HospitalInspections.org

Based on observation, document review, and interview, the facility did not utilize its Quality Assurance Program to identify problems with the security of infants and implement plans of corrections to ensure patient safety.

Findings include:

Review of the facility "Risk Assessment for Security" conducted on 5/15/15 revealed that the Neonate Intensive Care Unit (NICU), Mother Baby and Labor and Delivery Units are at significant security risk for infant abduction.

On 8/29/17 at approximately 2:00PM, during a tour of the NICU, Staff A, Nurse Manager stated that a security band is placed on each infant upon admission to prevent infant abduction. Staff A demonstrated the infant abduction system utilizing a baby doll with a security sensor attached to the doll's wrist. The security alarm activated when Staff A, holding the doll approached each exit door, including stairway doors and elevators.

During the testing of the Infant Abduction System, Staff A was asked to demonstrate a different scenario where the band was cut or removed by an abductor. Staff A stated, "If you cut the band, the Infant Abduction System will not work, the band has to be on the doll for the alarm to activate."

Review of document titled "Code: Pink-Infant/Child Abduction for 2015, 2016, and 2017 showed that in 2015 four drills were conducted, fifteen drills in 2016 and ten drills in 2017. All twenty-nine drills used the same scenario where an infant is abducted with a security band in place.

There was no documentation that the facility explored other scenarios in order to identify vulnerabilities in its safety plan that relies solely on activation of an alarm when a baby is wearing an intact sensor.

During interview with Staff G, Director of Security on 8/29/17 at approximately 3:30 PM, staff stated that he is aware that the Infant Abduction System will only activate when the sensor is on the baby. He acknowledged the facility has not considered other scenarios when conducting mock codes for infant/child abduction.