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Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined that the hospital failed to ensure that hospital services and the physical environment were safe and appropriate as required by OARs. On 03/19/2023 the hospital closed its FBC Unit and discontinued the provision of maternity services within its long-standing, organized, and secure department that contained LDRP rooms, C-section surgical suites, and a nursery:
* LMHMC is licensed by the State of Oregon as a "General Hospital." That classification requires a hospital to provide an organized and secure maternity services department.
* LMHMC had submitted a waiver to the SA to close its FBC Unit. The waiver review was in process and the waiver had not been approved on 03/19/2023 when the Unit was closed.
* Space in the existing LMHMC ED had been dedicated for maternity services use without building plans review and the approval of the SA to ensure that space was safe and constructed in accordance with State licensing building plans requirements. The provision of maternity services to pregnant patients in that space began on 03/19/2023.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency.

Findings include:

1. Refer to the deficiency cited at Tag A-0022, CFR 482.11(b)(2) - Standard: Approved as meeting SA licensing standards.




































































29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined that the hospital failed to ensure that hospital services and the physical environment were safe and appropriate as required by OARs. On 03/19/2023 the hospital closed its FBC Unit and discontinued the provision of maternity services within its long-standing, organized, and secure department that contained LDRP rooms, C-section surgical suites, and a nursery:
* LMHMC is licensed by the State of Oregon as a "General Hospital." That classification requires a hospital to provide an organized and secure maternity services department.
* LMHMC had submitted a waiver to the SA to close its FBC Unit. The waiver review was in process and the waiver had not been approved on 03/19/2023 when the Unit was closed.
* Space in the existing LMHMC ED had been dedicated for maternity services use without building plans review and the approval of the SA to ensure that space was safe and constructed in accordance with State licensing building plans requirements. The provision of maternity services to pregnant patients in that space began on 03/19/2023.

Findings include:

1.a. OAR 333-500-0032(2) requires that "(a) A hospital classified as a general hospital shall: (A) Provide at least general medical, maternity and surgical services."

1.b Review of the LMHMC hospital licensing documents issued by OHA-PHD-HCRQI reflected that the hospital has been licensed as a General Hospital since 06/14/1971. The annual "Hospital License Application ... License Renewal" form signed by the CEO on 12/14/2022 reflects that the "services provided by the hospital" included "Maternity." The current hospital license form issued 12/21/2022 reflects the hospital's classification as a General Hospital.

1.c. During interviews with the CEO, the CMO, and the CNO on 03/20/2023 beginning at 1210 they stated that the hospital's FBC unit had closed and discontinued operations on 03/19/2023 at 1200 noon, and provided the following information:
* They were planning for maternity patients to come into the ED after the FBC closed.
* FBC unit RNs have left for work at other hospitals or are in process of leaving.
* On 03/19/2023 at noon was "officially called the end of scheduled shifts" and the "last time an OB MD was scheduled to be onsite at the hospital."
* There were no planned deliveries effective 03/19/2023 at noon.

1.d. Observations of the hospital's FBC unit on 03/20/2023 beginning at ~1330 reflected the following:
* A posterboard sign placed on an easel in the unit's waiting room reflected "Congratulations to Legacy Mount Hood Medical Center's Family Birth Center" and under that "Closing FBC March 17th."
* The FBC NM and the FBC ANM were present on the unit and stated that the last patient had presented on 03/19/2023 in the morning and the unit had closed on 03/19/2023 at 1200 noon.
* The handwritten "MH Family Birth" census/patient assignment forms for each 12-hour shift from 03/17/2023 through 03/19/2023 were observed at the nurse's station. Those reflected that eight (8) patients were present on the unit and had received maternity services between 03/17/2023 and 03/19/2023. The last patient treated in the FBC had presented on 03/19/2023 at 0727 and was the last patient discharged from the FBC on 03/19/2023 at 0941.
* There were no patients on the unit and no evidence of patient care or services in the LDRP corridors, in the C-section suites, and in the newborn nursery.
* A facility staff person was observed in the patient care area to be gathering pump devices and placing them on a large cart. Facility staff stated at the time of the observation that those were to be distributed to other patient care areas in the hospital.

1.e. Review of the hospital's website, and other marketing materials and documents developed by the hospital, reflected it had informed patients and the community that the FBC was closing on 03/17/2023. Those materials were reviewed with the CNO, the ACCC, and the MS on 03/22/2023 beginning at 0900. Materials reviewed included, but were not limited to, the following examples:
* The front webpage of the LMHMC website reflected: "Legacy Health Mount Hood Family Birth Center will close on March 17. After March 17, Legacy's Labor and Delivery services for East Multnomah County patients will be available at the Family Birth Center at Randall Children's Hospital in North Portland."
* The LMHMC website reflected under hospital "Services" only "Cancer care" and "Surgery." During interview at that time of the review the MS confirmed that maternity services references had been removed from the "About" and "Services" sections of the LMHMC website.
* A document identified as "LMG Clinic Patient Flyer ..." contained the following language: "Mount Hood Family Birth Center Closure ... Legacy Health Mount Hood Family Birth Center will close on March 17, 2023, pending approval by the State of Oregon."
* A presentation identified as "Multnomah County Leader Meeting Presentation" was titled "East County Women's Health Needs"and was dated 03/16/2023. It contained the following language: "No new FBC elective patient admissions after 11:59 p.m. on March 17."
* A letter identified as "Multnomah County EMS Divert Notice" was dated 03/06/2023. It contained the following language: "... Legacy Mount Hood Medical Center is notifying Multnomah County that the medical center will be on obstetrical (OB) divert as of March 17, 2023, due to staffing issues."
* A document identified as "OHP Clinic Closure Letter LMG" was dated 02/15/2023 and reflected "Dear valued patient ... We want to let you know that the Family Birth Center unit in the Legacy Health Mount Hood Medical Center will close on March 17, 2023. The State of Oregon must approve the closing. I wanted you to have the most correct information about this as soon as possible ... Labor/deliveries will move to the Family Birth Center unit in the Randall Children's Hospital ... You will continue to receive your care through the LMG-Mount Hood Women's Health Clinic..."
* A document identified as "Patient Message Final" reflected "Legacy Mount Hood Medical Center operates on divert for labor and delivery service starting March 17. Starting on March 17, Legacy Health will have no new elective admissions at the Mount Hood Family Birth Center.

2.a. OAR 333-500-0065 allows for a hospital to submit a request for a waiver from a rule and specifies under Section (3) that "A hospital may not implement a waiver until it has received written approval from the Division."

2.b. Review of State licensing records for LMHMC reflected that on 03/06/2023 the hospital CEO submitted a written waiver request to discontinue maternity services. Review of the request by the State licensing authority revealed the information in the initial waiver request was insufficient to make a determination. On 03/13/2023 an email was sent to LMHMC that requested additional information and included reminders about the criteria for waiver evaluations and that the OARs prohibit the hospital from implementing a waiver without written approval from the State licensing authority.

2.c. The waiver activity described above was in contrast to findings from this survey that reflected as early as 01/27/2023, and more than five (5) weeks prior to submission of a waiver request, the hospital had issued public and patient notices that the FBC would close on 03/17/2023. For example:
* A "News Release" article posted on the LMHMC website reflected it was posted and released to the media on 01/27/2023 and reflects: "PORTLAND, ORE - Jan. 27, 2023 - Legacy Health, like hospitals across the country, faces a concerning trend of financial losses in the aftermath of the COVID-19 pandemic. As a result, we are taking actions that will allow us to continue fulfilling our mission and offering essential services for our patients ... After much discussion, planning, and working with our staff, we have made the difficult decision to stop delivering babies at Legacy Mount Hood's Family Birth Center. The date for that change is tentatively set for Friday, March 17 ... Our plan is to close the Mount Hood Family Birth Center, pending approval by the State of Oregon. We will be working with the state to review the situation and seek their guidance on our plan for a temporary or permanent closure of the Family Birth Center ..."
* A "LMG Clinic Patient Flyer" in English was provided to clinics for distribution to patients beginning on 02/13/2023. Spanish and Russian translations followed on 02/15/2023 and 03/10/2023 respectively. This information was confirmed in an email from the ACCC received on 03/22/2023 at 1333. This flyer contained the following language: "... Legacy Health Mount Hood Family Birth Center will close on March 17, 2023, pending approval by the State of Oregon."

3.a. OARs require that a hospital submit building construction plans to the hospital State licensing authority for review and approval prior to a change of use or relocation of services. Those areas may not operate until approval and licensure to commence services is received from the State licensing authority. OAR 333-500-0045(2) of this OAR requires: "Submissions shall comply with OAR chapter 333, division 675."

3.b. OAR 333-675-0000(1) requires: "Any person proposing to make certain alterations or additions to an existing health care or residential care facility, or to construct new facilities must, before commencing such alteration, addition or new construction, submit plans and specifications to the Oregon Health Authority, Public Health Division, Facilities Planning and Safety, 800 NE Oregon Street, Suite 465, Portland, OR 97232 for plans approval or recommendations with respect to compliance with rules authorized by ORS 441.025, 443.420 and for compliance with National Fire Protection Association standards when the facility is also to be Medicare or Medicaid certified."

3.c. OAR 333-675-0000(2) requires: "Project plans and specifications must be submitted for review and approval to Facilities Planning and Safety when the project conforms to one or more of the following criteria: ... (c) When a clinically related health or ancillary service, or dietary or laundry service is to be initiated or relocated within the facility; or when significant changes in the use of rooms or corridors within such areas will occur, regardless of cost; ..."

3.d. Review of State licensing authority building plans records revealed no evidence that the hospital had submitted building plans for the relocation of maternity services to the hospital's ED.

4. Refer to the deficiency cited at Tag A-0043, CFR 482.12 - Condition of Participation: Governing Body.

5. Refer to the deficiency cited at Tag A-0115, CFR 482.13 - Condition of Participation: Patient Rights.

6. Refer to the deficiency cited at Tag A-0700, CFR 482.41 - Condition of Participation: Physical Environment.

7. Refer to the deficiency cited at Tag A-1100, CFR 482.55 - Condition of Participation: Emergency Services.








29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined that the governing body of the hospital had not been responsible for the operation of the hospital to ensure the provision of safe, organized, and appropriate care and services as follows:
* The hospital closed its organized and secure FBC Unit, required by the hospital's State licensing classification, without the approval of the State licensing authority.
* The hospital failed to submit building plans for review to the State licensing authority for the transition of maternity services from the hospital's dedicated FBC unit to a dedicated space in the hospital's ED.
* Prior to and following the FBC closure, the hospital's scope of services and P&Ps did not clearly reflect the provision of maternity services.
* The hospital's QAPI plan had not been developed to include monitoring of the provision of maternity services in the ED.
* The hospital had not ensured patients were provided clear and accurate notification of changes to the hospital's maternity services.
* The hospital had not ensured the provision of safe maternity services in the hospital's ED which created a potential for patient harm.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency.

Findings include:

1.a. The LMHMC "Board of Directors Meeting Minutes" dated 03/09/2023 were reviewed. At the time the minutes were provided on 03/21/2023 the CNO stated that they were the only governing body minutes in 2023 that reflected discussion about the hospital's closure of its FBC unit. The 03/09/2023 minutes contained only the following language related to the hospital's FBC unit: "[Legacy Health President & CEO] shared updates regarding Mount Hood Medical Center. Primarily discussing the Family Birth Center and union activity. [They] reiterated the application for a waiver related to the FBC was not related to union activity." There was no other related information in those minutes.

1.b. In an email from the ACCC received on 03/23/2023 at 1707 they wrote: "We communicated with our Board of Directors on January 27, 2023 of our intention to apply for a waiver related to the Mt. Hood Family Birth Center. Our Chief Executive Officer continued to subsequently keep our board trustee leadership apprised of our efforts related to the waiver. The board has been apprised of the difficulties associated with our delivery model at Mt. Hood via the board finance committee. Legacy Health was not required to seek board approval for the waiver request as it was not a permanent service line closure. Our application shows intent for a temporary suspension of services." No minutes were provided from the January 27, 2023 meeting that reflected the information described in the email message. The minutes of 03/09/2023 reflect the only subsequent documented communication between the CEO and the Governing body related to the waiver.

1.c. Although the waiver request document signed by the CEO on 03/06/2023 indicated that "we seek a three-year waiver to allow for the temporary closure of the Mount Hood Family Birth Center" and the ACCC stated in the email above that the FBC closure was "not a permanent service line closure" but a "temporary suspension of services," that timeline was not consistent with the observations, interviews and document findings from this survey that are described in this report. It was not evident during interviews, and review of documents and records including public and patient notices, that the FBC closure was "temporary."

2. Refer to the deficiency cited at Tag A-0057, CFR 482.12 - Standard: Chief Executive Officer.

3. Refer to the deficiency cited at Tag A-0020, CFR 482.11 - Condition of Participation: Compliance with Federal, State and Local Laws.

4. Refer to the deficiency cited at Tag A-0115, CFR 482.13 - Condition of Participation: Patient Rights.

5. Refer to the deficiency cited at Tag A-0263, CFR 482.21 - Condition of Participation: Quality Assessment and Performance Improvement Program.

6. Refer to the deficiency cited at Tag A-0700, CFR 482.41 - Condition of Participation: Physical Environment.

7. Refer to the deficiency cited at Tag A-1100, CFR 482.55 - Condition of Participation: Emergency Services.



29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined the CEO of the hospital had not been responsible for the operation of the hospital to ensure the provision of safe, organized, and appropriate care and services as follows:
* The hospital closed its organized and secure FBC Unit, required by the hospital's State licensing classification, without the approval of the State licensing authority.
* The hospital failed to submit building plans for review to the State licensing authority for the transition of maternity services from the hospital's dedicated FBC unit to a dedicated space in the hospital's ED.
* Prior to and following the FBC closure, the hospital's scope of services and P&Ps did not clearly reflect the provision of maternity services.
* The hospital's QAPI plan had not been developed to include monitoring of the provision of maternity services in the ED.
* The hospital had not ensured patients were provided clear and accurate notification of changes to the hospital's maternity services.
* The hospital had not ensured the provision of safe maternity services in the hospital's ED which created a potential for patient harm.

Findings include:

1. Refer to the deficiency cited at Tag A-0020, CFR 482.11 - Condition of Participation: Compliance with Federal, State and Local Laws.

2. Refer to the deficiency cited at Tag A-0115, CFR 482.13 - Condition of Participation: Patient Rights.

3. Refer to the deficiency cited at Tag A-0263, CFR 482.21 - Condition of Participation: Quality Assessment and Performance Improvement Program.

4. Refer to the deficiency cited at Tag A-0700, CFR 482.41 - Condition of Participation: Physical Environment.

5. Refer to the deficiency cited at Tag A-1100, CFR 482.55 - Condition of Participation: Emergency Services.



29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined that the hospital failed to ensure patients' rights to be fully informed about the hospital's services and to the provision of safe care:
* Patients were not provided clear and accurate notification of changes to the hospital's maternity services. Notice was provided to patients that the hospital was closing its organized and secure FBC Unit before the change had been approved by the hospital State licensing authority, and the hospital's P&Ps and scope of services documents and descriptions did not clearly and consistently reflect how and where at the hospital maternity services would be provided.
* Patients were not ensured the provision of safe maternity services in the hospital's ED. The hospital had closed its organized and secure FBC Unit and moved maternity services to a treatment room in the ED where the space was inadequate to manage patients in labor and newborns, particularly in the event of maternal or newborn complications, and in which the space, supplies, and equipment were disorganized and incomplete. In addition, signage in the hospital continued to direct patients to the closed FBC located on the opposite end of the hospital from the emergency department. These conditions represented a potential for harm to patients.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency.

Findings include:

1. Refer to the deficiency cited at Tag A-0131, CFR 482.13(b)(2) - Standard: Right to be fully informed.

2. Refer to the deficiency cited at Tag A-0144, CFR 482.13(c)(2) - Standard: Right to care in a safe setting.


29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined that the hospital failed to ensure patients' rights to be fully informed about the hospital's services:
* Patients were not provided clear and accurate notification of changes to the hospital's maternity services. Notice was provided to patients that the hospital was closing its organized and secure FBC Unit before the change had been approved by the hospital State licensing authority, and the hospital's P&Ps and scope of services documents and descriptions did not clearly and consistently reflect how and where at the hospital maternity services would be provided.

Findings include:

1.a. The P&P titled "Patient Rights and Responsibilities" with "last revision date: 11/20" was reviewed. It included the following:
* "Patients have the right to be informed regarding their care and treatment ..."
* "Legacy policy Scope of Service; Patient Care (Hospital: 900.2307 ...) defines the processes that care providers will follow in order to collaborate with patients and families and/or decision makers in maximizing their health and welfare through clinical practice, health teaching, patient advocacy and coordination of care and service."

The hospital's P&Ps and documents that described its services were unclear and inconsistent. For example:
* The P&P titled "Scope of Service; Patient Care (Hospital: 900.2307 ...)," referenced in the Patient Rights" P&P above, was not provided. Beginning during the survey entrance conference on 03/20/2023 repeated requests for the LMHMC scope of services document that contained all of LMHMC services, capabilities, and capacity were made. A P&P titled "System Scope of Service Plan" with "Plan #: 900.3307" and "last revision date: July 2022" was provided. It reflected in the broadest of terms some of the "Clinical Service" areas (i.e. "Women's and Newborn Services") provided across the Legacy Health System at six (6) Legacy hospitals including one in Washington State. It did not identify or describe the services provided at each of the individual Legacy hospitals, including LMHMC.
* During interview on 03/21/2023 the CNO and ACCC stated that there was not a scope of services plan/P&P for LMHMC other than a presentation slide used for an AO TJC survey that listed the hospital's services. An undated presentation slide page provided was titled "Key Services" and consisted of a list of 11 services including "Family Birth Center (awaiting waiver)."
* The current LMHMC "Leadership Organization Chart - 2023" was requested and provided. It included the department/unit of "Family Birth Center."
* The "Legacy Mount Hood Medical Center Emergency Department Scope of Service" with "last review date: July 2020" was reviewed. Although it stated that "All types of physiologic and psychological complaints may be seen in the Mount Hood Medical Center Emergency Department," under the lengthy list of "types and conditions seen in the emergency department" was no specific reference to pregnant patients, patients in labor, or pregnancy complications.

1.b. Review of the hospital's website, and other marketing materials and documents developed by the hospital, reflected it had informed patients and the public that the FBC was closing on 03/17/2023. Those materials were reviewed with the CNO, the ACCC, and the MS on 03/22/2023 beginning at 0900. The review of those materials and documents revealed the information provided to patients and the public was confusing, misleading, and was not adequate to ensure patients' rights to have accurate information about the nature of the change to the maternity services provided at LMHMC. For example:
* A document identified as "LMG Clinic Patient Flyer ..." contained the following language: "Mount Hood Family Birth Center Closure ... Legacy Health Mount Hood Family Birth Center will close on March 17, 2023, pending approval by the State of Oregon."
* A document identified as "OHP Clinic Closure Letter LMG" was dated 02/15/2023 and reflected "Dear valued patient ... We want to let you know that the Family Birth Center unit in the Legacy Health Mount Hood Medical Center will close on March 17, 2023. The State of Oregon must approve the closing. I wanted you to have the most correct information about this as soon as possible ... Labor/deliveries will move to the Family Birth Center unit in the Randall Children's Hospital ... You will continue to receive your care through the LMG-Mount Hood Women's Health Clinic..."
* A document identified as "Patient Message Final" reflected "Legacy Mount Hood Medical Center operates on divert for labor and delivery service starting March 17. Starting on March 17, Legacy Health will have no new elective admissions at the Mount Hood Family Birth Center
* A presentation identified as "Multnomah County Leader Meeting Presentation" was titled "East County Women's Health Needs" and was dated 03/16/2023. It contained the following language: "No new FBC elective patient admissions after 11:59 p.m. on March 17."
* A letter identified as "Multnomah County EMS Divert Notice" was dated 03/06/2023. It contained the following language: "... Legacy Mount Hood Medical Center is notifying Multnomah County that the medical center will be on obstetrical (OB) divert as of March 17, 2023, due to staffing issues."

1.c. The EHRs of patients who received prenatal maternity outpatient services at LMHMC were reviewed with hospital staff on 03/21/2023 beginning at 1605. Documentation in those reflected that all patients had not received clear and adequate information regarding the change of maternity services at LMHMC:
* Patient 3's EHR included documentation of a 02/09/2023 prenatal visit. Documentation by the MD reflected "Discussed potential of FBC closing ... We discussed that with spontaneous early labor [patient] may make cutoff to be able to deliver at Mt Hood."
* Patient 5's EHR included an electronic message sent to the patient by the CNM on 01/31/2023. It contained the following language: "I wanted to reach out to you personally to notify you and your family of the upcoming changes at Legacy Mount Hood's Family Birth Center. On Friday, January 27th 2023, the upper leadership of Legacy Mount Hood announced to the staff a Mount Hood that they decided to close the Family Birth Center due to ongoing finical [sic] deficits ... At this time, pending the state's approval of the closure, the date to close is March 17th 2023."
* Patient 6's EHR included documentation of a 02/07/2023 prenatal visit. Documentation by the CNM reflected "Discussed tentative Mt. Hood FBC closure 3/17 ..."
* Patient 7's EHR included documentation of a prenatal visit on 01/25/2023 that reflected the delivery was planned at "Hospital: Mt Hood."
- Documentation of a prenatal visit on 02/27/2023 reflected only that the patient "has a hospital tour scheduled for March 22 at Randalls."
- Documentation of a prenatal visit on 03/08/2023 reflected the patient "has a tour of Randall's scheduled on 03/20 ... Discussed early labor/when to call/where to go." However there was no documentation to reflect what the discussion about "where to go" entailed.
- At the time of this review Patient 7's EHR continued to state that the delivery was planned at "Hospital: Mt Hood."
* Patient 8's EHR included documentation of a 01/30/2023 prenatal visit. Documentation by the CNM reflected "Discussed tentative Mt. Hood FBC closure 3/17 ..."

1.d. LMHMC inappropriately provided notice of closure to patients prior to the approval of closure by the hospital licensing authority. Where the notices, documents, and patient records stated that the FBC closure was "pending approval by the State of Oregon" and "The State of Oregon must approve the closing" and was described as "tentative" and "potential" it was unclear what the implications for patient care would be if "The State of Oregon" did not approve the closure by 03/17/2023.

Further, the patient and public notices did not clearly reflect or delineate the care and services that would no longer be available at LMHMC. The notices referenced that there would be "No new FBC elective patient admissions," no "labor/deliveries," and the hospital was operating "on divert for labor and delivery" all of which indicated that planned labor and delivery would not be provided. The only other description of services was that "You will continue to receive your care through the LMG-Mount Hood Women's Health Clinic" but what was meant by "care" was not described. There was no indication in the notices where patients were to go for non-elective patient admissions, and for non-urgent and emergency non-labor and labor checks and care previously provided at the LMHMC FBC. In addition, the use of the term "divert" was not clear, particularly in its use in patient notices, as that term applies only to EMS/Ambulance vehicles.

2. Refer to the deficiency cited at Tag A-0020, CFR 482.11 - Condition of Participation: Compliance with Federal, State and Local Laws.

3. Refer to the deficiency cited at Tag A-0043, CFR 482.12 - Condition of Participation: Governing Body.

4. Refer to the deficiency cited at Tag A-0263, CFR 482.21 - Condition of Participation: Quality Assessment and Performance Improvement Program.

5. Refer to the deficiency cited at Tag A-0700, CFR 482.41 - Condition of Participation: Physical Environment.

6. Refer to the deficiency cited at Tag A-1100, CFR 482.55 - Condition of Participation: Emergency Services.

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined that the hospital failed to ensure patients' rights to be fully informed about the hospital's services:
* Patients were not ensured the provision of safe maternity services in the hospital's ED. The hospital had closed its organized and secure FBC Unit and moved maternity services to a treatment room in the ED where the space was inadequate to manage patients in labor and newborns, particularly in the event of maternal or newborn complications, and in which the space, supplies, and equipment were disorganized and incomplete. In addition, signage in the hospital continued to direct patients to the closed FBC located on the opposite end of the hospital from the emergency department. These conditions represented a potential for harm to patients.

Findings include:

1.a. The P&P titled "Patient Rights and Responsibilities" was "last revision date: 11/20" was reviewed. It included the following:
* "Patients have the right to personal privacy and safety ..."
* "The environment is created to provide for auditory, visual and olfactory privacy and comfort."
* "Safety of the environment of care is a primary focus for all Legacy staff."

1.b. The hospital had closed its FBC as evidenced by the findings in this report. However, provisions had not been made to ensure that pregnant people who entered the hospital in an emergency did not navigate their way to the FBC unit located on the opposite end of the hospital from the ED, only to find it closed. That unnecessary activity could delay treatment and created a potential for harm to patients.

Observations on 03/20/2023 beginning at ~1330 reflected the following:
* There were no signs posted outside or inside of the hospital's main entrance or emergency entrance that informed patients that the FBC unit had been closed.
* A sign near the ceiling to the left inside of the hospital's main entrance and adjacent to the hospital's "Gift Shop" reflected "Family Birth Center" with an arrow pointing to the left corridor.
* A second sign down the left corridor and past the "Gift Shop" suspended from the ceiling reflected "Family Birth Center" with an arrow pointing to the right.
* A set of automatic double doors was to the right of the second sign. Painted on the doors was "Welcome to Family Birth Center." The doors opened without a secure badge swipe when the automatic door opener pad on the wall was pressed.
* Through those double doors was the FBC waiting room. A posterboard sign placed on an easel near a wall was observed that contained the wording "Congratulations to Legacy Mount Hood Medical Center's Family Birth Center" and under that "Closing FBC March 17th." However, the posterboard was almost entirely covered with numerous notes on pieces of paper and sticky notes so the language on the posterboard was not easily seen.
* There were no other signs or notices indicating the unit was closed posted in the waiting room, including on or near the secure entrance double doors to the FBC patient care areas.

During observations on 03/20/2023 at 1510, while revisiting the FBC waiting room, a LMHMC security staff person was observed through the waiting room windows to enter the hospital through the adjacent exterior door to the left of the FBC entrance. Although that exterior entrance was a staff entrance that required a badge swipe for entry, the security staff person was observed to open the door from the exterior without a badge swipe. During interview at that time staff present confirmed that the badge swipe for that door did not work and the door could be opened by individuals without a badge.

2. Refer to the deficiency cited at Tag A-0020, CFR 482.11 - Condition of Participation: Compliance with Federal, State and Local Laws.

3. Refer to the deficiency cited at Tag A-0043, CFR 482.12 - Condition of Participation: Governing Body.

4. Refer to the deficiency cited at Tag A-0263, CFR 482.21 - Condition of Participation: Quality Assessment and Performance Improvement Program.

5. Refer to the deficiency cited at Tag A-0700, CFR 482.41 - Condition of Participation: Physical Environment.

6. Refer to the deficiency cited at Tag A-1100, CFR 482.55 - Condition of Participation: Emergency Services.




29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of patient and public notices and information, review of medical record documentation for 5 of 7 undelivered patients who received prenatal maternity services at LMHMC (Patients 3, 5, 6, 7, and 8), review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of ED physician training documentation, and review of P&Ps and other documents it was determined that the hospital failed to ensure that, at the time this survey was initiated on 03/20/2023, the hospital's written QAPI plan reflected the complexity of the hospital's organization and services to include provisions for evaluation and monitoring of maternity services rendered in the hospital's ED to ensure those services were safe and appropriate after the closure of its organized and secure FBC Unit.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency.

Findings include:

1.a. A "Legacy Health Severe Maternal Morbidity Review Committee Charter (Updated March 2023)" was provided on 03/21/2023 at 1730 in response to repeated requests for evidence of a QAPI plan to address the provision of the hospital's maternity services that began at the time of the entrance conference on 03/20/2023. The charter reflected the Legacy Health System committee's membership included staff from each of the FBCs at other Legacy hospitals. It reflected the "Criteria for Review of a Severe Maternal Morbidity Event" was specific to "Pregnant, peripartum or postpartum women receiving 4 or more units of PRBC ... with planned or unplanned admission to an ICU ... who experience an unexpected and severe maternal morbidity and review is deemed appropriate by the birth facility."

The committee charter was not sufficient to reflect that the maternity care and services provided in LMHMC's ED upon closure of its FBC would be evaluated and monitored for safety and appropriateness in accordance with QAPI principles.

1.b. A two-page document titled "Legacy Mount Hood Medical Center Quality Monitoring Plan" dated as "Developed: March 2023" was provided in an email received on 03/24/2023 at 1616. The document contained four OB related "Focus Areas" and stated that "Case Reviews and chart audits will be done for all OB patients presenting to the ED." There was no documentation to reflect that the plan had been approved or when the plan would be implemented as part of the facility-wide QAPI program.

In response to a request for clarification about the development date of the OB plan, the ACCC confirmed the plan was developed after the start of this survey that began on Monday, 03/20/2023. The ACCC stated in text messages on Monday, 03/28/2023 at 1244 and 1248 that "We did in fact create the document last week ..." and "It was finalized on [03/23/2023]."

2. Refer to the deficiency cited at Tag A-0020, CFR 482.11 - Condition of Participation: Compliance with Federal, State and Local Laws.

3. Refer to the deficiency cited at Tag A-0043, CFR 482.12 - Condition of Participation: Governing Body.

4. Refer to the deficiency cited at Tag A-0115, CFR 482.13 - Condition of Participation: Patient Rights.

5. Refer to the deficiency cited at Tag A-0700, CFR 482.41 - Condition of Participation: Physical Environment.

6. Refer to the deficiency cited at Tag A-1100, CFR 482.55 - Condition of Participation: Emergency Services.




29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), and review of P&Ps and other documents it was determined that the hospital failed to ensure that the physical environment was constructed, arranged, and maintained to provide safe care within adequate facilities for special hospital services appropriate to the needs of the community:
* The hospital had closed its FBC Unit and discontinued the provision of maternity services within its long-standing, organized, and secure department that contained LDRP rooms, C-section surgical suites, and a nursery. Maternity services were moved to a dedicated treatment room in the ED where the space was inadequate to manage patients in labor and newborns, particularly in the event of maternal or newborn complications, and in which the space, supplies, and equipment were disorganized and incomplete. In addition, signage in the hospital continued to direct patients to the closed FBC located on the opposite end of the hospital from the emergency department. These conditions represented a potential for harm to patients.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency.

Findings include:

1. Refer to the deficiency cited at Tag A-0722, CFR 482.41(d) - Standard: Facilities.




















































29708

Based on observation, interview, review of State licensing records related to license classifications, waivers, and building plans submission, review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), and review of P&Ps and other documents it was determined that the hospital failed to ensure that the physical environment was constructed, arranged, and maintained to provide safe care within adequate facilities for special hospital services appropriate to the needs of the community:
* The hospital had closed its FBC Unit and discontinued the provision of maternity services within its long-standing, organized, and secure department that contained LDRP rooms, C-section surgical suites, and a nursery. Maternity services were moved to a dedicated treatment room in the ED where the space was inadequate to manage patients in labor and newborns, particularly in the event of maternal or newborn complications, and in which the space, supplies, and equipment were disorganized and incomplete. In addition, signage in the hospital continued to direct patients to the closed FBC located on the opposite end of the hospital from the emergency department. These conditions represented a potential for harm to patients.

Findings include:

1. Refer to the deficiency cited at Tag A-0020, CFR 482.11 - Condition of Participation: Compliance with Federal, State and Local Laws.

2. Refer to the deficiency cited at Tag A-0043, CFR 482.12 - Condition of Participation: Governing Body.

3. Refer to the deficiency cited at Tag A-0115, CFR 482.13 - Condition of Participation: Patient Rights.

4. Refer to the deficiency cited at Tag A-0263, CFR 482.21 - Condition of Participation: Quality Assessment and Performance Improvement Program.

5. Refer to the deficiency cited at Tag A-1100, CFR 482.55 - Condition of Participation: Emergency Services.

Based on observation, interview, review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of physician training documentation, and review of P&Ps and other documents it was determined the hospital failed to ensure the provision of organized, safe and appropriate maternity services in the ED. The hospital had closed its FBC Unit and discontinued the provision of maternity services within its long-standing, organized, and secure department that contained LDRP rooms, C-section surgical suites, and a nursery. Maternity services were moved to the ED where the provision of safe and appropriate maternity services was not ensured and a potential for harm to patients existed as follows:
* The ED treatment room dedicated for the provision of maternity services to pregnant patients and newborns was inadequate in size to ensure safe and efficient management of labor and delivery, particularly in the event of maternal or newborn complications.
* The dedicated maternity services ED treatment room contained emergency supplies that were not consistent with inventory/supply lists.
* ED P&Ps, posted instructions and emergency protocols, and training materials that described emergency management of pregnant patients and newborns were unclear, contradictory, and inconsistent.
* ED physician training related to the management of pregnant patients and newborns in the ED organized and assigned by LMHMC had not been completed by all ED physicians on staff.
* RN training related to the RN role in the management of pregnant patients and newborns in the ED organized and assigned by LMHMC had not been completed by all ED RNs on staff.
* ED Tech training related to their role in the management of pregnant patients and newborns in the ED had been planned, but not organized and implemented.

The findings identified during the survey reflect the hospital's limited capacity to provide safe and adequate care and services and represent a Condition-level deficiency.

Findings include:

1. Refer to the deficiency cited at Tag A-1101, CFR 482.55(a) - Standard: Organization and Direction.

2. Refer to the deficiency cited at Tag A-1104, CFR 482.55(a)(3) - Standard: Policies and procedures.

3. Refer to the deficiency cited at Tag A-1112, CFR 482.55(b)(2) - Standard: Personnel to meet patient needs anticipated by the facility.


29708

Based on observation, interview, review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of physician training documentation, and review of P&Ps and other documents it was determined the hospital failed to ensure the provision of organized, safe and appropriate maternity services in the ED. The hospital had closed its FBC Unit and discontinued the provision of maternity services within its long-standing, organized, and secure department that contained LDRP rooms, C-section surgical suites, and a nursery. Maternity services were moved to the ED where the provision of safe and appropriate maternity services was not ensured and a potential for harm to patients existed as follows:
* The ED treatment room dedicated for the provision of maternity services to pregnant patients and newborns was inadequate in size to ensure safe and efficient management of labor and delivery, particularly in the event of maternal or newborn complications.
* The dedicated maternity services ED treatment room contained emergency supplies that were not consistent with inventory/supply lists.
* ED P&Ps, posted instructions and emergency protocols, and training materials that described emergency management of pregnant patients and newborns were unclear, contradictory, and inconsistent.
* ED physician training related to the management of pregnant patients and newborns in the ED organized and assigned by LMHMC had not been completed by all ED physicians on staff.
* RN training related to the RN role in the management of pregnant patients and newborns in the ED organized and assigned by LMHMC had not been completed by all ED RNs on staff.
* ED Tech training related to their role in the management of pregnant patients and newborns in the ED had been planned for, but had not been organized and scheduled.

Findings include:

1. During interview with the EDNM on 03/20/2023 at the time of a tour of the ED beginning at 1400, they stated patients presenting to the ED greater than 20 weeks pregnant were taken to ED Room 19 and an overhead page would be made announcing their arrival. The EDNM stated ED Room 19 had been newly set up and was being held for OB patients and neonates and that two pregnant patients presented to the ED on 03/19/2023 and were taken to ED Room 19 for care. They also stated there were two telemedicine "robots" available in the ED that would be brought into ED Room 19 for care of pregnant patients and newborns. During interview with EDE on 03/20/2023 at the time of ED Room 19 observations, they stated carts and inventory supplies lists had just been brought from FBC to ED Room 19 after FBC closed the night before on 03/19/2023, and they were not sure if cart contents, and supplies lists had been finalized.

2.a. During tour of the ED on 03/20/2023 beginning at 1400 the following observations of ED Room 19 included:
* A patient bed/gurney extended diagonally toward the center of the room from a corner and opposite wall.
* The space between bed/gurney and wall was crowded with a wall mounted computer near foot of bed, red biohazard container on the floor, chair near head of bed, and wall mounted sharps disposal container with yellow sticky note that read "Replace with smaller sharps" mounted just above the top edge of the chair back. The space between the bed/gurney and wall was insufficient for multiple staff to readily access and care for a patient in labor particularly a patient experiencing complications necessitating elevated room activity and multiple staff involvement and movement.
* Wall mounted monitor and equipment with numerous cords and tubing, including pulse oximetry finger clip/cord and blood pressure cuff/cord looped together and hung below the monitor, wall oxygen flowmeter labeled "OB," two wall suction meters, wall suction canister, and three plastic bags containing resuscitation supplies were observed near the bed/gurney head.
* A baby warmer was observed extending outward from the wall and corner opposite room entry along the right side of the room. The baby warmer had an upper shelf with packages of supplies on it near the head that extended outward toward the wall and corner of the room. The baby warmer also had two lower supplies drawers that opened toward the center of the room in the direction of the bed/gurney.
* The space between the baby warmer and wall was insufficient for staff to reasonably reach the supplies shelf and provide care for a newborn during an emergency with increased room activity and multiple staff presence and movement. Similarly, the space between the baby warmer and bed/gurney lacked space to permit multiple staff access to maternity and newborn patients and movement between the two particularly when the baby warmer supplies lower drawers were open requiring staff to squat or bend over to reach supplies.
* Wall mounted otoscope, ophthalmoscope, and accessories were observed near the baby warmer head between baby warmer and bed/gurney.
* In an alcove on the right side of the room, wall mounted medical gloves containers, patient monitoring equipment on a rolling stand, 5-drawer neonatal resuscitation cart (Cart 2), wall mounted sharps container, and mayo stand with tall garbage container partially underneath were observed.
* A handwash sink, paper towel dispenser, soap dispenser, work counter; and upper and lower cupboards labeled "Linens," "RT Supplies," "Sterile Gloves," "Baby Blankets," "Blood Cultures," "IV Fluid/LR," "ABGS," "Kleenex," "White Pads," "White Chux," "Purple Wipes," and "Urine Hat" were observed extending from the corner and along the wall to the right of room entry. Disinfectant wipes, IV infusion pump, handheld Doppler and other equipment and supplies were observed on the work counter. A rolling stool and a second mayo stand were in front of the work counter, lower cupboards, and drawers. The handwash sink, supplies cupboards, drawers, and items on the work counter were not readily accessible because the mayo stands, and garbage container were in front of them.

3.a. During the tour on 03/20/2023 a 5-drawer OB/maternal supplies cart (Cart 1) was observed in ED Room 19 between the end of the work counter and room entry and two inventory supplies lists for Cart 1 were provided.
* One was titled "LMH ED OB/Maternal Cart Supply List. The list was undated and included 36 items, each with a drawer location, an item "Amount" number, and a blank space for expiration date.
* The other list, also titled "LMH ED OB/Maternal Cart Supply List" was undated and separated into two sections. The top section had two columns with headings, "Other items needed" and "Location?" Under "Other items needed," it reflected:
"white chux" and under "Location?" column, "Cupboard." There was no par number, amount number, or other number. Additional items, also listed under "Other items needed" and "Location?" included similar information as follows:
"white peripads ... Cupboard"
"ice pack pads ... Cupboard"
"Urine hat? ... Cupboard?"
"disposable panties ... Cupboard"
"baby blankets ... Cupboard"
"pressure bag ... Hag [sic] from IV pole in room"
The bottom of the list had no headings, no specific supplies or number of supplies, and reflected only:
"Drawer 1 IV starts
Drawer 2 Labs
Drawer 3 Exams
Drawer 4 Hemorrhage
Drawer 5 Delivery"
* The inventory supplies list was not fully developed as it suggested other items were needed, and included unclear and incomplete information such as "Location?," "urine hat?," and "cupboard?".

3.b. Observations of Cart 1 and review of Cart 1 inventory supplies list with EDE revealed items and supplies on top of the cart and 5 of 5 drawers in the cart did not match the inventory supplies list. Examples included:
* Observation of the top of the cart revealed four packages single use ultrasound gel, no binder, no OB hemorrhage laminated sheet, no cart log, and no monthly check log. However, review of Cart 1 inventory supplies list reflected the top of the cart should have a "Top of Cart Binder" with one "MH ED Modified OB Hemorrhage Laminated Sheet," one "OB/Maternal Cart Log," and one "OB/Maternal Monthly Check Log." Ultrasound gel packages were not on the Cart 1 inventory supplies list.
* Observation of Drawer 1, labeled "OB IV Starts" revealed it contained two packages IV tubing. However, review of Cart 1 supplies list, Drawer 1 included no packages IV tubing.
* Observation of Drawer 2, labeled "OB Labs" revealed it contained three rolls medical tape and a small, plastic container with lid containing cotton balls. Cart 1 supplies list, Drawer 2 included no medical tape and no cotton balls.
* Observation of Drawer 3, labeled "OB Exams" revealed it contained two 0.25 L plastic containers ultrasound transmission gel and no reflex hammer. However, review of Cart 1 supplies list included one "Reflex Hammer (non-disposable)." Ultrasound gel was not on the Cart 1 inventory supplies list.
* Observation of Drawer 4, labeled "OB Hemorrhage" revealed it contained one Bair Hugger gown, one 16 Fr 10mL 2-way Foley catheter, one Foley catheter kit, and no 16 Fr 3-way Foley catheter. However, review of Cart 1 supplies list, Drawer 4 reflected no Bair Hugger gown, no 16 Fr 10 mL 2-way Foley catheter, no Foley catheter kit, and one 16 Fr 3-way Foley catheter.
* Observation of Drawer 5, labeled "OB Delivery" revealed it contained no cord gas kits. Review of Cart 1 supplies list, Drawer 5 reflected it included two "Cord Gas Kits (made by RT)."

3.c. During interview with EDNM on 03/20/2023 at the time of Cart 1 observations, they stated they were not sure if the Cart 1 inventory supplies list was fully accurate, and no monthly check log had been created. During interview with other staff present at the time of the observations, they stated the hospital had only one reflex hammer and it was used for education purposes, and they would have to remind education staff to return it when they were done using it. The findings for Cart 1 were confirmed by the EDE on 03/20/2023 at the time of the observations.

3.d. Review of ED staff training materials titled "Obstetric Patient in the LMHMC ED Skills Station" reflected it included DTRs evaluation with a diagram demonstrating this was conducted with a reflex hammer.

4.a. During the tour on 03/20/2023 a second 5-drawer cart, Cart 2 was observed in ED Room 19 along the wall between the baby warmer and the handwash sink work counter and an inventory supplies list for Cart 2 was provided.
* Inventory supplies list for Cart 2, titled "LMH ED Neonatal Cart Supply List," dated "Created "2/2023" included 53 items, each with a drawer location, a par number, and a blank space for expiration date.

4.b. Observations of Cart 2 and review of Cart 2 inventory supplies list with EDE revealed items and supplies on top of the cart and in 3 of 3 drawers in the cart did not match the inventory supplies list. Examples included:
* Observation of the top of the cart revealed numerous items including two clipboards with papers on them, colored laminated cards with medication information, a blue and red box, plastic storage box with syringe, Sharpie marker, and scissor-like instrument inside, laminated documents, and other items. No binder containing neonatal resuscitation sheets, cart supplies list and monthly cart check log was observed. Review of Cart 2 inventory supplies list reflected the top of the cart should have a "Top of Cart Binder" with ten "Neonatal Resuscitation [Sheets]," one "Neonatal Cart Supply List" and one "Neonatal Cart Monthly Check Log."
* Observation of the front of Drawer 3, revealed it was labeled with three white labels, "Laryngoscope," "ET Tubes" and "Suction Caths." Drawer 3 contents included one bulb syringe, one Pedi C02 detector that had expired 12/09/2022, no laryngoscope kit with handle and blade sizes 00, 0, and 1. Review of Cart 2 inventory supplies list, Drawer 3 included two bulb syringes, two C02 detectors, and one laryngoscope kit with handle and blade sizes 00, 0, and 1.
* Observation of the front of Drawer 4 revealed it was labeled with one white label, "UAC Tray." Drawer 4 contents included a package containing a surgical gown, yellow disposable gowns, packages sterile surgical gloves, and a package of Sensicare Micro surgical gloves. Review of Cart 2 inventory supplies list, Drawer 4 included none of these items.
* Observation of the front of Drawer 5 revealed it was labeled with two red labels, "Extreme Premie Pack (includes 00 Blade)" and "Chest Tube Tray." Drawer 5 contents included neonatal resuscitation masks, a box containing isolation bags, a clear plastic resealable Ziploc-like bag with items inside and a white notepad paper taped to the outside with informal, undated, unauthored supplies information handwritten on it that reflected:
"Extreme Newborn Kit Includes:
*Bag cut to wrap [a square divided in four parts and scissors were hand drawn next to this]
*XS Masks
*LMA
*00 Laryngoscope Blade
Heating Pad in Box"
Review of Cart 2 inventory supplies list, Drawer 5 included three items, one "Small Baby Kit," one Mattress Warmer," and one "Pneumo Kit" and did not include, isolation bags, neonatal resuscitation masks, or "Extreme Newborn Kit."

4.c. The findings for Cart 2 were confirmed by the EDE on 03/20/2023 at the time of the observations.

5.a. During the tour on 03/20/2023 a baby warmer described under Finding 1 above in this Tag was observed in ED Room 19 and an inventory supplies list was provided.
* Inventory supplies list for baby warmer, titled "LMH ED Neonatal Warmer Supply List," dated "Created 2/2023" included 27 items, each with a drawer location, par number, and blank space for expiration date.

5.b. Observations of the baby warmer and review of baby warmer inventory supplies list with EDE revealed items and supplies in 1 of 1 drawer did not match the inventory supplies list. Examples included:
* Review of baby warmer inventory supplies list for "Bottom Drawer" included two Delee mucous traps, two bulb syringes, two infant skin temp probes, and two "extra" temp probes. Observation of the bottom drawer revealed it contained no Delee mucous traps, no bulb syringes, and it contained two infant skin temp probes.
* Observation of baby warmer bed surface revealed unorganized packages of patient supplies including temperature lead wires, tubing connected to baby warmer, and other supplies. The baby warmer inventory supplies list did not include baby warmer bed surface.

5.c. During interview with EDE on 03/20/2023 at the time of baby warmer observations, they stated some of the intubation supplies in the baby warmer drawers were not on the baby warmer inventory supplies list and should be in Cart 2.

6.a. Observations on 03/20/2023 beginning at 1400 in ED Room 19 revealed a sign posted on a wall in the room. Laminated emergency instructions titled "MH ED OB Hemorrhage Worksheet" dated "Rev: 02/2023" were observed posted on the wall near the corner of the room and bed/gurney head. A second laminated "MH ED OB Hemorrhage Worksheet," dated "Rev. 02/2023" was observed posted on an upper cupboard near the end of the work counter where the handwash sink was located.

6.b. Review of posted "MH ED OB Hemorrhage Worksheet," dated 02/2023 reflected "Criteria: Blood loss 500-1500 mL ... With continued bleeding With or Without stable vital signs and lab values." Under "Interventions," it reflected "Call for extra help: Charge RN, Provider, Anesthesia." Although the worksheet included calling anesthesia, during interview with hospital staff during the survey it was indicated anesthesia providers would not be available for maternity patients in the ED.

6.c. Review of the P&P titled "Care of Obstetric Patient in the Emergency Department," dated last revised "Mar 2023" reflected:
Attachment D titled "ED OB Hemorrhage Worksheet," dated "Rev. 03/2023" reflected "Criteria: Blood loss 500-1500 mL ... With continued bleeding With or Without stable vital signs and lab values." Under "Interventions," it reflected "Call for extra help: Charge RN, Provider, ED Tech, TeleOB." Although the worksheet included calling ED Techs for help, during interview on 03/21/2023 at 1310, EDNM stated training for ED Techs related to pregnant patients and newborns had not started yet. In addition, the policy did not reflect that Anesthesia providers were to be called for "extra help" as was described under Finding 6.b. on the worksheet posted in the room.

6.d. During email interview with ACCC on 03/23/2023 at 1710 regarding reference to anesthesia services on the hemorrhage worksheet that was posted in Room 19, they stated "The incorrect reference poster was hung in the transfer of posters from FBC to the ED."

7.a. Observations on 03/20/2023 beginning at 1400 in ED Room 19 revealed a sign posted on a wall in the room. Laminated emergency instructions titled "MH ED OB Sustained Severe Range Hypertension Worksheet," dated "Rev. 02/2023" were observed posted on the wall near the corner of the room and bed/gurney head. A second laminated instructions titled "MH ED OB Sustained Severe Range Hypertension Worksheet," dated "Rev. 03/2023" was observed posted on the wall near the bed/gurney foot and wall mounted computer.

7.b. Review of posted "MH ED OB Sustained Severe Range Hypertension Worksheet," dated "Rev. 02/2023," under "Medications (ASAP, within 60 mins)" reflected administration of medications that included:
* "20 mg IV Labetalol over 2 min Repeat BP in 20 minutes - if severe range."
* The worksheet did not include IV Magnesium Sulfate as reflected in Finding 7.c.

7.c. Review of the second posted "MH ED OB Sustained Severe Range Hypertension Worksheet," dated "Rev. 03/2023" reflected different information than "MH ED OB Sustained Severe Range Hypertension Worksheet," dated "Rev. 02/2023" in Finding 7.b. Under "Medications (ASAP, within 60 mins)," it reflected:
* "20 mg IV Labetalol over 2 min Repeat BP in 10 minutes - if severe range."
* The bottom section of the worksheet included "IV Magnesium Sulfate: Bolus + maintenance rate for preeclampsia/eclampsia"

7.d. Review of the P&P titled "Care of Obstetric Patient in the Emergency Department," dated "Mar 2023" reflected: Attachment E titled "ED OB Sustained Severe Range Hypertension Worksheet," dated "Rev. 03/2023," under "Medications (ASAP, within 60 mins)" included:
* "20 mg IV Labetalol over 2 min Repeat BP in 10 minutes - if severe range."
* The bottom section of the P&P included "IV Magnesium Sulfate: Bolus + maintenance rate for preeclampsia/eclampsia" This was inconsistent with the posted worksheet in Finding 7.b. that did not include IV Magnesium Sulfate.

8.a. Observations on 03/20/2023 beginning at 1400 in ED Room 19 revealed a sign posted on a wall in the room. A laminated emergency tip sheet with heading "Report Immediately to LIP" dated "Updated 2-2023" was observed posted on the wall near the corner of the room above the bed/gurney head. It included:
"OB Assessment (pregnant and postpartum < 12w) ... MEWT Triggers (see Vital Sign table) ... Preeclampsia/eclampsia ... Infections/sepsis ... Blood glucose ..."
"Pregnancy Assessment (Initial)" followed by three items, "Gestational age ... Fetal movement ... OB LIP, if known."
"Labor Assessment (pregnant, immediate/ongoing)" followed by nine checkbox items including "Abdominal pain, cramping ... Contractions ... Leaking or gush of fluid ... Vaginal bleeding ... Backache, pelvic pressure ... Signs of imminent delivery ... Fetal heart rate (110-160 bpm)"
"Pregnancy and Labor Interventions" followed by seven items including "Position ... Oxygenation ... IV fluids and/or bolus"
"Delivery Recovery & Postpartum assessment (1st 2 hours after delivery and ongoing)" followed by nine items including "Fundus ...Tone, level, position ... Lochia (vaginal bleeding) ... Color, amount, clots, odor ... Measure blood loss ... Perinium and labia ... Bladder ... Able to void, no fundal deviation"
"Postpartum Interventions" followed by eight items including "Pain ... Voiding ... Facilitate bonding (skin to skin) ... Encourage chest/breastfeeding within 1 hr ... Provide food and PO fluids once stable"
The tip sheet further reflected:
"Follow LH #905.5010 Care of OB patient in the ED"
"OB Hemorrhage: MH ED OB Hemorrhage Worksheet"
"Severe HTN: MH ED OB Sustained Severe Range Hypertension Worksheet ..."
The bottom of the tip sheet reflected "The frequencies noted in this tip sheet indicate minimum standards. Increase/decrease frequency as indicated by the patient condition, the nurse's clinical judgement, or LIP order. All times are appropriate."

8.b. The tip sheet was not easily readable and accessible as it was observed near the room corner behind the bed/gurney head. Further, it contained inconsistencies with P&P and worksheets. For example:
* The tip sheet referenced LH P&P #905.5010 Care of OB patient in the ED. Refer to Finding 6.c. which reflected the P&P directed staff to call for help from ED Techs. ED Techs had not been trained for maternity and newborn care.
* The tip sheet referenced MH ED OB Hemorrhage Worksheet. Refer to Finding 6.b. which reflected a posted hemorrhage worksheet directed staff to call anesthesia. Anesthesia was not available for maternity patients in the ED.
* The tip sheet referenced MH ED OB Sustained Severe Range Hypertension Worksheet. Refer to Findings 7.b. and 7.c. which reflected posted severe range hypertension worksheets contained inconsistent information.

9.a. Observations on 03/20/2023 beginning at 1400 in ED Room 19 revealed two informal, undated, unauthored handwritten notepad pages taped to the baby warmer with newborn assessment and other information. One page reflected information related to turning on warmer, admitting baby, heat adjustment, oxygen settings, suction, temperature probe, and APGAR timing. Next to oxygen settings notes, it reflected "(RT to check?)." The other page reflected APGAR indicators and point scoring information. There was no evidence that reflected the informal instructions were approved and authorized for use.

9.b. Laminated undated "The Apgar Score," instructions were observed posted on the wall next to the baby warmer. The laminated instructions included different information than the informal handwritten notepad pages taped to the baby warmer. For example, the posted laminated instructions reflected the indicator "Grimace" was given a score of one point for "Minimal Response when Stimulation." The informal handwritten instructions reflected only "minimal response" and did not include "when Stimulation."

10. Observations on 03/20/2023 beginning at 1400 in ED Room 19 revealed a "Neonatal Resuscitation Program reference chart" posted on the wall next to the baby warmer. The chart included information related to neonatal code medications, endotracheal intubation, ventilation corrective steps, target oxygen saturation, and other information. An undated, unauthored notepad page was observed taped to the chart with printed information that reflected "Cooling Criteria: 1. 35 weeks or more 2. Seizures, or moderate or severe encephalopathy 3. Apgar score of less than or equal to 5 @ 10min OR Continued need for mechanical ventilation @10min. 4. Metabolic acidosis w/in 60min."

11. Review of an architectural type diagram of ED Room 19 reflected it was 12 ft & 8 in by 13 ft & 8 in in size from wall to wall, or "170 [square feet]." The drawing reflected the space included a work counter with a Hondas sink to the right of the door to the room.

During observation on 03/20/2023 beginning at 1400 as described in the Findings above in this Tag, ED Room 19 was full of carts and equipment that lined the walls and space throughout the room that included a gurney, a large newborn warmer device that was placed between the gurney and a wall, two emergency supply carts that were located against two walls, a biohazard waste container, a straight back chair, a rolling chair, two mayo stands, a portable monitoring device, a large blue waste container. An infant weight scale was observed on a stand in the ED corridor outside of ED Room 19. As identified in Finding 1 in this Tag, staff interviewed stated that OB Telemedicine equipment was located elsewhere in the department and would need to be brought to ED Room 19 when needed. That equipment would further crowd the room in an emergency.

It was not clear how all personnel and equipment necessary to manage the range of obstetric complications of pregnant patients and newborns would fit in that crowded and diminished space, nor was it clear how the posted information on the walls that contained instructions for staff could be easily accessed and read with the myriad of equipment in the room that limited close access to the wall spaces.

12.a. A guidance document titled "LMH ED OB Patient Triage Guidance," dated 03/09/2023 was reviewed. The guidance document was an algorithm related to pregnant patients ">20 Weeks up to 6 weeks Post Partum" and included symptoms such as "Imminent Delivery ... Active Vaginal Bleeding ... Fetal Parts Visible ... Unstable High Risk Medical Conditions," maternal vital signs, assigning ESI level, and actions based on ESI level. For example, for ESI Level 1, the guidance reflected "Call for OB EDR Pt direct to Rm 19" and for ESI Level 2, "Call for OB Eval Pt direct to Rm 19." For "No OB related complaint," the guidance reflected "Standard ESI Triage" and "Notify Charge RN for Main ED Room Assignment." The guidance was unclear and incomplete, and no P&P was provided with the guidance. For example, there was no information in the guidance that reflected who was responsible for calling "OB EDR" and "OB Eval." It was not clear what "EDR" was. There was no information regarding who was responsible for taking the patient to Room 19, how patient was transported to Room 19, where the patient should be taken if Room 19 was occupied, and when the patient should be reevaluated if unable to be roomed.

12.b. During interview on 03/21/2023 at 1050, EDNM stated LMH ED OB Patient Triage Guidance in Finding 12.a. was a new guidance used in ED since the close of FBC and there was no P&P for the guidance.

13.a. In an email interview with ACCC dated 03/23/2023 at 1707, their response to "Provide policies and procedures for the care of postpartum patients and newborns in the ED" was "Provided in attachments. Titled: "Emergency Department Patients-Adult and Pediatric Standard of Care."

13.b. The P&P titled "Emergency Department Patients: Adult and Pediatric Standard of Care," dated last reviewed "Feb 2023" reflected:
* "Nursing Actions" for "Adult ED" and Pediatric ED" were the following topics: Triage, suicide screening, focused assessment of relevant body systems, intake assessments, vital signs, abuse/drug endangerment/neglect/sexual assault, fall risk, vascular access, skin integrity, transportation off unit, pain, social services, comfort care needs, toileting, personal hygiene, travel screening, contagious disease screenings/precautions, HAI, weights, patient activity, education, discharge, and transfer. The only references to neonates were related to pain management and spiritual care.

14.a. Review of ED nurse simulation training materials titled "ED Training: OB Hypertension" dated "02/2023" included references to posted hypertension worksheets:
* "Learning objectives ... Perform appropriate interventions for obstetric severe range blood pressure management based on the Hypertension Worksheet ..."
* "Orient to room ... hypertension worksheet (laminated handouts, dry-erase poster)"
* "Postpartum Severe Range Hypertension Case ... Initial RN assessment ... Instructor tips ... Reference the Hypertension Worksheet ..."

14.b. Refer to Findings 7.b. and 7.c. that reflected hypertension worksheets posted in ED Room 19 contained inconsistent information.

15.a. Review of ED nurse simulation training materials titled "ED Training: Hemorrhage" dated "02/2023" included references to posted hemorrhage worksheets:
* "Learning objectives ... Perform appropriate interventions for postpartum hemorrhage based on the Hemorrhage Worksheet."
* "Simulation set up ... Orient to room ... hemorrhage worksheet (laminated handouts, dry-erase poster) ..."
* "Initial RN assessment ... Instructor tips ... Reference the Hemorrhage Worksheet ..."

15.b. Refer to Finding 6.b. that reflects a hemorrhage worksheet posted in ED Room 19 contained inaccurate information related to availability of anesthesia services in ED for maternity patients.

16.a. Review of ED staff training records was conducted with the EDNM, the EDE, and the ACCC on 03/21/2023 beginning at 1310. Those staff provided the following information during interviews throughout the review:
* Prior to the FBC closure, a training plan for ED staff was developed to address the transition of maternity patients to the ED after the planned FBC closure.
* An eight (8) hour "NRP+" class with a limit of 12 students, was organized to be conducted on the LMHMC campus with the first class scheduled for 02/27/2023.
* A one-day "OB Day" class was organized to also be conducted on the LMHMC campus with the first class scheduled for 03/08/2023.
* The "roll-out plan" was to ensure that, beginning on 03/17/2023 the date of the planned FBC closure, there was at least one (1) RN on duty in the ED 24/7 who had completed both the NRP+ class and the OB Day.
* The ED techs were not included in this initial training and although training for them had been planned for, it had not been organized and scheduled at the time of this survey.

16.b. The current ED "Employee List" dated 03/20/2023 was reviewed and reflected that the ED had ~ 77 RN staff and 27 ED Tech staff.

16.c. An untitled, one-page document that contained a list of 38 ED RN and seven (7) Critical Care RN names and training completion dates for the NRP+ and OB Day trainings described above was reviewed with the EDNM, the EDE, and the ACCC on 03/21/2023. The first NRP+ class was conducted on 02/27/2023 and the first OB Day class was conducted on 03/08/2023. Not all of those RNs listed had completed both trainings prior to this survey:
* Twelve RNs had taken the NRP+ class on 02/27/2023.
* Eleven RNs had taken the NRP+ class on 03/06/2023.
* Twelve RNs had taken the NRP+ class on 03/16/2023.
* Fifteen RNs had taken the OB Day class on 03/08/2023.
* Twelve RNs had taken the OB Day class on 03/14/2023.
* Fifteen RNs were scheduled to take the OB Day class on 03/21/2023, Day 2 of this survey.

In total, 27 of the 77 RN ED staff had completed both the NRP+ and OB Day trainings prior to the FBC closure and transition of maternity services to the ED on 03/19/2023.

16.d. The training list described under Finding 16.c. did not include ED Tech training. There was no documentation of ED Tech training for the transition of maternity services to the ED.

16.e. Review of the EHR for Patient 9 who presented to the ED on 03/19/2023 at 1322 reflected they were 21-weeks pregnant and were sent to the ED by their PCP for complaints of cramping. The EHR reflected that RN D had started the triage for Patient 9 at 1322, and completed the triage and roomed the patient into Room 19 at 1326. Although RN D was on the training completion list as having completed the OB Day training, review of their training records on 03/21/2023 reflected that they had not completed the SLM training modules associated with the class.

16.f. Review of the EHR for Patient 10 who presented to the ED on 03/19/2023 at 1909 reflected they were between 25-weeks to 26-weeks pregnant and presented with complaints of abdominal pain and lack of fetal movement. The EHR reflected that RN J had started the triage for Patient 10 at 1914 and completed the triage at 1918. RN J was not on the training completion list. Review of the training schedule reflected that RN J was scheduled for the NRP+ class on 04/19/2023 and for the OB Day class on 03/30/2023.

16.g. The findings from RN D's and RN J's training records were confirmed during interviews with the EDNM and the EDE at the time of the staff training record review on 03/21/2023.

17.a. Review of ED physician training records was conducted with the CNO, the CMO, the OBMD, and the ACCC on 03/21/2023 beginning at 1510. Those staff provided the following information during interviews throughout the review:
* Prior to the FBC closure, a training plan for the ED physicians was developed to address the transition of maternity patients to the ED after the planned FBC closure.
* The ED physicians were scheduled to attend

Based on observation, interview, review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), and review of P&Ps and other documents it was determined the hospital failed to develop clear and complete policies and procedures and protocols to ensure the provision of safe and appropriate maternity services in the ED. The hospital had closed its FBC Unit and discontinued the provision of maternity services within its long-standing, organized, and secure department that contained LDRP rooms, C-section surgical suites, and a nursery. Maternity services were moved to the ED where the provision of safe and appropriate maternity services was not ensured and a potential for harm to patients existed as follows:
* The ED treatment room dedicated for the provision of maternity services to pregnant patients and newborns was inadequate in size to ensure safe and efficient management of labor and delivery, particularly in the event of maternal or newborn complications.
* The dedicated maternity services ED treatment room contained emergency supplies that were not consistent with inventory/supply lists.
* ED P&Ps, posted instructions and emergency protocols, and training materials that described emergency management of pregnant patients and newborns were unclear, contradictory, and inconsistent.

Findings include:

1. Refer to the deficiency cited at Tag A-1101, CFR 482.55(a) - Standard: Organization and Direction.



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Based on observation, interview, review of documentation in 3 of 3 medical records of pregnant patients who presented to the ED (Patients 9, 10, and 14), review of ED RN training documentation, review of physician training documentation, and review of P&Ps and other documents it was determined the hospital failed to ensure ED personnel were prepared to meet the maternity services needs anticipated by the facility in response to the closure of its long-standing, organized, and secure FBC Unit that contained LDRP rooms, C-section surgical suites, and a nursery. Maternity services were moved to the ED where the provision of safe and appropriate maternity services was not ensured and a potential for harm to patients existed as follows:
* ED P&Ps, posted instructions and emergency protocols, and training materials that described emergency management of pregnant patients and newborns were unclear, contradictory, and inconsistent.
* ED physician training related to the management of pregnant patients and newborns in the ED organized and assigned by LMHMC had not been completed by all ED physicians on staff.
* RN training related to the RN role in the management of pregnant patients and newborns in the ED organized and assigned by LMHMC had not been completed by all ED RNs on staff.
* ED Tech training related to their role in the management of pregnant patients and newborns in the ED had been planned, but not organized and implemented.

Findings include:

1. Refer to the deficiency cited at Tag A-1101, CFR 482.55(a) - Standard: Organization and Direction.