HospitalInspections.org

Based on interview and record review, the hospital failed to ensure that a registered nurse (RN) supervised the nursing care of a patient in the final stage of pregnancy through documenting whether or not appropriate symptoms were discussed in a telephone conversation with a physician for 1 of 20 sampled patients (#1).

Findings:

A review of the medical record pf patient #1 was performed. The patient was assessed in triage at the desk, on 1/19/18 at 1:23 AM.

A nurse's note of 1/19/18 at 1:45 AM by RN A read, "Vaginal exam...1/100 (1 centimeter dilated, 100% effaced), BBOW (Bulging Bag of Water) unable to feel presenting part....Cervical Dilation: 1. Cervical Effacement (%): 100....Bishop Score: 7."

A nurse's note at 2:16 AM on 1/19/18 by RN A read, "Paged Dr...." At 2:23 AM RN A's note read, "Dr...return call inform pt (patient) status 37 wks (weeks), G3P2 (gravida 3 para 2), breech and 1 CM (centimeter) on Tue (Tuesday), irreg (irregular) ctx (contractions), 1/100 unable to feel presenting part, still breech reactive cat (category) 1 tracing. Order to medicate pt with vistaril 100 MG (milligrams) and DC (discharge)." The pertinent symptom of a bulging bag of water was not documented as having been discussed with the physician.

A review of hospital policy "Assessment and Reassessment of Patients" revealed the following: "Documentation: As appropriate in the medical record." Since the pertinent symptom of a bulging bag of water was not documented as being part of the report to the physician, the nurse was not in compliance with this policy.

The finding was confirmed in a telephone interview with the Risk Manager on 5/04/18 at approximately 2:30 PM.