A brief delay after an infant at Children's Hospital of Pittsburgh of UPMC developed breathing problems this summer prompted the state Health Department to criticize the hospital for failing to follow up on the incident.

According to a state health inspection report, the unnamed infant suddenly turned blue while at Children's on June 12, something hospital officials say is a common occurrence.

But in this instance, the child's mother told a patient representative that a nurse was still sitting at the nurses' station even though an alarm was sounding. It was then, the report said, that "the nurse realized that the phone that alerted the nurse of emergent conditions was not working."

Hospital spokesman Marc Lukasiak said yesterday that an internal review found no failure of the alarm system, phones or phone network "and, most importantly, the nurse was immediately outside the patient's room and care was provided promptly. There was no harm to the patient."

The child's breathing was restored with bag ventilation, and no incident report was filed. State officials learned of the episode after a complaint was filed, prompting an investigation and unannounced visit on July 22.

One unidentified Children's staffer told investigators that the phone's battery apparently had become dislodged. "The battery was readjusted and changed, and the phone worked fine then."

But another unidentified employee said at the time that Children's had experienced phone system problems since they moved into the building on May 2.

"They were ringing all the time for everything. There were something like 12,000 alarms trying to go through the phone systems all the time," the employee told investigators.

From their interviews, investigators learned that the hospital had no mechanism for tracking or reporting monitor alarms failing to ring nurses' phones.

The investigator asked how they would know if there was a problem.

"I see what you mean," the employee replied. "I guess we wouldn't receive any reports."

The hospital has since set up a process for reporting alarms not received by the emergency phones, and Mr. Lukasiak said there were no problems now with the phone system.

Children's officials also said the hospital's patient safety staff "will review the policy and process for incident and occurrence reporting with the staff."

Investigators additionally found that Children's staff failed to maintain adequate records of central line dressing changes in six of 12 medical records reviewed, a point apparently conceded by staff.

"I'm embarrassed to say that sometimes we just miss charting that the dressing was changed," said one staffer, while another told investigators that "from a documentation side, things are fragmented."

State officials concluded that the hospital was out of compliance with state regulations, but plan no further action now that those issues have been addressed.

Hospital officials say that documentation of central line dressing changes is now overseen and monitored by the unit director.

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