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Based on medical record review, review of facility policies, and staff interview, the facility failed to ensure Emergency Department staff followed the current facility policies for the requirement of transfer of obstetric patients and obtaining vital signs of patients presenting to the Emergency Department (A1104). This affected patient #3.

The facility census was 235.

Based on medical record review, review of facility policies, and staff interview, the facility failed to ensure Emergency Department staff followed the current facility policies for the requirement of transfer of obstetric patients and obtaining vital signs of patients presenting to the Emergency Department. This affected patient #3.

Findings include:

The medical record of Patient #3 indicated the patient, a Gravida 2 Para 0 at 35.2 weeks gestation, presented to the Bethesda Butler Emergency Department (ED) on 06/28/14 at 03:12 PM complaining that she had not felt the fetus move in the last one to two days. Patient #3 was classified as a level 3 triage category. The ED Encounter Note, electronically signed by Staff E, also indicated the patient complained of minimal abdominal cramping. Staff E noted fetal movement and auscultation of fetal heart tones at 126 beats per minute with good beat to beat variability per hand held doppler. The medical record lacked documentation of any vital signs being taken. No ultrasound was performed to confirm fetal well being. The patient was discharged home at 04:10 PM with instructions to follow-up with her obstetrician the following week.

The patient presented to the clinic for a scheduled prenatal visit on 07/01/14. The patient continued to report not feeling the fetus move since before being seen in the ED. No fetal heart tones could be heard when staff placed the patient on the fetal monitor. An ultrasound was performed which revealed no cardiac activity. The patient's heart rate on admission was noted to be elevated at 112 beats per minute. The patient was counseled and consented to an induction of labor. On 07/03/14 the Delivery Summary indicated a cesarean section was required after shoulder dystocia occurred after vaginal delivery of the head. The obstetric physician's findings of the infant included bilateral clavicle fractures and extensive skin sloughing.

The facility policy titled Obstetrical Patients in the Emergency Department was reviewed on 08/19/14 at 03:30 PM. Under the heading 'Pregnant Patients' it was noted that patients presenting to the Emergency Department who are pregnant and experiencing abdominal pain will be screened. Unstable patients will be stabilized and transferred to Bethesda North ED (main campus). Stable patients will have the ED physician perform an ultrasound. If the Emergency physician on duty is not able to perform an ultrasound, the patient will be considered unstable and transferred. On 08/19/14 at approximately 03:50 PM it was confirmed during interview with Staff A and Staff D that the patient should have been transferred to the main campus where an ultrasound could have been performed to confirm fetal well-being .

The facility policy titled Standards of Practice of Care was reviewed on 08/19/14 at 02:45 PM. According to the policy staff are instructed that fundamental emergency department nursing interventions include vital signs every 2 hours on patients classified with a level 3-5 triage category. It was confirmed with Staff A and Staff D on 08/19/14 that the medical record of Patient #3 lacked documentation that any vital signs were obtained.