HospitalInspections.org

Based on staff interview and review of medical records, it was determined the hospital failed to ensure documentation was complete for 2 of 8 obstetric/newborn patients (#1 and #2), whose records were reviewed. This had the potential to interfere with clarity of information related to the course of treatment and completeness of the medical record. Findings include:

1. Patient #1's medical record documented a 36 year old female who was admitted to the CAH on 4/23/14 in active labor. She was transferred to an acute care hospital later that day. Patient #1's record included "PATIENT CARE ACTIVITIES" notes, which were completed by the RNs and separate "Patient Care Notes," which were also completed by the RNs. Patient #1's record also included documentation on "PHYSICIAN'S ORDER SHEET PROGRESS NOTE" and an "OPERATIVE CARE RECORD" which were not signed. The records, all which were documented on 4/23/14, were not complete as follows:

a. RN "PATIENT CARE ACTIVITIES," notes documented Patient #1's fetal heart tones dropped beginning at 7:53 AM. The notes stated the fetal heart rate declined and Patient #1 was taken to the operating room in preparation for an emergency caesarean section at 8:38 AM.

RN "Patient Care Notes" on 4/23/14 at 8:34 AM, stated Patient #1 was "on surgery table just delivered a baby boy [Patient #2] that was not breathing and was without a heart rate. Stood at mother's head of bed to comfort and explain what was potentially happening. Mother was stabilized and transported to PACU via bed."

RN "PATIENT CARE ACTIVITIES" notes on 4/23/14 at 8:40 AM, documented before the C-Section was started, Patient #1 delivered a "non-viable baby boy, copious amount of blood [were] expelled with delivery of baby."

A "PHYSICIAN'S ORDER SHEET/PROGRESS NOTE" documented Patient #1's care during delivery and Patient #2's resuscitation. The note was handwritten in black ink. The note was not timed. Someone had written the date, 4/23/14, in blue ink under the date column. The note did not indicate who wrote the date.

b. RN "Patient Care Notes" at 9:05 AM, stated Patient #1 was stable, alert, and her vital signs were stable. The note stated Patient #1's flow of blood following the delivery was "mild." However, at 10:45 AM, the RN documented "Bleeding continues to be extreme."

The "Patient Care Notes" notes following Patient #1's delivery at 8:34 AM and 9:05 AM did not document her post partum blood flow.

c. RN "Patient Care Notes" at 10:10 AM, stated Patient #1 was stable and her husband was with her in PACU. RN "Patient Care Notes" at 10:25 AM, documented Patient #1 was seen by the physician at that time.

Patient #1's medical record did not state whether she left PACU after her delivery.

d. RN "Patient Care Notes" at 11:02, stated Patient #1's blood pressure dropped and she became "...unresponsive for about 10 [seconds]."

e. Patient #1 returned to the OR where a D&C was performed related to her heavy bleeding. The "OPERATIVE CARE RECORD," dated 4/23/14 and untimed, was not authenticated by the person who wrote it. The consent form for Patient #1's surgery and anesthesia, dated 4/23/14 at 10:50 AM, contained a line for the physician's signature. It was not signed. An evaluation of Patient #1 by the anesthetist prior to administering anesthesia was not documented.

f. "The "OPERATIVE REPORT," dated 4/23/14 untimed, documented Patient #1 required a D&C with a diagnosis of "Postpartum hemorrhage with suspected retained placenta."

Patient #1's "OPERATIVE CARE RECORD," dated 4/23/14, untimed, stated she was left the operating room at 11:38 AM. The corresponding "Anesthesia Record," under the heading "Recovery Notes," stated "To PACU" and listed Patient #1's vital signs as blood pressure 67/36, pulse 102, respirations 20. The note stated Patient #1 was given Phenlyphrine to raise her blood pressure. Additional vital signs were documented as blood pressure 103/61, pulse 98, respirations 20. Neither set of vital signs were timed.

g. RN "Patient Care Notes," 4/23/14 at 12:00 noon, stated Patient #1 was "...returned to PACU. Vital signs stable," and her vital signs were included. The notes did not explain what happened to Patient #1 between 11:38 AM and 12:00 noon. Vital signs were not documented between 11:38 AM and 12:00 noon.

RN "PATIENT CARE ACTIVITIES" notes at 1:12 PM on 4/23/14 documented a medication was administered to Patient #1.

The final nursing note, at 1:15 PM on 4/23/14, stated Patient #1 was transported by helicopter to an acute care hospital.

During an interview on on 5/14/14 at 10:45 AM, the Director of the Emergency Department and the Risk Manager reviewed Patient #1's medical record with the surveyor. Both staff members confirmed the documentation in the record was not complete.

Patient #1's medical record was incomplete.

2. Patient #2's medical record documented a newborn male who was delivered on 4/23/14 at 8:35 AM. He was transferred to an acute care hospital for higher level of care later that day. Patient #2's record was not complete as follows:

a. The "DELIVERY NOTE," dated 4/23/14, stated Patient #2 was delivered spontaneously "with an exceedingly tight nuchal cord [cord wrapped around the baby's neck]..." The note stated the baby had Apgar scores of 0 at birth and 0 at 5 minutes of age indicating the baby was without a pulse, blue in color, not breathing, and had no tone or muscle movement. The note stated "aggressive resuscitation measures were undertaken including intubation and epinephrine administration." The note did not state when Patient #2's heart rate was established.

b. Patient #2's record included a form titled "PHYSICIAN'S ORDER SHEET PROGRESS NOTE" that was undated. The 2 page form contained hand written orders in the left column and progress notes in the right column. The form included orders for medications, intravenous fluids, lab work, and indicated Patient #2 was intubated. The orders and progress notes did not indicate the time or date they were written.

c. Patient #2's medical record did not have consistent timing of activities. For example, the print out from the Point of Care blood gas analyzer indicated the test was performed at 8:17 AM on 4/23/14. However, the printed laboratory report sheet that corresponded to the blood gas analyzer results noted the test was performed at 9:34 AM.

Further, the "Clinical Documentation Report," dated 8/23/14, stated the baby was born at 8:40 AM. However, the "PHYSICIAN'S ORDER SHEET PROGRESS NOTE," not dated, stated the baby was born at 8:35 AM.

During an interview on 5/14/14 at 10:45 AM, the Director of the Emergency Department and the Risk Manager reviewed Patient #2's medical record and confirmed the documentation was not complete.

Patient #2's medical record was not complete.