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Based on observation, interview, and record review the facility failed to ensure the Condition of Participation CFR 482.12 for Governing Body (GB) was met when:

1.The facility's Governing Body failed t to ensure a Physician provided ongoing monitoring and supervision of medical care for one (1) of 30 sampled Patients (Patient 1) and assured Patient1 received medical care in a safe and effective manner. Patient 1's baby was born nonviable at the facility and had the potential to place all neonatal (unborn babies)patients at risk for serious injury, harm, or death. (Refer to A-0068).

2.The facility's Governing Body failed to ensure a Registered Nurse was competent in the hemodialysis (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) out of 30 sampled patients. (Refer to A-0084)

The cumulative effect of these deficient practices resulted in the facility's inability to provide appropriate oversight on quality health care rendered to the facility's patients.

Based on interview and record review, the facility's Governing Body failed to ensure a Physician provided ongoing monitoring and supervision of medical care for one (1) of 30 sampled Patients (Patient 1) and assured Patient1 received medical care in a safe and effective manner.

This deficient practice resulted to Patient 1's baby being born nonviable (infant did not survive/dead) at the facility and had the potential to place all neonatal patients at risk for serious injury, harm, or death.

Findings:

A review of a facility document for Patient 1's History and Physical, dated 11/1/23 at 9:37 AM, indicated Patient1 was admitted to obstetrics (OB) Triage ( Medical care unit where Pregnant Patients are urgently evaluated for Pregnancy related concerns) Unit for uterine contractions and pain. Patient 1 Pelvic exam indicated Cervical Dilation ( Opening that allows Baby to descend into the Birth canal)of 4 cm, and Station (where Baby head is positioned) -1. Patient 1was diagnosed in in early labor with irregular contractions. Fetal well-being verified as category one ( Normal)Patient1 had diagnosis including gestational hypertension( Hypertension occurring during pregnancy) diagnosed on admission and plan included admit to Labor and Delivery (L&D, the facility's birthing center) for management of early labor continuous fetal heart monitoring (FHR,monitoring device to measure Baby heart rate and rhythm during pregnancy). Physicians admit orders included "Continuous fetal monitoring and to notify Provider for significant changes including abnormal FHR monitor findings and non-progression of labor." The record indicated Patient1 remained in triage for about 6 hours after admission to Labor and Delivery.

On 11/14/23 at 2:49 pm, during an interview and concurrent chart review with Nurse Manager 1(NM 1) and Perinatal Education Director (PED) of Patient1 medical records and FHR monitor, NM 1 and PED confirmed Patient was off FHR monitoring up to 15 min at a time due to movement and discomfort from labor contractions. NM 1 and PED confirmed there were no communication with a Physician about the repeated difficulty obtaining continuous FHR monitoring.

On 11/17/23 at 12:05 pm during an interview and concurrent chart review with PED of Patient 1's medical record titled Medication order, dated 11/1/23 at 2:14 pm, indicated a physician order to start Oxytocin (medication given to assist during uterine contraction during labor). PED confirmed Patient 1 was not started on Oxytocin. PED explained Oxytocin was not administered in Triage Unit. PED stated Patient 1 would have to be in Labor and Delivery room to administer Oxytocin. PED confirmed there was no Physician notification that Oxytocin had not been administered to Patient1 as ordered.

A review of the facility document for Patient 1's OB Delivery Note dated 11/1/23 completed at 4:21 pm, indicated Patient 1 was off the FHR monitoring due to mom moving around from painful contractions while in Triage Unit, and was off FHM for one hour when brought to the delivery room from the Triage Unit. At 3:42 PM Patient1 had a normal spontaneous vaginal delivery and membranes (layers of tissue with fluid [amniotic] surrounding fetus [baby] inside the womb) ruptured. There was thick meconium (baby first bowl movement inside the womb). The infant was non-viable (infant did not survive/dead) at 41-week-old and the APGARS (quick test performed on a baby at 1 and 5 minutes after birth) score were zero at one minute and zero at five minutes. The NICU (neonatal intensive care unit - area of the hospital specializing in the care if newborns needing round the clock care) team was called for resuscitative measures (a set of Emergency intervention measures taken to assist baby in breathing and circulation) for the Baby.

A review of a facility notes for Patient 1, dated 11/1/23 completed at 5:23 pm, titled clinical note respiratory therapy indicated Neonatal Intensive Care Unit Medical Doctor (NICUMD) intubated (tube inserted in the airway to assist with breathing) infant, and an umbilical line (medication given by the umbilical cord) was placed. Epinephrine (emergency medication used to restart the heart) was administered two times. The note indicated after 20 minutes of resuscitative intervention, Patient 1's baby was pronounced dead.

A review of Patient 1's History and Physical, dated 11/2/23 at 10:04 am completed by MD 1, indicated MD 1 was contacted on 11/1/23 at 9 am that Patient 1 was admitted for early labor. MD1 indicated "I did not get a call until time of delivery." There was no documentation that Patient 1 was examined or reassessed by a Physician after admission to Labor and Delivery on 11/1/23 at 9:50 am. There is no documentation that the Triage Nurses communicated difficulty in continuously monitoring of FHR or attempted to reassess and examined Patient 1's progression of labor (the development of the different stages of giving birth). There was no documentation that a Physician did examine and reassess Patient 1 after each contraction occurred from 9:50 am to 3:30 pm.

A review of the facility document title rules and regs of the medical staff dated July 18, 2023, under section 10 indicates, "General responsibilities of physician practitioner - the patient's admitting physician shall be responsible for the medical care and treatment of each patient in the hospital for the prompt completeness and accuracy of records necessary special instructions."

A review of this facility document titled medical staff bylaws dated September 21, 2021, indicated ongoing responsibilities of each member of the medical staff included providing patients with the quality of care that meets the professional standard of the medical staff.

A review of a facility document titled bylaws of Community Board dated April 28, 2022, indicated the Community board is responsible to ensure "high quality medical care practice and patient care "and "ensuring a safe environment within the hospital for patients."

Based on observation, interview, and record review, the facility's Governing Body failed to ensure registered nurses working with patients on a dialysis procedure (the process of removing excess fluid and waste from the body of a person whose kidneys are not working correctly) were competent in the hemodialysis ( emergency termination procedure (safe process of disconnecting a patient from the dialysis machine in case of an emergency) for one (1) out of 30 sampled patients (Patient 6).

This deficient practice had the potential to result in inadequate return of blood from the machine to one of thirty sampled Patients (Patient 6) which could lead to harm or even death during hemodialysis treatment.

Findings:

A review of Patient 6's, History and Physical (H&P), dated 11/13/23, indicated Patient 6 was admitted for Hemodialysis (a treatment to filter wastes and water from your blood.)

On 11/14/23 at 11:05 am, during a concurrent observation and interview on six (6) North with manager of 6 North (Registered Nurse, RN 7) and Dialysis RN(RN 11), RN 11 confirmed there was a sign posted in the dialysis machine regarding instructions on how to shut off the Hemodialysis machine safely in case of an emergency. RN 7 was asked for documentation of training in-service provided to the facility's RNs on how to shut off the Hemodialysis machine in case of an emergency. RN 7 was not able to provide training in-service for facility's RN on how to shut off Hemodialysis machine in case of an emergency.

During an interview, on 11/17/23 at 4 pm, with Director Nurse Educator (RN 9) and Nurse Educator telemetry (RN 10), RN 9 and RN 10 stated hemodialysis was being provided hospital wide and registered nurses had not received in-service on how to shut off the hemodialysis machine in case of an emergency such as during a power outage or an incapacitated dialysis nurse during dialysis. Both (RN 9 and RN 10) stated facility did not have a Policy and Procedure (P&P) regarding emergency termination of dialysis by a non-dialysis staff, and there was no record of Registered Nurses training or in-service for emergencies during hemodialysis including safely shutting shut off dialysis in case of an emergency.

A review of a facility document titled, Bylaws of Community Board, dated April 28, 2022, indicated the Community board was responsible to ensure, "High quality medical care practice and patient care," and "Ensuring a safe environment within the hospital for patients."

Based on observation, interview, and record review, the facility failed to:

1. Ensure One of two crash carts (Crash Cart 1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) was checked to ensure emergency supplies, equipment, and medications were readily available in the event of an emergency.

This deficient practice had the potential for emergency supplies to not be readily available in case of an emergency and had the potential to result in a delayed provision of emergency care needed by patients, which may lead to patient harm and/or death.

2. Ensure one of two crash carts (Crash Cart 2) in the Emergency Department (ED) was equipped with a backboard (a rigid plastic backboard or cardiac [heart] board used for the administration of chest compressions by providing a firm surface).

This deficient practice had the potential to negatively affect the quality of chest compression depth provided to the patient which may result in poor outcome such as patient death.

3. Ensure one out of four oxygen cylinders (a metal cylinder [tanks] containing oxygen under pressure used to deliver supplemental oxygen when patients have a lung condition or difficulty breathing) in the Emergency Department ' s (ED) patient care area was not empty.

This deficient practice had the potential for oxygen to not be readily available in case of an emergency which may result in the delay of patient care delivery.

4. Ensure one of one Malignant Hyperthermia Carts (a storage space for supplies such as intravenous [IV, through the vein] fluids, syringes, etc.) in the Labor and Delivery (L&D, the facility ' s birthing center) Operating Room (OR) Suite, was checked daily to ensure the integrity of the cart was maintained and all supplies and medications were readily available in the event a patient suffered from malignant hyperthermia (a rare and severe reaction to certain drugs used for anesthesia, without prompt treatment complications could be fatal) after receiving anesthesia.

This deficient practice had the potential for the integrity of the cart to be compromised and the medications and supplies not to be readily available in the event a patient suffered malignant hyperthermia after receiving anesthesia. This deficient practice also had the potential to result in patient harm and/or death.

Findings:

1. During an observation on 11/14/2023 at 11:16 a.m., in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), one of two Crash Cart ' s (Crash Cart 1, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) Log was reviewed. There was no documentation to indicate that the crash cart was checked for emergency medications, supplies, and equipment on 11/14/2023.

During an interview on 11/14/2023, at 11:16 a.m., with the Director of the ED (DED), the DED stated, the crash carts should be checked by a Charge Nurse or a designated nurse around 5 a.m. daily. The DED verified the "Crash Cart Log" was not checked on 11/14/2023 by the designated person at 5:00 a.m. on 11/14/2023.

A review of the "Crash Cart Log," dated 9/2023, the Crash Cart log indicated, there was no documented check of the crash cart for expiration of medications, and emergency supplies such as, oxygen tanks, back board ... on 11/14/2023. This lack of documentation was verified with the DED during an interview on 11/14/2023.

A review of the facility ' s policy and procedure (P&P) titled, "Crash Cart Checks," dated 10/21/2020, the P&P indicated, "An assigned licensed nurse will check and document a complete Crash Cart Log Sheet daily. The following items should be checked daily: Medications and/or supply items such as backboard attached to the back of the cart including an Ambu-bag (a hand-held device used to force air into the lungs of a patient who has either completely ceased breathing or struggling to breathe properly and in need of assistance), intubation (insertion of a flexible tube into the airway to assist with breathing) box, defibrillator (a device used to restore the heart ' s normal heartbeat) and cables, portable suction (used to clear the airway of secretions), oxygen cylinder, and transvenous pacemaker (a small electronic device that keeps the heart beating at a regular rate).

2. During an observation, on 11/14/2023 at 11:21 a.m., another crash cart (Crash Cart 2, a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency), in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) did not have a backboard.

During a concurrent interview and record review on 11/14/2023 at 11:21 a.m., with the Director of the ED (DED), the Crash Cart Log," dated 11/2023 was reviewed. The record indicated, the crash cart (Crash Cart 2) was checked on 11/14/2023 and the backboard attached to back of cart was marked as "Yes" (indicating present during inspection).

During a concurrent observation and record review, on 11/14/2023 at 11:21 a.m., with the Director of Emergency Department (DED), the second crash cart was observed not equipped with the backboard. The DED stated, the backboard must be stored on the back of the crash cart because the crash cart should be always equipped with all supplies and equipment, in case of emergency.

A review of the facility ' s P&P titled, "Crash Cart Checks," dated 10/21/2020, the P&P indicated, "An assigned licensed nurse will check and document a complete Crash Cart Log Sheet daily. The following items should be checked daily: Medications and/or supply items such as backboard attached to the back of the cart including an Ambu-bag, intubation box, defibrillator, and cables, portable suction , oxygen cylinder, and transvenous pacemaker.

3. During an observation, on 11/14/2023 at 10:00 a.m., in the Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care), in the rapid patient management (RPM) area, an area designated for quickly stabilizing patients in distress (patients with health issues such as difficulty breathing, chest pain, etc.), four oxygen cylinders stored in a rack were observed. One oxygen cylinder indicated the dial was within the red zone (red zone means that the cylinder is close to empty or empty and needs to be refilled with oxygen) and indicated empty.

During an interview on 11/14/2023 at 10:00 a.m. with the Emergency Department Technician (EMT), the EMT stated, empty oxygen cylinders (tanks) must be stored separately from Active (full of oxygen, readily available for use) cylinders in the dirty utility room. The EMT also said, "It has been very busy this morning in the ED, and all the tanks in this area need to be full. I did not have time to check."

During an interview on 11/14/2023 at 1:05 a.m., with the Director of the ED (DED), the DED stated, the rack with stored oxygen tanks in the RPM area should only contain full oxygen tanks because the area is designated for rapid stabilization of patients in distress.

A review of the facility ' s P&P titled, "Oxygen Storage and Transportation," dated 03/08/2023, the P&P indicated, "All cylinders must be identified in the storage areas with placards labeled as; Active or Empty. Active cylinders that are full and partially full can be stored in the same location in the tank holder designated as Active. Empty tanks must be stored separately from Active tanks. All associates working in patient care areas are oriented to the location, storage, handling, and dispensing of Oxygen in the hospital."

4. During an observation on 11/13/2023 at 11:08 a.m., with the Perinatal (period immediately before and after birth) Educator (PED), Nurse Manager (NM 1) for the Labor and Delivery (L&D, the facility ' s birthing center) Unit, the following was observed: There was a cart labeled "Malignant Hyperthermia (MH, a rare and severe reaction to certain drugs used for anesthesia, without prompt treatment complications could be fatal)," in the L&D operating room suite. There was a log on top of the MH cart (a storage space for supplies such as intravenous [IV, through the vein] fluids, syringes, etc.) titled, "Malignant Hyperthermia Cart, Nursing Daily Medication Drawer Check Log," dated 11/2023. The log indicated the following: Daily RN (registered nurse) Check: RN to check if (1) yellow lock is intact, (2) the yellow lock number matches with the number on the log, (3) any medication is missing in the 2nd tray, (4) meds (medications) not expired on the earliest expiration sticker ..." The log indicated that the cart was not checked on November 4, 5, 6, 8, 9 and 10th of 2023.

During an interview on 11/13/2023 at 11:08 a.m. with the PED, the PED stated the MH Cart contained emergency medications and supplies used to treat patients who suffered from malignant hyperthermia after receiving anesthesia. The PED stated the cart should be checked every day to ensure all the supplies and medications were readily available for use. The PED verified that the MH cart had not been checked on November 4, 5, 6, 8, 9 and 10th of 2023.

A review of the facility ' s policy and procedure (P&P) titled, "Management of Anesthetic - Induced Malignant Hyperthermia - Peri-Operative Services," dated 7/20/2022, indicated the following: General supplies: Stocked in the malignant hyperthermia cart ...

A review, on 11/13/2023 at 11:08 am., in the L&D operating room suite, the log titled, "Malignant Hyperthermia Cart, Nursing Daily Medication Drawer Check Log," dated 11/2023, was reviewed. The log indicated the following: Daily RN (registered nurse) Check: RN to check if (1) yellow lock is intact, (2) the yellow lock number matches with the number on the log, (3) any medication is missing in the 2nd tray, (4) meds (medications) not expired on the earliest expiration sticker ..." The log indicated that the cart was not checked on November 4, 5, 6, 8, 9 and 10th of 2023.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility failed to follow State and Federal regulatory standards regarding safe patient care assignments for one (1) of two (2) charge nurses (CN 2) by assigning CN 2 to the Labor & Delivery (L&D, the facility ' s birthing center) unit, Obstetric (OB, a branch of medicine concerned with childbirth) Triage (preliminary assessment in order to determine the urgency of patients ' need or treatment) Area, Antepartum (period before childbirth) Unit, the Operating Room and assigning CN 2 to perform individual patient care.

This deficient practice had the potential to result in patient needs not being met to assure patient safety especially when there is an emergency situation, and the charge nurse is not readily available to assist staff. (Refer to A - 0392)

2. The facility ' s nursing staff failed to perform an initial admission assessment (a comprehensive physical examination that shines a light on a patient ' s needs and problems) and reassessments to determine a patient ' s status and progression of labor (the process by which the fetus [unborn baby] leaves the uterus) for one of thirty sampled patients (Patient 1). In addition, nursing staff failed to take vital signs (Temperature, blood pressure, heart rate, respiratory rate, and pain) at least every hour and report abnormal findings, such as the inability to detect Patient 1 ' s Fetal Heart Rate (FHR, baby ' s heart rate), elevated blood pressures, severe abdominal pain, and complaints of headache to the physician (attending physician).

These deficient practices resulted in the facility ' s inability to identify and treat potential complications and the inability to determine the progression of Patient 1 ' s labor resulting in the death of Patient 1 ' s baby. (Refer to A-0395)

3. The facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented for one of 30 sampled patients (Patient 13) in accordance with the facility ' s policy and procedure regarding care plan development and implementation when Patient 13 was admitted with hypertensive crisis (very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter dysfunction .

This deficient practice had the potential to delay provision of care to Patient 13 by not identifying the patient ' s needs and risks, which may result in patient harm or death. (Refer to A-0396)

4. The facility failed to ensure nursing staff adhered to the facility ' s policies and procedures for three of thirty (30) sampled patients (Patient 13, Patient 11, and Patient 1) when:

a. Patient 13 ' s cardiac activity was not continuously monitored with a cardiac device that monitors and records heart rate and rhythm (the heart beats too fast or too slow) as per physician ' s order and in accordance with the facility ' s policy and procedure regarding cardiac monitoring.

This deficient practice had the potential to result in Patient 13 ' s abnormal heart rate and rhythm to be not properly monitored and detected, which may result in patient harm and/or death when left untreated. (Refer to A-0398)

b. Skin assessment was not performed and documented for one of 30 sampled patients (Patient 11) in accordance with the facility ' s policy and procedure regarding assessment and reassessment.

This deficient practice had the potential to result in the delay of implementation of interventions to prevent skin breakdown (tissue damage caused by friction, moisture, and pressure) for Patient 11. (Refer to A-0398)

c. Pain reassessment was not performed after administering a medication (acetaminophen [Tylenol, over the counter pain reliever]) to treat a headache for one of thirty (30) sampled patients (Patient 1) in accordance with the facility ' s policy and procedure regarding pain assessment and management.

This deficient practice resulted in the nurses ' inability to determine whether the pain medication was effective and also had the potential for Patient 1 ' s pain to remain unrelieved. (Refer to A-0398)

5. The facility failed to administer oxytocin (a hormone given to strengthen labor contractions [periodic tightening and relaxing of the uterine muscles] and control bleeding after childbirth) as ordered by the physician for one of thirty (30) sampled patients (Patient 1).

This deficient practice had the potential for the non-progression of labor (the process by which the fetus [unborn baby] leaves the uterus [a female organ that plays a critical role in pregnancy]) and excessive bleeding after childbirth. (Refer to A-0405)

The cumulative effect of these deficient practices resulted in the facility ' s inability to provide quality health care in a safe environment.

Based on interview and record review, the facility failed to follow State and Federal regulatory standards regarding safe patient care assignments for one of two charge nurses (CN 2) by assigning CN 2 to the Labor & Delivery (L&D, the facility ' s birthing center) unit, Obstetric (OB, a branch of medicine concerned with childbirth) Triage (preliminary assessment in order to determine the urgency of patients ' need or treatment) Area, Antepartum (period before childbirth) Unit, the Operating Room and assigning CN 2 to perform individual patient care.

This deficient practice had the potential to result in patient needs not being met to assure patient safety especially when there is an emergency situation, and the charge nurse is not readily available to assist staff.

Findings:

During an interview on 11/15/2023 at 3:02 p.m. with Charge Nurse (CN) 2, CN 2 stated she (CN 2) was assigned as the charge nurse for the OB (OB, a branch of medicine concerned with childbirth) Triage (preliminary assessment in order to determine the urgency of patients ' need or treatment) Area, the Labor and Delivery (L&D, the facility's birthing center) unit, the Antepartum (period before childbirth) Unit and was also assigned to care for two (2) L&D patients on 11/1/2023. CN 2 also said charge nurse duties included, making the unit assignments, making rounds (monitoring and re-assessment to ensure patient safety) on all patients, checking crash (emergency) carts (a cart stocked with emergency equipment, supplies and medications to be used in a medical emergency) and equipment, assisting other nurses with patient care, moving patients from OB Triage to the L&D unit, and giving report of all patients to the incoming charge nurse at change of shift.

During an interview on 11/15/2023 at 1:44 p.m. with the Director of Women and Children ' s Services (DWCS), the DWCS stated the following: CN 2 was assigned to be the charge nurse on 11/1/2023 during the day shift (6:30 a.m. to 7 p.m.). The DWCS was unable to provide the nursing assignment on 11/1/2023 for the OB Triage Area, L&D Unit, Antepartum Unit, and Operating room.

During an interview on 11/15/2023 at 3:54 p.m. with the Director of Risk Management (DRM), the DRM stated the facility followed State and Federal mandatory staffing ratios (maximum number of patients assigned to a Registered Nurse [RN] during one shift). The DRM also said charge nurses could take care of patients (which means the charge nurse has her designated patients). However, charge nurses should not be assigned to perform charge nurse duties when the charge nurse already has her designated patient assignment.

A review of the facility ' s policy and procedure (P&P) titled, "Staffing Assignment By Acuity (severity of a patient ' s illness)," dated 2/14/2023, the P&P indicated the following: "The facility adopts the following policy to standardize the process of defining patient acuity and need as they are used for determining staffing assignments, in addition to any State mandated ratio requirements ...General Parameters: The staffing assignment is prepared by the charge nurse/ shift leader or designee ...Additional Staffing Factors: ...State specific staffing requirements."

Based on interview and record review, the facility ' s nursing staff failed to perform an initial admission assessment (a comprehensive physical examination that shines a light on a patient ' s needs and problems) and reassessments to determine a patient ' s status and progression of labor (the process by which the fetus [unborn baby] leaves the uterus [a female organ that plays a critical role in pregnancy]) for one of thirty sampled patients (Patient 1). In addition, the nursing staff failed to take vital signs (Temperature, blood pressure, heart rate, respiratory rate, and pain) at least every hour and report abnormal findings, such as the inability to detect Patient 1 ' s Fetal Heart Rate (FHR, baby ' s heart rate), elevated blood pressures, severe abdominal pain, and complaints of headache to the physician (attending physician).

These deficient practices resulted in the facility ' s inability to identify and treat potential complications and the inability to determine the progression of Patient 1 ' s labor resulting in the death of Patient 1's baby.

On 11/16/2023 at 3:35 p.m., the survey team called an Immediate Jeopardy (IJ, a situation in which the facility ' s noncompliance with one or more requirements has caused, or is likely to cause, a serious injury, harm, impairment, or death to a patient) in the presence of the Manager of Accreditation & Regulatory Compliance (MARC), Systems Director of Accreditation & Licensing (SDAL), Retiring Patient Care Executive (PCE 1), and Incoming Patient Care Executive (PCE 2), Operations Executive (OE), and the President (Pres). On 11/1/2023 at 7:26 a.m., Patient 1 presented to the facility ' s Obstetrics (OB, a branch of medicine concerned with childbirth and the care of women given birth) Triage (preliminary assessment in order to determine the urgency of patients ' need or treatment) area on 11/1/2023 at 7:26 a.m. for uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]). Patient 1 arrived at the facility from home and alone. Patient 1 was found to be four (4) centimeters (cm, a unit of measurement) dilated (lower part of the uterus is open at 4 out of 10 cm). Patient 1 had an order to be admitted to the Labor and Delivery (L&D, the facility ' s birthing center) unit on 11/1/2023 at 9:50 a.m. However, Patient 1 continued to physically remain in the OB Triage area on 11/1/2023 from 9:50 a.m. to 3:32 p.m.

During this time (9:50 a.m., to 3:32 p.m.), Patient 1 ' s fetal heart rate (FHR, baby ' s heart rate) was undetectable for periods ranging from 4 to 9 minutes on multiple occasions, Patient 1 ' s blood pressure and heart rate were elevated, Patient 1 complained of pain to the abdomen and head rated at 10 of 10 (zero means no pain, 10 means severe). These abnormal signs and symptoms were not reported to the physician. In addition, nursing staff did not perform a head-to-toe assessment (a comprehensive physical examination that shines a light on a patient ' s needs and problems) for Patient 1 after the physician ordered Patient 1 to be admitted and nursing staff did not assess the progression of Patient 1 ' s labor (the process by which the fetus [unborn baby] leaves the uterus). On 11/1/2023 at 3:32 a.m., Patient 1 was transferred to the L&D unit and found to be fully dilated (10 cm, the cervix [lower portion of the uterus] is fully open for the baby to pass through during delivery) and ready to deliver (to give birth). On 11/1/2023 at 3:42 p.m., Patient 1 delivered the baby. The baby was limp (without muscle tone), cyanotic (bluish color due to lack of oxygen), was not breathing and did not have a heart rate. The baby was pronounced dead after twenty (20) minutes of resuscitative (an attempt to revive) efforts. These deficient practices resulted in the facility ' s inability to identify and treat potential complications and the inability to determine the progression of Patient 1 ' s labor resulting in the death of Patient 1 ' s baby.

On 11/17/2023 at 6:14 p.m., the IJ was removed in the presence of the MARC, SDAL, PCE 1, PCE 2, OE, Pres, and the Chief Medical Officer (CMO) after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practice). The elements of the IJ Removal Plan were verified and confirmed through observations, interviews, and record reviews. The IJ Removal Plan indicated all L&D staff would be re-educated on assessment (within 1 hour of admission) and reassessment (progression of labor) of patients and escalating abnormal signs and symptoms, including vital signs (Temperature, blood pressure, heart rate, respiratory rate, and pain) and the loss of fetal heart rate to the physician. The Plan also included assigning an L&D nurse to patients who had an order to be admitted to the L&D unit but remained in the OB Triage area. In addition, a new monitoring process was developed under which the Lead nurse or designee will perform rounds (monitoring and re-assessment to ensure patient safety) every two hours to ensure timely initial assessments (evaluation of a patient ' s state of health) are completed for newly admitted patients, progression of labor is monitored, and abnormal findings are reported to the physician.

Findings:

A review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/1/2023 at 9:37 a.m., the H&P indicated the following: Patient 1 presented to the Obstetrics (OB, branch of medicine concerned with childbirth and the care of women who have given birth) Triage (preliminary assessment in order to determine the urgency of patients ' need or treatment) area, alone and complaining of uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]). Patient 1 was 41 weeks plus 2 days pregnant (past due, full-term pregnancy is 40 weeks). Dilation was 4 cm (4 - 6 cm indicates early labor [the process by which the fetus leaves the uterus], 10 cm indicates the cervix [lower portion of the uterus] is fully dilated or open). Effacement (the cervix stretches and gets thinner) was 90 % (90 of 100 % indicates the cervix is almost ready for delivery) and Station was -1 (the position of the baby ' s head in relation to its position to the mother ' s pelvis, - 1 means one (1) cm above the pelvis). Patient 1 ' s blood pressure was 147/91 (elevated, normal is 120/90). Gestational hypertension (a woman with elevated blood pressure during pregnancy) was diagnosed on admission. "Plan: Admit to Labor and Delivery (L&D) unit for management of early labor. Continuous fetal monitoring ..."

During a review of a physician ' s order, dated 11/1/2023 at 9:50 a.m., the order indicated the following:

1. An order for Admission Status. "Inpatient level of care: Labor and Delivery."

2. Continuous order for fetal monitoring. Notify provider of significant changes.

3. To notify physician for rapid changes or non-progression in labor.

4. Vital signs (blood pressure [BP], Temperature [T], pulse [or heart rate, HR) check, pain, and fetal heart rate (FHR, baby ' s heart rate) check, every four hours (Q4H) and PRN (as needed) as the patient ' s (Patient 1) condition warrants.

A review of Patient 1's "Nursing Documentation - Flowsheet," dated 11/1/2023, indicated the following:

At 7:30 a.m., Temperature (T) was 98.2 degrees Fahrenheit (normal level from 97 degrees Fahrenheit [F] to 99 degrees F), Blood pressure was 148/97 millimeters of mercury (mmHg, unit of measurement) (high, normal blood pressure 120/80 mmHg to 120/80 mmHg), Pulse was 92 beats per minute (normal was 60 beats per minute [BPM] to 100 BPM), pain was 10 (10 of 10, zero indicates no pain, 10 indicates severe pain). Patient 1 complained of uterine contractions.

At 8:17 a.m., blood pressure (BP) was 150/89 mmHg (high), and maternal heart rate (MHR) was 85 BPM.

At 8:32 a.m., BP was 147/85 mmHg (high), and MHR was 86 BPM.

At 8:47 a.m., BP was 147/91 mmHg (high), and MHR was 82 BPM.

At 9 a.m., BP was 151/92 mmHg (high). MHR was 95 BPM.

At 9:13 a.m., cervical dilation (the cervix opening, zero [0] centimeter [cm, unit of measurement] closed to 10 cm [full dilation/open] ) was 4 centimeter (cm, unit of measurement), cervical effacement was 90 % (measured in percentages from zero (0) to 100 percent, zero is closed to 100 % open [cervix is ready for delivery]).

At 2:23 p.m., Patient 1 complained of headache rated at a level 10 (severe pain).

At 3:31 p.m., Registered Nurse (RN) 4 handed off (exchanged) Patient 1 to RN 5. RN 4 gave report to RN 5.

At 3:36 p.m., Resident Physician and Attending Physician were notified that Patient 1 was ready to deliver. Patient 1 was 10 cm dilated (fully), cervical effacement 100 %, and + 2 station (baby ' s head was 2 cm below the pelvis).

At 3:39 p.m., Patient ready to deliver ...Resident Physician at bedside, informed unable to detect fetal heart rate.

At 3:42 p.m., Psychosocial/bonding issues: Fetal demise (death of a baby) ...

During a review of Patient 1 ' s "Fetal Monitoring Strips and Annotations (comment or explanation)," dated 11/1/2023 from 7:48 a.m. through 3:48 p.m., indicated the following:

At 9:06 a.m., The TOCO (tocotransducer, round monitors [leads] placed on the belly, held in place with belts, that monitor fetal heart rate and uterine contractions) was not detected from 9:06 a.m. to 9:11 a.m.

At 9:20 a.m., RN (registered nurse) at bedside: Strip review; Position change; Toco/US (ultrasound) adjusted, loss of signal due to maternal frequent position changed, non-compliant to keep monitor on. At 10:32 a.m., BP was 142/92 mmHg (high), and MHR was 93 BPM.

At 11:02 a.m., BP was 150/77 mmHg (high), and MHR was 98 BPM.

At 11:32 a.m., BP was 144/69 mmHg (high), and MHR was 101 (high) BPM.

At 11:47 a.m., BP was 156/84 mmHg (high), and MHR was 98 BPM.

At 11:57 a.m., the TOCO lead was not detected from 11:57 a.m. to 12:06 p.m. At 12:07 p.m., BP was 151/99 mmHg (high), and MHR was 95 BPM.

At 12:12 p.m., Patient 1 refuses to lay back to get baby on the monitor due to her (Patient 1) pain.

At 12:17 p.m., BP was 169/87 mmHg (high), and MHR was 97 BPM.

At 12:19 p.m., BP was 152/89 mmHg (high), and MHR was 99 BPM.

At 12:32 p.m., BP was 155/95 mmHg (high), MHR was 96 BPM.

At 12:48 p.m., BP was 176/88 mmHg (high), and MHR was 99 BPM.

At 12:54 p.m., BP was 165/77 mmHg (high), and MHR was 94 BPM.

At 1:02 p.m., The TOCO lead was not detected from 1:03 p.m. to 1:06 p.m.

At 2:03 p.m., BP was 162/104 mmHg (severely high), and MHR was 104 BPM (high).

At 2:08 p.m., BP was 138/82 mmHg (high), and MHR was 111 BPM (high).

At 2:23 p.m., BP was 147/86 mmHg (high), and MHR was 102 BPM (high).

At 3:02 p.m., strip review, frequent loss of signal, Patient 1 unable to keep still due to labor pain. At 3:04 p.m., the TOCO lead was not detected.

At 3:10 p.m., up to BR (bathroom) and voided.

At 3:18 p.m., Patient 1 remained in the BR called her attention to go back to bed and patient did.

At 3:29 p.m., Patient has been disassociated (disconnected from the fetal monitor).

At 3:32 p.m., Patient 1 associated (placed on a fetal monitor).

At 3:36 p.m. Station: + 2, Effacement: 100 %, Dilation: 10 cm.

At 3:38 p.m., AROM (artificial rupture of membrane, or "breaking of the bag of water," (when the provider intentionally breaks a pregnant person ' s amniotic sac [holds fluid that surround the baby in the womb]).

At 3:39 p.m., OB provider (Resident Physician) at bedside. OB provider (Attending Physician) notified.

A review Patient 1 ' s "Fetal Monitoring Data," dated 11/1/2023, the data indicated that fetal heart rate baseline was unable to be determined at 3 p.m. and at 3:45 p.m.

A review of Patient 1 ' s vital signs (Temperature [T], blood pressure [BP], heart rate [HR], respiratory rate [RR] and pain), dated 11/1/2023 from 7:30 a.m. to 3:46 p.m., indicated that a full set of vital signs were only assessed once, as follows:

At 7:30 a.m., T was 98.2 degrees F, HR was 92 BPM, BP was 148/97 mmHg (high), RR was 18 (normal range 12 respiration per minute [RPM] - 18 RPM), and pain to abdomen rated at 10 out of 10 (severe pain).

A review of Patient 1's head to toe assessments (a comprehensive physical examination that shines a light on a patient ' s needs and problems) dated 11/1/2023, the assessments indicated that Patient 1 had an initial head to toe assessment at 4:30 p.m., over six (6) hours after Patient 1 was ordered to be admitted to the L&D unit (at 9:50 a.m.).

A review of Patient 1 ' s physician "Progress Note," dated 11/1/2023 at 4:21 p.m., the progress note indicated the following: Patient 1's infant was non-viable (unable to survive). Complications: "Patient (Patient 1) admitted to L&D at approximately 10 a.m. for eLabor (early labor) ...While in triage, baby falling off monitor for prolonged periods due to mother moving around from painful contractions ...When moved to labor room, baby had been off the monitor for 1 (one) hour ...Patient was checked and found to be 10 cm dilated, and + 2 station (2 cm below the pelvis). I (Resident Physician) was called to room for delivery. Patient was instructed to push. Membranes were ruptured during pushing with thick mec (meconium, a newborn ' s first poop) noted. Baby was delivered within two minutes of pushing. Poor tone was noted, and cord was immediately clamped and cut. Baby was brought to the warmer, where resuscitative measures (life-saving measures, such as chest compression (a life-saving procedure performed when someone ' s heart stops beating) and respiratory support and management) were started by the L&D team. NICU (Neonatal Intensive Care Unit, a unit of the hospital that specializes in the treatment of newborns with health problems or difficult births) was emergently called ...Please see NICU note for details on resuscitative efforts."

A review of Patient 1's, "CPR (cardiopulmonary resuscitation, a life-saving procedure performed when someone ' s heart stops beating) Record," for Patient 1's baby, dated 11/1/2023 at 3:45 p.m., indicated the following: CPR started at 3:43 p.m. by the L&D. Initial signs of arrest (heart stops beating): Apnea (breathing has stopped), absence of pulse, cyanosis (bluish discoloration of the skin from inadequate oxygenation of the blood), and unresponsive (not reacting in a quick or positive way). Code Team (a team that responds to the patient ' s bedside when patient is in need of resuscitation (to revive) such as cases of heart attack, etc.) arrival time was, on 11/1/2023 at 3:45 p.m. Patient 1's baby was intubated (a tube is inserted into the mouth or airway to allow air to get through) and emergency medications were given. The record indicated under Event End, Patient 1's baby expired (died), on 11/1/2023 at 4:03 p.m.

A review of Patient 1's "H&P" dated 11/2/2023 at 10:04 a.m., indicated the following, "This is a 22-year-old female who is a primigravida (pregnant for the first time) presented at 40 weeks gestation (pregnant) complaining of uterine contractions ...I (Attending Physician) was called at 9:00 in the morning. The patient (Patient 1) was noted to be in early labor of 4 cm (dilated) and 90 % (effacement). At that time, orders were given to admit the patient for labor management. Subsequently, I did not get a call until the time of delivery where I was called for the delivery. Upon my presentation to the labor and delivery suite along with the resident, I delivered a nonviable (not capable of living) infant. Neonatal team was present in order to perform resuscitation, however despite our aggressive resuscitation, the newborn had expired ..."

A review of Patient 1's "Clinical Pathway/Care Plan (provides a framework for evaluating and providing patient care needs)," dated 11/1/2023 at 9:50 a.m., indicated to notify MD for the following admission findings: Temperature 100.4 (F) or higher, pulse less than 60 or greater than 120, Respiration less than 12 and greater than 24, BP equal to or greater than 140 mmHg or greater than 90 diastolic (pressure the blood is exerting against the artery [blood vessels that deliver oxygenated blood to the body] walls of the heart while the heart muscles are resting) BP, BP less than 90/50, non-reassuring FHR, abnormal labor progress (no change in dilation or station less than or equal to 2 hours), abnormal vital signs, abnormal FHR ..."

During a concurrent interview and record review, on 11/14/2023 at 1:29 p.m., with the Perinatal Educator (PED) and the Nurse Manager (NM 1) for Labor & Delivery Unit, Patient 1's Nursing Flowsheets and Fetal Heart Monitoring Strips and annotations were reviewed. The PED and NM 1 stated the following: Patient presented to OB triage on 11/1/2023 at 7:26 a.m., with a chief complaint of uterine contractions. Patient 1 was 4 cm dilated, 90% effaced, and -2 station. Patient 1 had an order to be admitted to the L&D unit at 9:50 a.m. However, Patient 1 remained in the OB triage area until 3:32 p.m. During this time (9:50 to 3:32 p.m.) the PED and NM 1 verified Patient 1 ' s blood pressures were elevated and would require BP monitoring every 15 minutes. If the blood pressure was over or equal to 140/90, the physician should be notified. If the BP was equal to or greater than 160/110, the physician should be notified immediately to evaluate the patient and to determine the course of treatment, if any. High blood pressure could be associated with preeclampsia (persistently high blood pressure that develops during pregnancy), which could lead to seizures (convulsions, uncontrolled electrical activity between the brain cells that causes temporary abnormality in muscle tone and movements) or stroke (when blood flow to the brain is blocked).

During an interview, on 11/14/2023 at 1:29 p.m., the PED and the NM 1 verified Patient 1 ' s BP was consistently elevated, as follows: at 12:19 p.m., BP was 152/89. At 12:32 p.m., BP was 155/95. At 12:48 p.m., BP was 176/88 (high). At 12:54 p.m., BP was 165/77 (high). At 2:03 p.m., BP was 162/104 (severely high), and MHR was 104 (high). At 2:08 p.m., BP was 138/82 (high) and MHR was 111 (high). At 2:23 p.m., BP was 147/86 (high) and MHR was 102 (high). The PED stated that the BPs over 160/110 (176/88, 165/77, and 162/104) were severely high and should have been reported immediately. The MHR over 100 (102, 111, and 104) were not reported to the physician. The PED and the NM 1 stated Patient 1 ' s FHR and contractions were being monitored. However, there were multiple times when the FHR signal was not able to be detected, ranging from 4 to 9 minutes, therefore the FHR was unable to be determined. The PED stated if there was a concern or issues with the inability to determine the fetal heart rate, the issues should have been communicated to the physician so the physician could evaluate the FHR by performing an ultrasound (an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside the body).

During an interview, on 11/14/2023 at 1:29 p.m., the PED and the NM 1 also verified Patient 1 complained of abdominal pain rated at a 10 (severe) at 7:30 a.m., and at 2:23 p.m., Patient 1 complained of a headache rated at a 10. The PED and the NM 1 verified that there was no documentation in the medical record that the physician was notified of the pain. Moreover, the PED stated that pain should be assessed every hour, but was only assessed twice between 7:30 a.m. and 3:32 p.m. In addition, the PED and the NM 1 verified that there was no documentation indicating that nursing staff had performed an initial (admission) assessment after Patient 1 was ordered to be admitted to the L&D unit, nor was there documentation of the reassessment of the progression of labor from 9:50 a.m. to 3:32 p.m. while Patient 1 physically remained in the OB triage area. The PED stated it was important to conduct these assessments to determine the health status of Patient 1 and Patient 1 ' s baby and identify any potential complications.

During an interview on 11/15/2023 at 12:16 p.m., with Registered Nurse (RN) 3, in OB triage, RN 3 stated the following: RN 3 cared for Patient 1 on 11/1/2023 from 7:30 a.m. to approximately 11:30 a.m. in the OB triage area. Patient 1 was placed on monitor to detect FHR and MHR. Patient 1 had persistently elevated BPs and severe pain to the abdomen. The elevated BP and pain were not reported to the physician. A full set of vital signs should be taken every hour, and RN 3 verified this was not documented in the medical record. Patient 1 had an order to be admitted to the L&D unit, but physically remained in the OB Triage area. RN 3 stated, generally, an L&D nurse is assigned to an "admitted" patient in the Triage area and carries out admission orders. Patient 1 was not assigned a L&D nurse and remained under the care of the Triage nurses (RN 3, RN 4). RN 3 stated she (RN 3) was triaging other patients and was not able to perform an admission assessment, but RN 3 continued to monitor FHR, MHR, and BPs. At approximately 11:30 a.m., RN 3 endorsed Patient 1 to RN 4 (who is not available for interview).

During an interview, on 11/15/2023 at 3:02 p.m. with Charge Nurse (CN) 2, she (CN 2) said that she (CN 2) was assigned as the charge nurse and was also assigned to care for two (2) L&D patients on 11/1/2023. Patient 1 remained in the OB triage area after being admitted by the physician, because patients were brought to the L&D unit according to acuity (urgency for clinical intervention). Patient 1 remained under the care of the Triage nurse after the physician ordered for Patient 1 to be admitted. CN 2 said OB triage nurses should perform initial nursing assessments, reassessments, and perform VS at minimum of every hour. Patient 1 was moved to the L&D unit at approximately 3:36 p.m. CN 2 stated she (CN 2) was taking her break when she was called to assist in code (Code Blue, a term used to indicate a patient requires resuscitation or immediate attention, mostly as a result of a respiratory or cardiac arrest [when the heart stops beating]) for Patient 1 ' s baby. CN 2 stated "I coded the baby." NICU staff was called and attempted to resuscitate the baby. The baby did not survive.

During a second interview and record review of Patient 1 ' s Nursing Flow Sheets on 11/17/2023 at 10:15 a.m., with the PED and the NM 1, the PED and the NM 1 stated the following: On 11/1/2023 at 3:42 p.m., Patient 1 delivered her (Patient 1) baby. Thick meconium (baby ' s first stool) was noted. The umbilical cord was observed around the baby ' s neck and reduced (removed) prior to delivery. The baby ' s Apgar scores (based on baby ' s heart rate, muscle tone, grimace, color, respiration, ranges from 0 to 10) were assessed at 1 minute and 5 minutes of birth. The baby ' s scores were 0 at 1 minute and at 5 minutes, indicating there were no signs of life. L&D and NICU staff attempted to resuscitate the baby for 20 minutes. The baby was pronounced dead at 4:03 p.m.

A review of the facility ' s policy and procedure (P&P) titled, "Standards of the Nursing Practice Labor and Delivery," dated 3/17/2021, the P&P indicated the following: "Maternal and Fetal Assessment: Initial assessment and intervention for intra-partum (during labor) patient may occur concurrently and may include: Determining fetal and maternal status, vital signs and pain assessment ..., and completing a systems assessment (head to toe assessment). Ongoing assessment may include: Identifying maternal physical and psychological response to labor and plan nursing care from data obtained. Identify fetal response to labor, recognizing normal and abnormal fetal heart tracing or non-reassuring characteristics ...Identify progress of labor, recognizing normal and abnormal rate of cervical effacement (the cervix stretches and gets thinner), dilatation, descent of presenting parts and notification of MD. Identity complications diverting from the normal labor process ... Maternal and Fetal Surveillance: Fetal heart rate (FHR) will be continuously monitored, or fetal heart tone auscultation will be done. Nurse will document FHR and uterine contractions electronically. General Interventions... Nursing will observe and document abnormal fetal heart rate pattern, notify MD, and apply appropriate nursing interventions, according to Labor and Delivery (L&D) policies and procedures ... Obtain blood pressure, pulse, respiratory rate every hour or more often if indicated (i.e., hypertension (high blood pressure), abnormal bleeding etc.). Report any abnormal findings to MD. Obtain and document temperature every 4 hours normally ... Perform sterile vaginal examination, as necessary, to determine progression of labor and document. Notify MD of any signs of abnormal labor progress."

A review of the facility ' s policy and procedure (P&P) titled, "Assessment/Reassessment of Patients, Interdisciplinary," dated 10/20/2021, the P&P indicated the following: Nursing, Assessment Time frames: Labor & Delivery/Maternity - ante (before)/intra (during)/Post (after) - partum (childbirth), physical assessment within one (1) hour of admission. Labor assessment frequency per phase. Scope (of assessment) includes, vital signs, basic physical assessment, assessments if necessary, and pain ... Reassessment Time frames: Labor & Delivery: Per standards of care for labor patients. At a minimum of hourly until delivery. Scope (of reassessment), in general assessment, address the following. review of physical and psychosocial status, changes in condition, response to treatment and interventions, and need for additional referrals/communication to member of the multidisciplinary team.

A review of the facility ' s policy and procedure (P&P) titled, "Admission of Patient to Labor and Delivery," dated 10/21/2021, the P&P indicated to "Follow Standards of Nursing Practice in Labor & Delivery Policy ...Receive and carry out admission orders ..."

A review of the facility ' s policy and procedure (P&P) titled, "Hypertensive Disorders of Pregnancy," dated 9/16/2022, the P&P indicated the following: Screening process includes ...Preeclampsia Early Recognition Tool (PERT) and the following:

A. Notify provider (within 60 minutes or sooner, 30 is minutes is preferred) of worrisome "yellow" BPs (blood pressures) greater than or equal to 155 mmHg systolic AND/OR greater than or equal to 105 mmHg (taken at least 15 minutes apart on two occasions).

B. Notify provider (within 60 minutes) if 2 more worrisome "yellow" triggers are present.

C. Notify provider (within 30 minutes) if 1 or more "red" triggers are present.

Preeclampsia (condition in pregnancy characterized by high blood pressure, sometimes with fluid retention, and protein in the urine) Early Recognition Tool (PERT), indicated the following: Worrisome (Yellow) triggers included, but not limited to the following; agitation, confusion, mild headache, nausea (uneasiness in the stomach), vomiting, Systolic (measures the pressure in the arteries when the heart beats) BP (mmHg) over or equal to 155 - 159, Diastolic (pressure the blood is exerting against the artery [blood vessels that deliver oxygenated blood to the body] walls of the heart while the heart muscles are resting) BP (mmHg) between 90 - 109, HR between 110 - 120, abdominal pain, and fetal signs - non-reactive NST (non-stress test)...

Severe (Red) triggers included, but not limited to the following: unresponsiveness, unrelieved headache, Systolic BP (mmHg) over 160, Diastolic BP (mmHg) over 110, Heart rate over 120, and abdominal pain ...

Yellow=Worrisome: Increase assessment frequency: 1 trigger, to do: Notify provider. More than 1 trigger, to do: Notify charge nurse, in-person evaluation ...

Red=Severe: Trigger, 1 of any type: Immediate evaluation, transfer to higher level of care, 1:1 staff ratio ...

Based on interview, and record review, the facility failed to ensure that a comprehensive care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed and implemented for one (1) of 30 sampled patients (Patient 13) in accordance with the facility's policy and procedure regarding care plan development and implementation when Patient 13 was admitted with a hypertensive crisis (very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter dysfunction.

This deficient practice had the potential to delay provision of care to Patient 13 by not identifying the patient ' s needs and risks, which may result in patient harm or death.

Findings:

During a review of Patient 13's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/13/2023, indicated, on 11/13/2023, Patient 13 was admitted to the facility's telemetry unit (a hospital unit where patients are under cardiac monitoring [use of a device that continuously watches the electrical activity of the heart]) with a principal problem of hypertensive crisis (very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter malfunction. The H&P further indicated, Patient 13 ' s plan of treatment included peritoneal dialysis catheter dysfunction requiring a surgical interference and hypertensive urgency (severely elevated blood pressure without evidence of organ damage).

During a concurrent interview and record review on 11/14/2023 at 9:42 a.m. with the manager of the Emergency Department and ICU (MEDICU), Patient 13 ' s nursing care plan (NCP), dated 11/13/2023 to 11/15/2023 was reviewed. Patient 13 ' s NCP indicated, no care plan (provides a framework for evaluating and providing patient care needs related to the nursing process) was developed for hypertensive urgency and peritoneal dialysis. The MEDICU stated, nursing staff should develop a plan of care for each patient based on presenting and identified patient ' s health issues as per facility's policy since care plans serve to facilitate coordination and communication of care specific to problems identified.

A review of the facility ' s policy and procedures (P&P) titled, "Patient Plan of Care," dated 5/2022, the P&P indicated, "The patient's plan of care and goals are developed and documented in Power Chart [Electronic Medical Record], which includes the patient's problems, expected outcomes, and intervention. The care plan must be initiated within first 8 hours after admission by the Registered Nurse. The plan of care for the patient includes assessment based on comprehensive patient needs, treatments, and goals. Patient response to care plan must be documented."

Based on observation, interview and record review, the facility failed to ensure nursing staff adhered to the facility's policies and procedures for three (3) of thirty (30) sampled patients (Patient 13, Patient 11, and Patient 1) when:

1. Patient 13's cardiac activity was not continuously monitored with a cardiac device that monitors and records heart rate and rhythm (the heart beats too fast or too slow) as per physician ' s order and in accordance with the facility ' s policy and procedure regarding cardiac monitoring. This deficient practice had the potential to result in Patient 13 ' s abnormal heart rate and rhythm to be not properly monitored and detected, which may result in patient harm and/or death when left untreated.

2. Skin assessment was not performed and documented for one of 30 sampled patients (Patient 11) in accordance with the facility ' s policy and procedure regarding assessment and reassessment. This deficient practice had the potential to result in the delay of implementation of interventions to prevent skin breakdown (tissue damage caused by friction, moisture, and pressure) for Patient 11.

3. Pain reassessment was not performed after administering a medication (acetaminophen [Tylenol, over the counter pain reliever]) to treat a headache for one of thirty (30) sampled patients (Patient 1) in with the facility ' s policy and procedure regarding pain assessment and management. This deficient practice resulted in the nurses ' inability to determine whether the pain medication was effective and also had the potential for Patient 1 ' s pain to remain unrelieved.

Findings:

1. During a review of Patient 13's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 11/13/2023, the H&P indicated, on 11/13/2023, Patient 13 was admitted to the facility ' s telemetry unit (a hospital unit where patients are under cardiac monitoring [use of a device that continuously watches the electrical activity of the heart]) with a principal problem of hypertensive crisis (a very high blood pressure) and peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen to filter the blood via a catheter [tube]) catheter malfunction. The H&P further indicated, Patient 13 ' s principal problems included peritoneal dialysis catheter dysfunction (malfunction in the catheter) and hypertensive urgency (severely elevated blood pressure without evidence of organ damage).

During a concurrent observation and interview, on 11/14/2023 at 10:28 a.m. with Patient 13, in the emergency department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) patient care room, Patient 13 was observed in bed, with no cardiac electrodes (small, plastic patches that stick to the skin on chest to connect the wires to a monitor detecting heart ' s electric activity) and lead wires attached to Patient 13 ' s chest connecting Patient 13 to a cardiac monitor (a device that continuously watches the electrical activity of the heart) in the room. The cardiac monitor in Patient 13 ' s room, indicated, Patient 13 ' s heart electrical activity was not continuously monitored on 11/14/2023 at 10:28 a.m. Patient 13 stated, the cardiac monitor was not always connected to his (Patient 13) chest.

A review of Patient 13 ' s physician orders, dated 11/13/2023, at 1:16 p.m., the order indicated, Patient 13 required continuous cardiac monitoring with Telemetry level of care.

During a concurrent observation and interview on 11/14/2023 at 10:54 a.m., with Patient 13 ' s primary nurse, at the ED nurses ' station, the monitor displaying patient 13 ' s cardiac activity [in real time] and most recent vital signs ([VS], temperature, blood pressure, respiratory rate, heart rate that indicates the state of a patient's essential body functions) was observed. The monitor displaying Patient 13 ' s cardiac activity and VS indicated, Patient 13 ' s heart rhythm was not displayed. The primary nurse stated, Patient 13 was admitted to a telemetry unit on 11/13/2023, with continuous cardiac monitoring orders, but there were no inpatient hospital beds available, so Patient 13 was occupying the ED bed. The primary nurse further stated, Patient 13 appeared to be disconnected from the monitor but could not say how long Patient 13 ' s cardiac activity was not monitored.

During an interview on 11/17/2023 at 10:17 a.m. with the Manager of ED and ICU (MEDICU), the MEDICU stated, patients with orders for continuous telemetry monitoring must always be connected to a cardiac monitor and nurses should have a physician order if patient requires to be off the monitor. Nursing should continuously monitor patients on telemetry in case the cardiac activity change and requires an immediate assessment and intervention.

A review of the facility's policy and procedure (P&P) titled, "Telemetry Monitoring and Trouble Shooting," dated 3/2022, the P&P indicated, "Telemetry monitoring requires the monitor tech to continuously monitor the electrical activity of the heart, and the trained Registered Nurse is responsible for documenting the measurements and interpretation on all routine rhythms recordings. For the telemetry area being remotely monitored, the primary nurse is responsible for ensuring that the patient ' s monitor alarm is audible on the monitor screens of the units."

2. A review of Patient 11's History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 10/5/2023, the H&P indicated, Patient 11 presented to the facility ' s Emergency Department (ED, responsible for the provision of medical care for patients arriving at the hospital in need of immediate care) on 10/5/2023 with complaints of weakness, a fall (unintentional event resulting in a person coming to rest on the ground or another lower level) at home, with lacerations/skin tears on the left forearm and left leg. The record indicated Patient 11 ' s wounds were not amenable to suture (threads or strands used to close a wound) repair and the wounds were cleaned and dressed per ED staff on 10/5/2023.

A review of Patient 11 ' s nursing assessment documentation (NAD), dated 10/5/2023, the NAD indicated, Patient 11 ' s skin lacerations was recorded by the primary nurse. The NAD further indicated, there was no documentation of any intervention for the skin lacerations identified in Patient 11 ' s H&P on 10/5/2023.

During a concurrent interview and record review, on 11/17/2023 at 11:13 with the manager of the ED and ICU (MEDICU), Patient 11 ' s skin assessment record, dated 10/5/2023 was reviewed. The skin assessment record indicated, there was no documentation of skin issues identified for Patient 11 on 10/5/2023.The MEDICU stated, nursing should document all identified skin issues and document the assessment in the patient ' s skin assessment medical records. The MEDICU further stated, nursing should document all interventions for all identified skin issues, but the primary nurse did not.

During a review of the facility ' s policy and procedures (P&P) titled, "Assessment/Reassessment of Patients, Interdisciplinary [IDT]," dated 10/20/2021, the P&P indicated, "The initial assessment will be performed by a Registered Nurse within 60 minutes of receipt of a patient into the ED. Depth of assessment is based on patient care needs and the scope of services provided in a particular care area. The assessment should be documented in the patient ' s medical record."

3. During a review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/1/2023 at 9:37 a.m., the H&P indicated the following: Patient 1 presented to the Obstetrics (OB, branch of medicine concerned with childbirth and the care of women given birth) Triage (preliminary assessment in order to determine the urgency of their need or treatment), alone and complaining of uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]).

A review of Patient 1 ' s physician ' s order, dated 11/1/2023 at 10:50 a.m., the order indicated, to give acetaminophen (Tylenol, over the counter pain reliever) 650 milligrams (mg, a unit of measurement) by mouth, every six (6) hours as needed for headache.

A review of Patient 1 ' s "Medication Administration Record (MAR)," dated 11/1/2023 at 2:23 p.m., the MAR indicated, Patient 1 was given acetaminophen 650 mg by mouth for a headache, pain intensity level was 10.

During a concurrent interview and record review of Patient 1 ' s physician ' s orders and medication administration record (MAR), on 11/17/2023 at 10:15 a.m., with the Perinatal Educator (PED), the PED stated the following: Patient 1 was given Tylenol 650 mg for a headache, rated at 10 out of 10 (severe pain) pain scale, on 11/1/2023 at 2:23 p.m. The PED verified that there was no documentation in the medical record indicating that Patient 1 ' s pain was reassessed. The PED stated the pain should have been reassessed within 1 hour of administration of pain medication to determine for effectiveness. The PED stated that unrelieved headache can be a sign of preeclampsia (high blood pressure in pregnant women) and can lead to seizures (convulsions, (uncontrolled electrical activity between the brain cells that causes temporary abnormality in muscle tone and movements) or stroke (when blood flow to the brain is blocked).

A review of the facility ' s policy and procedure (P&P) titled, "Pain Assessment and Management," dated 6/22/2022, the P&P indicated the following: Reassessment: Patient will be reassessed after each pain management intervention to evaluate effectiveness, to recognize undesirable side effects and document in the electronic medical record (EMR). Pharmacological and non-pharmacological interventions will be reassessed within approximately 60 minutes.

A review of the facility's P&P titled, "Triage and Medical Screening Procedure, Labor & Delivery," dated 4/21/2022, indicated all patients will be promptly evaluated by triage for ...All patients presenting to Labor & Delivery / Triage are evaluated for hypertension ...Symptoms of pre-eclampsia / eclampsia (seizures during pregnancy) are headache (not relieved with medication) ...

Based on interview and record review, the facility failed to administer oxytocin (a hormone given to strengthen labor contractions [periodic tightening and relaxing of the uterine muscles] and control bleeding after childbirth) as ordered by the physician for one (1)of thirty (30) sampled patients (Patient 1).

This deficient practice had the potential for the non-progression of labor (the process by which the fetus [unborn baby] leaves the uterus [a female organ that plays a critical role in pregnancy]) and excessive bleeding after childbirth.

Findings.

A review of Patient 1's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 11/1/2023 at 9:37 a.m., the H&P indicated the following: Patient 1 presented to the Obstetrics (OB, branch of medicine concerned with childbirth and the care of women given birth) Triage (preliminary assessment in order to determine the urgency of their need or treatment), alone and complaining of uterine contractions (periodic tightening and relaxing of the uterine muscles that force the fetus [unborn baby] out of the uterus [a female organ that plays a critical role in pregnancy]).

A review of Patient 1's physician order dated 11/1/2023 at 9:50 a.m., the order indicated: oxytocin (a hormone given to strengthen labor contractions and control bleeding after childbirth) 30 units 95 ml/hour, comment: "After delivery of infant ' s shoulders: Program continuous infusion at dose of 5.7 units/hour (rate 95 milliliter [mL, unit of measurement]/hour [hr.]), then using the bolus function within the pump, deliver 10 units over duration of 30 minutes (333 mL/hr.). Following completion of bolus, continue at dose of 5.7 units/hr. (rate 95 mL/hr.) for 3 hours and 30 minutes. The record indicated to notify provider for excessive vaginal bleeding.

A review of Patient 1's physician order dated 11/1/2023 at 3:14 p.m., the order indicated: oxytocin 30 units ... for labor induction or augmentation (the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labor) ... Order Comment; Start oxytocin at 2 milliunit/minute (min), Titrate (to adjust the dose) by 2 milliunit/min every 30 minutes to maintain regular uterine contractions of moderate to strong intensity by palpation (method of feeling with hands during assessment) and patient perception ...

A review of Patient 1's physician order dated 11/1/2023 at 4:24 p.m., the order indicated: oxytocin 30 units, Postpartum (after childbirth) Vaginal Delivery ...Order Comment: Stop or hold main line infusion (intravenous [through the vein] administration of medication). The record indicated after delivery of infant's shoulder: infuse oxytocin at 334 mL/hr. for 167 mL (delivers 10 units over 30 minutes). Then reduce rate to 95 mL/hr. to finish the bag. The record indicated to notify provider for excessive vaginal bleeding.

During a concurrent interview and record review of Patient 1's physician orders and Medication Administration Record (MAR) on 11/17/2023 at 10:15 a.m., with the Perinatal Educator (PED), the PED stated the following: Patient 1 had orders for Oxytocin on 11/1/2023. The PED stated oxytocin was usually given prior to delivery to augment the patient ' s labor and given to prevent excessive bleeding after delivery. The PED stated Patient 1 gave birth on 11/1/2023 at 3:42 p.m. The PED verified that there was no documentation in the medical record indicating the Oxytocin had been administered to Patient 1 or the reasons why it (oxytocin) was not administered.

A review of the facility's policy and procedures (P&P) titled, "Admission of Patient to Labor and Delivery," dated 10/21/2021, the P&P indicated the following: Receive and carry out admission orders.