HospitalInspections.org

Based on document review and interview, the facility staff failed to ensure patients who arrived for care in Labor and Delivery (L&D) signed documents consenting to care, were made aware of their rights, and provided communication assistance as needed for three (3) of ten (10) patients records reviewed (Patient # 3 - two (2) separate admissions, Patient # 4, and Patient # 9).

The findings include:

1. A review of Patient # 3's medical record was conducted on 11/13/18 and revealed the following:
Patient # 3, a non-English speaking patient, was admitted to L&D for observation on 10/4/18 and on 10/12/18.

A signed "Consent for Treatment & Financial Agreement - VA" could not be found in the medical records of either admission (reviewed with Staff Member # 1). The above form included a patient signature area with acceptance or declination of:
Communication Assistance, and
receipt of patient Rights and Responsibilities/Notice of Nondiscrimination.

During a tour of L&D on 11/14/18 at approximately 9:15 A.M., Staff Member # 3 stated: "There is a person at the desk (a nursing station type desk at the entrance to L&D) who will register each patient who comes straight to L&D. These patients do not have to go to the ED (Emergency Department). Registration would include getting the Consents for Treatment signed."

The review of Patient # 3's medical record for both the 10/4/18 and 10/12/18 admissions did not reveal the use of any type of communication device other than the friend who came with Patient #3 and the nurse who provided care. Staff Member # 6 was interviewed on 11/13/18 at 1:35 P.M. and acknowledged being able to speak Patient # 3's language.

2. Patient # 9's medical record was reviewed with Staff Member # 1 on 11/14/18 at approximately 11:00 A.M. Patient # 9 was admitted on 10/27/18 with a complaint of abdominal pain. A signed "Consent for Treatment & Financial Agreement - VA" could not be located in the medical record.

On 11/14/18 at approximately 11:45 A.M., Staff Member # 1, # 3 and # 2 confirmed there should be signed Consents for Treatment in each patient's medical record each time they are admitted regardless of the reason.


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3. Document review for Patient # 4 on November 13, 2018 at 12:08 p.m. revealed Patient # 4 arrived ambulatory at the facility on October 16, 2018 at 9:00 p.m. There is no documentation that Patient # 4 was informed of or received any information on Patient Rights. A review of the facility form titled "Consent for treatment and financial agreement" revealed there was no initials or date by Patient # 4 under the statement "Your patient rights and responsibilities/notice of nondiscrimination: I have been offered a copy of (facility name) your patient rights and responsibilities/notice of nondiscrimination on this date".

A review of the facility's policy titled "Notification of Patient Rights and Responsibilities - Notice of Nondiscrimination" provided by Staff Member # 2 on November 7, 2018 at 12:00 p.m. reads in part "(Facility Name) shall provide all patients, parents of minors, guardians, and families with written notification of their rights and responsibilities as a patient and notice of nondiscrimination on the date of admission".

The findings were discussed with Staff Members # 4 and # 5 on November 13, 2018 at 12:45 p.m.

Based on document review and interview, it was determined that the facility failed to ensure the nursing staff developed and kept current a plan of care for two (2) of ten (10) patients (Patients # 4 and # 9).

The findings include:

1. Patient # 4 arrived ambulatory at the facility on October 16, 2018 at 8:51 p.m. with complaint of lower abdominal pain and pregnancy related problems. On the admission information form, it stated: "PCP, unknown".
Facility form titled "Communication request form" for Patient # 4 stated: "Limited English Proficiency My language: Spanish".
The nursing assessment of communication needs for Patient # 4 at 9:10 p.m. stated: "none, onsite interpreter". At 9:30 p.m. communication needs stated: "limited English, other, martti" and at 10:00 p.m. communication needs stated: "limited English, on site interpreter".
The "outpatient OB Nursing Summary" reads, in part:
"(Staff Member # 7's name) notified of patient's status. G3P2002, Estimated Date of Delivery: None noted., Unknown Chief Complaint: Abdominal burn.
Labs: urinalysis
Discharge instructions and follow up information reviewed with patient. Patient instructed to follow up Chesepeak at . Patient discharged in stable condition."

Progress notes read, in part: "2110 (9:10 p.m.) Patient arrived to triage 2110 (9:10 p.m.) with the complaint of lower abdomen pain. Patient placed on monitor to assess contraction. Nurse use doppler to verified heart tone 141. 2148 (9:48 p.m.) (Staff Member # 7's name) paged. 2150 (9:50 p.m.) Called back from (Staff Member # 7's name) gave telephone order for urine culture and sensitivity and follow up with Primary Doctor on 10/19/2018"
Patient # 4 was discharged at 10:20 p.m. with a diagnosis of: "other specified pregnancy related conditions, unspecific trimester, lower abdominal pain, unspecified and weeks of gestation of pregnancy not specified".

Patient # 4 was in observation for one hour and twenty eight minutes and there is no documentation of an estimated date of delivery, Obstetrician, pain scale or medication given.

An interview with Staff Members # 1 and # 4 on November 13, 2018 at 2:00 p.m. revealed "the nurse failed to document".


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2. A review of Patient # 9's medical record with Staff Member # 1, indicated Patient # 9 was admitted on 10/27/18 at 9:17 A.M. with the complaint of abdominal pain. Patient # 9 was an estimated 38.3 weeks pregnant. Patient # 9 was assessed and the following was noted: fetal movement was present, fetal heart rate good. A SVE (Sterile, Vaginal, Examination) was perform. Patient # 9 had no vaginal bleeding, membranes intact and the exam revealed the cervix was closed, thick and fetus was high. A urine analysis was performed and the patient was given fluids and juice.

There was no documentation that the Patient # 9's pain was treated, relieved or the same. Patient #9 was discharged at 10:20 A.M.

Staff Member #1 stated, "If we give them fluids and they are not in active labor, many times the pain they are experiencing will subside. But we should have documented they were not experiencing and pain when they left."

Based on document review and interview, it was determined that the facility failed to provide a discharge planning evaluation for two (2) of ten (10) patients (Patients # 3 and # 4).

The findings include:

1. Patient # 4 arrived ambulatory at the facility on October 16, 2018 at 8:51 p.m. with complaint of lower abdominal pain and pregnancy related problems. On the admission information form it stated: "PCP, unknown". On the facility form titled "Communication request form" it stated: "Limited English Proficiency My language: Spanish".
The nursing assessment of communication needs for Patient # 4 at 9:10 p.m. stated: "none, onsite interpreter". At 9:30 p.m. communication needs stated: "limited English, other, martti" and at 10:00 p.m. communication needs stated: "limited English, on site interpreter".
The "outpatient OB Nursing Summary" reads in part "(Staff Member # 7's name) notified of patient's status. G3P2002, Estimated Date of Delivery: None noted., Unknown Chief Complaint: Abdominal burn.
Labs: urinalysis
Discharge instructions and follow up information reviewed with patient. Patient instructed to follow up Chesepeak at . Patient discharged in stable condition."
Progress notes read, in part: "2110 (9:10 p.m.) Patient arrived to triage 2110 (9:10 p.m.) with the complaint of lower abdomen pain. Patient placed on monitor to assess contraction. Nurse use doppler to verified heart tone 141. 2148 (9:48 p.m.) (Staff Member # 7's name) paged. 2150 (9:50 p.m.) Called back from (Staff Member # 7's name) gave telephone order for urine culture and sensitivity and follow up with Primary Doctor on 10/19/2018"
Patient # 4 was discharged at 10:20 p.m. with a diagnosis of "other specified pregnancy related conditions, unspecific trimester, lower abdominal pain, unspecified and weeks of gestation of pregnancy not specified".

Patient # 4 was in observation for one hour and twenty eight minutes and there is no documentation of a discharge plan to include an Obstetrician and treatment for a urinary tract infection that was identified during this admission.

An interview with Staff Members # 1 and # 4 on November 13, 2018 at 2:00 p.m. revealed "the nurse failed to document".


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2. A review of Patient # 3's medical record was conducted on 11/13/18 and revealed the following:
Patient # 3, a non-English speaking patient, was admitted for observation to L&D on 10/4/18 and on 10/12/18.

The medical records indicated Patient # 3 had been seen at an out patient clinic at approximately 24 to 26 weeks gestation. Patient #3 was currently being followed by a community Mid Wife for external abdomen assessments only.

Patient # 3's medical record was reviewed and revealed the following:
On 10/12/18, Patient # 3 was admitted at 3:30 P.M. with the complaint of spotting. The Mid Wife on call was contacted and orders were obtained to place Patient #3 on observation status. Patient # 3 was placed on the Labor and Delivery (L&D) Triage Rule Out Preterm Labor Protocol which included observation for 24 hours, vital signs, IV was started at 4:48 P.M., fetal monitoring, sterile vaginal exam (SVE) and urine culture and labs were drawn per the on call Certified Mid-Wife's orders. Patient # 3's Estimated Date of Delivery (EDD) changed and was now 11/19/18; with pregnancy at 34 weeks and 5 days.

Patient # 3's vital signs were: Temperature 97.9°F, Respirations 18 and Blood Pressure 104/66 pulse 82.
An external monitor was placed on the abdomen of Patient # 3 for Fetal Assessment. Fetal Heart Rate was 130 (normal 110-160) with accelerations of greater than or equal to 15 bpm lasting 15 seconds. External exam of the uterus was soft by palpation with contraction frequency X1. Cervical exam noted 1 cm dilation (Patient # 3 was a gravida 4, para 2 (4 pregnancies including this one and 2 live births)), 0% effacement and Fetal Station at -3 in a posterior position. No active vaginal bleeding observed. A scant amount of pink bloody show was noted on the exam glove. Membranes had not ruptured and perineum dry.

At 6:00 P.M. the L&D received a call from the On-Call physician who informed Staff Member # 6 that Patient # 3 had to go to another facility and should be discharged with PTL (Pre Term Labor) precautions, no intercourse, hydration and pelvic rest.

At 6:25 P.M. a second call from the same On-Call physician was received again directing Staff Member # 6 to discharge Patient #3 to the other facility. Staff Member #6 documented they informed the On-Call physician Patient # 3 had had five (5) contractions and there had been cervical changes from the previous week. Staff Member # 6 documented the On-Call physician ordered Patient #3 be discharged home and to direct the friend who brought Patient #3 to take Patient # 3 to the other facility. Staff Member # 6 clarified with the On-Call physician they were taking order from the On-Call physician and not the On-Call Mid Wife.

An interview with Staff Member # 6 was conducted on 11/13/18 at 1:35 P.M. Staff Member # 6 stated, "She did not complain of pain to me. She had no active bleeding during the time she was here. The On-Call Mid Wife nor the On-Call physician saw her (Patient # 3) while she was here on this visit. She (Patient # 3) was told she would need to go to (Name of the other). She did not want to go there but never told me why. I did tell her she could always come back here and we would take care of her. No, I did not document her wish to not go to the other facility."

An interview was conducted with Staff Members # 1 and # 4 on 11/14/18 at approximately 10:00 A.M. Both Staff Members stated it was the practice of physicians in our area to not assume the care of a patient who had been seen by another physician. Obstetrics was a very litigious area and they are not willing to take on another physician's patient. Both Staff Members were asked if Patient # 3 had been giving a list of clinics or other places to be followed for the remainder of her pregnancy. Both stated, "no, we don't have a protocol for that."