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Based on medical record review and interview the Nursing failed to ensure obstetrical (OB) patients were assessed according to facility Policy Number, "ED.04.01.0005, Subject: Obstetrical Patient in the Emergency Department" in 5 of 5 (Patient #14, #20, #23, #27 and #28) medical records reviewed.

Refer to Tag A0395

Based on medical record review and interview the Nursing failed to ensure obstetrical (OB) patients were assessed according to facility Policy Number, "ED.04.01.0005, Subject: Obstetrical Patient in the Emergency Department" 5 of 5 (Patient #14, #20, #23, #27 and #28) medical records reviewed.


Findings:

Medical record reviews were completed in the administrative conference room on 7/17/2024 at 12:40 pm with RN Staff #7.

Patient #14
Patient #14 was a 22-year-old female who presented to the Emergency Room (ER) on 5/15/2024 at 4:43 pm. She was referred by the ophthalmologist (eye doctor) for an evaluation of acute papilledema (swelling of the optic nerve), headache, and photophobia (sensitivity to light). Also, Patient #14 was 30 weeks pregnant. She was triaged on 5/15/2024 at 4:46 pm by the Registered Nurse (RN) Staff #14 and assigned an ESI-3, Urgent. The ESI-Emergency Severity Index is a numeric tool used in the emergency room that scores a patient between 1 and 5. An ESI 1 is emergent/life threatening and an ESI 5 is non-urgent. The patient was moved to minor care patient room #6 at 6:52 pm.

A review of the vital signs (Blood Pressure, Pulse, Respirations, Temperature, Pulse Ox, and Pain scale) documented by Registered Nurse (RN) #14 at 4:48 pm revealed Patient #14 had a high pulse rate of 120 beats per minute (BPM), the normal pulse rate is 60-100, and the pain level was documented as a 2 (a pain scale is a numerical scale of 0-10 with 0 meaning no pain and 10 being the worst pain).

A review of the nursing assessments documented by Licensed Vocational Nurse (LVN) Staff #12 on 5/15/2024 at 7:17 pm, 9:30 pm, 11:38 pm, and on 5/16/2024 at 1:44 am and 2:35 am (time of transfer for a higher level of care) revealed there was no fetal heart tones (FHT's) assessed by nursing during the patients ER visit.

A review of Family Nurse Practitioner (FNP) #13's documentation revealed Patient #14 was medically screened at 8:30 pm. This was greater than 4 hours after the patient's arrival to the emergency room.

A review of the documentation by FNP #13 on 5/15/2024 at 9:11 pm was as follows:
" ...HPI: This 22-year-old white female presents to the ED (Emergency Department) via (by) walk-in with complaints of Blurry Vision, Vision Problem, and Headache. An emergency medical condition exists: yes .... 22-year-old presents to the ED with complaints of blurred vision and headache. She went to see he (sic) was told she had an inflamed optic nerve and was needed to come to the ER. She was diagnosed with Myopia and Papilledema according to paperwork ...She is also 30 weeks pregnant ...

21:13 (9:13 pm)
ROS (Review of Systems): ...
Neuro: Negative for headache, weakness, numbness, tingling, and seizure ... (Patient complained of a headache at 9:11 pm per FNP #13's documentation)
Eyes: Positive for blurry vision, pain, swelling, Papilledema, and double vision.
Exam:
Periorbital structures: appear normal, no abrasion (scratches), no cellulitis (swelling), no contusion (bruising), no erythema (rash).
Pupils: no acute changes, normal size ..."

A STAT order was written by Physician #15 for a CAT scan (a radiological exam) of the Brain/Head on 5/15/2024 at 7:30 pm and resulted in negative findings on 5/15/2024 at 10:16 pm.

Further review of the medical record revealed on 5/16/2024 at 6:23 pm FNP #13's documentation was as follows:

" ...ED Course ...Discussed case with ER attending doctor (Physician #15) he spoke with (accepting hospital name) physicians and determined that patient should be transferred for a higher level of care due to high-risk pregnancy ..."
Patient #14 was transferred by ambulance to another hospital for a higher level of care on 5/16/2024 at 2:35 am.
During an interview on 7/17/2024 at 12:45 pm, Staff #7 confirmed no fetal heart tones (FHTs) were taken. Also, RN Staff #7 confirmed Patient #14 had an abnormal pulse rate of 120 at the time of admission.

An interview was conducted with RN Staff #7 and #4 on 7/17/2024 at 12:45 PM. RN Staff #7 was asked if Physician #15 examined Patient #14 while she was in the ER. RN Staff #7 confirmed there was no documentation of an examination by Physician #15. RN Staff #7 was asked if FHTs were assessed by the ER Staff or the OB Department during Patient #14's ER visit. RN Staff #7 and #4 confirmed there were no FHTs, or fetal movement assessed during Patient #14's ER visit. RN Staff #7 was asked if the patient was assessed for any pregnancy-related complications during her ER visit. RN Staff #7 stated, "The only time the pregnancy was documented by the nursing staff was during her triage when she first got to the ER". RN Staff #4 was asked if someone from the OB Department came down to monitor the baby. RN Staff #4 stated, "No". RN Staff #4 was asked if the ER Department was monitoring OB patients to ensure the facility policy was followed and someone in the ER or from the OB department assessed the FHTs and fetal movement before the patient was discharged. RN Staff #4 confirmed there was no monitoring of OB patients who presented to the ER.



Patient #23
Patient #23 was a 37-year-old female who presented to the ER on 5/09/2024 at 8:07 pm with complaints of, "pain at baby site, headache, and right leg pain". Patient #23 was 16 weeks pregnant and referred to the ER by her OB Physician. Patient #23 was triaged by the RN and assigned an ESI 3-Urgent. She was assisted to the minor care area and placed in bed 10 on 5/09/2024 at 8:31 pm.

Further review of the medical record revealed the patient rated her pain at an 8. No fetal heart tones were documented on admission.

Patient #23 was medically screened by FNP #10 at 9:03 pm and found to not have an emergency medical condition. A review of the documentation by FNP #10 revealed the patient was examined on 5/09/2024 at 11:58 pm. The documentation of the examination by FNP #10 did not disclose that an assessment of the fetus had been completed. No fetal heart tones were documented during the patient's ER visit.

Patient #23 was diagnosed with an Upper Respiratory Infection, treated with antibiotics, and discharged home on 5/10/2024 at 12:03 am.

Further review of the medical record revealed Physician #11 documented an attestation statement on 5/10/2024 at 3:38 am. This was 3 hours and 35 minutes after a high-risk OB patient left the ER. There was no documentation by FNP #10 that the patient was discussed with the attending physician before the patient was discharged.


According to the American College of Obstetricians and Gynecologists (ACOG) pregnancy at age 35 or older is considered high risk. Some of the risks associated with advanced maternal age include:

*Higher risk of pregnancy-related complications
*Increased risk of chromosomal conditions in the baby
*Greater likelihood of miscarriage
*Higher rates of genetic defects
*Certain pregnancy complications like high blood pressure or gestational diabetes.

An interview was conducted with Registered Nurse (RN) Staff #9 on 7/17/2024 after 1:00 pm. RN Staff #9 was asked if Patient #23 was considered a high-risk OB patient. RN #9 confirmed Patient #23 was a high-risk OB patient due to her age and FHTs should have been assessed before the patient was discharged. RN Staff #9 confirmed no FHTs were documented during the patient's ER visit on 5/09-5/10/2024.

A review of the variance report with RN Staff #9 revealed Patient #23 was seen by Physician #15. RN Staff #9 confirmed Physician #15 did not document an examination of Patient #14 during the ER visit.


A review of the facility policy, Policy Number ED.04.01.0005 with a revised date of 6/2024 was as follows:

"SUBJECT: OBSTETRICAL PATIENT IN THE EMERGENCY DEPARTMENT
POLICY STATEMENT

It is the policy of Baptist Hospitals of Southeast Texas, Beaumont campus to provide a medical
screening examination and treatment for all obstetrical patients that present to the Emergency
Department.

PROCESS
1. Upon presentation to the Emergency Department, the patient will be triaged by an Emergency
Department Registered Nurse.
2. The triage Registered Nurse will determine whether the patient remains in the Emergency Department or will be sent to the Labor and Delivery department for further assessment.
*If a patient remains in the Emergency Department, the treatment plan of the Emergency Department Physician will be followed.
*If a patient is sent to the Labor and Delivery department, the Labor and Delivery The registered Nurse will assess the patient and will notify the obstetrician of the findings.
3. ED Physician shall have the discretion to notify and/or consult with other physicians as he/she
deems necessary for the treatment of any Emergency Department patient.

Unknown Gestational Age/No prenatal Care
*If the patient has no prenatal care and does not know their gestational age (pregnancy not confirmed) they will be registered and treated in the ED until gestational dates are determined.
* Gestational age will be determined by assessment from the ED provider OR an ultrasound.

Patients Under 20 weeks of Gestational Age
*Obstetrical patients less than 20 weeks gestation will be seen and treated in the ED. Fetal well-being should be determined as part of the treatment process via ultrasound and/or fetal heart tones and documented in the medical record.

Patients Over 20 weeks of Gestational Age
*If the patient is 20 weeks or greater with any of the following complaints they will be treated/medically cleared in the ED:

* Chest pain or cardiac related complaint with abnormal vital signs
* Shortness of breath with a SPO2 <90%
* Stroke or stroke-like symptoms
* Flu-like symptoms, covid-like symptoms, strep symptoms
* Urgent physical injury
* MVA

*For any patient with the above complaints. the L&D department will immediately be notified of the patient's arrival to the ED. The L&D nurse will come to the ED to perform fetal monitoring. If the patient requires additional OB monitoring they will be discharged to L&D for further evaluation once medically cleared in the ED.

*If the patient is 20 weeks or greater with any other complaint than the ones listed above, the L&D department will be notified and the patient will be brought to the L&D. If the patient is cleared of pregnancy-related complaints, they may be sent back to the ED for further clinical evaluation for non-pregnancy related care.

*If an obstetrical patient presents with any life-threatening injuries or instability of airway, breathing and/or circulation. this patient will be treated and stabilized in the emergency department, regardless of gestation."


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Findings;

Patient #27
A review of patient chart #27 revealed a 17 y/o pregnant female who came into the ED on 5/1/24 at 12:41 PM. The patient came in with a complaint of a seizure. The physician documentation stated per EMS she had a seizure while at school. The patient had experienced similar episodes in the past.

A review of the physician orders revealed an order to check fetal heart tones (FHT) at 12:47 PM. There was no documentation that fetal heart tones were obtained or that the OB department was informed of the patient in the ED.
A review of the ED physician notes dated 5/1/24 at 13:57 (1:57 PM) stated the ED physician had talked to a maternal-fetal medicine specialist in Houston, TX, regarding the patient's condition. The specialist wanted to see the patient "now", so the patient was discharged into the care of her family to take her to Houston. The ED physician felt she was stable and able to make the trip.

An incident report was placed by nursing concerning the patient not getting any FHTs and was not seen by Labor & Delivery(L&D) on 5-13-24. A review of the report stated the ED called L&D stating they had a 36 wk 17 y/o patient who had a seizure at school. The L&D nurse asked if she should come to the ED and monitor the baby. The L&D nurse was told it was an "eclamptic" seizure and that she would be coming to L&D after she was screened by the provider. The L&D nurse called at 13:53 to check on the patient's status and the ED nurse stated the physician was on the phone with the specialist in Houston. The L&D nurse called back to the ED at 14:50 (2:50 PM) and was informed the patient was discharged. The complainant stated per policy ED.04.01.005 obstetrical patient in the Emergency department and best practice for the pt's gestation, needed to have fetal monitoring while she was down in the ED to assure fetal well-being."

A review of the incident report revealed Staff # 4 RN ED Director addressed the incident on 5-14-24 at 8:39 AM. Staff # 4 described the patient's events in the ED but never addressed that the ED nurse did not document any information that the OB department was called, who they spoke to, what was the plan, and why the patient never got fht's while in the ED. The ED nurse failed to follow physician orders. Staff # 9 RN OB Services addressed the incident report on 5/15/24 at 8:12 AM. Staff # 9 stated that she reviewed the chart and thought it was appropriate to keep the patient in the ED but felt there should have been better communication with L&D. Staff #9 reported due to the AWHONN and ACOG guidelines the baby should have been monitored for at least 30 minutes. Staff #9 was concerned that the baby went 75 minutes with no monitoring.

The incident report revealed two different opinions from both departments. There was no documentation that the incident was resolved or that quality was working on a resolution. No information was provided that the nurses were counseled on failure to follow policy and physician orders.

Patient #20

A review of patient #20's ED chart stated presented to the ED on 7/11/24 at 12:08 PM. The patient reported she had been at urgent care and was diagnosed with COVID. The patient reported she was 25 weeks pregnant, and her pulse rate was elevated. She was instructed by urgent care to come to the ED.

A review of the physician's notes revealed she was being evaluated by a nurse practitioner (NP). The NP put in an order for FHTs on 7/11/24 at 13:21(1:27 PM) and at 13:48 (1:48 PM) an order for an ultrasound "OB Limited".
A review of the chart revealed there were no FHTs performed.

A review of the Diagnostic Imaging Report dated 7/11/24 revealed there was an ultrasound performed at 2:46 PM. The patient was 25 weeks pregnant and 5 days with a "fetal cardiac motion present at 144 bpm." The patient was in the ER for 2 hours and 40 minutes before an FHT was detected and documented. There was no evidence that the NP or nurse called OB services and informed them of a patient in the ER who was more than 21 weeks pregnant for observation, according to policy.

Patient # 28

A review of patient #28's ED chart revealed she was received in the ED on 6/2/24 at 5:02 AM with a complaint of flank pain. The patient reported that she was 27 weeks pregnant and had been to another hospital 2 days prior and was told she had kidney stones. A review of the nurse's notes revealed at 5:16 AM the nurse notified L&D and attempted to call in a report. The nurse documented, "Report to Labor and Delivery informed back pain is not a labor sign since pt has kidney stones and told must be cleared in ER first. 5:41 PM Focus assessment since L/D refused patient charge nurse, ERP, and house supervisor notified, pt moved to ED room and US order obtained."
There was no documented evidence that the house supervisor responded or attempted to investigate why an L&D nurse did not respond according to policy.

A review of the chart revealed there was a physician order to obtain FHTs at 5:23 AM and OB ultrasound limited was ordered at 5:38 AM. There was no documentation that any FHTs were obtained prior to the ultrasound. The physician documented that the ultrasound for OB limited with FHTs was interpreted at 7:22 AM, 2 hours after the order was obtained. The ultrasound for the kidneys revealed no stones and the patient was admitted to the L&D at 10:00AM.

A previous survey conducted by this surveyor on 2/13/24 revealed a maternal patient demise had occurred in October of 2023. The patient had previously been in the facility's ED. The facility had performed a Root Cause Analysis concerning the patient's visit and had identified that the patient never received FHTs in the ED. The facility revised its policy to read,

"Patients Under 20 weeks of Gestational Age
o Obstetrical patients less than 20 weeks gestation will be seen and treated in the ED. Fetal well-being should be determined as part of the treatment process via ultrasound and/or fetal heart tones and documented in the medical record.
Patients Over 20 weeks of Gestational Age
o If the patient is 20 weeks or greater with any of the following complaints they will be treated/medically cleared in the ED:
* Chest pain or cardiac related complaint with abnormal vital signs
* Shortness of breath with a SPO2 <90%
* Stroke or stroke-like symptoms
* Flu-like symptoms, covid-like symptoms, strep symptoms
* Urgent physical injury
* MVA
For any patient with the above complaints. the L&D department will immediately be notified of the patient's arrival to the ED. The L&D nurse will come to the ED to perform fetal monitoring. If the patient requires additional OB monitoring, they will be discharged to L&D for further evaluation once medically cleared in the ED.

o If the patient is 20 weeks or greater with any other complaint than the ones listed above, the L&D department will be notified, and the patient will be brought to the L&D. If the patient is cleared of pregnancy-related complaints, they may be sent back to the ED for further clinical evaluation for non-pregnancy related care.

o If an obstetrical patient presents with any life-threatening injuries or instability of airway, breathing and/or circulation. this patient will be treated and stabilized in the emergency department, regardless of gestation."

An interview was conducted 7/17/24 with staff # 3, #4, and #9. Staff #4 stated that she was aware there was a problem with pregnant patients 20 weeks or greater not being monitored for FHTs in the ER. Staff #4 stated that she had addressed her concerns on the incident reports and had meetings with the OB directors but stated it had not been followed through. Staff #4 confirmed no performance improvement on the incidents and no further follow-through.

Staff # 9 confirmed there was no follow-up from the incidents since the policy was changed and updated. Staff #9 confirmed the policy was changed due to an incident with a maternal death after the patient had been in the facility for treatment. The facility discovered through a root cause analysis that pregnant patients were not being monitored for FHTs. Staff in the ED and OB department were educated on the policy change. There was no data to reveal that the practice change, was monitored by the department or through quality.

Staff # 3 confirmed that the quality department had not followed through with the incident reports for failure to monitor the pregnant patient's FHTs. The quality department had no data, analysis of the data, or follow-through.