Leadership for Sentinel Events: Infant Abduction at Magee-Womens Hospital of UPMC Leslie C. Davis President Maribeth McLaughlin, RN, BSN, MPM Chief Nursing Officer & Vice President, Patient Care Services Magee-Womens Hospital of UPMC July 17, 2013 3:00 pm ET

Sentinel Event: Infant Abduction Objectives: Describe the preparedness training and precautions for infant security Describe the response and support needed for an infant abduction Describe the steps taken to heal the workforce post an infant abduction Describe the balance of a safe environment while maintaining your mission and values

Sentinel Event: Infant Abduction Infant Security Task Force - Purpose Through partnerships, the Infant Security Task Force is dedicated to providing a safe and secure environment that protects our infants, builds trust and enhances the quality of the infant protection program. The task force works both formally and informally to identify issues and concerns and to collectively problem solve.

Objectives of the Infant Security Task Force Reduce the probability of incidents resulting in harm to or abduction of an infant from the hospital. Identify and analyze vulnerabilities and implement reasonably appropriate safeguards to reduce the number of reportable incidents. Review practices, processes and procedures to identify areas of improvement.

Why a Task Force? “Work at working together” Small group of people (usually managers) and resources brought together to accomplish specific objectives, with the expectation that the group will persist to look at trends and future endeavors Understand the unique role each business has in the overall effort. Bring together the subject matter experts to dissect issues and look at trends Make recommendations to the Security Subcommittee

Structure & Membership Security- Responsible for data collection and analysis. Central repository for all infant protection issues. Works to immediately identify root cause of security breech, disruption or downtime. Clinical- Responsible for processes tied to infant protection Identification Admit/Discharge Patient Instructions

Structure & Membership Facilities- Responsible for physical assets integrated into the infant program Doors Locks Warning devices/Alarms Elevators Information Systems- Responsible for software/hardware, continuity of operations and servers

Components of the Plan: Infant Security Plan Components of the Plan: Identification Patient Visitation Infant/Mother Control Infant Safety Acknowledgement Statement Access Control and Security Devices Education Infant Security System Alarm Response Procedure Abduction Response Plan System Outage Procedures Always know your Census Security Desk prints a current census at the start of each shift Direct staff to report any failures/issues Security makes immediate notification of the outage to: Security Department Management IS Department Administrative Clinician Facilities Management Inpatient Nursing Units Vendor Security Officers immediately respond to stand post at post partum exits a copy of the current census Check all infants leaving the floor against the census Check infants for security tags and “I’m going home” Nursing staff immediately account for all infants and verify tag numbers to infants all infants should be banded and unbanded following normal procedures. Manual Enrollment Log

Response Plan Ensure all staff know their roles/assignments Create a response matrix Law Enforcement notification process Activate the command center and interface with law enforcement command Engage media relations immediately Keep in mind multiple events may be occurring (i.e. Bronze Alert)

Quality – Routine Checks Weekly test of a calibrated tag and random sampling – minimum of 5 tags or 10% of inventory Two trained staff members are needed with the ability to communicate with each other Standardize the test to reduce errors Test tags against one door/exit, rotate exits Test all components of the system monthly Note: Some of our smaller sites do 100% check

Infant Abduction Drills Infant abduction drills are completed quarterly Infant security task force meets prior to drill Discuss past scenarios Areas of weakness Test “new” features/upgrades Test new departments response Work off past incidents Review past drill scenarios Doors stayed open/mom and infant off the unit Test staff involvement/response and capability of system Test downtime procedures

Education and Preparedness February 2012 conducted a table top drill: FBI Local police Internal media Multidisciplinary team of hospital staff and providers Scenario was an infant abduction with shooting of a nurse by an estranged FOB. Conflicting response teams: Condition C rapid response team Bronze alert (active shooter response) Infant Abduction Response

Education and Preparedness Purpose of the Drill Built relationships with local law enforcement and FBI Understanding of the role of law enforcement and the role of the hospital staff Gained an understanding of communication issues Understanding of how to manage multiple events and response plans Lessons learned…..this could really happen!

Education and Preparedness May 2012 held an Infant Security Summit for UPMC hospitals FBI presented on infant abductions Identified the profile of an abductor Reviewed all Infant Security plans and tried to identify best practices Installation of more cameras across the facility

Sentinel Event: Infant Abduction Abductor Profile: Is usually female of “childbearing” age (range now 12 to 53) and often overweight. Abductor 19 years of age and heavy set. Is most likely compulsive; most often relies on manipulation, lying, and deception. The police characterized abductor as a ‘pathological liar’ and scam artist with an ability to con just about anybody. Frequently indicates she has lost a baby or is incapable of having one. This is true for abductor. Is often married or cohabitating; companion’s desire for a child or the abductor’s desire to provide her companion with “his” child may be the motivation for the abduction. Abductor was in a relationship and told the alleged FOB she was pregnant and had a desire to have “his” child.

Sentinel Event: Infant Abduction Abductor Profile (cont): Usually lives in the community where the abduction takes place. Abductor has close ties to the city and it is believed she intended to stay in the city/area. Frequently initially visits nursery and maternity units at more than one healthcare facility prior to the abduction; asks detailed questions about procedures and the maternity floor layout; frequently uses a fire-exit stairwell for her escape; and may also try to abduct from the home setting. Abductor visited several area hospitals and visited Magee at least the day before, it is unknown if she had conducted probing activities prior to that. Usually plans the abduction, but does not necessarily target a specific infant; frequently seizes any opportunity present. Abductor began her planning in early August. 

Sentinel Event: Infant Abduction Abductor Profile (cont): Frequently impersonates a nurse or other allied healthcare personnel. Abductor impersonated a staff member at least the day before and day of.  Often becomes familiar with healthcare staff members, staff members work routines, and victim parents. Abductor looked at the white board and obtained the names of nurses, she also learned the names of patients by looking at doorways and eavesdropping on conversations. Demonstrates a capability to provide “good” care to the baby once the abduction occurs.  The infant had been fed, clothed and was in good condition when found.

Sentinel Event: Infant Abduction 8/23/12 Mother and infant are ready for discharge Mother tells nurses that her sister is coming from work at another hospital Mother had several family members visiting in scrubs from other hospitals Abductor on unit on both 8/22/12 and 8/23/23 in visiting with patient Patient assumes abductor is a hospital employee, staff assume it is a visitor of the patient

Sentinel Event: Infant Abduction Abductor is seen leaving the hospital at 8:30 a.m. 9:00 a.m. She purchased black scrubs with a UPMC logo at the uniform store 2 blocks away 9:31 a.m. She is seen on camera entering the hospital She is seen on the PP unit and is questioned by staff. States she is visiting her sister (gave a patient name) who is pumping her breast. 12:15 p.m. Abductor approaches RN and states my sister is ready for her Motrin before she goes home (prior conversation between nurse and patient regarding taking Motrin prior to discharge).

Sentinel Event: Infant Abduction Nurse obtains the medication and performs HUGS discharge in the computer. 12:30 p.m. The nurse, mother, infant and abductor all in room when tag is cut off and final discharge occurs. RN leaves the room. 12:55 p.m. Mother goes into bathroom. Abductor has been in room watching TV and states she needs to take the baby for one final test. 12:58 p.m. Abductor is seen leaving the hospital with a large pink purse on video.

Sentinel Event: Infant Abduction 1:15 p.m. The FOB approaches nurse’s station asking when the infant would be returned so they can leave. RN immediately goes to room to see why baby isn’t there. 1:20 p.m. Search of the unit and Condition I initiated, security called and search of hospital is started, 911 activated. Description of the abductor is given. 1:41 p.m. Police on site. Media out front of hospital, overhead description of abductor and infant is overhead announced.

Sentinel Event: Infant Abduction Pittsburgh police and FBI respond and take jurisdiction of the hospital and incident command center in security. Operations command center is opened and staffed. MWH RN while searching walks to uniform store and gets the receipt of person who bought scrubs. Hospital Operator gets a call from Florida and a name is given of a suspected abductor posting on Facebook. Nurses identify abductor on camera footage in command center. Footage tracks her through the hospital on 8/22 & 8/23. Detectives conduct interviews with patients, staff and visitors.

Sentinel Event: Infant Abduction The purchased uniform is found in a dumpster across the street from the hospital. 2:00 p.m. TJC and DOH are notified of sentinel event. Media communications are being coordinated between the police and hospital media relations staff. Mother and family moved to a remote unit for privacy as family members coming into hospital. Mother’s room is sealed off as finger printing and pictures are obtained (crime scene). Police and staff are able to confirm postings and pictures on Facebook.

Sentinel Event: Infant Abduction MR of the now known abductor are reviewed. Profile is matching that of an abductor. Operations command center and police command center coordinating activities to maintain operations. Resolve Crisis center staff on site for employees. Police are able to triangulate her location through Facebook postings from cell phones. 6:00 p.m. Abductor is located in a building in the city of Pittsburgh. She has shown the baby to the alleged FOB. 6:20 p.m. Baby is returned to MWH ED and examined. Police ask for footprints and DNA testing. Confirmation by RN who assessed baby.

Sentinel Event: Infant Abduction 6:40 p.m. Baby is reunited with family. Decision made to keep them overnight to observe baby over night. Patient requests to go back to the unit she had been on. 8:00 p.m. Debriefing with police, FBI, hospital staff and internal media occurs. 8/24/12 Entire situation is debriefed again. Temporary measure are put in place to increase security, visitor control, revision to our policy on discharge, mandatory in-services are set up for staff.

Healing the Workforce During the Event: Frequent communication from the President to employees and physicians via email On site crisis counselors from WPIC brought in immediately to assist staff Deployed management to round in all areas of the hospital and provide support Senior leadership provided support to staff being interviewed by detectives

Healing the Workforce During the Event (cont): Unit staff provided relief and additional staffing resources Notification to Community Board Members Communication to Corporate and Media Relations Brief communication distributed to patients to balance media on television

Healing the Workforce After the event: Transparency and just culture related to RCA of the incident Staff debrief with crisis counselors after return of infant and arrangements are made to have counselors on site for next two weeks for any staff Specific meetings with Nursing staff and Security staff President conducted open forum town hall meetings in the auditorium explaining the events and allowing for questions. Support from Pastoral Care Created a site on our infonet to allow for security suggestions by staff Uninvolved staff (MedSurg) sent notes and gifts of support to the OB staff

Sentinel Event: Infant Abduction Actions Taken to date: Visit from the Center for Missing and Exploited Children with assessment of the facility. Three recommendations taken: Remove Mother’s first name from all door and bed cards Ensure all locker rooms are locked Place signage highlighting cameras throughout hospital Tightened the discharge process and auditing it More signage in room about the stork and safety measures Visit by DOH and Call with TJC both accepted our plans of correction Evaluation of more door accesses locked Corporate changed the contract with uniform vendors

Enhancing the Security Plan Balancing the Mission and Values while maintaining a secure environment Tightening up the visitation policy for obstetrics Enhancing the visitor management system in a high volume delivery service (11,000 deliveries) Maintaining a family centered approach Mandatory training for all staff and providers on site Education on the profile of the abductor

Enhancing the Security Plan Continuing to care for patients who meet the profile of the abductor Balancing HIPPA with sharing information on concerning patients with staff Example: Patient who is unable to get pregnant has presented multiple times claiming she is pregnant to a clinic/ ED. Brain injury patient who is 65 and claims to be pregnant calling and presenting to hospital

Enhancing the Security Plan Formation of a PFCC Care Experience team for Secure Environment Shadowed the experience Interviewed patients about security measures Membership included OB provider offices, Outpatient clinic, Pediatrics, security, nursing, transport, consumer education, etc. Development of branded educational materials to include room signs, brochures, website, video, signage

Sentinel Event: Infant Abduction Take Aways: Over communicate with the staff what transpired Staff are experiencing Post Traumatic Stress Drill with local Law Enforcement and media Even more education with parents Audit the process to ensure that all are following it Need for redundancy and layers of security World has changed: staff being trusting of patients and visitors

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