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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the medical staff failed to respond in a timely manner for a patient in distress.

Findings include:

Review on March 17, 2021, of the " Medical Staff Bylaws of Crozer-Chester Medical Center, " approved by the Governing Board April 20, 2018, revealed " Preamble Crozer-Chester Medical Center ( " Hospital " ) is owned and operated by Prospect CCMC, LLC, a Pennsylvania limited liability company. The Hospital is a licensed acute care general hospital and provides safe, high quality and accessible inpatient and outpatient healthcare services, education and research to meet its community ' s needs. The Medical Staff of the Hospital operates as an integral part of the Hospital and, through its Departments, committees and officers, is responsible and accountable to the Operations Committee and ultimately the Board of Managers of the Hospital for the quality of medical care provided to patients, the ethical conduct and professional practice of its members and others granted Clinical Privileges to provide patient care in the Hospital, and the performance of those duties and responsibilities delegated to it by the Operations Committee from time to time, with the ultimate authority resting with the Board. ... 2.2 Responsibilities The Medical Staff shall have the following responsibilities: (a) Ensure that Practitioners and APCs [Advanced Practice Clinician] cooperate with each other in providing quality care for patients in the Hospital; ... "

Review of facility documentation on February 8, 2021, revealed a patient (MR2) was admitted on January 17, 2021, with prolonged rupture of membranes. On February 3, 2021, a fetal monitor was applied at 2115. At 2120 the RN noted fetal tachycardia (increased heart rate) followed by the inability to obtain a fetal heart rate. At 2122, the RN notified the resident physician of the fetal tachycardia and requested an assessment. The resident physician was in the Operating Room. The RN called the resident physician a second time. The resident physician verbally ordered fluid initiation and would assess the patient following the delivery that was occurring. At 2127, the RN noted loss of the fetal heart rate. The RN escalated the patient ' s condition to a coworker, who advised the RN to obtain a Doppler. A Doppler was obtained. The fetal heart rate was 200 bpm. The resident physician arrived on the unit with an ultrasound which noted a fetal heart rate of 40 bpm. A Code Pink was initiated at 2200. The infant was delivered at 2210. The infant was taken to the Neonatal Intensive Care Unit (NICU). Overnight the infant ' s condition deteriorated. The infant was made comfort care and expired just before 0900.

Review of MR2 on March 17, 2021, revealed the mother was admitted on January 17, 2021, with a diagnosis of premature rupture of membranes at 22 weeks. She was discharged February 5, 2021. Fetal tachycardia was documented in the days prior to delivery. Fetal bradycardia was noted the evening of February 3, 2021. A stat cesarean-section was called and performed.

Nursing note dated February 3, 2021 at 2248 noted the RN first called CF1. CF1 was in the Operating Room at the time. The RN requested to speak to CF2, who was unavailable. The RN again called CF2 who verbally ordered fluids. CF2 noted they were attending a delivery and would be over after the delivery. The RN again called CF1, requesting an ultrasound. CF1 arrived with the ultrasound and noted bradycardia and called for assistance from EMP5.

Interview on March 15, 2021 with EMP5 revealed they were notified of the incident with MR2 and arrived one to two minutes prior to the Code Pink being called at 2200. EMP5 denied being aware of the fetal tachycardia occurring at 2122 or the loss of the fetal heart rate at 2127.

Interview on March 15, 2021, at approximately 1337 with EMP7 revealed they called Labor and Delivery for assistance with fetal tachycardia and episodes of the loss of fetal heart rate. EMP7 was told the first resident on the call list (CF1) was in the OR and the back-up resident (CF2) was on a call and would call EMP7 back. EMP7 stated when they returned to the patient's room, the patient was still experiencing tachycardia with episodes where the heart rate was lost. EMP7 stated since no return call was received, they made another call to Labor and Delivery. EMP7 spoke with CF2, the second resident on call. CF2 stated they were their way to a delivery and EMP7 gave a verbal order for fluids. CF2 stated they would check the patient when the delivery was complete.

EMP7 confirmed CF2 was not in a delivery at the time EMP7 spoke with CF2. EMP7 stated CF2 did not say it was an emergency delivery. The labor and delivery nurse did not inform EMP7 there was an emergency delivery. EMP7 stated " they usually tell you when it is." EMP7 noted the whole thing went on for about 45 minutes to an hour. EMP7 confirmed another RN obtained a Doppler, and the tachycardia persisted with drops of fetal heart rate. The on call resident was called again (CF1) and CF1 notified EMP5. EMP7 stated there was not a written protocol on an escalation process for staff to follow. EMP7 stated "We're just supposed to call if something is going on. There isn't anything that tells us times and how long we wait."

Interview on March 17, 2021 at approximately 1330 with EMP8 revealed sometime after 2100 they were approached by EMP7 to assist with getting a fetus on the monitor. EMP8 confirmed they were able to get the fetus on monitor in the left suprapubic area. The fetus was tachycardic afterwards. EMP8 returned to her assigned patient. EMP8 stated they were approached again by EMP7 with concerns. EMP8 asked if EMP7 had called for the resident. EMP7 said they were waiting for a response from CF2. EMP8 stated they were having a hard time obtaining the fetal heart rate and told EMP7 to obtain a Doppler from Labor and Delivery. EMP8 had a hard time obtaining a normal fetal heart rate with the Doppler. EMP7 was able to contact CF1 who had just left the Operating Room. EMP8 stated CF1 arrived, assessed the patient, and called EMP5. EMP8 confirmed, to their knowledge, CF2 was not actively in a delivery and did not come to assess patient.

Interview on March 15, 2021, with EMP4 at 1150 confirmed there was not a written protocol on an escalation process for staff to follow when a resident was unavailable.

Interview on March 15, 2021, with EMP6 at 1215 confirmed there was no written policy on notification. "The staff have been here a long time. They know that when you ' re having an issue you must get a resident or the attending [physician]."

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined nursing services failed to institute a corrective action plan for an escalation process in Maternity and Labor and Delivery for staff to follow.

Findings include:

Review on March 18, 2021, of the facility ' s job description " Title: Chief Nursing Officer, " effective date February 2019, revealed " Position Summary: To plan, organize, direct, and evaluate those Nursing Services activities involving personnel management, the implementation of collective bargaining agreements, the availability of patient care services, and capital equipment acquisition. People: Creates an environment which supports employee development and teamwork to deliver compassionate patient care in a safe environment. Service: Creates systems, processes and care standards to support the delivery of patient care in a safe, fiscally sound environment of service excellence. Quality: Provides accessible, timely, efficient, cost effective care by utilizing evidence-based practice and continuous performance improvement. ... Accountabilities/Criteria ... Ensures the delivery of quality patient care through the establishment and dissemination of appropriate Standards. ... Operational Administration Collaborates with quality, safety, risk, clinical education departments in developing and executing on root cause analysis action plans. ... "

Review on March 18, 2021, of the facility ' s job description " Title: Nurse Director, " effective date July 2009, revealed " Accountabilities/Competencies ... In cooperation with the Clinical Educator, identifies learning needs of the staff and develops programs to meet those needs. ... Operational Management Articulates and supports Medical Center and Departmental goals and philosophies to all personnel. ... Cooperates with other department directors to promote optimal utilization of personnel and resources.

Review of facility documentation on February 8, 2021, revealed a patient (MR2) was admitted on January 17, 2021, with prolonged rupture of membranes. On February 3, 2021, an event occurred requiring immediate physician intervention and assistance. Nursing called for physician assistance three times. The calls started at 2122. Code Pink was called at 2200 after CF1 arrived and assessed the patient.

Review on March 9, 2021, of documentation provided by EMP1 via email revealed the following action plan:
1) We did confirm that the current evidence based care of monitoring the fetus BID [two times a day] was being followed.
2) Appropriate escalation of issues has been reviewed with the staff and providers, to provide guidance when a provider may be in another delivery or a fetal condition is unclear.
3) Fetal monitoring will be reviewed by all staff and providers, with current annual competency being reviewed to assure it is adequate.
4) Patients who require monitoring will be transported to the L&D area and placed on central monitoring to assure appropriate assessment of the fetus.
5) Recommendation to Administration to evaluate central monitoring in the Mother/Baby area, so that L&D Staff and Providers all have access to see the monitoring.

An onsite visit was conducted on March 15, 2021. It was determined the protocols and education noted in the action plan were not instituted.

Interview on March 17, 2021 at 1215 with EMP9 revealed the items provided via email to the Department on March 9, 2021, by EMP1 were recommendations made by the Patient Safety Committee following their investigation of the event for MR2. The implementation of the action plan was the responsibility of the Department leaders. This did not occur. EMP9 stated this was the responsibility of EMP6 and EMP2.

Cross reference 482.22 - Medical Staff.