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Based on interview and record review, the hospital failed to ensure their standardized procedure (SP) for Obstetric (OB) Medical Screening Exams (MSE) as required by the California Board of Registered Nursing, was reviewed and approved by the hospital's Interdisciplinary Practice Committee as scheduled. This failure had the potential for the hospital's SP to not be up to date with current standards of practice.

Findings:

During an interview on 1/30/23, at 8:51 AM, with RN 8, RN 8 stated, she frequently works in the OB triage. RN 8 stated, there has been no review of the standardized procedure for OB MSE since the last skills lab (yearly scheduled event where all education and competencies are completed). RN 8 stated, she thought the last L&D skills lab was in 2021. RN 8 stated, she was hired in 2016.

During a review of the hospital's SP titled, "Standardized Procedure for Triage and Medical Screening of Obstetric Patients," dated 10/19, the SP indicated, "I. Purpose: To provide a standardized procedure for Registered Nurses (RN) and Advanced Practice Providers (APP [nurse practitioners, nurse midwives, and Physician Assistants]) for the effective triage, medical screening, treatment, admission and/or transfer of obstetric patients who present to Labor & Delivery (L&D) Triage for unscheduled evaluation. . . III. Policy Statement: It is the policy of [hospital] that qualified evaluators may triage the OB patient and complete the MSE according to this standardized procedure. . . VII. Education: A. Method of evaluating and maintaining competency for qualified evaluators: 1. Initial evaluation and competency: a) The qualified evaluator: 1) Will receive education pertaining to this Standardized Procedure at time of orientation to OB triage and as changes occur in legislation or regulatory requirements. . . 40 Will successfully complete annual skills lab. . . 2. Annual evaluation of continued competency: 1) The qualified evaluator will review standardized procedure and complete test annually. 3. Documentation of competency: a) A list of personnel authorized to perform medical screening of the obstetric patient will be maintained in L&D. b) Completion of initial and ongoing competency will be maintained in each RN's educational file. . . Approved by Interdisciplinary Practice Committee. . . October 2019. . .Requires Review. . . October 2022.

During a review of the California Board of Registered Nursing's guideline titled, "Standardized Procedure Guidelines," dated 1/11, the "Standardized Procedure Guidelines" indicated, "1470. Purpose The Board of Registered Nursing in conjunction with the Division of Allied Health Professions of the Board of Medical Quality Assurance (see the regulations of the Board of Medical Quality Assurance, Article 9.5, Chapter 13, Title 16 of the California Code of Regulations) intends, by adopting the regulations contained in the article, to jointly promulgate guidelines for the development of standardized procedures to be used in organized health care systems which are subject to this rule. The purpose of these guidelines is: (a) To protect consumers by providing evidence that the nurse meets all requirements to practice safely. (b) To provide uniformity in development of standardized procedures. 1474. . . Standardized Procedure Guidelines Following are the standardized procedure guidelines jointly promulgated by the Division of Allied Health Professions of the Board of Medical Quality Assurance and by the Board of Registered Nursing: (a) Standardized procedures shall include a written description of the method used in developing and approving them and any revision thereof. (b) Each standardized procedure shall: (1) Be in writing, dated and signed by the organized health care system personnel authorized to approve it. (2) Specify which standardized procedure functions registered nurses may perform and under what circumstances. (3) State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions. (4) Specify any experience, training, and/or education requirements for performance of standardized procedure functions. (5) Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions. (6) Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions. (7) Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician. (8) Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient's physician concerning the patient's condition. (9) State the limitations on settings, if any, in which standardized procedure functions may be performed. (10) Specify patient record keeping requirements. (11) Provide for a method of periodic review of the standardized procedures."

Based on interview and record review, the hospital failed to follow its standardized procedure (SP) for Obstetric (OB) Medical Screening Exam (MSE) as required by the California Board of Registered Nursing (BRN) to ensure Registered Nurses (RN) assigned to the OB triage completed initial competency and maintained competency to be qualified evaluators to perform OB MSEs on nine of 10 patients (Patient 11, Patient 12, Patient 13, Patient 14, Patient 15, Patient 16, Patient 17, Patient 19, and Patient 20). This failure resulted in mothers and fetuses receiving MSEs from unqualified nurses in Labor and Delivery (L&D).

Findings:

During an interview on 1/30/23, at 8:40 AM, with a hospital escort team including Licensing and Accreditation Registered Nurse (LARN), Director of Education and Staff Development (DESD), Manager of Operations Maternal/Child Services (MOMC), and Director of Maternal/Child Services (DMCS), a list of nurses authorized to perform OB MSEs was requested. MOMC stated, the hospital escorts were looking for the requested list.

During an interview on 1/30/23, at 8:46 AM, with RN 5, RN 5 stated, she had worked in the hospital's OB triage room (area of L&D where pregnant patients come to have MSE), since her travel contract started on 11/3/22. RN 5 stated, she had not been instructed on the hospital's OB Medical Screening SP, taken a post-test, nor did she complete a competency checklist prior to working in the OB triage.

During an interview on 1/30/23, at 8:48 AM, with RN 6, RN 6 stated, she had worked in the hospital's OB triage room since her travel contract started on 11/22 (actual start date 10/29/22). RN 6 stated, "I don't know what a standardized procedure is." RN 6 stated, she had not been instructed on the hospital's OB Medical Screening SP nor did she complete a competency checklist prior to working in the OB triage.

During an interview on 1/30/23, at 8:49 AM, with RN 7, RN 7 stated, she had worked in the hospital's OB triage room since her travel contract started on 11/13/22. RN 7 stated, she had not been instructed on the hospital's OB Medical Screening SP nor did she complete a competency checklist prior to working in the OB triage.

During an interview on 1/30/23, at 8:50 AM, at the L&D Nurse's Station, with Staff Development Coordinator (SDC), SDC stated, she was unable to find a list of nurses authorized to perform OB MSEs or OB triage nurse competencies on the computer. SDC stated, she "was going to check in their [nurses' educational] files."

During an interview on 1/30/23, at 8:51 AM, with RN 8, RN 8 stated, she frequently works in the OB triage. RN 8 stated, there has been no review of the standardized procedure for OB MSE since the last skills lab (yearly scheduled event where all education and competencies are completed). RN 8 stated, she thought the last L&D skills lab was in 2021. RN 8 stated, she was hired in 2016.

During an interview and record review on 1/30/23, at 09:20 AM, DESD, requested copies of education of the hospital's standardized procedure for OB MSE at the time of orientation to OB triage, annual skill's lab completion documentation, Maternal/Fetal Triage Index (MFTI- means of scoring a patient's clinical presentation to determine what order the patients are assessed), and documentation of annual review of the standardized procedure for OB MSE.

During a review of nurse education and competencies on 1/30/23, at 10:30 AM, with SDC and DESD, there was no documentation of RN 5, RN 6, or RN 7 having completed a competency check-off list prior to working in the OB triage room and conducting OB MSEs. DESD stated, there was no documentation of an annual review of the standardized procedure for OB MSE or post-review exam for RN 8 or any other L&D RN.

During a review of the Education and Competency List (ECL) for L&D nurses, on 1/30/23, at 10:30 AM, with SDC and DESD, SDC stated, the last L&D nurse skills lab was on 3/20/21.

During a review of Patient 11's medical record, on 1/30/23, at 11:52 AM, with Licensing and Accreditation Registered Nurse (LARN), the OB Triage form (OBTF- includes OB MSE), dated 12/8/22, at 9:35 PM, was reviewed. The OBTF indicated, RN 9 completed Patient 11's OB MSE. The facility was unable to provide documented evidence of RN 9's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test.

During a review of Patient 12's medical record, on 1/30/23, at 3:30 PM, with Director of Clinical Informatics (DCI), the OBTF, dated 11/3/22, at 8:29 PM, was reviewed. The OBTF indicated, RN 10 completed Patient 12's OB MSE. The facility was unable to provide documented evidence of RN 10's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test.

During a review of Patient 13's medical record, on 1/30/23, at 3:48 PM, the OBTF, dated 11/24/22, at 11:59 PM, was reviewed. The OBTF indicated, RN 11 completed Patient 13's OB MSE. The facility was unable to provide documented evidence of RN 11's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test.

During a review of Patient 14's medical record, on 1/30/23, at 4 PM, with DCI, the OBTF, dated 12/21/22, at 10:23 PM, was reviewed. The OBTF indicated, RN 12 completed Patient 14's OB MSE. The facility was unable to provide documented evidence of RN 12's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test.

During a review of Patient 15's medical record, on 1/30/23, at 4:12 PM, with DCI, the OBTF, dated 1/4/23, at 7:49 PM, was reviewed. The OBTF indicated, RN 9 completed Patient 15's OB MSE. The facility was unable to provide documented evidence of RN 9's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test.

During a review of Patient 16's medical record, on 1/30/23, at 4:19 PM, with DCI, the OBTF, dated 1/25/23, at 3:06 AM, was reviewed. The OBTF indicated, RN 9 completed Patient 16's OB MSE. The facility was unable to provide documented evidence of RN 9's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test.

During a review of Patient 17's medical record, on 1/30/23, at 4:29 PM, the OBTF, dated 11/3/22, at 1:16 AM, was reviewed. The OBTF indicated, RN 11 completed Patient 17's OB MSE. The facility was unable to provide documented evidence of RN 11's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test since 2/11/21.

During a review of Patient 19's medical record, on 1/30/23, at 4:46 PM, the OBTF, dated 11/4/22, at 10:06 PM, was reviewed. The OBTF indicated, RN 13 completed Patient 19's OB MSE. The facility was unable to provide documented evidence RN 13 had an "OB Triage" skills assessment, an annual review of the OB MSE SP, or a completed post-test since 3/16/21.

During a review of Patient 20's medical record, on 1/30/23, at 4:51 PM, with DCI, the OBTF, dated 11/7/22, at 1:03 AM, was reviewed. The OBTF indicated, RN 10 completed Patient 20's OB MSE. The facility was unable to provide documented evidence of RN 10's "OB Triage" skills assessment, a review of the OB MSE standardized procedure, or completed post-test.

During a review of the hospital's "Labor and Delivery Assignment Sheet: Day Shift", the following RNs worked in the hospital's OB Triage unit on the following dates:

RN 5 - 1/27/23
RN 6 - 11/1/22, 11/13/22, 11/20/22, 11/21/22, 12/11/22, 1/2/23, 1/3/23, 1/11/23, 1/12/23, and 1/14/23
RN 8 - 11/26/22 and 1/8/23
RN 12 - 11/24/22, 11/27/22, and 1/29/23
RN 13 - 11/4/22 and 11/5/22

During a review of the hospital's "Labor and Delivery Assignment Sheet: Night Shift", the following RNs worked in the hospital's OB Triage unit on the following dates:

RN 9 - 11/23/22, 12/9/22, 1/4/23, 1/5/23, and 1/24/23
RN 10 - 11/4/22, 11/5/22, 11/18/22, 11/27/22, 12/11/22, and 1/7/23
RN 11 - 11/1/22, 11/10/22, 11/13/22, 11/24/22, 11/25/22, 1/1/23, 1/2/23, 1/3/23, 1/8/23, 1/11/23 and 1/21/23
RN 12 - 11/26/22
RN 13 - 1/10/23

During a review of the hospital's SP titled, "Standardized Procedure for Triage and Medical Screening of Obstetric Patients," dated 10/19, the SP indicated, "I. Purpose: To provide a standardized procedure for Registered Nurses (RN) and Advanced Practice Providers (APP [nurse practitioners, nurse midwives, and Physician Assistants]) for the effective triage, medical screening, treatment, admission and/or transfer of obstetric patients who present to Labor & Delivery (L&D) Triage for unscheduled evaluation. . . III. Policy Statement: It is the policy of [hospital] that qualified evaluators may triage the OB patient and complete the MSE according to this standardized procedure. . . VII. Education: A. Method of evaluating and maintaining competency for qualified evaluators: 1. Initial evaluation and competency: a) The qualified evaluator: 1) Will receive education pertaining to this Standardized Procedure at time of orientation to OB triage and as changes occur in legislation or regulatory requirements. . . 40 Will successfully complete annual skills lab. . . 2. Annual evaluation of continued competency: 1) The qualified evaluator will review standardized procedure and complete test annually. 3. Documentation of competency: a) A list of personnel authorized to perform medical screening of the obstetric patient will be maintained in L&D. b) Completion of initial and ongoing competency will be maintained in each RN's educational file."

During a review of the California Board of Registered Nursing's guideline titled, "Standardized Procedure Guidelines," dated 1/11, the "Standardized Procedure Guidelines" indicated, "1470. Purpose The Board of Registered Nursing in conjunction with the Division of Allied Health Professions of the Board of Medical Quality Assurance (see the regulations of the Board of Medical Quality Assurance, Article 9.5, Chapter 13, Title 16 of the California Code of Regulations) intends, by adopting the regulations contained in the article, to jointly promulgate guidelines for the development of standardized procedures to be used in organized health care systems which are subject to this rule. The purpose of these guidelines is: (a) To protect consumers by providing evidence that the nurse meets all requirements to practice safely. (b) To provide uniformity in development of standardized procedures. 1474. . . Standardized Procedure Guidelines Following are the standardized procedure guidelines jointly promulgated by the Division of Allied Health Professions of the Board of Medical Quality Assurance and by the Board of Registered Nursing: (a) Standardized procedures shall include a written description of the method used in developing and approving them and any revision thereof. (b) Each standardized procedure shall: (1) Be in writing, dated and signed by the organized health care system personnel authorized to approve it. (2) Specify which standardized procedure functions registered nurses may perform and under what circumstances. (3) State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions. (4) Specify any experience, training, and/or education requirements for performance of standardized procedure functions. (5) Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions. (6) Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions. (7) Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician. (8) Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient's physician concerning the patient's condition. (9) State the limitations on settings, if any, in which standardized procedure functions may be performed. (10) Specify patient record keeping requirements. (11) Provide for a method of periodic review of the standardized procedures."

Based on interview and record review, the hospital failed to follow its standardized procedure (SP) for Obstetric (OB) Medical Screening Exams (MSE) as required by the California Board of Registered Nursing (BRN) maintain a list of qualified evaluators on the L&D unit. This failure resulted in unqualified evaluators being assigned to the OB triage and for OB MSEs to be performed by unqualified evaluators.

Findings:

During an interview on 1/30/23, at 8:40 AM, with a hospital escort team including Licensing and Accreditation Registered Nurse (LARN), Director of Education and Staff Development (DESD), Manager of Operations Maternal/Child Services (MOMC), and Director of Maternal/Child Services (DMCS), a list of nurses authorized to perform OB MSEs was requested. MOMC stated, the escorts looked for the requested list.

During an interview on 1/30/23, at 8:50 AM, with MOMC, MOMC stated, there was no list of nurses authorized to perform OB MSEs in the L&D.

During a review of the hospital's SP titled, "Standardized Procedure for Triage and Medical Screening of Obstetric Patients," dated 10/19, the SP indicated, "I. Purpose: To provide a standardized procedure for Registered Nurses (RN) and Advanced Practice Providers (APP [nurse practitioners, nurse midwives, and Physician Assistants]) for the effective triage, medical screening, treatment, admission and/or transfer of obstetric patients who present to Labor & Delivery (L&D) Triage for unscheduled evaluation. . . III. Policy Statement: It is the policy of [hospital] that qualified evaluators may triage the OB patient and complete the MSE according to this standardized procedure. . . VII. Education: A. Method of evaluating and maintaining competency for qualified evaluators: 1. Initial evaluation and competency: a) The qualified evaluator: 1) Will receive education pertaining to this Standardized Procedure at time of orientation to OB triage and as changes occur in legislation or regulatory requirements. . . 40 Will successfully complete annual skills lab. . . 2. Annual evaluation of continued competency: 1) The qualified evaluator will review standardized procedure and complete test annually. 3. Documentation of competency: a) A list of personnel authorized to perform medical screening of the obstetric patient will be maintained in L&D. b) Completion of initial and ongoing competency will be maintained in each RN's educational file."

During a review of the California Board of Registered Nursing's guideline titled, "Standardized Procedure Guidelines," dated 1/11, the "Standardized Procedure Guidelines" indicated, "1470. Purpose The Board of Registered Nursing in conjunction with the Division of Allied Health Professions of the Board of Medical Quality Assurance (see the regulations of the Board of Medical Quality Assurance, Article 9.5, Chapter 13, Title 16 of the California Code of Regulations) intends, by adopting the regulations contained in the article, to jointly promulgate guidelines for the development of standardized procedures to be used in organized health care systems which are subject to this rule. The purpose of these guidelines is: (a) To protect consumers by providing evidence that the nurse meets all requirements to practice safely. (b) To provide uniformity in development of standardized procedures. 1474. . . Standardized Procedure Guidelines Following are the standardized procedure guidelines jointly promulgated by the Division of Allied Health Professions of the Board of Medical Quality Assurance and by the Board of Registered Nursing: (a) Standardized procedures shall include a written description of the method used in developing and approving them and any revision thereof. (b) Each standardized procedure shall: (1) Be in writing, dated and signed by the organized health care system personnel authorized to approve it. (2) Specify which standardized procedure functions registered nurses may perform and under what circumstances. (3) State any specific requirements which are to be followed by registered nurses in performing particular standardized procedure functions. (4) Specify any experience, training, and/or education requirements for performance of standardized procedure functions. (5) Establish a method for initial and continuing evaluation of the competence of those registered nurses authorized to perform standardized procedure functions. (6) Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions. (7) Specify the scope of supervision required for performance of standardized procedure functions, for example, immediate supervision by a physician. (8) Set forth any specialized circumstances under which the registered nurse is to immediately communicate with a patient's physician concerning the patient's condition. (9) State the limitations on settings, if any, in which standardized procedure functions may be performed. (10) Specify patient record keeping requirements. (11) Provide for a method of periodic review of the standardized procedures."