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Based on review of medical staff by-laws, rules, regulations and policies, medical record review and staff and physician interviews, the medical staff failed to enforce the by-laws, rules and regulations by failing to effectively communicate the need for anesthesia services for 1 of 3 cesarean sections reviewed (#2).

The findings include:

Review of the medical staff by-laws, rules and regulations, revised 12/2010, revealed, "...D. Policies Regarding Surgical Care...The policies, regulations and rules for the surgical suite should be determined by the clinical service of surgery, ob-gyn, and anesthesiology with recommendations by the operating room committee. The institution and performance of policy will be the responsibility of the operating room committee...".

Review of the medical staff policy "Physician to Physician Communication for Patient Management", effective 10/19/2009, revealed "...Principles: 1. Patient care is improved when communication between appropriate level physicians is optimized. ...3. The reason for consultation and the question(s) to be addressed should be specific, explicit, negotiated and acknowledged at the time of request. ...5. Covering physicians have responsibility for maintaining established clinical care management. ...Procedure: 1. ...Response time must be agreed by both parties at the time of communication. ...".

Review of the hospital's Operative Services policy, "Scheduling and Management of Operating Room Cases", revised 03/2008, revealed, "...A. Procedure Definitions...3. Urgent Procedure- Procedure that needs to be done within 2 hours due to stabilization needs of the patient (i.e. C-Section...)...".

Closed record review of Patient #2 revealed a 28 year-old admitted 12/30/2010 at 1452 for induction of full-term labor due to oligohydramnios (decreased amniotic fluid) and elevated blood pressure. Record review revealed admission vital signs documented by the nurse on admission as: Temperature 37.2 (99 degrees); Blood Pressure 146/91 (elevated); Pulse 105; Respirations 18. Fetal heart rate via an external fetal monitor was documented as 150 (normal), with variability 6-25 bpm (beats per minute), accelerations greater than 15 bpm with no decelerations noted. Further record review revealed a cervical exam was performed by the registered nurse at 1939 with 3-4 cm (centimeters) dilatation, 80% effacement with membranes intact and baby at 0 station. Further record review revealed a Pitocin (medication that causes uterine contractions) intravenous drip was started at 1950 and uterine contractions started at 2118. Further record review revealed an epidural continuous pump (regional anesthetic) was started by Anesthesiologist #1 at 2353. Record review revealed the patient received a bolus of ropivicaine (anesthetic) via the epidural at 0333 due to pain intensity of 8 on a 10 point scale with 10 being the worst. Record review revealed the patient's epidural was replaced by Anesthesiologist #1 at 0441 due to no pain relief from the existing epidural. Record review revealed the patient's pain intensity remained 9 at 0448. Record review revealed documentation by Physician #1 dated 12/31/2010 at 0540, "continues to be 5 cm. Starting to have cervical edema, efw (estimated fetal weight) 9+ lbs and baby has not changed position for the last 6 hours. Have repetitively attempted to achieve pain control without success. Feel this probably represents a true cpd (cephalo-pelvic disproportion). Will proceed with primary ltcs (low transverse cesarean section)...0544 The risks, benefits, indications and alternatives to c section are discussed with the patient...will proceed". Review of the nursing documentation dated 12/31/2010 at 0555 revealed, "abdominal shave and prep completed". Nursing documentation at 0726 revealed, "Anesthesia called back and stated back up called in. Spoke with (Physician #1) and received order for Fentanyl (narcotic pain medication) 100 mcg (micrograms) IVP (intravenous push)". Nursing documentation at 0751 revealed, "(Anesthesiologist #2) and (Physician #1) returned page. POC (plan of care) rec'd (received). (Physician #1) to call anesthesia...". Further record review revealed Patient #2 was taken to the obstetrical operating room at 0853 and general anesthesia was started at 0903 (3 hours, 19 minutes after the decision for a c-section was called) and the male infant was delivered via cesarean section at 0917. Review of Physician #1's dictated operative report revealed, "...Indications and Findings: The patient was found to have what was felt to be arrest. She had progressed slowly to 5 cm and had remained 5 cm for more than two hours. She had significant pelvic pain with a nonfunctional epidural catheter. The baby had been tachycardic (fast heart rate) with a mild elevation in temperature but had shown no evidence of fetal distress. She had delivery of a viable male infant. This was found to be extremely difficult as the baby was found to be wedged in the pelvis. The shoulders were found to be above the pubic symphysis as was the major part of the skull. ...The baby was found to be straight OP (occiput posterior) as well. She had delivery with using upward pressure by a nurse through the vagina and with great difficulty, we were able to deliver the fetal vertex (head). This took approximately 50 (?) minutes post incision to delivery. ...The baby had APGARS (scoring for newborns with 10 being the best) of 2 and 9 and it was resuscitated by the NICU (neonatal intensive care unit) team. It was taken to the NICU for a probable pneumothorax (collapsed lung)...". Review of the discharge summary dictated 01/05/2011 revealed discharge diagnoses of cesarean section and chorioamnionitis (bacterial infection of the fetal membranes in the uterus). Patient #2 was discharged 01/05/2011 and the baby was discharged 01/07/2011.

Interview on 02/15/2011 at 1515 with Physician #1 revealed he was the attending physician for Patient #2. Interview revealed, "when I examined her around 5:30 in the morning, I considered we weren't going further with labor. I made the decision at that time to do a c-section. I called anesthesia and they are usually there within 20 to 30 minutes. I told the patient and the family we were on our way to the OR (operating room). I called again and was told by (Anesthesiologist #2) there were multiple gunshot wounds in the ED (emergency department) and they couldn't do it right then. I called anesthesia two times from the time of my decision. I considered it urgent because Mom was having a lot of pain, especially hip pain. Her epidural had failed". Interview further revealed "they did not meet my expectation for anesthesia services. I don't know if the delay caused problems at delivery".

Interview on 02/15/2011 at 1415 with Physician #2 revealed he was the physician supervising OB-GYN (obstetrical/gynecological) residents on 12/31/2010. Interview revealed, "all the residents were busy so I offered to assist (Physician #1) with the c-section. The patient had secondary arrest of labor". Interview further revealed, "it was an urgent c-section. Our policy is that for urgent cases we have 2 hours from call to cut".

Interview on 02/16/2011 at 0845 with a registered nurse (RN #1) revealed she was Patient #2's primary nurse in labor and delivery on 12/30/2010 at 1900 until 12/31/2010 at 0700. Interview revealed, "the decision to proceed with a c-section was made by (Physician #1) at 0540. (Anesthesiologist #1) was paged at different times. We were told at 6:00 it would be about an hour. When that time had come and gone, we called him again. He told us he had multiple traumas in the ED and he would call his back up in. The patient was in pain during this time. She had no significant relief from the epidural". Interview further revealed, "it was very unusual that we were waiting so long".

Interview on 02/16/2011 at 0945 with RN #2 revealed she was Patient #2's primary nurse in labor and delivery on 12/31/2010 beginning at 0700. Interview revealed, "she was in a lot of pain when I came on. We gave her Fentanyl three times, Terbutaline (muscle relaxer) twice and placed her in Trendelenburg (head lower than feet). We called anesthesia back at 7:00. They said they were calling in a backup and we called them back about 8:00. (Physician #1) was upset. He called them, too. Interview further revealed, "when they made the incision, they couldn't get the baby out. Anesthesia gave her Nitro (nitroglycerin-relaxes smooth muscle) to relax the uterus. I gloved and put pressure through the vagina on the baby's head. This can cause trauma to the baby. He did have a pneumothorax. She had general anesthesia and it took about 10 minutes or more to get the baby out so that caused the baby's respiratory depression". Interview further revealed, "If she had been taken to the OR sooner, it would not have been so difficult to get the baby out".

Interview on 02/16/2011 at 1215 with Anesthesiologist #1 revealed the anesthesiologist was providing anesthesia services for the hospital on 12/30/2010 beginning at 1900 until 12/31/2010 at 0700. Interview revealed, "I was busy. I was covering the Main Building and OB. I called (Anesthesiologist #2) to come in around 3:30 because I also had a case in the heart center. It was my responsibility to get the C-section done. (Physician #1) or the nurse called to tell me about it. I don't remember them telling me it was urgent. (Anesthesiologist #3) came in at 7:00. Then it was his responsibility".

Interview on 02/16/2011 at 1020 with Anesthesiologist #2 revealed , "I came in at 3:30. I took over the trauma case in the heart center OR. At 6:20, I went home. I did not get a message from (Anesthesiologist #1) that I needed to stay and provide anesthesia for (Patient #2)". Interview further revealed, "typically, we respond to L&D (labor and delivery) as a priority. There was a delay in what we normally like to see". Interview further revealed, "there was a communication break down by not getting this done within 2 hours from decision to incision".

Anesthesiologist #3 was not available for interview.

Consequently, Patient #2 was admitted for induction of labor on 12/30/2010, had an arrest of labor at 5 cm and the attending physician called for the baby to be delivered by cesarean section on 12/31/2010 at 0544. Anesthesia services was notified of the urgent cesarean section and did not arrive to begin anesthesia until 0903 (3 hours, 19 minutes) after notification.

Based on review of nursing job description, hospital policy, medical record review, staff and physician interview the nursing staff failed to supervise and evaluate patient care by failing to follow the chain of command for 1 of 3 cesarean sections reviewed (#2).

The findings include:

Review of the hospital's job description for a Registered Nurse revealed, "...Implements Patient Care...8. Seeks out resources when in difficult or new situations. ...Provides Leadership...3. Problem Solving...b. Reports unit-related problems using the appropriate chain of command...".

Review of the hospital's policy, "Chain of Command", revised 11/2009, revealed, ...a chain of command is established for reporting any situation that creates a threat to the health of a patient. This reporting must be done in a timely manner which is consistent with the patient's need for care. The procession through the chain of command is dependent upon needs for further communication in order to reach an acceptable resolution to a patient care problem. ...Implementation: ...3. If the questionable care is being provided by a physician and a satisfactory explanation has not been given, the staff member should collaborate with the supervisor regarding the situation and they then should contact the physician next in line in seniority...4. If the response by the attending physician is perceived to be inappropriate or if there has been any faulty communication or lack of communication with the attending physician, the staff member should also contact the Manager or Resource Nurse and Nursing Coordinator, who will seek clarification. The Manager, or in his/her absence the Nursing Coordinator, will contact the Medical Director/liaison of the department for assistance if the problem remains unsolved. The Departmental Administrator on call is notified if attempts in problem solving by the Medical Director/liaison are unsuccessful. 5. The Department Administrator will initiate contact with the Chief of Service, who is next in the chain of command. Risk Management is also notified at this time. 6. If the problem has not been resolved through intervention by the Chief of Service, the Vice President of the Division and the Hospital Administrator on call are contacted...7. These steps are objectively documented in the patient's record and an Event Report is completed...".

Closed record review of Patient #2 revealed a 28 year-old admitted 12/30/2010 at 1452 for induction of full-term labor due to oligohydramnios (decreased amniotic fluid) and elevated blood pressure. Record review revealed admission vital signs documented by the nurse on admission as: Temperature 37.2 (99 degrees); Blood Pressure 146/91 (elevated); Pulse 105; Respirations 18. Further record review revealed a cervical exam was performed by the registered nurse at 1939 with 3-4 cm (centimeters) dilatation, 80% effacement with membranes intact and baby at 0 station. Further record review revealed a Pitocin (medication that causes uterine contractions) intravenous drip was started at 1950 and uterine contractions started at 2118. Further record review revealed an epidural continuous pump (regional anesthetic) was started by Anesthesiologist #1 at 2353. Record review revealed the patient received a bolus of ropivicaine (anesthetic) via the epidural at 0333 due to pain intensity of 8 on a 10 point scale with 10 being the worst. Record review revealed the patient's epidural was replaced by Anesthesiologist #1 at 0441 due to no pain relief from the existing epidural. Record review revealed the patient's pain intensity remained 9 (on a scale of 1 to 10, with 10 being the greatest pain) at 0448. Record review revealed documentation by Physician #1 dated 12/31/2010 at 0540, "continues to be 5 cm. Starting to have cervical edema, efw (estimated fetal weight) 9+ lbs and baby has not changed position for the last 6 hours. Have repetitively attempted to achieve pain control without success. Feel this probably represents a true cpd (cephalo-pelvic disproportion). Will proceed with primary ltcs (low transverse cesarean section)...0544. The risks, benefits, indications and alternatives to c section are discussed with the patient...will proceed".

Review of the nursing documentation dated 12/31/2010 at 0555 revealed, "abdominal shave and prep completed". Nursing documentation at 0726 revealed, "Anesthesia called back and stated back up called in. Spoke with (Physician #1) and received order for Fentanyl (narcotic pain medication) 100 mcg (micrograms) IVP (intravenous push)". Nursing documentation at 0751 revealed, "(Anesthesiologist #2) and (Physician #1) returned page. POC (plan of care) rec'd (received). (Physician #1) to call anesthesia...". Further record review revealed Patient #2 was taken to the obstetrical operating room at 0853 and general anesthesia was started at 0903 (3 hours, 19 minutes after the decision for a c-section was called) and the male infant was delivered via cesarean section at 0917. Patient #2 was discharged 01/05/2011 and the baby was discharged 01/07/2011.

Interview on 02/16/2011 at 0845 with a registered nurse (RN #1) revealed she was Patient #2's primary nurse in labor and delivery on 12/30/2010 at 1900 until 12/31/2010 at 0700. Interview revealed, "the decision to proceed with a c-section was made by (Physician #1) at 0540. (Anesthesiologist #1) was paged at different times. We were told at 6:00 (a.m.) it would be about an hour. When that time had come and gone, we called him again. He told us he had multiple traumas in the ED and he would call his back up in. The patient was in pain during this time. She had no significant relief from the epidural". Interview further revealed, "it was very unusual that we were waiting so long". Interview revealed the chain of command policy was not followed.

Interview on 02/16/2011 at 0945 with RN #2 revealed she was Patient #2's primary nurse in labor and delivery on 12/31/2010 beginning at 0700. Interview revealed, "she was in a lot of pain when I came on. We gave her Fentanyl three times, Terbutaline (muscle relaxer) twice and placed her in Trendelenburg (head lower than feet). We called anesthesia back at 7:00. They said they were calling in a backup and we called them back about 8:00. (Physician #1) was upset. He called them, too. Interview further revealed, "when they made the incision, they couldn't get the baby out. Anesthesia gave her Nitro (nitroglycerin-relaxes smooth muscle) to relax the uterus. I gloved and put pressure through the vagina on the baby's head. This can cause trauma to the baby. He did have a pneumothorax. She had general anesthesia and it took about 10 minutes or more to get the baby out so that caused the baby's respiratory depression". Interview further revealed, "If she had been taken to the OR sooner, it would not have been so difficult to get the baby out". Interview revealed the chain of command policy was not followed.

Interview on 02/15/2011 at 1600 with RN #3 revealed she was the charge nurse for labor and delivery beginning at 0700 on 12/31/2010. Interview revealed, "I could hear her (Patient #2) crying in pain. I was told she was waiting for a C-section. At about 7:30, I beeped anesthesia. When they called back, they told me they had called their back-up in. I don't remember who I talked to". Interview further revealed, "a lady came out to the desk and wanted to know how much longer it would be. She was very upset that it was taking so long. I called (name of manager) before 8:00 to come help out with the family". Interview further revealed, "this C-section was urgent and should have been done quicker than it was".

Interview on 02/15/2011 at 1620 with administrative labor and delivery staff revealed, "I got a call from the charge nurse around 8:30 that a family was very upset about waiting for a C-section. When I got there, she was in the OR (operating room) and they were happy". Interview further revealed, "I reviewed the record (Patient #2) and couldn't tell why there was a delay. I never talked to anesthesia about it". Further interview revealed an event report was not completed and the chain of command was not followed by nursing staff.

Consequently, Patient #2 was admitted for induction of labor on 12/30/2010, had an arrest of labor at 5 cm and the attending physician called for the baby to be delivered by cesarean section on 12/31/2010 at 0544. Anesthesia services was notified of the urgent cesarean section and did not arrive to begin anesthesia until 0903 (3 hours, 19 minutes) after notification. Nursing services failed to follow the chain of command by notifying the appropriate supervisor/coordinator of the delay in patient care.

Based on review of medical staff by-laws, rules, regulations and policies, anesthesia contract review, medical record review and staff and physician interviews, the hospital failed to provide anesthesia services to meet the needs of a patient for 1 of 3 cesarean section patients reviewed (#2).

The findings include:

Review of the medical staff by-laws, rules and regulations, revised 12/2010, revealed, "...D. Policies Regarding Surgical Care...The policies, regulations and rules for the surgical suite should be determined by the clinical service of surgery, ob-gyn, and anesthesiology with recommendations by the operating room committee. The institution and performance of policy will be the responsibility of the operating room committee...".

Review of the hospital's Operative Services policy, "Scheduling and Management of Operating Room Cases", revised 03/2008, revealed, "...A. Procedure Definitions...3. Urgent Procedure- Procedure that needs to be done within 2 hours due to stabilization needs of the patient (i.e. C-Section...)...".

Review of the perioperative services policy, "Anesthesia", revised 01/2009, revealed, "The Department of Anesthesia at (name of hospital) is responsible to the administration of the hospital and abides by the policies set forth by the hospital. The services of the Department of Anesthesia includes the administration of anesthesia in the Operating Room Suites, the Obstetrical Suites...".

Review of the contract between the hospital and the (name of anesthesia group) dated 02/01/2009 revealed, "...1. Duties of (name of anesthesia group): A. (Name of anesthesia group) is responsible for recruitment and retention of a sufficient number of Providers as is necessary to meet the requirements of a demand schedule prepared in advance by the Hospital and agreed to by (name of anesthesia group), in accordance with the policy set forth on Attachment 1...". Review of Attachment 1 revealed "Demand Schedule for Contract Year 2010...OB Service Coverage will be 1 physician (24 hours/day)...".

Closed record review of Patient #2 revealed a 28 year-old admitted 12/30/2010 at 1452 for induction of full-term labor due to oligohydramnios (decreased amniotic fluid) and elevated blood pressure. Record review revealed admission vital signs documented by the nurse on admission as: Temperature 37.2 (99 degrees); Blood Pressure 146/91(elevated); Pulse 105; Respirations 18. Fetal heart rate via an external fetal monitor was documented as 150 (normal), with variability 6-25 bpm (beats per minute), accelerations greater than 15 bpm with no decelerations noted. Further record review revealed a cervical exam was performed by the registered nurse at 1939 with 3-4 cm (centimeters) dilatation, 80% effacement with membranes intact and baby at 0 station. Further record review revealed a Pitocin (medication that causes uterine contractions) intravenous drip was started at 1950 and uterine contractions started at 2118. Further record review revealed an epidural continuous pump (regional anesthetic) was started by Anesthesiologist #1 at 2353. Record review revealed the patient received a bolus of ropivicaine (anesthetic) via the epidural at 0333 due to pain intensity of 8 on a 10 point scale with 10 being the worst. Record review revealed the patient's epidural was replaced by Anesthesiologist #1 at 0441 due to no pain relief from the existing epidural. Record review revealed the patient's pain intensity remained 9 at 0448. Record review revealed documentation by Physician #1 dated 12/31/2010 at 0540, "continues to be 5 cm. Starting to have cervical edema, efw (estimated fetal weight) 9+ lbs and baby has not changed position for the last 6 hours. Have repetitively attempted to achieve pain control without success. Feel this probably represents a true cpd (cephalo-pelvic disproportion). Will proceed with primary ltcs (low transverse cesarean section)...0544 The risks, benefits, indications and alternatives to c section are discussed with the patient...will proceed".
Review of the nursing documentation dated 12/31/2010 at 0555 revealed, "abdominal shave and prep completed". Nursing documentation at 0726 revealed, "Anesthesia called back and stated back up called in. Spoke with (Physician #1) and received order for Fentanyl (narcotic pain medication) 100 mcg (micrograms) IVP (intravenous push)". Nursing documentation at 0751 revealed, "(Anesthesiologist #2) and (Physician #1) returned page. POC (plan of care) rec'd (received). (Physician #1) to call anesthesia...". Further record review revealed Patient #2 was taken to the obstetrical operating room at 0853 and general anesthesia was started at 0903 (3 hours, 19 minutes after the decision for a c-section was called) and the male infant was delivered via cesarean section at 0917. Review of Physician #1's dictated operative report revealed, "...Indications and Findings: The patient was found to have what was felt to be arrest. She had progressed slowly to 5 cm and had remained 5 cm for more than two hours. She had significant pelvic pain with a nonfunctional epidural catheter. The baby had been tachycardic (fast heart rate) with a mild elevation in temperature but had shown no evidence of fetal distress. She had delivery of a viable male infant. This was found to be extremely difficult as the baby was found to be wedged in the pelvis. The shoulders were found to be above the pubic symphysis as was the major part of the skull. ...The baby was found to be straight OP (occiput posterior) as well. She had delivery with using upward pressure by a nurse through the vagina and with great difficulty, we were able to deliver the fetal vertex (head). This took approximately 50 (?) minutes post incision to delivery. ...The baby had APGARS (scoring for newborns with 10 being the best) of 2 and 9 and it was resuscitated by the NICU (neonatal intensive care unit) team. It was taken to the NICU for a probable pneumothorax (collapsed lung)...". Review of the discharge summary dictated 01/05/2011 revealed discharge diagnoses of cesarean section and chorioamnionitis (bacterial infection of the fetal membranes in the uterus). Patient #2 was discharged 01/05/2011 and the baby was discharged 01/07/2011.

Interview on 02/15/2011 at 1515 with Physician #1 revealed he was the attending physician for Patient #2. Interview revealed, "when I examined her around 5:30 in the morning, I considered we weren't going further with labor. I made the decision at that time to do a c-section. I called anesthesia and they are usually there within 20 to 30 minutes. I told the patient and the family we were on our way to the OR (operating room). I called again and was told by (Anesthesiologist #2) there were multiple gunshot wounds in the ED (emergency department) and they couldn't do it right then. I called anesthesia two times from the time of my decision. I considered it urgent because Mom was having a lot of pain, especially hip pain. Her epidural had failed". Interview further revealed "they did not meet my expectation for anesthesia services. I don't know if the delay caused problems at delivery".

Interview on 02/15/2011 at 1415 with Physician #2 revealed he was the physician supervising OB-GYN (obstetrical/gynecological) residents on 12/31/2010. Interview revealed, "all the residents were busy so I offered to assist (Physician #1) with the c-section. The patient had secondary arrest of labor". Interview further revealed, "it was an urgent c-section. Our policy is that for urgent cases we have 2 hours from call to cut".

Interview on 02/16/2011 at 0845 with a registered nurse (RN #1) revealed she was Patient #2's primary nurse in labor and delivery on 12/30/2010 at 1900 until 12/31/2010 at 0700. Interview revealed, "the decision to proceed with a c-section was made by (Physician #1) at 0540. (Anesthesiologist #1) was paged at different times. We were told at 6:00 it would be about an hour. When that time had come and gone, we called him again. He told us he had multiple traumas in the ED and he would call his back up in. The patient was in pain during this time. She had no significant relief from the epidural". Interview further revealed, "it was very unusual that we were waiting so long".

Interview on 02/16/2011 at 0945 with RN #2 revealed she was Patient #2's primary nurse in labor and delivery on 12/31/2010 beginning at 0700. Interview revealed, "she was in a lot of pain when I came on. We gave her Fentanyl three times, Terbutaline (muscle relaxer) twice and placed her in Trendelenburg (head lower than feet). We called anesthesia back at 7:00. They said they were calling in a backup and we called them back about 8:00. (Physician #1) was upset. He called them, too. Interview further revealed, "when they made the incision, they couldn't get the baby out. Anesthesia gave her Nitro (nitroglycerin-relaxes smooth muscle) to relax the uterus. I gloved and put pressure through the vagina on the baby's head. This can cause trauma to the baby. He did have a pneumothorax. She had general anesthesia and it took about 10 minutes or more to get the baby out so that caused the baby's respiratory depression". Interview further revealed, "If she had been taken to the OR sooner, it would not have been so difficult to get the baby out".

Interview on 02/16/2011 at 1215 with Anesthesiologist #1 revealed the anesthesiologist was providing anesthesia services for the hospital on 12/30/2010 beginning at 1900 until 12/31/2010 at 0700. Interview revealed, "I was busy. I was covering the Main Building and OB. I called (Anesthesiologist #2) to come in around 3:30 because I also had a case in the heart center. It was my responsibility to get the C-section done. (Physician #1) or the nurse called to tell me about it. I don't remember them telling me it was urgent. (Anesthesiologist #3) came in at 7:00. Then it was his responsibility".

Interview on 02/16/2011 at 1020 with Anesthesiologist #2 revealed , "I came in at 3:30. I took over the trauma case in the heart center OR. At 6:20, I went home. I did not get a message from (Anesthesiologist #1) that I needed to stay and provide anesthesia for (Patient #2)". Interview further revealed, "typically, we respond to L&D (labor and delivery) as a priority. There was a delay in what we normally like to see". Interview further revealed, "there was a communication break down by not getting this done within 2 hours from decision to incision".

Anesthesiologist #3 was not available for interview.

Consequently, Patient #2 was admitted for induction of labor on 12/30/2010, had an arrest of labor at 5 cm and the attending physician called for the baby to be delivered by cesarean section on 12/31/2010 at 0544. Anesthesia services was notified of the urgent cesarean section and did not arrive to begin anesthesia until 0903 (3 hours, 19 minutes) after notification.


NC00070061

Based on review of medical staff by-laws, rules, regulations and policies, medical record review and staff and physician interviews, the medical staff failed to enforce the by-laws, rules and regulations by failing to effectively communicate the need for anesthesia services for 1 of 3 cesarean sections reviewed (#2).

The findings include:

Review of the medical staff by-laws, rules and regulations, revised 12/2010, revealed, "...D. Policies Regarding Surgical Care...The policies, regulations and rules for the surgical suite should be determined by the clinical service of surgery, ob-gyn, and anesthesiology with recommendations by the operating room committee. The institution and performance of policy will be the responsibility of the operating room committee...".

Review of the medical staff policy "Physician to Physician Communication for Patient Management", effective 10/19/2009, revealed "...Principles: 1. Patient care is improved when communication between appropriate level physicians is optimized. ...3. The reason for consultation and the question(s) to be addressed should be specific, explicit, negotiated and acknowledged at the time of request. ...5. Covering physicians have responsibility for maintaining established clinical care management. ...Procedure: 1. ...Response time must be agreed by both parties at the time of communication. ...".

Review of the hospital's Operative Services policy, "Scheduling and Management of Operating Room Cases", revised 03/2008, revealed, "...A. Procedure Definitions...3. Urgent Procedure- Procedure that needs to be done within 2 hours due to stabilization needs of the patient (i.e. C-Section...)...".

Closed record review of Patient #2 revealed a 28 year-old admitted 12/30/2010 at 1452 for induction of full-term labor due to oligohydramnios (decreased amniotic fluid) and elevated blood pressure. Record review revealed admission vital signs documented by the nurse on admission as: Temperature 37.2 (99 degrees); Blood Pressure 146/91 (elevated); Pulse 105; Respirations 18. Fetal heart rate via an external fetal monitor was documented as 150 (normal), with variability 6-25 bpm (beats per minute), accelerations greater than 15 bpm with no decelerations noted. Further record review revealed a cervical exam was performed by the registered nurse at 1939 with 3-4 cm (centimeters) dilatation, 80% effacement with membranes intact and baby at 0 station. Further record review revealed a Pitocin (medication that causes uterine contractions) intravenous drip was started at 1950 and uterine contractions started at 2118. Further record review revealed an epidural continuous pump (regional anesthetic) was started by Anesthesiologist #1 at 2353. Record review revealed the patient received a bolus of ropivicaine (anesthetic) via the epidural at 0333 due to pain intensity of 8 on a 10 point scale with 10 being the worst. Record review revealed the patient's epidural was replaced by Anesthesiologist #1 at 0441 due to no pain relief from the existing epidural. Record review revealed the patient's pain intensity remained 9 at 0448. Record review revealed documentation by Physician #1 dated 12/31/2010 at 0540, "continues to be 5 cm. Starting to have cervical edema, efw (estimated fetal weight) 9+ lbs and baby has not changed position for the last 6 hours. Have repetitively attempted to achieve pain control without success. Feel this probably represents a true cpd (cephalo-pelvic disproportion). Will proceed with primary ltcs (low transverse cesarean section)...0544 The risks, benefits, indications and alternatives to c section are discussed with the patient...will proceed". Review of the nursing documentation dated 12/31/2010 at 0555 revealed, "abdominal shave and prep completed". Nursing documentation at 0726 revealed, "Anesthesia called back and stated back up called in. Spoke with (Physician #1) and received order for Fentanyl (narcotic pain medication) 100 mcg (micrograms) IVP (intravenous push)". Nursing documentation at 0751 revealed, "(Anesthesiologist #2) and (Physician #1) returned page. POC (plan of care) rec'd (received). (Physician #1) to call anesthesia...". Further record review revealed Patient #2 was taken to the obstetrical operating room at 0853 and general anesthesia was started at 0903 (3 hours, 19 minutes after the decision for a c-section was called) and the male infant was delivered via cesarean section at 0917. Review of Physician #1's dictated operative report revealed, "...Indications and Findings: The patient was found to have what was felt to be arrest. She had progressed slowly to 5 cm and had remained 5 cm for more than two hours. She had significant pelvic pain with a nonfunctional epidural catheter. The baby had been tachycardic (fast heart rate) with a mild elevation in temperature but had shown no evidence of fetal distress. She had delivery of a viable male infant. This was found to be extremely difficult as the baby was found to be wedged in the pelvis. The shoulders were found to be above the pubic symphysis as was the major part of the skull. ...The baby was found to be straight OP (occiput posterior) as well. She had delivery with using upward pressure by a nurse through the vagina and with great difficulty, we were able to deliver the fetal vertex (head). This took approximately 50 (?) minutes post incision to delivery. ...The baby had APGARS (scoring for newborns with 10 being the best) of 2 and 9 and it was resuscitated by the NICU (neonatal intensive care unit) team. It was taken to the NICU for a probable pneumothorax (collapsed lung)...". Review of the discharge summary dictated 01/05/2011 revealed discharge diagnoses of cesarean section and chorioamnionitis (bacterial infection of the fetal membranes in the uterus). Patient #2 was discharged 01/05/2011 and the baby was discharged 01/07/2011.

Interview on 02/15/2011 at 1515 with Physician #1 revealed he was the attending physician for Patient #2. Interview revealed, "when I examined her around 5:30 in the morning, I considered we weren't going further with labor. I made the decision at that time to do a c-section. I called anesthesia and they are usually there within 20 to 30 minutes. I told the patient and the family we were on our way to the OR (operating room). I called again and was told by (Anesthesiologist #2) there were multiple gunshot wounds in the ED (emergency department) and they couldn't do it right then. I called anesthesia two times from the time of my decision. I considered it urgent because Mom was having a lot of pain, especially hip pain. Her epidural had failed". Interview further revealed "they did not meet my expectation for anesthesia services. I don't know if the delay caused problems at delivery".

Interview on 02/15/2011 at 1415 with Physician #2 revealed he was the physician supervising OB-GYN (obstetrical/gynecological) residents on 12/31/2010. Interview revealed, "all the residents were busy so I offered to assist (Physician #1) with the c-section. The patient had secondary arrest of labor". Interview further revealed, "it was an urgent c-section. Our policy is that for urgent cases we have 2 hours from call to cut".

Interview on 02/16/2011 at 0845 with a registered nurse (RN #1) revealed she was Patient #2's primary nurse in labor and delivery on 12/30/2010 at 1900 until 12/31/2010 at 0700. Interview revealed, "the decision to proceed with a c-section was made by (Physician #1) at 0540. (Anesthesiologist #1) was paged at different times. We were told at 6:00 it would be about an hour. When that time had come and gone, we called him again. He told us he had multiple traumas in the ED and he would call his back up in. The patient was in pain during this time. She had no significant relief from the epidural". Interview further revealed, "it was very unusual that we were waiting so long".

Interview on 02/16/2011 at 0945 with RN #2 revealed she was Patient #2's primary nurse in labor and delivery on 12/31/2010 beginning at 0700. Interview revealed, "she was in a lot of pain when I came on. We gave her Fentanyl three t

Based on review of nursing job description, hospital policy, medical record review, staff and physician interview the nursing staff failed to supervise and evaluate patient care by failing to follow the chain of command for 1 of 3 cesarean sections reviewed (#2).

The findings include:

Review of the hospital's job description for a Registered Nurse revealed, "...Implements Patient Care...8. Seeks out resources when in difficult or new situations. ...Provides Leadership...3. Problem Solving...b. Reports unit-related problems using the appropriate chain of command...".

Review of the hospital's policy, "Chain of Command", revised 11/2009, revealed, ...a chain of command is established for reporting any situation that creates a threat to the health of a patient. This reporting must be done in a timely manner which is consistent with the patient's need for care. The procession through the chain of command is dependent upon needs for further communication in order to reach an acceptable resolution to a patient care problem. ...Implementation: ...3. If the questionable care is being provided by a physician and a satisfactory explanation has not been given, the staff member should collaborate with the supervisor regarding the situation and they then should contact the physician next in line in seniority...4. If the response by the attending physician is perceived to be inappropriate or if there has been any faulty communication or lack of communication with the attending physician, the staff member should also contact the Manager or Resource Nurse and Nursing Coordinator, who will seek clarification. The Manager, or in his/her absence the Nursing Coordinator, will contact the Medical Director/liaison of the department for assistance if the problem remains unsolved. The Departmental Administrator on call is notified if attempts in problem solving by the Medical Director/liaison are unsuccessful. 5. The Department Administrator will initiate contact with the Chief of Service, who is next in the chain of command. Risk Management is also notified at this time. 6. If the problem has not been resolved through intervention by the Chief of Service, the Vice President of the Division and the Hospital Administrator on call are contacted...7. These steps are objectively documented in the patient's record and an Event Report is completed...".

Closed record review of Patient #2 revealed a 28 year-old admitted 12/30/2010 at 1452 for induction of full-term labor due to oligohydramnios (decreased amniotic fluid) and elevated blood pressure. Record review revealed admission vital signs documented by the nurse on admission as: Temperature 37.2 (99 degrees); Blood Pressure 146/91 (elevated); Pulse 105; Respirations 18. Further record review revealed a cervical exam was performed by the registered nurse at 1939 with 3-4 cm (centimeters) dilatation, 80% effacement with membranes intact and baby at 0 station. Further record review revealed a Pitocin (medication that causes uterine contractions) intravenous drip was started at 1950 and uterine contractions started at 2118. Further record review revealed an epidural continuous pump (regional anesthetic) was started by Anesthesiologist #1 at 2353. Record review revealed the patient received a bolus of ropivicaine (anesthetic) via the epidural at 0333 due to pain intensity of 8 on a 10 point scale with 10 being the worst. Record review revealed the patient's epidural was replaced by Anesthesiologist #1 at 0441 due to no pain relief from the existing epidural. Record review revealed the patient's pain intensity remained 9 (on a scale of 1 to 10, with 10 being the greatest pain) at 0448. Record review revealed documentation by Physician #1 dated 12/31/2010 at 0540, "continues to be 5 cm. Starting to have cervical edema, efw (estimated fetal weight) 9+ lbs and baby has not changed position for the last 6 hours. Have repetitively attempted to achieve pain control without success. Feel this probably represents a true cpd (cephalo-pelvic disproportion). Will proceed with primary ltcs (low transverse cesarean section)...0544. The risks, benefits, indications and alternatives to c section are discussed with the patient...will proceed".

Review of the nursing documentation dated 12/31/2010 at 0555 revealed, "abdominal shave and prep completed". Nursing documentation at 0726 revealed, "Anesthesia called back and stated back up called in. Spoke with (Physician #1) and received order for Fentanyl (narcotic pain medication) 100 mcg (micrograms) IVP (intravenous push)". Nursing documentation at 0751 revealed, "(Anesthesiologist #2) and (Physician #1) returned page. POC (plan of care) rec'd (received). (Physician #1) to call anesthesia...". Further record review revealed Patient #2 was taken to the obstetrical operating room at 0853 and general anesthesia was started at 0903 (3 hours, 19 minutes after the decision for a c-section was called) and the male infant was delivered via cesarean section at 0917. Patient #2 was discharged 01/05/2011 and the baby was discharged 01/07/2011.

Interview on 02/16/2011 at 0845 with a registered nurse (RN #1) revealed she was Patient #2's primary nurse in labor and delivery on 12/30/2010 at 1900 until 12/31/2010 at 0700. Interview revealed, "the decision to proceed with a c-section was made by (Physician #1) at 0540. (Anesthesiologist #1) was paged at different times. We were told at 6:00 (a.m.) it would be about an hour. When that time had come and gone, we called him again. He told us he had multiple traumas in the ED and he would call his back up in. The patient was in pain during this time. She had no significant relief from the epidural". Interview further revealed, "it was very unusual that we were waiting so long". Interview revealed the chain of command policy was not followed.

Interview on 02/16/2011 at 0945 with RN #2 revealed she was Patient #2's primary nurse in labor and delivery on 12/31/2010 beginning at 0700. Interview revealed, "she was in a lot of pain when I came on. We gave her Fentanyl three times, Terbutaline (muscle relaxer) twice and placed her in Trendelenburg (head lower than feet). We called anesthesia back at 7:00. They said they were calling in a backup and we called them back about 8:00. (Physician #1) was upset. He called them, too. Interview further revealed, "when they made the incision, they couldn't get the baby out. Anesthesia gave her Nitro (nitroglycerin-relaxes smooth muscle) to relax the uterus. I gloved and put pressure through the vagina on the baby's head. This can cause trauma to the baby. He did have a pneumothorax. She had general anesthesia and it took about 10 minutes or more to get the baby out so that caused the baby's respiratory depression". Interview further revealed, "If she had been taken to the OR sooner, it would not have been so difficult to get the baby out". Interview revealed the chain of command policy was not followed.

Interview on 02/15/2011 at 1600 with RN #3 revealed she was the charge nurse for labor and delivery beginning at 0700 on 12/31/2010. Interview revealed, "I could hear her (Patient #2) crying in pain. I was told she was waiting for a C-section. At about 7:30, I beeped anesthesia. When they called back, they told me they had called their back-up in. I don't remember who I talked to". Interview further revealed, "a lady came out to the desk and wanted to know how much longer it would be. She was very upset that it was taking so long. I called (name of manager) before 8:00 to come help out with the family". Interview further revealed, "this C-section was urgent and should have been done quicker than it was".

Interview on 02/15/2011 at 1620 with administrative labor and delivery staff revealed, "I got a call from the charge nurse around 8:30 that a family was very upset about waiting for a C-section. When I got there, she was in the OR (operating room) and they were happy". Interview further revealed, "I reviewed the record (Patient #2) and couldn't tell why there was a delay. I never talked to anesthesia about it". Further interview revealed a

Based on review of medical staff by-laws, rules, regulations and policies, anesthesia contract review, medical record review and staff and physician interviews, the hospital failed to provide anesthesia services to meet the needs of a patient for 1 of 3 cesarean section patients reviewed (#2).

The findings include:

Review of the medical staff by-laws, rules and regulations, revised 12/2010, revealed, "...D. Policies Regarding Surgical Care...The policies, regulations and rules for the surgical suite should be determined by the clinical service of surgery, ob-gyn, and anesthesiology with recommendations by the operating room committee. The institution and performance of policy will be the responsibility of the operating room committee...".

Review of the hospital's Operative Services policy, "Scheduling and Management of Operating Room Cases", revised 03/2008, revealed, "...A. Procedure Definitions...3. Urgent Procedure- Procedure that needs to be done within 2 hours due to stabilization needs of the patient (i.e. C-Section...)...".

Review of the perioperative services policy, "Anesthesia", revised 01/2009, revealed, "The Department of Anesthesia at (name of hospital) is responsible to the administration of the hospital and abides by the policies set forth by the hospital. The services of the Department of Anesthesia includes the administration of anesthesia in the Operating Room Suites, the Obstetrical Suites...".

Review of the contract between the hospital and the (name of anesthesia group) dated 02/01/2009 revealed, "...1. Duties of (name of anesthesia group): A. (Name of anesthesia group) is responsible for recruitment and retention of a sufficient number of Providers as is necessary to meet the requirements of a demand schedule prepared in advance by the Hospital and agreed to by (name of anesthesia group), in accordance with the policy set forth on Attachment 1...". Review of Attachment 1 revealed "Demand Schedule for Contract Year 2010...OB Service Coverage will be 1 physician (24 hours/day)...".

Closed record review of Patient #2 revealed a 28 year-old admitted 12/30/2010 at 1452 for induction of full-term labor due to oligohydramnios (decreased amniotic fluid) and elevated blood pressure. Record review revealed admission vital signs documented by the nurse on admission as: Temperature 37.2 (99 degrees); Blood Pressure 146/91(elevated); Pulse 105; Respirations 18. Fetal heart rate via an external fetal monitor was documented as 150 (normal), with variability 6-25 bpm (beats per minute), accelerations greater than 15 bpm with no decelerations noted. Further record review revealed a cervical exam was performed by the registered nurse at 1939 with 3-4 cm (centimeters) dilatation, 80% effacement with membranes intact and baby at 0 station. Further record review revealed a Pitocin (medication that causes uterine contractions) intravenous drip was started at 1950 and uterine contractions started at 2118. Further record review revealed an epidural continuous pump (regional anesthetic) was started by Anesthesiologist #1 at 2353. Record review revealed the patient received a bolus of ropivicaine (anesthetic) via the epidural at 0333 due to pain intensity of 8 on a 10 point scale with 10 being the worst. Record review revealed the patient's epidural was replaced by Anesthesiologist #1 at 0441 due to no pain relief from the existing epidural. Record review revealed the patient's pain intensity remained 9 at 0448. Record review revealed documentation by Physician #1 dated 12/31/2010 at 0540, "continues to be 5 cm. Starting to have cervical edema, efw (estimated fetal weight) 9+ lbs and baby has not changed position for the last 6 hours. Have repetitively attempted to achieve pain control without success. Feel this probably represents a true cpd (cephalo-pelvic disproportion). Will proceed with primary ltcs (low transverse cesarean section)...0544 The risks, benefits, indications and alternatives to c section are discussed with the patient...will proceed".
Review of the nursing documentation dated 12/31/2010 at 0555 revealed, "abdominal shave and prep completed". Nursing documentation at 0726 revealed, "Anesthesia called back and stated back up called in. Spoke with (Physician #1) and received order for Fentanyl (narcotic pain medication) 100 mcg (micrograms) IVP (intravenous push)". Nursing documentation at 0751 revealed, "(Anesthesiologist #2) and (Physician #1) returned page. POC (plan of care) rec'd (received). (Physician #1) to call anesthesia...". Further record review revealed Patient #2 was taken to the obstetrical operating room at 0853 and general anesthesia was started at 0903 (3 hours, 19 minutes after the decision for a c-section was called) and the male infant was delivered via cesarean section at 0917. Review of Physician #1's dictated operative report revealed, "...Indications and Findings: The patient was found to have what was felt to be arrest. She had progressed slowly to 5 cm and had remained 5 cm for more than two hours. She had significant pelvic pain with a nonfunctional epidural catheter. The baby had been tachycardic (fast heart rate) with a mild elevation in temperature but had shown no evidence of fetal distress. She had delivery of a viable male infant. This was found to be extremely difficult as the baby was found to be wedged in the pelvis. The shoulders were found to be above the pubic symphysis as was the major part of the skull. ...The baby was found to be straight OP (occiput posterior) as well. She had delivery with using upward pressure by a nurse through the vagina and with great difficulty, we were able to deliver the fetal vertex (head). This took approximately 50 (?) minutes post incision to delivery. ...The baby had APGARS (scoring for newborns with 10 being the best) of 2 and 9 and it was resuscitated by the NICU (neonatal intensive care unit) team. It was taken to the NICU for a probable pneumothorax (collapsed lung)...". Review of the discharge summary dictated 01/05/2011 revealed discharge diagnoses of cesarean section and chorioamnionitis (bacterial infection of the fetal membranes in the uterus). Patient #2 was discharged 01/05/2011 and the baby was discharged 01/07/2011.

Interview on 02/15/2011 at 1515 with Physician #1 revealed he was the attending physician for Patient #2. Interview revealed, "when I examined her around 5:30 in the morning, I considered we weren't going further with labor. I made the decision at that time to do a c-section. I called anesthesia and they are usually there within 20 to 30 minutes. I told the patient and the family we were on our way to the OR (operating room). I called again and was told by (Anesthesiologist #2) there were multiple gunshot wounds in the ED (emergency department) and they couldn't do it right then. I called anesthesia two times from the time of my decision. I considered it urgent because Mom was having a lot of pain, especially hip pain. Her epidural had failed". Interview further revealed "they did not meet my expectation for anesthesia services. I don't know if the delay caused problems at delivery".

Interview on 02/15/2011 at 1415 with Physician #2 revealed he was the physician supervising OB-GYN (obstetrical/gynecological) residents on 12/31/2010. Interview revealed, "all the residents were busy so I offered to assist (Physician #1) with the c-section. The patient had secondary arrest of labor". Interview further revealed, "it was an urgent c-section. Our policy is that for urgent cases we have 2 hours from call to cut".

Interview on 02/16/2011 at 0845 with a registered nurse (RN #1) revealed she was Patient #2's primary nurse in labor and delivery on 12/30/2010 at 1900 until 12/31/2010 at 0700. Interview revealed, "the decision to proceed with a c-section was made by (Physician #1) at 0540. (Anesthesiologist #1) was paged at different times. We were told at 6:00 it would be about an hour. When that time had come and gone, we called him again. He told us he had multiple traumas in the ED and he would call his back up in. The patient was in pain during this time.