Nationwide Children’s Hospital

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 32088 Based on medical record review, policy review, and staff and patient family interview, the facility failed to have a discharge process that focuses on patient goals and treatment preferences to ensure an effective transition of the patient to post-discharge care, and reduce the factors leading to a preventable hospital readmission. The condition of participation is not met, affecting two patients (Patient #1 and #2) of three patients reviewed for discharge planning. See A802.”

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 32088 Based on medical record review, review of the hospitals policy and staff and patient interview it was determined the hospital failed to ensure re-evaluation of patient condition and needs to identify changes that required modification of the discharge plan. This affected two (Patient #1 and Patient #2) of three medical records reviewed. The census was 513. Findings include: 1. Review of Patient (Pt) #1’s medical record revealed the 14 year old arrived to the hospital on 09/09/25 at 7:07 PM via emergency medical services (EMS) and law enforcement after she ran away from home and tried to throw herself in the road. Review of the patients Behavioral Health Crisis Intervention assessment dated 09/10/25 at 5:55 AM completed by a licensed independent social worker (LISW) revealed the patient reported that she got upset and went on walk like her safety plan allows but she wandered too far looking for glass to harm herself. She stated her anxiety was unmanageable, she was in high distress and no safety skills were effective in that moment. She stated she has frequent thoughts of self harm, denied true intent to harm herself but she struggles when she is in distress. The patient stated she needs ways to manage high distress moments and wants to go home to her foster family. The LISW noted the patient had an extensive history of suicide attempts. The LISW noted the patients suicide risk was moderate reported he felt safe to discharge while she was limited in her ability to prevent another similar episode. LSW L completed the second portion of the Behavioral Health Crisis Intervention assessment on 09/10/25 at 10:42 AM with Pt #1’s Franklin County Children Services Case Manager (FCCS CM), the Buckeye Ranch Case Manager (BR CM) and her foster mother. She noted the foster mother reported the patient had became frustrated and wanted to go for a walk. The mother noted the patient was going further than allowed and her foster father followed and at one point her foster sister had to push her out of traffic to keep her from getting hit. The police were called and brought her to the hospital. LSW L noted the patient had been in the foster home since July 2025 with incidents of self harm a behavioral escalations and the foster family expressed concerns regarding whether the patients current level of care/treatment was appropriate to address her ongoing needs. The Psychiatrist assessed the patient on 09/10/25 at 12:36 PM and noted the patient became upset and began walking to find glass to cut herself as her urge to harm herself was very intense. She noted the patient got so lost in this plan that she didn’t realize she got off her normal path until her sister found her and informed her that her foster father had wrecked his bike trying to find her. This made her more upset and she decided things would be easier if she was dead and her only thought due to her location was to get hit by a car. She noted the patient denied suicidal intent at the time prior to when she tried to throw herself in traffic and she denied suicidal intent at the time of the assessment or upon returning home. She reported having feelings of guilt, self doubt and worthlessness due to concerns of letting her foster family down. She noted the safety plan was reviewed and the patient felt safe going home. The psychiatrist noted the patient did not appear to require inpatient hospitalization. The psychiatrists diagnosed the patient with major depressive disorder (mdd), post traumatic stress disorder (PTSD) and child in foster care. The disposition was to discharge the patient to home with intensive home based services and medication management later on 09/10/25. Further review of the medical record revealed on 09/10/25 at 2:46 PM Pt #1 verbalized frustration to mental health staff and requested to speak with someone from the treatment team. On 09/10/25 at 2:46 PM the patient was informed by the hospital staff that she was going to a group home and was discharged with FCCS CM. There was no mention the psychiatrist was aware or that the patient was reassessed to ensure safety after being informed that she would not be going home with her foster family. Further review of the medical record revealed the patient presented to the hospital on 07/06/25 through 07/14/25, 08/10/25, 08/27/25 and 09/02/25 for suicide attempts. Interview on 09/15/25 at 11:08 AM with Clinical Lead SV (oversee’s clinicians and discharge planners) revealed they determine a patient is safe and stable for discharge by having an ongoing conversation with the psychiatrist, who ultimately determines a patient is safe to discharge. They work with the patient and their family to develop a safety plan, they assist in locating outpatient community services to ensure the family feels empowered to take child home if another crisis were to arise. She stated outpatient appointments are scheduled prior to discharge. These may include psychiatric, therapy and ensuring they are linked with services if they are not already linked. She stated they make sure they have these appointments scheduled and no one leaves without these services secured. The latest timeframe for these appointments should be within 30 days but they are usually within week or two of the discharge date. She stated her staff works with patients to ensure they are able to notice signs and symptoms (s/s) of their illness and to help identify triggers precipitating events. They help the patients identify things that make them feel calm and safe and things that do not and outline those with patients to see what they can do when those s/s arise. They ensure patients and their families are sufficiently stable to manage their symptoms by providing psycho-education with multiple family sessions throughout the stay. They are educated on the diagnosis, symptom presentation, and coping strategies. Patient’s are provided with this education on their discharge paperwork. The discharge paperwork contains the safety plan, and things the patients can do or the people they can call if the patient is feeling stressed out. They ensure the families are aware of outpatient home services. She stated they ensure patients have access to ongoing treatment and medication management by setting up appointments, having the hospitals pharmacy call in a 30 day supply of medications, and ensuring medication management is managed by outpatient providers, if the patient is not linked to psychiatrist to ensure they have management. She stated for patients that are discharged to a group home or in different residential treatment they ensure that the home staff can meet the patient in person or via zoom to provide them with safety plans and a strong hand off. They have phone calls and conferences to ensure they are aware of the support that the patient needs. They make sure the caretaker is informed of the safety measures, plans and triggers of the patient. They make the patients, families or caretakers aware of the crisis line at the hospital in case of an emergency to allow them to talk to someone they don’t know to help talk them through a crisis, give coping mechanisms or direct them to the Psychiatric Crisis Department (PCD). Interview on 09/16/25 at 2:16 PM with LSW L, revealed she was the clinician that spoke with Patient #1’s foster mother, the Franklin County Children’s Services Case Manager and the Buckeye Ranch Case Manager prior to Pt #1’s discharge for a discharge care planning meeting. She stated they were discussing finding more intensive services and getting extra help in the home. She stated the foster family did not feel that they could keep the patient safe in their home, so Franklin County Children’s Services had to find alternative placement. She stated during Pt #1’s visit, hospital staff reviewed her safety plan to see if the plan was effective anymore. She stated the patient stayed in the extended observation area during her stay, she interacted with the metal health specialists (MHS), and she was assessed by a clinician and the psychiatrist. She stated Pt #1 had chronic behavioral health issues which is a challenge to deal with. She stated the patient has had frequent admissions and that has not stopped the behavioral health issues. She stated they try to see how they can keep the patient safe in the community. She verified that when the patient was told that she would not be going back to her foster home there should have been a reassessment and there was none documented. Interview on 09/16/25 at 2:51 PM with the Director of Clinical Services verified the discharge summary for Pt #1 the psychiatrist noted that the patient was being discharged home with her family with interventions to follow up with outpatient services but the discharge location changed to a group home. She stated any changes in the patients discharge status should be reported to the psychiatrist to ensure the discharge instructions are still appropriate for a safe discharge. She stated the psychiatrist should be made aware of changes before the discharge disposition is set. She verified patients would be at increased risk for harm when their living environment changes. She stated she was unaware that when the FCCS CM picked up Pt #1, she ran into the busy traffic on Livingston Avenue immediately after being discharged from the hospital. Interview on 09/16/25 at 3:00 PM with Patient #1’s foster mother revealed prior to the patient running into traffic on 09/10/25, she had done it before a month prior on 08/09/25. She stated her husband picked the patient up from Nationwide Children’s Hospital Behavioral Health and once she made it to the door she ran towards traffic. She stated someone from the hospital came out, but they did not do anything to help. She said for the 09/10/25 visit the patient was not ready to come home. She stated she; the Franklin County Children Services and Buckeye Ranch Case managers met with the hospital and told them that. She stated she wanted the patient to come back to her home, but the Buckeye Ranch Case Manager would not allow her to take the patient because she did not feel the patient had received appropriate treatment to be safe. She stated she does not remember the name of the clinician that they met with from the hospital via a Zoom meeting. She stated the patient ran once she was discharged and then was admitted to Riverside Hospital. She stated Riverside staff informed her that this was the second 14 year old in three days that was discharged from Nationwide Children’s Behavioral Health that ended up at their hospital. She stated the patient is now at Sun Behavioral Health awaiting placement in a 21-day treatment facility. She stated she is going to get the patient back after her treatment. She stated, “that is my daughter”. Interview on 09/16/25 at 3:51 PM with Psychiatrist W revealed if a patient with a history of suicidal ideation was set to be discharged to their home and the discharge summary had been completed but the discharge location changed to group home she would expect to receive communication from the team. She stated this is important because she would need to ensure the previous outpatient follow up is still feasible with the new location, and to see if the initial plan should be revised. She stated she would expect that the patient be reassessed to get their perspective and consider their new feelings to ensure they do not have increased thoughts of suicidal ideation with intent. Interview on 09/16/25 at 4:17 PM with Pt #1’s Franklin County Children Services Case Manager (FCCS CM) revealed prior to Patient #1’s discharge she, the foster mother and the Buckeye Ranch (BR) Foster Agency Case Manager had a meeting with Licensed Social Worker (LSW) L. She stated in that meeting she informed the hospital that she did not feel that Pt #1 was safe to return home because she needed more treatment. She said the foster mother was willing to take the patient back but wanted the hospital to ensure the patient was safe to return home first. The BR Foster Agency Case Manager requested that the hospital provide more treatment before the foster family would be able to safely take the patient back. The hospital refused to provide further treatment and informed her that if they did not come to pick up the patient they would call Franklin County Children’s Services to file “some sort of action” (she could not remember what the hospital employee called it). She then informed her supervisor who eventually told her to go pickup Pt #1. The BR Foster Agency Case Manager stated they would not allow the foster family to take the patient without proper behavioral health treatment so she would have to go to a group home. The FCCS CM stated she asked the hospital not to tell Pt #1 that she was not going to her foster home because she has history with Pt #1 and knew she was in a cycle and would be extremely upset and try to hurt herself again. She said she wanted to tell Pt #1 once she got her back to the agency safely. She stated she took a co-worker because she needed assistance with the patient as she did not want the patient to hurt herself or her while she was driving. When she arrived, she was made aware that the patient already knew she was not going back to her foster family even though she asked the hospital staff not to tell her. She asked the patient if she was okay and she said she was fine, but she could tell that she was not. The FCCS CM stated she knew the patient would try to run once she got out of the hospital, so she stayed close to her side, and her co-worker was on the patient’s other side. She stated as soon as they got to the door by the yellow parking garage the patient took off running. She stated she ran after her and yelled to her co-worker to go get help. She stated the patient ran in and out of the busy traffic on Livingston Avenue trying to get hit and then she sat in traffic. She stated she sat in traffic with the patient trying to comfort her and the patient got back up and proceeded to run. People were stopping in the cars and calling the police. Finally, the police and EMS arrived and took the patient to Riverside Hospital. The patient was admitted for a few days and then transferred to Sun Behavioral. After discharge she is going to a 21-day treatment facility. 2. Review of Patient #2’s medical record revealed the 13 year old patient arrived to the hospital on 09/08/25 at 7:23 PM via emergency medical services (EMS) from another hospital after being treated for self injurious behavior (SIB) to her forearm. The patient had broken a mirror and cut her left lower wrist. The patient reported thoughts of suicidal ideation with a plan and stated she felt like no matter what she said she felt like no one would one was taking her serious. She reported she was unable to keep herself safe at home. The patient stated, “I feel like I can’t trust anyone. I feel like no matter what I say, people don’t want to taken me in.” Her mother stated, “You guys have labeled her hospital dependent and she keeps getting ignored. She was at Grady (hospital) last night for threatening to stab herself in the neck with a knife. She is saying no one is taking her serious.” The triage nurse noted the patient had suicidal ideation’s without a plan. Review of the patients Behavioral Health Crisis Intervention assessment dated 09/08/25 at 8:40 PM revealed the patients mother reported the patient has been treated by an outside hospital for SIB three times in the past couple weeks, with the most recent being earlier today. The clinician noted the patient has an extensive mental health history with multiple acts of SIB and suicidal ideation. On 07/06/25 the patient held scissors up to her mothers throat and spat on a police officer. He noted the patient has received extensive outpatient and inpatient treatment and is currently linked with I Am Boundless (organization that offers center and community based behavioral health services) and OhioRise (a medicaid managed care program that offers specialized behavioral healthcare for youth). Pt #2’s mother reported that outpatient services is seeking residential treatment but they are having trouble finding placement due to her autism spectrum disorder diagnosis. The patient reported that she would be better off if she was no longer alive and her mother reported she is not comfortable maintaining the patient in the home. The clinician noted the patient was a moderate suicide risk and he recommended that another psychiatric admission would not be beneficial at this time due to concerns for secondary gain and her outpatient team recommending residential treatment. On 09/08/25 at 10:53 PM the patient was admitted to the Extended Observation Unit (EOS) for observation. On 09/09/25 at 8:49 the nurse noted while doing the C-SSRS (Columbia Suicide Severity Rating Scale), the patient disclosed feeling suicidal. The RN asked the patient if she had a plan, and the patient disclosed using a spork to hurt herself with. The nurse retrieved the spork and asked doctor to change her diet order to finger foods. On 09/09/25 at 1:15 PM the psychologist noted an unsuccessful attempt to contact Pt #2’s mother and a voicemail message was left requesting a call back. Review of the after visit summary provided to the mother upon discharge revealed the only appointment that was set up for the patient was for 09/24/25 with the LSW Care Coordinator. On 09/09/25 at 3:50 PM the advance practice nurse set the patients disposition to discharge and at 8:59 PM the patient was discharged to her mother. On 09/10/25 the patient presented to a neighboring hospital after cutting her wrist. Interview on 09/17/25 at 4:45 PM with Accreditation and Regulatory Consultant C revealed Pt #2 arrived on 09/08/25 at 7:23 PM from the hospital after self injurious behavior (SIB) to one of her forearms. She verified Pt #2’s mom stated she could not keep the patient safe in her home as she has another smaller child and the patient was reporting that she was going to stab herself in the throat with a knife on 09/07/25 prior to cutting herself. She verified that on 09/09/25 at 8:49 AM the patient was trying to hurt her wrist with a spork and told the nurse that she wanted to kill herself with it and there was no notation the mother or doctor was made aware of this. She stated the doctor must have been aware of the spork incident because Pt’s #2 meals were changed to finger foods after the incident by the advanced care practice nurse. She verified that no therapy or psychiatry appointments had been set up for Pt #2 prior to discharge but stated staff reached out to OhioRise and left messages for I Am Boundless. She also verified that Pt #2’s mother was upset with the decision to discharge her daughter stating she did not feel she was safe to return home. Interview on 09/17/25 at 4:51 PM with the Medical Director of the Behavioral Health Service Line revealed in regard to Pt #2 stating she was suicidal the day of discharge, she only threatened to do it with a spork which could hurt her but would not cause death. That was low risk for suicide. He stated for patients with chronic issues and repeated inpatient stays, they are probably always going to have suicidal thoughts and he has to determine if a hospital stay would decrease the risk for suicide. He stated the patient may just want to be hospitalized and admission could just make things worse. He verified that Patient #2 would have more access to sharper more harmful objects outside of the hospital at home and that she had a history of cutting herself. He stated she has never cut herself to the point of suicide and that in her safety plan they went over it with her mother to lock up harmful objects. This surveyor stated the patient had previously cut herself with a piece of a mirror that she broke out and some things in the home are hard to safe proof like forks, mirrors and windows. He stated they discussed having someone with the patient 1:1 and having increased psychiatric help in the home. He verified that neither of these interventions were set up for the patient prior to discharge and stated they take some time to get the services financed and set up. He verified that there was no documentation evidencing that Pt #2’s mother was made aware of the patient stating that she wanted to kill herself with a spork on 09/09/25 at 8:49 AM and even though her mother requested more treatment for the patient the hospital discharged the patient on 09/09/25 at approximately 3:50 PM. He verified on 09/10/25 the patient presented to a neighboring hospital after cutting her left wrist. He stated the psychiatrist recommended that the patient follow up with I Am Boundless but verified staff tried to reach out to them but was unable to make contact prior to the patients discharge. He verified that the mother informed staff that the I Am Boundless therapist was hard to get in contact with on 09/09/25 and that the psychiatrist discharged the patient stating her self injurious behaviors had improved even though the patient had just tried to cut herself with a spork the morning of her discharge. Review of the hospitals policy titled, Discharge Planning revealed discharge planning is an ongoing process initiated on admission and reassessed as needed based on patient changing conditions. The discharge plan will consider as appropriate follow up care, the need for community resources/referrals and safety and accessibility of the home environment. Patients with unplanned readmissions within 30 days require documentation that includes the reason for readmission, caregivers understanding of the care needs any community services being utilized and access to other needed resources and supplies. The after visit summary (AVS) provided to the patient and caregiver at minimum includes: treatments as appropriate and follow up care/appointments.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 32088 Based on record review and interview, the hospital failed to ensure a newborn was safe from accidents involving falls, resulting in a skull fracture and a subdural hematoma. This affected one (Patient #1) of ten patients. Findings include: Record review revealed Patient #1 was diagnosed at 23 weeks gestation with left ventricular dilation with severe left ventricular dysfunction and endocardial fibroelastosis (EFE) so Patient #1’s mother was followed by the Fetal Center. On 03/04/25 at 8:29 AM the patient was delivered via cesarean section at 37 6/7 weeks gestation at the hospital with an Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score of eight at one minute of life and nine at five minutes of life (a normal score is between seven and nine). Following the delivery, Patient #1 was vigorous with appropriate perfusion and weighed six pounds and 15.5 ounces with a head circumference was 32.2 centimeters (cm). An umbilical venous catheter was placed and Patient #1 was admitted to the Cardiothoracic Intensive Care Unit (CTICU) with recommendations for a cardiac catheterization as physicians noted this would help them better understand Patient #1’s hemodynamics. On 03/12/25 at 11:33 AM Patient #1 underwent a cardiac catheterization which revealed a thrombus to the right femoral artery. The patient was started on Lovenox (blood thinner). The cardiologist, Staff M, noted “Overall reassuring hemodynamics and normal cardiac index.” On 03/15/25 at 11:54 AM Patient #1 was transferred to the Cardiac Stepdown unit. Review of Patient #1’s medical record revealed Patient #1’s nurse and the PCA, Staff E were in the room at 7:21 PM. Review of the nursing note dated 03/25/25 at 9:40 PM by the Registered Nurse (RN) Staff stated she was notified by another RN, Staff G, that Patient #1 had fallen approximately three to four feet from the crib to the floor onto her left side. When Staff F arrived to the room, Patient #1 was accompanied by the Charge Nurse, Staff G and the Medical Doctor, Staff H. An assessment of Patient #1 revealed localized edema to left side of head and periorbital swelling. The neurological assessment was appropriate with equal and reactive pupils. Patient #1 was responding appropriately with purposeful movement and agitation but was not consolable. A complete bone survey X-ray and head CT were ordered at this time by Staff H. Staff F transported the patient to scans accompanied by an additional RN. Due to scan results communicated with the team, Staff F expressed concerns for the patient needing close monitoring. Staff H notified Patient #1’s responsible parties of the results of the scans. Review of physician notes by Staff H dated 03/25/25 at 10:05 PM documented he was called to Patient #1’s beside at 9:45 PM to assess the patient after being informed that at approximately 9:30 PM, while a Patient Care Assistant (PCA), Staff E, was in the room caring for Patient #1, they left facing guard rail was down. The telemetry box was in Staff E’s pocket and the leads were still attached to Patient #1 while she was laying down in the crib. Staff E moved away from the crib to access the workstation by the bed, pulling the patient out of the crib by the telemetry wires causing her to fall to the floor on her left side. Patient #1 was returned to the bed. Since this time she has been reportedly been irritable and crying. Upon Staff H’s arrival at 9:50 PM he assessed the patient. Patient #1 was crying but intermittently consoled, with some redness and swelling to the left posterior parietal scalp. The physician noted this was likely a fall of three to four feet and given this they would pursue computed tomography (CT) of the head to rule out intracranial/skull trauma. Patient #1’s mother was called at 10:04 PM to inform her that the patient had fallen. Immediate concern was expressed and the phone was hung up. Attempted to call again at 10:05 PM with no answer. Review of Patient #1’s CT scan without contrast of the head dated 03/25/25 at 11:07 PM revealed a minimally depressed left parietal bone fracture with extra-axial hemorrhage deep to the fracture overlying the left cerebral convexity, subdural versus epidural. Left parietal scalp hematoma overlying the fracture. On 03/25/25 at 11:48 PM the patient was transferred back to CTICU. Review of a Hematology Oncology Consult note by Staff T, dated 03/26/25 revealed they received a call from Patient #1’s primary team regarding patient with extra-axial hemorrhage after falling three to four feet on 03/25/25 from the crib and a head CT revealed a parietal bone fracture and accompanying small extra-axial hemorrhage with questions regarding dosing for possible protamine reversal as the patient is on Lovenox. He noted Patient #1 has dilated cardiomyopathy and developed a right lower extremity arterial thrombus after a cardiac catheterization performed on 03/12/25. The physician noted he would continue to monitor and determine definitively tomorrow whether surgical intervention warranted. He noted the patient had no other bleeding and the Lovenox, last received eight hours ago was being held. Review of the echocardiogram completed on 03/27/25 at 2:40 PM revealed results were findings of new moderately or severely depressed right or left ventricular systolic function. Review of progress notes by RN Staff V documented on 03/28/25 at 5:45 AM, Patient #1 coded and at 6:00 AM the patient was intubated with placement verified due to apnea and respiratory failure. Review of another progress noted by RN Staff W documented on 03/28/25 at 6:53 AM Patient #1 coded again and an emergent median sternotomy allowing central extracorporeal membrane oxygenation (ECMO, a life-support system that provides temporary support for the heart and/or lungs when these organs are unable to function properly) cannulation at 7:29 AM. Review of the note by the ECMO surgeon, Staff DD, dated 03/28/25 at 8:00 AM documented Patient #1 was a three week old baby that had a prenatal diagnosis of cardiomyopathy, such that she was born at the Heart Center at Nationwide Children’s Hospital via planned cesarean section with a separate operating room available for the baby if she required emergent mechanical cardiopulmonary support. The surgeon noted fortunately, the baby initially did very well, requiring no mechanical support, and eventually only oral heart failure medicines. She was improving on the step-down unit and then had an unfortunate fall, requiring observation in the Cardiothoracic Intensive Care Unit. Overnight, she had some unusual findings necessitating a head CT scan. Upon return from this advanced imaging, she had worsening respiratory distress, and then a sudden cardiopulmonary arrest. Despite being a witness arrest in the Cardiothoracic Intensive Care Unit with active CPR and resuscitation efforts, the baby was not able to be resuscitated. At the request of the CT ICU team and the family, the decision was made to proceed with ECMO cannulation. Given that the baby was recovering from a potential brain injury, it was felt that compromising a carotid artery for cannulation would be suboptimal. Plus the respiratory therapy team was having some challenges with the endotracheal tube and finally, the potential need for longer-term central ventricular assist device. Therefore, the decision was made to proceed with an emergent median sternotomy allowing central ECMO cannulation. Review of provider progress notes dated 03/28/25 at 10:57 AM revealed Physician Staff X noted Patient #1 was on ECMO, intubated, sedated, with mottling in all four extremities. No palpable pulses on either lower extremity. Review of a neurology note dated 03/28/25 at 11:10 AM revealed the neurologist physician, Staff J, noted Patient #1 was a three week old baby girl with prenatally diagnosed dilated cardiomyopathy who was admitted to the CTICU post-natally for cardiac catheterization (3/12/25) and cardiac MRI. The hospital course was complicated by a fall from a crib resulting in a left parietal skull fracture and left parietal scalp hematoma, as well as worsening of ventricular function noted by echocardiogram completed on 03/27/25. The physician noted on the morning on 03/28/23 at around 6:00 AM, Patient #1 was initially tachycardic but then had bradycardia in to the high 60’s. The patient required bagging and then intubation. Review of a provider progress note dated 03/28/25 at 5:23 PM revealed Staff J reviewed Patient #1’s initial head CT from the fall and then from this morning post-intubation and there is a small subdural hematoma over the left parietal lobe, with associated skull fracture and cephalohematoma. Review of the CT scan dated 03/29/25 revealed the patient had increased intracranial hemorrhage, with new dense hemorrhage now seen layering within posterior interhemispheric fissure and along bilateral tentorial leaflets, with increased thickness of extra-axial hemorrhage over left parietal lobe also noted. The bilateral lateral ventricles and third ventricle are slightly increased in size, and the left parietal bone fracture morphology is stable. On 03/29/25 at 1:17 AM, the neurologist physcian, Staff Y noted Patient #1 had seven electrographic seizures on 03/28/25 at 11:50 PM and continued having seizures after administering phenobarbitol (medication used to control seizures). ECMO adjustments were made and the patient was taken to CT. The patient continued to have seizures in longer increments and Versed (treats epilepsy) was administered. On 03/29/25 at 11:39 AM, RN Staff Z noted Patient #1’s pupil sizes were different between the left and right eye upon assessment with pupilometer. The provider was notified. Review of a head CT without contrast on 03/30/25 revealed findings consistent with diffuse cerebral hypoxic ischemic injury. Loss of cerebral gray-white matter differentiation and diffuse edema. Areas of hyperattenuation throughout the cortex could represent some degree of laminar necrosis. However, a small amount of intraparenchymal hemorrhage cannot be excluded. Basal ganglia also appear indistinct, likely involved as well. Review of Neurology Notes revealed on 03/30/25 at 4:06 PM, Staff J noted Patient #1 continued to have electrographic seizures overnight requiring treatment although there appeared to be a decrease in the frequency of seizures. Electroencephalogram (EEG) background otherwise overall suppressed without normal background features. On neurological examination, the patient continues to have pupillary response to light but otherwise no reactivity on examination. CT of the head obtained today demonstrated extensive hypoxic ischemic injury throughout the cerebral cortex and no significant change in the side of the left frontal subdural hematoma. Clinical picture overall remains concerning for significant hypoxic-ischemic injury to Patient #1’s brain during her prolonged cardiac arrest. The provider discussed with the family that the injury that has already occurred to Patient #1’s brain could not be reversed and the ultimate goal with management of the seizures is to prevent additional injury to her brain. Based on the degree of injury we can see on Patient #1’s CT of the head and the abnormalities on her EEG, the patient is going to have a degree of neurodevelopment impairment with the possibility that she will not be able to communicate, ambulate, or possibly even eat or breathe without technological assistance. The family lovingly shared that they did not want Patient #1 to suffer or experience any pain. At that time, family wanted to continue to give the patient time to see how she recovers. The physician noted they would continue to monitor the patient on continuous EEG with the plan to treat prolonged seizures or electrographic status epilepticus with >12 minutes of seizure burden per hour, and noted they would also will be judicious with seizure management given that she also has required increased blood pressure support. Review of a Social Work note dated 03/30/25 at 4:45 PM revealed Licensed Social Worker (LSW) Staff BB noted Patient #1 coded on 03/28/25 and was subsequently placed on ECMO. Staff BB noted Patient #1’s most recent head MRI showed concern for a significant hypoxic injury, likely secondary to her cardiac arrest on 03/28/25. Staff BB noted the MRI results revealed findings consistent with diffuse cerebral hypoxic ischemic injury, loss of cerebral gray-white matter differentiation and diffuse edema. Staff BB noted areas of hyperattenuation throughout the cortex could represent some degree of laminar necrosis. However, a small amount of intraparenchymal hemorrhage could not be excluded. Basal ganglia also appeared indistinct, likely involved as well. Staff BB, Spiritual Care, the Charge RN, and the Neurology team to include Staff J met with Patient #1’s mom and dad to discuss these results. The doctor explained that this injury could not be reversed and shared concern that Patient #1 would not be able to talk, ambulate or potentially breathe on her own. The parents stated that they did not want Patient #1 to be in pain or to suffer, but they were not ready to give up on her yet and wanted to see how she does in the next couple of days. Review of a physician progress note dated 03/30/25 at 5:56 PM revealed after carefully considering the information provided from neurology concerning Patient #1’s condition, the family wished to withdraw support after the patient was baptized. On 03/31/25 at 3:38 PM after Patient #1 was baptized, the order was placed to allow natural death. Review of physician progress notes dated 03/31/25 at 7:22 PM revealed Physician Staff CC noted Patient #1 was extubated per her parents request to allow them to hold her. When the family was ready, and the patient was in the mother’s arms, a one hour bolus of morphine (pain medicine) and versed (sedative) were administered, after which the ECMO flow was stopped and circuit clamped and cut away from the patient ending ECMO support. The child was initially comfortable appearing without respiratory effort or distress and no evidence of pain. Approximately 10 minutes later the patient had evidence of distress and an additional one hour bolus of both morphine and versed were given. Patient #1 developed bradycardia with cessation of support and was pronounced at 7:50 PM. Review of the Autopsy-Anatomic Preliminary Report dated 04/01/25 revealed the following anatomic preliminary diagnoses; congenital cardiomyopathy, a palpable left parietal subgaleal soft tissue mass consistent with a hematoma, minimally depressed left parietal skull fracture (status post fall out of bed), subcapsular hematoma on medial, inferior area of the left lobe of the liver, distended urinary bladder and, and slightly low-set and posteriorly rotated ears. Histopathology, detailed cardiopulmonary, microbiologic cultures, electron microscopy of the left ventricular myocardium and fibroblast cultures for possible future studies were pending. Review of the Discharge Summary dated 03/31/25 revealed the preliminary cause of death was listed as dilated cardiomyopathy. During an interview on 04/02/25 at 11:30 AM, Staff G revealed she responded to Patient #1’s room on 03/25/25 at approximately 9:40 PM because Patient #1’s assigned nurse was busy and she was near the telemetry monitor when the patient’s oxygen saturations dropped. Staff G stated she went in the room and saw Staff E holding Patient #1. Staff G stated she asked Staff E to put Patient #1 in the bed so that she could assess her. She stated Patient #1’s oxygen saturations were now okay, so she tried to swaddle the baby to calm her. The baby was still crying and she began to speak calmly to the baby. Staff E said “I think I can tell you why the baby is crying.” Staff E said she put the telemetry monitor box in her pocket while she was feeding Patient #1. After the feeding she put Patient #1 back in the crib with the side rail down. She walked away to chart and dragged Patient #1 from the crib by the monitor wires to the floor. Patient #1 landed on her left side. Staff G stated she immediately assessed Patient #1’s head and noted swelling. She stated they were unable to assess her pupil size because Patient #1 would not open her eyes. She then informed the charge nurse, Patient #1’s nurse and the physician of the incident. She stated safety reports were completed on 03/25/25 by her and Staff E. She stated she was not sure what time Patient #1 fell out of bed as she was not called in because the newborn had fallen. She went in because Patient #1’s oxygen saturations had declined and the monitor’s alarm was sounding. During an interview on 04/02/25 at 11:45 AM, with Staff O, the Clinical Staff Educator for the CTICU stated Staff E was a recent hire and was not scheduled to work again until the Tuesday following the incident, 04/01/25. Staff O stated Staff E has not been back to work since the incident on 03/25/25 with Patient #1. During an interview on 04/02/25 at 3:15 PM, Staff P, the Clinical Leader Cardiac Stepdown, stated the unit uses only two types of cribs for newborns. Both of the beds have four sides (forming a rectangle) of bars and each side can be lowered. Staff P stated staff is instructed to have one hand on the patient or you must have the side rails up.”