HospitalInspections.org

Based on medical record review, document review and interview, in six (6) of six (6) medical records reviewed, it was determined:
(a) Obstetric patients did not receive a medical screening evaluation from Qualified Medical Personnel (QMP) in accordance with State regulation. Pregnant patients who presented to the Labor and Delivery unit with medical complaints and symptoms of possible labor, were assessed by labor and delivery nurses. There was no documented evidence that the nurses were designated by the hospital to perform assessments for pregnant patients for signs of labor.
(b) The facility does not have a policy that directs the Labor and Delivery Nurses to assess patients who presented with medical complaints and complications during pregnancy.
(c) Providers failed to document examinations and findings of pregnant patients who were having contractions. (Patient #s 1, 2, 3, 4, 5 and 6).


This finding may have placed the mothers and their unborn babies at risk for harm.


Findings include:

Review of the facility's policy titled "Labor Evaluation" which was last reviewed 2/2019 states the purpose of the policy is "patients will be referred to the Birthing Center by their provider for evaluation of labor. Patients may be evaluated in the Labor and Delivery area by a Labor and Delivery nurse."

Review of the facility's rules and regulations and medical staff bylaws identified that Labor and Delivery Nurses were not authorized or designated as Qualified Medical Personnel to perform medical screening examinations on pregnant patients. These nurses were conducting evaluations and assessments of pregnant patients who are in possible labor.


Review of the medical record for Patient #1 identified the following: This twenty-one year old pregnant patient presented to the facility on 4/12/19 at 6:00 PM with a complaint of headache, and to rule out labor. At 6:15 PM the patient reported to the nurse that she was having irregular uterine contractions. At 6:23 PM, the nurse assessed the patient and documented vital signs. A Certified Nurse Midwife (CNM) ordered urine tests at 6:48 PM, blood tests at 6:51 PM and Tylenol 650 mg orally for pain, which a nurse administered to the patient at 7:30 PM. The nursing staff performed a fetal non-stress test along with an external tocodynamometer (a medical device used to measure the frequency and duration of uterine contractions) reading to detect uterine contractions and there is documentation of continuous fetal heart rate monitoring by the nursing staff. The last pain assessment was documented at 7:32 PM and the patient was noted to be aching and on and off. A nurse documented at 7:51 PM "report given to CNM, labs, blood pressure tracing reactive and occ contraction." The nursing staff discharged the patient from the facility at 8:05 PM that night with instructions that included signs and symptoms of preeclampsia (a complication of pregnancy) and hypertensive disorder of pregnancy.

There was no physician/provider order to discharge the patient from the facility. There is no documented evidence that the patient was assessed by the CNM. There was no documented evidence that the patient was assessed for the presenting symptom of an headache.

The patient returned to the facility on 4/21/19 at 12:36 PM to rule out labor. The patient reported to a nurse that she had mild uterine contraction at 12:30 PM and at 1:00 PM. The nurse documented vital signs. A nurse performed an external tocodynamometer reading to detect uterine contraction at 1:00 PM, at 1:15 PM a nurse conducted a vaginal examination and a fetal non-stress test at 1:48 PM, and there was continuous fetal heart rate monitoring. A nurse documented that an obstetrician "inquires of patient status, made aware of rare contraction, no SROM (spontaneous rupture of membranes), no vaginal bleeding" at 1:15 PM. The patient was discharged at 1:49 PM that day. There was no physician order for the patient's discharge.


Review of medical record for Patient #2 identified the following: This thirty-three year old patient presented to the facility on 2/5/19 at approximately 3:30 PM, referred by her physician because the patient had an elevated blood pressure in his office that day. The patient was 38 weeks 5 days pregnant with a due date of 2/22/19. The nursing staff performed an external fetal heart rate monitoring at 3:35 PM as the physician ordered. The physician also ordered blood test and urine tests at 3:35 PM and at 3:47 PM. Nursing staff performed a fetal non-stress test along with an external tocodynamometer reading for uterine contractions as well as an external ultrasound.
At 3:45 PM the nursing staff documented patient's vital signs. Patient denied having pain. The nurse discharged the patient home at 5:34 PM with a diagnosis of fatigue in pregnancy and pelvic pain. The nurse gave the patient instructions for preeclampsia and to follow-up with a cardiologist the next day. The nurse also instructed the patient to start a 24 hour urine collection that night. There was no physician order to discharge the patient home.


Review of medical record for Patient #3 identified the following: This is a twenty-one year old pregnant patient who presented to the facility at 3:02 AM on 3/1/19 with a complaint of abdominal pain. The patient had a previous medical history of miscarriage and Lyme Meningitis (a bacterial infection of the nervous system), with a gestational age of 38 weeks and 3 days and a due date of 3/24/19. A physician ordered a fetal non-stress test at 3:31 AM and external fetal monitoring at 3:32 AM. The nursing staff conducted an assessment of the patient at 3:02 AM and documented a pain score - 2( on a pain scale of 0 to 10. Zero means "no pain," and 5 or 10 means "the worst possible), and the assessment included review of the patient's skin, psychosocial status and activities of daily living. The nurse documented a Blood Pressure of 119/70 which was not timed. There were no other vital signs in the medical record for the visit. The medical record contained a physician's order to discharge the patient home at 3:32 AM. The nursing staff discharged the patient from the facility at 3:45 AM with instructions that included information for preterm labor.


A similar finding was noted for Patient #4, who presented to the facility on 4/4/19 with a complaint of contractions and was assessed by the Labor Delivery Nurse and discharged home.



Review of medical record for Patient #5 identified the following: This is a 26 year old pregnant patient who presented on 3/16/19 at 9:35 PM for an evaluation of labor. The patient's due date was 3/30/19 and she had a gestational age of 39 weeks and 3 days. The nurses' assessment revealed the patient had irregular contractions, cervical dilatation and effacement. A nurse documented that a Certified Midwife examined the patient but there was no documentation of the midwife's assessment and findings of her examination. The nursing staff discharged the patient at 10:50 PM that night.

Review of medical record for Patient #6 identified the following: This 34 year old pregnant patient presented to the facility on 3/13/19 at 3:50 PM with mild contractions. The nursing staff drew blood samples and fetal monitoring was done. A nurse documented that a physician examined the patient and oxytocin (medication to induce labor) was ordered to induce labor but this order was later cancelled. The patient was discharged home at 7:05 PM that night. There was no documentation in the medical record of the physician's examination and findings.

These findings were shared with Staff A, the Director of Quality on 6/21/19 at approximately 3:00 PM.