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Tag No.: A0385
Based on medical record review and staff interview, the facility failed to ensure a registered nurse appropriately supervised and evaluated the care of a patient related to the lack of physician notification of a patient's change in condition. (A0395)
Tag No.: A0395
Based on medical record review and staff interview, the facility failed to ensure a registered nurse appropriately supervised and evaluated the care of a patient related to the lack of physician notification of a patient's change in condition. This affected one (Patient #1) of 11 sampled patients.
Findings include:
Record review revealed Patient #1 was admitted to the facility on 01/03/23. Review of the history and physical completed by the Certified Nurse Midwife (CNM) revealed Patient #1 presented to the hospital at 12:39 AM through the emergency department (ED) with a chief complaint of abdominal pain, back pain, possible rupture of membranes, and leg swelling. The patient was admitted at 3:37 AM. The patient was 35 weeks and two days pregnant with an due date of 02/05/23. The active problem list contained the following: abnormal pregnancy ultrasound, body mass index (BI) 40.0-44.9, gonorrhea affecting pregnancy in second trimester, tobacco abuse, mild intermittent asthma without complication, hidradenitis suppurativa (small painful lumps under the skin), intrauterine pregnancy, obesity affecting pregnancy in third trimester, and history of cesarean delivery, currently pregnant. Upon physical exam, the patient was alert and oriented to person, place and time, and appeared in no apparent distress. No neurological deficits were identified during the physical exam. The patient had red very fine raised rash on the inner upper and lower legs. The patient had multiple social concerns.
Upon admission, Patient #1 reported good fetal movement, intermittent left lower abdominal pain, and pain in her upper legs. The history and physical revealed the patient had a history of two previous cesarean sections (C/S) and two miscarriages. The CNM, Staff K, completed a sterile speculum exam (SSE) at 4:03 AM with no pooling of fluid seen. The Nitrazine and Ferning tests revealed negative results, indicating fetal membranes were intact. The patient was noted to be dilated to 1 cm, 30% effaced, and at a high, breech station. Notes from the CNM on 01/03/23 at 5:28 AM revealed the patient complained of abdominal pain, beginning the night before around 9:00 PM. The CNM note further stated the patient had a pinpoint rash and mild swelling to both lower legs with no pitting edema.
An ultrasound was completed by the maternal fetal medicine physician at 10:22 AM. The report stated the fetal heart tones were 144 beats per minute, amniotic fluid assessment was normal, however the fetus' femur length was less than 1st percentile. Recommendations based on the ultrasound were to notify the pediatrician at time of delivery regarding the short femur length so an appropriate postnatal skeletal evaluation could be performed.
A lower leg venous duplex scan was completed for Patient #1 at 3:31 PM with results indicating no evidence of deep or superficial vein thrombosis of the lower extremities.
Fetal monitoring continued throughout the day with Patient #1 taken off the monitor at 4:25 PM. Fetal heart tones were noted to be 120 beats per minute with moderate variability, accelerations present, no decelerations, and no contractions noted. Notes from the CNM on 01/03/23 at 4:41 PM stated labor, rupture of membranes and deep vein thrombosis were all ruled out. The CNM stated that the patient had been up ambulating throughout the day and took a shower without difficulty and denied discomfort. A non-stress fetal monitoring test was completed and documented as reactive. The CNM discussed the above findings with the attending obstetric physician (Staff M) and the decision was made that the patient could be discharged home. The note further stated Patient #1 was having issues with transportation and would be staying in the hospital as a "Courtesy" and would be leaving tomorrow around 10:30 AM.
A note by Staff J dated 01/04/23 at 2:08 AM revealed Patient #1 was entered back into the hospital's charting system (EPIC) while on a courtesy stay until the patient's transportation could come. The patient was entered back into the system to receive a steroid (Celestone) injection at 2:13 AM, and could be discharged back out of the EPIC system. The patient remained on a courtesy stay until transportation arrived.
Review of a nursing note composed by Staff J and dated 01/04/23 at 9:18 AM documented Patient #1 was a courtesy stay. The nurse walked into the patient's room to refill the water pitcher several times through the night. Upon entering the room, Patient #1 was nude and pacing the room. Patient #1 began to ramble nervously and made frequent comments stating "the spirits are in her house and inside her" and became teary-eyed and stated "the world is ending". Patient #1 continued throughout the night with rambling and restlessness. She remained nude and declined the need for a gown or clothing. The nurse walked in and found Patient #1 sitting on the bed, wearing only gloves. There was an obvious amount of body hair on the bed. Patient #1 claimed the hairs were the cause for itching and needed to come out, and she had to battle demons. The patient stated she was not suicidal or homicidal. The nurse witnessed the patient pulling hair viciously from her pubic area and legs. Patient #1 asked "is it safe out there?". The nurse assured the patient she was in a safe place.
The nurse decided to escalate the bizarre, psychotic behavior to the CNM. The CNM gave no orders. The nurse and the next shift nurse collaborated and decided further escalation should be implemented for the safety of the patient. The nurse told the CNM, they were going to have the patient psychiatrically evaluated by the ED. The CNM was ok with that, but gave no new orders. The nurse explained to the patient concerns over the patient's behavior throughout the night. The nurse encouraged the patient to be psychiatrically evaluated by the ED. The patient became defensive and refused to be evaluated by the ED. The OB Manager called the unit, and the nurse explained the situation. The OB Manager stated she would voice the nurse's concerns to the President/CEO. The ED Manager called the nurse to obtain information on the situation of the patient, and the ED Manager instructed the nurse to call Risk Management to explain the situation. The nurse called Risk Management and explained the situation. Risk Management stated there was nothing they could do, as the patient was not homicidal or suicidal, and was not an active patient, but was a courtesy stay. The nurse contacted the CNM's office and left a message with the LPN that worked in the office. There was no evidence a physician was notified of Patient #1's bizarre behaviors.
An interview with Staff J on 01/30/23 at 2:06 PM confirmed obvious concerns about the patient. The nurse stated they did not want to discharge Patient #1 to the street, so they offered courtesy stay. Patient#1 would repeatedly sniff each armpit. Also, the patient was entered back into the system in order to receive a steroid injection, but discharged again after ten minutes. The patient's behavior became concerning on 01/04/23 around 3:00 AM after the patient was discharged. The behavior progressed throughout the night and peaked around 6:00 AM or 7:00 AM. At one point, the patient was sitting in bed, and had the bed raised about as high as it would go, and told the nurse "I have to be way up in the atmosphere away from the spirits". The patient was restless and talking about hearing voices and spirits. At another time, the patient was sitting in bed indian style with sterile gloves on, and raised hands in the air claiming to be praying. The patient was pulling out hairs, including pubic hairs, one by one. The patient pulled out what the nurse described to be a glob of pubic hairs in front of the nurse. The nurse did not feel the patient was mentally ready to go home. The nurse called the CNM around 7:00 AM, and reported what was witnessed. The CNM did not know what to do, and gave no orders. The nurse contacted the CNM again, and expressed wanting to take the patient to the ED. When the nurse attempted to take the patient to the ED, the patient refused. The nurse talked to the ED Manager to report the patient, and tried to figure out what to do, since the patient was discharged out of the system and refused to go to the ED. The nurse talked to the Director of Quality/Risk Management and Accreditation, and was told technically you cannot force someone to be seen in the ED if they refuse. The patient got dressed when hearing talks of being evaluated. The Director of Quality/Risk Management and Accreditation told the nurse to report and chart everything.
Interview with the collaborating physician (Staff M) on 01/31/23 at 10:40 AM revealed they were aware Patient #1 was admitted to the obstetrical unit when they came to the unit on 01/03/23 to see another patient. The collaborating physician stated the CNM filled them in and they ordered a NST, Doppler studies and an ultrasound. The collaborating physician stated a social worker got involved due to transportation issues and TRIPPS was arranged for the next day. The collaborating physician stated the next notification they received was when the patient arrived to another hospital on 01/05/23. The collaborating physician stated they had not been notified of Patient #1's strange behavior when she stayed as a "Courtesy" stay during the night. The collaborating physician further stated that if the CNM came in to evaluate the patient and found significant changes, they would expect to be notified of this change in behavior.
Interview with Staff A and B on 02/01/23 at 3:30 PM confirmed that staff failed to notify the attending obstetric physician when a change in condition occurred with Patient #1.