Covenant Childrens Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 33326 The facility failed to protect a patient’s rights when, The facility failed to protect an infant’s (Patient #2) right to privacy when the facility’s Guest Services (Staff #8 and #14) provided an unidentified man information confirming an unaccompanied baby, he was looking for, was on the NICU (Neonatal Intensive Care Unit) and provided the bed location. The facility failed to protect an infant’s safety when facility staffs did not enforce security measures, an unidentified man gained access into the facility’s secure NICU. The individual was given a security badge; he had not cleared the security screening. This failure places infants at risk of abduction and death. Refer to A0143 and A0144.”

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 33326 Based on record review and interview, the facility failed to protect an infant’s (Patient #2) right to privacy when the facility’s Guest Services (Staff #8 and #14) provided an unidentified man information confirming an unaccompanied baby, he was looking for, was on the NICU (Neonatal Intensive Care Unit) and the bed location. This information allowed the individual to go to the NICU to try to locate the infant, placing this infant at risk of abduction and possible death. Findings: Review of the facility provided document Covenant Children’s Guidelines for NIP (No Information Patient) reflected the following: By choosing to be designated as a No Information Patient (NIP) you play an essential role in safeguarding yourself and those around you. Our Team takes strict measures to ensure the protection of you and your personal information, and we kindly request that you avoid sharing your location on social media or any other communication platforms, including location services such as “find my ...” with apple products. We also ask that you advise your friends and family to do the same - please do not share your location while you are under our care. What to Expect As a No Information Patient, your information is not visible to Front Desk Personnel, meaning that if someone contacts the hospital or arrives to visit you, our Team will not share that you or your family member, are currently admitted or receiving treatment here at Covenant Children’s Hospital and the Women’s Care Center. If your Guests cannot provide the required information listed below, they will be informed that you are not here and will not be allowed access. Due to the delicacy of our patient population, Guest Check-In is required. To ensure your Safety and Security, we request a list of restricted or prohibited guests - people that you do NOT wish to see. For Un-restricted Guests, the following information will be required. Guests must offer/provide this information to our Front Desk Personnel when Checking In. - Photo ID (Driver’s License, Passport, Student Badge, etc.) o Guests who cannot present a hard copy of a photo ID, will NOT be allowed access. - Patient Identifiers: o Patient Name AND Room# o 4-digit Access Code o Password o due to your NIP status, we will not ask/prompt for the code and password, your Guest must offer it. o The password is SPECIFIC to NIP cases only. If your Guests cannot provide the above information, we will inform them that you are not here, and we will turn them away. During an interview on the afternoon of 01/29/24, Staff #1, CNO stated in part the infants are not automatically placed on NIP unless the parent requests it. On the afternoon of 01/29/24, during a telephone interview from her home, discharged Patient #1 stated, “The NICU secretary called me and said a man was holding my baby. She asked me if he was the father? I told her no, the father was at home with me. She (the secretary) called me back 30 minutes later and said the man was escorted off the premises.” Review of the facility provided Staff #8, Guest Services written statement reflected, “On the night of January 29th, 2024, a man came in to visit a woman and a baby in the hospital around 8:50pm. At the time Staff #14 was at the computer checking people in. He had mentioned the woman’s name and that she (Patient #1) was already discharged, but the baby was still here. Staff #14 continued to search for her name in Epic but was unsuccessful, so I stepped in to assist and noticed that the names provided were connected to the NICU. Since he said he was here to visit mom and baby, and no restrictions were present, we proceeded with our normal check-in process. We had asked him to present us with an ID, to which he gave us his driver’s license; we also asked him if he was given a code because the NICU is a locked unit, he confirmed he had the code and gave us the number. At the time, we were unable to verify the code because this information was not provided by the NICU ...Once the guests are checked in, we either escort them to their destination or instruct them on how to get there.” During an interview, on the afternoon of 02/01/2024, in a facility office, when asked about the Guest Services providing an unidentified man with a NICU baby’s location and providing him with a badge with the baby’s bed number, Staff #4, Supervisor Guest Relations stated, “This was a newer staff member. She (Staff #8, Guest Relations) had only been working here for about 3 months. She (Staff #8) had received training on the visitation procedure. I had a one-to-one training with her to go over the new policy. She understands what she did wrong.””

“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: 33326 Based on record review and interview the facility failed to provide care in a safe setting when the facility failed to enforce security measures; an unidentified man gained access into the facility’s secure NICU. The individual was given a security badge; he had not cleared the security screening. This failure places infants at risk of abduction and death. Findings: Review of the facility provided document Covenant Children’s Guidelines for NIP (No Information Patient) reflected the following: By choosing to be designated as a No Information Patient (NIP) you play an essential role in safeguarding yourself and those around you. Our Team takes strict measures to ensure the protection of you and your personal information, and we kindly request that you avoid sharing your location on social media or any other communication platforms, including location services such as “find my ...” with apple products. We also ask that you advise your friends and family to do the same - please do not share your location while you are under our care. What to Expect As a No Information Patient, your information is not visible to Front Desk Personnel, meaning that if someone contacts the hospital or arrives to visit you, our Team will not share that you or your family member, are currently admitted or receiving treatment here at Covenant Children’s Hospital and the Women’s Care Center. If your Guests cannot provide the required information listed below, they will be informed that you are not here and will not be allowed access. Due to the delicacy of our patient population, Guest Check-In is required. To ensure your Safety and Security, we request a list of restricted or prohibited guests - people that you do NOT wish to see. For Un-restricted Guests, the following information will be required. Guests must offer/provide this information to our Front Desk Personnel when Checking In. - Photo ID (Driver’s License, Passport, Student Badge, etc.) o Guests who cannot present a hard copy of a photo ID, will NOT be allowed access. - Patient Identifiers: o Patient Name AND Room# o 4-digit Access Code o Password o due to your NIP status, we will not ask/prompt for the code and password, your Guest must offer it. o The password is SPECIFIC to NIP cases only. If your Guests cannot provide the above information, we will inform them that you are not here, and we will turn them away. On the afternoon of 01/29/24, during a telephone interview from her home, discharged Patient #1 stated, “The NICU secretary called me and said a man was holding my baby. She asked me if he was the father? I told her no, the father was at home with me. She (the secretary) called me back 30 minutes later and said the man was escorted off the premises.” Guest Services Review of the facility provided Staff #8, Guest Services written statement reflected, “On the night of January 29th, 2024, a man came in to visit a woman and a baby in the hospital around 8:50pm. At the time Staff #14 was at the computer checking people in. He had mentioned the woman’s name and that she (Patient #1) was already discharged, but the baby was still here. Staff #14 continued to search for her name in Epic but was unsuccessful, so I stepped in to assist and noticed that the names provided were connected to the NICU. Since he said he was here to visit mom and baby, and no restrictions were present, we proceeded with our normal check-in process. We had asked him to present us with an ID, to which he gave us his driver’s license; we also asked him if he was given a code because the NICU is a locked unit, he confirmed he had the code and gave us the number. At the time, we were unable to verify the code because this information was not provided by the NICU ...Once the guests are checked in, we either escort them to their destination or instruct them on how to get there.” Neonatal Intensive Care Unit Review of the facility provided Staff #12, Antepartum nurse’s written statement reflected, “I saw his front desk tag said NICU 11, I asked if he was looking for a baby. He said yes and told me what the last name was. He indicated that he had been out of town when the baby was born. I went back to Antepartum and checked and saw that there was a baby in NICU 11 with the same name he was looking for and had been born 2 days before. Not an NIP pt. So I went out and told him we’d go around the corner to NICU and check with them. I asked the man if he had a number or band and he said no. I pushed the intercom button and waited outside the doors. The doors opened before anyone answered and a parent came out. The man patiently waited with me while the doors closed behind the other parent. The secretary answered and I told her that he was looking for the pt in bed 11 as indicated by his name tag, but that he did not have the babies # or a wrist band on. She said ok, that she would take care of it and proceeded to open the door. I walked the man into the secretary’s desk, pointed the secretary out to the man and told him that she would help him. Then I left.” Staffs #8, #12, and #14 did not follow the facility’s policy after the visitor said he did not have the band number or know the baby’s band number. Review of the Staff #13, NICU secretary’s written statement reflected, “On the evening in question, I was not at the desk because I was stocking the unit when the man arrived. A nurse answered the door and was bringing a man through the NICU toward the location of the baby. I saw them and I asked him who was here to see and if he had a band number. He did not. He didn’t know what a band number was but stated he was looking for Patient #1 and her baby. During an interview, on the afternoon of 02/01/2024, in a facility office, when asked about the Guest Services providing an unidentified man with a NICU baby’s location and providing him with a badge with the baby’s bed number, Staff #4, Supervisor Guest Relations stated, “This was a newer staff member. She (Staff #8, Guest Relations) had only been working here for about 3 months. She (Staff #8) had received training on the visitation procedure. I had a one-to-one training with her to go over the new policy. She understands what she did wrong.””