UnityPoint Health-Meriter didn’t respond appropriately when an infant was found bruised in the hospital’s newborn intensive care unit in April 2017, and four more babies were injured, including two with fractures of the skull, ribs or arm, a federal agency said.
Early last month, hospital staff noticed two babies with bruises, according to a federal inspection report. Doctors initially thought the bruising came from blanket wrapping or clutching of wires, but an internal investigation revealed two similar cases from last year and one from this January.
The same nurse had cared for each infant. The hospital suspended the nurse Feb. 8, and the Madison Police Department is investigating. Neither Meriter, police or federal officials have identified the nurse.
Meriter should have done more to prevent further injuries after the first incident, said the Centers for Medicare and Medicaid Services, or CMS.
The hospital “failed to develop and implement an effective policy to prevent, screen, identify, train, protect, thoroughly investigate, report, and respond to any allegations of suspected abuse related to injuries or unknown origin,” the agency said in a report from an inspection Feb. 15-19.
The violation “is so serious that it constitutes an immediate threat to patient health safety,” Maria Vergel De Dios, acting branch manager for the CMS office in Chicago, wrote in a letter to Meriter Feb. 23.
The agency issued an “immediate jeopardy” violation, the most serious kind. The hospital’s Medicare contract could be terminated if the problem is not corrected, the letter said.
Meriter told CMS that in addition to suspending the nurse, the hospital assigned a security guard to the newborn unit and is putting cameras in all of the rooms. Supervisors are randomly checking the unit, two people are now present for all patient care activities, and each nurse will have two patients instead of three, Meriter said.
The hospital said it would connect a “root cause analysis” to prevent similar events.
Federal officials accepted the hospital’s correction plan, but Meriter must fix other problems found in the inspection before CMS will remove the threat of cutting off Medicare business, CMS spokeswoman Elizabeth Schinderle said Thursday. She wouldn’t say what the additional problems are.
Meriter spokeswoman Jessika Kasten said the hospital “has been and continues working cooperatively with local, state and federal agencies involved in the review of our NICU ... We have implemented enhanced safety measures, and our commitment to provide safe care to our patients and families has never been stronger.”
According to the inspection report, staff in Meriter’s 42-bed newborn unit noticed bruising on the arm of an infant on Feb. 2. A doctor thought it might be from clutching wires or an IV device arm board.
The next day, a Saturday, staff noticed unexplained bruising on the right arm and left wrist of another baby. Another doctor thought it might be from blanket wrapping.
The following day, staff saw bruising on the second baby’s face. On Feb. 7, a Wednesday, they discovered a lump on the baby’s head.
On Feb. 8, a CT scan showed the baby had skull and arm fractures. The hospital suspended the nurse.
The next day, the hospital reported the nurse to the police and launched an internal investigation in collaboration with child protective services.
Through the probe, a doctor recalled a baby from September with unexplained bruising on the left foot and scalp. A chart review showed another baby, from April, with bruising on the left foot and both ankles and legs.
Meriter notified parents of the investigation, leading to a fifth case of a baby who had bruising on the lower extremities in January, initially thought to be related to the birth. A CT scan revealed rib and arm fractures.
The hospital didn’t file internal reports about the two babies found bruised on Feb. 2 and 3 until six days later, and some key staff were out early the next week, the inspection report said.