HospitalInspections.org

Based on record review, interview and policy review, the facility failed to ensure staff staff followed the current facility policy related to clinical escalations in one Labor and Delivery patient. This affected Patient #4.

See A392

Based on record review, interview and policy review, the facility failed to ensure staff staff followed the current facility policy related to clinical escalations in one Labor and Delivery patient. This affected Patient #4.

Findings include:

Review of the medical record revealed Patient #4, a Gravida 1 Para 0 at 36.3 weeks gestation, presented to Obstetric Triage on 08/07/24 at 6:22 PM with complaints of vaginal bleeding and pain from contractions. At 6:27 PM the patient was placed on external fetal monitor and tocodynamometer to assess the fetal heart rate and uterine activity. A Category I, or normal fetal heart tracing was documented, but contractions were occurring every one to two minutes. At 6:30 PM, the patient's vital signs included a blood pressure of 140/83 and pulse of 97 beats per minute. The Attending Obstetric Physician's (Staff P) history and physical revealed the patient had a current obstetrical history remarkable for pre-eclampsia without severe features and a low lying placenta (placenta that partially covers the cervix). The history and physical stated the patient reported intermittent cramping and unprovoked vaginal bleeding that was more than just with wiping. The plan, outlined in the history and physical, was to administer an intravenous (IV) bolus of lactated ringers, continue home Labetalol (medication used to treat high blood pressure in pregnant women) at 300 mg three times a day, and administer two doses of Betamethasone (steroid administered to preterm pregnant women to accelerate fetal lung maturity). The physician further stated the patient and her husband were advised it would be preferred to wait 12-24 hours to give Betamethasone time to aid in fetal maturity but if the fetal heart tracing began to show decelerations, increased bleeding, or pain increased significantly, the physician would move to delivery. According to the history and physical, the plan was always to perform a cesarean section due to the low lying placenta, however, since the patient was less than 37 weeks, the protocol was to administer Betamethasone.

At 6:35 PM, the labor flowsheet revealed the patient rated her pain a 4 on a 0-10 scale. At 7:00 PM, contractions with a moderate quality were occurring every 1-2 minutes. The baseline fetal heart rate was 140 beats per minute with moderate variability at this time. A nurse's note at 6:40 PM stated the Attending Obstetric Physician was notified of the patient's arrival due to vaginal bleeding and the nurse being uncomfortable performing a sterile speculum exam due to the patient's low lying placenta. The nurse also informed the physician that the patient was contracting every 1-2 minutes, however the abdomen was soft between contractions. The physician stated she would come to the hospital. Review of the Medication Administration Record (MAR) revealed the patient was medicated with a 1000 mL bolus of lactated ringers, from 7:01 PM to 7:46 PM, to eliminate the contractions, and at 7:02 PM, Betamethasone 12 mg was administered intramuscularly. At 7:40 PM, the Attending Obstetric Physician was at the bedside of the patient. The patient's cervix was visually closed and a digital exam was deferred.

At 8:30 PM, the labor flowsheet noted a baseline fetal heart rate of 130 beats per minute with late decelerations, a Category II fetal heart tracing. The patient was positioned left lateral and an IV fluid bolus of lactated ringers was initiated at 8:40 PM as intrauterine resuscitative measures. The MAR noted the patient was medicated with 4 mg of IV Zofran (medication used to treat nausea and/or vomiting). According to the labor flowsheet, at 9:00 PM, the Category II fetal heart tracing continued with a baseline fetal heart rate of 120 beats per minute with late decelerations. The patient was positioned side to side as an intrauterine resuscitative measure. Contractions continued to occur every 1-2 minutes. The patients pulse was 112 beats per minute at this time. A nurse's note, at 9:15 PM stated a call was placed to the Attending Obstetric Physician to notify her that the patient was reporting the contractions were more intense but vaginal bleeding was still scant. The note further stated the physician was notified that the fetal heart rate was in the 100's-110's with the staff nurse and the charge nurse agreeing there appeared to be late decelerations with moderate variability. The physician ordered the nurse to administer acetaminophen and advised the nurse that she would review the fetal heart tracing from home.

At 9:23 PM, the labor flowsheet revealed that the patient rated her pain from contractions a 6 on a 0-10 scale. The MAR noted the patient was medicated with 1,000 mg of acetaminophen at this time. An indeterminate deceleration was audible at 9:30 PM. A nurse's note at 9:33 PM stated the physician called back to the unit after reviewing the fetal heart tracing and stated she did not see late decelerations but advised the nurse to keep watching the patient's bleeding and pain, and if either increased, to call back. A nurse's note at 10:15 PM stated the patient called out reporting she was bleeding more. The nurse further documented a small amount of bleeding was noted on the pad and peri area. A deceleration in the fetal heart rate was also noted. A nurse's note, at 10:30 PM, stated the patient advised the nurse that she needed to urinate. The nurse went to the room to assess the patient's bleeding and discovered increased bleeding with clots when the patient got up to the bathroom. A nursing note, at 10:46 PM, stated a call was placed to the Attending Obstetric Physician to notify her that the contractions were "back to back" and the patient was not getting any relief between contractions. The physician advised the nurse that she would be coming to the hospital to perform a cesarean section. The Attending Physician's Progress Note at 11:09 PM stated she was notified that the patient was becoming increasingly uncomfortable with contractions. The physician further stated there was a Category II fetal tracing with a wandering baseline and nonrecurrent late decelerations, and tocodynamometer with consistent contractions every 1-2 minutes. The physician discussed with the patient, she would "proceed toward delivery via primary cesarean section now." The physician stated two units of packed red blood cells were placed on hold and the hemorrhage kit was immediately available in the OR.

The patient was removed from the external fetal monitor and tocodynamometer at 11:15 PM and taken to the Operating Room (OR). The Intraoperative Report noted the patient was in the OR at 11:19 PM. The Attending Obstetric Physician was also in the OR at this time. Anesthesia began placement of spinal anesthesia at 11:25 PM and ended the procedure at 11:28 PM. According to the anesthesia record, the patient's blood pressure and pulse were 171/98 and 124 beats per minute at 11:25 PM, her pulse was 117 beats per minute at 11:26 PM, 110 beats per minute at 11:27 PM, and 108 beats per minute at 11:28 PM. At 11:29 PM, using a doppler, a staff nurse obtained a fetal heart rate of 120 beats per minute. At 11:32 PM, the patient's blood pressure was 109/57. The incision was made at 11:43 AM.

The Delivery Summary revealed the infant girl was delivered at 11:51 PM. The infant was limp, cyanotic, and apneic with Apgars of 0 and 0. The infant was brought directly to the warmer where a pediatrician, present during delivery, performed aggressive resuscitative measures including positive pressure ventilation with FiO2 at 100%, chest compressions, and intubation. Despite these aggressive resuscitative measures for more than an hour, the infant never had a heart rate and was pronounced deceased. A cause of death of acute blood loss due to placental abruption was identified by the pediatrician.

The Operative Report noted an estimated blood loss of 1200 mL. A placental abruption was suspected. Although the parents requested an autopsy, no results were available in the medical record.

Staff Q was interviewed via phone on 10/09/24 at 5:30 PM. Staff Q identified herself as the primary nurse caring for Patient #4 during labor and delivery. She stated she was concerned about the patient.

Staff P, the Attending Obstetric Physician, was interviewed via phone on 10/16/24 at 4:31 PM. She reported that the patient informed her she had a gush of blood at home and immediately came to the hospital. She stated the patient's contractions looked "impressive" on admission but she didn't believe she was feeling them. The physician stated she was unaware that on admission, the patient rated her pain from contractions a 4 on a 0-10 scale but stated that the patient was calmly conversing and didn't appear overly uncomfortable. Staff P stated she was aware there was tachysystole in the contraction pattern. She was unaware that the patient was medicated with Zofran for complaints of nausea. Staff P stated that the patient did not present like placental abruptions that she has seen in the past so she was shocked and horrified at the outcome. She stated it wasn't at all what she expected and was a tragic outcome.

Staff C, Director of Women & Children, was interviewed via phone on 10/18/24 at 2:24 PM. It was confirmed that the patient presented to Obstetric Triage with complaints of pain from contractions, the pain worsened and she rated the pain a 6 on the same 0=10 scale. It was further confirmed that the physician was notified of the patient's report of contractions getting more intense at 9:15 PM but did not present to the hospital until more than two hours later, at 11:19 PM. It was confirmed that despite the physician advising both the patient and the nurse that she would move to a cesarean section in the event of increased pain, despite intrauterine resuscitative measures being administered due to the Category II fetal heart tracing, and despite the nurse's admitted concern for the patient, the medical record lacked documentation a charge nurse clinical coordinator, or manager contacted the physician regarding the concern as outlined in the facility policy.

The facility policy titled "Fetal Monitoring:, effective 07/12/24, defined tachysystole as excessive uterine activity, more than five contractions in a 10 minute segment averaged over a 30 minute period. Tachysystole can be the result of both spontaneous and stimulated labor. Addendum C of the policy advised staff nurses of intrauterine resuscitative measures to reduce uterine activity in the event of tachysystole. Staff nurses are advised to administer an intravenous fluid bolus of lactated ringers solution, position the patient either to the left or right lateral position, and if no response, consider administration of Terbutaline 0.25 mg subcutaneously.

The facility policy titled "Clinical Escalations in Labor and Delivery and Postpartum", effective 05/10/24, stated if a nurse is caring for an obstetrical patient and believes they have received an unsatisfactory telephonic response from the practitioner, the following steps are to be followed:

1.1. The nurse will notify the charge nurse, clinical coordinator, or manager who will contact the practitioner regarding the concern.
1.2. If there is an unsatisfactory response, the charge nurse, clinical coordinator or manager may contact the director or may contact the appropriate Women's Services line chair or vice chair regarding the concern.


This deficiency represents non-compliance investigated under Substantial Allegation OH00157253.