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.

Based on review of documents and interviews, it was determined that the facility did not comply with its Quality Improvement Plan to ensure implementation of actions to correct identified problems.


Review of the facility ' s investigation report revealed that lighting in the Labor and Delivery unit was dim.

The facility ' s action plan noted that the hospital Administration will work with facilities to develop a minimum lighting setting in the Labor and Delivery Rooms.

The facility did not provide any evidence that the lighting in the Labor and Delivery Rooms which was identified in their Quality Improvement Plan was addressed.

This finding was confirmed with staff O (VP for Legal Risk & Regulatory Affairs & Chief Legal Officer) on 04/01/2016 at 2:30 PM.
Based on document review and interview the facility Administration failed to ensure Quality Performance Improvement review for tracking and trending of all "Code 444 Documentation" sheets. This finding was evident in one (1) of two (2) medical records reviewed (Patient #19).


Medical record review for Patient #19 contained no documented evidence that a Code 444 Documentation Form was completed for the cardiopulmonary resuscitation (CPR) code incident that occurred on 03/10/15 at 9:40 PM in Labor and Delivery.

Review of Policy titled, "Cardiac Arrest Cardiopulmonary Arrest (Code 444)." dated 06/14, revealed, "the Administrative Supervisors role in the Code 444 team is to record all events and medicines on the 444 Documentation Form. The Administrative Supervisor will document and submit for review to the Safety Event Reporting System."

During interview on 04/22/2016 at 10:17 AM Staff W (RN Supervisor) stated, " I did not record the code although I know that is a part of my job responsibilities. By the time I got to the neonatal intensive care unit (NICU), the code was in progress and a nurse was writing things down."

Review of Critical Care Committee Meeting Minutes for March 2015 revealed no documented evidence that the "Code 444 Documentation Form " was completed and submitted to the Committee for Patient #19.

During interview on 4/23/16 at 11AM Staff P (Director of Regulatory Affairs) confirmed that the Committee did not receive a code 444 form for review.
Staff P stated, " The ICU safety committee did not review the code 444 sheet. There probably wasn't a code sheet sent to them."

The surveyors requested the policy for the Critical Care Committee Meeting performance improvement process. The facility could not provide a written policy for these quality assurance activities.

Based on review of medical records, document review and interviews it was determined that the facility did not implement procedures or develop policies to ensure the safety and welfare of all patients (Patients #19).

This failure placed all patients at risk for adverse outcomes.


The facility failed to ensure Registered Nurses were available and immediately responded to the patient ' s bedside when a patient was found unresponsive and in need of emergency lifesaving interventions. (See Tag A0392)

Based on document review and interviews the Nursing Leadership failed to develop the facility Policy " Cardiopulmonary Resuscitation in Infants and Children (444-JUNIOR) " with specified Procedures for staff when responding to cardiac arrest for pediatric patients.
This finding placed all patients at risk for poor quality outcomes.


Review of policy titled " Cardiopulmonary Resuscitation in Infants and Children (444-JUNIOR) " policy dated 05/04/2015 states, " A pediatric patient (less than 18 years of age) experiencing a respiratory and/or cardiac arrest will have the 444 response team called as per Northern Westchester Hospital (NWH) Guidelines, and resuscitation delivered according to the guidelines established by the American Academy of Pediatrics and the American Heart Association as set forth in the Advanced Cardiac life Support (ACLS) Pediatric Advanced Life Support (PALS) Neonatal Resuscitation Program (NRP) Provider Manuals and reference made to the NWH Emergency Profile Cards and PALS or NRP algorithms as deemed necessary. "

Nursing Leadership failed to develop a clear comprehensive policy specifying a list of nursing procedures that the Provider Manual guidelines and the NRP algorithm are referencing.

On 04/25/16 at 10:40 AM, Staff D and K provided surveyors with the training manuals and books titled American Heart Association Newborn Resuscitation Program and the Neonatal Resuscitation Program- Reference Chart (NRP Algorithm).

During interview with Staff D and K on 4/25/16 at 10:45 AM, Staff D stated, "These are the manuals that are referred to in the policy."


Based on document review and interviews the facility failed to ensure Registered Nurses were available and immediately responded to the patient ' s bedside when a patient was found unresponsive and in need of emergency lifesaving interventions.
Specifically, Nurses failed to initiate Cardiopulmonary Resuscitation (CPR) and immediately call a 'CPR Code 444' when a newborn baby was found without vital signs in a Labor and Delivery Room.
This was found in one (1) of two (2) medical records reviewed. (Patient #19)


Medical record review of Patient #19, the physician (Obstetrician) documented on 03/10/15, at 3:59 PM, "this [AGE] year old female patient GBS (Group B Streptococcus) positive and with prior history of Cesarean section presented to the hospital after spontaneous rupture of membranes at 37 weeks of gestation."

Between 8:45 PM when the newborn baby was given to his mother and at 9:41 PM when the newborn was found unresponsive there was no documentation of a nursing assessment of this patient.

Review of medical record revealed that on 3/10/15 Staff J (LPN Nursery Nurse) documented at 10:34 PM on the Newborn Assessment Record , that at 8:21 PM, a live male infant was born by vaginal delivery with an Apgar score (Apgar testing is the assessment of the newborn rating color, heart rate, stimulus response, muscle tone, and respirations on a scale of zero to two, for a maximum possible score of 10. It is performed twice, first at one minute and then again at five minutes after birth) of eight (8) and nine (9) at one and five minutes after birth respectively. At 8:45 PM, the patient temperature was recorded as 98.4 degrees, heart rate 150 beats per minute and respiratory rate 52.

Staff J documented on 3/10/15 at 11:21 PM, "At 9:40 PM, the infant was found unresponsive with "skin to skin" contact on his mom. Mottled and cold. No respiratory effort or heart rate noted. Nurse (Staff J) picked up infant and ran to the NICU (Neonatal Intensive Care Unit)."

Further review of medical record revealed the NICU nurses admission note dated 03/11/15 at 3:34 AM documented, "Staff Members J (LPN Nursery Nurse) and V (Postpartum RN) arrived to NICU at 9:41 PM with unresponsive, floppy, pale and cyanotic baby. Infant in Staff V arms. Infant placed on warmer. No heart rate noted. Positive Pressure Ventilation with 100% oxygen given. Oxygen saturation in the 30's (percent). At 9:42 PM compressions were given. Infant remains cyanotic (blue) for heart rate in the 60's (beats per minutes). Code 444 called. Respiratory, Anesthesiologist and Nursing Supervisor (Staff W) arrived at bedside. At 9:55 PM the infant was intubated. At 11:30 PM the transport team arrived and on 03/11/2015 at 12:40 AM Patient #19 was transferred to level 1 facility (A facility equipped to handle any level of emergency trauma care)."

The Nurses did not activate the "Code 444" Policy.

Review of 'Telephone Records' provided by the facility on 04/22/16 titled, " March 2015 Codes" documented on 03/10/15 at 9:48 PM a phone call was made to the facility telephone Operator to activate the Code 444 response. This is seven minutes after patient #19 arrival in the NICU, unresponsive. A second phone call was documented on 03/10/15 at 9:51 PM to activate the Code 444 response. This is ten minutes after patient #19 arrival in the NICU, unresponsive.

Review of hospital Policy titled, "Cardiopulmonary Resuscitation in Infants and Children (444-JUNIOR)" dated 04/2013 documented, " A pediatric patient (less than 18 years of age) experiencing a respiratory and/or cardiac arrest will have the Code 444 response team called. (The policy does not delineate the Personnel and Responsibilities of the Code Team).
Hospital Wide alert to the Pediatric code will be made by the Telecom operator who will announce ' 444 Junior ' and the location. Appropriate resuscitation equipment will be brought to the bedside of the patient. "

Review of hospital Policy titled, "Cardiac Arrest: Cardiopulmonary Arrest Protocol (444)" dated 04/2013 documented, "Personnel and Responsibilities. The nurse (First Responder) who discovers the patient will initiate calling the Telecom Operator to announce the code, and remain with the patient and initiate resuscitation. The Second responder brings in the Code Cart. The Telecom Operator announces 444 and location. The Emergency Department Physician will respond and will be the Team Leader."

The Nurses did not implement these two Policies, "Cardiopulmonary Resuscitation in Infants and Children (444-JUNIOR)" and "Cardiac Arrest: Cardiopulmonary Arrest Protocol (444)" and as a result there was a significant delay in the initiation of cardiopulmonary resuscitation for Patient #19.

During interview on 04/21/2016 at 3:17 PM Staff J, stated, " At 8:50 PM I left the Labor and Delivery room. I returned at 9:30PM and I went to check on patient #19 who was under a blanket on the Mothers chest. I took the blanket down and saw he was lying prone, face down into the middle of her chest. I saw his color was cyanotic and he was mottled. I picked him up and he was cold. I thought I needed to take him to the NICU, because in my judgement that is where he needed to be. So I put him in the bassinet and took him there." Staff J was asked, were a code 444 to occur today would the response be the same. Staff J replied, "Yes, I would do it the same way again. I believe the best place for that baby was in the NICU."

There is a ten minute gap between when the LPN (Staff J) stated she arrived in the Labor and Delivery room to "check on Patient #19" and when she arrived in the NICU at 9:41 PM to initiate CPR.

During interview on 04/22/2016 at 12:05 PM Staff V (Postpartum RN) stated, " I wasn ' t working that night. I just happened to be outside of the Labor and Delivery area (in a corridor) and noticed Staff J came through the doors with a baby in a bassinet and heard Staff J say " I need help. " The baby was blue and I picked the baby up and turned him over and I tapped the baby a couple of times on the back. He was cold to touch. Nothing happened when I tapped the baby. Staff J said " We need to get the baby to the NICU. " There are two sets of security doors we needed to get through so I held the baby while Staff J swiped her card to let us through the recovery room area and into the nursery area. When we got to the NICU, I put the baby under a warmer and told the staff there that we needed help. "

During interview on 04/21/2016 at 1:37 PM Staff F (Primary RN) stated, "After the baby was delivered the nursery nurse (Staff J) was caring for the newborn. I was primarily focused on the mother of the newborn who was bleeding heavily with a lot of lochia (discharges from the vagina of mucus, blood, and tissue debris, following childbirth) and she needed a Foley catheter. I was in and out of the room getting supplies and at some point I asked Staff R (Charge Nurse) to help me place the Foley. After the Foley was placed I left the room and I went to a Pyxis machine and that ' s where I was when I heard there was a code " Junior 444 " in the NICU. I didn ' t know it was patient #19 at that time but found out soon afterwards when I went to the NICU to see what was going on."

During interview on 04/21/2016 at 4:47 PM Staff R (Charge Nurse) stated, " On 03/10/15, I worked as the charge nurse and there were three RN's working. As charge nurse I make the assignments. Staff F asked me to help put in a Foley catheter for her patient and then Staff J came into the room and adjusted the light for us. I did not know that the baby was with the mother. Staff J walked to the mother and took the newborn and left the room. Staff R was asked whether staff J informed either of the two Registered Nurses in the room about the newborn ' s unresponsive condition. Staff R stated that "Staff J is seasoned. She is not really required to say anything. If staff J does something then it means that she knows what she is doing. "

During interview on 04/22/2016 at 10:17 AM Staff W (RN Supervisor) stated, " I do not remember if I heard the code. I do not remember hearing the code. I was in the emergency room . When I went up to the unit, I was trying to facilitate things."
Staff W was asked if she would call the code 444 in the Labor (L)and Delivery (D) unit if it were to happen today. Staff W stated, " I do not know if I would call the code right there taking into consideration that the equipment is in NICU which is right next door to L and D. In every code, since I have been working here, the infant would be brought to the back (NICU). "
Staff W was asked if she knows about the facility ' s policy regarding newborn resuscitation. Staff W stated, " I would have to read the policy. To be honest I have to read the policy because I don ' t know. "

Review of medical record obtained from the receiving hospital the physician documented on 3/14/15 " On 03/11/2015, at 2:10 AM the newborn was received from the Northern Westchester hospital in a critical condition. Unresponsive to tactile stimuli. The patient with an IV Saline Lock in place, remained intubated, suctioned, head cooling started for hypoxic [DIAGNOSIS REDACTED] (generally permanent brain injury resulting from a lack of oxygen or inadequate blood flow to the brain) following postnatal cardiac arrest. After 72 hours of head cooling with no significant improvement in clinical status, decision was made to withdraw care. Child was declared dead on 3/14 with no respiratory effort or cardiac activity. "

Based on review of 1 of 1 (patient #19) medical record and staff interview, the facility failed to ensure that medication is administered in accordance with laws and facility's policies.

Review of policy titled " Admission of Newborn Infant " (revised 09/07) revealed that a nurse shall return to delivery room within an hour after birth of a newborn to: " 3. Administer Vitamin K (phytonadione) per medication protocol. To correct transient low levels of clotting factor produced by the liver. 4. Administer eye prophylaxis per medication protocol ...."

As per " Ophthalmic Prophylaxis-Newborn " policy (revised 04/14), "All infants admitted directly to NWH nursery after birth will have antibiotic eye prophylaxis administered to both eyes within one hour of birth in accordance with New York State Code. "

Review of the medical record # 19 revealed that the patient was born at 8:21 PM. Vitamin K and Erythromycin ointment were administered at 9:40 PM. This was the time when the Nursery Nurse (LPN) found the patient unresponsive. The medications were not administered within one hour after the patient ' s birth. This finding was confirmed with staff E (Quality Management Coordinator).