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Based on clinical record reviews, interviews with staff, and review of hospital policies for one newborn (Baby #1), the hospital failed to protect the baby when the baby was left unattended with his/her mother who tested positive for durgs. The findings include:

Patient #1 was admitted on 1/6/10 in active labor and delivered baby #1 on 1/6/10 at 10:36 AM. Although Patient #1 denied using alcohol and street drugs on admission, a routine drug screen dated 1/6/10 identified that Patient #1 was positive for THC (cannaboid). Based on the positive drug screen, a referral was made to the hospital's Family Advocate (social worker) and to the State Department of Children and Families (DCF). Although Patient #1 was seen by the Family Advocate on 1/7/10 at 11:30 AM, the clinical record lacked evidence that a safety or risk assessment of Patient #1 was conducted on 1/6/10, or 1/7/10, following the positive drug screen, to ensure Baby #1 was safe when with Patient #1 unattended. On 1/8/10 at 7:05 AM, RN #1 heard a baby's cry coming from Patient #1's room. RN #1 found Baby #1 face up on the floor beside Patient #1's bed. Patient #1 was identified as unarousable at that time. A CT scan of the baby's head identified three areas of hemorrhage and a subtle fracture of the posterior left convexity. Based on these findings, Baby #1 was transferred to Hospital #2 for further neonatal intensive care.

Please refer to A144

Based on clinical record reviews, interviews with staff, and review of hospital policies for one patient (Baby #1) whose mother tested positive for drugs prior to delivery of the baby, the hospital failed to ensure that the baby received care in a safe setting when the baby was left unsupervised with the mother. The findings include:

Patient #1 was admitted on 1/6/10 in active labor and delivered baby #1 on 1/6/10 at 10:36 AM. Although Patient #1 denied using alcohol and street drugs on admission, a routine drug screen dated 1/6/10 identified that Patient #1 was positive for THC (cannaboid). Based on the positive drug screen, a referral was made to the hospital's Family Advocate (social worker) and to the State Department of Children and Families (DCF). Although Patient #1 was seen by the Family Advocate on 1/7/10 at 11:30 AM, the clinical record lacked evidence that a safety or risk assessment of Patient #1 was conducted on 1/6/10, following the positive drug screen, to ensure Baby #1 was safe when with Patient #1 unattended. Review of Patient #1's care plan dated 1/6/10 to 1/8/10 failed to identified the patient's positive drug screen, and failed to identify the potential need to increase monitoring of Patient #1, while in possession of Baby #1, and failed to address psychosocial issues related to the patient's drug use. On 1/8/10 at 7:05 AM, RN #1 heard a baby's cry coming from Patient #1's room. RN #1 found Baby #1 face up on the floor beside Patient #1's bed. Patient #1 was identified as unarousable at that time. RN #1 picked the baby up off the floor, placed the baby in a bassinet and brought the baby to the special nursery. Baby #1 was examined by APRN #1; and a CT scan of the baby's head was obtained at 7:56 AM. The CT scan identified three areas of hemorrhage and a subtle fracture of the posterior left convexity. Based on these findings, Baby #1 was transferred to Hospital #2 for further neonatal intensive care. A subsequent investigation revealed that Patient #1 had been given drugs and alcohol by visitors during the hospitalization.

Although the hospital policy for drug and alcohol exposure identified that a DCF employee would determine the level of risk to the infant upon discharge home, the hospital lacked internal policies to assess the level of risk for the infant during the hospitalization.

According to an interview with RN #1, Patient #1 and Baby #1 were last seen at 4:30 AM and no issues were identified at that time. At 7:05 AM, Patient #1 was noted to be unarousable for a short period of time, and staff identified an odor of alcohol in the room. Patient #1 eventually was arousable, denied drinking alcohol or taking drugs, and had no recollection that the baby was found on the floor. Urine and drug screens, obtained with the patient's permission, tested positive for benzodiazepine and a high level of alcohol (74 mg/dl). Patient #1 later admitted to drinking alcohol and taking Valium during the night.

Based on clinical record reviews, interviews with staff, and review of hospital policies for six of nine newborns (Babies #1, #2, #4, #5, #6, #7), the hospital failed to assess and develop a plan of care to protect the babies whose mothers tested positive for durgs. The findings include:

Patient #1 was admitted on 1/6/10 in active labor and delivered Baby #1 on 1/6/10 at 10:36 AM. Although Patient #1 denied using alcohol and street drugs on admission, a routine drug screen dated 1/6/10 identified that Patient #1 was positive for THC (cannaboid). Based on the positive drug screen, a referral was made to the hospital's Family Advocate (social worker) and to the State Department of Children and Families (DCF). Although Patient #1 was seen by the Family Advocate on 1/7/10 at 11:30 AM, the clinical record lacked evidence that a safety or risk assessment of Patient #1 was conducted on 1/6/10, or 1/7/10, following the positive drug screen, to ensure Baby #1 was safe when with Patient #1 unattended. On 1/8/10 at 7:05 AM, RN #1 heard a baby's cry coming from Patient #1's room. RN #1 found Baby #1 face up on the floor beside Patient #1's bed. Patient #1 was identified as unarousable at that time. A CT scan of the baby's head identified three areas of hemorrhage and a subtle fracture of the posterior left convexity. Based on these findings, Baby #1 was transferred to Hospital #2 for further neonatal intensive care. In addition, a review of the clinical records of Patients #2, #4, #5, #6, #7 failed to reflect that a risk assessment and plan of care had been developed to ensure the safety of the mothers and babies following identification of drug use in the mothers.

The hospital policy for the provision of patient care in the pregnancy and birth center identied that following an initial assesment, nursing is responsible and accountable for the development, execution, and management of the nursing care plan.


Please refer to A395 and A396

Based on clinical record reviews, interviews with staff, and review of hospital policies for six of nine patients (Patients #1, #2, #4, #5, #6, and #7) whose toxicology screens were positive at the time of labor and delivery, the hospital failed to ensure that risk assessments were completed; and/or that referrals were conducted, to ensure the safety of the patients and their babies while hospitalized. The findings include:


1. Patient #1 was admitted on 1/6/10 in active labor and delivered Baby #1 on 1/6/10 at 10:36 AM. Although Patient #1 denied using alcohol and street drugs on admission, a routine drug screen dated 1/6/10 identified that Patient #1 was positive for THC (cannaboid). Based on the positive drug screen, a referral was made to the hospital's Family Advocate (social worker) and to the State Department of Children and Families (DCF). Although Patient #1 was seen by the Family Advocate on 1/7/10 at 11:30 AM, the clinical record lacked evidence that a safety or risk assessment of Patient #1 was conducted on 1/6/10, following the positive drug screen, to ensure Baby #1 was safe when with Patient #1 unattended. On 1/8/10 at 7:05 AM, RN #1 heard a baby's cry coming from Patient #1's room. RN #1 found Baby #1 face up on the floor beside Patient #1's bed. Patient #1 was identified as unarousable at that time. RN #1 picked the baby up off the floor, placed the baby in a bassinet and brought the baby to the special nursery. Baby #1 was examined by APRN #1; and a CT scan of the baby's head was obtained at 7:56 AM. The CT scan identified three areas of hemorrhage and a subtle fracture of the posterior left convexity. Based on these findings, Baby #1 was transferred to Hospital #2 for further neonatal intensive care. A subsequent investigation revealed that Patient #1 had been given drugs and alcohol by visitors during the hospitalization.

2. Patient #2 was admitted and gave birth to Baby #2 on 1/17/10. At the time of admission, Patient #2 had a positive toxicology screen (for drugs of abuse), as defined by the hospital. Review of the clinical records with the Nurse Manager, Assistant Nurse Manager, and Regulatory Manager on 1/25/10 and 1/26/10 identified that there was no risk assessment conducted for Patient #2 or Baby #2, to ensure their safety during hospitalization, following the positive toxicology screen.

3. Patient #4 was admitted and gave birth to Baby #4 on 8/7/09. At the time of admission, Patient #4 had been on Methadone and had a positive toxicology screen. On admission, Patient #4 also admitted to using Heroin within the past month. Review of the clinical records with the Nurse Manager, Assistant Nurse Manager, and Regulatory Manager on 1/25/10 and 1/26/10 identified that there was no risk assessment conducted for Patient #4 or Baby #4, to ensure their safety during hospitalization, following the positive toxicology screen and recent use of Heroin.

4. Patient #5 was admitted and gave birth to Baby #5 on 11/7/09. At the time of admission, Patient #5 had a positive toxicology screen. Review of the clinical records with the Nurse Manager, Assistant Nurse Manager, and Regulatory Manager on 1/25/10 and 1/26/10 identified that there was no risk assessment conducted for Patient #5 or Baby #5, to ensure their safety during hospitalization, following the positive toxicology screen.

5. Patient #6 was admitted and gave birth to Baby #6 on 9/5/09. At the time of admission, Patient #6 had a positive toxicology screen. Review of the clinical records with the Nurse Manager, Assistant Nurse Manager, and Regulatory Manager on 1/25/10 and 1/26/10 identified that there was no risk assessment conducted for Patient #6 or Baby #6, to ensure their safety during hospitalization, following the positive toxicology screen.

6. Patient #7 was admitted and gave birth to Baby #7 on 1/3/10. At the time of admission, Patient #7 had a positive toxicology screen. Review of the clinical records with the Nurse Manager, Assistant Nurse Manager, and Regulatory Manager on 1/25/10 and 1/26/10 identified that there was no risk assessment conducted for Patient #7 or Baby #7, to ensure their safety during hospitalization, following the positive toxicology screen.


7. Patient #2 was admitted and gave birth to Baby #2 on 1/17/10. At the time of admission, Patient #2 had a positive toxicology screen (for drugs of abuse), as defined by the hospital. Review of the patient's care plan failed to identify Patient #2's positive toxicology screen, and failed to reflect that safety measures were initiated to ensure that Patient #2 and Baby #2 remained safe while in the hospital. In addition, the Hospital policy for drug and alcohol exposure reporting protocol identified that following confirmation or suspicion of drug or alcohol abuse during pregnancy, DCF shall be notified within 12 hours. Review of Patient #2's clinical record identified that the positive drug exposure was known on 1/17/10 at 6:07 AM and the Family Advocate failed to notify DCF until 1/18/10 at 10:45 AM. Interview with the Family Advocate on 1/26/10 at 11:30 AM identified that he/she was aware that the DCF report was not made in a timely manner, per hospital policy.

8. Patient #6 was admitted and gave birth to Baby #6 on 9/5/09. At the time of admission, Patient #6 had a positive toxicology screen (for drugs of abuse), as defined by the hospital. Review of the patient's care plan failed to identify Patient #6's positive toxicology screen, and failed to reflect that safety measures were initiated to ensure that Patient #6 and Baby #6 remained safe while in the hospital. In addition, the Hospital policy for drug and alcohol exposure reporting protocol identified that following confirmation or suspicion of drug or alcohol abuse during pregnancy, DCF shall be notified within 12 hours. Review of Patient #6's clinical record failed to identify that the Family Advocate or DCF were notified of Patient #6's positive Toxicology screen. Documentation on the hospital's Pregnancy and Birth center on-call log identified that on 9/6/09, a call would be placed to DCF, however, the clinical record lacked documentation that this occurred.

Based on clinical record reviews, interviews with staff, and review of hospital policies for six of nine patients (Patients #1, 2, 4, 5, 6, and 7) whose toxicology screens were positive at the time of labor and delivery, the hospital failed to ensure that care plans reflected the positive toxicology screens and any safety needs the patients and their babies while hospitalized. The findings include:

1. Patient #1 was admitted on 1/6/10 in active labor and delivered Baby #1 on 1/6/10 at 10:36 AM. Although Patient #1 denied using alcohol and street drugs on admission, a routine drug screen dated 1/6/10 identified that Patient #1 was positive for THC (cannaboid). Based on the positive drug screen, a referral was made to the hospital's Family Advocate (social worker) and to the State Department of Children and Families (DCF). Review of Patient #1's care plan dated from 1/6/10 to 1/8/10 failed to identified the patient's positive drug screen, and failed to identify the potential need to increase monitoring of Patient #1, while in possession of Baby #1. On 1/8/10 at 7:05 AM, RN #1 heard a baby's cry coming from Patient #1's room. RN #1 found Baby #1 face up on the floor beside Patient #1's bed. Patient #1 was identified as unarousable at that time. RN #1 picked the baby up off the floor, placed the baby in a bassinet and brought the baby to the special nursery. Baby #1 was examined by APRN #1, a CT scan of the baby's head was obtained at 7:56 AM that identified three areas of hemorrhage and a subtle fracture of the posterior left convexity. Based on these findings, Baby #1 was transferred to Hospital #2 for further neonatal intensive care.

2. Patient #2 was admitted and gave birth to Baby #2 on 1/17/10. At the time of admission, Patient #2 had a positive toxicology screen (for drugs of abuse), as defined by the hospital. Review of the patient's care plan failed to identify Patient #2's positive toxicology screen, and failed to reflect that safety measures were initiated to ensure that Patient #2 and Baby #2 remained safe while in the hospital.

3. Patient #4 was admitted and gave birth to Baby #4 on 8/7/09. At the time of admission, Patient #4 had been on Methadone and had a positive toxicology screen (for drugs of abuse), as defined by the hospital. On admission, Patient #4 also admitted to using Heroin within the past month. Review of the patient's care plan failed to identify Patient #4's positive toxicology screen and Heroin use, and failed to reflect that safety measures were initiated to ensure that Patient #4 and Baby #4 remained safe while in the hospital.

4. Patient #5 was admitted and gave birth to Baby #5 on 11/7/09. At the time of admission, Patient #5 had a positive toxicology screen (for drugs of abuse), as defined by the hospital. Review of the patient's care plan failed to identify Patient #5's positive toxicology screen, and failed to reflect that safety measures were initiated to ensure that Patient #5 and Baby #5 remained safe while in the hospital.

5. Patient #6 was admitted and gave birth to Baby #6 on 9/5/09. At the time of admission, Patient #6 had a positive toxicology screen (for drugs of abuse), as defined by the hospital. Review of the patient's care plan failed to identify Patient #6's positive toxicology screen, and failed to reflect that safety measures were initiated to ensure that Patient #6 and Baby #6 remained safe while in the hospital.

6. Patient #7 was admitted and gave birth to Baby #7 on 1/3/10. At the time of admission, Patient #7 had a positive toxicology screen (for drugs of abuse), as defined by the hospital. Review of the patient's care plan failed to identify Patient #7's positive toxicology screen, and failed to reflect that safety measures were initiated to ensure that Patient #7 and Baby #7 remained safe while in the hospital.

The hospital policy for the provision of patient care in the pregnancy and birth center identied that following an initial assesment, nursing is responsible and accountable for the development, execution, and management of the nursing care plan.