduction drills, safety huddle messaging, and employee counseling. The facility provided proof of education, a tour, and staff interviews were conducted. It was determined that the IJ removal plan was successfully implemented and the IJ was removed on 11/24/21.