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.

UNITYPOINT HEALTH - MERITER 202 S PARK ST MADISON, WI 53715 Feb. 19, 2018
VIOLATION: QAPI Tag No: A0263
Based on record review and interview the facility failed to thoroughly investigate, report,and respond to any allegations of suspected abuse related to injuries of unknown origin in 5 of 6 patients (#1, 2, 3, 4 and 6) per policy. In a total sample of 20 records.

Findings include:

The facilities failed to document, analyze, and track incident reports for patients with injuries of unknown origin to ensure that aspects of staff performance and patient care that would provide relevant data to improve patient safety or that incident reports were thoroughly investigated in 3 of 9 events reviewed for 5 of 20 patients (Patient #4, #3, #6, #1 and # 2). See (A073)

The hospital's medical staff and administrative officials failed to take responsibility for the quality of care provided to 5 or 6 patients (Patient #4, #3, #1, #2, and #6) in a total of 20 Newborn Intensive Care Unit records reviewed.
(See Tag A-309)

The cumulative effect of these deficiencies affected all patients in the Newborn Intensive Care Unit during this survey (patient census 2/15/18 was 16, 2/16/18 was 17 and 2/19/18 was 18) and prevented the hospital from having data-driven quality assessment and performance improvement program.
.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to document, analyze, and track incident reports for patients with injuries of unknown origin to ensure that aspects of staff performance and patient care that would provide relevant data to improve patient safety or that incident reports were thoroughly investigated in 3 of 9 events reviewed for 5 of 20 patients (Patient #4, #3, #6, #1 and # 2).

Findings include:

Review of policy titled "Incident or Accident Reporting System" #30 dated 8/31/15 under Policy Statement revealed "The system facilitates risk management interventions and provides an overview of Meriter's exposure pattern as a basis for quality improvement activities to improve patient care and organizational safety... Definition of an Incident:...1. "perceived" injury... D...2. If the incident involves a patient, include an assessment of the patient's condition following the incident and any clinical action taken as a result of the incident... 5...all incidents are required to be entered into the online incident reporting system via MyMeriter as soon as possible. Supervisor review and follow-up is expected within 72 hours of the incident."

Patient #4
Review of Patient # 4 medical record revealed, Patient #4 had injuries of unknown origin documented in the nursing notes on 4/12/17 at 9 AM described as bruising, scattered; right leg; left leg bilateral; calf and ankle and documented in physician notes 4/12/17 at 7:19 AM Bruises on lower extremities bilaterally, linear in shape-likely due to cords (from monitor leads) wrapped in swaddle with infant.

Record review of the corresponding Incident report written on 4/12/2017 at 9 AM revealed injuries described as bilateral bruising on calves, ankles and left foot, bruises consistent with monitor cord size. "Severity Level" revealed "Temporary Intervention Needed"
"Follow-Up Actions" revealed "Not Specified".
"Final Severity Level" revealed "Harm - Temporary, Intervention Needed." However, there was no documentation of intervention or follow up.

Patient #3
Record review Patient #3's medical record revealed, Patient #3 had injuries of unknown origin documented in the nursing notes on 9/21/17 at 5:36 AM described as bruising on left foot and scalp and in physician notes on 9/22/17 at 7:16 AM described as non-blanching linear macules on bilateral palms bilaterally.

Review of incident log revealed, the staff did not documentation on an incident report the injuries of unknown origin that were documented in Patient #3's medical record on 9/21/17.

Patient #6
Record review Patient #6's medical record revealed, Patient #6 had injuries of unknown origin documented in the nursing notes on 1/20/18 at 11 AM that were described as scattered bruising lower extremities.

Review of incident log revealed, the staff did not documentation on an incident report the injuries of unknown origin that were documented in Patient #6's medical record on 1/20/2018.

Patient #1
Review of Patient #1's medical record revealed, Patient #1's had injuries of unknown origin documented in the nursing notes on 2/02/18 at 2:08 AM described as bruising of left forehand, wrist and palm and documented in the physician notes on 2/02/18 at 7:55 AM described as hyperpigmentation of left lower forearm and bruising over dorsal left hand and palm.

Record review of the corresponding incident report written on 02/02/18 at 9:00 AM revealed, injuries described in nurses notes on 02/02/18 at 9:30 AM described as bruising left hand, palm, and arm.
"Severity Level" revealed "Intervention Needed."
"Follow-Up Actions" revealed "Not Specified",
"Final Severity Level" revealed "Harm - Temporary, Intervention Needed." However, there was no documentation of intervention or follow up.

Patient #2 (injury #1)
Review of Patient #2's medical record revealed, Patient #2 had injuries of unknown origin documented in the nursing notes on 2/03/18 at 9:00 AM described as bruising, [DIAGNOSES REDACTED], and abrasions on bilateral hands and forearms and in the physician notes on 02/04/18 at 7:37 AM described as bruising on the right greater than left forearm and left inner wrist that were linear in nature.

Review of the incident log identified a corresponding Incident report written on 02/09/18 (6 days after the injury was documented in #2's medical record) revealed abrasions, scratching on left wrist, bruising right forearm, bruising right and left hands, bruising right wrist, and left forearm.
"Severity Level" revealed, "No Harm-Reached Patient Monitoring Required"
"Follow-Up Actions" revealed, "Not Specified"
"Final Severity Level" revealed, "No Harm - Reached Patient Monitoring Required". However, there was no documentation of intervention or follow up.

Patient #2 (injury #2)
Review of Patient #2's medical record revealed, four days (4 days) after the first documented injury Patient #2 had sustained a second injury of unknown origin documented in the nursing notes on 2/07/18 at 2:00 PM as fluid wave in posterior scalp and in physician notes on 2/08/18 at 7:06 AM fluid wave over the posterior occiput.

Review of incident report log confirmed there was no incident report documentation on this event.
Interview with Patient Safety Officer Y on 2/16/18 at approximately 1:55 PM, Y confirmed there were no incident reports of patient event on Patient #3 or #6, or on the second event on patient #2.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital's medical staff and administrative officials failed to take responsibility for the quality of care provided to 5 of 6 patients (Patient #4, #3, #6, #1, and #2) in 20 Newborn Intensive Care Unit records reviewed.

Findings include:

Review of Policy titled "Code of Conduct" dated 02/2015 revealed "This Code of Conduct has been adopted by" the facilities Board of Directors "to provide standards by which directors, officers, employees, reporting physicians and volunteers will conduct themselves in order to protect and promote organization-wide integrity." Page 8 Quality of Care and Clinical Values "to provide high-quality medical services that are appropriate, safe and in compliance with all applicable laws, regulations and professional standards." Page 9 3.4 Protection from Abuse revealed "Any concerns about potential abuse, neglect or exploitation should be immediately." 11. Responsibilities of Leaders, 11.2 Standards for Patient care revealed "Leaders are called upon to create a culture with the organization of high ethical standards, to respect the importance of compliance with legal requirements and to establish a working environment in which all Covered Persons are encouraged to raise concerns and contribute ideas to achieve the organization's goals in a safe and healthy work environment."

Review of Bylaws and Rules and Regulation of the Medical Staff dated January 2017, approved by the Medical Executive Committee on November 15, 2016, approved by the Medical Staff at the annual meeting on January 17, 2017 and approved by the UnityPoint Health-Meriter Health Services Board on and effective January 25, 2017 under Membership and Privileges Section 1 Qualifications C. revealed "Members of the Medical Staff shall ...comply with the safety policies and guidelines put in place by the hospital and/or Medical Staff".

Review of policy titled "Incident or Accident Reporting System" #30 dated 8/31/15 under Policy Statement revealed "The system facilitates risk management interventions and provides an overview of Meriter's exposure pattern as a basis for quality improvement activities to improve patient care and organizational safety... Definition of an Incident:...1. "perceived" injury... D...2. If the incident involves a patient, include an assessment of the patient's condition following the incident and any clinical action taken as a result of the incident... 5...all incidents are required to be entered into the online incident reporting system via MyMeriter as soon as possible. Supervisor review and follow-up is expected within 72 hours of the incident."

Review of policy titled "Child at Risk Abuse and Neglect" Policy #57 dated January 2010 Policy Statement revealed "Meriter Hospital will take actions to protect the "abused ..." from the possibility of further abuse... 9. All hospital staff shall formally write up their observations immediately... All hospital staff involved are responsible for filling out appropriate documentation in a timely manner."

Patient #4

Review of incident report for Patient #4 "Skin Tissue Event # 5" dated 4/12/17 at 9 AM by Registered Nurse (RN) W, revealed "Severity Level " " Intervention Needed". Follow-up Actions:" "Not Specified". "Resolutions and Outcomes:" "Intervention Needed." Final Severity Level revealed "Harm - Temporary, Intervention Needed." No interventions were documented to protect or report the injuries of unknown origin on Patient #4. There was no additional documentation of further investigation of the injuries or intervention to protect Patient #4.

Review of Patient # 4 medical record revealed, Patient #4 had injuries of unknown origin documented in the nursing notes on 4/12/17 at 9 AM described as bruising, scattered; right leg; left leg bilateral; calf and ankle.

Continued Review of Patient # 4 medical record revealed, Patient #4 had injuries of unknown origin documented in the physician notes 4/12/17 at 7:19 AM Bruises on lower extremities bilaterally, linear in shape-likely due to cords (from monitor leads) wrapped in swaddle with infant.

During interview with Patient Safety Officer Y on 2/16/18 at 1:25 PM, Y confirmed there was no further follow-up on Event # 5 on patient #4.

Patient #3

Patient #3's medical record was reviewed an revealed in the nursing plan of care 9/21/17 at 5:36 AM "Bruising on left foot and scalp" in the physician note on 9/22/17 at 7:16 AM non-blanching linear macules on bilateral palms and bruise-like macules on palms bilaterally.

Interview with Patient Safety Officer Y on 2/16/18 at approximately 1:55 PM, Y confirmed there was no event report for patient #3.

Patient #6

Record review Patient #6's medical record revealed, Patient #6 had injuries of unknown origin documented in the nursing notes on 1/20/18 11 AM described as scattered bruising lower extremities.

Interview with Patient Safety Officer Y on 2/16/18 at approximately 1:55 PM, Y confirmed there was no event report for patient #6.

Patient #1

Review of incident report Skin/Tissue Event # 1 titled "Current Summary" for patient #1 was not entered until "02-08-2018" (6 days after staff identified injuries of unknown origin) by RN HH. Date of occurrence "02-02-2018" estimated time 9 AM, listed the "Severity Level" "Temporary, Intervention Needed" "Follow-Up Actions:" "Not Specified" Resolutions and Outcomes of the Event" "Harm - Temporary, Intervention Needed." There was no additional documentation of further investigation of the injuries or intervention to protect Patient #1.

Review of Patient #1's medical record revealed, Patient #1's had injuries of unknown origin documented in the nursing notes on 2/02/18 at 2:08 AM described as bruising of left forehand, wrist and palm and documented in the physician notes on 2/02/18 at 7:55 AM described as hyperpigmentation of left lower forearm and bruising over dorsal left hand and palm and on 02/03/18 at 8:52 AM By Physician O, "mild bruising noted on left hand and forearm ... Left forearm has a linear bruise about 1 cm long consistent with possible pushing against a lead. [Patient #1] also has a 3 X 2 mm bruise on the inside of the right wrist and a linear bruise on her palm ...We will check growth curves in the a.m. Linear [DIAGNOSES REDACTED]/bruise on left arm is most consistent with a mechanical injury, possibly entanglement in a lead.".

During Interview with Patient Safety Officer Y on 2/16/18 at 1:55 PM, Y confirmed Event # 1 on Patient #1, which took place on 2/02/18, was entered on 2/08/18.

Patient #2

Incident report revealed "Severity Level" as "No Harm-Reached Patient Monitoring Required" Follow-Up Actions revealed "Not Specified", Final Severity Level revealed "No Harm - Reached Patient Monitoring Required" APNP R, Neonatologist O, Nurse Manager D, Assistant Nurse Manager T were notified of the incident report events. However, there was no documentation of intervention or follow up. There was no additional documentation of further investigation of the injuries or intervention to protect Patient #2.

Review of Patient #2's medical record revealed, Patient #2 had injuries of unknown origin documented in the in the physician notes 02/04/18 at 7:37 AM described as bruising on the right greater than left forearm and left inner wrist that were linear in nature and physician notes on 2/08/18 at 7:06 AM fluid wave over the posterior occiput (back of the head).

During interview with Patient Safety Officer Y on 2/16/18 at 1:40 PM, Y confirmed incident event # 0 on Patient #2 occurred on 2/03/18 at approximately 9 AM and was entered on 2/09/18 stating "the investigation is ongoing."
During interview with Medical Director of NICU K on 2/16/18 at 11:05 AM, K when asked about the reporting of these incidents, K stated it was not his/her responsibility to complete an event report, "that would be the nurse's job."

During interview with APNP R on 2/16/18 at 1:40 PM R when asked if R had submitted an incident report, R stated it was "out of [his/her] realm" to complete an event report, "it is the nurses job".

During interview with the Chief Nursing Executive (CNE) C on 2/15/18 at 9:16 AM, when C was asked if the facility had reported the incidents, C confirmed they had not completed form F- Misconduct Incident Report to report to the Wisconsin Department of Health Services.

During interview with Chief Medical Officer A on 2/15/18 at 1:15 PM, when A was asked if the facility had reported the incidents, A stated no.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on record review and interview, the facility failed to immediately immediately adhere to their policies and procedures to delineate their administrative responsibilities for patient care in 5 of 6 patients (#4, #3, #6, #1 and #2). (Patient census 2/15/18 was 16, 2/16/18 was 17 and 2/17/18 was 18).

Findings include:

Review of policy titled Caregiver Misconduct (Reporting and Investigating)" Policy # HR-48 dated 8/05/16 revealed Policy Statement Meriter will comply with all investigation and reporting requirements of ... injuries of unknown source of its patients... 4.0 "Injury of unknown source" is an injury where both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury cannot be explained by the patient; and, The injury is suspicious because of the extent of the injury or the location of the injury... or the number of injuries observed at one particular point in time or the incidence of injuries over time... 2.0 Incident Investigation "will investigate all claims or concerns... in a timely manner."

Review of policy titled "Child at Risk Abuse and Neglect" Policy #57 dated January 2010 Policy Statement revealed "Meriter Hospital will take actions to protect the "abused ..." from the possibility of further abuse... 9. All hospital staff shall formally write up their observations immediately... All hospital staff involved are responsible for filling out appropriate documentation in a timely manner."

Review of Policy titled "Code of Conduct" dated 02/2015 revealed 11. Responsibilities of Leaders, 11.2 Standards for Patient care revealed "Leaders are called upon to create a culture with the organization to establish a working environment in which all Covered Persons are encouraged to raise concerns... to achieve the organization's goals in a safe...environment."

Record review of Skin Tissue Event # 5 on Patient # 4 event date 4/12/17, entered 4/12/17 at 9 AM by Registered Nurse (RN) W, Severity Level " Intervention Needed". Follow-up Actions "Not Specified", Resolutions and Outcomes "Intervention Needed." No further intervention was documented.

Record review of Skin Tissue Event # 1 on Patient #1 event date 02/02/18, entered 02/08/18 at 9 AM (6 days after event occurred) by RN HH, Severity Level "Intervention Needed". Resolutions and Outcomes "Intervention Needed." However, no additional documentation was found to investigate the injuries or the immediate intervention taken to protect patient #1 or report to authorities

Record review of Safety Security Event # 0 on Patient #2 event date 2/03/18, entered 02/09/18 at 8 AM (6 days after event occurred) by RN P. No additional documentation was found to investigate the injuries or the immediate action taken to protect patient #2.

Patient Safety Officer Y on 2/16/18 at 1:55 PM, Y confirmed Event # 5 on Patient #4 had no other follow-up.

Patient Safety Officer Y on 2/16/18 at 1:55 PM, Y confirmed, Event # 1 on Patient #1, event date 2/02/18, was entered 2/08/18, and Event # 0 on Patient #2 Event date was 2/03/18 entered 2/09/18 (6 days later), there was no additional documentation available on these events (# 1 and # 0) (6 days after the injuries were identified).

An interview was conducted with Registered Nurse P on 2/16/18 at 1:26 PM, RN P stated s/he was so concerned about patient #1 and #2 injuries s/he sent an e-mail to Nurse Manager D and Assistant Nurse Manager T on the evening of 2/03/18 to notify them of her/his concerns. On Monday 2/05/18 s/he "made sure" Assistant Nurse Manager T had the pictures and voiced her/his concerns. RN P stated physicians "took a wait and watch position."

Interview on 2/15/18 at 9:16 AM with CNE C, C stated the facility was aware of the Wisconsin Statues 48.981 (2) and that they were mandated reporters.

Interview on 2/16/18 at 2:12 PM with Director of Performance Improvement B, B confirmed there were no other nursing or physician policies to direct reporting of patient events when patients had injuries of unknown origin.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview the facility failed to develop and implement effective policy and procedures to prevent, screen, identify, train, protect, thoroughly investigate, report,and respond to any allegations of suspected abuse related to injuries of unknown origin in 5 of 6 patients (#4, #3, #6, #1, and #2) in the Newborn Intensive Care Unit when the first case was reported for Patient #4 on 4/12/17. Total sample 20.

Findings include:

The facility failed to ensure a safe environment to protect vulnerable patients by failing to thoroughly investigate injuries of unknown origin to protect and report 5 of 6 patients (#4, #3, #6, #1, and #2.) in the Newborn Intensive Care Unit (NICU) identified with injuries of unknown origins from when the first case was reported for Patient #4 on 4/12/17 in 6 patients records reviewed . (See Tag A-0144)

The facility failed to thoroughly investigate and protect 5 of 6 patients (#4, #3, #6, #1, and #2) in the Newborn Intensive Care Unit when the first case was reported for Patient #4 on 4/12/17. (See Tag A 0145)

The cumulative effects of these deficiencies resulted in an Immediate Jeopardy potentially affecting all patients in the Newborn Intensive Care Unit during this survey (patient census 2/15/18 was 16, 2/16/18 was 17 and 2/19/18 was 18).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to protect vulnerable patients and report to authorities for a thorough investigation of injuries of unknown origin for 5 of 6 patients (#4, #3, #1, #2, and #6) in the Newborn Intensive Care Unit (NICU) identified with injuries of unknown origins from when the first case was reported for Patient #4 on 4/12/17. A total sample of 20 patient records reviewed.

Findings Include:

Review of Policy titled "Code of Conduct" dated 02/2015 revealed 11. Responsibilities of Leaders, 11.2 Standards for Patient care revealed "Leaders are called upon to create a culture with the organization to establish a working environment in which all Covered Persons are encouraged to raise concerns... to achieve the organization's goals in a safe...environment."

Review of policy titled "Child at Risk Abuse and Neglect" Policy #57 dated January 2010 Policy Statement revealed "Meriter Hospital will take actions to protect the "abused... child from the possibility of further abuse and neglect to the extent mandated by law."

Review of Bylaws and Rules and Regulation of the Medical Staff dated January 2017, approved by the Medical Executive Committee on November 15, 2016, approved by the Medical Staff at the annual meeting on January 17, 2017 and approved by the UnityPoint Health-Meriter Health Services Board on and effective January 25, 2017 under Membership and Privileges Section 1 Qualifications C. revealed "Members of the Medical Staff shall ...comply with the safety policies and guidelines put in place by the hospital and/or Medical Staff".

Review of policy titled Caregiver Misconduct (Reporting and Investigating)" Policy # HR-48 dated 8/05/16 revealed under Policy Statement "Employees are responsible for immediately reporting concerns regarding... injuries of unknown source of its patients... Page 4 I. Wisconsin Department of Health Services (DHS) - Caregiver Misconduct (DHS-13) 4.0 "Injury of unknown source" is an injury where both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury cannot be explained by the patient; and, The injury is suspicious because of the extent of the injury or the location of the injury... or the number of injuries observed at one particular point in time or the incidence of injuries over time... 2.0 Incident Investigation UnityPoint - Meriter will investigate all claims or concerns... in a timely manner."

Review of policy titled "Child at Risk Abuse and Neglect" Policy #57 dated January 2010 Policy Statement revealed "Meriter Hospital will take actions to protect the "abused ...from the possibility of further abuse... 9. All hospital staff shall formally write up their observations immediately... All hospital staff involved are responsible for filling out appropriate documentation in a timely manner."

Patient #4
Patient #4's medical record was reviewed and revealed Patient #4 was born 3/19/17 at 12 AM weighing 3# 6 ounces and transferred from another hospital on [DATE] at 3:14 to the NICU with an admitting diagnosis of [DIAGNOSES REDACTED]

Review of incident report for Patient #4 "Skin Tissue Event # 5" dated 4/12/17 at 9 AM by Registered Nurse (RN) W, revealed "Severity Level " " Intervention Needed". Follow-up Actions:" "Not Specified". "Resolutions and Outcomes:" "Intervention Needed." Final Severity Level revealed "Harm - Temporary, Intervention Needed." No interventions were documented to protect or report the injuries of unknown origin on Patient #4.

During interview with Patient Safety Officer Y on 2/16/18 at 1:25 PM, Y confirmed there was no further follow-up on Event # 5 on patient #4.

Patient #3
Patient #3's medical record was reviewed and revealed Patient #3 was delivered on 9/17/17 at 3:31 AM by normal vaginal delivery weighing 4# 12.2 ounces, 43 centimeters long admitted to NICU for prematurity and discharged [DATE].

Review of plan of care by RN OO 9/21/17 at 5:36 AM revealed "scattered newborn rash noted. Bruising on left foot and scalp as well." Review of Neonatology Addendum to Physician Resident AA's progress note by Physician O on 9/22/17 at 7:16 AM revealed "I agree with resident note, bruise-like macules noted on palms bilaterally."

During interview on 2/15/18 at 9:16 AM, Chief Nursing Executive C (CNE C) confirmed, Physician V recalled that there was a patient [#3] with unexplained bruising documented in the medical record, as a part of the hospital investigation, the hospital consulted Child Abuse Expert N on 02/12/18 who viewed photographs obtained from Patient #3's parent PP. Child Abuse Expert N reported this case to Madison Police Department on 2/12/18 (144 days after nursing documentation of injury of unknown origin in patient #3's medical record) as the bruising was consistent with child abuse, confirmed in an interview with NICU Nurse Manager D on 2/16/2018 at 4:30 PM.

On 2/16/18 at 1:55 PM during an interview Patient Safety Officer Y confirmed there was no incident report or follow up for the injuries of unknown origin on patient #3 documented on 9/21/17 at 5:36 AM and that the incident was not reported to Wisconsin Department of Health Services.

Patient #6

Closed medical review of the "Birth Record" for Patient #6 revealed Patient #6 was born C-Section on 1/19/18 at 20:44 (10:44 PM) weighing 1.61 Kg (3 pounds 6 ounces) and was 39.4 cm (15.5 inches).

An interview was conducted 2/15/18 at 9:16 AM, Chief Nursing Officer C (CNO C) confirmed, as a part of the Hospital's investigation, since Patient #6 was in NICU (Newborn Intensive Care Unit) from 1/19/18 to 1/26/18, and medical record identified Patient #6 had scattered bruising on lower extremities the hospital contacted Patient #6's Parents EE and notified them of their safety plan.

Review of the investigation revealed the (EE) of Patient #6 informed hospital staff they were uncomfortable with caregiver RN H, who was the primary caregiver on the night shift for Patient #6 on January 23-24, 2018 (confirmed with staff schedules). The hospital decided, due to these concerns, Physician Z consulted Child Abuse Expert N on 02/12/18 who recommended skeletal survey and a CT (computerized tomography). The hospital investigation revealed Patient #6 had multiple fractures, including rib and arm fractures, which were confirmed in an interview with NICU Nurse Manager D on 2/16/2018 at 4:30 PM.

On 2/16/18 at 1:40 PM during an interview Patient Safety Officer Y confirmed there was no incident report in for injuries of unknown origin found on Patient #6 while in the NICU (Newborn Intensive Care Unit) from 1/19/18 to 1/26/18 and no other documentation of intervention to protect Patient #6 during this hospital stay. The facility failed to report event to Wisconsin Department of Health Services.

Patient #1
Review of Patient #1's medical record revealed that Patient #1 was admitted on [DATE] and was born at 14:55 (2:55 PM) weighting 3 pounds 6.5 ounces and was 15.75 inches and induced vaginal delivery . Patient #1 was admitted to the NICU at 2:55 PM after birth for prematurity, RDS ([DIAGNOSES REDACTED]) and sepsis evaluation. On 1/7/18 at 9:45 PM had a hypoxic event, was intubated and diagnosed with [DIAGNOSES REDACTED].

Review of Patient #1's "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" "Outcome" revealed on 01/14/2018 at 5:04 PM "Abrasions noted on bottom of L foot unchanged. Bruising noted to R hand and bottom of L foot."

Review of incident report Skin/Tissue Event # 1 titled "Current Summary" for patient #1 was not entered until "02-08-2018" (6 days after staff identified injuries of unknown origin) by RN HH. Date of occurrence "02-02-2018" estimated time 9 AM, listed the "Severity Level" "Temporary, Intervention Needed" "Follow-Up Actions:" "Not Specified" Resolutions and Outcomes of the Event" "Harm - Temporary, Intervention Needed." There was no additional documentation of further investigation of the injuries or intervention to protect Patient #1.

On 2/16/18 at 1:40 PM during an interview Patient Safety Officer Y, Y confirmed incident event # 1 on Patient #1 occurred on 2/02/18 and was entered on 2/08/18 (6 days after staff identified the injuries).

Patient #2
Review of Patient #2's medical record revealed that Patient was born via C-section (caesarean section) [the delivery of a baby through a surgical incision in the mother's abdomen and uterus] on 11/30/17 at 11:39 AM, weighing 1 pound and 8.3 ounces.

Review of the incident report # 0 titled "Current Summary" revealed on Saturday 02/03/18 at 8:00 AM, Patient #2's parent (DD) noticed "abrasions/scratching on left wrist" and notified RN P. RN P completed an assessment and identified "right palm /heal of hand with reddened intact areas", "scattered purple/red bruising on the opposite side of right hand and a few scattered areas of bruising up the right forearm and inner wrist", purple red bruising on left palm extending from area between thumb and first finger", small red bruises on second and third distal fingers, mostly located ulnar side of left wrist", "scattered linear abrasion", scattered purple/red bruising extending up left forearm". Further review of the same incident report revealed Patient #2's parent (CC) told RN P that s/he had "done skin care the previous day and felt very confident all these markings were new this morning". RN P documented taking photos of the injuries 2/3/18. The 2/3/18 incident was not recorded into their incident reporting system until 02/09/18 (6 days after the injuries were reported to hospital staff).

Further review of the incident report # 0 revealed additional injuries "right subconjunctival hemorrhage" (per review of patient #2's medical record facial/head injuries were not discovered until on 02/04/2018) however the incident report does not include clarification that these were two separate incidents/injuries as no date or time included in this notation.

Review of the incident report for Patient #2 (# 0) "revealed under "Resolution and Outcome", final severity level as "D. No Harm-Reached Patient Monitoring Required" and under the "Follow-Up Actions:" "Not Specified" There was no additional documentation of further investigation of the injuries or intervention to protect Patient #2. There is no separate incident report on this event.

Review of Patient #2's NICU "Nursing Notes" revealed on 2/04/18 RN U had documented that Patient #2 had additional injuries documented as bruising on face, periorbital edema.

Review of the incident report log revealed the staff did not document on an incident report for Patient #2 the injuries of unknown origin identified by hospital staff 02/04/2018.

Review of Patient #2s "Attending Neonatologist (L) Addendum" in the "Physicians Progress Note" dated 02/08/18 at 7:06 AM revealed scalp swelling noted last evening unknown etiology.

On 2/16/2018 at 4:30 PM during an interview Nurse Manager NICU D confirmed on Thursday 2/08/18 ( 6 days after the first injury was reported and 4 days after the second injury was identified) Physician L consulted Child Abuse Expert N regarding unexplained injuries of Patient #2 and N recommended additional tests including a skeletal survey and head computed tomography (CT) which revealed recent skull fractures and arm fractures.

Review of Patient #2's "Consult-Encounter Note" dated 2/9/2018 at 12:22 PM by Neurosurgery Physician AA revealed, "suspected nondisplaced fracture of the right parietal skull", "Fluid collection overlying the parieto-occipital skull...this collection to the suspected fracture suggests a traumatic scalp hematoma".

On 2/16/18 at 1:40 PM during an interview Patient Safety Officer Y confirmed incident event # 0 on Patient #2 was not entered until 6 days after the injury of unknown origin was identified by nursing staff. Y confirmed there was no incident report documented on the injury of unknown origin that occurred 2/07/18.

An interview was conducted with Registered Nurse P on 2/16/18 at 1:26 PM., P stated in the past s/he had been a forensic nurse, trained as a Sexual Assault Nurse Examiner (SANE) and worked in the emergency room for 2 years. RN P stated s/he reported incident of scratching and bruising on the wrists of Patient #2 to APNP R on 2/03/18 when s/he first identified it on assessment at 8 AM. RN P stated Physician O was aware of the bruising of Patient #1 and Patient #2 during rounds on 2/03/18. RN P took pictures of Patient #2 and stated s/he encouraged the nurse of Patient #1 to also take pictures of Patient #1. RN P stated s/he was so concerned RN P sent an e-mail to Nurse Manager D and Assistant Nurse Manager TT on the evening of Friday 2/03/18 to notify them of her/his concerns hoping they would be addressed first thing Monday morning. On Monday 2/05/18 s/he "made sure" Assistant Nurse Manager TT had the pictures and voiced her/his concerns. RN P stated physicians "took a wait and watch position."

On 2/16/18 at 4:25 PM during an interview Nurse Manager D, confirmed that s/he was called by Assistant Nurse Manger T on Monday, 2/05/18 and questioned what s/he should do about the bruising found on Patient #1 and #2. Nurse Manger D confirmed "I told [T] to ask the staff."

During interview with Medical Director of NICU K on 2/16/18 at 11:05 AM, K stated it was not his/her responsibility to complete an event report, "that would be the nurse's job."

During interview with APNP R on 2/16/18 at 1:40 PM R when asked if R had submitted an incident report, R stated it was "out of [his/her] realm" to complete an event report, "it is the nurses job".

On 2/15/18 at 9:16 AM during an interview CNE C confirmed the hospital was aware of the Wisconsin Statues 48.981 (2) and that they were mandated reporters and had not reported prior to this interview. C confirmed they had not completed form F- caregiver misconduct Incident Report to report to the Wisconsin Department of Health Services.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the facility failed to develop and implement an effective policy to prevent, screen, identify, train, protect, thoroughly investigate, report,and respond to any allegations of suspected abuse related to injuries of unknown origin and failed to thoroughly investigate injuries of unknown origin and protect 5 of 6 patients (#1, #2, #3 #4 and #6) in the Newborn Intensive Care Unit (NICU) identified with injuries of unknown origins when the first case was reported for Patient #4 on 4/12/17.

Findings include:

Review of Bylaws and Rules and Regulation of the Medical Staff dated January 2017, approved by the Medical Executive Committee on November 15, 2016, approved by the Medical Staff at the annual meeting on January 17, 2017 and approved by the UnityPoint Health-Merrier Health Services Board on and effective January 25, 2017 under Membership and Privileges Section 1 Qualifications C. revealed "Members of the Medical Staff shall ...comply with the safety policies and guidelines put in place by the hospital and/or Medical Staff".

Review of policy titled "Child at Risk Abuse and Neglect" dated March 2001 revised 8/2016 under II. C. Statutory requirements for reporting child abuse under Wisconsin Statute 48.981 3. revealed "Each person who has a concern about suspected child abuse or neglect is responsible for either making a report directly or for verifying that the report was actually made to County Human Services or law enforcement". Under D. Investigation and documentation 1. revealed "when a concern about abuse or neglect is identified by a person required to report...that person immediately consults with, by telephone or personally... determined by the primary clinical area the child is receiving care through."

Patient #2
Review of Patient #2's medical record revealed that Patient was born via C-section (caesarean section) [the delivery of a baby through a surgical incision in the mother's abdomen and uterus] on 11/30/17 at 11:39 AM, weighing 1 pound and 8.3 ounces.

Review of Patient #2's NICU "Nursing Notes" revealed on 2/04/18 RN U had documented that Patient #2 had additional injuries documented as bruising on face, periorbital edema.

Review of the incident report log revealed no incident report was completed for the new injuries of unknown origin found on 02/04/2018 for Patient #2.

Review of Patient #2s "Attending Neonatologist (L) Addendum" in the "Physicians Progress Note" dated 02/08/18 at 7:06 AM revealed scalp swelling noted last evening unknown etiology. Review of Patient #2's Attending Neonatologist (L) summary of the ultrasound dated 02/08/18 revealed "normal intercranial ultrasound".

Review of the incident report # 0 titled "Current Summary" revealed on Saturday 02/03/18 at 8:00 AM, Patient #2s parent (DD) noticed "abrasions/scratching on left wrist" and notified RN P. RN P completed an assessment and identified "right palm /heal of hand with reddened intact areas", "scattered purple/red bruising on the opposite side of right hand and a few scattered areas of bruising up the right forearm and inner wrist", purple red bruising on left palm extending from area between thumb and first finger", small red bruises on second and third distal fingers, mostly located ulnar side of left wrist", "scattered linear abrasion", scattered purple/red bruising extending up left forearm". Further review of the same incident report revealed Patient #2s parent (CC) told RN P that s/he had "done skin care the previous day and felt very confident all these markings were new this morning". RN P documented taking photos of the injuries 2/3/18. The 2/3/18 incident was not recorded into their incident reporting system until 02/09/18, 6 days after the event. Included in this incident report were additional injuries "right subconjunctival hemorrhage" (per review of medical record were not discovered until on 02/04/2018) however the incident report does not include clarification that these were two separate incidents/injuries as no date or time included in this notation. No additional incident report was completed for second 02/04/18) injury of unknown origin for Patient #2
.
Review of the incident report for Patient #2 (# 0) "revealed under "Resolution and Outcome", final severity level as "D. No Harm-Reached Patient Monitoring Required" and under the "Follow-Up Actions" revealed, "Not Specified"

On 2/16/2018 at 4:30 PM Nurse Manager NICU D confirmed on Thursday 2/08/18 Physician L consulted Child Abuse Expert N regarding unexplained injuries of Patient #2 and N recommended additional tests including a skeletal survey and head computed tomography (CT) which revealed recent skull fractures and arm fractures.

Review of Patient #2's "Consult-Encounter Note" dated 2/9/2018 at 12:22 PM by Neurosurgery Physician AA revealed, "suspected nondisplaced fracture of the right parietal skull", "Fluid collection overlying the parieto-occipital skill...this collection to the suspected fracture suggests a traumatic scalp hematoma".

Patient #4
Review of Patient #4s "Admission Record" revealed that Patient #4 was born on 3/19/17 at another hospital and was transferred to this hospital on 03/19/17 at 3:14 PM with an admitting diagnosis of [DIAGNOSES REDACTED]

Review of Patient #4's medical record with Patient Safety Officer Y revealed Patient #4 had a two view x-ray completed on 4/12/17 of the tibia, first view "normal", second view "somewhat limited evaluation". Record review confirmed RN H was primary caregiver on night shift April 11-12, 2017. "Physician Notes" from 04/12/17 at 7:29 AM by Physician K, revealed bruising.

Review of Patient #4's incident report for event # 5 titled "Current Summary" dated 4/12/17 and documented by RN W, revealed injuries of unknown origin were identified at 9:00 AM on 4/12/17, as "bilateral bruising on calves, ankles and left foot" (photos were taken and placed in the medical record), and X-rays ordered. Further review of Patient #4s incident report "Resolution and Outcome" for the 04/12/17 event "Severity Level" revealed "E. Harm-temporary, Intervention Needed" and the "Follow-Up Actions" revealed, "Not Specified".

Patient #1
Review of Patient #1's medical record revealed that Patient #1 was admitted on [DATE] and was born at 14:55 (2:55 PM) weighting 3 pounds 6.5 ounces and was 15.75 inches and induced vaginal delivery . Patient #1 was admitted to the NICU 14:55 (2:55 PM) after birth for prematurity, RDS ([DIAGNOSES REDACTED]) and sepsis evaluation and retinopathy (disease of the retina that results in impairment or loss of vision r/t to the premature birth) and diagnosed with [DIAGNOSES REDACTED]

Review of Patient #1's "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" "Outcome" revealed on 01/14/2018 at 5:04 PM "Abrasions noted on bottom of L foot unchanged. Bruising noted to R hand and bottom of L foot."

Review of Patient #1's "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" "Outcome" revealed on 1/15/2018 6:46 AM "Continues to be ruddy/jaundice with bruising/abrasion to bottom of left foot. Bruising to right hand noted."

Review of Patient # 1's "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" revealed on 2/2/2018 9:17 PM "Bruising remains on left arm and hand."

Review of Patient #1's medical record dated Friday 02/02/18 "AM Nursing Progress Notes" by RN P identified "bruising [DIAGNOSES REDACTED] and abrasions of bilateral hands and forearms" of Patient #1, at 8:00 AM cares and notified APNP R and Physician O.

Review of Patient #1's "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" "Outcome" revealed on 2/4/2018 5:35 AM "Bruising noted on left hand"

Review of Patient #1's "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" "Outcome" revealed on 2/9/2018 12:33 PM "Back of left hand with resolving bruise noted"

Review of Patient #1's "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" "Outcome" revealed on 2/10/2018 at 2:58 PM "Bruising to top of L hand noted, primarily extending up from 4th and 5th fingers"

Review of Patient #'s "Nursing Notes" "Plan of Care" "Problem: Skin Integrity" - "Impaired, Risk of" revealed on 2/13/2018 8:24 PM "Continues to have very light bruising to her left arm/hand - almost unable to see today"

Review of incident report titled "Current Summary" dated 02/08/18 for Patient #1 revealed Patient #1 had injury on unknown origin that was identified on 2/2/2018 but was not recorded in their incident reporting system by RN CC (6 days after the event).

Interview with (APNP) R on 2/16/18 at 1:40 PM confirmed R notified Physician O and Physician K on 2/02/18 of injuries on Patient #1.

On 2/16/18 at 11:05 AM during an interview Physician K confirmed Patient #1's injuries on 2/02/18 may have been from patient clutching wires or peripheral intravenous device arm board used for stabilization. Physician K stated S/he was contacted by a RN about the injuries identified on Patient #1 Friday 02/02/18 and assessed Patient #1 and called Physician O to discuss her/his findings.

Patient #3
Record review of Patient #3's "Birth Record" revealed Patient #3 was born vaginal delivery on 9/17/17 at 3:31 AM weighting 4 pounds 12.2 ounces and was 43 cm (16.9 inches) long Review of the medical record "Birth History" reveal: [Patient #3]"is a male infant born at 34w5d via normal spontaneous vaginal delivery, admitted to NICU for prematurity.

Review for patient #3 revealed in "Physician Progress Notes" dated 9/22/2017 at 7:16 AM "non-blanching linear macules on bilateral palms, no other rashes or lesions." Neonatology Addendum 09/22/17 (not timed) "I examined baby, reviewed data and directed plans on rounds. I agree with resident note, Bruise-like macules noted on palms bilaterally.

Review of nursing documentation for Patient #3 by RN H 9/19/17 through 9/22/17, failed to document bruising or skin assessments.

Review of the Hospital's investigation report dated on 2/09/18 revelaed that Physician V had recalled Patient #3 had unexplained bruising. The Hospital investigation report verified RN H had been a primary caregivers during Patient #3's hospitalization in the NICU 9/17/17 thru 10/13/17. During this hospitalization , Patient #3 had bruising of left foot and scalp bruising. Patient #3's mother had taken pictures of the bruising at that time, which were presented to Child Abuse Specialist N on 2/09/18. On 2/09/18 N reviewed the photographs of Patient #3 from the past hospitalization and determined bruising was consistent with child abuse. RN H was primary caregiver on nights for Patient #3 September 21-22, 2017. The medical record review during the hospital investigation for Patient #3 revealed, there were no marks/bruises or injuries documented in medical record prior to 9/21/17. RN H did not note any bruising in any documentation.

No incident report was documented for the 9/22/17 when injury of unknown origin bruising of left foot and scalp bruising of Patient #3.

Patient #6
Closed medical review of the "Birth Record" for Patient #6 revealed Patient #6 was born C-Section on 1/19/18 at 20:44 (10:44 PM) weighing 1.61 Kg (3 pounds 6 ounces) and was 39.4 cm (15.5 inches).

During interview on 2/15/18 at 9:16 AM, Chief Nursing Officer C (CNO C) confirmed as a part of the Hospital's investigation that ever since Patient #6 was in the care of RN H, the hospital contacted Patient #6's parents EE and notified them of safety plan because Patient #6 had scattered bruising on lower extremities during the hospital stay on 01/20/18. The investigation revealed the Parents (EE) of Patient #6 informed hospital staff they were uncomfortable with caregiver RN H, who was the primary caregiver on the night shift for Patient #6 on January 23-24, 2018. The hospital decided due to these concerns, Physician Z consulted Child Abuse Expert N on 02/12/18 who recommended skeletal survey and a CT. The hospital investigation revealed Patient #6 had multiple fractures ,including rib and arm fractures which was confirmed in an interview with NICU Nurse Manager D on 2/16/2018 at 4:30 PM.

No incident report was documented for Patient #6 related to scattered bruising on lower extremities during the hospital stay on 01/20/18.

Interview on 2/15/18 at 9:16 AM with CNO C revealed that they had not reported the suspected abuse immediately because the hospital was working on their investigation and they were collecting the information to report. When asked about reporting suspected abuse CNO C, confirmed S/he understand the need to report abuse or neglect ASAP (as soon as possible).

On 2/16/18 at 11:05 AM during an interview Medical Director of Neonatal Intensive Care Unit K confirmed it was not his/her expectation of the physicians to complete incident reports, "they are "filled out by nurses."

Interview on 2/16/18 at 1:26 PM with Registered Nurse (RN) P confirmed Patient #2 had unexplained bruising similar to Patient #1 and notified attending Physician O on 2/03/18 between 9:30 AM and 11 AM. RN P was concerned and stated on the evening of 2/03/18 RN P sent an E-mail to Nurse Manager D and Assistant Nurse Manager T regarding his/her concerns of unusual markings, and similarity of the bruising on Patient #1 and Patient #2 to make sure this was follow up on, and thought this would be addressed first thing Monday 2/05/18, but it was not.

On 2/16/18 at 1:40 PM during an interview Advanced Practice Nurse Prescribe (APNP) R stated S/he discussed common factors with RN's P & X on Monday 2/05/18, who identified RN H had cared for both Patient #1 and Patient #2.

Interview on 2/16/18 at 2:12 PMwith the Director of Performance Improvement B confirmed there was no policy or process that directed staff on their responsibility to prevent, screen, identify, train, protect, thoroughly investigate, report,and respond to any allegations of suspected abuse related to injuries of unknown origin.

On 2/16/2018 at 4:25 PM during an interview Nurse Manager NICU D stated based on the current evidence and staffing logs the hospital suspended suspected Caregiver RN H, disabled RN Hs badge access and RN Hs access to the hospital electronic medical record. Manager NICU D confirmed that on Monday 2/05/18 when Assistant Manager T called Manager D asking what to do [staff concerns and injuries on Patient #1 and #2], Nurse Manager D stated S/he told Assistant Manager T "to ask staff".