VDH finds Henrico Doctors’ NICU failed to prevent abuse of premature babies
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HENRICO COUNTY, Va. (WRIC) -- Henrico Doctors' Hospital failed to prevent the abuse of babies within its neonatal intensive care unit (NICU) for multiple years, according to the results of an on-site survey performed by the Virginia Department of Health (VDH).
The VDH has been looking into Henrico Doctors' Hospital as part of an ongoing investigation after several babies were found with "unexplainable fractures" between 2023 and 2024.
The results of this survey, as well as two corrective actions the facility must take for several listed violations, were released by the VDH Office of Licensure and Certification on Friday, April 24. They were compiled after an unannounced on-site complaint survey carried out on Jan. 24.
Overall, the VDH found that Henrico Doctors' Hospital was "not in substantial compliance with the requirements of CFR," or the conditions of participation for hospitals.
ALL COVERAGE: Babies injured, abused at Henrico Doctors’ Hospital’s NICU
"It was determined that the facility failed to protect patients from abuse and neglect," the VDH said. "Specifically, the hospital failed to prevent abuse, identify injuries of unknown origin as indicators of potential abuse or neglect, report and investigate injuries of unknown origin [across multiple incidents], implement actions to protect patients from abuse and neglect and educate all health care professionals on abuse and neglect."
According to a letter obtained by 8News, Henrico Doctors' Hospital has said it "has taken and will continue to take" actions that provide "credible evidence of compliance with the deficiencies cited" in VDH's investigative report.
However, this is not the first time Henrico Doctors' Hospital has stated its intent to follow a Plan of Correction to prevent abuse and neglect of babies in its NICU. In 2023, the VDH found that the hospital failed to promptly notify Child Protective Services (CPS) after four babies were abused. Evidence was uncovered that an employee was likely involved.
In this new report, the VDH said that Henrico Doctors' Hospital did nothing to protect its patients after those findings in 2023.
"There was no evidence that, after receipt of the CPS findings, the facility implemented actions to prevent abuse, identify injuries of unknown origin as indicators of potential abuse, report and investigate all injuries of unknown origin, implement actions to protect patients from abuse and neglect, or educate all health care professionals on abuse and neglect," the VDH said.
A former nurse at Henrico Doctors' Hospital, identified as Erin Strotman, now faces 12 charges in relation to allegedly hurting and neglecting several babies from 2022 to 2024.
Several details in the report surrounding an "EMP11" appear to identify that employee as Strotman. This includes notes of their firing and subsequent arrest, as well as descriptions of interactions with babies that match up with surveillance video prosecutors said depicts Strotman.
No "governing body" overseeing hospital's conduct
The report states that, based on evidence such as videos, medical records and interviews with staff, Henrico Doctors' Hospital failed to have an effective "governing body."
The report references failures to ensure safe handling of infants in the NICU and to validate the identification of visitors entering the NICU.
Additionally, there was a failure to identify injuries of unknown origin as indicators of potential abuse, report and investigate these injuries, as well as take actions to protect patients from abuse and neglect, according to the report.
The governing body must ensure that services performed under a contract are provided in a safe and effective manner, however, the investigation found discrepancies in contracted radiologist reports.
According to the report, a patient had an X-ray on Nov. 20, 2024, with the review of the radiologist's report indicating a finding of "bones normal," however, the next day, Nov. 21, 2024, the patient had another X-ray and the radiologist reported that "the fractures were unchanged."
Further review found no documented evidence that the radiologist reported the discrepancy to the hospital or the Chief Medical Officer (CMO).
An interview on Jan. 23, 2025, indicated that all NICU radiology is performed by a group of radiologists contracted by the facility.
Failure to adhere to patient rights
EDITOR'S NOTE: This section of the article contains descriptions of injuries to premature babies. Viewer discretion is advised.
The report found that the condition for the hospital to "protect and promote each patient's rights" was also not met, as it was determined that Henrico Doctors' Hospital failed to ensure the safe handling of babies in the NICU to prevent injury, and to make sure consent was obtained before administering a vaccine.
A review of a baby listed in the report as "MR5" showed that the parents signed a consent form not granting permission for nursing staff to administer a Hepatitis-B vaccination to the baby on Sept. 1, 2024.
However, nursing documentation revealed MR5 was administered the Hepatitis-B vaccine the next day on Sept. 2, 2024, with no medical record that MR5's parents gave consent to the vaccine.
The hospital previously stated that it had significantly improved its policies surrounding the recording, reporting and investigation of injuries and suspected abuse. However, the VDH said the hospital failed to investigate six cases of fractures and other injuries to babies between May 2024 and Jan. 2025. Documentation on all of these incidents was overall limited.
The VDH detailed a series of injuries noted on a baby "MR34" over the course of two weeks:
- 9 a.m. on Nov. 9, 2024: Bruising on right shin and left elbow
- 3 p.m. on Nov. 9, 2024: Bruises on right foot, left thigh and back
- 9 a.m. and 9 p.m. on Nov. 10, 2024: Bruising to right shin, right ankle, left thigh, left elbow and back
- 9 a.m. on Nov. 11, 2024: Bruising to right shin, left thigh and left arm. Bruising/abrasion to right foot, right ankle and left foot.
- 9 a.m. on Nov. 12, 2024: Bruising to right shin, left thigh, left wrist, back and both feet
- 9 a.m. on Nov. 13, 2024: Bruising on back of both calves
- 3 p.m. on Nov. 13, 2024: Bruising "inside groin and at front"
- 8 p.m. on Nov. 15, 2024: Bruising in both sides of groin, sides of abdomen and left wrist
- 11 a.m. and 8 p.m. on Nov. 16, 2024: "Large" bruising to both sides of groin
- 8 a.m. and 8 p.m. on Nov. 17, 2024: Bruising on both sides of groin, "bigger on right side"
- 8 a.m. and 8 p.m. on Nov. 18, 2024: Bruising to both sides of groin and in the middle of scalp
- 8 a.m. on Nov. 22, 2024: Bruising on the left labia major, or the left outer fold of female genitalia
Bruising to the baby's labia continued to be documented from that date until Dec. 9, 2024 -- over two weeks later.
"Review of the medical record and facility documents revealed no documented evidence staff identified the cause of the injuries, reported the injuries through the event reporting system or investigated the injuries for potential indicators of abuse," the VDH said.
Other changes that Henrico Doctors' Hospital said it implemented in 2023 included adding cameras to NICU patient rooms and implementing head-to-toe examinations led by neonatologists.
Per the VDH, these cameras were never audited or reviewed to ensure proper care unless there was a complaint, or to "look at some hand hygiene."
Head-to-toe examinations were only completed routinely until July or August 2024, per the VDH.
Handling of babies
EDITOR'S NOTE: This section of the article contains descriptions of premature babies being neglected, mishandled and harmed. Viewer discretion is advised.
A video review and interview on Dec. 26, 2024, to employees providing care to a baby listed at "MR1" on Sept. 14, 2024, revealed that an employee lifted the infant by both ankles and placed a swaddle blanket under the baby.
According to the report, only the crown of the baby's head remained on the bed, and its head was bent towards its chest at about a 45-degree angle.
Another video review on Dec. 30, 2024, revealed "EMP11" -- who appears to be Strotman -- providing care to MR1 on Nov. 10, 2024, where the employee "forcefully pushed the infant's legs towards the abdomen with the feet almost touching the infant's face," releases the baby's legs, then repeats the action again. This is something prosecutors say Strotman was caught on video doing.
EMP11 is also reported to have walked away from the crib while the baby was lying unattended in the crib multiple times, without raising the crib rails. The employee then picks up the baby with one hand and carries it to a rocker using one hand.
On Nov. 13, 2024, EMP11 is reportedly seen on video again pushing that baby's legs towards their face, with their feet almost touching their mouth.
Another video recorded on Nov. 11, 2024 shows EMP11 taking the baby's head and pushing it towards their chest. They then picked the baby up by the head and right leg, lifted the baby several inches off the bed and pushed their legs towards their chest.
VDH showed this video to multiple employees. One employee told VDH staff that "'we don't know why [EMP11] is doing anything [EMP11] is doing,'" per the report.
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Another employee added that "you can tell the baby is not tolerating that well," noting their vitals were not in the normal range during this experience. Their heart rate was in the 170s, while normal is somewhere between 120 and 160. Their oxygen saturation was in the 70s, while normal is somewhere between 90 and 95.
EMP11 can be seen on another Nov. 13, 2024 video turning the baby over from their back to their stomach by grabbing them by the arm and pulling them. They then bend the baby's legs towards their chest again, as they had twice prior.
Later that same day, EMP11 was caught on video "forcefully" pushing a tube not meant to be inserted into babies' noses "deeply into the [baby's] nostril," per the report. The VDH added that the tube used is instead meant for intubation.
In both this video and the one mentioned before it, EMP11 can be seen using what the VDH describes as a "positioning device" to ensure the baby cannot remove their pacifier.
The final video the VDH mentions from Nov. 13, 2024 reportedly shows EMP11 feeding the baby while sitting on the floor. The employee slides themselves backward to lean back against a chair. As they do so, they pull the baby along by their head, providing no support to any other part of their body.
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Two nurses, including EMP11, were put on administrative leave in 2023 and returned to work in Sept. 2024 after a Child Protective Services investigation was completed, per the VDH.
EMP11 was observed for three days upon their return "and the facility had no concerns with [their] care during that time." The other employee was not observed. Both completed some corrective training.
"There were no stipulations, restrictions or conditions for the nurses to return to work, they just had to complete the education, and it was only discussed verbally," the VDH said.
On Nov. 23, 2024, both nurses were reportedly put on administrative leave again after the facility learned of the first new NICU infant fracture.
On Jan. 3, the state survey agency became aware that EMP11 was terminated from the facility and arrested for child abuse based on law enforcement's investigation of events in Henrico Doctors' Hospital's NICU. Strotman was arrested on Jan. 2 in connection with this investigation. She also no longer works at Henrico Doctors' Hospital.
8News reached out to HCA Healthcare for comment on this report and received the following statement:
"The CMS report identified some areas that did not meet the standard of care that we expect and that our patients deserve. We worked diligently to address the findings and CMS has accepted our action plan. We have been closely collaborating with regulators to further improve our NICU by increasing our training, implementing new security measures and changing our reporting protocols. We appreciate the regulators’ commitment to safety and the dedication of our colleagues who have helped our hospital care for our community for more than 50 years." Spokesperson for HCA Healthcare on behalf of Henrico Doctors' Hospital
Stay with 8News as we work through the over 97-page report. Updates will be provided when possible.
