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Based on record review and staff interview, the facility failed to provide appropriate and timely nursing care in a manner consistent with accepted standards of nursing practice and hospital policy for 1 of 3 patient records (#1) sampled receiving postpartum (after child delivery) care for hemorrhage (excessive bleeding).

The findings are:

Review of the medical record for patient #1 revealed that the patient was forty weeks pregnant and presented to the hospital with contractions. On 2/2/15 she vaginally delivered a healthy baby. The record revealed that patient #1 suffered some vaginal tears during the delivery and received treatment in an attempt to stop the patient ' s bleeding but the treatment was not successful. According to the medical record, patient #1 began to experience signs of low blood pressure (hypotension) and an elevated heart rate (tachycardia) at 4:45pm, but was alert and responsive at that time. The medical team continued to attempt to stop the patient ' s bleeding but were not successful. At 5:30pm, the on-call physician was summoned to the patient ' s room and the team continued in their attempts to stop the patient ' s bleeding. The patient remained hypotensive and tachycardic for approximately one hour and ten before the first medication was given. At 6:32pm the physician spoke with the patient ' s family and a decision was made to proceed to surgery for an emergency hysterectomy (removal of the uterus).
Patient #1 was taken to the operating room at 7:00pm. Her vital signs were recorded at varying intervals throughout the surgical procedure; however, the patient remained hypotensive and tachycardic throughout the approximate two hour procedure. While in the operating room the patient suffered cardiac arrest and had to be resuscitated. She was transferred to Intensive Care Unit after surgery and was later discharged home.

Review of the facility ' s action plan revealed that an investigation was started immediately, and the incident was reported as a sentinel event.
Interview with the Perinatal Director on 3/20/15 at 10:00am revealed that the unit did not have a policy for postpartum hemorrhage, but did have a hemorrhage crash cart on the unit that was implemented a couple of years ago. She stated that there was an algorithm on this cart to follow for postpartum hemorrhage. The director confirmed that the nurses had not used the algorithm during the event and stated that the Certified Nurse Midwife (CNM) had stated that she didn't need the algorithm. The director stated that she thought the staff should have intervened earlier in the incident to prevent further bleeding and that they should have taken patient #1 to surgery sooner. She stated that staff had not weighed the blood soaked pads, and thus didn't know how much blood was actually lost. She also confirmed that patient #1 had received an epidural (local anesthesia) and that the anesthesia department had not been called when patient #1 became hypotensive and tachycardic. She stated that the anesthesiologist had confirmed that according to policy, anesthesia should have been called after two low blood pressures due to the patient having an epidural.
She stated that since the incident, they had implemented new policies, changed polices and had ordered new equipment. She stated that staff was being trained and that medical staff would be trained later.

An interview conducted with the Certified Nurse Midwife (CNM) on 3/19/15 at approximately 12:30pm indicated that she had arrived at the hospital at about 2:00pm and that the baby of patient #1 had been delivered at 4:13pm. She stated that patient #1 had experienced some vaginal tears and bleeding, and within 15 minutes of delivery her blood pressure dropped despite being given fluids and being sutured. She confirmed that she had experienced difficulty controlling the bleeding that patient #1 had experienced. She stated that physician " D " had looked in on her while she had been working with patient #1, and had ordered blood work to be collected. She further explained that after 5:00 pm, patient #1 had been given medication in an attempt to stop the bleeding but stated that while the bleeding had not stopped, it was not excessive. She explained that patient #1 had been tachycardic at that time and that they had been waiting for the results of the blood work that had been collected. She stated that the bleeding continued during that time but would stop with the application of pressure. She stated that physician " C " who had been on call at the time of the incident had stepped in to check on how things were going. After conducting a physical exam of patient #1, he ordered medications to clot the patient ' s blood. He also suggested vaginal packing and that was performed per his suggestion. The CNM stated that patient #1 remained hypotensive and tachycardic , but was responsive. She stated that physician " C " had again stepped in and performed another assessment of the patient. He then spoke to the patient ' s family and the decision was made for emergency surgery to remove the patient ' s uterus. She confirmed that rapid response had been called after that when patient #1 lost responsiveness. When asked about the hemorrhage cart, the CNM stated that she did not know about it.

An interview was conducted on 3/19/15 at 10:00 am with a registered nurse (RN), employee " A " , who cared for patient #1 during her labor. The RN stated that around 4:30pm the CNM had been repairing tears on patient #1 when the nurse noticed that the amount of bleeding being experienced by patient #1 was more than normal for a vaginal birth. She stated that she and the tech, who were present, alerted the CNM that the patient's color was not good and she replied " OK " . She further stated that the patient ' s vitals had been taken at 4:42pm and that the patient had been tachycardic and hypotensive and the CNM was again alerted and again replied " OK " . She stated that at 4:51pm, the patient ' s blood pressure had dropped some more and her heart rate was further elevated when the physician had stepped in to see how things were going. She stated that the CNM told the physician that " she was fine and everything was under control. " The RN stated that during the vaginal delivery the CNM had used twelve packs of sutures which is a lot compared to the normal three or four used. She stated that they had also used forty pads compared to a normal amount of about five and that the pads had all been saturated. She stated that she had asked the CNM if she wanted the hemorrhage cart, which has most everything we need during an emergency, but the CNM had said she didn't need the cart. She stated that they were running out of supplies and running everywhere trying to find extra items and equipment and were giving vital sign updates about every two to five minutes to the CNM. She explained that the tech had alerted the doctor, telling him that they were in trouble and that is when he stepped in and began giving orders. She stated that at 8:11pm the patient ' s eyes rolled back in to her head and she called rapid response. She states that she knew something was wrong, and should have called rapid response before she did. She confirmed that the facility now had a policy for postpartum hemorrhaging (PPH) and that she was to be trained on it that day. She stated that she did know what the hemorrhage cart had on it, but was not sure when to use it. She stated that she had not had any postpartum hemorrhage training upon hire.

Review of The Family Birthplace Policies stated that nursing staff laboring patients would meet have postpartum hemorrhage on line training completed during orientation.
Review of the employee file for the registered nurse, employee " A " revealed that she had been hired last year and had not received the post-partum hemorrhage training that is required within 90 days.

Review of the facility ' s policy on rapid response indicated that anyone could call for a rapid response. It stated that a registered nurse would notify the physician for acute changes in a patient ' s heart rate that resulted in the rate being less than 40 or greater than 130, and any acute change in blood pressure resulting in a systolic less than 90 or diastolic greater than 120, and any uncontrolled or excessive bleeding.

Review of the facility ' s new policy for postpartum hemorrhage indicated that an estimated blood loss greater than 500 milliliters (ml) for a vaginal would initiate the medical team to obtain the hemorrhage, keep an accurate record of all blood loss and intake and output, and monitor vital signs every 15 minutes or more if needed. Heart rate over 120 equals 30% blood loss and heart rate over 140 equals 40% blood loss. Staff training on this policy was started until March 19, 2015, which is a month and a half after incident. Medical staff was not scheduled to receive education on the policy until March 27, 2015. Review of the training manual for postpartum hemorrhage (PPH) written by the Perinatal Director and dated February 2015 indicated PPH is the leading cause of maternal deaths in the United States and 54% to 93 % of these deaths may have been preventable. It further explained that PPH is an emergency, and treatment should be started at first evidence of hemorrhage, before rapid heart rate, hypotension or other signs of shock. It also directed the staff to contact anesthesiology for a patient with two consecutive hypotensive episodes.

Based on record review and staff interview, the facility failed to provide appropriate and timely nursing care in a manner consistent with accepted standards of nursing practice and hospital policy for 1 of 3 patient records (#1) sampled receiving postpartum (after child delivery) care for hemorrhage (excessive bleeding).

The findings are:

Review of the medical record for patient #1 revealed that the patient was forty weeks pregnant and presented to the hospital with contractions. On 2/2/15 she vaginally delivered a healthy baby. The record revealed that patient #1 suffered some vaginal tears during the delivery and received treatment in an attempt to stop the patient ' s bleeding but the treatment was not successful. According to the medical record, patient #1 began to experience signs of low blood pressure (hypotension) and an elevated heart rate (tachycardia) at 4:45pm, but was alert and responsive at that time. The medical team continued to attempt to stop the patient ' s bleeding but were not successful. At 5:30pm, the on-call physician was summoned to the patient ' s room and the team continued in their attempts to stop the patient ' s bleeding. The patient remained hypotensive and tachycardic for approximately one hour and ten before the first medication was given. At 6:32pm the physician spoke with the patient ' s family and a decision was made to proceed to surgery for an emergency hysterectomy (removal of the uterus).
Patient #1 was taken to the operating room at 7:00pm. Her vital signs were recorded at varying intervals throughout the surgical procedure; however, the patient remained hypotensive and tachycardic throughout the approximate two hour procedure. While in the operating room the patient suffered cardiac arrest and had to be resuscitated. She was transferred to Intensive Care Unit after surgery and was later discharged home.

Review of the facility ' s action plan revealed that an investigation was started immediately, and the incident was reported as a sentinel event.
Interview with the Perinatal Director on 3/20/15 at 10:00am revealed that the unit did not have a policy for postpartum hemorrhage, but did have a hemorrhage crash cart on the unit that was implemented a couple of years ago. She stated that there was an algorithm on this cart to follow for postpartum hemorrhage. The director confirmed that the nurses had not used the algorithm during the event and stated that the Certified Nurse Midwife (CNM) had stated that she didn't need the algorithm. The director stated that she thought the staff should have intervened earlier in the incident to prevent further bleeding and that they should have taken patient #1 to surgery sooner. She stated that staff had not weighed the blood soaked pads, and thus didn't know how much blood was actually lost. She also confirmed that patient #1 had received an epidural (local anesthesia) and that the anesthesia department had not been called when patient #1 became hypotensive and tachycardic. She stated that the anesthesiologist had confirmed that according to policy, anesthesia should have been called after two low blood pressures due to the patient having an epidural.
She stated that since the incident, they had implemented new policies, changed polices and had ordered new equipment. She stated that staff was being trained and that medical staff would be trained later.

An interview conducted with the Certified Nurse Midwife (CNM) on 3/19/15 at approximately 12:30pm indicated that she had arrived at the hospital at about 2:00pm and that the baby of patient #1 had been delivered at 4:13pm. She stated that patient #1 had experienced some vaginal tears and bleeding, and within 15 minutes of delivery her blood pressure dropped despite being given fluids and being sutured. She confirmed that she had experienced difficulty controlling the bleeding that patient #1 had experienced. She stated that physician " D " had looked in on her while she had been working with patient #1, and had ordered blood work to be collected. She further explained that after 5:00 pm, patient #1 had been given medication in an attempt to stop the bleeding but stated that while the bleeding had not stopped, it was not excessive. She explained that patient #1 had been tachycardic at that time and that they had been waiting for the results of the blood work that had been collected. She stated that the bleeding continued during that time but would stop with the application of pressure. She stated that physician " C " who had been on call at the time of the incident had stepped in to check on how things were going. After conducting a physical exam of patient #1, he ordered medications to clot the patient ' s blood. He also suggested vaginal packing and that was performed per his suggestion. The CNM stated that patient #1 remained hypotensive and tachycardic , but was responsive. She stated that physician " C " had again stepped in and performed another assessment of the patient. He then spoke to the patient ' s family and the decision was made for emergency surgery to remove the patient ' s uterus. She confirmed that rapid response had been called after that when patient #1 lost responsiveness. When asked about the hemorrhage cart, the CNM stated that she did not know about it.

An interview was conducted on 3/19/15 at 10:00 am with a registered nurse (RN), employee " A " , who cared for patient #1 during her labor. The RN stated that around 4:30pm the CNM had been repairing tears on patient #1 when the nurse noticed that the amount of bleeding being experienced by patient #1 was more than normal for a vaginal birth. She stated that she and the tech, who were present, alerted the CNM that the patient's color was not good and she replied " OK " . She further stated that the patient ' s vitals had been taken at 4:42pm and that the patient had been tachycardic and hypotensive and the CNM was again alerted and again replied " OK " . She stated that at 4:51pm, the patient ' s blood pressure had dropped some more and her heart rate was further elevated when the physician had stepped in to see how things were going. She stated that the CNM told the physician that " she was fine and everything was under control. " The RN stated that during the vaginal delivery the CNM had used twelve packs of sutures which is a lot compared to the normal three or four used. She stated that they had also used forty pads compared to a normal amount of about five and that the pads had all been saturated. She stated that she had asked the CNM if she wanted the hemorrhage cart, which has most everything we need during an emergency, but the CNM had said she didn't need the cart. She stated that they were running out of supplies and running everywhere trying to find extra items and equipment and were giving vital sign updates about every two to five minutes to the CNM. She explained that the tech had alerted the doctor, telling him that they were in trouble and that is when he stepped in and began giving orders. She stated that at 8:11pm the patient ' s eyes rolled back in to her head and she called rapid response. She states that she knew something was wrong, and should have called rapid response before she did. She confirmed that the facility now had a policy for postpartum hemorrhaging (PPH) and that she was to be trained on it that day. She stated that she did know what the hemorrhage cart had on it, but was not sure when to use it. She stated that she had not had any postpartum hemorrhage training upon hire.

Review of The Family Birthplace Policies stated that nursing staff laboring patients would meet have postpartum hemorrhage on line training completed during orientation.
Review of the employee file for the registered nurse, employee " A " revealed that she had been hired last year and had not received the post-partum hemorrhage training that is required within 90 days.

Review of the facility ' s policy on rapid response indicated that anyone could call for a rapid response. It stated that a registered nurse would notify the physician for acute changes in a patient ' s heart rate that resulted in the rate being less than 40 or greater than 130, and any acute change in blood pressure resulting in a systolic less than 90 or diastolic greater than 120, and any uncontrolled or excessive bleeding.

Review of the facility ' s new policy for postpartum hemorrhage indicated that an estimated blood loss greater than 500 milliliters (ml) for a vaginal would initiate the medical team to obtain the hemorrhage, keep an accurate record of all blood loss and intake and output, and monitor vital signs every 15 minutes or more if needed. Heart rate over 120 equals 30% blood loss and heart rate over 140 equals 40% blood loss. Staff training on this policy was started until March 19, 2015, which is a month and a half after incident. Medical staff was not scheduled to receive education on the policy until March 27, 2015. Review of the training manual for postpartum hemorrhage (PPH) written by the Perinatal Director and dated February 2015 indicated PPH is the leading cause of maternal deaths in the United States and 54% to 93 % of these deaths may have been preventable. It further explained that PPH is an emergency, and treatment should be started at first evidence of hemorrhage, before rapid heart rate, hypotension or other signs of shock. It also directed the staff to contact anesthesiology for a patient with two consecutive hypotensive episodes.