St. Marys Hospital for Children: Alarm Failures - NY
That sequence of events triggered an immediate jeopardy citation, the most serious designation federal inspectors can assign, meaning the facility's own failures put residents at risk of serious harm or death. The inspection, completed March 31, 2026, was filed as a complaint. The facility is disputing the citation.
The alarm system at the center of the incident is called Vocera Edge, a device-based alert platform that routes clinical notifications to nursing and respiratory staff. Camera footage reviewed by inspectors covered the period from 8:43 AM to 10:02 AM and, combined with records from the Patient Safe Solution phone verification system, gave investigators a timestamped account of when the pulse oximetry alarm was initiated and how long it took before anyone responded. The report does not describe what happened to the resident during that window.
Two registered nurses, identified in the report as Registered Nurse 2 and Registered Nurse 3, were found to have failed to respond to the alarms. A respiratory therapist was also cited for the same failure. After the facility conducted its own interviews, the Director of Nursing and the Director of Human Resources met with the two nurses and issued written counseling. Both received three days of administrative leave and were required to complete mandatory Vocera Edge training before returning to work.
The administrator was not in the loop when it happened. During an interview at 5:16 PM on the date inspectors spoke with them, the administrator said they were present at the facility the day of the Code Blue but did not learn about it until the Chief Medical Officer notified them, on a later date. They learned that nurses and the respiratory therapist had delayed their response only during an administrative meeting that followed. The administrator then directed the Director of Nursing to report the incident to the New York State Department of Health. That report was filed.
After the incident, the administrator inserted themselves into the Code Blue debriefing process and instructed assistant directors of nursing, nursing supervisors, and the respiratory director to report all incidents directly to them going forward.
The facility's response was extensive on paper. IT staff checked and confirmed that the monitoring equipment was functioning properly, meaning the failure was not a technical one. The Vocera devices themselves were reviewed, and staff were told the devices must remain accessible and operational at all times. A voice alarm presentation was sent by email to all assistant nurse managers and assistant directors of nursing to review during evening and morning huddles. All nursing and respiratory staff were scheduled for Vocera in-service training. The Director of Nursing called for mock code drills throughout the year.
The pulse oximetry policy was reviewed and revised. A root cause analysis was discussed and formally initiated. The Director of Quality told inspectors the facility uses a Plan Do Study Act model for performance improvement and a fishbone root cause analysis to examine deficient practice. Going forward, the facility said it would audit two specific steps: how long it takes a clinician to respond after an alarm initiates, and whether escalation procedures are being followed and accepted.
Inspectors concluded that the facility had corrected the identified non-compliance and reached substantial compliance before their on-site visit. The immediate jeopardy designation was lifted based on those corrective actions.
The facility is disputing the citation.
What the record does not resolve is what happened to the resident in the room where the Code Blue alarm was sounding while the nurses responsible for answering it did not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Marys Hospital For Children from 2026-03-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ST MARYS HOSPITAL FOR CHILDREN in BAYSIDE, NY was cited for violations during a health inspection on March 31, 2026.
The inspection, completed March 31, 2026, was filed as a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.