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43881


Based on review of medical records, review of facility documents, and staff and patient interviews, it was determined that the Hospital failed to meet CFR, 482.23 Condition of Participation: Nursing Services after the following was identified:

- The Nursing Supervisor failed to follow the Chain of Command outlined in the Clinical Escalation of Concern policy to ensure the necessary personnel were available to provide nursing care in the Labor and Delivery unit (A-0386).

- The hospital failed to ensure the Labor and Delivery unit had sufficient staff immediately available to provide nursing care to a patient who was induced for labor and had requested an epidural for pain control while on the Antepartum Care Unit, which resulted in the patient experiencing pain for an extended time period subsequently delivering an infant without pain medication as requested. (A-0392).

These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients.

Findings are as follows:

A CMS authorized Substantial Allegation Survey was conducted from 11/4/2024 through 11/8/2024, at Woman and Infants Hospital to determine compliance with the requirements of CFR 482.23 Condition of Participation: Nursing Services following a community reported complaint in which a patient alleged that the hospital did not have sufficient personnel in the Labor and Delivery unit to accommodate the patient's laboring process and pain control needs.

On 11/7/2024, a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 482.23 A-0385 Condition of Participation: Nursing Services, related to Patient ID #1 who underwent cervical ripening (the process of softening the opening of the cervix) for the induction of labor in the Antepartum Care Unit on 10/12/2024. During the evening, the patient experienced rapid labor progression and cervical changes which prompted the Midwife to request transfer to the Labor and Delivery Unit at 2:18 AM on 10/13/2024 for further management, comfort measures and/or an epidural. At the time of the request, it was identified that the Labor and Delivery Unit was not adequately staffed and although the unit had an available bed, the patient could not be transferred to the Labor and Delivery unit until 4:23 AM on 10/13/2024.

As a result of the identified non-compliance, Patient ID #1 did not receive any additional pain medication after receiving pain medication at 11:29 PM on 10/12/2024. Patient ID #1 had ongoing communication of discomfort and repeated requests for pain medication/epidural from 2:02 AM on 10/13/2024 until 4:23 AM on the same day. The patient was then rushed to the Labor and Delivery Unit without receiving the epidural/pain medication she/he had requested to address his/her pain and subsequently delivered an infant without pain medication, as requested.

The hospital's Director of Risk Management and Professional Practice Specialist were informed of the Immediate Jeopardy, which was identified on 11/7/2024 and were provided with the Immediate Jeopardy template at approximately 11:15 AM on this date.

On 11/7/2024, the hospital submitted the Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented:

-The hospital created a guideline to clarify adjustment of nursing assignments due to critical level staffing and to support the accommodation of additional patients on the labor and delivery unit.

-This guideline will be distributed to the labor and delivery unit nursing staff on November 7, 2024, by the Nurse Director and posted at the nursing station of the Labor and Delivery Unit.

-The Labor and Delivery Nursing Director will provide a written staffing plan expected over the upcoming weekend to the Nursing Supervisor to include the Nursing Director's contact information and, if necessary, to strategize staffing issues.

-The Chain of Command algorithms will be posted at the nursing stations of the Labor and Delivery Unit and the Antenatal Care Unit (before birth) on Thursday, November 7, 2024.

-Reinforcement of the chain of command with all nursing supervisors via email will be sent by the Chief Nursing Officer on November 7, 2024.

On 11/8/2024, interviews with staff on duty on the Antenatal Care Unit and the Labor and Delivery Unit were conducted by the State surveyors and the IPOC was verified as being fully implemented by confirming that staff received and reviewed the escalation of care posting on both units and patient assignment guidelines in the Labor and Delivery Unit. As of 11/8/2024 the IJ was removed.

Based on record review and staff interviews, it was determined that the hospital failed to ensure that the Nursing Supervisor followed the Chain of Command outlined in the Chain of Command-Escalation of Concern Policy to ensure the necessary personnel were available to provide nursing care in the Labor and Delivery Unit for 1 of 4 patients reviewed who were induced for labor, (Patient ID #1).

Findings are as follows:

The hospital's policy titled, "Chain of Command, Escalation of Care" last revised on 9/2024 states in part...

" ...The Chain of Command is used when a clinical issue or concern arises that is unresolved at the staffing level ..."

" ...Involved parties will proceed to the next level on the chain of command until resolution is reached ..."

During a surveyor interview on 11/4/2024 at approximately 10:50 AM with the Nursing Supervisor, Manager, Staff E, she explained that she thinks that on 10/12/2024 the units were "appropriately staffed because the manager wasn't called." When asked if she was made aware that the Nursing Supervisor, Staff F, was called by the nursing staff, she stated, "if she was, she did not tell me about it." She explained that if the unit calls the Nursing Supervisor with a patient issue, the supervisor will usually go up to the unit, and she expects them to go up to the unit as she would do the same as Nursing Supervisor.

During a surveyor interview on 11/4/2024 with Nursing Director, Staff I she stated that staffing was critical over the holiday weekend of 10/12 and 10/13. Double time was offered. She then stated that she was never called that night by the nursing supervisor or the labor and delivery room staff to come in and staff the unit.

During a surveyor interview on 11/4/2024 at 11:59 AM, with Nursing Supervisor, Staff F, she stated her frustration over the holiday weekend staffing. She went on to say that the staffing throughout the hospital was a challenge due to the abundance of sick calls. At this time, she could not differentiate Saturday night from Sunday night. When asked if she notified the Administrator on call (AOC) of the situation she stated that they were not notified.

During a surveyor interview on 11/6/2024, with Registered Nurse (RN) Staff L, when asked if the Nursing Director was called to discuss the staffing needs, she replied that she was so busy she did not have time to call the Director.


43881

Based on record review and staff interview it has been determined that the hospital failed to ensure the Labor and Delivery unit had sufficient staff immediately available to provide nursing care to a patient who was induced for labor and had requested an epidural for pain control while on the Antenatal (before birth) Care Unit (ACU) , which resulted in the patient experiencing pain for an extended time period subsequently delivering an infant without pain medication for 1 of 4 patients who were induced for labor in the Antenatal Care Unit, Patient ID #1.

Findings are as follows:

Review of the medical record revealed that Patient ID #1 was a gravita 1(first pregnancy) Para 0 (birth history) at 41 weeks 2 days, who was a direct admission to the Antenatal Care Unit on 10/12/2024 at 11:38 AM for induction of labor. At 3:42 PM the patient received the first dose of 50 micrograms of Misoprostol (medication used to promote uterine contractions).

Review of the patient's flowsheet revealed that the patient began to complain of pain at 9:10 PM, identifying his/her pain score as a 7. The covering Midwife, Staff H, was paged by Nurse, Staff N to check the patient who was given 8 mg (milligrams) IV (into the vein) of Morphine for pain control and 10 mg of Prochlorperazine for nausea. The patient continued to report a pain level of 7 despite being medicated and at 10:32 PM, Staff H was repaged by Staff N to notify her that the patient was requesting a different pain medication because the Morphine did not help. At 11:29 PM, 57 minutes after the nurse notified Staff H, the patient was given 2 mg of Stadol IV (Narcotic used during labor). Prior to the administration of the Stadol the patient reported a pain level of 7.

At 2:02 AM on 10/13/2024, the record revealed that Staff H was paged by Staff N again to come up and evaluate the patient, explaining that the patient remained very uncomfortable despite the Stadol that was given to him/her at 11:29 PM. At 2:15 AM the Charge Nurse, Staff O, documented in the patient's record that the nursing supervisor was aware that the patient was uncomfortable.

At 2:18 AM on 10/13/2024, a vaginal exam was performed by Staff H and the patient was now 5 cm (centimeters) dilated.

At 2:21 AM on 10/13/2024, a nursing progress note authored by Staff O, revealed that the labor room was called and updated on the patient's exam and that the patient was very uncomfortable.

Review of the Obstetrics Progress Note authored by Staff H, revealed that given the progress of the patient's cervical change and discomfort, will send the patient to the labor and delivery room for continue induction. The note also stated that the patient was "ok for comfort measures and or epidural as desired".

At 3:38 AM on 10/13/2024, a nursing progress note authored by Staff O revealed that a call was made to the Labor and Delivery Unit again for a bed and was informed they had no beds.

At 3:42 AM on 10/13/2024, a nursing progress note authored by Staff N documented that the patient was very uncomfortable and was asking for an epidural. The note did not reveal any documentation of a pain assessment after 11:29 PM on 10/12/2024.

At 3:48 AM on 10/13/2024, a nursing progress note authored by Staff N documented that the Nursing Supervisor was called to come up to talk to the patient and to check on the status of the Labor and Delivery room bed.

At 4:05 AM on 10/13/2024, the record revealed a second vaginal exam documenting that the patient was now 8 cm dilated.

At 4:20 AM on 10/13/2024, a nursing progress note authored by Staff O revealed that the Labor and Delivery Unit was called again and was notified that the patient had the urge to push.

At 4:23 AM on 10/13/2024, the patient was assigned bed 14 on the Labor and Delivery Unit and arrived on the unit at 4:33 AM.

At 4:37 AM on 10/13/2024, a vaginal exam revealed the patient was now 10 cm dilated, and 100% effaced.

At 4:43 AM on 10/13/2024, review of the delivery room progress note authored by Staff J, revealed that the patient was requesting an epidural and anesthesia was made aware. The note also revealed that the patient was pushing involuntary.

At 5:08 AM on 10/13/2024, Staff J documented that the patient was on his/her hands and knees pushing and bleeding was noted.

At 5:09 AM on 10/13/2024, Certified Nurse Midwife, Staff D arrived to the room for delivery.

The record revealed an OB Vaginal Delivery/Labor and Delivery Summary Note dated 10/13/2024 authored by Staff D which stated that the patient arrived from the Antepartum Care Unit to the Labor and Delivery Unit spontaneously pushing and an infant was born.

The patient's medical record revealed that the patient did not receive pain medication after 11:29 PM on 10/12/2024. The record also failed to reveal documentation that the Nursing Supervisor came to speak to the patient after being requested by the staff.

During a surveyor interview on 11/6/2024 at 2:00 PM with Patient ID #1, she/he explained that on 10/12/2024 at approximately 4:30 PM, she/he received the first dose of an induction medication and described his/her response to the medication as, "fast and furious" as his/her body responded quickly. She/he indicated that at 8:30 PM, she/he received the second dose of the induction medication and by the time she/he was 5 centimeters dilated, she/he requested an epidural but was told by either the "nurse or the Midwife that a room was not available in the labor unit as there were no staff available." She/he stated that staff told him/her, nothing could be done, and she/he would have to stay in ACU. The patient explained that she/he was checked again at some point by the Midwife who told her/her that she/he was now 8 centimeters dilated and staff began to "panic" that she/he was progressing quickly, and staff were eventually running him/her down the hall on a stretcher toward the labor room, with his/her spouse running behind. The patient stated that she/he was told not to push while in route, but his/her body was pushing on its own and she/he was 10 centimeters dilated by the time she/he arrived at the Labor room. The patient revealed she/he was told they had to "piece together staff" to accommodate delivery.

During a surveyor interview with Staff H, Certified Nurse Midwife, on 11/4/2024 at 12:27 PM, she revealed that when she presented to her overnight shift on 10/12/2024 at 5:30 PM, Patient ID #1's induction was already in process and explained that she "had to push very hard" to get Patient ID #1 to the Labor and Delivery Unit since she and other staff thought the patient would deliver his/her baby in the Antenatal Care Unit. Staff H stated that the Labor and Delivery Unit was going to take the patient when the patient was 5 centimeters dilated, but this did not happen. She revealed that when the patient was 8 centimeters dilated, the supervisor was notified, but the patient was still not transferred to the Labor and Delivery Unit. Staff H then stated that eventually, the Nursing Supervisor took the role of Charge Nurse on the Labor and Delivery Unit so that the nurse could take over the care of the patient. Staff H indicated that "the Labor and Delivery Unit had rooms available at the time, but not staff."

Review of email correspondence between the Risk Manager and the Certified Nurse Midwife Director, Staff B, dated 11/6/2024 at 6:12 PM revealed that she briefly reviewed this case with the Midwives on duty on 10/12/2024. Staff B stated in the email that the "primary issues" related to the patient's care had to do with nurse staffing on the Labor and Delivery Unit "impacting patient flow rather than provider clinical decision-making" which caused "delays in transfer."

During a surveyor interview on 11/6/2024 with Registered Nurse (RN) Staff L, she stated that she was the dedicated Charge Nurse on the Labor and Delivery Unit on the night of 10/12/2024 from 7:00 PM to 7:00 AM. Staff L stated that she had voiced her concerns to the Nursing Director of the unit on 10/8/2024, regarding the number of RN vacancies on the night shift for the upcoming holiday weekend. She explained that at the time, there were 4 RNs out on a medical leave of absence, 2 RNs out on workmen's compensation and 4 RNs with previously approved vacation requests.

Staff L indicated that the previous shift had a total of 17 RNs, 16 RNs for patient care and 1 RN as Charge Nurse who does not take a patient assignment. She explained that the Labor and Delivery Unit has the capacity for 16 patients, along with a catch and recover c-section room and 1 alternative birthing room.

Staff L stated that at 7:00 PM the staffing level of the Labor and Delivery Unit dropped down to 15 RNs, 14 RNs for patient care and 1 RN as Charge Nurse. At 11:00 PM, the staffing level dropped again to 10 nurses for the care of 12 patients.

Staff L then explained that at 8:00 PM on 10/12/2024 the Nursing Director of the unit called her to check in and go over the board. At that time, there were 3 patients in the Emergency Department in labor and 4 patients on the Antenatal Care Unit who were undergoing IOL (induction of labor). Staff L stated that the advice that she received from the Director was not to take anyone to the unit unless they were ready to deliver or in need of an epidural. She went on to say that the Director was aware that the staffing numbers would decrease at 11:00 PM and she stated that she would call back prior to the shift to review the staffing plan. Staff L indicated that at 9:00 PM, the "patient board" was reviewed with the Maternal Fetal Medicine Attending Physician, herself, and the Nursing Supervisor.

Staff L was then asked about her communication with the ACU Charge Nurse, Staff O, regarding Patient ID #1. She revealed that she remembered hearing about the patient when she was 5 cm dilated and at that time, she was told that the patient had been medicated with IV Morphine for pain. Staff L then stated that she was not made aware of the patient's request for an epidural or her continued discomfort. The next call she received regarding Patient #1 was at 4:20 AM when the patient was 9 cm dilated and she immediately rearranged the staffing to accommodate the patient and notified the Nursing Supervisor to come up and assist. Staff L explained that the unit had an available bed, but not enough staff to cover all the rooms. When asked if the Nursing Director was called to discuss the staffing needs, she replied that the Director was going to call the unit back and at the time Staff L stated she was so busy she did not have time to call the Director.

During a surveyor interview on 11/4/2024 at 11:59 AM with Nursing Supervisor, Staff F, she stated her frustration over the holiday weekend staffing. She went on to say that the staffing throughout the hospital was a challenge due to the abundance of sick calls. At this time, she could not differentiate Saturday night from Sunday night. She explained that the ED triage was busy and staffing was a challenge on all the units especially in the Labor and Delivery Unit, and she is only one person. She indicated that she did not recall going to the unit to speak to Patient ID #1 and stated that the staff often calls her when a patient is upset about not being able to be transferred to the Labor and Delivery Unit. In addition, Staff F stated that there are two issues that impact Labor and Delivery beds, adequate number of staff and bed availability.



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