HospitalInspections.org

Based on interview and record review, the facility failed to ensure pregnant patients, who presented to the Emergency Department (ED), were assessed/reassessed to determine the status of the second patient, the infant, for two sampled patients (Patients 14 and 34). This resulted in the facility being unaware of the fetal heart tones and well being of the infants.

Findings:

1. On June 7, 2016, the record for Patient 14 was reviewed. Patient 14 presented to the facility ED on June 1, 2016, at 9:40 p.m., with the chief complaint of anxiety and feeling stressed about her pregnancy.

The record indicated this was Patient 14's third pregnancy and her last menstrual period (LMP) was February 3, 2016 [based on the LMP Patient 14 was 17 weeks pregnant].

The "Emergency Department" record dated June 1, 2016, at 1:07 a.m., indicated Patient 14 had a panic attack and was "19 weeks" pregnant [term pregnancy 40 weeks].

Patient 14 was discharged from the facility on June 2, 2016, at 6:15 a.m.

There was no indication the infant's fetal heart tones were assessed.

During an interview with the Assistant Chief Nursing Officer (ACNO), on June 9, 2016, at 10:30 a.m., she reviewed the record for Patient 14 and was unable to find documentation of the infant's fetal heart tones. The ACNO stated Patient 14's unborn infant should have been assessed for fetal heart tones.


2. On June 9, 2016, the record for Patient 34 was reviewed. Patient 34 presented to the facility ED on June 8, 2016, at 12:43 p.m., with the chief complaint of abdominal and back pain, pain with urination, and 18 weeks pregnant [term pregnancy 40 weeks].

The record indicated this was a "high risk pregnancy," and an appendicitis was ruled out.

There was no documentation in the record to indicate Patient 34's number of pregnancies, number of children, last menstrual period, or expected delivery date.

Patient 34 was discharged from the facility on June 8, 2016, at 8:30 p.m.

There was no indication the infant's fetal heart tones were assessed.

During an interview with the Assistant Chief Nursing Officer (ACNO), on June 9, 2016, at 10:30 a.m., she reviewed the record for Patient 34 and was unable to find documentation of the infant's fetal heart tones. The ACNO stated Patient 34's unborn infant should have been assessed for fetal heart tones.

The facility policy and procedure titled "Emergency Department Process of Care" reviewed/revised January 2015, revealed "... Data collected by emergency department personnel is guided by the relevant electronic or paper forms. Information asked for by the forms shall be collected to the extent relevant and consistent with operational or clinical concerns. ... Other nursing assessments and reassessments should be appropriate in content and frequency to the condition of the patient ..."

The facility policy and procedure titled "Obstetric (OB/GYN) Patients in the Emergency Department (ED)" reviewed/revised August 2014, revealed " ... All OB/GYN patients less than 20 weeks gestation will be seen by the ED provider. ..."