HospitalInspections.org

Based on observations of care, staff interviews, and review of hospital policies/procedures and video surveillance footage, it was determined that the hospital failed to provide a safe environment of care to its pregnant patients. Specifically, the hospital staff failed to follow the established care procedures for pregnant patients who presented to the Emergency Department (ED) and provide a hospital escort to the Labor and Delivery (L&D) Birthing Center for a 32-week pregnant patient, Patient #1, with signs of potential labor.

The findings include:

During the survey entrance activities in the hospital's Emergency Department (ED) on September 13, 2021, the surveyor noted a pregnant patient, Patient #1 (P1), who presented to the ED between 9:00 am and 9:30 am. The surveyor observed and overheard excerpts of the conversation of P1 with a Telecommunication Attendant working at the ED information desk. The surveyor overheard P1 stating to be 32+ weeks pregnant and in need of an examination. P1 and the attendant exchanged a few more words, after which P1 came over to the security desk, received a visitor band, and proceeded to walk down a hall and out of line of sight of the surveyor.

Review of the P1's medical record on September 14, 2021 determined that P1 was a 20+ year old patient who presented to the ED's information desk with the complaint of a ruptured membrane, commonly known as "the water breaking" This was P1's first pregnancy.

Interviews with staff in the ED and the L&D Birthing Center indicated that staff would escort pregnant patients > 20 weeks of gestation who presented with a pregnancy related complaint up to the L&D Birthing Center. An L&D nurse in the Birthing Center reported to the surveyors that there had been newborn deliveries off the unit, including in the elevator, as the birthing process could be spontaneous. Of note, the path from the ED to the Birthing Center included walking down several hallways and a ride in an elevator up several floors.

Review of the hospital policies corroborated the process described by the hospital staff: an escort should accompany this patient population.

The L&D Birthing Center policy titled "Triage of Pregnant and Postpartum (up to 6 weeks) Patients at Shore Medical Center at Easton" (last revised 03/21) stated in part in Section 3.2: "If delivery in not imminent and the patient is stable but exhibiting signs of Active Labor, the patient will be escorted to the Birthing Center by an ES [Emergency Services] health care worker."

Additionally, the Emergency Department policy titled "Management of the Pregnant Patient in Emergency Department Easton Campus Only" (dated 10/20) stated in part in Section 3.0:

Pregnant Patients > 20 Weeks Gestation:

If the patient has presented for evaluation to the ED at the Direction of their obstetrician, then the patient will be escorted to the Birthing Center for initial evaluation...

If a patient > 20 weeks gestation presents to ED, not sent by OB, they will have their symptoms reviewed by an ED RN. Patients with pregnancy related complaints and delivery is not imminent will be escorted to the Birthing Center. Examples of likely pregnancy-related complaints include: Decrease in fetal movement, active vaginal bleeding, Contractions or episodic/crampy abdominal or back pain, Rupture of membranes or vaginal fluid leakage, and Headache...

Review of the video surveillance footage from the ED entrance and other locations within the hospital corroborated the surveyor's observation of P1 presenting to the ED information desk, communicating with the hospital staff, and then walking alone through multiple corridors and up an elevator to reach the Birthing Center triage area.

The staff's failure to recognize the need and accompany a pregnant patient who presented to the ED with a pregnancy related complaint to the L&D Birthing Center created an unsafe environment of care and increased the risk for an adverse event, as no clinical personnel was immediately present/able to assist in case of an emergent condition change.

Based on observations of care and review of hospital policies and procedures, it was determined that the hospital failed to monitor staff adherence to its infection prevention and control policies.

The findings include:

On September 13, 2021 at approximately 9: 00 am, the surveyors entered the hospital through the Emergency Department entrance and observed a sign that stated that the hospital was under "Orange Precautions".

The surveyors reviewed the hospital's policy titled "UMMS Tiered Approach to Infection Prevention Practice and Presence at the Workplace", which provided a chart with different levels of restrictions and required Personal Protective Equipment (PPE) based on the infection risk. The chart had four different levels, including red, orange, yellow, and green. Under the column titled "Orange" and section titled "Masking - Indoors", the policy stated, "At least a KN95 mask or respirator required for unvaccinated team members at all times. At least a well fitted medical mask (no gapping) required at all times for fully vaccinated team members. KN95 mask or respirator required for all patient contact for all team members regardless of team member vaccination status." Furthermore, under the section titled "Eye Protection", the policy stated, "Required for patient contact (with all patients)."

At approximately 10:00 am the same day, the surveyors performed observations of care in the Emergency Department, including the triage area. The surveyors noted that the majority of clinical staff and other hospital staff who entered patient care areas were wearing various types of facial masks, including surgical masks, cloth masks, KN95's, and varying types of respirators. Upon observation by surveyors, multiple hospital staff members were seen entering patient care areas with only surgical masks and cloth masks. The observation also determined that the majority of clinical staff and hospital staff that entered patient care areas were not wearing protective eyewear.

In an interview with the hospital's Infection Control Nurse (ICN), on September 14, 2021 at approximately 1:00pm, the surveyors asked: "What is the process for auditing clinical staff for PPE compliance with hospital's policies and procedures". The ICN responded that the hospital had a process for auditing compliance with hand hygiene requirements, but did not assess PPE compliance. The ICN also stated that would be up to the managers of the units to determine if they found it necessary to monitor PPE compliance.

No evidence was found to support that the hospital had a process for monitoring staff adherence with established infection prevention and control policies/procedures related to PPE. Failure of hospital to audit staff adherence to infection prevention and control policies and procedures resulted in hospital personnel not wearing the required PPE during patient care encounters and increased the risk of infection spread within the hospital.