HospitalInspections.org

Based on 2 of 14 MR reviews, staff interview, policy/procedure review, and other facility document reviews, this facility failed to ensure a safe environment for 2 of 2 (Pt. 2 and Pt. 6) newborns as evidenced by the failure to verify patient identifications which resulted in body fluid exposure and failed to ensure all newborns are appropriately banded with identifications. This has the potential to affect all newborns and their mothers.

Findings include:

The hospital failed to protect 2 of 6 newborns (Pt. 2 and 6) from body fluids of non-related persons. (See A-144)

The hospital failed to follow policy/protocol for applying and recording safety identification bands to newborns. (See A-144)

Failure to provide a safe environment for newborn infants has the potential to affect all newborns in the facility, including the 10 newborns present during the course of the survey (5/29/12-5/30/12).

The cumulative effect of these failures resulted in the facility's inability to ensure that newborn infants are in a safe and secure environment which is a violation of Patient Rights.

Based on policy and procedure review, staff interview, MR review (2 out of 14 MR reviewed), and review of other facility documentation, this facility failed to protect newborn infants (Pt. #2 and 6) from exposure to body fluids, and failed to properly apply/record security bands, thereby not ensuring a safe environment. Failure to provide a safe environment for newborn infants has the potential to affect all newborns in the facility, including the 10 newborns present during the course of the survey (5/29/12-5/30/12).

Findings include:

The facility policy titled, "Patient Bill of Rights and Patient Complaint Resolution Policy," dated 7/1/2009, was reviewed on 5/30/2012 at 8:35 a.m. On page 2, I. M. states, "Personal Safety-Medical and healthcare facility staff will do everything possible to ensure safety while in the medical center."

The facility policy titled, "Women & Families: Infant Safety & Security, BirthPlace and NICU (Neonatal Intensive Care Unit)," dated 5/4/2011, was reviewed on 5/29/2012 at 6:36 p.m. In the policy statement, the policy says, "All Women & Families staff members are responsible for adhering to the processes and practices included in this policy, to assure the safety and security of infants on BirthPlace and in the NICU."

In this same policy, II. Procedure. A. states, "Multiple processes and practices are utilized within BirthPlace and NICU to promote the highest level of safety and security for all infants including, but not limited to: prior to being taken from the Delivery Room/C-section [cesarean] suite a 4-band patient identification process, with matching bands for mother, significant other, and infant is utilized."

The facility policy titled, "Women & Families: Identification of Newborns & Mothers in BirthPlace," dated 4/8/2004, was reviewed on 5/29/2012 at 11:20 a.m. The policy states, in II. Procedure D., "Identification bracelets must be checked and verified each time the infant is taken to the mother's room or is picked up from the nursery....Key Point: The mother's account number, found on both the mother's band and one of the infant's bands will be matched during the verification process."

The facility policy titled, "Women & Families: Expressed Human Milk (Breast Milk)," which is not dated, states in part, "An infant/child will receive breast milk expressed from his/her mother only....Human milk is a bodily fluid and will be handled accordingly to prevent cross-contamination of that milk with other feedings, and to ensure the safety of those handling the milk. Breast milk will be regarded as a potentially infectious fluid requiring use of barrier precautions and spill clean up in the same manner as blood."

The policy outlines the protocol staff are to follow when preparing the breast milk for storage in a designated refrigerator, and when preparing the breast milk for a feeding. There is a 4-step verification process, which includes 2 nursing staff to verify, through identification numbers, that the correct milk is being prepared for the correct baby, and also a nurse and a mom to verify, through identification numbers, that the correct milk was brought to the room for the correct baby.

In an interview with Mgr. D on 5/29/2012 at 10:45 a.m., Mgr D described the identification process as follows: immediately after birth a baby is fitted with an identification band that matches mom, one of their own identification bands specific to just them, and a HUG band, which is the facility's safety device that alarms when baby is taken too close to areas that could be considered an exit.

Mgr. D explained the details of the incident reported to the Department of Health Services, in which Pt. #2 was taken to the wrong room by LPN G on 5/18/2012 and breast fed from the wrong mother. Mgr D stated, "Everybody on our unit knows what the policy is when taking baby out to the room," and indicated that LPN G did not follow policy by not verifying identification upon delivering Pt. #2 to the wrong mother to be breast fed.

An interview with LPN G was conducted on 5/30/2012 at 9:10 a.m. LPN G stated G was not aware of the error of delivering Pt. #2 to the wrong mother on 5/18/12 until Mgr D contacted G at home via phone after the incident. When asked if LPN G checked the identification of Pt. #2 upon delivery to the wrong mother ' s room, G stated, "Evidently I did not."

LPN G did confirm that G does know what the policy/protocol is for confirming identification between mom and baby.

In a phone interview with RN I on 5/30/2012 at 9:35 a.m., RN I confirmed that RN I discovered Pt. #2 was in the wrong room with the wrong mom on 5/18/12 and observed Pt. #2 breastfeeding from Pt. #3, who was not Pt. #2's mother.

On 5/29/2012 at 12:00 p.m. President C, Director of Nursing B, Mgr D , CC E, and QM A, disclosed to Surveyor #26711 of another incident on 5/25/2012 involving Pt. #6 who was fed a bottle of breast milk from Pt. #7, who was not Pt. #6's mother. It was determined that RN F did not follow policy and did not verify identification numbers against mom's and baby's bands on 5/25/12.

An interview with RN F was conducted on 5/29/2012 at 2:20 p.m. RN F confirmed that F did deliver the wrong breast milk to patients on 5/25/12 and failed to verify patient and bottle identifications.

RN F did confirm that F does know what the policy/protocol is for confirming identification between mom and baby.

MR reviews were completed on Pt. #2 and 6's closed newborn MRs and Pt. #1, 3, 5, and 7's closed Maternity MRs on 5/29/2012 between 1:35 p.m. and 3:00 p.m. in the presence of CC E. The MRs indicate that Pt. #2 and Pt. #6 were exposed to the wrong mother's breast milk and disclosure was done to all four mothers shortly after discovery. The "Breast Milk Exposure Check List" was initiated in both cases and all four mothers were ordered blood draws for Hepatitis and Human Immunodeficiency Virus (HIV).

In further interviews on 5/29/2012-5/30/2012 with WFH staff who wish to be anonymous, it was disclosed that more safety issues have occurred since the 5/25/2012 incident with Pt. #6; dispite the hospital's actions since 5/18/12 of reinforcing hospital policies regarding patient verification, patient security measures, and personnel actions for those who fail to follow protocol.

WFH staff K informed Surveyor #26711 in an interview that a baby over the weekend of 5/25/2012-5/28/2012 went 2 days without having the HUG security band on. Without this security band on, no alarm would sound if the baby was carried too close to an exit thereby creating a potential abduction hazard.

WFH staff M informed Surveyor #26711 in an interview that over this same weekend a baby's identification band came off after the laboratory staff removed the heel warmer which is used to warm baby's heel to make obtaining a blood sample easier. The identification band was discarded in the trash with the heel warmer.

WFH staff J informed Surveyor #26711 in an interview that over this same weekend two baby's HUG alarm system information was not recorded in the computer. Without this information in the computer the alarm system will only bring up a number when baby is taken too close to an exit and not which baby is potentially at risk for abduction.

These findings were discussed with Mgr. D and CC E on 5/30/2012 at 11:15 a.m. Mgr D and CC E denied knowledge of these incidents.

Occurrence reports for the WFH department were reviewed on 5/30/2012 at 10:15 a.m., the above safety issues were not recorded.