2. Purpose:
• To provide for the safety/security of all infants in
the New Life Center.
• To have a plan of action to implement in the event
an infant is found missing.
3. Policy:
• All visitors are monitored by NLC associates
• NLC associates wear hospital provided photo identification, and
purple/white uniforms at all times
• Infants are transported to and from the mother’s room in a crib.
• Visitors or family members are not permitted to walk in the hallways
holding the infant.
• On the initial visit with the infant’s mother, the mother is instructed on the
purpose of the HUGs bracelet, the Identification bracelets, and reminded of
the items on the “Rooming in Contract” which was signed by the mother on
admission.
• The nurse will check the mother’s I.D. bracelet
number, comparing it to the infant’s I.D. bracelet
number each time the infant is brought into the mother’s
room from the Newborn Nursery.
4. • All doors leading directly to the Nursery shall remain closed. Only
authorized personnel are permitted in the Nursery.
• NLC associates must immediately report any unusual behavior or
questioning about hospital procedures to the nursing supervisors.
• The Hugs Infant Protection System shall be used at all times until the
infant is discharged from the hospital. If a mother refuses to allow the
Hugs tag to be applied to the infant’s ankle, the “Refusal to Use the
Hugs Infant Protection System” Consent (Appendix B) must be signed
by the mother.
• In the event of a Code Pink, “Duty Cards” are kept inside the red
emergency box in each area of the hospital.
6. The Hugs Infant Protection System is a system which uses infant ankle
bands (“tags”), mother arm tags, and an alarm system which activates
an alarm when an infant wearing the Hugs tag is taken out of “the safe
area” of the New Life Center.
The alarm will also be activated when:
• Tag has been tampered with
• Tag’s signal has not been received by the system for a set amount of time
• Tag signal absent from the NLC for longer than the “sign out” time.
• Tag has not been attached to the infant properly
• When two tags have the same identification number
• Tag’s battery is low.
When an alarm occurs, it is important to quickly determine the cause of the
alarm activation. The proper immediate response is to locate the infant.
7. •Hugs tags should be attached only in the safe area of the NLC.
•Attaching the tag in any other location will create problems
with the system operation.
Each time one attaches a tag, one must check the following:
1. No part of the strap is protruding from either tag slot,
2. The tag rotates freely on the infant’s ankle,
3. The tag cannot be slipped over the ankle or foot
8. • The nurse documents the application of the HUGs band on the
baby, and the application of mother’s Kisses band after an
explanation of the purpose of the bands is given to the parents.
This is then documented in the mother’s and infant’s records.
• Upon daily 12 hour assessment, an entry is written by the nurse
stating that “the HUG”s tag #____ is in place and secured on the
infant” infant’s medical record under “security.”
•
10. • A set of four identification bands with matching numbers is provided
for each infant and parent.
• At delivery, the appropriate information is documented on the bands:
*Infant’s gender
*Mother’s first and last name
*Date of birth
*Time of birth
*Name of mother’s doctor
*Medical record number of mother
• Parents verify matching numbers with delivery room nurse prior to
placing bands on infant and parents.
• The two small bands are placed on the infant’s arm and opposite leg. A
band with the same ID number also is placed on the mother’s wrist and
the significant other’s wrist after verifying with them that the numbers
match those of the infant’s band.
11. In the case of an infant with a missing
band, verify remaining bands on all infants with
their parents. After verification is completed, re-
band the infant and parent(s) with a new set of
bands to replace the missing bands, and
document on the mother’s and infant’s record.
13. • Upon being made aware that an infant is missing, NLC associates immediately
seal off the unit, utilizing the duty cards. It is imperative to protect the crime
scene, to preserve any evidence, and to appoint a recorder who will begin
documenting exact times of actions on the “Code Pink Log”
• Notify the operator immediately, and the operator is to immediately announce
the following alert three times over the P.A. System in the hospital: ”Attention,
all associates: We are now under a Code Pink.”
• New Life Center Staff notifies the Searcy Police Department, the hospital
security department, and hospital administration.
• A search of the immediate area is conducted. A “head count” of all infants is
performed, matching the infant’s bands with those of their mother’s bands.
• The NLC HUC or Charge Nurse will notify the nurse manager and/or house
supervisor and the physician(s) caring for the infant and mother.
14. • Upon hearing the “Code Pink”, all available hospital personnel obtain
“Duty cards” from the red emergency box, and respond
immediately to monitor assigned areas of the hospital.
• Persons requesting to exit the hospital will be directed to the main entrance. All
other entrances will be locked until the Code Adam/Code Pink has been cleared.
Law enforcement officers will be asked to perform the interviews of people
requesting to leave the building and will excuse each person on an individual basis.
• The parents of the abducted child are moved to a private room away from the NLC.
A staff nurse (preferably the nurse who had been assigned to the mother or infant)
is assigned to remain with the parents.
• The charge nurse will notify Social Work Services and Community Relations.
15. • The nurse manager/house supervisor briefs all staff on the NLC unit.
Afterward, the staff nurses will explain the situation to each mother (preferably
while mother and her baby are together).
• Staff nurses document as much information as possible about the incident
and surrounding events. An appointed recorder maintains a log of all actions,
including “times initiated,” and “times completed,” recording all actions until
relieved of recorder duties.
Clearing the Code Pink:
When it is determined that the Code Pink has been resolved, either the
administrator on call, or the administrative representative are authorized to
clear the Code Pink.
16. Duty Cards
• “Duty Cards” are kept in the red emergency box in each area of the hospital
(in a pink envelope). Duty cards are the same for both Code Pink and Code Adam.
• Upon hearing the “Code Pink”, hospital associates immediately retrieve the pink
envelope from the red emergency box located in each department.
• Cards are passed out to available associates to enable a quick response so that the
outside exits and the parking lot will be monitored immediately.
After the “Code Pink All Clear” (see Part III, Number 13) is announced over the
hospital P. A. system (only as authorized by the administrator on call, or the
administrative representative), the duty cards are gathered together and placed back
into the pink envelope. Then they are secured in their proper place in the red
emergency box in each department.
