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Based on review of documentation, interviews and hospital policy, the Hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient based on the lack of an immediate nursing assessment conducted on the Infant upon arrival at the Birthplace.

Findings included:

The Complainant alleged that there was a delay in nursing assessment and care of an Infant whom the ambulance Emergency Medical Technicians called into the Emergency Department [ED] en-route to report they were transporting a woman who had a miscarriage during the 6th [24 weeks] month of pregnancy and the fetus.

Background information:

Review of the medical record indicated the Patient presented to the Birthplace on 6/22/10 at 5:11 am following delivery at home with a what EMTs described as a stillborn fetus. The Hospital's Maternal Newborn Service is licensed as a Level IIA. [This level of care indicates the Special Care Nursery is staffed with an onsite Pediatrician and/or Neonatologist on a 24/7 basis. This level of service can provide care to obstetrical and newborn patients at moderate level of risk and provide initial stabilization of a critically ill newborn who requires mechanical ventilation prior to transfer to a Tertiary Care Center].

Review of the Ambulance Trip Sheet dated 6/22/10 indicated that both the Basic Life Support [BLS] and the Advanced Life Support [ALS] ambulances were dispatched at 4:57 am. Documentation indicated that BLS arrived on the scene at 5:01 and ALS arrived at 5:02 am.

Documentation indicated that the ALS EMTS "examined" the fetus and "determined" the Infant which they perceived to be "non-viable". There was no documentation recorded that vital signs were obtained on the infant at any point during the EMTs time at the Patient's home, or that any medical care was provided to the fetus while the teams were at the home.

1) Review of nursing documentation dated 6/22/10 at 5:11 am confirms that the Emergency Medical Technicians [EMTs] reported the Infant was nonviable because the Mother was only 6 months pregnant. There was never a fetal heart check in the field. This is verified in the EMT's note. Documentation indicated the Mother's affect was flat and requested the Infant not be in the room until the finance arrived.

2) The EMT crew presented the "fetus" in a wrapped, plastic bag inside a closed Tupperware container. The Patient was admitted to the antenatal room. The EMT asked Nurse #1 if he could give report in a private area because the Patient did not want to see the Infant. The EMT and Nurse #1 entered the restroom of the Patient's room where the plastic bag was opened. The Infant was inside the plastic bag with the umbilical cord still attached to the placenta.

3) Please note that what follows is that additional nurses, four of them, were directly involved in the examination of the Infant and their documentation is timed as 5:11 am and 5:13 am and included what occurred while they removed the Infant from the plastic bag and began to examine the Infant in the newborn nursery. Please note that specific times are not documented, but approximately 2 minutes passed from leaving the Antepartum room and Nurse #1 entering the nursery with the crib. The assessment phase of the Infant spans several minutes because the heartbeat is barely audible by stethoscope and several nurses listen.

4) Review of Nursing documentation dated 6/22/10 at 5:13 am indicated that the Infant was placed in a crib and moved from the Antepartum room as the Patient/Mother requested. When Nurse #1 entered the nursery and removed the blanket covering the crib and took the Infant out of the plastic bag, Nurse #1 thought she saw the Infant move. Documentation indicated that Nurse #2 placed the stethoscope on the Infant's chest and listened for a heartbeat. Nurse #3 then listens and confirms the heartbeat. Documentation indicated the nurses then 'rushed" [the nurses said they ran with the crib] the Infant to the SCN for resuscitation.

5) This Surveyor determined the following time line of care in the Hospital:

Basic Life Support ambulance crew arrives at hospital - 5:16 am.

Nurses document the arrival of the Infant at 5:11 and 5:13. However, this is not in logical time sequence with the ambulance crew documentation of 5:16 am as the arrival. Nursing staff document their questioning of the detection of a heart beat, but no specific time is documented.

The infant resuscitation sheet indicated the presence of a "faint" heartbeat 5:30 am.

Resuscitation is recorded as starting at 5:40 am.

Transport team arrives at 7:43 am to transfer the Infant to Tertiary Care Center.

The Hospital provided a tape recording of the report phoned in to the Hospital as the ambulance was enroute to the Hospital. The call was received on the ED line. The caller is heard asking to "speak to a nurse in the ED" and the response is, "you are speaking to a nurse". The Caller reported they had a 23 year old female who had a" miscarriage at 6 months" and they had "the fetus with them". The ED Nurse is heard saying, "we don't want that- not at all." The ED Nurse then consults with someone in the area and is heard directing the ambulance team to the Labor and Delivery Unit at the Birthplace. The ED Nurse then asks the Caller for report. The ED Nurse is informed of the Mother's blood pressure and pulse. The ED Nurse said that more information is needed. The ED Nurse asks who the Mother's doctor is and where is the patient at [facility where the Patient is receiving prenatal care] and the Caller is heard answering, "that's all I have." The ED Nurse again directs the Caller to take the Mother and Fetus to the Labor and Delivery Unit at the Birthplace.