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Based on interview and record review, the facility triage (assessment of patients to determine the level of care needed) nurses failed to recognize a potential Emergency Medical Condition existed for one of 14 pregnant women (Patient 8) who presented with complaints of lower abdominal pain, weakness and a low blood pressure of 85/45 (normal blood pressure 120/80). This failure may have contributed to the death of Patient 8's baby.

Findings:

During a review of Patient 8's "Consultation Notes," the Consultation Notes indicated, "Patient 8 was a 33 year-old female, with 33 weeks and 5 days intrauterine (inside the uterus) pregnancy, G 3 P 2 A 1 (Gravida - number of pregnancies; Para - number of births, A - abortion, spontaneous or induced) came into the ED with abdominal pain. Pregnancy was complicated by history of two previous classical caesarean section [surgical delivery of a baby] deliveries. [Patient 8] was found to be hypotensive [low blood pressure, less than 90/60] with a blood pressure of 85/45 with a fetal [baby] heart rate of 50 [expected 110 or higher]. Uterine rupture [life threatening emergency resulting from tearing open of the uterine wall] was suspected. Patient 8 underwent an emergency Caesarean Section and repair of the uterus."

During an interview on 9/29/22, at 9:08 AM, with ED Triage Nurse (EDTN) 1, EDTN 1 stated, he was unable to obtain Patient 8's blood pressure with the blood pressure machine, so he changed blood pressure cuffs. EDTN 1 stated, Patient 8's blood pressure was 85/45.

During an interview on 10/6/22, at 2:12 PM, with Labor & Delivery (L&D) Nurse Manager (LDNM), LDNM stated, on 8/26/22, L&D Charge Nurse (LDCN) called her regarding an OB patient, with possible uterine rupture. LDNM stated, Patient 8 first presented in the ED at triage with a blood pressure of 85/45. EDTN1 brought Patient 8 to the OB ED triage desk; the OB ED Triage Nurse (OBEDTN) 1 could not attend to Patient 8 right then. LDNM stated, OBEDTN 1 was admitting another patient and about to start an intravenous (IV-within the vein, used to provide fluids and medication) line. LDNM stated, Patient 8 was taken to the OB ED waiting room until LDCN could attend to her. LDNM stated, no one triaged nor assessed Patient 8 (upon arrival to the OB ED).

During an interview on 10/6/22, at 2:37 PM, with LDNM, LDNM stated, "I don't believe the OB Triage Nurse received a report about the patient. A piece of paper indicating pelvic pain, BP 80 systolic was handed over [to an unknown staff member]. The information was not communicated with the OBED Triage Nurse. [EDTN 1] wheeled [Patient 8]'s wheelchair to the waiting room and left her there." LDNM stated, "we [OB triage nurse] repeat the vital signs; nobody goes
into the waiting room without being triaged." LDNM stated, "Nobody rechecked the patient's vital signs" upon arrival to the OB ED.

During a concurrent interview and record review on 10/6/22, at 3:46 PM, with LDNM, Patient 8's ED Triage Record, dated 8/26/22, was reviewed. Patient 8's ED Triage Record indicated, Patient 8 arrived at the ED on 8/26/22, at 3:12 PM. EDTN 1 began Patient 8's triage at 3:19 PM. EDTN 1 documented Patient 8's vital signs at ED triage as Heart Rate (HR) 67, Respiratory Rate (RR) 18, Blood Pressure (BP) 85/45, and Oxygen Saturation (level of oxygen in the blood) 100 %, Fetal Heart Tone (FHT) 157 beats per minute (bpm). LDNM stated, Patient 8 was not seen in the ED because she was more than 20 weeks pregnant. LDNM was unable to provide documentation, in Patient 8's EMR that EDTN 1 notified the ED medical doctor (MD) of Patient 8's low blood pressure. LDNM was unable to provide documentation, in Patient 8's EMR that EDTN 1 rechecked Patient 8's vital signs in the ED prior to transporting Patient 8 to the OB ED.

During an interview on 10/6/22, at 4:20 PM, with ED Nurse Manager (EDNM), EDNM stated, Patient 8's BP of 85/45 was not considered an "acute change" and did not meet the OB Alert criteria for obstetric emergency of systolic BP of less than 90. EDNM stated, there was no blood pressure trend to determine there was an acute change. EDNM was unable to provide documentation, in Patient 8's Electronic Medical Record (EMR), EDTN 1 rechecked Patient 8's blood pressure in the ED to determine there was an acute change.

During an interview on 10/6/22, at 4:22 PM, EDNM stated, it has been the consensus of ED MDs to take OB patients greater than 20 weeks gestation to OB ED for evaluation. EDNM stated, triage nurses did not normally notify ED MDs when OB patients with greater than 20 weeks gestation presented to the ED. The ED protocol was to take the patient to OB ED for evaluation. EDNM stated, EDTN 1's intent was to take Patient 8 as quickly as possible to OB ED for evaluation. EDNM stated, EDTN 1 attempted to call OB ED but there was no answer so he took the patient by wheelchair himself.

During a record review, on 9/29/22, Patient 1's "ED to L&D (labor and delivery) Hand-Off Communication Tool," dated 8/26/22, at 3:20 PM, the Hand-Off Tool indicated, Patient 8's arrival time to the ED 3:15 PM, Time of evaluation 3:19 PM, ED/MCH (maternal child health) transfer reason: Sent to OB for obstetric evaluation, Chief Complaint ED: pt. [patient] 33 weeks and c/o pelvic pain, Physician Name, Has patient been seen by ED physician: No, Is patient to be returned to ED: No

During a concurrent interview and record review on 10/6/22, at 3:46 PM, with LDNM, Patient 8's OB ED Triage Record, dated 8/26/22, was reviewed. The OBED Triage Record indicated, at 3:38 PM, EDTN 1 brought Patient 8 to the OB ED triage desk by wheelchair. LDNM was unable to provide documentation, in Patient 8's EMR, that an OB nurse completed a maternal and a fetal assessment when Patient 8 arrived. LDNM stated, the OBED Triage Record indicated, the following: at 4:03 PM, LDCN transferred Patient 8 from the OB ED waiting room to OB Exam Room 101. At 4:04 PM, LDCN began Patient 8's triage and documented the following vital signs: HR 83, RR 20, BP 78/32, FHT 50 bpm (slow heart rate, less than 100 bpm, can indicate baby has inadequate oxygen supply). LDCN called the OB Hospitalist (OBH-MD) and an OB Alert (obstetric emergencies). At 4:08 PM, the OBH-MD determined Patient 8 had an EMC. OBH-MD ordered OB staff to take Patient 8 to the operating room (OR) immediately. At 4:15 PM, LDCN was unable to obtain a fetal heart rate using a Doppler (a medical device used to measure fetal heart tone/rate).

During a review of Patient 8's Operative Report, dated 8/26/22, Patient 8 underwent an emergency repeat Caesarean Section and repair of the uterus on 8/26/22, at 4:22 PM.

During a review of Patient 8's baby boy's "Discharge Summary," dated 8/26/22, the Discharge Summary indicated, the baby was delivered on 8/26/22, at 4:24 PM. The baby's Apgar Score was zero (no sign of life). The baby was intubated (insertion of a breathing tube) and resuscitated (procedure to restore heart and lung functions), after successful resuscitation, the baby was transferred to the Neonatal Intensive Care Unit (NICU-a specialty area for newborns/infants requiring critical care). Shortly after baby arrived in NICU, the baby's condition deteriorated. The baby coded (heart/breathing stop) and resuscitated again, but resuscitation was unsuccessful. The Neonatal Intensivist (NI-doctor who specializes in newborn/infant care) discussed the baby's worsening condition with the father. The baby's father requested to not continue painful interventions and let the baby die at peace. Baby was pronounced dead on 8/26/22, at 5:42 PM.

During an interview on 10/7/22, at 9:12 AM, with OBEDTN 1, OBEDTN 1 stated, she had a brief encounter with EDTN 1. OBEDTN 1 stated, "EDTN 1 brought [Patient 8] to OB ED via wheelchair, but I was not able to take care of [Patient 8] at that time. I was about to start an IV and admit a patient who was already in the room. Anytime a patient arrives in OB ED, we place the patient in the room and we take vital signs, assess for fetal heart tones, do a full assessment of the patient, and put the patient on the monitor. The complaint of the patient guides the care of the patient such as, bleeding or low fetal heart tone. We call the MD to see the patient and the MD completes the MSE. On this day, we had no room available so [Patient 8] had to go to the waiting room. One room was available but it needed to be cleaned and turned over as soon as we had a chance to clean." OBEDTN 1 stated, "Typically, the nurses clean and turnover the rooms. As far as RN staffing, we started with three registered nurses, but one nurse left to take care of an [personal] emergency. She had no replacement. The charge nurse was aware. The charge nurse of OB and L&D departments came over to assist us. When [Patient 8] arrived, OBH-MD was at the triage desk, but there was no room available for the doctor to see the patient. OBH-MD did not talk to the patient. OBH-MD did not examine the patient." OBEDTN 1 stated, there were times when a triage nurse would not be present at the desk, especially if both nurses were busy with patient care in the rooms. OBEDTN 1 stated, there was no dedicated OB ED triage nurse.

During a review of the facility's policy and procedure (P&P) titled, "Obstetrical Patient Triage in the Emergency Department or Obstetrical Emergency Department," dated 2/1/21, the P&P indicated, "3. Patients who present in the ED: a) Patients greater or equal to 20 weeks with a life threatening condition or who are medically unstable (in association with or independent of their pregnancy) will remain in the ED and the OB ED RN will be notified. . .3) the patient will be placed on a fetal monitor and, if warranted, a vaginal examination may be performed. 4. The Labor and Delivery RN will remain involved with the patient care until the patient is cleared obstetrically. . ."

During a review of the facility's policies and procedures (P&P) titled, "Emergency Medical Care/Emergency Medical Treatment and Labor Act (EMTALA) Corporate Policy," dated 9/25/18, the P&P indicated, "Process: 1 Screening and Stabilization Requirements: A. Medical Screening Examination: All individuals who come to a DED (Dedicated Emergency Department) of the hospital (whether on-campus or off-campus) for examination or treatment, and all individuals who present on hospital property requesting examination or treatment of an Emergency Medical Condition shall receive an appropriate Medical Screening Examination or necessary stabilizing treatment. . ."

During a review of the facility's policy and procedure (P&P) titled, "OB Alert," dated 10/27/21, the P&P indicated, "An OB Alert should be initiated when an Obstetric Emergency occurs within the Emergency Department, Labor and Delivery, or Family Care Unit, and may occur anywhere on the premises of the hospital ...an OB Alert may be called but is not limited to the following situations for pregnant patients greater than or equal to 20 weeks gestation ...9. Acute changes in: b. Systolic blood pressure less than 90 or greater than 200."