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.
|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.