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Based on observation, staff interviews, and review of procedures it was determined the facility failed to ensure the proper functioning of electronic transponder system that tracks the safety of the pediatric patients on the fourth floor.

Specific reference is made to findings related to the malfunctioning of an otherwise operational surveillance system in place for protection of infants and young children after unrelated repair work was conducted in the ceiling of that floor.

Findings include:

During the tour on the 4th Floor of the Pediatric Unit in the afternoon of 05/19/15 at approximately 2:50 PM, it was observed that the facility's electronic transponder system, provided to augment safety and tracking of Pediatric patients on the 4th Floor, malfunctioned when an attempt was made to activate the system.

At approximately 2:50 PM transponder #F17B86 was removed by a staff nurse and was carried out of the first exit door, to intentionally breach the system, by the Assistant Vice President Of Ancillary Services. An Alarm sounded at the exit door indicating that the door was opened, but a visual pop alarm and an audio alarm appeared on the monitors at the nursing station #42 after a delay of 10 minutes.

Intentional breaching of the system was repeated at approximately 3:00 PM, and it was noted that there was a 10 minute delay before audio and visual popups appeared on the monitor. However, it was observed that the sensors were working, as evidenced by the inability of the staff member to exit the unit with the transponder.


The facility called the vendor in to fix the system and identified that the malfunction of the system was due to mis-wiring of the receiver that was installed above the ceiling. Interview of the Assistant Vice President Of Ancillary Services on 05/20/15 at approximately 10:00 AM, revealed that a hospital worker removed the transponder from a ceiling tile prior to replacing the ceiling tile, and while re-attaching the receiver to the new ceiling tile inadvertently mis-wired the receiver. In addition, the hospital worker did not notify the supervisors regarding the work that was completed, so that assessment of all systems could be performed.

Therefore, the hospital did not provide sufficient safety monitoring of the environment of care for infants and children to minimize risk of harm or potential for abduction. The hospital failed to have a mechanism in place to ensure that all electrical, fire alarm and other alarm systems were left in fully operational mode after repairs were performed.





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