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WOMEN & INFANTS HOSPITAL OF RHODE ISLAND 101 DUDLEY STREET PROVIDENCE, RI 02905 Dec. 15, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review and staff interview, it has been determined that the hospital has failed to provide care in a safe setting, relative to infant identification, for 1 sample baby (ID#1).

Findings are as follows:

The hospital's Policy and Procedure titled: "Infant Identification - Security", effective 4/20/2017, states in part:

"d. If infant is in the nursery...

When infant is returned to mother's room by a staff member, the infant's ID bands are verified against the mother's or support person's ID band verbalizing infant's name and ID number..."

Record review revealed that on 11/5/2017, baby ID #1 was mistakenly brought to and left in the room with the wrong mother.

Review of the Hospital Investigation Summary revealed that on 11/5/2017, Nurse A completed Baby ID #1's circumcision and asked Nurse B to bring the baby to its mother.

Nurse B did not check the baby's ID band against the pram identification card, which correctly identified room X. Upon entering the room, Nurse B quickly looked at baby's band and mother's band which she stated looked "blurry". Nurse B left the baby in the room with the wrong mother.

Nurse A completed baby ID #2's circumcision and went to bring him to room X. Upon opening the door, she saw a pram in the room and the mother holding a baby. She immediately left the room and asked Nurse B "What baby is in room X?". Nurse B realized the error and went to room X and removed baby ID#1 from the room.

The nurse manager was interviewed on 12/14/2017 at 10:20 AM and stated Nurse B should have checked the baby's band with the pram card before the baby left the nursery. Additionally, Nurse B should have checked the pram card with the room number before entering the room. When nurse B thought the band looked "blurry", she should have taken additional steps to verify the correct identification information and to replace the band. The nurse manager further stated that, if nurse B followed the hospital's policy, this would not have happened.

Nurse B was interviewed on 12/15/2017 at 11:45 AM, she acknowledged that she did not follow's the hospital's policy.

On 12/15/ at approximately 12:00 PM, the Risk Manager, was unable to explain why the above policy was not followed.

Staff failed to follow their policy, which resulted in baby ID #1 left in the room with the wrong mother.