HospitalInspections.org

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Based on medical record review, document review and interview, the facility failed to:
1) Recognize the need for timely management and interventions of a patient who developed fetal decelerations during labor. (Patient #1);
2) Ensure the operative report for Patient #2 included documentation on intraoperative complications, and implement timely actions for the management of post-operative complications.

These failures were identified in two (2) of six (6) medical records reviewed.

Findings include:

See Tags A0951 and A0959
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Based on document review and staff interview, the hospital did not ensure that in its review of incidents/adverse events, proposed corrective actions were timely implemented. These findings were noted in two (2) of three (3) incidents reviewed. (Patient #1 and #2).

Findings include:

Review of the Incidents/Adverse Events Log from 10/01/2023 to 11/12/2023, documented two (2) incidents which resulted in the implementation of an improvement plan on 11/30/2024.

A review of the implementation of corrective actions for both incidents revealed education to Obstetric (OB) staff had not been completed prior to the start date of the survey. There was no documented evidence that all applicable staff received education on OB STAT process (Activation of Maternal Team for maternal complications), Team strategies and tools to enhance performance and patient safety, Fetal Heart Rate Tracings, Implementation of Maternal Early Warning System (MEWS) to facilitate timely recognition, diagnosis, and treatment of Obstetrics/Gynecology; Care of OB Patients in the Post Anesthesia Care Unit (PACU), and OB mock codes.

Review of staffing records revealed staff members who have not been educated to the improvement actions were on duty and others were scheduled to work.

During interview with Staff O, Chief of OB/GYN on 12/13/2023 at 12:30 PM, Staff O acknowledged that education and training were on-going and has not been completed.
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Based on medical record review, document review, and staff interview, in one (1) of six (6) medical records reviewed, the medical provider failed to ensure Patient #1 who developed fetal complications of decreased heart rate during Trial of Labor After Cesarean (TOLAC) (attempting to have vaginal birth after a previous cesarian birth) was promptly managed.

Findings include:

Review of the triage nursing notes on 10/29/2023 at 11:45PM identified Patient #1, with a history of previous caesarean birth, presented to the Labor and Delivery (L&D) triage in labor and was admitted for TOLAC. Per nursing documentation on 10/30/2023 from 4:15AM to 8:40AM, the patient 's blood pressure ranged between 105/45 and 89/40 (Normal Blood Pressure range: 90/60 to 120/80).

There was no documentation indicating the OB provider was notified.

Nursing note on 10/30/2023 at 8:40AM revealed the patient received intravenous fluids and her blood pressure improved to 110/57.

Per nursing documentation on flowsheet on 10/30/23, fetal heart rate measured every fifteen minutes from 8:00 AM to 11:30 AM, were between 62 to 84 beats per minute (bpm) (normal is between 110 and 160 beats per minute).

There was no documentation indicating the OB provider was notified.

Certified Nurse Midwife (CNM) on 10/30/2023 at 7:00 PM noted the fetus had an episode of decrease heart rate to 105 and at 10:51 PM, CNM documented the patient reported increased rectal pressure. FHR 145, contractions every 2-3 mins.

The CNM note 10/31/2023 at 1:00 AM indicated that the fetus was not doing well for greater than one hour, and at this time the obstetric attending (OB) counseled the patient regarding the need for cesarian section.

There was no documentation in the medical record that indicated the attending physician was notified of the abnormal fetal heart rate prior to CNM note on 10/31/2023 at 1:00 AM.

The brief operative note by the OB Attending on 10/31/2023 initiated at 2:17 AM, revealed that the patient had an emergency cesarian section, and during the procedure was found to have a uterine wall tear, with the tear extending down to the bladder which resulted in a removal of the uterus and surgical repair of the bladder wall. The infant was delivered at 2:42AM and required resuscitation (efforts to restore a heartbeat and/or breathing). Resuscitation efforts were unsuccessful.

During interview with Staff P (Chief Medical Officer) on 12/12/2023 at 11:19 AM, they stated, "There was a significant delay in recognizing abnormal fetal tracing, which led to delay in cesarian section."

An Immediate Jeopardy situation was identified on 12/18/2023 at 4:05 PM due to the facility's failure to ensure Patient #1 was promptly managed.

The facility provided an IJ Removal Plan to survey staff on 12/18/23 at 11:55 PM which included the following:
-An OB Safety Plan highlighting improving response to interpretation and management of category 2 fetal heart tracings, management of Trial of Labor After C-section (TOLAC), collaboration of the obstetric team, improving obstetric emergency response time, and decision to incision time.
-A new policy titled OB STAT delineates the roles of the various members of the OB team during an obstetrical emergency.
- Revision of the TOLAC policy to indicate the OB doctors as primarily responsible for the care of the TOLAC patients.

The IJ was removed on 12/19/2023 at 5:15 PM after an onsite verification of newly created and revised policies and procedures, interviews, and verification of staff education to the newly created and revised policies and procedures.

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Based on medical record review, document review, and interview, in one (1) of six (6) medical records reviewed, the provider failed to ensure operative report for Patient #2 included documentation of surgical complications and implement timely actions for the management of post-operative complications.

Findings include:

Review of the medical record of Patient #2 identified the following:
Labor and Delivery triage note on 11/12/2023 at 5:52 AM indicate patient presented with a complaint of contractions since 11/11/23 at 11:00 PM.

Midwife notes on 11/13/23 at 12:54 AM documented that on 11/12/2023 at 11:41 PM, the patient was taken to the Operating Room.

The surgeon's brief operative report on 11/13/23 at 2:29 AM (filed at 7:40 AM), indicated "no intraoperative surgical complications."

Late entry notes by Staff H on 11/13/2023 at 10:56 AM revealed the patient was in the recovery room at 1:09 AM with the anesthesiologist at the bedside. At 2:50 AM, the patient was visibly agitated, removing leads and pulling at intravenous access. The patient was evaluated by the anesthesiologist and a Rapid Response was called at 3:02 AM.

Anesthesiologist's notes on 11/13/2023 at 5:52 AM revealed the patient became pale and bluish with tachycardia in the range of 179 beats per minute and high respiratory rate with clenching jaws and lower pulse oximeter reading (indicating low oxygen levels in body tissues). The patient was intubated.

Senior Medical Resident (PGY3) code documentation on 11/13/2023 at 8:57 PM indicated that due to fetal bradycardia (low fetal heartbeat) the patient underwent an emergent cesarian section at 11:41 PM. Rapid Response was called at 3:30 AM due to patient's agitation. The patient's Blood Pressure was 120/60 (normal is 120/80) heart rate 140 (normal is 60-100 beats per minute). At 3:36 AM, the patient rapidly became bradycardic (low heartbeat), and pulse was lost. The patient's heartbeat returned during cardiopulmonary resuscitation (to get the heart to start beating again). During transfer of the patient to the Intensive Care Unit (ICU), the patient lost pulse again, resuscitation efforts were unsuccessful. The patient was pronounced dead at 4:41 AM.

Review of the Medical Bylaws stated operative reports shall include a detailed account of the findings during surgery including complications.

During interview on 12/11/2023 at 2:06 PM, Staff O, Chief of Obstetric Services stated that during discussion with the assisting surgeon, she learned an injury had occurred during the cesarean section. Post operative bleeding and resulting signs and symptoms of low oxygen in the body from this complication were not identified by the clinical staff.

During interview on 12/12/2023 at 11:19 AM, Staff P, the Chief Medical Officer acknowledged there was no documentation in the operative report of a complication during the cesarian section and the injury was not reported to other members of the clinical team.

An Immediate jeopardy situation was identified on 12/18/2023 at 4:05 PM due to the facility failure to document an intraoperative complication of Patient #2, and timely manage the patient postoperatively.

The facility provided an IJ Removal Plan to survey staff on 12/18/2023 at 11:55 PM.
The plan included:
1) A new policy titled "Obstetric Post Anesthesia Care Unit (PACU) describing nursing care documentation and monitoring for the OB post anesthesia patient.
2) A new policy titled " OB STAT." The policy delineates roles and responsibilities of various OB team members during an obstetric emergency.
3) A memo issued by the Chief Medical Officer to all surgeons detailing the need for prompt and complete documentation of the operative report.

The IJ was removed on 12/19/2023 at 5:15 PM based on onsite verification of newly created and revised policies and procedures, interviews, and verification of staff education to revised policies and procedures.

All the staff interviewed on 12/19/2023 verbalized knowledge and completion of the education and training regarding the IJ Removal Plan. Staff were not permitted to begin their shift without completion of the training.

Staff members who have not been trained will not begin their shift until they have been trained on all new and revised policies.