HospitalInspections.org

Based on record review, credentialing review, and staff interview, it was determined the CAH failed to furnish services in accordance with applicable state laws and regulations. This resulted in the CNM directing and managing the care of patients which were outside of her privileges for the facility, and not within her scope of practice. This had the potential to result in the inappropriate care of patients and negative outcomes. Findings include:

The Idaho Board of Nursing, IDAPA 23.01.01.400.01(c) states "The decision-making model is the process by which a licensed nurse evaluates whether a particular act is within the legal scope of that nurse's practice and determines whether to delegate the performance of a particular nursing task in a given setting. This model applies to all licensure categories permitting active practice, regardless of the practice setting." Additionally, it states "Determining Scope of Practice. To evaluate whether a specific act is within the legal scope of nursing practice, a licensed nurse shall determine whether: (c.) The act does not exceed any existing policies and procedure's established by the nurse's employer".

A facility policy "Maternal Transfer to Higher Level Acuity Facility," revised 12/09/15, stated "The following obstetrical populations would necessitate mandatory transfer to a tertiary care facility: Pre-term labor under 35 weeks gestation requiring ongoing labor suppression." Additionally, the policy stated "Mothers who are suspected or known as high risk must immediately be assessed by a provider/physician."

1. A CNM managed the care of patients which was outside of her privileges and scope of practice.

a. Patient #6 was a 19 year old female admitted on 8/18/15 at 2:00 AM. She was 23 and 5/7 weeks pregnant and experiencing contractions every 3 to 5 minutes.

Patient #6 arrived to L&D at 1:45 AM, complaining of contractions every 3 to 5 minutes which started at 9:00 PM on 8/17/15. She was also complaining of low back pain which was 9 out of 10, on a 1 to 10 scale with 10 being the worst pain.

The RN documented the CNM was notified by phone of Patient #6's arrival and her status at 2:08 AM. The RN documented she received verbal orders from the CNM at that time. At 2:50 AM, the RN documented she contacted the CNM again by phone and updated her on Patient #6's status. Patient #6 was continuing to have contractions 3 to 5 minutes apart and experiencing continued back pain.

Patient #6's record documented the CNM was called at 3:37 AM and updated on her status. She was continuing to have contractions with increased pain. Patient #6 stated she was having vaginal discharge. The RN documented "This nurse suggest to call Dr. [doctor] on call and asked CNM [proper name] to come in and examine pt [patient]. CNM [proper name] replied if you are going to call [proper name] on call Dr. then I will not be in." The RN documented at 3:38 AM she contacted the on call physician, and he was on his way to the CAH.

Patient #6's record included 3 telephone orders for medication, signed by the RN, and received from the CNM. The orders, dated 8/18/15, were for Terbutaline 0.25 mg IM at 2:08 AM, 2:51 AM, and 3:37 AM, prior to physical evaluation and examination.

A document titled "8.27.15. Jerome Visit Premature Birth Debrief--Action items and notes" stated Is there a standard of practice regarding the management of a patient in the ER? Standard of care is for a patient to physically be seen within (30 min - need to confirm). Impression: There was a delay between the time that she was seen by a provider and the time she arrived in the ER. Question: What is Jerome's...standard of practice for triage and phone triage versus in person triage?"

A form titled "Certified Nurse-Midwife Privileges," with an appointment date of 5/28/15, documented core privileges which were requested by the CNM and granted by the medical staff. The privileges included management of low risk, singleton pregnancies.

The privileges included "Delivery Management Care," which was requested by the CNM and granted by the medical staff. The delivery management section stated the CNM may "Perform and manage uncomplicated spontaneous vaginal deliveries in patients of 37-42 weeks." However, Patient #6's record did not include documentation the supervising physician was contacted for consultation by the CNM. The on-call physician was contacted by the RN at 3:38 AM, almost 2 hours after her arrival to the facility.

During an interview on 3/17/16 beginning at 7:00 AM, the CNM reviewed Patient #6's record and confirmed she spoke with the RN by phone the early morning of 8/18/15. The CNM confirmed she gave telephone orders for Terbutaline for Patient #6's contractions on 3 occasions. The CNM stated when the RN contacted her the third time, she asked the RN to contact the physician on call. The CNM confirmed that managing preterm laboring patients was not in her scope of practice, nor was she privileged to manage preterm laboring patients.

The Chief of Staff was interviewed on 3/17/16 beginning at 9:10 AM. When asked about the case of the premature birth and the delay in examination by a provider, he stated he did not remember if the case was reviewed by the Medical Staff. He stated he did not remember if the Medical Staff had any recommendations or if any action had been taken as a result of reviewing the case.

The Chief of Staff stated he did not remember any concerns from the case that warranted a discussion by the Medical Executive Committee. "My expectation is that any patient in premature labor would be evaluated. Recognizing preterm labor [versus contractions] requires a physical evaluation to determine." He stated if a patient was in preterm labor the CNM cannot treat and would need to call the physician. The Chief of Staff was unable to recall the PRQC (Peer Review Quality Committee) reviewing this case.

b. Patient #5 was a 24 year old female admitted to L&D on 12/01/15 in active labor. Complications included a stillborn delivery, and chorioamnionitis. The CNM managed her care during her hospitalization. Patient #5 did not have recent prenatal care and it could not be determined if her pregnancy was a high risk pregnancy. Additionally, the record included an H&P which stated "She reports that she thinks she might have felt the baby move a couple of days ago."

A form titled "Certified Nurse-Midwife Privileges," with an appointment date of 5/28/15, documented core privileges which were requested by the CNM and granted by the medical staff. The privileges included management of low risk, singleton pregnancies.

The privileges included "Indication for CNM Collaboration," which was requested by the CNM and granted by the medical staff. The collaboration section stated the supervising physician would be consulted for complications such as elevated temperature, induction or arrest of labor, and for fetal demise. However, Patient #5's record did not include documentation the supervising physician was contacted for consultation by the CNM.

During an interview on 3/17/16 beginning at 7:00 AM, the CNM reviewed Patient #5's record and confirmed she performed the delivery of Patient #5's stillborn infant. The CNM confirmed there was no documentation of physician consultation prior to the delivery of the infant. Additionally, the CNM confirmed that she was contacted rather than the physician on call for the delivery.

The CNM provided care to OB patients outside of her scope of practice according to IDAPA and outside of her privileges for the facility.

Based on staff interview and review of meeting minutes, hospital logs, and administrative documents, it was determined the CAH failed to ensure its organizational structure was sufficient to direct patient care. This impeded the ability of the CAH to provide effective care. Findings include:

Refer to C241 as it relates to the failure of the Governing Body to assume responsibility for determining and implementing policies to provide uninterrupted services to the community it served.

These systemic negative practices seriously impeded the ability of the CAH to provide services to patients.

Based on staff interview and review of meeting minutes, hospital logs, and administrative documents, it was determined the CAH's Governing Body failed to assume responsibility for determining and implementing policies to provide uninterrupted services to the community it served. This resulted in the inability of the CAH to provide consistent health care to patients. Findings include:

Diversion is a temporary status for a health care facility, in which it informs local EMS, and surrounding hospitals, that its beds are full and it cannot take new patients.

The CAH repeatedly invoked the diversion status in 2013 through March 2016, including diversion for OB, medical/surgical, and surgical services.

The Clinical Director, interviewed on 3/17/16 beginning at 2:00 PM, stated the diversion episodes had resulted in postponement of induction of labor for some patients.

A document titled "Float Pool for St. Lukes Jerome," dated January 2015, stated the CAH had "at least 28 incidents of going on divert - majority of which were related to staffing" for calendar year 2013. The document also stated "at least 37 incidents of going on divert" for calendar year 2014.

A request was made on 3/16/16, for documentation regarding diversion status of the CAH for 2015 and 2016. On 3/17/16, 2 reports were received which included documentation of the date of the diversion status, the time diversion was implemented, the time diversion was discontinued, the reason for diversion, and the type of diversion (e.g.. lack of staff, no patient beds, no OR staff). The diversion reports documented the CAH was closed to admission of patients, for the amount of time that follows:

For the year 2015:

- 1/2015 4 days
- 2/2015 7 days
- 3/2015 1.5 days
- 4/2015 1 day
- 5/2015 16 hours
- 7/2015 14 days
- 8/2015 9 days
- 10/2015 15 days
- 11/2015 3 days

The diversion report documented a total of 55 days the CAH was on diversion. Of the 55 days documented for 2015, 48 of those days were due to lack of available staff.

For the year 2016:

- 2/2016 9 days
- 3/2016 10 days

The diversion report documented a total of 19 days the CAH was on diversion. Of the 19 days documented for 2016, 18 of those days were due to lack of available staff.

The CAH annual evaluation stated 158 babies were born from October 2014 through September 2015. There was no mention of number of days the OB service was on diversion. This was confirmed by the Performance Improvement Coordinator on 3/17/16 at 12:40 PM.

A document titled "Women's Service Line-January 2014, Topic Site Visit with Jerome SWOT analysis," not otherwise dated, stated "Weaknesses...the facility goes on divert due to RN staffing and provider c-section coverage. Difficult to staff the hospital due to nursing multi-skill set requirements. The nursing staff cares for both medical and obstetrical patients."

All "ST LUKES EAST BOARD OF DIRECTORS" meeting minutes, dated between 4/28/15 to 2/23/16, were reviewed. The 4/28/15 minutes stated the swing bed project at the CAH had positively impacted readmissions. No other minutes included mention of specific services provided at the CAH. None of the minutes included mention of the CAH being on diversion status or specifically addressed ways to decrease the number of diversion episodes. None of the minutes addressed the impact of the numerous diversion episodes.

The CAH was licensed for 25 inpatient beds. The Clinical Director, interviewed on 3/17/16 beginning at 2:00 PM, stated the CAH utilized 11 beds plus 3 labor and delivery beds. She stated the CAH was under pressure to save beds for the obstetrical, emergency, and surgical departments. She stated a lack of available beds was the cause for some episodes of diversion.

No Governing Body meeting minutes, dated between 4/28/15 to 2/23/16, mentioned the lack of available beds or the discrepancy between the number of licensed beds or the actual utilization of beds.

The Administrator was interviewed on 3/17/16 beginning at 10:05 AM, he stated the main reason the CAH went on diversion was the lack of OB nurses. He stated other reasons included the lack of nursing staff available for surgical services, the lack of physicians with privileges to perform Caesarean Section surgeries, and the lack of bed availability. He stated the CAH had increased the number of swing bed admissions in order to stabilize the overall census but this increase in swing bed admissions led to a shortage of acute care beds at times.

The Administrator was again interviewed on 3/17/16 beginning at 2:10 PM. He stated there was no documentation that the Governing Body had assessed services that were diverted at the CAH. He stated there was no documentation specific action was taken by the Governing Body related to the inability to provide OB, medical, and surgical services at specific times.

The Governing Body failed to address the ongoing reliance on the use of diversion and to take action to ensure services were not interrupted.

Based on review of administrative records and staff interview, it was determined the CAH failed to ensure staffing was sufficient to provide services offered. This resulted in closure of the CAH to services for the community for several days a month over the last 15 months. This placed patients at risk of not receiving medical care for their condition in a timely manner. Findings include:

A request was made on 3/16/16, for documentation regarding diversion status of the CAH for 2015 and 2016. On 3/17/16, 2 reports were received which included documentation of the date of the diversion status, the time diversion was implemented, the time diversion was discontinued, the reason for diversion, and the type of diversion (e.g.. lack of staff, no available patient beds, no OR staff, no OB staff). The diversion reports documented the CAH was closed to admission of patients, for the amount of time that follows:

For the year 2015:

- 1/2015 4 days
- 2/2015 7 days
- 3/2015 1.5 days
- 4/2015 1 day
- 5/2015 16 hours
- 7/2015 14 days
- 8/2015 9 days
- 10/2015 15 days
- 11/2015 3 days

The 2015 report documented a total of 55 days the CAH was on diversion. Of the 55 days documented for diversion status, 48 of those days were due to lack of available staff. Additionally, 17.5 days were due to staffing difficulties for the OB unit.

For the year 2016:

- 2/2016 9 days
- 3/2016 10 days

The 2016 report documented a total of 19 days the CAH was on diversion. Of the 19 days documented for diversion status, 18 of those days were due to lack of available staff. Additionally, 18 days were due to staffing difficulties for the Medical Surgical unit.

A request was made to review The Medical Executive Committee meeting minutes for the previous 12 months. The Medical Executive Committee meeting minutes were reviewed from 4/07/15 to 3/01/16.

The Medical Executive Committee meeting minutes, dated 7/07/15, included documentation of the CNO update which included issues regarding staffing. The update stated a float pool was under way and was going to be available in September of 2015. The meeting minutes documented the conclusions were "informational" and no actions were initiated by the committee.

The Medical Executive Committee meeting minutes, dated 9/01/15, documented the CNO update included training of OB staff and filling open positions with traveling nurses. The meeting minutes documented the conclusions were "informational" and no actions were initiated by the committee.

During an interview on 3/17/16 at 9:10 AM, the Chief of Staff confirmed the CAH was on diversion for OB services. He stated diversion times were for 12 hours or less. The Chief of Staff stated he was aware the administration was attempting to hire more nurses and also reviewing patient census. He stated the CAH was limiting admission of Swing Bed patients to 9 beds. The Chief of Staff stated the CAH was hiring another OB physician, but he would not begin working until the summer of 2016, upon completion of his fellowship.

During an interview on 3/17/16 at 10:00 AM, the Administrator confirmed the CAH was on diversion for staffing problems and also due to census. He confirmed staffing of the CAH was the primary reason for not accepting new patients. The Administrator stated the CAH was working on staffing problems over the last year by training staff to work in different units and hiring new staff.

During an interview on 3/17/16 at 11:35 AM, the CNO reviewed the diversion report and Medical Executive Committee meeting minutes and confirmed the main reason for diversion at the CAH was staffing problems. She stated diverting patients was "a last resort only." The CNO stated the CAH was having difficulty filling open RN positions because nurses must be willing to float around the hospital as needed, due to patient census and needs. She stated many nurses wanted to specialize within a unit and not float to where they are needed. The CNO confirmed a float pool of nurses was implemented in September of 2015, with the hospital in Magic Valley. She stated, at the time of survey, only Medical/Surgical nurses were available through the float pool. The CNO stated the CAH was cross training RNs to work in OB and OR, but this required a significant amount of time.

The CAH failed to ensure adequate staffing to provide the services offered.

Based on staff interview and review of medical records, provider privileges, and Medical Staff meeting minutes, it was determined the CAH failed to ensure the Medical Staff provided medical direction for obstetrical services. This affected the care of 1 of 3 obstetrical patients (#6) cared for by a nurse midwife and had the potential to affect all obstetrical patients. This resulted in a lack of oversight of the medical care provided to obstetrical patients. Findings include:

Patient #6 was a 19 year old female admitted on 8/18/15 at 2:00 AM. She was 23 and 5/7 weeks pregnant. She was having severe low back pain and contractions every 3 to 5 minutes.

Patient #6 arrived at the L&D at 1:45 AM, complaining of contractions every 3 to 5 minutes which started at 9:00 PM on 8/17/15. She was also complaining of low back pain which was 9 out of 10, on a 1 to 10 scale with 10 being the worst pain.

The RN documented the CNM was notified, by phone, of Patient #6's arrival and her status at 2:08 AM. The RN documented she received telephone orders from the CNM at that time. At 2:50 AM, the RN documented she contacted the CNM by phone again and updated her on Patient #6's status. Patient #6 was continuing to have contractions 3 to 5 minutes apart and experiencing continued back pain.

Patient #6's record documented the CNM was called at 3:37 AM and updated on her status. She was continuing to have contractions with increased pain. Patient #6 stated she was having vaginal discharge. The RN documented "This nurse suggest to call Dr. [doctor] on call and asked CNM [proper name] to come in and examine pt [patient]. CNM [proper name] replied if you are going to call [proper name] on call Dr. then I will not be in." The RN documented at 3:38 AM she contacted the on call physician, and he was on his way to the CAH.

Patient #6's record included 3 telephone orders for medication, signed by the RN, and received from the CNM. The orders, dated 8/18/15, were for Terbutaline 0.25 mg IM at 2:08 AM, 2:51 AM, and 3:37 AM, prior to physical evaluation and examination.

Nursing progress notes documented the pre-term baby was delivered at 7:33 AM on 8/18/15. The baby required stabilization and was transferred by air to an acute care hospital with a neonatal intensive care unit on 8/18/15 at 10:05 AM, 2 hours and 32 minutes after birth. A discharge planning note by the RN Case Manager, dated 8/21/15 at 9:17 AM, stated the baby was transferred "...in critical condition."

A form titled "Certified Nurse-Midwife Privileges," with an appointment date of 5/28/15, documented core privileges which were requested by the CNM and granted by the medical staff. The privileges included management of low risk, singleton pregnancies.

The privileges included "Delivery Management Care," which was requested by the CNM and granted by the medical staff. The delivery management section stated the CNM may "Perform and manage uncomplicated spontaneous vaginal deliveries in patients of 37-42 weeks." However, Patient #6's record did not include documentation the supervising physician was contacted for consultation by the CNM. The on-call physician was contacted by the RN at 3:38 AM, almost 2 hours after her arrival to the facility.

During an interview on 3/17/16 beginning at 7:00 AM, the CNM reviewed Patient #6's record and confirmed she spoke with the RN by phone the early morning of 8/18/15. The CNM confirmed she gave telephone orders for Terbutaline for Patient #6's contractions on 3 occasions. The CNM stated when the RN contacted her the third time, she asked the RN to contact the physician on call. The CNM confirmed that managing preterm laboring patients was not in her scope of practice, nor was she privileged to manage preterm laboring patients.

The Medical Executive Committee meeting minutes were reviewed from 4/07/15 to 3/01/16. The Medical Executive Committee meeting minutes, dated 9/01/15, documented the CNO update included a debrief on a 22 week old neonate. The minutes did not include documentation of NP and PA responsibilities regarding management of preterm labor. Additionally, there was no documentation in the meeting minutes regarding standard of practice, privileges, or need for consultation by a physician for NPs or PAs regarding management of preterm labor.

A document attached to the Medical Executive Committee meeting minutes, dated 9/01/15, was titled "8.27.15. Jerome Visit Premature Birth Debrief--Action items and notes" stated, "Is there a standard of practice regarding the management of a patient in the ER? Standard of care is for a patient to physically be seen within (30 min - need to confirm). Impression: There was a delay between the time that she was seen by a provider and the time she arrived in the ER. Question: What is Jerome's...standard of practice for triage and phone triage versus in person triage?"

During an interview on 3/17/16 beginning at 7:00 AM, the CNM reviewed Patient #6's record and confirmed she spoke with the RN by phone the early morning of 8/18/15. The CNM confirmed she gave telephone orders for Terbutaline for Patient #6's contractions on 3 occasions. The CNM stated when the RN contacted her the third time, she asked the RN to contact the physician on call. The CNM confirmed that managing preterm laboring patients was not in her scope of practice, nor was she privileged to manage preterm laboring patients.

The Chief of Staff was interviewed on 3/17/16 beginning at 9:10 AM. When asked about the case of the premature birth and the delay in examination by a provider, he stated he did not remember if the case was reviewed by the Medical Staff. He stated he did not remember any concerns from the case that warranted a discussion by the Medical Executive Committee. He stated "My expectation is that any patient in premature labor would be evaluated. Recognizing preterm labor requires a physical evaluation to determine." He stated if a patient was in preterm labor the CNM could not treat her and would need to call the physician. He stated did not recall the Peer Review Quality Committee reviewing the case. He stated he did not remember if the Medical Staff had any recommendations or if any action had been taken as a result reviewing the case.

The Medical Executive Committee did not examine Patient #6's care and address care deficiencies that were identified. The Medical Executive Committee did not take action to ensure standards of care were met including the enforcement of staff privileges.

Based on record review, policy review, provider privileges review, and staff interview, it was determined the CAH failed to ensure the CNM provided services in accordance with facility policies for 2 of 3 patients (Patient #5 and #6) who received care from a CNM. This resulted in inappropriate care of OB patients and had the potential to result in negative outcomes for patients. Findings include:

A facility policy "Maternal Transfer to Higher Level Acuity Facility," revised 12/09/15, stated "The following obstetrical populations would necessitate mandatory transfer to a tertiary care facility: Pre-term labor under 35 weeks gestation requiring ongoing labor suppression." Additionally, the policy stated "Mothers who are suspected or known as high risk must immediately be assessed by a provider/physician."

A form titled "Certified Nurse-Midwife Privileges," with an appointment date of 5/28/15, documented core privileges which were requested by the CNM and granted by the medical staff. The privileges included management of low risk, singleton pregnancies.

The privileges included "Delivery Management Care," which was requested by the CNM and granted by the medical staff. The delivery management section stated the CNM may "Perform and manage uncomplicated spontaneous vaginal deliveries in patients of 37-42 weeks." However, Patient #6's record did not include documentation the supervising physician was contacted for consultation by the CNM. The on-call physician was contacted by the RN at 3:38 AM, almost 2 hours after her arrival to the facility.

1. Patient #6 was a 19 year old female admitted on 8/18/15 at 2:00 AM. She was 23 and 5/7 weeks pregnant. She was having severe low back pain and contractions every 3 to 5 minutes.

Patient #6 arrived at the L&D at 1:45 AM, complaining of contractions every 3 to 5 minutes which started at 9:00 PM on 8/17/15. She was also complaining of low back pain which was 9 out of 10, on a 1 to 10 scale with 10 being the worst pain.

The RN documented the CNM was notified of Patient #6's arrival and her status at 2:08 AM. The RN documented she received orders from the CNM at that time. At 2:50 AM, the RN documented she contacted the CNM again and updated her on Patient #6's status. Patient #6 was continuing to have contractions 3 to 5 minutes apart and experiencing continued back pain.

Patient #6's record documented the CNM was called at 3:37 AM and updated on her status. She was continuing to have contractions with increased pain. Patient #6 stated she was having vaginal discharge. The RN documented "This nurse suggest to call Dr. [doctor] on call and asked CNM [proper name] to come in and examine pt [patient]. CNM [proper name] replied if you are going to call [proper name] on call Dr. then I will not be in." The RN documented at 3:38 AM she contacted the on call physician, and he was on his way to the CAH.

Patient #6's record included 3 telephone orders for medication, signed by the RN, and received from the CNM. The orders, dated 8/18/15, were for Terbutaline 0.25 mg IM at 2:08 AM, 2:51 AM, and 3:37 AM, prior to physical evaluation and examination.

A document titled "8.27.15. Jerome Visit Premature Birth Debrief--Action items and notes" stated, "Is there a standard of practice regarding the management of a patient in the ER? Standard of care is for a patient to physically be seen within (30 min - need to confirm). Impression: There was a delay between the time that she was seen by a provider and the time she arrived in the ER. Question: What is Jerome's...standard of practice for triage and phone triage versus in person triage?"

The Chief of Staff did not remember any concerns from the case that warranted a discussion by the Medical Executive Committee. "My expectation is that any patient in premature labor would be evaluated. Recognizing preterm labor [versus contractions] requires a physical evaluation to determine." He stated if a patient was in preterm labor the CNM cannot treat and would need to call the physician.

During an interview on 3/17/16 beginning at 7:00 AM, the CNM reviewed Patient #6's record and confirmed she spoke with the RN by phone the early morning of 8/18/15. The CNM confirmed she gave telephone orders for Terbutaline for Patient #6's contractions on 3 occasions. The CNM stated when the RN contacted her the third time, she asked the RN to contact the physician on call. The CNM confirmed that managing preterm laboring patients was not in her scope of practice, nor was she privileged to manage preterm laboring patients.

The CNM failed to follow CAH policies.

2. Patient #5 was a 24 year old female admitted to L&D on 12/01/15 in active labor. Complications included a stillborn delivery, and chorioamnionitis. The CNM managed her care during her hospitalization.

Patient #5 did not have recent prenatal care and it could not be determined if her pregnancy was a high risk pregnancy.

Patient #5's record included an H&P, dated 12/01/15, which stated Patient #5 reported she had a couple of prenatal visits early in her pregnancy with a CNM. The H&P stated "She reports that she thinks she might have felt the baby move a couple of days ago." The H&P further stated when the CNM palpated the neonate's head it felt swollen and the neonate was probably nonviable (not able to grow or survive).

The neonate was delivered at 2:37 AM on 12/01/15, and was stillborn at delivery. There was no documentation in Patient #5's record a physician was consulted by the CNM.

During an interview on 3/17/16 beginning at 7:00 AM, the CNM reviewed Patient #5's record and confirmed she performed the delivery of Patient #5's stillborn infant. The CNM confirmed there was no documentation of physician consultation prior to the delivery of the infant. Additionally, the CNM confirmed that she was contacted rather than the physician on call for the delivery.

The CNM failed to follow CAH policies.

Based on staff interview and review of policies, it was determined the CAH failed to ensure guidelines for the medical management of health problems that included the conditions requiring medical consultation and/or patient referral, had been developed. This resulted in a lack of guidance to providers. Findings include:

A policy that specified the conditions requiring medical consultation and/or patient referral was not present at the CAH.

The Chief of Staff was interviewed on 3/17/16 beginning at 9:10 AM. He stated he was not aware of a policy that discussed the conditions requiring medical consultation and/or patient referral.

The CAH did not develop a policy that specified the conditions requiring medical consultation and/or patient referral.

Based on record review and staff interview, it was determined the facility failed to ensure an RN evaluated the care for each patient upon admission and, when appropriate, on an ongoing basis. This directly impacted the care of 2 of 7 obstetrical patients (Patients #19 and #5) whose records were reviewed. This resulted in incomplete assessments and orders not followed. Findings include:

1. Patient #19 was a 19 year old female who was admitted to L&D on 3/10/16, for induction of labor. Patient #19 delivered a baby girl on 3/11/16. Complications included chorioamnionitis, and Patient #19 and her newborn were treated with antibiotics.

Patient #19's medical record was reviewed and the following was noted:

a. Her record included a "screen shot" of an undated computer image that was titled "View Critical Care Indicators." The form stated "Does Pt [patient] have a Hx [history] of MRSA/VRE or Other Resistant Organism?" The box included a "Y" to indicate yes. However, Patient #19's record did not include further information related to an MRSA, VRE, or other antibiotic resistent infection.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #19's record and stated the form was printed by the admissions department when Patient #19 was admitted to the facility. She stated the information triggered the RN to look up laboratory results or do a swab to determine if the patient had an active infection. The SME was unable to find documentation that it was done.

b. Patient #19's record documented a CRNA placed an epidural catheter for pain management. Her record included an order sheet titled "Epidural-Intrathecal Standing Orders-CRNA," dated 3/11/16 at 4:40 AM, and signed by the CRNA. The form included specific orders for documentation by the RN, which stated "Monitor and record vital signs, including respiratory rate, level of sedation, for duration of infusion every 5 minutes times 30 minutes, then every 1/2 hour." Additionally, the orders stated "Monitor and record sensory level every 5 minutes times 30 minutes, then every 1/2 hour for duration of infusion."

The RN providing care for Patient #19 documented at 4:26 AM, "epidural in, lying down, and back on monitors, B/P [blood pressure] set for every 5 minutes." However, the monitoring and documentation as ordered by the CRNA did not occur. Vital signs were documented at 4:20 AM, 4:56 AM, 5:20 AM, 6:20 AM, 6:58 AM, and 7:50 AM. They did not follow the frequency of every 5 minutes for 30 minutes, and every 1/2 hour as ordered by the CRNA. Additionally, the Patient #19's record did not include documentation of a sensory level after the epidural was performed.

Patient #19's record did not include vital signs as ordered during the epidural process.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #19's record and confirmed vital signs and other documentation were not performed as ordered, and as the policy directed. She provided a packet of papers, identified as the fetal heart tracing. The fetal heart tracing included documentation of the blood pressure cuff readings automatically printed on the strips, at a frequency of every 5 minutes after the epidural was placed. The SME confirmed the orders for documentation of all components of the orders were not performed.

Patient #19 was not monitored during labor as per facility policy and orders specified.

2. Patient #5 was a 24 year old female admitted to L&D on 12/01/15 in active labor. Complications included a stillborn delivery, and chorioamnionitis. Patient #5 did not have recent prenatal care. A CNM managed her care during her hospitalization.

Patient #5's record included an order for an A1c (a blood test to determine a 3 month average of blood sugar, a test routinely performed on individuals with diabetes). Patient #5's record did not include evidence the test was performed as ordered.

This was confirmed during an interview with the SME on 3/16/16 beginning at 3:30 PM.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure medications were correctly ordered, administered, and documented for 5 of 11 obstetrical and neonatal patients (#1, #6, #18, #19, and #20), whose records were reviewed. This resulted in medications administered at the wrong rate and by the wrong route, administered without orders, administered with orders written incorrectly, and had the potential to result in patient harm and/or death to obstetrical and neonate patients. Findings include:

A policy titled "Medications-Ordering, Dispensing, Administration, and Monitoring," revised 12/01/15, included the required medication order elements:

- Date and Time
- Patient Name
- Drug Name
- Dosage
- Route
- Frequency
- Rate (e.g. IV fluids)
- Indications for use (with the order or within the medical record.)

The CAH policy stated, for verbal and telephone orders, the orders were to be authenticated, dated, and timed by the prescriber within 48 hours. Additionally, the policy stated Pediatric orders should be written on a weight basis. However, the policy was not followed.

1. Patient #6 was a 19 year old female that was admitted to L&D on 8/18/15, for preterm labor and delivery of a 23 5/7 week male. Medications were ordered by her CNM which were not consistent with the facility medication policy:

a. Patient #6's record included 3 telephone orders for medication, signed by the RN, and received from the CNM. The orders, dated 8/18/15, were for Terbutaline 0.25 mg IM at 2:08 AM, 2:51 AM, and 3:37 AM. A portion of the medication orders were written over with a different pen. The parts which were written over was the route of administration for the medication. It was rewritten as SQ, rather than IM. According to the Nursing 2015 Drug Handbook, Terbutaline for preterm labor is to be administered SQ, not IM. The Drug Handbook includes a Black Box Warning which states "Don't use injectable form in pregnant women for prevention or prolonged treatment (beyond 48 to 72 hours) of preterm labor in either the hospital or outpatient setting because of the potential for serious maternal heart problems and death."

b. Patient #6's record included documentation Terbutaline 0.25 mg was administered IM in the left deltoid at 2:20 AM. Additional doses were administered at 2:55 AM via IM in her right deltoid, and 3:40 AM via IM in her left deltoid. The portion of the record which documented the route of administration was written over in a different pen, and documented the medications was given SQ rather than IM.

c. The RN documented, in the narrative portion of the nursing note, Terbutaline 0.25 mg was administered at 2:20 AM and 2:55 AM. The original documentation by the RN stated the medication was given IM both times. The IM portion of the narrative note was written over in a different pen and written as SQ.

d. Patient #6's record included a physician order for 4 grams of Magnesium Sulfate (MgSO4) as a bolus (a large dose of a medication used to accelerate a response by the body), then 2 grams an hour after the bolus was infused. However, the physician did not include the route of administration.

e. Patient #6's MAR included documentation the administration of the MgSO4 bolus was started at 5:47 AM on 8/18/15. The continuous infusion of MgSO4 was started at 5:50 AM, which indicated the 4 gram bolus infused over 3 minutes. According to the Nursing 2015 Drug Handbook, the rate of a MgSO4 bolus should be no greater than 150 mg/minute, or 30 minutes, to avoid cardiac or respiratory arrest.

During an interview on 3/16/16 beginning at 9:00 AM, the SME, who was also an RN, reviewed Patient #6's record and confirmed the telephone orders from the CNM received by the RN included documentation of an "over write." She was unable to determine if the medication was ordered and administered as IM or SQ, and she confirmed the "over write" was not initialed to indicate who did that. Additionally, the SME confirmed the order for MgSO4 did not include a route to be delivered, and confirmed the documentation of bolus and continuous infusion was 3 minutes apart, which would indicate an unsafe rapid delivery of the bolus.

Patient #6 received medications that were not administered in a safe and correct manner.

2. Patient #20 was a full term newborn female, born on 3/11/16 at 1:56 PM. Her mother showed signs of chorioamnionitis (Inflammation of the fetal membranes due to a bacterial infection which is most often associated with prolonged labor, and can lead to infections in the mother and baby).

Patient #20's physician ordered antibiotics shortly after her birth at 2:18 PM on 3/11/16. The physician order Ampicillin 100 mg/kg IV and Gentamicin 4 mg/kg IV. The medication orders did not include Patient #20's weight for calculating the appropriate dose of medication.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #20's record and confirmed the orders written by her physician did not follow the CAH policy.

Patient #20's medication orders did not include her weight according to the CAH's policy.

3. Patient #18 was a 37 week gestational age neonate who was born on 12/20/15 at 8:55 PM. He immediately presented with signs of respiratory distress and was ultimately transferred to a higher level of care facility.

The CNM wrote orders for medications, however the medication orders were incorrect as follows:

a. An order was written for IV fluid 10 ml/kg. The order did not specify the type of IV fluid for administration. Additionally, the time noted by the CNM was 8:10 PM, 45 minutes before Patient #18 was born.

b. At 11:00 PM on 12/20/15, the CNM ordered Gentamicin 4 mg/kg IV. However, the medication order did not include Patient #18's weight for calculating the appropriate dose of medication.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #18's record and confirmed the orders written by the CNM were not in accordance with the policy.

Patient #18's medication orders did not include his weight or the type of IV fluid for administration, according to the CAH's policy.

4. Patient #1 was a 19 year old pregnant female that was admitted to the hospital at 1:27 PM on 1/24/16, in active labor.

The facility policy titled "Fentanyl Use in L&D," revised 11/08/13, stated "Monitoring shall include patient mental status, pulse, blood pressure, SpO2, and respiratory rate every 15 minutes X4 and as needed." The policy further stated a sterile vaginal exam shall be performed within 30 minutes of the Fentanyl administration. The monitoring and exam were not performed as the policy dictated.

Patient #1's record included a pre-printed order set titled "Intrapartum Orders" which were not signed by the physician. The order set included a section titled "Medications." However, the boxes next to the orders were un-marked. The bottom of the page included a section for Cesarean Section Orders which was signed by Patient #1's physician and dated 1/24/16. However, the order was not timed by the physician, as required by the CAH's policies.

Patient #1's record included documentation she received 50 mcg of Fentanyl at 2:13 PM. Patient #1's record did not include an order from her physician for Fentanyl.

Patient #1's record documented on 1/24/16 at 2:13 PM, vital signs were obtained, and Fentanyl 50 mcg was administered. Vital signs were documented again at 2:30 PM, her heart rate and respiratory rate were documented at 2:51 PM and 2:58 PM. Her record documented she received an epidural at 2:58 PM. The next vital signs were documented at 3:05 PM, and 3:10 PM, a vaginal exam was performed at that time. Vital signs were assessed 4 times over the course of 35 minutes. Patient #1's post Fentanyl assessments were not completed 4 times at 15 minute intervals (one hour) in accordance with the policy.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #1's record and confirmed Fentanyl was administered without an order from a provider. She confirmed the policy for medication administration was not followed.

Patient #1 received a narcotic without a physician order.

5. Patient #19 was a 19 year old female who was admitted to L&D on 3/10/16, for induction of labor. Patient #19 delivered a baby girl on 3/11/16. Complications included chorioamnionitis, and Patient #19 and her newborn were treated with antibiotics.

Patient #19's record documented at 2:21 AM, a vaginal exam was performed, vital signs were obtained, and Fentanyl 50 mcg was administered. Vital signs were documented again at 2:40 AM, and at 2:56 AM. Her record documented she received an epidural at 4:20 AM, and vital signs were obtained. The next vital signs were documented at 4:56 AM, and a vaginal exam was performed at that time. Vital signs were assessed 4 times over the course of 2 hours and 35 minutes. Patient #19's post Fentanyl assessments were not completed 4 times at 15 minute intervals (one hour) in accordance with the policy.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #19's record and confirmed vital signs and other documentation was not performed as ordered, and as the policy directed.

Patient #19 was not monitored after medication administration per facility policy.

The facility failed to ensure all components of safe medication delivery were followed.

Based on staff interviews and review of medical records, it was determined the CAH failed to ensure nursing care plans were individualized and complete for 1 of 7 obstetrical patients (Patient #5) whose records were reviewed. This resulted in a lack of care planning to address the unique needs of a mother whose baby was stillborn. Findings include:

Patient #5 was a 24 year old female admitted to L&D on 12/01/15 in active labor. Complications included a stillborn delivery, and chorioamnionitis. Patient #5 did not have recent prenatal care. A CNM managed her care during her hospitalization.

Patient #5's record did not include a care plan which was individualized and specific to newborn loss, grieving, or interventions to relieve engorged breasts due to milk production and no infant to feed.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #5's record and confirmed there was no nursing care plan which addressed her unique needs after delivery of a stillborn infant.

Patient #5's care plan was incomplete.

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure the patient medical records included documentation of properly executed admission and surgical consents for 10 of 11 obstetrical and newborn patients (#1, #2, #3, #4, #5, #7, #18, #19, #20 and #21) whose records were reviewed. This resulted in outpatient consents signed for inpatient admissions, and missing components of a properly executed surgical consent. Findings include:

1. Patients were admitted to the facility as inpatients, however, their record did not include the appropriate consent, as follows:

A facility policy titled "Consent Process," revised 9/20/14, stated "For inpatient admission to the hospital and/or for routine tests and procedures, a Hospital Admission Consent is obtained from the patient." Inpatient records did not include a Hospital Admission Consent.

a. Patient #1 was a 19 year old female who was admitted to L&D on 1/24/16, in active labor. She was discharged on 1/27/16.

Patient #1's record included a consent signed and dated 1/24/16 at 11:16 AM. The consent was titled "Outpatient Services Consent." The consent was two pages, the first of which was numbered 1-10. The second page included sections numbered 12-16, and was signed by Patient #1 on 1/24/16 at 1:40 PM.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #1's record and confirmed her record did not include an Inpatient Admissions Consent.

Patient #1's record did not include an Inpatient Admissions Consent.

b. Patient #21 was a 25 year old female admitted to L&D on 12/20/15 in active labor.

Patient #21's record included a consent signed and dated 12/20/15 at 2:25 PM. The consent was titled "Outpatient Services Consent." The consent was two pages, the first of which was numbered 1-10. The second page included sections numbered 12-16, and was signed by Patient #21 on 12/20/15 at 3:22 PM.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #21's record and confirmed her record did not include an Inpatient Admissions Consent.

Patient #21's record did not include an Inpatient Admissions Consent.

c. Patient #20 was a newborn female, born on 3/11/16. Her record did not include an Inpatient Admissions Consent. This was confirmed by the SME during an interview on 3/16/16 beginning at 9:00 AM.

The CAH did not ensure Patient #20's record included an Inpatient Admissions Consent signed by his parent(s).

d. Patient #5 was a 24 year old female admitted to L&D on 12/01/15, in active labor.

Patient #5's record included a consent titled "Outpatient Services Consent." The consent was two pages, the first of which was numbered 1-10. The second page included sections numbered 12-16, and was signed and dated by Patient #5 on 12/01/15 at 2:37 AM.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #5's record and confirmed her record did not include an Inpatient Admissions Consent.

The CAH did not ensure Patient #5's record included an Inpatient Admissions Consent.

e. Patient #7 was a newborn male, born on 8/18/15. His record documented he was transferred to a higher level of care at approximately 4 hours of age. Patient #7's record did not include an Inpatient Admissions Consent.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #7's record and confirmed his record did not include an Inpatient Admissions Consent signed by his parent(s).

The CAH did not ensure Patient #7's record included an Inpatient Admissions Consent.

f. Patient #18 was a newborn male, born on 12/20/15. His record documented he was transferred to a higher level of care at approximately 4 hours of age. Patient #18's record did not include an Inpatient Admissions Consent. His record included what appeared to be page "2" of the consent. It was signed by Patient #18's father on 12/20/15 at 9:22 PM.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #18's record and confirmed his record did not include a form titled "Inpatient Admissions Consent". She stated the page "2" was the second page of the consent, and confirmed the first page was not included in his record.

The CAH did not ensure Patient #18's record included an Inpatient Admissions Consent.

g. Patient #4 was a newborn male, born on 1/29/16. Patient #4's record did not include an Inpatient Admissions Consent. His record included what appeared to be page "2" of the consent. It was signed by Patient #4's mother on 1/29/16 at 6:22 PM.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #4's record and confirmed his record did not include a form titled "Inpatient Admissions Consent". She stated the page "2" was the second page of the consent, and confirmed the first page was not included in his record.

The CAH did not ensure Patient #4's record included an Inpatient Admissions Consent.

h. Patient #2 was a newborn female, born on 1/24/16. Patient #2's record did not include an Inpatient Admissions Consent. Her record included what appeared to be page "2" of the consent, signed by Patient #2's father on 1/24/16 at 7:02 PM.

During an interview on 3/16/16 beginning at 9:00 AM, the SME reviewed Patient #2's record and confirmed her record did not include a form titled "Inpatient Admissions Consent". She stated the page "2" was the second page of the consent, and confirmed the first page was not included in his record.

The CAH did not ensure Patient #2's record included an Inpatient Admissions Consent.

2. The policy "Consent Process," included a section titled "Informed Consent Inpatient, Outpatient." It stated "For certain surgical and non-routine medical procedures or treatment involving more than a slight risk, which will be performed in the hospital. Informed Consent must be documented through an appropriate Informed Consent form which is signed by the patient or when appropriate, the patient's representative."

Consent forms did not include signatures, date, and/or time when signed or witnessed. Examples include:

a. Patient #3 was a 24 year old female who was admitted to L&D on 1/29/16, for induction of labor for post dates. Patient #3 delivered a baby boy on 1/29/16. Complications included failure of labor to progress, and a Cesarean Section was performed.

Patient #3's record included a form titled "Informed Consent."

i. The Informed Consent included the name of the procedure for induction of labor, however, the section where the physician's name was to be listed remained empty. The physician signed the form, however, he did not date or time when he signed the consent.

ii. The Informed Consent was signed by Patient #3, however, there was no date or time as to when it was signed.

iii. The Informed Consent included a section for the individual to sign as a witness to Patient #3's signature, however, the signature line, date, and time were blank.

During an interview on 3/16/16 beginning at 3:30 PM, the SME reviewed Patient #3's record and confirmed the consent form was incomplete.

Consents for Patient #3 were incomplete.

b. Patient #19 was a 19 year old female who was admitted to L&D on 3/10/16, for induction of labor. Patient #19 delivered a baby girl on 3/11/16. Complications included chorioamnionitis, and Patient #19 and her newborn were treated with antibiotics.

i. The Informed Consent included the name of the procedure for induction of labor, however, the section where the physician was to sign the form indicating the procedure was explained along with the risks, benefits, and alternatives, was not signed by the physician or dated.

ii. The Informed Consent for induction of labor was signed, dated and timed by Patient #19, however, the section for the witness did not include a date or time.

iii. The Consent for Anesthesia Services was signed by Patient #19. The consent included 6 different modes of anesthesia, however, none of modes were selected as the one(s) to be used by the CRNA. Additionally, Patient #19's signature on the form did not include a time or date.

During an interview on 3/16/16 beginning at 10:50 AM, the CRNA reviewed Patient #19's record and confirmed the "Consent For Anesthesia Services," signed by he and Patient #19, did not include a time or date as to when she signed the form. The CRNA stated Patient #19 signed the consent just before he signed as a witness. Additionally, the CRNA confirmed the Informed Consent did not specify that he would be performing an epidural anesthesia for Patient #19's labor pain.

Consent forms for Patient #19 were incomplete.

Based on review of policies, medical records, and staff interview, it was determined the facility failed to ensure telephone, verbal, and written orders included the appropriate components for 8 of 11 obstetrical and newborn patients (#1, #3, #4, #5, #6, #18, #19, and #21) whose records were reviewed. This had the potential to result in incomplete authentication of orders and missed times and/or dates when the order was authenticated. Findings include:

In a CAH policy titled "Medical Records," undated, stated "All orders must be written clearly, legibly and completely." Additionally, for verbal orders, the policy stated "The individual receiving the order must immediately reduce the verbal order to writing on the order sheet of the practitioner who originated the order and immediately sign, date and time the entry. All verbal orders must be read back to the practitioner immediately after they have been written on the order sheet to ensure accuracy."

For Authentication of Orders, the policy stated "Verbal orders must be authenticated by the practitioner who originated the order in a timely manner as prescribed by law." The CAH staff did not follow the policy as follows:

1. Patient #1 was a 19 year old female who was admitted to the CAH on 1/24/16, for induction of labor.

a. Patient #1's record included pre-printed "OB Outpatient/Observation Orders." They were signed on 1/24/16 by her physician , however they did not include a time when they were written by the physician. Additionally, the orders were not noted by the RN.

b. Patient #1's record included pre-printed "Intrapartum Provider Orders," that were not signed by her physician, The bottom of the form included a section titled "Cesarean Section Orders," signed by her physician, and dated, however they did not include a time as to when they were written. Additionally, the orders were not noted by the RN.

c. Patient #1's record included pre-printed "Postpartum Provider Orders," signed by her physician on 1/24/16, but not timed. The order sheet included a written "add on" dated 1/26/16. The "Add on" was written in a different handwritting than the physician who signed the orders. It read "Lactation rounds: recommend pt has electric breast pump prior to discharge." The "Postpartum Provider Orders" were not noted by the RN.

d. Patient #1's record included an order clarification dated 1/25/16, however it was not timed. The "Order clarification" was noted as a T.O.R.B., however the RN included her name followed by her name. The physician name was not written by the RN. The order was authenticated by the physician, however, it did not include a time or date when it was authenticated.

e. The physician wrote an order on 1/25/16 at 8:20 AM, for Rhogam. The order was noted by the RN, however she did not include the date or time when the order was noted. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

2. Patient #18 was a newborn male who was born at the CAH on 12/20/15.

a. The CNM wrote orders for Patient #18 to be transferred to a higher level of care on 12/20/15 at 8:00 PM. The orders were not noted by the RN.

b. The CNM wrote an order for Patient #18 to receive an IV at 8:10 PM on 12/20/15. The order was not noted by the RN.

c. Pre-printed orders titled "Newborn Nursery Provider Orders," dated 12/20/15 at 10:00 PM. The pre-printed orders were not noted by an RN. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

3. Patient #21 was a 25 year old female who was admitted to the CAH on 12/20/15, in active labor.

a. Patient #21's record included admission orders, documented as T.O.R.B. from the CNM. However, the RN who wrote the order did not document a date or a time when the telephone order was received, and the order was not noted by an RN. The order was authenticated by the CNM on 12/26/15 at 9:00 PM.

b. Patient #21's record included pre-printed "Intrapartum Provider Orders." The first section of the order sheet was documented as T.O.R.B the midwife/RN name. However, the telephone order was dated 12/20/15, and no time was documented as to when she received the order. Additionally, the order did not include evidence it was noted by the RN.

c. Patient #21's record included pre-printed "Postpartum Provider Orders." They were signed and dated, however the CNM did not include a time when she wrote the orders.

d. Patient #21's record included orders written on 12/21/15 at 8:45 AM, by the CNM. The orders stated "Discharge home, F/U 6 weeks." However the orders were not noted by an RN. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

4. Patient #5 was a 24 year old female who was admitted to the CAH on 12/01/15, in active labor.

a. Order written 12/01/15 at 3:15 PM, "Discharge home, F/U [follow up] 2 weeks." The order was signed by the CNM, however it was not noted by an RN.

b. Order dated 12/01/15, but not timed "Do A1C before discharge. T.O.R.B. [CNM name/RN name]." The order was authenticated on 12/07/15 by the CNM at 8:30 AM. The order was not noted by the RN, and the result was not in Patient #5's record. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

5. Patient #6 was a 19 year old female who was admitted to the CAH on 8/18/15, in active labor, which was premature labor. She delivered a preterm male infant that was transferred to a higher level of care.

Patient #6's physician wrote orders on 8/18/15 at 5:30 AM, however they were not noted by the RN. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

6. Patient #19 was a 19 year old female who was admitted to the CAH on 3/10/16, for induction of labor.

The CRNA completed a pre-printed "Epidural Standing Orders," on 3/10/16 at 4:00 AM. However, the orders were not noted by an RN. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

7. Patient #3 was a 24 year old female who was admitted to the CAH on 1/29/16, for induction of labor.

Her record included orders dated 1/29/16 at 7:30 AM. The order was "Admit to inpt [inpatient] status for induction of labor. V.O.R.B. [physician name/RN name]. The order included a signature indicating it was authenticated, however, it did not include a time or date when the physician authenticated it. Additionally, the order was not noted by the RN. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

8. Patient #4 was a newborn male who was born at the CAH on 1/29/16.

Pre-printed orders titled "Newborn Nursery Provider Orders," were signed as T.O.R.B. on 1/29/16 at 7:58 PM. The orders were authenticated, however, the physician did not include a time or date when he authenticated the orders. This was confirmed during an interview with the SME on 3/16/16 beginning at 9:00 AM.

The CAH did not ensure orders were written and received accurately and completely.

Based on review of medical records and staff interview, it was determined the CAH failed to ensure a post-anethesia evaluation was completed by an individual qualified to administer anethesia. This directly impacted 1 of 7 obstetrical patients (Patient #3) whose records were reviewed. This had the potential to result in negative patient outcomes. Findings include:

Patient #3 was a 24 year old female who was admitted to L&D on 1/29/16, for induction of labor. Patient #3 delivered a baby boy on 1/29/16. Complications included failure of labor to progress, and a Cesarean Section was performed.

Patient #3 received a spinal anesthetic for the Cesarean Section. The spinal was administered by a CNRA. A form titled "Anesthesia Evaluation," was found in Patient #3's record. The form included a section titled "Postanesthesia Note". This section was to document cardiopulmonary status, LOC, follow up care or observations. The section also included 2 boxes to check, if applicable, for "No apparent anesthesia complications at this time" and "See progress notes." The section included a signature line with date and time. This section of the form was blank. The form was not signed or dated.

During an interview on 3/16/16 beginning at 3:30 PM, the SME reviewed Patient #3's record and confirmed the section of the form to be completed by the CRNA was blank. She confirmed a post-anesthesia evaluation was not documented by the CRNA.

Patient #3 did not receive a post-anethesia evaluation by the CNRA.