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Based on an isolated medical record review for one (1) of ten (10) closed records reviewed, it was determined that the governing body failed to ensure the emergency department physician fully assessed and acted with timeliness, in notifying the obstetrical team as it relates to the management of the fetus of an obstetrical patient that presented to the emergency department in respiratory distress This resulted in a delay in assessing the patient and decline in her condition (Patient #90).


The findings include:

Failure of the hospital to meet the Conditions of Participation for Surgical Services A0940 and Emergency Services A1100. Cross-reference CFR§482.51 Surgical Services and 482.55 Emergency Services.

Patient #90 presented to the emergency department (ED) on June 24, 2017 at approximately 12:35 PM with a medical history of asthma and a chief complaint of difficulty breathing. She was assessed as being 34 weeks pregnant, morbidly obese with a weight of 520 pounds (lbs.).


The nursing triage note at 12:59 on June 24, 2017 included the following: "...Stated complaint - SOB [shortness of breath]/34 weeks pregnant...alert and oriented x 3 [person; place; time]... [history of] asthma - yes..."

The facility's "Medication Reconciliation" Form was not completed by the nurse and nursing documentation lacked evidence of the patient's current medications and any medications taken prior to presentation to the emergency department.

According to the initial physical examination recorded by the emergency physician managing Patient #90's care; upon arrival to the ED, Patient #90 was assessed as follows: "...moderate distress...morbidly obese in respiratory distress with retraction and use of accessory muscle, limited moving air with inspiratory and expiratory wheezing..." Additionally, the assessment included but was not limited to the following review of systems: Genitourinary - denies other (vaginal bleeding), [indicative that the patient did not have vaginal bleeding]; Gastrointestinal - normal bowel sounds, non-tender, soft, no organomegaly, morbidly obese mostly on the abdominal area, no tenderness was appreciated and Cardiovascular - no edema, no gallop, no JVD (jugular vein distention).

The physician's initial physical examination lacked evidence of an assessment regarding the status of the fetus.


A physician's order at 12:37 PM on June 24, 2017 directed "Fetal Heart Tones ER." The physician failed to order the frequency for assessing the patient's fetal heart tones.


The clinical record revealed that Fetal Heart Tones were initially assessed greater than 2 hours later at approximately 2:53 PM during an ultrasound test.


The emergency department physician contacted [doctor's name], intensivist to evaluate Patient #90. He/she was asked "to consult Ob/Gyn first and contact him again." A physician's progress note at 1336 (1:36 PM) on June 24, 2017 revealed the attending physician consulted the obstetrician regarding Patient #90 approximately one hour after her presentation to the emergency department.

The obstetrician advised [s/he] would come to see Patient #90 in the Emergency Department. The obstetrician presented to the ED at approximately 1354 (1:54 PM) and recommended that Patient #90 be transferred to a higher level of care secondary to the high risk factors involved.

The Emergency Medical team arrived to transport the patient to another hospital for higher medical management at 18:00 (6:00 PM). The patient became bradycardic (slow pulse) and asystolic (no pulse); resuscitative measures were initiated and the decision was made to perform an emergency cesarean section.

Through interview with Employee #34, it was determined that Patient #90 was initially transported from the ED, to the main operating room (OR) (both located on the first floor); however, the patient had to be moved to the Labor and Delivery operating room (located on the 3rd floor) because there was no "specialized" neonatal equipment available in the main OR.

A telephone interview was conducted with Employee #34 on July 12, 2017 at approximately 12:20 PM. He/she stated, the patient was taken to the main operating room, but the patient had to be moved to Labor and Delivery operating room because there was more neonatal equipment.

The record lacked evidence that an integration of services between the emergency department and the main operating room were immediately available to meet Patient #90's need for an emergent cesarean section. There was a critical time delay when Patient #90 had to be transported from the emergency department to the main operating room; and subsequently to the labor and delivery OR in order to provide the needed interventions for the emergent cesarean section. There was a time lapse of approximately 35 minutes from the time a decision for an emergent C-section was made and the actual surgical intervention.

An emergency cesarean section was performed at approximately 6:38 PM on June 24, 2017 and a "viable" fetus was delivered. However; Patient #90 was pronounced dead at 7:35 PM on June 24, 2017 and the fetus expired four (4) days later at another hospital on June 28, 2017.

The emergency department physician failed to evaluate the status of the fetus during an initial physical assessment. Fetal heart tones were not monitored after an initial assessment performed two (2) hours subsequent to Patient #90's emergency department presentation. There was an approximate one (1) hour delay before the 34 week patient was assessed by an obstetrician.

The closed record was reviewed July 11, 2017.

Cross referenced: CFR§ 482.24(b) Medical Records; 482.23(b) (3) Nursing Services; 482.51 Surgical Services and 482.55 Emergency Services.

Based on an isolated medical record review for one (1) of ten (10) closed records reviewed, it was determined that the physician failed to fully assess and act with timeliness, in notifying the obstetrical team as it relates to the management of the fetus of an obstetrical patient that presented to the emergency department in respiratory distress (Patient #90).

The findings include:

Patient #90 presented to the emergency department (ED) on June 24, 2017 at approximately 12:35 PM with a medical history of asthma and a chief complaint of difficulty breathing.

The nursing triage note at 12:59 on June 24, 2017 included the following: "...Stated complaint - SOB [shortness of breath] /34 weeks pregnant...alert and oriented x 3 [person; place; time]... [history of] asthma - yes..."

According to the initial physical examination recorded by the emergency physician managing Patient #90's care; upon arrival to the ED, Patient #90 was assessed as follows: "...moderate distress...morbidly obese in respiratory distress with retraction and use of accessory muscle, limited moving air with inspiratory and expiratory wheezing..." Additionally, the assessment included but was not limited to the following review of systems: Genitourinary - denies other (vaginal bleeding), [indicative that the patient did not have vaginal bleeding]; Gastrointestinal - normal bowel sounds, non-tender, soft, no organomegaly, morbidly obese mostly on the abdominal area, no tenderness was appreciated and Cardiovascular - no edema, no gallop, no JVD (jugular vein distention).

The physician's initial physical examination lacked evidence of an assessment regarding the status of the fetus.

According to physician's progress notes, an entry at 1336 (1:36 PM) on June 24, 2017 revealed the attending physician consulted an obstetrics physician regarding Patient #90. The obstetrician advised [s/he] would come to see Patient #90 in the ED.

A physician's entry at 1354 (1:54 PM) revealed that the obstetrician presented to the ED to see Patient #90.

A period greater than one (1) hour lapsed before the attending emergency physician consulted the obstetrical care provider to assess Patient #90. Additionally, the attending emergency physician failed to include an assessment of the status of the fetus during the initial physical examination. The closed records were reviewed July 11, 2017.

Cross referenced: CFR§482.24(b) Medical Records and 482.23(b)(3) Nursing Services.

Based on medical record review, policy review, and staff interview for one (1) of ten (10) records reviewed, it was determined that the nursing staff failed to assess fetal heart tones for an obstetrical patient (Patient #90).

The findings include:

Patient #90 presented to the Emergency Department (ED) by ambulance on June 24, 2017 at 12:31 PM from home with a chief complaint of worsening shortness of breath for three (3) days.

The surveyor conducted a review of the medical record on July 6, 2017, at approximately 2:00 PM. The medical staff conducted the initial History and Physical to include a Review of System on June 24, 2017, at 12:35 PM. The patient presented to the ED in respiratory distress with a pulse ox (oxygen saturation) of 61 percent on room air (normal oxygen saturation ranges from 90-100 percent) and was started on Bi-level Positive Air Pressure (BiPAP). The patient had a history of asthma and was assessed as being 34 weeks pregnant, morbidly obese, with a weight of 520 pounds (lbs.). During the triage assessment, the nurse documented Patient #90 had a confirmed history of preeclampsia during her first and the current pregnancy. The patient was Gravida 2 (total number of confirmed pregnancies, regardless of the outcome); and Para 1 (number of delivered pregnancies) The patient's general appearance was described as being in respiratory distress, exhibiting symptoms of audible inspiratory and expiratory wheezing with chest retraction and use of accessory muscles. The patient received BIPAP with continuous nebulization, which improved her oxygen saturation to 90-100%

A review of the physician's orders dated June 24, 2017, at 12:37 PM directed; "Fetal Heart Tones." According to a nursing note dated June 24, 2017, at 5:00 PM, the nurse from Labor and Delivery was called to perform Fetal Heart Tones.

According to a physician's entry dated June 24, 2017 at 1330 (1:30 PM), a bedside ultrasound revealed a gestational age calculated at 35 weeks and a positive fetal heart rate of 157 beats per minute (bpm) [Normal fetal heart rate (tones) ranges from 120 to 160 beats per minute according to the National Institutes of Health]. The ultrasound revealed there was fetal movement with sufficient amniotic fluid.

According to a physician's reassessment note on June 24, 2017, at 2:53 PM, the ultrasound was performed with an Obstetrician in the room. The baby was 35 weeks and 2 days viable, with a fetal heart rate of 156.

The medical record lacked evidence that nursing staff assessed fetal heart tones (heart rate). The only documented fetal heart rate that was assessed was via ultrasound, as noted above.

On July 12, 2017, at approximately 12:20 PM, a telephone interview was conducted with Employee #34, who stated that s/he presented to the Emergency Room to obtain a fetal heart tone on Patient #90. S/he stated that s/he had been attempting to get the fetal heart rate for approximately 45 minutes, with the assistance of two staff members. However, because of the patient's size, it was difficult to obtain the fetal heart rate [tone]. Employee #34 stated that Employee #11 interrupted him/her while s/he was trying to find the fetal heart tone and said they were busy working with the patient and that an ultrasound had been done, so he/she did not need to continue with trying to get the fetal heart rate. In addition, Employee #34 informed Employee #11 that if the fetal heart rate could not be obtained, Employee #12 recommended hourly ultrasound assessments.

The medical record lacked documented evidence that the medical staff was notified of Employee #11's inability to obtain the fetal heart tones as ordered.

Employee #34 acknowledged that s/he was unable to assess Patient #90's fetal heart tone. Further, he/she agreed that there was no documentation in the medical record regarding his/her difficulty in obtaining the fetal heart tone and the communication with other medical staff.

Cross referenced to §482.24(c)(4)(vi) A-0467 Medical Records.

Based on record review and staff interview for one (1) of ten (10) records reviewed, it was determined that the physician failed to ensure that an order for fetal heart tone assessment was accurately written for Patient #90.

The findings include:

A review of the closed clinical record on July 11, 2017 at approximately 10:00 AM revealed the following:

Patient #90 presented to the Emergency Department (ED) by ambulance on June 24, 2017 at 12:31 PM from home with a chief complaint of worsening shortness of breath for three (3) days.

The patient had a history of asthma and was assessed as being 34 weeks pregnant, morbidly obese with a weight of 520 pounds (lbs.).

A physician's order dated June 24, 2017 at 12:37 PM directed; "Fetal Heart Tones (ER) [Emergency Room]."

The physician failed to include in the order, the frequency and duration for assessing the fetal heart tones (fetal heart rate).

A face-to-face interview was conducted with Employee #24 was conducted on July 11, 2017 at approximately 12:30 PM. When queried regarding the frequency and duration of the fetal heart tone. He/she stated, the order was not clarified with the physician and the nurse had to come from Labor and Delivery to monitor the fetal heart tone (fetal heart rate).

1. Based on medical record review, policy review, and staff interview, it was determined that the nursing staff failed to ensure complete and accurate documentation on the code blue record for one (1) of ten (10) records reviewed (Patient #90).


The findings include:


The United Medical Center Policy, effective October 2006, revised May 2016, titled, 'Cardiopulmonary Resuscitation Blue,' stipulates, "...Centrex/Page Operator: Activate the code by announcing "Code Blue" through the overhead page system indicating the location of the code ...The Cardiopulmonary Resuscitation Summary is placed in the patient's chart upon completion of documentation and signatures for all area except Labor & Delivery. The Neonatal Resuscitation Record and Labor & Delivery summary is completed and placed on the patient's chart."


The Emergency Department staff treated Patient #90 for Shortness of Breath and Hypoxia.


The surveyor conducted a medical record review on July 11, 2017, at approximately 11:30 AM, which revealed a 'Code Blue Record,' dated June 24, 2017, starting at 6:02 PM. The initial 'Code Blue Record' failed to indicate the following: "Time of arrest, Time CPR Started, Location, Time called to Centrex, Arrest Recognized by: (Medical Doctor), Time Code Terminated, Patient Outcome and Transferred to ..."


The 'Code Blue Record' lacked evidence that the nursing staff followed the hospital's policy to document complete and accurate information to reflect the patient's status.


The surveyor conducted a face- to- face interview with Employee #24 on July 11, 2017, at approximately 1:35 PM, regarding the absence of documentation on the code record. S/he acknowledged the findings.



2. Based on medical record review and staff interview, it was determined that the clinical staff failed to consistently document pulse oximetry in accordance with the physician order, in one (1) of ten (10) records reviewed (Patient #90).


The findings include:


Patient #90 presented to the Emergency Department (ED) by ambulance from home for complaints of worsening shortness of breath for three (3) days.


The surveyor conducted a review of the medical record on July 6, 2017, at approximately 2:00 PM. A History and Physical examination dated June 24, 2017, at 12:35 PM revealed that the patient presented to the ED in respiratory distress with a pulse ox (oxygen saturation) of 61 percent and the patient was started on Bi-level Positive Air Pressure (BiPAP).


The surveyor conducted a subsequent medical record review on July 11, 2017, at approximately 11:00 AM. A physician's order dated June 24, 2017, directed continuous Pulse Ox (oximetry) monitoring to be performed by the Respiratory Therapist. Further review of the vital signs documentation revealed there was no entry for "Pulse Ox" on June 24, 2017 at 1:30 PM; at 3:12 PM; and at 5:41 PM.


The record lacked documented evidence that Respiratory Therapy continuously documented pulse oximetry to assess and determine the effectiveness of the intervention.


On July 11, 2017, at approximately 1:00 PM, the surveyor conducted a face-to-face interview with Employees #24, who acknowledged the findings.

Based on medical record review and policy review, it was determined that the emergency department nursing staff failed to follow the hospital policy, "Medication Reconciliation" upon admission in (1) of 10 records reviewed (Patient #90).


The findings include:

The United Medical Center Administrative Policy number, 03-024, entitled, "Medication Reconciliation", revised November 2016, Section C. Emergency Department Medication Reconciliation stipulates, "- Triage Nurse: 1. Indicate "none taken" on the triage form in the medication section, if the patient does not take medications. 2. Document all medications (name, lose, frequency, route) that the patient/family/nursing home report the patient is currently taking on the Medication Reconciliation Form. Treating Physician/Physician Assistant: 1. Ensure completeness/accuracy of all medication order elements (name, dosage, frequency, and route). 2. Review all home medications prior to ordering any new medication ....."

Patient #90 presented to the Emergency Department (ED) by ambulance on June 24, 2017 at 12:31 PM from home with a chief complaint of worsening shortness of breath for three (3) days.


The surveyor conducted a review of the medical record on July 6, 2017, at approximately 2:00 PM. During the triage assessment, the nurse-documented Patient #90 had a confirmed history of preeclampsia during her first and the current pregnancy. The patient was Gravida 2 (total number of confirmed pregnancies, regardless of the outcome); and Para 1 (number of delivered pregnancies) The patient's general appearance was described as being in respiratory distress, exhibiting symptoms of audible inspiratory and expiratory wheezing with chest retraction and use of accessory muscles. The patient received BIPAP with continuous nebulization, which improved her oxygen saturation to 90-100%.

The nursing triage assessment form, under the section labeled "Home Medications," revealed "Unable to Obtain Home Medication History."


The medical record lacked evidence that the nurse obtained and documented a list of the patient's current medications in accordance with hospital policy. The closed record was reviewed July 11, 2017.

Based on medical record review, and staff interview, it was determined that staff failed to ensure the hospital was maintained in a manner to ensure patient safety and quality of care in the main Operating Room. The facility failed to ensure essential equipment was immediately available and accessible to render appropriate care for an emergent cesarean section procedure, and for the potential stabilization of a neonate. Since equipment was not immediately available, there was a significant delay in initiating the cesarean section. (Patient #90).


The findings include:



Patient #90 presented to the Emergency Department (ED) by ambulance on June 24, 2017 at 12:31 PM from home with a chief complaint of worsening shortness of breath for three (3) days.


The patient had a history of asthma and was assessed as being 34 weeks pregnant, morbidly obese, with a weight of 520 pounds (lbs.).


During the triage assessment, the nurse-documented Patient #90 had a confirmed history of preeclampsia during her first and the current pregnancy. The patient was Gravida 2 (total number of confirmed pregnancies, regardless of the outcome); and Para 1 (number of delivered pregnancies). The patient's general appearance was documented as follows: respiratory distress, pulse ox (oxygen saturation) of 61 percent on room air (normal oxygen saturation ranges from 90-100 percent); audible inspiratory and expiratory wheezing with chest retraction and use of accessory muscles. The patient received Bi-level Positive Airway Pressure (BIPAP) with continuous nebulization, which improved her oxygen saturation to 90-100%.


The obstetrician recommended that the patient be transferred to a higher level [another hospital] of care secondary to the high risk factors involved.


According to the physician's progress note dated June 24, 2017 at 1830 (6:30 PM); the Emergency Medical team arrived to transport the patient to another facility for higher medical management at 18:00 (6:00 PM) at which time, the patient became bradycardic (slow pulse) and asystolic (no pulse); resuscitative measures were initiated, and the decision was made to perform an emergency cesarean section. The patient arrived in the labor and delivery Operating Room at 18:35 (6:35 PM) and at 18:38 (6:38 PM) a "viable baby girl" was delivered. Cardiopulmonary measures (for Patient #90) continued during the cesarean section procedure. Subsequently, Patient #90 expired; she was pronounced dead at 19:35 PM (7:35 PM).


Through interview with Employee #34, it was determined that Patient #90 was initially transported from the Emergency Department, to the main operating room (OR) (both located on the first floor); however, the patient had to be moved to the Labor and Delivery operating room (located on the 3rd floor) because there was no "specialized" neonatal equipment available in the main OR. Additionally, there was a critical time delay when Patient #90 had to be transported from the emergency department to the main operating room; and subsequently to the labor and delivery Operating Room in order to provide the needed interventions for the emergent cesarean section. There was a time lapse of approximately 35 minutes from the time a decision for an emergent C-section was made in the emergency department and the actual surgical intervention performed in the labor and delivery OR, located on the 3rd floor.


A telephone interview was conducted with Employee #34 on July 12, 2017 at approximately 12:20 PM. He/she stated, the patient was taken to the main operating room, but the patient had to be moved to Labor and Delivery operating room because there was more neonatal equipment.


The facility failed to ensure that essential equipment was immediately available and accessible to render appropriate care for an emergent cesarean section procedure and for stabilization of a neonate. Further, review of the closed medical record, revealed a fetal demise approximately 4 days post-cesarean section delivery at another hospital on June 28, 2017.

Based on medical record review, and staff interview, it was determined that staff failed to ensure the hospital provided appropriate equipment necessary to furnish the surgical services offered, as evidenced by a lack of specialized equipment in the main Operating Room to accommodate emergent obstetrical surgical intervention. (Patient #90).

The findings include:


Patient #90 presented to the Emergency Department (ED) by ambulance on June 24, 2017 at 12:31 PM from home with a chief complaint of worsening shortness of breath for three (3) days.


The patient had a history of asthma and was assessed as being 34 weeks pregnant, morbidly obese, with a weight of 520 pounds (lbs.).


During the triage assessment, the nurse-documented Patient #90 had a confirmed history of preeclampsia during her first and the current pregnancy. The patient was Gravida 2 (total number of confirmed pregnancies, regardless of the outcome); and Para 1 (number of delivered pregnancies). The patient's general appearance was documented as follows: respiratory distress, pulse ox (oxygen saturation) of 61 percent on room air (normal oxygen saturation ranges from 90-100 percent); audible inspiratory and expiratory wheezing with chest retraction and use of accessory muscles. The patient received Bi-level Positive Airway Pressure (BIPAP) with continuous nebulization, which improved her oxygen saturation to 90-100%.


The obstetrician recommended that the patient be transferred to a higher level [another hospital] of care secondary to the high risk factors involved.


According to the physician's progress note dated June 24, 2017 at 1830 (6:30 PM); the Emergency Medical team arrived to transport the patient to another facility for higher medical management at 18:00 (6:00 PM) at which time, the patient became bradycardic (slow pulse) and asystolic (no pulse); resuscitative measures were initiated, and the decision was made to perform an emergency cesarean section. The patient arrived in the labor and delivery Operating Room at 18:35 (6:35 PM) and at 18:38 (6:38 PM), a "viable baby girl" was delivered. Cardiopulmonary measures (for Patient #90) continued during the cesarean section procedure. Subsequently, Patient #90 expired; she was pronounced dead at 19:35 PM (7:35 PM).


Through interview with Employee #34, it was determined that Patient #90 was initially transported from the Emergency Department, to the main operating room (OR) (both located on the first floor); however, the patient had to be moved to the Labor and Delivery operating room (located on the 3rd floor) because there was no "specialized" neonatal equipment available in the main OR. There was a time lapse of approximately 35 minutes from the time a decision for an emergent C-section was made in the emergency department and the actual surgical intervention performed in the labor and delivery OR, located on the 3rd floor.


A telephone interview was conducted with Employee #34 on July 12, 2017 at approximately 12:20 PM. He/she stated, the patient was taken to the main operating room, but the patient had to be moved to Labor and Delivery operating room because there was more neonatal equipment.


The facility failed to ensure that essential equipment was immediately available and accessible in the main operating room to render appropriate care for an emergent cesarean section procedure and for stabilization of a neonate.

Based on medical record review, and staff interview, it was determined that staff failed to provide emergency services and timely diagnostic and care interventions to meet one (1) of 10 patient's needs. The clinical record revealed a lack of integration of services between the emergency department, obstetrical and surgical services which caused the patient/fetus' condition to deteriorate. Patient #90.

The findings include:

A review of the closed medical record for Patient #90 on July 11, 2017 at approximately 10 AM revealed the following:

Patient #90 presented to the Emergency Department (ED) by ambulance on June 24, 2017 at 12:31 PM from home with a chief complaint of worsening shortness of breath for three (3) days.


The patient had a history of asthma and was assessed as being 34 weeks pregnant, morbidly obese, with a weight of 520 pounds (lbs.).


According to the initial physical examination recorded by the emergency physician managing Patient #90's care; upon arrival to the ED, Patient #90 was assessed as follows: "...moderate distress...morbidly obese in respiratory distress with retraction and use of accessory muscle, limited moving air with inspiratory and expiratory wheezing..." Additionally, the assessment included but was not limited to the following review of systems: Genitourinary - denies other (vaginal bleeding), [indicative that the patient did not have vaginal bleeding]; Gastrointestinal - normal bowel sounds, non-tender, soft, no organomegaly, morbidly obese mostly on the abdominal area, no tenderness was appreciated and Cardiovascular - no edema, no gallop, no JVD (jugular vein distention)." However, the physician's initial physical examination lacked evidence of an assessment regarding the status of the fetus.


During the triage assessment, the nurse-documented Patient #90 had a confirmed history of preeclampsia during her first and the current pregnancy. The patient was Gravida 2 (total number of confirmed pregnancies, regardless of the outcome); and Para 1 (number of delivered pregnancies). The patient's general appearance was documented as follows: respiratory distress, pulse ox (oxygen saturation) of 61 percent on room air (normal oxygen saturation ranges from 90-100 percent); audible inspiratory and expiratory wheezing with chest retraction and use of accessory muscles. The patient received Bi-level Positive Airway Pressure (BIPAP) with continuous nebulization, which improved her oxygen saturation to 90-100%.


A review of the physician's orders dated June 24, 2017, at 12:37 PM directed; "Fetal Heart Tones." The medical record lacked evidence that nursing staff assessed fetal heart tones (heart rate). A period of greater than two (2) hours lapsed and the only documented fetal heart rate that was assessed was via ultrasound, on June 24, 2017, at 2:53 PM.


The obstetrician recommended that the patient be transferred to a higher level of care [another hospital] secondary to the high risk factors involved.


The Emergency Medical team arrived to transport the patient to another facility for higher medical management at 18:00 (6:00 PM). The patient became bradycardic (slow pulse) and asystolic (no pulse); resuscitative measures were initiated, and the decision was made to perform an emergency cesarean section. The immediate availability of "specialized equipment" for an emergent cesarean section was not available in the emergency department.


Through interview with Employee #34, it was determined that Patient #90 was initially transported from the ED, to the main operating room (OR) (both located on the first floor); however, the patient had to be moved to the Labor and Delivery operating room (located on the 3rd floor) because there was no "specialized" neonatal equipment available in the main OR. Additionally, there was a critical time delay when Patient #90 had to be transported from the emergency department to the main operating room; and subsequently to the labor and delivery OR in order to provide the needed interventions for the emergent cesarean section. There was a time lapse of approximately 35 minutes from the time a decision for an emergent C-section was made and the actual surgical intervention.


A telephone interview was conducted with Employee #34 on July 12, 2017 at approximately 12:20 PM. He/she stated, the patient was taken to the main operating room, but the patient had to be moved to Labor and Delivery operating room because there was more neonatal equipment.


The record lacked evidence that an integration of services between the emergency department and the main operating room were immediately available to meet Patient #90's need for an emergent cesarean section. There was a critical time delay when Patient #90 had to be transported from the emergency department to the main operating room; and subsequently to the labor and delivery OR in order to provide the needed interventions for the emergent cesarean section. There was a time lapse of approximately 35 minutes from the time a decision for an emergent C-section was made and the actual surgical intervention.

Subsequently, Patient #90 expired; she was pronounced dead at 19:35 PM (7:35 PM) on June 24, 2017. Further review of the closed medical record revealed a fetal demise approximately 4 days post-cesarean section delivery at another hospital on June 28, 2017.

Based on record review and staff interview, for one (1) of ten records reviewed, it was determined that the facility failed to ensure that essential equipment was immediately available and accessible to render appropriate care for an emergent cesarean section procedure, and for the potential stabilization of a neonate and failed to promote an integration of services between the emergency department, obstetrical and surgical services. (Patient #90).


The findings include:


Patient #90 presented to the Emergency Department (ED) by ambulance on June 24, 2017 at 12:31 PM from home with a chief complaint of worsening shortness of breath for three (3) days.


The patient had a history of asthma and was assessed as being 34 weeks pregnant, morbidly obese, with a weight of 520 pounds (lbs.).


During the triage assessment, the nurse documented Patient #90 had a confirmed history of preeclampsia during her first and the current pregnancy. The patient was Gravida 2 (total number of confirmed pregnancies, regardless of the outcome); and Para 1 (number of delivered pregnancies). The patient's general appearance was documented as follows: respiratory distress, pulse ox (oxygen saturation) of 61 percent on room air (normal oxygen saturation ranges from 90-100 percent); audible inspiratory and expiratory wheezing with chest retraction and use of accessory muscles. The patient received Bi-level Positive Airway Pressure (BIPAP) with continuous nebulization, which improved her oxygen saturation to 90-100%.

According to the initial physical examination recorded by the emergency physician managing Patient #90's care; upon arrival to the ED, Patient #90 was assessed as follows: "...moderate distress...morbidly obese in respiratory distress with retraction and use of accessory muscle, limited moving air with inspiratory and expiratory wheezing..." Additionally, the assessment included but was not limited to the following review of systems: Genitourinary - denies other (vaginal bleeding), [indicative that the patient did not have vaginal bleeding]; Gastrointestinal - normal bowel sounds, non-tender, soft, no organomegaly, morbidly obese mostly on the abdominal area, no tenderness was appreciated and Cardiovascular - no edema, no gallop, no JVD (jugular vein distention).

However, there was no evidence that the physician communicated with the obstetrical provider with timeliness. A period greater than one (1) hour lapsed before the attending emergency physician consulted the obstetrical care provider to assess Patient #90.

The obstetrician presented to the ED at approximately 1354 (1:54 PM) and recommended that Patient #90 be transferred to a higher level of care secondary to the high risk factors involved.

The Emergency Medical team arrived to transport the patient to another hospital for higher medical management at 18:00 (6:00 PM). The patient became bradycardic (slow pulse) and asystolic (no pulse); resuscitative measures were initiated, and the decision was made to perform an emergency cesarean section.


Through interview with Employee #34, it was determined that Patient #90 was initially transported from the ED, to the main operating room (OR) (both located on the first floor); however, the patient had to be moved to the Labor and Delivery operating room (located on the 3rd floor) because there was no "specialized" neonatal equipment available in the main OR.


A telephone interview was conducted with Employee #34 on July 12, 2017 at approximately 12:20 PM. He/she stated, the patient was taken to the main operating room, but the patient had to be moved to Labor and Delivery operating room because there was more neonatal equipment.

The record lacked evidence that an integration of services between the emergency department and the main operating room were immediately available to meet Patient #90's need for an emergent cesarean section. There was a critical time delay when Patient #90 had to be transported from the emergency department to the main operating room; and subsequently to the labor and delivery OR in order to provide the needed interventions for the emergent cesarean section. There was a time lapse of approximately 35 minutes from the time a decision for an emergent C-section was made and the actual surgical intervention.