VDH finds Henrico NICU violated state standards, failed to maintain medical records

HENRICO COUNTY, Va. (WRIC) -- A recent report from the Virginia Department of Health (VDH) revealed a lack of training, repeated failure to report bruising and injuries in babies and a missing medical records system in Henrico Doctors' Hospital's neonatal intensive care unit (NICU), violating state standards for hospital care.

The hospital failed to ensure that these nurses received the proper training before their shifts, as several babies have since been found with fractures and bruising between 2022 and 2024, with some dying.

The most recent action by the VDH was to carry out a survey on behalf of the Centers for Medicare and Medicaid Services (CMS), a federal agency.

ALL COVERAGE: Babies injured, abused at Henrico Doctors’ Hospital’s NICU

The report states that a registered nurse must assign care for each patient based on what the patient needs and the qualifications of the nursing staff, however, according the VDH, "This STANDARD is not met as evidenced by: Based on review of facility documents and interviews with staff (EMP), it was determined that the facility failed to ensure that nurses from another hospital had onboarding training or competencies prior to performing their shifts in the NICU."

In a Jan. 2, 2025, interview, an employee said the hospital failed to document evidence of orientation or training for at least nine employees -- some of these employees were also working at other hospitals besides Henrico Doctors' Hospital.

VDH also revealed that the hospital's director of nursing services failed to supervise and evaluate staff, and based on medical records, documentation and staff interviews, the report emphasizes that the facility did not adhere to the hospital policies related to:

• Fall prevention, safe handling practices and nasal suctioning (MR1)
• Accurately documented skin assessments and notified the physician of abnormal assessment findings (MR1, MR28, MR34, MR46)
• Obtained a physician's order for wound care (MR46)
• Completed daily checks for the NICU code cart and defibrillator
• Removed expired dietary supplements and powdered formula from formula preparation rooms

Failure to document bruising, abnormal skin assessments, bruising or abrasions

According to assessments in 2024, employees were not guided on abnormal skin assessments, bruising or abrasions.

In a Jan. 17, 2024, interview, it was found that nurses should be documenting the location, size and color of a baby's bruise. While employees were allegedly told to do so, the hospital "did not provide documentation of education provided to nurses related to documentation of abnormal skin assessment findings, bruising or abrasions."

According to an employee, they teach NICU nurses skin assessment in either an in-person course or online. However, VDH found there to be no skin assessment review of "MR1" on July 21, 2024, for separate incidents:

The VDH detailed two injuries noted on a baby "MR46" in a single day:

• 3 a.m. on July 21, 2024: Bruising to the shin on the right leg
• 9 a.m. on July 21, 2024: Bruising of two places on the right shin, he left shin and back of the calf
  • There was no documentation that the physician was notified of the new abrasion until 12 p.m. on Oct. 10, 2024.

The VDH revealed that there was identical documentation of these injuries on subsequent days: 8 a.m. and 8 p.m. on July 22, 2024, 9 a.m. on July 23, 2024 and 3 a.m. on July 24, 2024. On Jan. 17, 2025, an employee indicated that previous assessment data is automatically input into the current flowsheet.

The VDH detailed two injuries noted on a baby "MR46" in a single day:

• 8 p.m. on Oct. 9: Abrasion on left leg/calf
  • There was no documentation of notification of the abrasions and bruising to the physician on November 6, 2024.

The VDH also detailed a series of injuries noted on a baby "MR34" over the course of two weeks, which failed to be documented regarding notification of the abrasions and bruising to the physician on

• Nov. 6, 2024: Bruising on the legs
• 9 a.m. and 3 p.m. on Nov. 9, 2024: Bruising to right shin and left elbow. 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

On Jan. 24, 2025, it was indicated that the attorney representing neonatologists "refused to permit the surveyors to interview any NICU physician," according to the VDH.

Failure to use a proper medical records system

On Nov. 13, 2024, an employee indicated that three open powdered formula containers -- Similac Advanced on Sept. 30, 2024, Enfamil on Oct. 29, 2024 and Similac Sensitive on Nov. 14, 2024, were past the one-month open date and should have been discarded, despite employee responsibility for stocking and ordering formula

According to VDH, the hospital must maintain a record for each inpatient and outpatient and must use "a system of author identification and record maintenance," and have written, completed and properly filled medical records.

The report indicated that the hospital failed to have accurate and complete medical records for MR1 and MR47, as well as a proper medical records system that was easy to access.

Numerous facility documents between October 2024 and January 2025 were also found to not have been reviewed or checked weekly by a NICU director. Sheets include Adult/Pediatric Defibrillator Check Sheet and Neonatal Code Cart Check Sheet.

Other standards are not being met by the NICU

VDH also revealed that the hospital to adhere to other hospital policies related to:

• Properly implement a system for control of infections, active said hospital-wide program and failed to monitor and track infection prevention to mitigate outbreaks
• Failed to implement a consistent method of hand hygiene upon entering the NICU and staff failed to perform hand hygiene
• Failed to clean and disinfect an isolette, a small bed in plastic, which controls temperature and humidity

According to the hospital policy's infection prevention and control plan, the infection preventionists are responsible for collecting and then analyzing data. Reviews of this include disinfection techniques and certain procedures to ensure the infections do not spread, including storage, cleaning, sterilization and disinfection practices, central service and housekeeping should be evaluated and revised as necessary.

In a Jan. 23, 2025, interview, an employee indicated that there has been an MRSA outbreak in the NICU for over three years, and there was "no national infection prevention guidance followed for NICU." But that employee added that there was no way to track strategies to prevent an MRSA outbreak, and said hospital staff is responsible for cleaning the scale for weighing babies, but that there is no electronic system to see if the item was cleaned or tested again.

As a result, the employee said it was difficult to track MRSA, because the hospital no longer tracked which babies contacted NICU equipment used to track potential MRSA transmission -- despite five new infections.

While hospital employees who come into direct contact with babies must perform a three-minute handwashing and three pumps of hand antiseptic, the VDH also detailed numerous instances where employees failed to follow their hygiene policies:

• 11:45 a.m. on Dec. 20, 2024: An employee was seeing going into a baby's room with an untied gown falling of their body, and no personal protective equipment. They also did not clean their hands after leaving.
• 9:28 a.m. on Nov. 26, 2024: An employee changed a diaper and then gave a patient medications without changing their gloves or washing their hands.
• 4:45 a.m. on Jan. 3, 2025: An employee was not wearing PPE when entering a room with a sign indicating the baby was on "contact precautions."
• 7:18 and 8:37 a.m. on Jan. 21, 2025: An employee was seen with their hands in the small bed touching the patient and items and was not wearing gloves.
• 8:41 a.m. on Jan. 21, 2025: An employee removed their left hand from the small bed, touched the screen of a machine, put their hand and back into the small bed and proceeded to touch and pick up the baby without washing their hands.
  • 8:43 a.m. on Jan. 21, 2025: That same employee was seen applying gloves and placed their hands back into the small bed.
  • 8:44 a.m. on Jan. 21, 2025: They were then seen removing their hands from the small bed, retrieving a supply, returning to the small bed and placing their gloved hands back inside the small bed. They then removed their left arm out of the small bed and wiped their face with their gloved wrist -- all without washing their hands.
  • 9:08 a.m. on Jan. 21, 2025: They retrieved a disinfectant wipe and wiped one side of the small bed, then opened a drawer and retrieved a supply. They put their hands in the small bed, touched the infant's head and adjusted the pacifier in the infant's mouth without washing their hands.
  • 9:11 to 9:12 a.m. on Jan. 21, 2025: They wiped the top and side of the small bed with a disinfecting wipe, threw the wipe away and then put their hands back into the small bed without wearing gloves or washing hands.
• 8:32 a.m. on Jan. 21, 2025: NEO55, who was providing care to "MR9," putting on gloves then touched the video monitoring device, and without cleaning their hands or changing gloves, they touched the baby.
  • 8:36 a.m. on Jan. 21, 2025: NEO55 touched medical equipment and scratched their face. They then touched the monitor with their gloved hands.
• 8:57 to 9:05 p.m. on Jan. 21, 2025: An employee was seen putting on a pair of gloves, touching equipment and then touching the baby,
  • 9:01 p.m. on Jan. 21, 2025: They walked away from the crib wearing the same gloves and touched the infant again when they came back.
  • 9:04 p.m. on Jan. 21, 2025: They put on new gloves, touched the communication device they were wearing and then touched MR34.

In a Jan. 24, 2025, interview, the VDH found that the NICU did not document what small beds babies slept in for four months in 2024, and as a result, there fails to be a system in place that tracks infection surveillance, prevention and control, and antibiotic use activities -- a state standard.