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Based on record review, staff interview and review of policy and procedures the facility staff failed to ensure the nursing staff provided adequate supervision by nursing to provide care per protocols for provider orders/medication orders while supervising 1 of 4 sampled obstetric patient's (Patient 5) in labor and delivery. This failure has the potential to effect all patients in the hospital.

Findings are:

A. Record review revealed Patient 5 was admitted to labor and delivery floor on 3/21/22 at 6:34 AM with contractions at 38 weeks 6 days gestation (full term gestation of a baby is 40 weeks). Patient 5 was put on an external TOCO monitor (a tocodynamometer is a device for monitoring and recording uterine contractions before and during labor by placing a pressure transducer over the uterus using a belt) to monitor the fetal heart rate (FHR) and the contraction strength/duration/timing. On admission the TOCO measured the FHR at 120's with moderate variability (the monitoring of the FHR shows that with uterine activity, there is the presence of accelerations [FHR goes up temporarily then returns to baseline] and no decelerations [the decrease of the FHR related to uterine contractions which could identify the baby is under stress with the contractions]. The uterine monitoring at time of admission identifies mild contractions that have been intensifying. On admission a vaginal check was done to determine the status of the cervix as the mothers body prepares for the delivery of the baby. The admission vaginal check showed Dilation: 1 cm (centimeter); Effaced: 40%; Station -2. [At the time of delivery the cervix will dilate to 10; show 100% effaced -a thinning of the cervix to allow the baby to move into the birth canal; Station will be +4 to +5 meaning that the baby's presenting part is engaged and considered to be near the outlet in the birth canal.]

Review of Cervical Examination on 3/21/22 by the Certified Nurse Midwife (CNM) revealed:
-at 11:00 AM dilated 3/ 90% effaced; and -1 station
-at 11:30 AM dilated 6/100% effaced; and 0 station
-at 12:00 Noon dilated 8/100% effaced; and +2 station
-at 12:56 PM dilated 9/100% effaced; and +2 station
-at 1:20 PM dilated 9.5/100% effaced; and +2 station
-at 1:45 PM dilated 9/80% effaced; and 0 station
-at 2:20 PM dilated 7/70% effaced; and 0 station
-the record lacked documentation of cervical examinations from 2:20 PM until delivery by emergency cesarean section at 4:42 PM.

Review of Patient 5's nursing documentation for 3/21/22 revealed:
-7:04 AM VS- 123/73-62-97.7°
-11:10 AM VS- 115/59-73- oximetry 99%
-12:01 PM VS-118/67-84-oximetry 93% - oxygen applied and repositioned
-12:04 PM Terbutaline 1 mg given SQ instead of Terbutaline 0.25 mg SQ
-12:16 PM VS 87/39 - 129
-12:20 PM VS 83/39-121
-12:24 PM VS 112/56-120
-1:28 PM VS 114/54-98
-2:29 PM VS 98/55-115 Pitocin started at 2 ml decreased to 1 ml
-3:28 PM VS 110/57-77 Pitocin stopped due to baby having decelerations
-4:20 PM VS 109/52-76 monitoring strip shows prolonged deceleration and frequent contractions. FHR recovers with late decelerations. Prepared for emergency c-section

Review of a progress note by the Certified Nurse Midwife (CNM) revealed:
-at 1:55 PM revealed, "Pt 5's labor was progressing quickly 3 cm at 11:00 AM and 8 cm by 12:15 PM. With spontaneous tachysytole (when the uterus is having excessively frequent uterine contractions), FHR was unable to recover to baseline and remained in the 100's. Fluid bolus given, position changes and O2 (oxygen). Without improvement terbutaline (a medication given to help slow the contractions of the uterus) .25 mg (milligram) SQ (subcutaneous injection- injection into the fatty tissue) ordered. 7 min labor FHR recovered and no further decelerations (noted for a long time. With return of contractions I attempted rotation of asynclitic (baby's head tipped towards one shoulder which can make passing through the birth canal harder) transverse presentation, no rotation occurred and FHR bradycardia resulted to 50 beats per minute lasting >2 minutes. (Dr K) notified and FHR recovered with repositioning alone. Now I examined her again and instead of vertex (head first through birth canal) being >9 [dilated]/100 [fully effaced]/+2, vertex was 0 station and cervix swollen. Bladder emptied of 450 ml (milliliter). She has strength of uterine contractions at 50 mmHg (a measurement of contractions-intensity of contraction in true labor ranges from 40-50 mmHg to 50-80 mmHg when you are ready for childbirth) with variable decelerations with marked variability during contractions. Rotated to severe left lateral position and watching closely."
-at 2:56 PM revealed, "Mild uterine contractions continue. FHR with normal baseline and moderate variability and no decelerations for >10 minutes. Discussed arrest of descent and dilation. We can proceed with non urgent cesarean or try pitocin augmentation to get to complete dilation. She consents to pitocin augmentation and her and her family are aware this could result in an urgent cesarean if baby does not tolerate labor."
-at 4:20 PM revealed, "Prolonged deceleration again now that contractions are strong and close. FHR recovers with late decelerations. She has minimal resting tone again (uterus does not rest between contractions). Dr K has been in house for the past hour and is present at bedside. Current category 3 tracing (a fetal monitoring tracing indicating fetal distress, that requires immediate and prompt delivery via cesarean section) No cervical change for 4 hours. Arrest of decent and dilation. Patient is ready for a cesarean."

Review of medication administration for the 3/21/22 12:04 PM dose of Terbutaline, showed that the medication is distributed via a 1 mg vial. The review showed that RN A overrode the pyxis (medication administration cabinet) to get the medication. Review of the medical record showed no order for the medication inputted into the electronic medical record as a verbal order with read back prior to administration.

Interview with the Pharmacist and RN B (nurse manager on OB floor) on 11/2/22 at 3:15 PM, revealed that the order set that was used for Patient 5 was identified as "Trial of Labor" order set. This order set does not have Terbutaline in it. The Pharmacist stated, "That if the Terbutaline would have been in the order set being used by this patient, that the medication administration instructions including the correct dose (0.25 mg) would have been available to the nurse and the override would not have been necessary." RN B stated that the CNM had given a verbal order to give Terbutaline, so RN A went to get the medication and overrode it and got a vial out of the pyxis. This was not a medication we give frequently and RN A said that she asked the CNM give the whole thing, but did not clarify what dose. Therefore the nurse RN A drew up the full vial which was 1 mg and administered it SQ.

Based on record review, staff interview and review of policy and procedures the facility staff failed to ensure the nursing staff provided medication per provider orders/medication orders for 1 of 4 sampled obstetric patient's (Patient 5) in labor and delivery. This failure has the potential to effect all patients in the hospital.

Findings are:

A. Record review revealed Patient 5 was admitted to labor and delivery floor on 3/21/22 at 6:34 AM with contractions at 38 weeks 6 days gestation (full term gestation of a baby is 40 weeks). Patient 5 was put on an external TOCO monitor (a tocodynamometer is a device for monitoring and recording uterine contractions before and during labor by placing a pressure transducer over the uterus using a belt) to monitor the fetal heart rate (FHR) and the contraction strength/duration/timing. On admission the TOCO measured the FHR at 120's with moderate variability (the monitoring of the FHR shows that with uterine activity, there is the presence of accelerations [FHR goes up temporarily then returns to baseline] and no decelerations [the decrease of the FHR related to uterine contractions which could identify the baby is under stress with the contractions]. The uterine monitoring at time of admission identifies mild contractions that have been intensifying. On admission a vaginal check was done to determine the status of the cervix as the mothers body prepares for the delivery of the baby. The admission vaginal check showed Dilation: 1 cm (centimeter); Effaced: 40%; Station -2. [At the time of delivery the cervix will dilate to 10; show 100% effaced -a thinning of the cervix to allow the baby to move into the birth canal; Station will be +4 to +5 meaning that the baby's presenting part is engaged and considered to be near the outlet in the birth canal].

Review of Patient 5's medical record lacked a verbal order with read back for the order of Terbutaline. The pharmacy pyxis override document showed that the medication was removed at 3/21/22 12:04 PM dose of Terbutaline. The medication is distributed via a 1 mg/ml vial. Review of the "Medication Management: Prescribing/Medication Order Management Policy" last revised on 4/2022, a verbal or telephone order will be limited when possible; will be documented by the authorized agent (RN) immediately, and are to include the complete content of the medication order [pt name, location, birth date, generic or brand name with medication form, specific dose, route of administration, frequency &/or interval of medication, date and time of order, date I time on which the order is written, the prescribing provider]; and the authorized agent accepting the verbal or telephone orders will read back the order to the prescriber for verification."

Interview with the Pharmacist and RN B (nurse manager on OB floor) on 11/2/22 at 3:15 PM, verified that the medical record lacked the order for the Terbutaline prior to administering on 3/21/22 at 12:04 PM.

In an Interview with the Certified Nurse Midwife on 11/1/22 at 12:05 PM revealed, that "Patient 5 was having uterine contractions without a rest period, and the baby was having some decelerations so gave a verbal order for Terbutaline. The dose of Terbutaline to be administered is 0.25 mg, the nurse (RN A) went and got the Terbutaline and gave it subcutaneously. I then wanted to repeat the dose at 1:00 PM and that is when the nurses asked me to step outside of the room to speak to me. The nurses told me that (RN A) gave the full vial (1 mg) instead of 0.25 mg. So we did not repeat the dose."