St Marys Hospital For Children
ST MARYS HOSPITAL FOR CHILDREN in BAYSIDE, NY — inspection on March 31, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
of the Code Blue and the resident being transferred to the hospital.
They were not aware that nursing
reported to New York State Department of Health and that it is the Administrator's responsibility to
Administrator stated they were in the facility on [DATE] and was not notified of the Code Blue.
They stated the Chief Medical Officer notified them on [DATE] about the incident and the Code Blue.
The Administrator stated during an administrative meeting on [DATE] they were made aware of the incident involving the Registered Nurses and Respiratory Therapist not responding promptly to the Vocera alarm.
The Administrator stated in the meeting they informed the Director of Nursing that the incident was reportable to the New York State Department of Health, and they proceeded with the submission.
The Administrator stated they are now included in the Code Blue debriefing.
The Administrator stated they instructed the Assistant Directors of Nursing, the Nursing Supervisors and Respiratory Director to report all incidents to the Administrator directly.10 New York Codes, Rules, and Regulations 415.4(b)(2).
33A081 03/31/2026
St Marys Hospital for Children 29 01 216 Street Bayside, NY 11360
were not informed about the Code Blue incident until they were notified by the Chief Medical Officer on [DATE].
The Administrator learned about the delayed response of the registered nurses and respiratory therapist to the Vocera alarm during an administrative meeting on [DATE].
They advised the Director of Nursing that the incident needed to be reported to the New York State Department of Health, and the necessary submission was made.
The Administrator also mentioned that they are now part of the Code Blue debriefing process and have directed the assistant directors of nursing, nursing supervisors, and the respiratory director to report all incidents directly to them.
During an interview on [DATE] at 4:00 PM, Director of Quality stated they reviewed the Quality Assurance Performance Improvement Plan with the committee members and conduct quarterly meetings.
They stated areas for improvement are evaluated by using the Plan Do Study Act performance improvement model and a fish bone Root Cause analysis is further used to analyze the deficient practice.
The Director of Quality stated they currently conduct monthly audits for compliance with following physician orders to set respirator and pulse oximeter parameters.
They stated based on the incident on [DATE], they are planning audits to monitor the two (2) steps in the process of response and action to alarms/alerts.
First step, review the alert system report for time alarm initiated and time it took clinician to respond.
Second step, check for escalation and accepted. In addition, observe when clinicians are at residents' bedside.Based on the corrective actions taken by the facility there was sufficient evidence that the facility corrected the identified non-compliance and was in substantial compliance for this specific regulatory requirement on [DATE], prior to surveyor's onsite visit on [DATE].10 New York Codes, Rules and Regulations 415.12(k)(4,6)Corrective actions taken by the facility as of [DATE]
Review of the camera footage (8:43 AM to 10:02 AM), Patient Safe Solution phone verification notifications, pulse oximetry policy.Re-education to involved staff on the pulse oximetry alarm response, notification handling and escalation expectations.Voice alarm presentation sent via email to all assistant nurse managers/assistant directors of nursing to review during evening huddle [DATE] and morning huddle [DATE].Enforce that Vocera device functionality was reviewed, and staff were instructed to ensure devices always remain accessible and operational.IT/MIS checked and confirmed monitoring equipment to be functioning properly.Disciplinary action to the staff involved - three (3) registered nurses and one (1) respiratory therapist.A root cause analysis was discussed on [DATE] and formally initiated on [DATE].Review and revision of pulse oximetry policyLeadership oversightAn audit for alert response time audit to be implemented.