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Based on interviews, clinical record review and review of hospital documents, the hospital staff failed to a) check for an allergy to an ordered intervention/treatment for 1 of 3 patients (Patient #7) and b) document the position of the fetus before induction of labor for one patient. (Patient #7)

The findings include:

a) Patient #7 was admitted to the hospital on 12/13/2023 at 12:13 AM for a scheduled induction of labor. At 11:59 AM, a Foley catheter was placed using aseptic technique. During the survey the catheter was identified as containing latex by the supply or purchasing number. The Foley was in place for approximately 10 hours and removed at 10:32 PM on 12/13/23 with no adverse effect documented and patient was discharged home on 12/15/22.

Patient #7 presented to the ED (emergency department) on 1/3/23 at 10:51 AM, arriving by ambulance. At 8:30 PM, Patient #7 was admitted to ICU with community acquired pneumonia and respiratory failure. During the hospital stay beginning on 1/3/23, a Foley catheter was inserted at 11:35 AM, while Patient #7 was in the ED. At 8:30 PM, when Patient #7 was admitted to ICU the Foley was removed and a temperature sensing Foley was placed. Staff #11 removed the catheter on 1/6/23 at 1:10 PM and documented labia being swollen and patient complaining of burning with swelling. Staff #14 documented at 8:00 PM, "(Patient #7) Complains of vaginal pain and upon inspection labia inflamed and swollen. Cool compress applied." and at 10:25 PM, "No improvement to swelling of labial pain with compress. NP notified. Benadryl given per order." On 1/7/23 at 6:00 PM, Staff #15 documented, "C/O's that periarea is swolen (sic) and burning. Coolpack and orders per MD given after MD notified." On 1/10/23 at 00:15 AM, Staff #16, documented "Mother of patient called concerned of the fact her daughter's postpartum bleeding had returned and questioned as to whether or not it could be related to the foley catheter she had that was latex given she has a latex allergy. Consulted Practitioner on matter and returned mothers call. Mother still unsatified (sic) with answer provided. Consulted on call OB/GYN and gave her the circumstances of the situation. OB/GYN and NP in agreeace (sic). Called mother again and mother still dissatisfied, convinced that the bleeding could be urethral. After explaining the previous discussions with patient and obtaining permission to do so, did visual inspection of the area. No swelling noted in the area and minimal bleeding noted on feminine pad. Returned call to mother and she did seem satified (sic) with results."

Review of the clinical record found documentation of a latex allergy in multiple places. An allergy to latex was initially entered on 2/8/13 and was confirmed during both hospital admissions. During the course of the survey, Staff #1 confirmed that all Foley catheters used for Patient #7 were latex and that all temperature sensing Foley available for use are latex. Review of hospital policy "Latex Allergy" effective 3/2021, read in part as follows: "viii. Confirm presence or absence of latex allergy/sensitivity prior to placing a Foley catheter to determine if a latex free type should be utilized for patient."

b) Patient #7 was admitted to the hospital on 12/13/2023 at 12:13 AM for a scheduled induction of labor. Prior to the induction of labor a baseline assessment of Patient #7 was completed along with a reactive non-stress test documented at 1:07 AM (commonly, the nonstress test is considered reactive, or normal, if there are two or more fetal heart rate (FHR) accelerations within a 20-minute period). Patient #7's blood pressure, heart rate and oxygen saturation as well as, fetal heart rate were closely monitored and the medical record evidenced detailed documentation of changes and intervention provided when maternal blood pressure and heart rate declined. At 1:30 AM, Staff #8 documented completion of a vaginal exam as follows: "Fetal station: -3; Cervical dilation: 2; Cervical effacement: 50" Presentation/position of the fetus in the uterus was not documented. Patient #7 received 50 mcg misoprostol orally at 1:39 AM as ordered. (Misoprostol is a synthetic prostaglandin medication used to induce labor). Mother's vitals remained stable and FHR Category remained Category I (per hospital reference document defined as"Baseline rate: 110-160 beats per minute (bpm); Baseline FHR variability: moderate; Late or variable decelerations: absent; Early decelerations: present or absent; Accelerations: present or absent".) until 3:00 AM when maternal blood pressure was documented as 89/70 mmHg, FHR Baseline at 135 bpm in last 15 minutes and FHR as Category II (examples of Category II may include: baseline bradycardia, tachycardia, baseline FHR minimal variability, absent baseline variability not accompanied by recurrent decelerations, marked baseline variability, absence of induced accelerations after fetal stimulation, recurrent variable decelerations accompanied by minimal or moderate baseline variability, prolonged deceleration >2 minutes but < 10 minutes, recurrent late decelerations with moderate baseline variability, variable decelerations with other characteristics such as slow return to baseline). Documentation per Staff #4 showed moderate variability and variable decelerations. Patient #7's blood pressure improved to 99/65 mmHg at 3:15 AM with FHR baseline remaining at 135 bpm. FHR Category remained at II, ranging 130-140 bpm, with variable decelerations and moderate variability documented until 6:00 AM. Vaginal exam was performed at 5:45 AM by Staff #8 and read, "Fetal station: -3; Cervical dilation: 2; Cervical effacement: 50". No documentation of fetal presentation/position was present. At 5:52 AM, Patient #7 received misoprostol 50 mcg oral as ordered. At 6:00 AM, FHR Category I was documented with no decelerations present and maternal blood pressure recovered to 103/62 mmHg. At 8:13 AM, Staff #11 documented artificial rupture of membranes with clear odorless fluid noted and vaginal exam documented, "Fetal station: -3; Cervical dilation: 2; Cervical effacement: 60". Documentation of fetal position prior to initiation of pitocin was not found in the medical record. Pitocin is a hormone that is used to induce labor or strengthen uterine contractions. At 8:40 AM, pitocin was initiated IV at a rate of 2 milliunits/min. After administration of epidural analgesia Patient #7 experienced decline in blood pressure and heart rate that required pharmacological interventions. At 12:29 PM - pitocin infusion increased to 4 milliunits/min and to 6 milliunits/min at 1:09 PM while FHR remained Category I and maternal blood pressure and heart rate were stable. At 2:00 PM Staff #11 performed a vaginal exam that documented, "Fetal station: -2; Cervical dilation: 4; Cervical effacement: 80". At this time, FHR Category II with late decelerations was documented, patient was placed in semi-fowlers position and Provider #1 notified. At 2:04 PM the medical record evidenced that Provider #1 stated "on (their) way" and pitocin infusion was stopped.

Review of the clinical record failed to find evidence that nursing staff determined the position of the fetus prior to induction of labor as noted in the above summary. In an interview on 2/16/23 at 1:20 PM, Staff #4 (Director of the Women's Center) confirmed the nurse should always chart the position of the baby but stated if the baby is "up high, the nurse may not have felt the presenting part." When asked if the nurse should have documented that they were not able to determine the position, Staff #4 replied, "Yes". Hospital policy "Women's Center-Oxytocin/Pitocin Administration" effective 2/21, read in part "A. Prior to the administration of Oxytocin/Pitocin, the baseline assessment will be completed including the following parameters to determine if the patient meets criteria for induction: 1. Presentation of the fetus by a qualified member of the obstetric team via a vaginal exam. Malpresentations are contraindicated for Oxytocin induction." Staff #4 stated that the nurse would have had to have known the position of the fetus in order to place the monitoring equipment in the right location, but agreed there is no evidence of this in the clinical record. Review of personal files found all nurses involved in the care of Patient #7 had completed advanced training in fetal monitoring and were qualified to determine the position of the fetus.

The above findings were reviewed with Staff #1 prior to the exit on 2/17/23.