The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVENTHEALTH ORLANDO 601 E ROLLINS ST ORLANDO, FL 32803 May 30, 2013
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, record review and a review of facility documentation, the facility failed to ensure that patient's in the second floor Neonatal Intensive Care Unit received care in a safe setting through the proper use of baby swings for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted on [DATE]. A nurse's note on 5/14/13 at 6:40 PM read, "I was called to room by father of baby.... who was passing by in hallway. He stated '(nurse's name)' I think this baby fell out of his swing.' When I entered the room, I observed Baby ... was fallen over forward in his swing, with the swing also toppled over on top of him. He was still strapped into the swing. I immediately righted the swing and removed the baby from it. I placed him in the supine position on his bed, and assessed him for any signs of injury. He was not crying, was alert and looking around, and I found no signs of injury, or even any red marks on his skin. I then called the Nurse Practitioner's office, and Dr. ...answered. I reported the fall to him, and asked that one of our Physician/ARNPs (Advanced Registered Nurse Practitioner) come and examine the baby. He said he would send someone immediately. I then notified the Charge Nurse ... "

A physician progress note of 5/14/13 at 10:11 PM read, "Infant had been in a baby swing and was found to be on the floor by the nurse with the swing tipped over. Swing height less than about 18 inches off the floor. Infant examined." A nurse's note of 5/14/13 at 10:40 PM read, "Child Protective services from DCF (Department of Children and Families) arrived and said they had received a report that the baby had taken a fall and it needed to be checked out .... We also showed them the baby swing and the position of the swing when the baby was found and the fact that the baby was still in restraints in the swing". A report for a "CT Pediatric Brain wo (without) Contrast", dictated on 5/15/13 at 2:21 PM read, "Reason for Exam: "Child's infant swing tipped over during the night shift and child was found strapped in with head down on floor." A physician progress note of 5/15/13 at 2:48 PM read, "Child was found during night shift tipped over in his low-lying infant swing, strapped into his swing, crying vigorously."

An interview was performed with the nurse who had placed patient #1 in the swing at 2:30 PM on 5/30/13, in the presence of the Risk Manager and a facility Attorney. She indicated that the baby was placed in the swing right after feeding and holding the baby for a bit, at approximately 5:40 PM. The swing was placed directly on the floor. The baby was restrained by a waist belt. The swing was stationary and not placed into a swinging motion. After placing the baby in the swing, she left the room and told another nurse that the baby was in the swing. She said that at around 6-6:10 PM, she saw the baby in the swing in the room, along with the other nurse. She indicated this was the last time she saw the baby before the incident as described above. She said that the baby was in the same, non-swinging, waist-belted position and location as when she had originally placed him. She said that when the other nurse described the position of the swing when she herself discovered it as being toppled forward, it was mentioned that the baby's head was touching the floor. When a "Comfort & Harmony" swing which had been located in a storage room was pointed out to her during the interview, she indicated that was the same type of device as was involved in the previously described incident. In a follow-up interview at 3:50 PM on 5/30/13, she confirmed that only a lap belt had been used by patient #1 and that shoulder straps were not used or observed in use on 5/14/13.

During an interview of the Nurse Manager of the Neonatal Intensive Care Unit, on 5/30/13 at approximately 11:48 AM, she stated that the swing was placed (and found) in the northeast corner of patient #1' s room, #2156.

During a tour of the storage room for the second floor of the Neonatal Intensive Care Unit, on 5/30/13 at approximately 11:59 AM, in the presence of the Nurse Manager, five "Comfort & Harmony Bright Stars" swings were discovered. The fabric seats for these swings were found to have model numbers of 6936. None of these swings had shoulder straps with them.

An interview was performed with the Neonatal Intensive Care Unit Nurse Manager, on 5/30/13 at approximately 3:15 PM, in the presence of the Risk Manager and the facility Attorney. She indicated the following in response to questions. She learned from the nurse author of the 6:40 PM entry on 5/14/13 that the baby was found strapped in the swing and the swing had tipped forward. The involved swing did not have shoulder straps in use during the incident. She stated that none of the facility's swings, including the one involved with #1 on 5/14/13, were equipped with shoulder straps.

A review of policy "Fall Prevention: Assessment and Interventions (100.500-1) revealed: "Infants and children less than six (6) years of age shall be considered a 'High Risk for Fall' patient .... When patient is placed in swing, car safety seat, or infant carrier, the safety belt is to be utilized and secured properly." This does not specify a specific belt by body location, such as waist or shoulder.

A review of the 2009 manual for the involved "Bright Starts" swing revealed the following: "The Comfort & Harmony Portable Swing has a 5-point seat restraint for child safety .... Shoulder straps .... Waist Straps." The manual continued to describe how a child may be positioned via secure points between the legs, over the shoulders and both sides of the waists. Use of the shoulder straps provides the greatest safety. Shoulder straps were not used with patient #1.

Also, the text on the fabric of a remaining swing was read. The text stated, "Always use safety belt system". Again, the shoulder strap part of the system was not used with patient #1. As a result, the patient had not received care in a safe setting.

During an interview of the Risk Manager on 5/30/13 at approximately 5:30 PM, she confirmed the preceding.