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Based on clinical record reviews and staff interviews the nursing staff failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5)FS as evidenced by failure to assess 2 of 2 sampled patients (Patient # 8 and 11) who received Pitocin as per facility protocol, failure to notify physician of 2 of 5 sampled patients (Patient # 10 and 11) who experienced abnormal blood pressure readings and failure to reassess pain for 4 of 5 sampled patients (Patient # 8, 9, 11 and 12) as per facility policy and professional practice standards.


The findings include:

Facility policy titled "Induction of Labor" documents Pitocin infusion, Assess uterine activity and fetal heart rate every 15 minutes, also when dose is initiated, increased or decreased.

1) Clinical record review, on 03/26/14, revealed Patient # 11 was admitted to the facility on 02/22/14 for late latent labor. Physician's Order dated 02/22/14 documents Pitocin 20 units/one liter, 1000 milliliter bag; intravenous infusion at 125 ml/hour over eight hours.
Nurses Notes document the Pitocin infusion was initiated on 02/22/14 at 10:25 PM and continued thru 02/23/14 at 12:30 PM when the patient had a physician unattended spontaneous vaginal delivery. Further review of the record failed to provide evidence Patient # 11's fetal heart tone and uterine activity was reassessed every fifteen minutes while on Pitocin as per the facility policy.

In addition, Physician's Order dated 02/22/14 documents Notify Physician/Midwife if systolic blood pressure is greater than 140 or less than 90. The record revealed Patient # 11's blood pressure met the physician established defined parameters with readings of 131/96 on 02/23/14 at 12:11 PM; the record does not contain evidence the Physician or the Midwife was notified.


2) Clinical record review conducted on 03/26/14 revealed Patient # 8 was admitted to the facility on 02/22/14 for spontaneous rupture of membranes. Physician's Order dated 02/22/14 documents Pitocin 20 units/one liter, 1000 milliliter bag; intravenous infusion at 125 ml/hour over eight hours. Nurses Notes document the Pitocin infusion was initiated on 02/22/14 at 5:33 PM and continued thru 8:25 PM, then the infusion was restarted at 8:35 PM lasting thur 11:08 PM. Further review of the record failed to provide evidence Patient # 8's fetal heart tone and uterine activity were reassessed every fifteen minutes while on Pitocin as per the facility policy.


3) Clinical record review revealed Patient # 10 was admitted to the facility on 02/14/14 for full term pregnancy. Physician's Order dated 02/14/14 documents Notify Physician/Midwife if systolic blood pressure is greater than 140 or less than 90. The record revealed Patient # 10's blood pressure met the out of range Physician defined parameters with readings of 149/84 on 02/14/14 at 5:33 PM; 160/82 at 11:40 PM; 156/72 at 11:56 and 147/90 at 12:42 PM. The record does not yield evidence the Physician or the Midwife were notified.


4) Facility Policy titled "Pain Management" documents "The efficacy of pain management interventions should be continually evaluated and dosages adjusted on the changing nature of the pain. Pain should be reassessed at least once per shift and when the condition warrants. For those patients having pain, documentation of interventions must occur at least once per shift on the problem list or plan of care. A pain reassessment will include pain scale and location. Pain reassessment will be completed as soon as possible but not to exceed 2 hours. Pain reassessment is documented".

Clinical record reviews conducted on 03/26/14 and 03/27/14 revealed the following:

Physician's Order dated 01/06/14 documents Oxycodone give 5 mg for pain scale 3-5 and 10 mg for pain scale 6-10 every four hours as needed for Patient # 9. Medication Administration Record documents the patient received the Oxycodone on 01/08/14 at 9 AM, the record failed to provide evidence of the pain reassessment after the medication administration per policy and professional standards of practice (Chapter 464, F.S).

Physician's Order dated 02/23/14 documents Motrin 600 mg every six hours as needed for pain for Patient # 8. Medication Administration Record documents the patient received the Motrin on 02/26/14 at 6:07 AM, the record failed to disclose evidence of the pain reassessment after the medication administration.

Physician's Order dated 02/23/14 documents Tylenol with Codeine # 3 give one tab for pain scale 4-6 every three hours as needed for pain for Patient # 11. Medication Administration Record documents the patient received the Tylenol # 3 on 03/23/14 at 4:59 AM, the record does not contain evidence of the pain reassessment after the medication administration.

Physician's Order dated 03/17/14 documents Dilaudid intravenously give 0.25 mg for pain level 3-4, give 0.50 mg for pain 5-6 and give 1 mg for pain 7-10, every four as needed for pain for Patient # 12. Medication Administration Record documents the patient received the Dilaudid on 03/18/14 at 6:48 AM and 10:38 AM and on 03/19/14 at 10:39 AM. The record does not contain evidence of the pain reassessment after the medication administration.

Interview with The Clinical Manager for Labor and Delivery, on 03/26/14 at 4 PM, revealed the facility policy is to reassess labor and delivery patients while on Pitocin every half hour and every time the dose is changed.

During interview with The Director of the Women and Children Services and the Clinical Manager on 03/27/14 at approximately 9:45 AM, the Director and Manager were presented with "the policy for induction of labor which documents reassessments of patients on Pitocin are to be competed every fifteen minutes". The Manager explained it has always been the facility practice to document reassessments every half hour. Upon request the Manager and Director presented a document titled Standard of Care for Pitocin Induction and Infant Services. This policy/document notes Monitor vital signs, including pulse oximetry every time Pitocin is increased or every 30 minutes. Assess and document FHT (fetal heart tone) status and uterine activity per Pitocin Protocol. The Director and The Clinical Manager acknowledged there are no documented reassessments for Patients # 8 and # 11 every 15 minutes while on Pitocin. Upon request, The Clinical Manager explained the nurses would not document notification of abnormal vital signs to the physician; The Director interjected and stated the nurses would document physician's notification when vital signs are out or defined parameters, most likely the nurses would notify the physician if it was a sustained reading. The Director acknowledged the physician's order does not read "sustained readings." The Manager reviewed the records for Patients # 10 and # 11 and was not able to provide evidence substantiating the physician was made aware of the patient's abnormal blood pressures readings.
Upon request, the Manager and Director reviewed the records for Patient # 8, # 9, # 11 and # 12 and acknowledged the lack of pain reassessment is inconsistent with the facility policy.