HENRICO COUNTY, Va. (WRIC) -- Henrico Doctors' Hospital (HDH) failed to report the suspected abuse of four premature babies in its neonatal intensive care unit (NICU) who sustained fractures to various bones while in the ward, according to the Virginia Department of Health (VDH). The NICU at Henrico Doctors' Hospital stopped accepting admissions on Dec. 26, 2024, after learning that several babies had "unexplainable fractures." Since then, the NICU has been under investigation by multiple agencies and a former nurse has been arraigned on her alleged treatment of one such baby. As of the time of this reporting, a total of seven injured babies are having their cases examined -- four babies who were hurt in 2023 and three who were hurt in 2024. 8News has since learned that the VDH conducted an inspection of HDH in 2023 and found that the hospital did not report suspicions of abuse of those four babies in a timely manner. This is required by the VDH to occur within 24 hours of having reason to suspect abuse. ALL COVERAGE: Babies injured, abused at Henrico Doctors’ Hospital’s NICU Additionally, the VDH reported that NICU staff were not recording who took babies to have labs done, which is another violation of policy. In the investigative report obtained by 8News, HDH provided a list of corrective actions it intended to take in order to address the policy violations the VDH found. It also provided the dates on which the corrective action reportedly took place. In the report -- with its finalized date being March 25, 2024 -- the hospital writes, "Since the implementation of these measures, there have been no additional unexplained fractures occurring in our NICU." The three new cases of "unexplained fractures" occurred in November and December 2024. An overview of the policies HDH did not follow In the report, the VDH listed two policies that HDH was found not in compliance with as of the time of its unannounced inspection, which took place between Sept. 21 and 26, 2023. These policies have to do with any facilities' participation in Medicare/Medicaid. According to the VDH, "a hospital must protect and promote patient's rights," which the HDH reportedly did not do in two ways. The first was in failing to report four premature babies' fractures within 24 hours of suspecting a reportable offense of child abuse, according to the report. The VDH said that four premature babies were found with fractures in HDH's NICU between Aug. 5 and Sept. 5, 2023. These injuries and the related suspicions of abuse were not reported to the appropriate agencies until Sept. 20, 2023, despite -- in at least one baby's case -- said suspicions being documented on Sept. 5, 2023. PREVIOUS: ‘Finally,' Chesterfield father elated to find son’s case of proven child abuse at Henrico Doctor’s Hospital’s NICU has been reopened The second had to do with the way that patient records were kept -- or not kept, in this case. According to the VDH, it is necessary for facilities to be able to identify all staff who come into contact with vulnerable patients, like premature babies in a NICU. HDH reportedly could not identify staff who ran tests on and collected lab specimens from NICU patients. When asked, multiple interviewees blamed this on the technology they use for lab testing. Failure to report fractures on four injured babies The report identifies the four injured babies as "Patient #1," "Patient #2," "Patient #3" and "Patient #4." According to the report, Patient #1 had a fracture to their left tibia, which was found on Sept. 3, 2023, on imaging. A Chesterfield County family told 8News about a tibia fracture their premature son experienced around this same time, though that baby being Patient #1 is not explicitly confirmed. Patient #2 had a fracture on their right radius and ulna documented on Aug. 16, 2023, a fracture of their sixth right rib documented on Aug. 29, 2023, and a fracture to their left femoral metaphysis -- a leg bone -- documented on Aug. 29, 2023. Patient #3 had a fracture to the shaft of their left radius, which was an "incidental finding" during an x-ray on Aug. 5, 2023. Patient #4 had a "buckle fracture" to their left radial -- a lower arm bone -- documented on Sept. 5, 2023. According to the VDH, this sort of fracture is caused by "sudden pressure on a bone." PREVIOUS: Virginia Child Protective Services found child was abused in Henrico Neonatal Intensive Care Unit in 2023 In the case of Patient #1, the baby's x-ray report -- dated Sept. 5, 2023 -- read, in part: "There is mild angulation and bands of increased density within the distal left radius with adjacent periosteal reaction consistent with a 'buckle' fracture. There is mild angulation of the distal ulnar metaphysis as well. Concern for nonaccidental trauma is raised." Patient #1's fracture would then be similar to Patient #4's in that it was caused by "sudden pressure on a bone." A day later, on Sept. 6, 2023, a review from an orthopedic physician's consult read, in part: "We have discussed with the NICU team that nonaccidental trauma needs to be considered. Treatment will be okay and sufficient with the AFO [ankle and foot orthoses] type splint that has been made by occupational survey. I recommend a skeletal survey [x-ray of the entire skeleton] to ensure that there are no other issues identified. We will repeat x-rays of the left lower extremity at three weeks and it may take longer given [the baby's] prematurity." All of these four babies' injuries were reported on Sept. 20, 2023, via two phone calls and one email to the Department of Social Services (DSS), according to the VDH. "Staff Member #2 stated the facility also notified The Joint Commission [on Health Care] 'simply because of what happened,'" the report reads. PREVIOUS: ‘It makes me sick,' Families of babies hurt at Henrico Doctors’ Hospital NICU speak out after former nurse arrested When asked about why it took until Sept. 20, 2023, for these incidents to be reported, "Staff Member #2" said that HDH had "conducted interviews and had 'outside experts' including consults with a radiologist, a geneticist and a neonatologist" and had "retained a pediatric radiologist and pediatric orthopedist, to investigate." The report maintains that policy requires reporting to related authorities within 24 hours of suspecting abuse. Failure to record all who interact with vulnerable patients The VDH found that HDH was not appropriately documenting lab draws or intravenous (IV) catheter insertion procedures with NICU patients. According to the report, during interviewing, "Staff Member #6" told VDH inspectors that "staff are unable to determine who obtains labs from the NICU patients and they do not have a way to 'track that piece.'" This interviewee added that this is, in part, because one staff member may print a lab label and another may perform the procedure. The software the HDH uses to verify labs, "Mobilab," notes who printed the lab label but does not record who performs the procedure. The VDH discovered additional issues with how staff recorded these procedures. "Staff Member #22" told inspectors that "sometimes the staff will use a patient label to label the lab specimens, instead of printing from Mobilab, and then put their initials on that label." They added that nurses would then document the details of the lab draw in the nursing notes -- "but Staff Member #2 was unable to locate that documentation in the medical records," according to the report. Additionally, according to "Staff Member #18," Mobilab can take two registered nurses into account when confirming a patient's identity. PREVIOUS: Henrico police respond to social media claims of racial bias in NICU investigation "Staff Member #18 then stated that [they do] not know if the nursing staff is using the second RN verification in the NICU as per the facility's policy, but that the second RN verification is 'not happening with Mobilab,'" the report reads. According to that interviewee, lab draw information is "not documented anywhere unless the nursing staff are documenting it in the nursing flow sheets or nursing notes." However, sometimes "CBN" -- or Certified Bariatric Nurse -- is documented, meaning the specific nurse can thusly not be identified. "Staff Member #18 stated that there have been times when the lab received multiple hemolysed specimens on one shift, for example," the report reads. "The lab had to determine who drew the labs by looking at the initials on the lab specimens, so that they could reeducate the staff member." Inspectors interviewed a "Staff Member #21," who said two registered nurses initial a label for patient identification. However, a "Staff Member #6" told inspectors that Mobilab checks these identifiers, adding that they were told nurses "don't have to sign anything anymore." "Staff Member #6 stated that 'I don't know that I document anything in the chart, just what Mobi' documents," the report reads. Former nurse makes first court appearance after being charged with child abuse in Henrico Doctors’ Hospital’s NICU investigation Additionally, that interviewee said that Mobilab has no place where a nurse can note the site on a patient's body where a lab was taken from. "Staff Member #21" said the lab report does not state a location on the body or the type of blood vessel accessed, adding that this is something that is "not necessarily documented" in general. "Staff Member #6 stated that the nursing staff [rotates] heel stick sites, but you would only know which foot was stuck last based on which foot the Band-Aid was located on the patient," the report reads. The VDH reviewed HDH's training documentation. In doing so, it located multiple relevant portions, including training on how this two-staff-member patient identification and the documentation of the site of a lab are both required. Henrico Doctors' Hospital's corrective action plans in 2023 The report includes the corrective action plans that HDH stated it would be taking in the wake of these 2023 violations. The plan began with the following statement: "Henrico Doctors’ Hospital (HDH) holds the safety of all patients, staff, and visitors as its highest priority," HDH said. "Upon identification of the fractures of the four (4) premature infants in the Neonatal Intensive Care Unit (NICU), the executive leadership team notified Division leadership and convened an intensive analysis of practices to identify potential contributing factors. The analysis included a review of medical records, policies, procedures and practices currently in place as well as interviews of individuals involved in the care of the infants. We took immediate steps to protect all infants in the NICU. We also notified the families, proper authorities, and regulatory organizations." The HDH said that the delay in the reporting of the babies' injuries was the result of "a gap in the hospital's policy and a lack of staff awareness." It said that the issue with lab documentation was caused by "a gap in the hospital's policy and oversight of the process verification." According to the report, HDH amended the relevant policies and it said that "all members of senior leadership understand and attest to these new requirements." PREVIOUS: Henrico County Commonwealth’s Attorney weighs in on investigation into Henrico Doctor’s Hospital Neonatal Intensive Care Unit In September 2023, HDH reportedly took two relevant corrective actions: adding further, daily examinations of NICU babies led by neonatologists and launching a new unit-wide in-person safety program. As a result of these daily examinations, as of the time of the report being filed, "100% of suspected abuse" has been reported to hospital leadership "immediately upon discovery," according to HDH. The hospital did not specify if that meant it was also immediately reported to relevant agencies. In October 2023, HDH reportedly implemented a new technology associated with Mobilab. Starting on Oct. 31, staff could use Mobilab on their "Mobile" devices and both the collection time and identification were required to be documented. Additionally, the caregiver must positively identify a patient by their wristband and confirm a secondary identification method in order to print a label and draw a lab. Safety education on patient safety during lab draws and the lab draw procedure checklist was completed by 100% of NICU staff by Dec. 31, 2023, according to HDH. Two new security systems were reportedly added in Jan. 2024, including cameras in each NICU room through which parents can view their babies 24/7. Additionally, as of Feb. 1, 2024, safety handling training for premature babies during lab draws was added to both new hire orientation and annual competency validations, according to the report. Beginning on April 1, 2024, a minimum of 10 medical records per week were to be audited for the proper labeling of lab draws for three consecutive months. Then they were to be audited quarterly for the next four quarters. As this report was published in March 2024, information on these lab draw documentation audits is not included. RELATED: Henrico Doctors’ Hospital NICU license to operate on ‘conditional renewal’ By April 26, 2024, the HCH said it would implement a "robust education plan with all staff involved" aimed at tackling the two specific policy violations. It was to include education on patient rights and blood collection policies, with some of the reported objectives being: Explanation of mandatory reporting laws Identification of mandatory reporters Steps involved in reporting Required information when filing a child abuse report Review of “Abuse and Neglect” Policy Utilizing Mobilab to label labs to include collector’s identification, date, and time labs were drawn Documentation in the medical record of the procedure, site and pain level This training was to be completed by, not just NICU staff, but staff throughout the hospital, including its emergency department, clinical staff and more. The completion goal for both sets of training was 100%. As this report was published in March 2024, information on the completion status of these trainings is not included. Following the new investigation into its NICU in December 2024, HDH put out the following list of safety measures it had implemented: Requiring all NICU caregivers to participate in supplemental unit-wide, in-person safety training programs. Adopting the practice of conducting additional head-to-toe examinations of each NICU baby, led by neonatologists. Instituting mandatory training for all healthcare providers who interact with minors, educating the providers on the identification and reporting of suspected neglect or abuse. Installing two new security systems to ensure proper care and parents’ peace of mind. A camera system that records all activity in its NICU rooms 24/7 and is available for viewing in real-time or at a later date. Live-streaming technology allowing parents to view their babies. Multiple of these items -- if not all of them, depending on the content of the "in-person safety programs" and "mandatory training" -- appear to be the same ones listed in the 2023 report. Earlier on Thursday, Jan. 9, VDH released a statement addressing the 2023 report and the new investigation that was launched in December 2024.