HospitalInspections.org

Based on interviews and documentation review, it was determined the Hospital's Internal Investigation related to the care and transfer of a patient (Patient #1) did not identify nursing staff learning needs related to preterm labor (PTL).

Findings included:

1.) Medical record documentation indicated Patient #1 presented to the ED with complaint of nausea, vomiting, diarrhea, abdominal cramping and urinary frequency at 7:32 AM. Patient #1 was 30 weeks pregnant with twins and had gestational insulin-dependent diabetes and stable vital signs. Patient #1 was triaged to the Birth Center (BC) and arrived there by wheelchair; at 7:55 AM.

BC documentation indicated Patient #1: was receiving obstetric care from an Obstetric Practice associated with Hospital #2 (Obstetric Practice A); planned to deliver at Hospital #2; had a history of a preterm cesarean delivery due to a non-reassuring fetal heart rate (FHR); was assessed by Staff RN #1 at 8:21 AM; had fetal movement and stable vital signs; acknowledged (uterine) contractions commencing at 8:00 PM the evening before and; denied rupture of the fetal membranes and vaginal bleeding. BC documentation also indicated: an external fetal monitor (monitors FHR and maternal contractions) was attached to Patient #1; Fetus A had a compound presentation (position) and Fetus B had a breech presentation (the fetal body part entering the maternal pelvis was the buttocks); fetal monitoring revealed mild contractions lasting 30-50 seconds every 2-3 minutes and reassuring FHRs and; Certified Nurse Midwife (CNM) #1 was notified of Patient #1's arrival and clinical status.

CNM #1 was interviewed in person at 8:50 AM on 3/29/10. CNM #1 reported obtaining Patient #1's history and reviewing the fetal monitoring data. CNM #1 said gastrointestinal (GI) illness was going around the community, the BC staff had evaluated several obstetric patients with it, and Patient #1 indicated her toddler had it. CNM #1 reported thinking Patient #1's contractions were due to dehydration secondary to GI illness and ordering intravenous (IV) fluid.

Documentation indicated CNM #1 ordered a 1 liter IV bolus of lactated Ringer (LR) solution to be followed by an infusion (of LR) to run at 250 milliliters (mls)/hour for Patient #1 and: an IV line was inserted into the Patient; the fluid bolus was initiated; the Patient complained of feeling crampy at 8:40 AM; fetal monitoring revealed reassuring FHRs; the monitoring of Fetus A was discontinued at 9:08 AM; the Patient was having mild contractions lasting 40-60 seconds every 2-3 minutes, Fetus B had a reassuring FHR and fetal monitoring was discontinued at 9:30 AM; the Patient reported urinary frequency/burning and a urine sample was sent to the Laboratory for culture; point-of-care urine testing did not reveal abnormalities, and at 9:55 AM; Patient #1 had received 700 mls of LR, but reported feeling more uncomfortable and was still having contractions every 2-3 minutes, and CNM #1 was notified.

CNM #1 said when Patient #1's contractions did not diminish or subside with hydration; a PTL evaluation was initiated. CNM #1 also said: a speculum was inserted into Patient #1's vagina in order to test for fetal fibronectin (the presence of fetal fibronectin can be indicative of labor; the absence of fetal fibronectin rules out labor), but the test could not be performed because Patient #1 had bloody show (discharge) at the os (opening of the cervix); Patient #1's cervix was 100% effaced (thinned/shortened) and 1 centimeter (cm) dilated (the cervix becomes 100% effaced and 10 cms dilated for birth); the bag of waters (fetal sac) was bulging; there was no presenting (fetal) part; a transfer to Hospital #3 (a tertiary care hospital) was discussed with Patient #1 (because the Hospital is a community hospital and does not have the capability of caring for neonates born before 35 weeks gestation) and; Patient #1 indicated she wanted to be transferred to Hospital #2.

Staff RN #1 was interviewed in person at 8:10 AM on 3/29/10. Staff RN #1 said the cervical exam was performed on Patient #1 at 10:00 AM (and medical record documentation indicating it was performed at 1:45 PM was incorrect).

CNM #1 reported contacting Hospital #2 (a community hospital) to find out if they accepted PTL patients at 30 weeks gestation, speaking with an obstetrician associated with Obstetric Practice A (Obstetrician #2), and learning that Hospital #2 had the capability of caring for 30-week gestation neonates. CNM #1 said Obstetrician #2 indicated Patient #1 should be given magnesium sulfate (an anticonvulsant medication that is administered IV to manage PTL), betamethasone (a corticosteroid medication that is administered to pregnant women who are likely to deliver before 34 weeks gestation that helps fetal lungs with surfactant production) and ampicillin (an antibiotic), and then; transported to Hospital #2. CNM #1 reported ordering the magnesium sulfate, betamethasone and ampicillin, putting a call in to the On-Call Obstetrician, and instructing the Unit Clerk to call for a Stat (immediate) ambulance; almost simultaneously.

Documentation indicated: CNM #1 individualized and signed standardized Preterm Labor On Magnesium Sulfate Orders for Patient #1 at 10:15 AM; the Orders included orders for continuous fetal monitoring, physician notification of a non-reassuring FHR, intramuscular betamethasone, IV ampicillin, an IV bolus of magnesium sulfate to be administered over 20 minutes, and a maintenance magnesium sulfate infusion to follow the bolus; the betamethasone was administered at 10:15 AM; Patient #1 signed a Transfer Consent Form for transfer to Hospital #2 at 10:20 AM; Patient vital signs were stable; the magnesium sulfate bolus was initiated at 10:25 AM; the ampicillin was administered at 10:30 AM and; the Patient's reflexes and respiratory status were monitored (depressed reflexes and respirations are signs of impending magnesium toxicity). Documentation did not indicate the fetuses were placed back on fetal monitoring or that FHRs were obtained or that blood testing was ordered.

The nurse in charge of the BC during Patient #1's stay (Charge Nurse #1) was interviewed in person at 9:30 AM on 3/29/10. Charge Nurse #1 said Patient #1 had PTL and needed to be transferred.

Documentation on Patient #1's Ambulance Care Report indicated the ambulance arrived at the Patient's bedside at 10:30 AM.

BC documentation indicated CNM #1 ordered 10 milligrams (mgs) of IV Nubain (a narcotic pain medication; normal adult IV dose = 10-20 mgs) for Patient #1 at 10:30 AM and at 10:40 AM: Staff RN #1 administered the Nubain and initiated the maintenance magnesium sulfate infusion; CNM #1 said goodbye to the Patient; paramedics placed the Patient on the ambulance stretcher and; Patient #1, Staff RN #1 and the Paramedics left for Hospital #2. Documentation did not indicate a cervical exam was performed on Patient #1 or FHRs were checked before the transfer.

CNM #1 and Staff RN #1 said a cervical exam was not performed on Patient #1 following the initiation of the magnesium sulfate therapy and/or prior to the Patient's transfer to Hospital #2.

Staff RN #1 said: Patient #1 was disconnected from the fetal monitor prior to transfer; the On-Call Obstetrician did not call or come to the BC prior to the transfer; Hospital nurses do not perform cervical exams on PTL patients; FHRs were not checked prior to, or during the transfer, but the fetuses had been reactive; Patient #1 didn't act like someone in labor; delivery of the fetuses didn't seem imminent and; an emergency delivery kit and neonatal resuscitation equipment were brought to the ambulance/on the transfer.

Documentation obtained from Hospital #2 indicated Patient #1 arrived in the BC at 11:50 AM having painful contractions 3-4 minutes apart and was immediately evaluated by Obstetrician #3 (another obstetrician in Obstetric Practice A). The documentation also indicated: an exam revealed Patient #1's cervix was 100% effaced and 5 cms dilated and a bulging bag of waters; a bedside ultrasound revealed a breech Fetus with feet in the bag of waters/through the cervix; Patient #1 was counseled regarding the need for urgent (cesarean) delivery (given advancing dilation and malpresentation of twins) and moved to an Operating Room; a Neonatal Intensive Care Team was summoned; the fetal membranes spontaneously ruptured at 12:09 PM and the (amniotic) fluid was bloody; Patient #1 was administered spinal anesthesia at 12:15 PM; Twin A had placental abruption (premature detachment of the placenta) and was born at 12:21 PM and; Twin B was born at 12:24 PM.

Documentation indicated the Hospital had conducted an Internal Investigation concerning Patient #1's care and transfer and identified Patient care issues including that: Certified Nurse Midwife (CNM) #1 practiced outside of her scope of practice and the Hospital's policy titled "Privileges: Certified Nurse Midwife" and did not notify the On-Call Obstetrician (or any other physician) of the Patient's arrival, clinical status or need for transfer; other nursing staff involved in the Patient's care did not recognize that CNM #1 was practicing outside of her scope of practice/Hospital policy and therefore did not take corrective action; CNM #1 performed an inadequate Patient evaluation and made a rushed diagnosis without considering the differential (all possible/probable diagnoses based on the patient's symptoms, examination and history); the Patient and fetuses were not appropriately monitored prior to transfer; an obstetrician did not evaluate the Patient prior to transfer/arrange the transfer; calls and messages left to/for the On-Call Obstetrician were not placed/delivered with appropriate urgency; concern regarding a delay in reaching the On-Call Obstetrician was not addressed through utilization of the BC's policy/procedure titled "Chain of Command"; a cervical exam was not performed immediately prior to the Patient's transfer; Hospital staff did not have a good awareness and/or understanding of EMTALA regulations and; there were documentation issues related to Patient transport and the documentation of the of the risks and benefits of transfer. The investigation did not identify staff learning needs related to PTL.

Based on review of 25 medical records of patients transferred from the Emergency Department (ED) or Birthing Center (BC) during the time period of 9/6/09-3/14/10, it was determined that:
1.) signatures were illegible in 3 records.
2.) entries were not timed in 4 records.
3.) orders and/or progress notes written by a certified nurse midwife (CNM) were not co-signed as required by Hospital policy/procedure in 3 records.

Findings included:

1.) The signature on Patient #7's mid-October 2009 Emergency Physician Record was illegible.

Three signatures on Patient #11's mid-November 2009 BC Encounter Form were illegible.

Three signatures on Patient #20's late-January 2010 BC Encounter Form were illegible.

2.) Orders written by CNM #1 in Patient #1's record in early-March 2010 were not timed.

Orders written by CNM #1 in Patient #9's record in early-November 2009 were not timed.

A Progress Note written by CNM #1 in Patient #18's record in late-February 2010 was not timed.

A late-January 2010 Progress Note with an illegible signature in Patient #20's record was not timed.

3.) The Hospital's policy titled "Privileges: Certified Nurse Midwife" indicated
CNMs are permitted to write orders, progress notes and discharge summaries provided they are reviewed and countersigned by a sponsoring physician within 24 hours.

Orders and a progress note written by CNM #1 in Patient #1's medical record in early-March 2010 were not co-signed by a sponsoring physician.

Orders written by CNM #1 in Patient #9's medical record in early-November 2009 were not co-signed by a sponsoring physician.

Orders written by CNM #1 in Patient #18's medical record in mid-January 2010 were not co-signed by a sponsoring physician.

Orders and a progress note written by CNM #2 in Patient #18's medical record in mid-January 2010 were not co-signed by a sponsoring physician.

Orders and a progress note written by CNM #1 in Patient #18's medical record in late-February 2010 were not co-signed by a sponsoring physician.

Based on review of 25 medical records of patients transferred from the ED or BC during the time period of 9/6/09-3/14/10, it was determined that:
1.) Orders were not timed in 2 records.
2.) Orders were not promptly authenticated by the ordering practitioner or another practitioner responsible for the care of the patient in 3 records.

Findings included:

1.) Orders written by CNM #1 in Patient #1's record in early-March 2010 were not timed.

Orders written by CNM #1 in Patient #9's record in early-November 2009 were not timed.

2.) The Hospital's policy titled "Privileges: Certified Nurse Midwife" indicated
CNMs are permitted to write orders provided they are reviewed and countersigned by a sponsoring physician within 24 hours.

Orders written by CNM #1 in Patient #1's medical record in early-March 2010 were not co-signed by a sponsoring physician.

Orders written by CNM #1 in Patient #9's medical record in early-November 2009 were not co-signed by a sponsoring physician.

Orders written by CNM #1 in Patient #18's medical record in mid-January 2010 were not co-signed by a sponsoring physician.

Orders written by CNM #2 in Patient #18's medical record in mid-January 2010 were not co-signed by a sponsoring physician.

Orders written by CNM #1 in Patient #18's medical record in late-February 2010 were not co-signed by a sponsoring physician.

A telephone order for an intravenous (IV) bolus and IV infusion given by Obstetrician #4 for Patient #18 in mid-January 2010 was not signed by Obstetrician #4 or other physician.

A verbal order to cancel cervical length given by CNM #1 for Patient #18 in mid-January was not signed by CNM #1 and/or a sponsoring physician.