HospitalInspections.org

Based on clinical record review and staff interview the Hospital nursing staff failed to identify a change in the patient's clinical status/condition, and failed to notify the physician of the health status change and the patient's response to nursing intervention. This failure affected 1 of 10 sampled patients (Patient #1).

The findings include:

Review of the clinical record for Patient #1 revealed the patient was a direct admission to Labor and Delivery on 12/18/11 at 7:50 PM for Induction of labor due to mild pregnancy induced hypertension (mild preeclampsia).
A physician order for Continuous fetal monitoring is dated 12/18/11 at 7:50 PM. The order includes Cervidil 10 mg to be administered intra-vaginal. This order was implemented at 9:40 PM on 12/18/11 as ordered. The physician's order also documents, if Tachystole occurs, give one dose of Terbutaline (Brethine) 0.25 mg subsutaneous immmediately and notify physician or Certificed Nurse Midwife. Fetal monitor showed Tachysystole at 03:30 AM on 12/19/11 indicating the labor contractions are greater than five (5) contractions in ten minutes during two consecutive ten minute periods. The Tachysystole pattern continued for another hour until 04:30 AM.
The nurse documentation does not indicate the nurse identified the Tachysystole, and notified the physician or Certified Nurse Midwife/Manager.
In an interview with the nurse manager and assistant nurse manager at approximately 10:30 AM on 02/03/12, the assistant nurse manager stated, the Cervidil should have been pulled out, and the physician notified.

The hospital policy titled "Prostaglandin Use in Pregnancy" documents, Cervidil continues to release Prostaglandin while in place for 12 hours following insertion. The policy requires the physician or certified nurse midwife to be notified of Tachysystole contractions. There is no evidence found substantiating the implementation of the policy/physician's order regarding Tachystole.

Based on clinical record review, staff interview and hospital policy review, a non-employee Registered Nurse working in the hospital failed to adhere to the hospital chain of command policy that provide guidelines for resolving differences of opinion between nurses and physician in regards to patient care decisions. This failure affected 1 of 10 sample patients (Patient #1).

The finding include:

The review of the clinical record for Patient #1, with the unit managers on 02/03/12, revealed a contracted (Agency) non-employee Registered Nurse was the primary care nurse for Patient #1 beginning at 07:00 AM on 12/19/11. The nurse documented an abnormal fetal heart rate beginning at 12:15 PM on 12/19/11 and continuing to 3:50 PM when the patient was transferred to the operating room for an emergency Caesarian section. The nursing documentation indicates the physician and the nurse disagreed with or regarding the fetal monitor readings/results. This nurse did not inform the charge nurse or the nurse manager of the changes in the patient's condition or the abnormal fetal heart rate, which indicated the baby is experiencing lack of Oxygen (inadequate oxygenation). The baby was delivered by Caesarian section at 4:03 PMon 12/19/11 without heart rate, and resuscitation was unsuccessful.
During an interview with an assistant nurse manager on 02/03/12 at approximately 10:30 AM, the nurse stated, if the nurse had informed her of the abnormal fetal heart rate she would have insisted the physician take action immediately or would have called another physician from the group to see the patient.
Review of the hospital policy titled "Chain of Command" reveals the policy specifies:
4. "When differences of opinion cannot be resolved between the staff nurse, physician/ ARNP, the staff nurse should report the situation to the charge nurse and if necessary to the Nurse manager.
5. If the charge nurse and nurse manager are unable to resolve the situation to their satisfaction, the charge nurse /nurse manager should report the situation to nursing administration or its representative.
6. If nursing administration is unable to to resolve the situation,the chairman of the department and Hospital Administration should be notified by nursing administration.

The above procedures were not implemented. The patient's clinical record is silent as it relates to the implementation of the hospital's policy/protocol for addressing chain of command in handling differences of opinion in the provision of care/nursing services.