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Based on interview and record review, the facility failed to ensure the facility had an effective Governing Body when:

1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and the facility was unable to care for two of 31 sample patients (Patients 2 and 31) and the Governing Body was not aware (Refer to A-0083); and

2. There was no pediatrician coverage (a physician specializing in treating children who is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) scheduled for two shifts and the Governing Body was not aware (Refer to A-0084).

The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients in the perinatal unit, and may cause delays in the provision of patient care.

Based on interview and record review, the facility failed to ensure care is provided, for three of 31 sampled patients (Patients 2, 25, and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when:

1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and the facilitywas unable to care for two of 31 sample patients (Patients 2 and 31) (Refer to A-0144);

2. There was no pediatrician coverage (a physician specializing in treating children who is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) scheduled for two shifts (Refer to A-0144); and

3. For Patient 25, a signed informed consent was not obtained prior to a the insertion of an epidural catheter (a thin flexible plastic tube inserted into the spinal cord for administration of pain medication) (Refer to A- 0131).

The cumulative effects of these systemic failures had the potential to impact the health and treatment of the patients seen at the perinatal unit, jeopardize their safety and may cause delays in the provision of their care.

Based on interview and record review, the facility failed to ensure care was provided, for two of 31 sampled patients (Patients 2 and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when:

1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and the facility was unable to care for two of 31 sample patients (Patients 2 and 31) (Refer to A-0392);

2. Emergency equipment and supplies at the perinatal unit and the Emergency Department were not inspected, in accordance with the facility's policy and procedure (Refer to A-0398).

The cumulative effects of these systemic failures had the potential to impact the health, safety, and treatment of the patients, and may cause delays in the provision of patient care.

Based on interview and record review, the facility failed to ensure there is an effective Governing Body, when the staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery) was insufficient to care for two of 31 sample patients (Patients 2 and 31) and the Governing Body was not aware.

This failure resulted in Patients 2 and 31 to not receive the necessary care in the perinatal unit and had the potential to cause harm to the patients.

Findings:

On November 1, 2024, at 3 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated the facility was on "OB [obstetrics, pertaining to the care of the mother during labor and delivery) diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals]" on October 31, 2024, night shift (7 p.m. to 7 a.m.) because there was not enough nursing staff scheduled to work.

On November 1, 2024, at 3 p.m., a review of the facility document titled, "OB Department Daily Staffing Sheet," dated October 31, 2024, for the night shift, was conducted. The document indicated there was a sick call in the Labor and Delivery unit (OB unit). The document indicated, "Diversion."

A facility document titled, "OB Department Daily Staffing Sheet," dated October 17, 2024, for the day shift, was reviewed. The document indicated there were two registered nurses (RN) scheduled to work in the Labor and Delivery and there was one sick call (when a staff is sick and unable to come to work). The document indicated, " ...Diversion ..."

a. On November 4, 2024, at 10:45 a.m., Patient 2's record was reviewed with Supervisor 1. A facility document titled, "[Facility name] ED Summary Report," dated October 31, 2024, was reviewed and indicated, " ...Narrative...Pt [Patient 2] 40 weeks pregnant [a full-term pregnancy], says sent by Dr. [Physician 2]..."

A facility document titled, "[Facility name] Daily Focus Assessment Report," dated October 31, 2024, at 4:25 p.m., was reviewed. The document indicated, " ...Category Note: On arrival, OB staff stated they are preparing to go on diversion. The patient [Patient 2] says that she was at Dr. [Physician 2] office and was sent here 'to check the baby.' Charge nurse made aware, patient was denying complaints, no SROM [spontaneous rupture of membranes, when the sac of fluid around the infant in the uterus breaks on its own] though she said in the office Dr. [name of Physician 2] wasn't sure if she had ruptured. She says fetal movement [movement of the infant inside the uterus] has been normal, no pain other than chronic [long term] low back pain that she had the last few weeks of pregnancy. While in triage [area in emergency department where patients are categorized and prioritized based on the severity of their illness], the patient received a phone call by Dr. [Physician 2] telling her to go directly to [name of another acute care hospital]. Patient agreed to have MSE [medical screening exam, an examination conducted by the emergency department (ED) physician] here before leaving, [Name of ED physician] saw patient in triage and was preparing to discharge her when OB staff called and said Dr. [name of Physician 2] had contacted them and wanted 'the baby checked due to the heart rate.' Patient was taken immediately to OB..."

A facility document titled, "Detail Notes Log," dated October 31, 2024, at 6:11 p.m., was reviewed. The document indicated, "...Comment: [name of Physician 1] discussing condition and plan of mgmt [management] of care with patient and significant other who verbalized understanding and agreement. Physician certifies patient is not in labor, fetal heart rate stable, discharge to go to [name of another acute care hospital] for further evaluation/ plans for delivery d/t [due to] this unit not staffed adequately on pm [night] shift tonight to provide care for patient..."

On November 5, 2024, at 11:05 a.m., an interview was conducted with Physician 1 (the physician who examined Patient 2 at the OB unit). Physician 1 stated Patient 2 was evaluated when she arrived at the facility on October 31, 2024. Physician 1 stated because the facility was going to be on diversion at 7 p.m., and Patient 2 was not in active labor, he advised Patient 2 to drive to another facility for continued care.

On November 5, 2024, at 11:30 a.m., an interview was conducted with Physician 2. Physician 2 stated Patient 2 was sent to the facility on October 31, 2024, because of her concern about premature rupture of membranes (when the sac of fluid around the infant in the uterus breaks on its own earlier than expected) and low heart tones (infant's heart rate). Physician 2 stated the facility was going to be on diversion starting at 7 p.m. on October 31, 2024, and wanted Patient 2 to be checked prior to driving to another facility because of the time it would take to drive to another facility. Physician 2 stated there was another incident of OB diversion on October 17, 2024, when Patient 31 was scheduled for a repeat Cesarean Section (C-section, a surgical procedure to deliver a baby through incision in the mother's abdomen] on October 17, 2024. Physician 2 stated Patient 31 arrived at the facility but the OB department was on diversion and Patient 31 had to go to another facility for the C-section.

On November 6, 2024, at 10 a.m., an interview was conducted with RN 2. RN 2 stated she worked on the OB unit on October 31, 2024, from 7 a.m., until 3 p.m. RN 2 stated the OB unit went on diversion for the night shift of October 31, 2024, due to not having enough nurses scheduled to work for the night shift. RN 2 stated the OB unit also went on diversion on the day shift (7 a.m. to 7 p.m.) on October 17, 2024, due to nursing staff shortage.

b. On November 6, 2024, at 9:30 a.m., a concurrent interview and review of Patient 31's record were conducted with Supervisor 1. Patient 31's face sheet was reviewed and indicated Patient 31 came in on October 15, 2024, for "Service: LABS [laboratory] C SECTION # [number] 3 [three]."

A facility document titled, "OR [operating room] Schedule by Room," dated October 17, 2024, was reviewed. The document indicated, "09:30-11:00 [9:30 a.m. to 11 a.m.]...[name of Patient 31]...[name of Physician 2]...PREGNANCY AT 39 WEEKS [full term pregnancy] H/O [history of] C-SECTION X 2 (two times) REPEAT...CESAREAN SECTION #3 [third C-section]..." The document indicated a handwritten line across the page and the word, "CNL [canceled]." There were no documented evidence indicating Patient 31 was notified or that arrangements were made for the patient to have the procedure at another hospital.

Supervisor 1 stated there was no record for Patient 31 for October 17, 2024, since she did not have her scheduled C-section at the facility.

On November 6, 2024, at 11:15 a.m., an interview was conducted with the Chief Operating Officer (COO). The COO stated the OB unit was on diversion on October 17, 2024, day shift, due to not having enough nursing staff at the OB unit and arrangements were made for Patient 31 to go to another hospital for C-section. The COO stated the patient drove to another facility for the C-section.

A review of the facility policy and procedure titled, "[Facility name] STAFFING PLAN," dated December 2023 was conducted. The policy indicated, "Labor & Delivery suite of perinatal services...1:2 [one RN assigned to two patients] or fewer active labor patients at all times...Antepartum [period of time before childbirth] patients not in active labor...1:4 [one RN assigned to four patient] or fewer at all times...Perinatal services...1:4 mother-baby couplets [a mother and her newborn being cared for together in the same room after birth] or fewer at all times...In an effort to assure there are sufficient numbers of qualified staff available to specific units, systems are developed..."

Based on interview and record review, the facility failed to ensure there is an effective Governing Body, when the facility did not have pediatrician coverage (a physician who specialized on treating children and is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) for two shifts and the Governing Body was not aware.

This failure had the potential to impact the health and treatment of the patients and cause delays in patient care and treatment.

Findings:

On November 5, 2024, at 12 p.m., a concurrent interview and record review were conducted with the Director of Medical Staff (DMS). A facility document titled, "[Name of facility] Emergency Room [ER] Specialty Call Roster November 2024," was reviewed and indicated Physician 3 (a pediatrician) was scheduled on call on November 5, 2024, and November 6, 2024, for pediatrics (a branch of medicine specializing in the care of patients from birth to age 18). The DMS stated there were no lapses in pediatrician coverage for the months of October and November, 2024.

On November 6, 2024, at 10 a.m., an interview with RN 2 was conducted. RN 2 stated she was informed by the night shift (7 p.m. to 7 a.m.) nursery nurse that Physician 3 was not on call for November 6, 2024, and was out of the country. RN 2 stated there was no one on call for pediatrics if a newborn was delivered at the facility on November 5, 2024, night shift or November 6, 2024, day shift (7 a.m. to 7 a.m.).

On November 6, 2024, at 11:15 a.m., an interview with the COO was conducted. The COO stated she was informed on November 5, 2024, at 11 a.m., by nursing staff Physician 3 was not on call for pediatrics. The COO stated there was no pediatric coverage for November 5, 2024, night shift, and November 6, 2024, day shift.

A facility document titled, "SECTION VI: EMERGENCY SERVICES," from the medical staff's Rules and Regulations was reviewed. The document indicated, "...Specialty Backup Coverage...ER Back Up Roster... Each clinical division shall establish an emergency room back up roster which is submitted to the Medical Staff Office by the fifteenth of the month prior to the month of call. The purpose of the back up (sic) roster is to provide a schedule of those physicians who, on a rotating basis, provide on call coverage in their respective specialties. Divisions may combine their call rosters if mutually agreeable with each Division and acceptable to the Medical Executive Committee..."

Based on interview and record review, the facility failed to ensure an informed consent was signed by one of 30 sample patients (Patient 25) prior to the insertion of an epidural catheter (a thin flexible catheter inserted in the spinal cord for administration of pain medication), in accordance with the facility's policy and procedure (P&P).

This failure had the potential for Patient 25 to not understand the benefits and risks related to the procedure and may jeopardize the patient's safety.

Findings:

On November 4, 2024, at 1:30 p.m., Patient 25's record was reviewed with the Quality Analyst (QA). The face sheet, dated October 13, 2024, was reviewed and indicated Patient 25 was admitted to the facility's obstetrical unit (unit where pregnant patients are monitored and treated, and infants are delivered) on October 13, 2024, for abdominal pain and being in active labor.

A facility document titled, "Detail Notes Log," dated October 13, 2024, at 2:09 a.m., authored by Certified Registered Nurse Anesthetist (CRNA) was reviewed. The document indicated Patient 25 had an epidural catheter inserted.

There was no documented evidence Patient 25 signed an informed consent for the insertion of the epidural catheter.

An interview was conducted on October 6, 2024, with RN 2. RN 2 stated, "Anesthesia [a department made up of physicians who specialized in pain management] gives informed consent and then the patient signs." RN 2 stated an informed consent should have been signed by Patient 25 prior to the insertion of the epidural catheter procedure.

A review of the facility's P&P titled, "Informed Consent," revised September 2024, was conducted. The policy indicated, "...the hospital is required to obtain documentation of consent to hospital services and to verify that the physician has obtained informed consent as appropriate...A procedural consent form, dated, timed, and signed by the patient and witnesses by hospital staff are required for surgical invasive procedures..."

Based on interview and record review, the facility failed to ensure care is provided, for two of 31 sampled patients (Patients 2 and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when:

1. There was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]) and was unable to care for two of 31 sample patients (Patients 2 and 31) (Refer to A-0083); and

2. There was no pediatrician coverage (a physician specializing in treating children who is to be called and assigned to take care of a patient when the patient did not have his own pediatrician) scheduled for two shifts (Refer to A-0084).

These failures had the potential to impact the health and treatment of the patients admitted at the perinatal unit and may cause delays in providing patient care.

Findings:

1. On November 1, 2024, at 3 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated the facility was on "OB [obstetrics, pertaining to the care of the mother during labor and delivery) diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals]" on October 31, 2024, night shift (7 p.m. to 7 a.m.) because there was not enough nursing staff scheduled to work.

On November 1, 2024, at 3 p.m., a review of the facility document titled, "OB Department Daily Staffing Sheet," dated October 31, 2024, for the night shift, was conducted. The document indicated there was a sick call in the Labor and Delivery unit (OB unit). The document indicated, "Diversion."

A facility document titled, "OB Department Daily Staffing Sheet," dated October 17, 2024, for the day shift, was reviewed. The document indicated there were two registered nurses (RN) scheduled to work in the Labor and Delivery and there was one sick call (when a staff is sick and unable to come to work). The document indicated, " ...Diversion ..."

a. On November 4, 2024, at 10:45 a.m., Patient 2's record was reviewed with Supervisor 1. A facility document titled, "[Facility name] ED Summary Report," dated October 31, 2024, was reviewed and indicated, " ...Narrative...Pt [Patient 2] 40 weeks pregnant [a full-term pregnancy], says sent by Dr. [name of Physician 2]..."

A facility document titled, "[Facility name] Daily Focus Assessment Report," dated October 31, 2024, at 4:25 p.m., was reviewed. The document indicated, " ...Category Note: On arrival, OB staff stated they are preparing to go on diversion. The patient [Patient 2] says that she was at Dr. [Physician 2] office and was sent here 'to check the baby.' Charge nurse made aware, patient was denying complaints, no SROM [spontaneous rupture of membranes, when the sac of fluid around the infant in the uterus breaks on its own] though she said in the office Dr. [name of Physician 2] wasn't sure if she had ruptured. She says fetal movement [movement of the infant inside the uterus] has been normal, no pain other than chronic [long term] low back pain that she had the last few weeks of pregnancy. While in triage [area in emergency department where patients are categorized and prioritized based on the severity of their illness], the patient received a phone call by Dr. [Physician 2] telling her to go directly to [name of another acute care hospital]. Patient agreed to have MSE [medical screening exam, an examination conducted by the emergency department (ED) physician] here before leaving, [Name of ED physician] saw patient in triage and was preparing to discharge her when OB staff called and said Dr. [name of Physician 2] had contacted them and wanted 'the baby checked due to the heart rate.' Patient was taken immediately to OB..."

A facility document titled, "Detail Notes Log," dated October 31, 2024, at 6:11 p.m., was reviewed. The document indicated, "...Comment: [name of Physician 1] discussing condition and plan of mgmt [management] of care with patient and significant other who verbalized understanding and agreement. Physician certifies patient is not in labor, fetal heart rate stable, discharge to go to [name of another acute care hospital] for further evaluation/ plans for delivery d/t [due to] this unit not staffed adequately on pm [night] shift tonight to provide care for patient..."

On November 5, 2024, at 11:05 a.m., an interview was conducted with Physician 1 (the physician who examined Patient 2 at the OB unit). Physician 1 stated Patient 2 was evaluated when she arrived at the facility on October 31, 2024. Physician 1 stated because the facility was going to be on diversion at 7 p.m., and Patient 2 was not in active labor, he advised Patient 2 to drive to another facility for continued care.

On November 5, 2024, at 11:30 a.m., an interview was conducted with Physician 2. Physician 2 stated Patient 2 was sent to the facility on October 31, 2024, because of her concern about premature rupture of membranes (when the sac of fluid around the infant in the uterus breaks on its own earlier than expected) and low heart tones (infant's heart rate). Physician 2 stated the facility was going to be on diversion starting at 7 p.m. on October 31, 2024, and wanted Patient 2 to be checked prior to driving to another facility because of the time it would take to drive to another facility. Physician 2 stated there was another incident of OB diversion on October 17, 2024, when Patient 31 was scheduled for a repeat Cesarean Section (C-section, a surgical procedure to deliver a baby through incision in the mother's abdomen] on October 17, 2024. Physician 2 stated Patient 31 arrived at the facility but the OB department was on diversion and Patient 31 had to go to another facility for the C-section.

On November 6, 2024, at 10 a.m., an interview was conducted with RN 2. RN 2 stated she worked at the OB unit on October 31, 2024, from 7 a.m., until 3 p.m. RN 2 stated the OB unit went on diversion for the night shift of October 31, 2024, due to not having enough nurses scheduled to work for the night shift. RN 2 stated the OB unit also went on diversion on the day shift (7 a.m. to 7 p.m.) on October 17, 2024, due to nursing staff shortage.

b. On November 6, 2024, at 9:30 a.m., a concurrent interview and review of Patient 31's record were conducted with Supervisor 1. Patient 31's face sheet was reviewed and indicated Patient 31 came in on October 15, 2024, for "Service: LABS [laboratory] C SECTION # [number] 3 [three]."

A facility document titled, "OR [operating room] Schedule by Room," dated October 17, 2024, was reviewed. The document indicated, "09:30-11:00 [9:30 a.m. to 11 a.m.]...[name of Patient 31]...[name of Physician 2]...PREGNANCY AT 39 WEEKS [full term pregnancy] H/O [history of] C-SECTION X 2 (two times) REPEAT...CESAREAN SECTION #3 [third C-section]..." The document indicated a handwritten line across the page and the word, "CNL [canceled]." There were no documented evidence indicating Patient 31 was notified or that arrangements were made for the patient to have the procedure at another hospital.

Supervisor 1 stated there was no record for Patient 13 for October 17, 2024, since she did not have her scheduled C-section at the facility.

On November 6, 2024, at 11:15 a.m., an interview was conducted with the Chief Operating Officer (COO). The COO stated the OB unit was on diversion on October 17, 2024, day shift, due to not having enough nursing staff at the OB unit and arrangements were made for Patient 31 to go to another hospital for C-section. The COO stated the patient drove to another facility for the C-section.

A review of the facility policy and procedure titled, "[Facility name] STAFFING PLAN," dated December 2023 was conducted. The policy indicated, "Labor & Delivery suite of perinatal services...1:2 [one RN assigned to two patients] or fewer active labor patients at all times...Antepartum [period of time before childbirth] patients not in active labor...1:4 [one RN assigned to four patient] or fewer at all times...Perinatal services...1:4 mother-baby couplets [a mother and her newborn being cared for together in the same room after birth] or fewer at all times...In an effort to assure there are sufficient numbers of qualified staff available to specific units, systems are developed..."

2. On November 5, 2024, at 12 p.m., a concurrent interview and record review were conducted with the Director of Medical Staff administration (DMS). A facility document titled, "[Name of facility] Emergency Room [ER] Specialty Call Roster November 2024," was reviewed and indicated Physician 3 (a pediatrician) was on call on November 5, 2024, and November 6, 2024, for pediatrics (a branch of medicine specializing in the care of patients from birth to age 18). The DMS stated there were no lapses in pediatrician coverage for the months of October and November 2024.

On November 6, 2024, at 10 a.m., an interview with RN 2 was conducted. RN 2 stated she was informed Physician 3 was not on call for November 6, 2024, and was out of the country. RN 2 stated there was no one on call for pediatrics if a newborn was delivered at the facility on November 5, 2024, night shift (7 p.m. to 7 a.m.) or November 6, 2024, day shift (7 a.m. to 7 a.m.).

On November 6, 2024, at 11:15 a.m., an interview with the COO was conducted. The COO stated she was informed on November 5, 2024, at 11 a.m., by nursing staff Physician 3 was not on call for pediatrics. The COO stated there was no pediatric coverage for November 5, 2024, night shift, and November 6, 2024, day shift.

A facility document titled, "SECTION VI: EMERGENCY SERVICES," from the medical staff's Rules and Regulations was reviewed. The document indicated, "...Specialty Backup Coverage...ER Back Up Roster... Each clinical division shall establish an emergency room back up roster which is submitted to the Medical Staff Office by the fifteenth of the month prior to the month of call. The purpose of the back up (sic) roster is to provide a schedule of those physicians who, on a rotating basis, provide on call coverage in their respective specialties. Divisions may combine their call rosters if mutually agreeable with each Division and acceptable to the Medical Executive Committee..."

Based on interview and record review, the facility failed to ensure care is provided, for two of 31 sampled patients (Patients 2 and 31) with obstetrical conditions (pertains to conditions related to pregnancy and childbirth), when there was insufficient staffing (number of nursing staff working in a unit) on the perinatal unit (unit designated for the care of patient in labor and of the mother and the infant during and after delivery, which includes the labor and delivery unit, the postpartum unit [unit where the mother is placed after delivery of the infant], and the nursery [unit where the infant is admitted after delivery]).

This failure resulted in Patients 2 and 31 to not receive the necessary care in the perinatal unit and had the potential to cause harm to the patients and delay in the provision of patient care.

Findings:

On November 1, 2024, at 3 p.m., an interview was conducted with the Interim Chief Nursing Officer (ICNO). The ICNO stated the facility was on "OB [obstetrics, pertaining to the care of the mother during labor and delivery) diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals]" on October 31, 2024, night shift (7 p.m. to 7 a.m.) because there was not enough nursing staff scheduled to work.

On November 1, 2024, at 3 p.m., a review of the facility document titled, "OB Department Daily Staffing Sheet," dated October 31, 2024, for the night shift, was conducted. The document indicated there was a sick call in the Labor and Delivery unit (OB unit). The document indicated, "Diversion."

A facility document titled, "OB Department Daily Staffing Sheet," dated October 17, 2024, for the day shift, was reviewed. The document indicated there were two registered nurses (RN) scheduled to work in the Labor and Delivery and there was one sick call (when a staff is sick and unable to come to work). The document indicated, " ...Diversion ..."

1. On November 4, 2024, at 10:45 a.m., Patient 2's record was reviewed with Supervisor 1. A facility document titled, "[Facility name] ED Summary Report," dated October 31, 2024, was reviewed and indicated, " ...Narrative...Pt [Patient 2] 40 weeks pregnant [a full-term pregnancy], says sent by Dr. [Physician 2]..."

A facility document titled, "[Facility name] Daily Focus Assessment Report," dated October 31, 2024, at 4:25 p.m., was reviewed. The document indicated, " ...Category Note: On arrival, OB staff stated they are preparing to go on diversion. The patient [Patient 2] says that she was at Dr. [Physician 2] office and was sent here 'to check the baby.' Charge nurse made aware, patient was denying complaints, no SROM [spontaneous rupture of membranes, when the sac of fluid around the infant in the uterus breaks on its own] though she said in the office Dr. [name of Physician 2] wasn't sure if she had ruptured. She says fetal movement [movement of the infant inside the uterus] has been normal, no pain other than chronic [long term] low back pain that she had the last few weeks of pregnancy. While in triage [area in emergency department where patients are categorized and prioritized based on the severity of their illness], the patient received a phone call by Dr. [Name of Physician 2] telling her to go directly to [name of another acute care hospital]. Patient agreed to have MSE [medical screening exam, an examination conducted by the emergency department (ED) physician] here before leaving, [Name of ED physician] saw patient in triage and was preparing to discharge her when OB staff called and said Dr. [name of Physician 2] had contacted them and wanted 'the baby checked due to the heart rate.' Patient was taken immediately to OB..."

A facility document titled, "Detail Notes Log," dated October 31, 2024, at 6:11 p.m., was reviewed. The document indicated, "...Comment: [name of Physician 1] discussing condition and plan of mgmt [management] of care with patient and significant other who verbalized understanding and agreement. Physician certifies patient is not in labor, fetal heart rate stable, discharge to go to [name of another acute care hospital] for further evaluation/ plans for delivery d/t [due to] this unit not staffed adequately on pm [night] shift tonight to provide care for patient..."

On November 5, 2024, at 11:05 a.m., an interview was conducted with Physician 1 (the physician who examined Patient 2 at the OB unit). Physician 1 stated Patient 2 was evaluated when she arrived at the facility on October 31, 2024. Physician 1 stated because the facility was going to be on diversion at 7 p.m., and Patient 2 was not in active labor, he advised Patient 2 to drive to another facility for continued care.

On November 5, 2024, at 11:30 a.m., an interview was conducted with Physician 2. Physician 2 stated Patient 2 was sent to the facility on October 31, 2024, because of a concern about premature rupture of membranes (when the sac of fluid around the infant in the uterus breaks on its own earlier than expected) and low heart tones (infant's heart rate). Physician 2 stated the facility was going to be on diversion starting at 7 p.m. on October 31, 2024, and wanted Patient 2 to be checked prior to driving to another facility because of the time it would take to drive to another facility. Physician 2 stated there was another incident of OB diversion on October 17, 2024. Physician 2 stated Patient 31 was scheduled for a repeat Cesarean Section (C-section, a surgical procedure to deliver a baby through incision in the mother's abdomen] on October 17, 2024, and arrived at the facility, but the OB department was on diversion and Patient 31 had to go to another facility for the C-section.

On November 6, 2024, at 10 a.m., an interview was conducted with RN 2. RN 2 stated she worked at the OB unit on October 31, 2024, from 7 a.m., until 3 p.m. RN 2 stated the OB unit went on diversion for the night shift of October 31, 2024, due to not having enough nurses scheduled to work for the night shift. RN 2 stated the OB unit also went on diversion on the day shift (7 a.m. to 7 p.m.) on October 17, 2024, due to nursing staff shortage.

2. On November 6, 2024, at 9:30 a.m., a concurrent interview and review of Patient 31's record were conducted with Supervisor 1. Patient 31's face sheet was reviewed and indicated Patient 31 came in on October 15, 2024, for "Service: LABS [laboratory] C SECTION # [number] 3 [three]."

A facility document titled, "OR [operating room] Schedule by Room," dated October 17, 2024, was reviewed. The document indicated, "09:30-11:00 [9:30 a.m. to 11 a.m.]...[name of Patient 31]...[name of Physician 2]...PREGNANCY AT 39 WEEKS [full term pregnancy] H/O [history of] C-SECTION X 2 (two times) REPEAT...CESAREAN SECTION #3 [third C-section]..." The document indicated a handwritten line across the page and the word, "CNL [canceled]." There were no documented evidence indicating Patient 13 was notified or that arrangements were made for the patient to have the procedure at another hospital.

Supervisor 1 stated there was no record for this patient for October 17, 2024, since she did not have her scheduled C-section at the facility.

On November 6, 2024, at 11:15 a.m., an interview was conducted with the Chief Operating Officer (COO). The COO stated the OB unit was on diversion on October 17, 2024, day shift, due to not having enough nursing staff at the OB unit and arrangements were made for Patient 31 to go to another hospital for C-section. The COO stated the patient drove to another facility for the C-section.

A review of the facility policy and procedure titled, "[Facility name] STAFFING PLAN," dated December 2023 was conducted. The policy indicated, "Labor & Delivery suite of perinatal services...1:2 [one RN assigned to two patients] or fewer active labor patients at all times...Antepartum [period of time before childbirth] patients not in active labor...1:4 [one RN assigned to four patient] or fewer at all times...Perinatal services...1:4 mother-baby couplets [a mother and her newborn being cared for together in the same room after birth] or fewer at all times...In an effort to assure there are sufficient numbers of qualified staff available to specific units, systems are developed..."

Based on interview and record review, the facility failed to ensure crash carts (a wheeled container for medicine and equipment used during emergencies), emergency equipment, and supply logs were inspected in accordance with the facility's policy and procedure (P&P).

This failure had the potential to jeopardize patient safety and may cause delay in the provision of treatment during an emergency.

Findings:

1. On November 4, 2024, at 9:25 a.m., a tour of the Obstetrics Unit (unit where care and treatment are provided to pregnant patients during labor and delivery of infants) was conducted with Registered Nurse (RN)1.

On November 4, 2024, at 9:30 a.m., a record review was conducted with RN 1. A facility document titled, "Daily Crash Cart Check," dated November 2024, was reviewed. There was no documented evidence inspection of the following items listed on the document was conducted on November 2, 2024: if pharmacy drawer is sealed, defibrillator (an apparatus used to control heart fibrillation by the application of an electric current to the chest wall and the heart) was plugged in a red plug (an emergency backup power outlet which is used to power critical equipment during a power outage), if the battery charge is on, watt check (a test to ensure that the wattage testing dose on defibrillator machine is properly working, paper (paper used to print the heart rate and rhythm from the defibrillator) supply, if the board (a rigid board used during chest compressions when the heel of the palm is pushed towards the chest) is present, if the oxygen tank is half full, lead wires (essential devices used to connect the patient to a heart monitoring equipment), pads (equipment used to provide an electric shock to the heart), bag valve mask (BVM, equipment to establish airway to help in breathing) airway, and the first expiration date of medications.

A facility document titled, "Nov [November] 2024 Preeclampsia [a potentially serious condition involving persistent high blood pressure and signs of liver or kidney damage which occurs during pregnancy or after giving birth] Box," was reviewed. The document indicated, " ...Diversion [when a department is too busy to safely treat more patients and must redirect ambulances to other hospitals] ...," on November 2, 2024. There was no documented evidence the lock numbers and expiration date of the preeclampsia box were inspected on November 2, 2024.

A facility document titled, "Nov 2024 Hemorrhage [loss of blood from a damaged blood vessel] Box," was reviewed. The document indicated, " ...Diversion ...," on November 2, 2024. There was no documented evidence the lock number and expiration date of the hemorrhage box were inspected.

A facility document titled, "[Facility Name] OB [a branch of medicine which specialize in the care of the pregnant patient before, during, and after the delivery of the infant] NORMAL QUALITY CONTROL LOG," dated November 2024, was reviewed. The document indicated, " ...Diversion ...," on November 2, 2024. There was no documented evidence the daily quality control check for urine dipstick (a thin plastic strip with chemical patches that changes color when dipped into a urine sample to indicate the presence of certain substances) was conducted on November 2, 2024.

A facility document titled, "Hemorrhage Cart Checklist," dated November 2024, was reviewed. The document indicated, " ...Diversion ...," on November 2, 2024. There was no documented evidence the expiration date and lock number of the hemorrahge cart were inspected on November 2, 2024.

A facility document titled, "Stop & [and] Drop Box [emergency medications used during an emergency during childbirth]," dated November 2024, was reviewed. The document indicated, "...Diversion...," on November 2, 2024. There was no documented evidence the lock number and expiration date of the Stop and Drop box were inspected on November 2, 2024.

A facility document titled, "Infant Warmer [an equipment used to maintain a newborn's body temperature] Check ...LD [labor and delivery] # [number]1 [one]," dated November 2024, was reviewed. There was no documented evidence inspection of the following items was conducted on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature (infants born before 37 weeks of pregnancy) sized bag and mask (a handheld device used to assist in breathing and provide oxygen to a patient), oxygen connection and tubing, oxygen tank if full, stethoscope (a medical device used to listen to heart sounds), suction (an equipment used to remove solid and liquid substances from a patient), bulb syringe (a device used to suction liquid substances from a patient), and intubation (a procedure to establish an airway to allow a person to breathe by inserting a flexible plastic tube in the airway) tray.

A facility document titled, "Infant Warmer Check...LD #2 [two]," dated November 2024, was reviewed. There was no documented evidence inspection of the following items was conducted on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, oxygen tank if full, stethoscope, suction, bulb syringe, and intubation tray.

A facility document titled, "Infant Warmer Check...LD #3 [three]," dated November 2024, was reviewed. There was no documented evidence inspection of the following items was conducted on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, if oxygen tank was full, stethoscope, suction, bulb syringe, and intubation tray.

2. On November 4, 2024, at 9:50 a.m., a tour of the Emergency Department (ED) was conducted with RN 1.

On November 5, 2024, at 9:50 a.m., a record review was conducted with RN 1. A facility document titled, "Infant Warmer Check...ED," dated November 2024, was reviewed. There was no documented evidence inspection was conducted for the following items on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, oxygen tank if full, stethoscope, suction, bulb syringe, and intubation tray.

A facility document titled, "Infant Warmer Check...OR [Operating Room]," dated November 2024, was reviewed. There was no documented evidence inspection was conducted for the following items on November 1, 2024, November 2, 2024, and November 3, 2024: regular and premature sized bag and mask, oxygen connection and tubing, oxygen tank if full, stethoscope, suction, bulb syringe, and intubation tray.

A facility document titled, "OB UNIT ORIENTATION," was reviewed. The document indicated, "...Competency Requirements Returned to Supervisor Labor and Delivery...Area of Review...Tour of Labor & Delivery...crash cart open & review...Area of Review...Tour of Nursery & Mother/Baby Rooms...Infant Warmers...Neonatal [relating to newborn children] Crash Cart...Labor and Patient Management...Logbooks: Triage/Observation, Delivery, and Nursery...," should be completed.

A facility document titled, "Newborn Nursery Competency for Post-Partum [period after the infant was delivered by the patient] and Labor and Delivery," was reviewed. The document indicated, "...the staff member must be able to demonstrate the knowledge and skills necessary to provide care based on physical, psychosocial, educational, safety, and related criteria appropriate to the age of the patients served in his/her assigned service area...Validation to be completed by co-worker with minimum of equivalent licensure and/or supervisor/manager...Demonstrates a working knowledge of emergency equipment and documents:
1. Is familiar with location & function of emergency supplies
2. Is able to set up intubation equipment
3. Checks emergency equipment and documents appropriately
4. Neonatal/Pediatric (relating to the branch of medicine dealing with children) & Adult Crash Carts..."

An interview was conducted on November 4, 2024, at 9:20 a.m., with RN 1. RN 1 stated the daily logs are completed by any staff working on the unit for the day. RN 1 stated the signature on the log indicated inspection of the specific item or equipment that is marked on the log. RN 1 further indicated staff from a sister facility came to the facility to work due to the facility not having staff to work in the perinatal unit. RN stated the staff from the sister facility was not given orientation in the unit. RN 1 stated she did not know why some logs indicated "Diversion" on November 2, 2024. RN 1 stated, "The logs should have been completed and the equipment should have been inspected by the staff."

An interview was conducted on November 4, 2024, at 1:25 p.m., with the Chief Operating Officer (COO). The COO stated, "Logs should not say Diversion, we had staff. It was a mistake." The COO further stated, "[Name of sister facility] staff that worked in the perinatal unit already had competencies but did not get orientation to the unit."

An interview was conducted on November 6, 2024, at 2:30 p.m., with RN 2. RN 2 stated, "Orientation packet states the check boxes and logs are listed there and the staff sign that they are completed." RN 2 stated the charge nurse is ultimately responsible for the completion of the logs. She stated the reason the logs were not completed on November 2, 2024, is because the staff who worked in the unit on that date was from another facility and was not given orientation to the perinatal unit.

A facility P&P titled, "...Policy and Procedure...Crash Cart," was reviewed. The P&P indicated, "...Verification of the contents of the crash cart is to be checked according to the following...All twenty-four (24) hour nursing units are to do crash cart checks once a day by Licensed Nurse or designated licensed personnel ...Verification of completing the crash cart checklist will be documented on the Crash Cart Check form..."

A facility P&P titled, "...Policy and Procedure Resuscitation [the process of reviving someone from unconsciousness or apparent death] of the Newborn At Deliver [sic]," was reviewed. The P&P indicated, "...Appropriate staff and equipment for resuscitation will be provided at all births...The Nursery Nurse is responsible for ensuring completeness of the neonatal crash cart...The neonatal crash cart and resuscitation equipment will be checked for presence at infant resuscitation warmer and proper functioning at the beginning of every 12 hour shift and prior to each delivery. This equipment check will be documented on the Neonatal Crash Cart Checklist daily and the neonatal resuscitation warmer supply list every shift..."