HospitalInspections.org

Based on interview and record review, registered nurse A (RN A) failed to follow hospital policy for 1 of 30 patients (1), when the physician was not notified of changes in Patient 1's fetal heart rate (FHR) tracings. The failure resulted in not providing the needed management for the changes in the FHR tracings.

Findings:

Patient 1, on 40 weeks gestational age, was admitted on 2/11/15 at 9:12 a.m. for uterine contractions which started at 5 a.m. and became stronger at 7:15 a.m. with spontaneous rupture of the membrane 10 minutes prior to admission.

Review of Patient 1's Order Summary dated 2/11/15 at 9:16 a.m. indicated orders for management of term labor which included continuous electronic fetal monitoring and application of an internal scalp electrode as needed, and notify doctor as needed for non-reassuring FHR patterns.

Review of Patient 1's OB Patient Notes dated 2/11/15 indicated at 11:05 a.m. a change from category 1 (fetal heart rate drops with contraction and recovers to normal (110 - 160 beats per minute (bpm)) at end of contraction) to category 3 (drops dramatically or after contraction), the baby's heart rate dropped down to 60 - 90 bpm for 4.5 minutes. There was no documentation the doctor was notified nor of placement of a fetal scalp electrode (a measuring device placed on the baby's scalp before birth).

Review of the hospital's 02/2015 "Electronic Fetal Heart Rate Monitoring, Interpretation and Documentation for Laboring Patients" policy indicated the three categories of FHR tracings were:

Category 1 (Normal):

Category 2 (Indeterminate):
Baseline rate
1. Bradycardia not accompanied by absent baseline variability
2. Tachycardia

Category 3 (Abnormal):
1. Absent baseline FHR variability and
a. Recurrent late decelerations
b. Recurrent variable decelerations
c. Bradycardia

Review of the hospital's 08/2013 "Fetal Heart Rate Monitoring in L&D & Antepartum" policy indicated the management of FHR tracings for:

Category 1:
Routine assessment and care

Category 2:
1. Provide intrauterine resuscitative measures as per the likely cause of the heart rate abnormality
2. Consider fetal scalp electrode (FSE)
3. If not improved or progresses to Category 3, notify physician and prepare for possible delivery.

Category 3:
1. Notify provider immediately
2. Initiate intrauterine resuscitation measures
3. Place FSE if not already in use (unless contraindications exist)
4. Prepare for delivery
5. Notify anesthesia
6. Notify NICU

During an interview on 4/28/15 at 9:20 a.m. RN A stated she called physician A (MD A) on 2/11/15 at 9:30 a.m. when Patient 1 was admitted. RN A stated she did not try to contact MD A at 11:05 a.m. when the fetal heart rate tracing changed from category 1 to a category 3. RN A stated she called MD A again at 12:15 p.m., but was not able to reach him by telephone. RN A also stated she did not place a fetal scalp electrode.