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Based on observation, interview, record review and policy review, the facility failed to protect and promote the rights of pediatric patients to ensure care was provided in a safe setting to ensure pediatric patients were protected from abuse and neglect (neglect is considered as a form of abuse) when 2 (Pediatric Patient #1 and #2) out of 10 sampled pediatric patients were dropped/fell to the floor by the nurse due to a lack of adequate monitoring and appropriate safety measures. Based on the findings, the Condition of Participation at 42 CFR, Part 482.13 Patient Rights was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients was identified.

The findings included:

Based on observation, interview, record review and policy review, the facility failed to ensure all patients received care in a safe setting. The cumulative effect resulted in Immediate Jeopardy at A144. 2 out of 10 (Pediatric Patient #1 and Pediatric Patient #2) sampled pediatric patients were not appropriately supervised by nursing staff and provided with adequate monitoring and safety measures to prevent a drop/fall to the floor due to unsafe practices. Patient #1 experienced a drop/fall from the lap of a nurse during bottle feeding resulting in an additional 36 days of hospitalization. Patient #2 experienced a fall from an isolette when the door was not properly closed. Refer to A144.

Based on interview, record review and policy review, the facility failed to provide nursing care and services in accordance with accepted standards of nursing practice and ensure that patients at high risk for falls had adequate supervision and safety measures in place for 2 (Newborn Pediatric Patients #1 and Pediatric Patient #2) out of 10 sampled patients that were dropped/fell to the floor while under the care of a nurse. Based on the findings, the Condition of Participation at Code of Federal Regulations (CFR) 42, Part 482.23 Nursing Services was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients were identified.

The findings included:

Based on interview, record review and policy review, the facility failed to ensure all patients were appropriately supervised according to a patient specific plan of care based on assessed needs. The cumulative effect resulted in Immediate Jeopardy at A395. Two (Newborn Pediatric Patients #1 and Pediatric Patient #2) out of 10 sampled pediatric patients were not appropriately supervised by nursing staff and provided with adequate safety measures to prevent a drop/fall to the floor due to unsafe practices. Patient #1 experienced a drop/fall from the lap of a nurse during bottle feeding possibly resulting in additional days of hospitalization. Patient #2 experienced a fall from an isolette/crib when the door was not properly closed. Refer to A395.

Based on observation, interview, record review and policy review, the facility failed to ensure all patients received care in a safe setting. The cumulative effect resulted in Immediate Jeopardy at A144. 2 out of 10 (Pediatric Patient #1 and Pediatric Patient #2) sampled pediatric patients were not appropriately supervised by nursing staff and provided with adequate monitoring and safety measures to prevent a drop/fall to the floor due to unsafe practices. Patient #1 experienced a drop/fall from the lap of a nurse during bottle feeding resulting in additional days of hospitalization. Patient #2 experienced a fall from an isolette when the door was not properly closed. Based on the findings, the Condition of Participation at 42 CFR, Part 482.13 Patient Rights was determined to be out of compliance and Immediate Jeopardy to the health and safety of patients was identified. Refer to A115.

The findings included:

Review of facility Policy No. 400.005; Subject: Patient Rights and Responsibilities, Last Revised 09/20/2023 documented in part, I. Purpose: The facility supports the Patient's Bill of Rights and Responsibilities which is recognized as applying to all adult and pediatric patients, their parents and/or guardians. A patient has the right to a prompt and reasonable response to questions and requests. Any patient, patient advocate, parent or guardian who feels the patient is not being treated properly has the right, without recrimination, to voice complaints/grievances regarding the care received and to have those complaints/grievances reviewed and resolved. This includes the right to file a verbal or written complaint/grievance with the State against the hospital or a healthcare professional. (xiv) Receive Care in a Safe Setting.

Review of facility Policy No. 400.095; Subject: Fall and Fall Injury Prevention and Management Program, Last Revised 01/10/2022 documented in part, I. Purpose: The purpose of this policy is to promote a culture of safety, foster an environment of care to reduce the incidence of patient falls and minimize the risk of injury. This policy aims to accomplish these goals by establishing procedures to systematically assess fall risk and risk of injury due to fall factors by providing guidelines for fall interventions and by outlining procedures for education, communication, and documentation.

Ill. Procedure: A. Responsibility (1) The following staff members are responsible for the implementation and oversight of an individualized patient's fall prevention care as follows: (a) Registered Nurses (b) Interdisciplinary Team (c) Therapy Staff. B. Fall Risk Assessment (1b) Humpty Dumpty Scale for Pediatric Inpatients (>12 High Risk) Key points: Patients may also be identified as high fall risk even when Humpty Dumpty Scale Score is less than 12, based on unit-specific risk factors and/or the caregiver's judgment. (2) For children less than 3 years old the scale is to be done on admission and transfer only, as they are always high risk for falls.

A review of Pediatric Patient #1's medical record revealed that Pediatric Patient #1 was born at the facility on 08/12/2024 prematurely at 34.3 weeks of gestation weighing 3.5 pounds and admitted to the Level IV Newborn Intensive Care Unit (NICU) for respiratory distress.

Review of Neonatology Progress Note dated 8/17/2024 at 11:37AM documented Pediatric Patient #1 transferred from NICU B, status post respiratory distress, tolerating feeds well.
Vitals & Measurements: Temperature: 98.06°F (Axillary) Heart Rate: 138(Monitored) Respiratory Rate: 44; Blood Pressure: 61/33; Oxygenation (SpO2): 98%; Weight: 1.970 kg (4.3 pounds).

Physical Exam
General: Well nourished, well hydrated. No distress.
Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion
Cardiovascular: Normal rate, Regular rhythm, No murmur.
Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds.
Eye: Extraocular movements are intact. Normal conjunctiva.
Head: Normal, fontanelles soft, sutures movable.
Integumentary: Normal color, No rash, No edema.
Neurologic: Alert, Normal motor function, No focal deficits.
Ins/Outs: Enteral feeding: 119 ml/kg/day. Urine output: 3.4 ml/kg/hour. Stools: 5.

Reason For Continuing Hospitalization: Pediatric Patient #1 with low birth weight (LBW) in isolette. Starting feeds.

Review of Neonatology Progress Note dated 08/20/2024 at 10:48AM documented Reason For Continuing Hospitalization - Pediatric Patient #1 still small, weaning well from isolette , now gaining weight better, will increase feeds, probable discharge in AM (08/21/2024).

On the morning of 08/21/2024 around 6AM while being bottle-fed by a nurse, Pediatric Patient #1 was dropped/fell to the floor from the nurse's lap. The fall incident was not reported by the nurse and Patient #1 did not receive immediate medical attention. After the fall, Patient #1 was no longer able to be bottle fed and required a feeding tube for weight management.

Review of Neonatology Progress Note dated 08/21/2024 at 11:20AM (approximately 4 hours post morning fall) documented Pediatric Patient #1 weaned to open isolette, but lost weight and nippling very slowly this AM. Temperature: 97.88 °F (Axillary) Heart Rate: 154 (Apical) Respiratory Rate: 64; Blood Pressure: 67/42; Oxygenation (SpO2): 99%; Weight: 1.750 kg (3.85 pounds). Feeding tube inserted.

Review of Neonatology Progress Note dated 08/22/2024 at 10:35AM (1-day post fall) documented Pediatric Patient failed weaning and failed to take all feeds 8/21/2024, now continues to require gavage to complete feeds.

Review of Neonatology Progress Note dated 08/23/2024 at 1:22PM (2-days post fall) documented Reason For Continuing Hospitalization: Pediatric Patient #1 requiring gavage feeds. Needs isolette to keep temperature stable. Will get screening complete blood count (CBC) as Pediatric Patient #1 now nippling poorly (was nippling well 2 days ago).

Review of Neonatology Progress Note dated 08/27/2024 at 9:10AM (6-days post fall). Pediatric Patient #1 still requiring gavage feeds, plan discharge when nippling all.

Review of Neonatology Progress Note dated 08/29/2024 at 10:21AM (8-days post fall). Discharge plans for the next 1 to 2 days if Pediatric Patient #1 consistently take all feeds well.

Review of Neonatology Progress Note dated 09/01/2024 at 10:33AM (11-days post fall). Pediatric Patient #1 nippled almost all, in open crib, but lost a bit of weight. Reason For Continuing Hospitalization: Very low hemoglobin/hematocrit.

Over a 3-week period, Pediatric Patient #1 remained hospitalized in the unit and slowly progressed with feeding and improved anemia and was discharged home on 09/16/2024 (26 days post fall). The fall incident was eventually reported on 09/23/2024 by another parent who was in the unit and witnessed Pediatric Patient #1's fall.


On 09/26/2024 (10 days post discharge), during a clinic visit dated 09/26/2024, the parents of Pediatric Patient #1 were notified that Pediatric Patient #1 was dropped by the nurse on 08/20/2024. Review of the Assessment/Plan revealed Pediatric Patient #1 was preterm with a history of trauma to head 1 month prior - exam at this time unremarkable, but Pediatric Patient #1 had no imaging done as incident was not known so Head Ultrasound ordered. The Head Ultrasound showed a right germinoloytic cyst versus grade 1 intravascular hemorrhage (IVH), so repeat was ordered in 2 weeks. Pediatric Patient will be followed in clinic. Discussion was held with parents who voiced concern over future consequences of the fall, they were particularly concerned as another child in the family had been dropped as a baby and though no injury was found at the time the child had developmental issues.

A statement from the nurse dated 09/24/2024 at 1:05PM documented the fall occurred when Pediatric Patient #1 became wiggly while being bottle fed on her lap (thigh). Pediatric Patient #1 was wrapped in several blanks and the nurse was unable to maintain a firm grasp of Pediatric Patient #1. Pediatric Patient #1 slipped out of the nurse's hand and fell to the floor. Pediatric Patient #1 was picked up and consoled by the nurse. Vital signs were monitored but the nurse failed to report the fall to a medical provider because the vital signs were normal. As a result, Pediatric Patient #1 was not assessed for hospital acquired fall related injuries until 09/26/2024.


An interview was conducted on 03/19/2025 at 10AM with the mother of Pediatric Patient #1 after a clinic visit using professional interpreter services provided to patient by the facility.
The mother stated that after the fall was disclosed on 09/26/2024 Pediatric Patient #1 is being followed in a program to identify if developmental milestones are being reached and receiving occupational therapy once a week for spasticity (muscles stiffen or tighten), left side affected more than the right side. During an interview conducted with Pediatric Patient #1's mother in the clinic on 03/18/2025, it was revealed she is having difficulty obtaining an appointment for pediatric neurology related to the spasticity Pediatric Patient #1 is experiencing and audiology to address Pediatric Patient #1 not reacting to a bell ring The appointments have been requested multiple times since December 2024. As of this visit (03/19/2025), Pediatric Patient #1 has not seen either specialist.

During an interview on 03/14/2025 at 2:45PM with the Senior Vice-President and Chief Executive Officer (CEO) of the Children's and Women's Center, it was revealed that a Root Cause Analysis (RCA) was not performed because "criteria was not met".

During an interview conducted with the facility Risk Manager (RM) on 03/19/2025 at 9AM it was acknowledged that the education efforts were focused on reporting the incident not how Pediatric Patient #1 was positioned during feeding. The RM also acknowledged post fall management was reviewed but did not explore how to avoid or prevent the incident.

Pediatric Patient #2
A review of Pediatric Patient #2's medical record revealed that Pediatric Patient #2 was born 08/02/2023 prematurely at 26 weeks gestation weighing 0.8kg (1.76 pounds).

On 10/02/2023 a physician reported that a parent of another baby reported to her that she saw Pediatric Patient #2 fall from the isolette on 09/26/2023 between 9PM and 12 midnight. Following confirmation, a meeting was immediately requested with the parents of Pediatric Patient #2. On 10/03/2023 a meeting was held with the parents, nurse manager, director of pediatric services, risk manager, and physician. The parents were informed that their baby had an accidental fall from an isolette on 09/26/2023. A head ultrasound done prior to and after 09/26/2023 were unchanged and skeletal survey done 10/03/2023 did not show any fractures. The parents were surprised and asked how this occurred. The parents were informed that in the process of changing the baby's bed linens, an isolette door was not properly closed. Apologies were extended for the occurrence and the late disclosure. The parents expressed concerns about a swollen arm, and it was explained that this was secondary to a peripherally inserted central catheter (PICC) line and this was removed. The parents also wanted to know the plans for the fluid in the brain and the physician explained via speaker phone (and interpreter) that she hopes to do a reservoir very soon, however a lot of cerebrospinal fluid (CSF) drained out during the previous surgery, and it would not have been safe to place a reservoir during that surgery. The parents were also informed that a brain MRI would be done as head ultrasounds are not good for imaging the posterior fossa. The parents voiced understanding and were told that we are available at any time to address any further concerns.

Per bystander report, Pediatric Patient #2 fell from an incubator onto the floor while the bedside nurse was providing care on Tuesday evening, September 26, 2023. The nurse did not report the fall to the clinical team. Pediatric Patient #2 was returned to the incubator and routine care provided. The bystander reported this event to the physician on October 2, 2023, at 3PM.

Interviews conducted with NICU Intermediate nursing staff on 03/19/2025 between 2PM and 3PM revealed that newborns and premature infants are at risk for falls if not secured properly during feeding or routine activities because of their small size and weight.

Two pediatric falls occurred in the facility's Newborn Intensive Care Unit between 09/26/2023 and 08/21/2024. Both fall events were not reported by the nursing staff to provide an opportunity for immediate medical attention. The falls were discovered when the parents of other infants witnessed the fall events and reported their observations.

On 09/26/2024 and 09/28/2024 the facility conducted nursing staff education focused on reporting fall events via unit huddles. The staff were also instructed to review Lippincott Procedures - Fall prevention for neonates. Huddle attendance was signed by approximately 61 out of 165 nursing staff working in the 4 newborn ICU's. The unit consists of 4 contiguous areas totaling 121 beds. The nursing staff may be assigned to any of the areas to provide nursing care.

Based on interview, record review and policy review, the facility failed to provide nursing care and services in accordance with accepted standards of nursing practice to ensure that patients at high risk for falls had adequate supervision and safety measures in place. 2 (Pediatric Patient #1 and Pediatric Patient #2) out of 10 sampled patients were dropped/fell to the floor while under the direct care of a nurse (during feeding and during bed linen change).

The findings included:

Review of facility Policy No. 400.095; Subject: Fall and Fall Injury Prevention and Management Program, Last Revised 01/10/2022 documented in part, I. Purpose: The purpose of this policy is to promote a culture of safety, foster an environment of care to reduce the incidence of patient falls and minimize the risk of injury. This policy aims to accomplish these goals by establishing procedures to systematically assess fall risk and risk of injury due to fall factors by providing guidelines for fall interventions and by outlining procedures for education, communication, and documentation. Ill. Procedure: A. Responsibility (1) The following staff members are responsible for the implementation and oversight of an individualized patient's fall prevention care as follows: (a) Registered Nurses (b) Interdisciplinary Team (c) Therapy Staff. B. Fall Risk Assessment (1b) Humpty Dumpty Scale for Pediatric Inpatients (>12 High Risk) Key points: Patients may also be identified as high fall risk even when Humpty Dumpty Scale Score is less than 12, based on unit-specific risk factors and/or the caregiver's judgment. (2) For children less than 3 years old the scale is to be done on admission and transfer only, as they are always high risk for falls.

Review of Policy No. 400.095, Subject: Interdisciplinary Plan of Care (IPOC), Last Reviewed 04/10/2023 documented in part, I. Purpose: To describe the process by which the clinical members of the interdisciplinary care team collaborate to customize and implement an interdisciplinary Plan of Care (IPOC) that focuses on the patient needs, problems, and outcomes.

A review of Pediatric Patient #1's medical record revealed that Pediatric Patient #1 was born at the facility on 08/12/2024 prematurely at 34.3 weeks of gestation weighing 3.5 pounds and admitted to the Level IV Newborn Intensive Care Unit (NICU) for respiratory distress.

Review of Neonatology Progress Note dated 8/17/2024 at 11:37AM documented Pediatric Patient #1 transferred from NICU B, status post respiratory distress, tolerating feeds well.
Vitals & Measurements: Temperature: 98.06°F (Axillary) Heart Rate: 138(Monitored) Respiratory Rate: 44; Blood Pressure: 61/33; Oxygenation (SpO2): 98%; Weight: 1.970 kg (4.3 pounds).

Physical Exam
General: Well nourished, well hydrated. No distress.
Respiratory: Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, Symmetrical chest wall expansion
Cardiovascular: Normal rate, Regular rhythm, No murmur.
Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds.
Eye: Extraocular movements are intact. Normal conjunctiva.
Head: Normal, fontanelles soft, sutures movable.
Integumentary: Normal color, No rash, No edema.
Neurologic: Alert, Normal motor function, No focal deficits.
Ins/Outs: Enteral feeding: 119 ml/kg/day. Urine output: 3.4 ml/kg/hour. Stools: 5.

Reason For Continuing Hospitalization: Pediatric Patient #1 with low birth weight (LBW) in isolette. Starting feeds.

Review of Neonatology Progress Note dated 08/20/2024 at 10:48AM documented Reason For Continuing Hospitalization - Pediatric Patient #1 still small, weaning well from isolette , now gaining weight better, will increase feeds, probable discharge in AM (08/21/2024).

On the morning of 08/21/2024 around 6AM while being bottle-fed by a nurse, Pediatric Patient #1 was dropped/fell to the floor from the nurse's lap. The fall incident was not reported by the nurse and Patient #1 did not receive immediate medical attention. After the fall, Patient #1 was no longer able to be bottle fed and required a feeding tube for weight management.

Review of Neonatology Progress Note dated 08/21/2024 at 11:20AM (approximately 4 hours post morning fall) documented Pediatric Patient #1 weaned to open isolette, but lost weight and nippling very slowly this AM. Temperature: 97.88 °F (Axillary) Heart Rate: 154 (Apical) Respiratory Rate: 64; Blood Pressure: 67/42; Oxygenation (SpO2): 99%; Weight: 1.750 kg (3.85 pounds). Feeding tube inserted.

Review of Neonatology Progress Note dated 08/22/2024 at 10:35AM (1-day post fall) documented Pediatric Patient failed weaning and failed to take all feeds 8/21/2024, now continues to require gavage to complete feeds.

Review of Neonatology Progress Note dated 08/23/2024 at 1:22PM (2-days post fall) documented Reason For Continuing Hospitalization: Pediatric Patient #1 requiring gavage feeds. Needs isolette to keep temperature stable. Will get screening complete blood count (CBC) as Pediatric Patient #1 now nippling poorly (was nippling well 2 days ago).

Review of Neonatology Progress Note dated 08/27/2024 at 9:10AM (6-days post fall). Pediatric Patient #1 still requiring gavage feeds, plan discharge when nippling all.

Review of Neonatology Progress Note dated 08/29/2024 at 10:21AM (8-days post fall). Discharge plans for next 1 to 2 days if Pediatric Patient #1 consistently taking all feeds well.

Review of Neonatology Progress Note dated 09/01/2024 at 10:33AM (11-days post fall). Pediatric Patient #1 nippled almost all, in open crib, but lost a bit of weight. Reason For Continuing Hospitalization: Very low hemoglobin/hematocrit.

Over a 3 week period, Pediatric Patient #1 remained hospitalized in the unit and slowly progressed with feeding and improved anemia and was discharged home on 09/16/2024 (26 days post fall). The fall incident was eventually reported on 09/23/2024 by another parent who was in the unit and witnessed Pediatric Patient #1's fall.

On 09/26/2024 (10 days post discharge), during a clinic visit dated 09/26/2024, the parents of Pediatric Patient #1 were notified that Pediatric Patient #1 was dropped by the nurse on 08/20/2024. Review of the Assessment/Plan revealed Pediatric Patient #1 was preterm with a history of trauma to head 1 month prior - exam at this time unremarkable, but Pediatric Patient #1 had no imaging done as incident was not known so Head Ultrasound ordered. The Head Ultrasound showed a right germinoloytic cyst versus grade 1 intravascular hemorrhage (IVH) so repeat was ordered in 2 weeks. Pediatric Patient will be followed in clinic. Discussion was held with parents who voiced concern over future consequences of the fall, they were particularly concerned as another child in the family had been dropped as a baby and though no injury found at the time the child had developmental issues.

A statement from the nurse dated 09/24/2024 at 1:05PM documented the fall occurred when Pediatric Patient #1 became wiggly while being bottle fed on her lap (thigh). Pediatric Patient #1 was wrapped in several blanks and the nurse was unable to maintain a firm grasp of Pediatric Patient #1. Pediatric Patient #1 slipped out of the nurses' hand and fell to the floor. Pediatric Patient #1 was picked up and consoled by the nurse. Vital signs were monitored but the nurse failed to report the fall to a medical provider because the vital signs were normal. As a result, Pediatric Patient #1 was not assessed for hospital acquired fall related injuries until 09/26/2024.

An interview was conducted on 03/19/2025 at 10AM with the mother of Pediatric Patient #1 after a clinic visit using professional interpreter services provided to patient by the facility.
The mother stated that after the fall was disclosed on 09/26/2024 Pediatric Patient #1 is being followed in a program to identify if developmental milestones are being reached and receiving occupational therapy once a week for spasticity (muscles stiffen or tighten), left side affected more than the right side. During an interview conducted with Pediatric Patient #1's mother in the clinic on 03/18/2025, it was revealed she is having difficulty obtaining an appointment for pediatric neurology related to the spasticity Pediatric Patient #1 is experiencing and audiology to address Pediatric Patient #1 not reacting to a bell ring The appointments have been requested multiple times since December 2024. As of this visit (03/19/2025), Pediatric Patient #1 has not seen either specialist.

During an interview on 03/14/2025 at 2:45PM with the Senior Vice-President and Chief Executive Officer (CEO) of the Children's and Women's Center, it was revealed that a Root Cause Analysis (RCA) was not performed because "criteria was not met".

During an interview conducted with the facility Risk Manager (RM) on 03/19/2025 at 9AM it was acknowledged that the education efforts were focused on reporting the incident not how Pediatric Patient #1 was positioned during feeding. The RM also acknowledged post fall management was reviewed but did not explore how to avoid or prevent the incident.

Pediatric Patient #2
A review of Pediatric Patient #2's medical record revealed that Pediatric Patient #2 was born 08/02/2023 prematurely at 26 weeks gestation weighing 0.8kg (1.76 pounds).

On 10/02/2023 a physician reported that a parent of another baby reported to her that she saw Pediatric Patient #2 fall from the isolette on 09/26/2023 between 9PM and 12 midnight. Following confirmation, a meeting was immediately requested with the parents of Pediatric Patient #2. On 10/03/2023 a meeting was held with the parents, nurse manager, director of pediatric services, risk manager, and the physician. The parents were informed that their baby had an accidental fall from an isolette on 09/26/2023. A head ultrasound done prior to and after 09/26/2023 were unchanged and skeletal survey done 10/03/2023 did not show any fractures. The parents were surprised and asked how this occurred. The parents were informed that in the process of changing the baby's bed linens, an isolette door was not properly closed. Apologies were extended for the occurrence and the late disclosure. The parents expressed concerns about a swollen arm and it was explained that this was secondary to a peripherally inserted central catheter (PICC) line and this was removed. The parents also wanted to know the plans for the fluid in the brain and the physician explained via speaker phone (and interpreter) that she hopes to do a reservoir very soon, however a lot of cerebrospinal fluid (CSF) drained out during the previous surgery and it would not have been safe to place a reservoir during that surgery. The parents were also informed that a brain MRI would be done as head ultrasounds are not good for imaging the posterior fossa. The parents voiced understanding and were told that we are available at anytime to address any further concerns.

Per bystander report, Pediatric Patient #2 fell from an incubator onto the floor while the bedside nurse was providing care on Tuesday evening, September 26, 2023. The nurse did not report the fall to the clinical team. Pediatric Patient #2 was returned to the incubator and routine care provided. The bystander reported this event to the physician on October 2, 2023 at 3PM.

Interviews conducted with NICU Intermediate nursing staff on 03/19/2025 between 2PM and 3PM revealed that newborns and premature infants are at risk for falls if not secured properly during feeding or routine activities because of their small size and weight.

Two pediatric falls occurred in the facility's Newborn Intensive Care Unit between 09/26/2023 and 08/21/2024. Both fall events were not reported by nursing staff to provide an opportunity for immediate medical attention. The falls were discovered when the parents of other infants witnessed the fall events and reported their observations.

On 09/26/2024 and 09/28/2024 the facility conducted nursing staff education focused on reporting fall events via unit huddles. The staff was also instructed to review Lippincott Procedures - Fall prevention for neonates. Huddle attendance was signed by approximately 61 out of 165 nursing staff working in the 4 newborn ICU's. The unit consists of 4 contiguous areas totaling 121 beds. The nursing staff may be assigned to any of the areas to provide nursing care.