HospitalInspections.org

Based on interview and record review, the hospital failed to follow their policy and procedures (P&P) titled, "Radiology-Pregnant Patient" and "Patients' Rights and Responsibilities, and Non-Discrimination" for one of three sampled patients (Patient 3) when Medical Staff did not inform Patient 3 of a positive pregnancy test or provide the risk, benefits or alternatives prior to having a radiological procedure while pregnant. This failure resulted in hospital staff performing a computed tomography (CT, medical imaging technique) on Patient 3 without Patient 3 knowing her pregnancy diagnosis, and being informed of the risks, benefits, and alternatives of exposure to radiation to an unborn child.

Findings:

During a review of Patient 3's "ED Note Physician Final Report" (EDPN), dated 5/31/24 at 11:51 a.m. the EDPN indicated, on 5/13/24, at 10:27 am, Patient 3, a 34 year old female) came to the emergency department (ED) because of pain and possible abscess (painful swollen lump filled with pus) or cyst (cavity filled with fluid). The physician ordered a CT exam for further evaluation.

During a review of Patient 3's EDPN, the EDPN indicated, "Sensitive Lab Results Latest Results Beta HCG [beta-human chorionic gonadotropin - hormone that can be detected in the blood or urine during pregnancy] Serum Qualitative [blood test that gives result pregnancy as a positive or negative] 5/31/24 14:49 [2:29 p.m.] Weak Pos [positive for pregnancy]."

During a review of Patient 3's "CT" results dated 5/31/24 at 8:30 p.m. the CT indicated, "Report Exam: CT Pelvis Indication: concern for left perineal abscess, concern for left perineal abscess [sic]"

During a concurrent interview and record review on 10/29/24 at 10:15 a.m. with Assistant Nurse Manager Emergency Department (ANMED), Patient 3's electronic health record (EHR) was reviewed. ANMED stated Patient 3's physician notes did not have documentation of a Patient 3's positive pregnancy test. ANMED stated the process was a patient should not be taken for a CT scan until the pregnancy test has been confirmed.

During a concurrent interview and record review on 10/29/24 at 10:30 a.m. with ANMED, and Imaging Service Manager of Radiology (ISMR), Patient 3's EHR was reviewed. ISMR stated the process was to confirm pregnancy status for any female up to age 55 prior to a CT exam for the pelvis or abdomen. ISMR stated the provider should review the risks and benefits and alternatives of having a CT performed while pregnant. ISMR reviewed Patient's EHR and stated Patient 3 had not signed an informed consent. ISMR stated the informed consent should have been completed prior to Patient 3's CT scan. ADMED stated the expectations would be the results of the positive pregnancy test be communicated to Patient 3.

During an interview on 10/29/24 at 2:15 p.m. with Patient 3, Patient 3 stated no one from the hospital informed her of her positive pregnancy test. Patient 3 stated she was concerned she might be pregnant when she arrived at the emergency department and she notified her (unidentified) provider. Patient 3 stated when she was being transferred to the CT exam, she had asked the (unidentified) technologist, if her pregnancy test results were available. Patient 3 stated, the unidentified technologist responded "Oh, you thought you were pregnant?" Patient 3 stated the unidentified technologist then assured her results of the pregnancy test were negative.

During a concurrent interview and record review on 10/29/24 at 2:30 p.m. with Medical Doctor (MD) 3, MD 3 reviewed Patient 3's EHR. MD 3 stated multiple providers took care of Patient 3 on 5/31/24. MD 3 stated any patient of child-bearing age would be checked for positive pregnancy prior to a CT. MD 3 stated the risks and benefits would be discussed by the provider, then the patient could make a decision as to whether or not to have the CT exam. MD 3 stated the Radiology department had a form for the patient to sign if they were pregnant before they proceed with the CT exam. MD 3 stated it was safe to say the physicians providing care to Patient 3 were not aware Patient 3 was pregnant as it had not been documented in the EHR. MD 3 stated if he was aware of Patient 3's pregnancy then he would have ordered a quantitative pregnancy test (measures the amount of hormone HCG in your blood).

During a review of the hospital's P&P titled, "Patients' Rights and Responsibilities, and Non- Discrimination," dated 9/6/23, the P&P indicated, "1. Patient Rights A. . . . 4. Receive information about their health status, diagnosis, prognosis, course of treatment, prospect for recovery and outcomes of care (including unanticipated outcomes) in terms the patient can understand. The patient has the right to effective communication and to participate in the development and implementation of their plan of care. The patient has the right to participate in ethical questions that arise in the course of their care, including issues of conflict resolution, withholding resuscitative services, and foregoing or withdrawing life-sustaining treatment."

During a review of the hospitals P&P titled, "Radiology - Pregnant Patient" dated 1/10/24, the P&P indicated, "Policy: Prior to administering any imaging study which includes exposure to radiation (diagnostic radiology), Computed Tomography (CT), Radioisotopes (Nuclear Medicine) or Magnetic Resonance Imaging (MRI), staff will follow the following guidelines to assure potential risks are reviewed. This will include ALARA, (as low as reasonably achievable) standards are taking place on patients who may be pregnant. II. Procedure for CT Pregnant Patients: A. For female patients ranging in age from puberty, 12 years to 50 years, prior to administering any contrast or ionizing radiation, the technologist will ask if the patient is or could be pregnant. B. If patient can confirm they are not pregnant, technologists will note this on the ordering requisition and document the electronic health record (EHR) in Cerner when completing the order. C. If patient is unable to confirm or deny pregnancy, ordering LIP must obtain a urine or blood pregnancy test ONLY if the X-ray beam goes through the abdominal and pelvic area. Consult with LIP for risk versus benefit. IF LIP determines to move forward, LIP will document in EHR. . . E. If results are negative, the technologist may proceed with scan/procedure. F. If results are positive for pregnancy, the technologist must consult a radiologist or the LIP... If the radiologist or LIP decide to proceed with the exam, the patient must sign the Pregnancy Consent for Abdominopelvic CT during Pregnancy form when able (see Appendix B). If patient is unable to sign pregnancy declaration form and physician feels the benefits outweighs the risk to the fetus, physician may decide to move forward. CT technologist will document decision and physician name in EHR."

Based on interview and record review, the hospital failed to ensure nurses followed national standards for the care of obstetric (OB- relating to pregnancy, labor, and delivery) patient for two of six sampled patients (Patient 1[mother] and Patient 2 [fetus baby still in the mother's womb]) when:

1. Labor and Delivery (L&D- nursing unit caring for pregnant patients during labor and childbirth) Registered Nurse (RN) 1 did not follow the hospital's policy and procedure (P&P) titled, "Oxytocin [Pitocin- used to cause or speed up labor contractions] Induction [start]/Administration for Induction/Augmentation [speed up]." When RN 1 started, maintained, or increased Pitocin infusion when the fetal heart rate (FHR) had minimal variability (range of changes is detectable but is less than or equal to 5 beats per minute [bpm]). and during signs of fetal distress (fetus not tolerating labor and/or delivery process, due to not receiving sufficient oxygen). (Refer A-398)

2. L&D RN did not follow the hospital's P&P titled "Fetal Distress, management of," when the OB Physician (doctor specializing in the care of women during pregnancy and delivery) 1 was not notified when the fetal heart rate (FHR) tracing (continuous method of recording the fetus' heart rate and mother's uterine (womb) contractions (tightening and relaxing of the womb muscles to cause labor to progress to delivery) (UCs) indicated fetal distress. (Refer A-398)

3. RN 1 did not monitor and record the FHR tracing (Category I- Normal tracing with a baseline rate of 110-160 beats per minute, moderate variability (variation in time between a fetus's heartbeats), and possibly early decelerations. This category indicates a lack of fetal acidosis (serious condition that occurs when there is too much acid in the body's fluids), and no intervention is required. Category II- Vaguely defined tracing that can indicate normal or rapidly developing acidosis. This category is present in most laboring patients. Key factors that make a Category II tracing non-reassuring include absent variability and increased depth and frequency of decelerations. Category III- Abnormal tracing that indicates a high risk of fetal acidosis. This category is characterized by absent variability, recurrent late (smooth, shallow dips in the FHR that can indicate the fetus is not getting enough oxygen) or variable decelerations, bradycardia, or a sinusoidal pattern. If immediate interventions don't improve the tracing, delivery should be sped up) or UCs (strength, frequency, and duration) every 15 minutes when Patient 1 was receiving Pitocin. (Refer A-398)

These failures resulted in Patient 1 undergoing an emergency cesarean section (surgical method of delivering a baby) and the "unexpected neonatal [newborn] death" of Patient 2.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure nursing services were provided in a safe manner, patient care need were being met, and had the potential to contribute to Patient 2's death.

Based on interview and record review, the hospital failed to ensure nurses followed national standards for the care of obstetric (OB- relating to pregnancy, labor, and delivery) patient for two of six sampled patients (Patient 1[mother] and Patient 2 [fetus baby still in the mother's womb]) when:

1. Labor and Delivery (L&D- nursing unit caring for pregnant patients during labor and childbirth) Registered Nurse (RN) 1 did not follow the hospital's policy and procedure (P&P) titled, "Oxytocin [Pitocin- used to cause or speed up labor contractions] Induction [start]/Administration for Induction/Augmentation [speed up]." When RN 1 started, maintained, or increased Pitocin infusion when the fetal heart rate (FHR) had minimal variability (range of changes is detectable but is less than or equal to 5 beats per minute [bpm]). and during signs of fetal distress (fetus not tolerating labor and/or delivery process, due to not receiving sufficient oxygen).

2. L&D RN did not follow the hospital's P&P titled "Fetal Distress, management of," when the OB Physician (doctor specializing in the care of women during pregnancy and delivery) 1 was not notified when the fetal heart rate (FHR) tracing (continuous method of recording the fetus' heart rate and mother's uterine (womb) contractions (tightening and relaxing of the womb muscles to cause labor to progress to delivery) (UCs) indicated fetal distress.

3. RN 1 did not monitor and record the FHR tracing (Category I- Normal tracing with a baseline rate of 110-160 beats per minute, moderate variability (variation in time between a fetus's heartbeats), and possibly early decelerations. This category indicates a lack of fetal acidosis (serious condition that occurs when there is too much acid in the body's fluids), and no intervention is required. Category II- Vaguely defined tracing that can indicate normal or rapidly developing acidosis. This category is present in most laboring patients. Key factors that make a Category II tracing non-reassuring include absent variability and increased depth and frequency of decelerations. Category III- Abnormal tracing that indicates a high risk of fetal acidosis. This category is characterized by absent variability, recurrent late (smooth, shallow dips in the FHR that can indicate the fetus is not getting enough oxygen) or variable decelerations, bradycardia, or a sinusoidal pattern. If immediate interventions don't improve the tracing, delivery should be sped up) or UCs (strength, frequency, and duration) every 15 minutes when Patient 1 was receiving Pitocin.

These failures resulted in Patient 1 undergoing an emergency cesarean section (surgical method of delivering a baby) and the "unexpected neonatal [newborn] death" of Patient 2.

Findings:

1. During a review of the hospital's "Risk Management Report" (RMR), undated, the RMR indicated Patient 1 presented to the L&D Triage (method to determine which patients need to be seen and treated first) on 9/6/24 at 4:42 a.m.

During a review of Patient 1's Physician Orders (PO), dated 9/6/24 at 10:48 a.m. the PO indicated start Pitocin solution augmentation intravenously (through the vein) at 2 mU/minute and increase by 2 mU/minute every 30 minutes until regular UCs achieved.

During a review of Patient 1's FHR tracing (FHRT), the FHRT indicated the following:
9/6/24 at 11:36 a.m. RN 1 started Pitocin augmentation. FHR had minimal variability from 11:35 a.m. to 11:51:20 a.m.
9/6/24 at 12:10 p.m. Variable deceleration (decrease in heart rate) of FHR to 80 bpm taking 50 seconds to return to baseline of 140 bpm.
9/6/24 at 12:13:20 p.m. Variable deceleration of FHR to 110 taking 50 seconds to return to baseline of 140 bpm.
9/6/24 at 12:15 p.m. RN 1 increased Pitocin to 4 mU/minute.
9/6/24 at 12:24 p.m. Late deceleration of FHR, taking 90 seconds to return to baseline of 140 bpm.
9/6/24 at 2:36 p.m. to 2:48 p.m. FHR had minimal variability.
9/6/24 at 2:39 p.m. RN 1 increased Pitocin to 6 mU/minute.
9/6/24 at 3:07:10 p.m. UC started and lasted 120 seconds (UC during labor typically lasts between 30 and 70 seconds and may be around 45 to 90 seconds long and occur every 3 to 5 minutes as labor progresses) and ended at 3:09:10 p.m. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 3:09:40 p.m. UC started and lasted 120 seconds and ended at 3:11:40 p.m. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 3:12 p.m. UC started and lasted 120 seconds and ended at 3:14 p.m. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 3:22:30 p.m. to 3:51 p.m. FHR tracing sinusoidal (rare, ominous sign of severe fetal distress and impending death). Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 4:33:30 p.m. FHR variable deceleration.
9/6/24 at 4:53:30 p.m. FHR variable deceleration.
9/6/24 at 5:01:30 p.m. FHR variable deceleration.
9/6/24 at 5:06:50 p.m. FHR variable deceleration.
9/6/24 at 5:07:30 p.m. FHR prolonged deceleration began, return to baseline 140 bpm at 5:15:50 p.m. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 5:22:10 p.m. FHR variable deceleration.
9/6/24 at 5:24:30 p.m. FHR variable deceleration.
9/6/24 at 5:27:50 p.m. FHR variable deceleration.
9/6/24 at 5:30:50 p.m. FHR late deceleration.
9/6/24 at 5:33:30 p.m. FHR late deceleration.
9/6/24 at 5:35:30 p.m. FHR late deceleration.
9/6/24 at 5:40:20 p.m. FHR late deceleration. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 5:43:10 p.m. FHR variable deceleration.
9/6/24 at 5:47:20 p.m. FHR variable deceleration.
9/6/24 at 5:53:50 p.m. FHR variable deceleration.
9/6/24 at 5:57:30 p.m. FHR variable deceleration.
9/6/24 at 5:58:20 p.m. FHR late deceleration.
9/6/24 at 6:00:30 p.m. FHR late deceleration.
9/6/24 at 6:10:10 p.m. FHR late deceleration. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 6:13:20 p.m. FHR late deceleration. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 6:15:20 p.m. FHR late deceleration. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 6:18:10 p.m. Absent FHR variability. Recurrent variable and late decelerations. Category III. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 6:33 p.m. Absent FHR variability. Recurrent variable and late decelerations. Category III tracing continued. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 6:43 p.m. Oxytocin off.
9/6/24 at 6:18:10 p.m. Absent FHR variability. Recurrent variable and late decelerations. Category III. Oxytocin remained infusing at 6 mU/minute.
9/6/24 at 6:52 p.m. Emergency cesarean section called.
9/6/24 at 6:54 p.m. Patient 1 taken to L&D operating room.
9/6/24 at 6:56 p.m. Patient 1 in L&D operating room.
9/6/24 at 7:04 p.m. Infant delivered (Patient 2).

During a review of Patient 1's "Gynecology-Obstetrics" (GO) dated 9/6/24, the GO indicated, "Result Comments Resuscitation at Birth: Resuscitation record completed. 20 minutes of resuscitation done. Cooling measures [methods used to lower a newborn's head or whole-body temperature to prevent further brain damage in newborns who were deprived of sufficient oxygen in the womb] initiated per provider, awaiting transport to tertiary care [specialized care delivered in a hospital or similar care setting]."

During an interview on 10/28/24 at 9:40 a.m. with RN 2, RN 2 stated, "Patient [Patient 2] went into category two a few times; when a patient goes into category two, we need to intervene and notify the physician. We can also turn off the Pitocin."

During a review of the hospital's P&P titled, "Oxytocin Induction /Administration for Induction/Augmentation" dated 10/2/24, the P&P indicated, "Policy: The Labor and Delivery RN will initiate and maintain Oxytocin infusions while monitoring patients for possible adverse reactions/results. Procedure. . . X. If Category II tracing and tachysystole, assist patient to lateral position and administer IV bolus. If unresolved consider the following: A. Discontinue if fetal distress or hypertonus and notify OB provider within 5 minutes that Oxytocin was discontinued. . . XI. Notify OB Provider should any of the following occur. . .C. Category III tracing, bradycardia, or tachycardia."

2. During a review of Patient 1's FHR tracing (FHRT), the FHRT indicated the following:
9/6/24 at 11:36 a.m. RN 1 started Pitocin augmentation. FHR had minimal variability from 11:35 a.m. to 11:51:20 a.m. The "Clinician Notification" (CN) dated 9/6/24 indicated Physician 2 was not notified of the Category II FHR tracing.
9/6/24 at 12:24 p.m. Late deceleration (smooth, shallow dips in the FHR that can indicate the fetus is not getting enough oxygen) of FHR, taking 90 seconds to return to baseline of 140 bpm. The CN dated 9/6/24 indicated Physician 2 was not notified of the FHR late deceleration.
9/6/24 at 2:36 p.m. to 2:48 p.m. FHR had minimal variability. The CN dated 9/6/24 indicated Physician 2 was not notified of the Category II FHR tracing.
9/6/24 at 3:07:10 p.m. UC started and lasted 120 seconds and ended at 3:09:10 p.m., followed by a UC which started at 3:09:40 p.m. and lasted 120 seconds and ended at 3:11:40 p.m. followed by a UC which started at 3:12 and lasted 120 seconds and ended at 3:14 p.m. The CN dated 9/6/24 indicated Physician 2 was not notified of UCs abnormal frequency and duration.
9/6/24 at 3:22:30 p.m. to 3:51 p.m. FHR tracing sinusoidal (rare, ominous sign of severe fetal distress and impending death) and indicated a Category III FHR tracing. The CN dated 9/6/24 indicated Physician 2 was not notified of the Category III FHR tracing.

During an interview on 10/28/24 at 1:38 p.m. with RN 1 and RN 2, RN 2 stated variable decelerations, minimal variability, or absent variability can indicate fetal distress. RN 2 stated Patient 2's FHR tracing went into Category II a few times. RN 2 stated the expectation is for the nurse intervene first, and then notify the physician, and try to document as events occur. RN 2 stated she did not talk to Physician 2 about every single Category II, and she should have had according to the facility policy. RN 1 stated the importance of notifying Physician 2 of these category changes is for Physician 2 to make a change to the plan of care if needed. RN 2 stated she reported to RN 3 during handoff and told RN 3 Physician 2 was aware of variables. RN 2 stated Physician 2 ordered for Patient 1 keep pushing. RN 2 stated her biggest concern was the Patient 1's bleeding and pain and that had resolved.

During an interview on 10/28/24 at 2:19 p.m. with Charge Nurse (CN) 2, CN 2 stated she remembers that she was told that Patient 1 had been bleeding in triage, and the strip did not look the best. CN 2 stated she looked at the fetal monitoring strip when there were variability and when there was none. CN 2 stated Physician 2 was in the unit, and she assumed Physician 2 was aware of Patient 1's FHR variables.

During a concurrent interview and record review on 10/28/24 at 3:59 p.m. with Nurse Manager Labor and Delivery (NMLD) Patient 1's Clinician Notification "Flowsheet Print Request" (FPR) was reviewed. The FPD indicated there were no clinician notifications from 8:04 a.m. to 4:29 p.m. NMLD stated during a review of the medical record there is no documentation that RN 1 or RN 2 contacted Physician 2. NMLD stated the nurses should always communicate and document Category IIs to the MD and MD's responses.

During an interview on 10/29/24 at 12:27 p.m. with Physician 2, Physician 2 stated around 6:30 p.m. RN 3 called him that Patient 1 was fully dilated. Physician 2 stated he was not aware of the decelerations when Patient 1 was pushing, and he became aware after RN 3 called out for him. Physician 2 stated looking at the FHR tracing if at around 5:15 p.m. he was notified of the tracing he would have watched the tracing very closely and had ordered to stop the Pitocin and if no improvement he would have done an emergency C-Section. Physician 2 stated variable decelerations can indicate that Patient 2 is being deprived of oxygen. Physician 2 stated if Patient 1 had a C-Section sooner maybe Patient 2's APGAR would have not been "as bad". Physician 2 stated it seems Patient 1's ruptured uterus happened late, possibly when pushing and when Patient 1 was screaming, but he is not sure. Physician 2 stated when Patient 1 is having variable decelerations, pushing needs to stop, Pitocin stopped, hydrate patient, give oxygen if needed, and if interventions are not working then a vaginal operative technique or C-Section.

During an interview on 10/30/24 at 4:41 p.m. with Chief Medical Officer (CMO), CMO stated any change in patient condition needed to be communicated to the physician, the physician should understand changes that occur with patients to decide what the plan of care will be.

During a review of the facility's P&P titled, "Fetal Distress, Management of," dated 7/3/24, the P&P indicated, "Policy: Nursing intervention during fetal distress will attempt to correct indeterminate and/or abnormal fetal heart rate patterns and support fetal physiological stability. Procedure: I. The RN will notify the obstetrician and the lead RN of any changes in maternal or fetal heart rate (FHR) status (i.e.: unstable maternal vital signs, FHR characteristics consistent with Category II or III tracings as defined by National Institute of Child Health and Human Development (NICHD) terminology. II. Nursing interventions will be to maximize uteroplacental blood flow, increase fetal oxygenation, and minimize hypoxic insult to the fetus. IV. For patients with persistent Category II tracing as defined by NICHD, where the RN has utilized all appropriate interventions and has notified the provider and the provider, and the provider indicates to continue with plan of care. If the tracing does not resolve to Category I and the RN remains concerned and has contacted the provider a 2nd time and either the provider does not respond or no change in the plan of care, then initiate the "Code EFM" algorithm [steps to guide RN of who to contact when concerned of patient]."

3. During a review of Patient 1's FHR tracing (FHRT), dated 9/6/24 at 11:36 a.m., the FHRT indicated RN 1 started Pitocin augmentation.
During a review of Patient 1's Vital Signs, Labor Assessment, and Electronic Fetal Monitoring flow sheet (FS), dated 9/6/24, the FS indicated entries at 12 p.m., 12:30 p.m., 1 p.m., 1:30 p.m., 2 p.m., and 2:30 p.m.

During a review of Patient 1's Electronic Fetal Herat Rate Annotations (EFHRA), the EFHRA indicated Patient 1's vital signs (blood pressure and maternal heart rate) were recorded every 30 minutes from 3:02 p.m. to until 6:22 p.m. No FHR tracing or UC assessments were documented.

During a review of the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN- National organization which provides nursing guidelines for the care of obstetric patients and newborns) guidelines for induction and augmentation of labor, the guidelines indicated, "Frequency of Fetal Heart Monitoring Assessment Using Continuous Electronic Fetal Monitoring With oxytocin or risk factors every 15 min [minutes] with oxytocin. AWHONN supports development of interprofessional institutional policies, procedures, and protocols that outline responsibility for ongoing FHM documentation. Documentation should contain streamlined, factual, and objective information and should include but should not be limited to the following: A systematic admission assessment of the woman and fetus; Ongoing assessments of the woman and fetus, including FHR and uterine activity data; Interventions provided and evaluation of responses; Communication with the woman and her family or primary support person; Communication with providers; and Communication related to escalation of concerns" Retrieved from: https://ilpqc.org/ILPQC%202020+/PVB/Toolkit/FI/AWHONN%20Position%20Statement%20FH.pdf

Based on interview and record review, the facility failed to ensure documentation was accurate and complete for two of 37 sampled patients (Patient 1 and Patient 2). This failure had the potential to miss important information for patient 1's continuum of care due to inadequate documentation.

Findings:

During a review of Patient 1's "Discharge Summary" (DS), dated 9/7/24 at 4:04 p.m. the DS indicated, Patient 1 admitted for induction of labor, at term with diagnosis of gestational HTN. Patient 1 progressed to complete dilatation (10 cm) and pushed [trying to deliver baby vaginally] for one hour. Patient 2 experienced sudden fetal distress without recovery, Patient 1 was taken to emergent cesarean section confirming uterine rupture. Baby [Patient 2] born with poor APGARS [medical assessment to evaluate the health of newborn] with need of prolong resuscitation. Baby transfer to [Facility 2]. Patient had 1000 ml [milliliters] of blood loss, she received 2 units of RBC [red blood cells - blood]."

During a concurrent interview and record review on 10/29/24 at 9:27 a.m. with Nurse Manager for Labor & Delivery (NMLD), Patient 1 and Patient 2's electronic fetal monitoring strips (FMS) and "Timeline of Events" (TOE), dated 9/6/24, were reviewed. The FMS had no annotations indicating the different variables [abnormal baby heart rates] and MD notifications. NMLD stated the FMS and TOE indicated the following on 9/6/24:

a. Minimal variability (MV - low amplitude rage of less than or equal to 5 beats per minute [bpm]):
11:40 a.m. to 11:51 a.m. (11 minutes) Minimal variability.
12:44 p.m. to 12:48 p.m. (4 minutes) minimal variability.
1:32 p.m. to 1:35 p.m. (3 minutes) minimal variability.
2:37 p.m. to 2:48 p.m. (11 minutes) Minimal variability.

b. Variable deceleration (VD - a sudden, noticeable decrease in the fetal heart rate of at least 15 bpm that lasts at least 15 seconds):
9:23 a.m. Variable deceleration.
9:26 a.m. Variable deceleration
9:30 a.m. Variable deceleration.
9:32 a.m. Variable deceleration.
12:10 p.m. Variable deceleration.
12:13 p.m. Variable deceleration.
12:25 p.m. Variable deceleration.
12:28 p.m. Variable deceleration.
1:20 p.m. Variable deceleration.
1:31 p.m. Variable deceleration.
2:36 p.m. Variable deceleration.
4:08 p.m. Variable deceleration

c. Late deceleration (LD - a gradual decrease in a fetus's heart rate that occurs after a uterine contraction):
10:44 a.m. Late deceleration.
1:01 p.m. Late deceleration.
1:04 p.m. Late deceleration.

During a review of Patient 1's "LABOR RECORD" (LR), dated 9/6/24, the LR indicated Registered (RN) 1 and RN 2 documented Variable Decelerations at 10 a.m. and 2:30 p.m. and Late Decelerations at 11 a.m. and 12:30 p.m.

During an interview on 10/28/24 at 1:38 p.m. with Registered Nurse (RN) 1 and RN 2, RN 2 stated variable decelerations, minimal variability, or absent variability can indicate fetal distress. RN 2 stated Patient 1 went into Category 2 (an indeterminate tracing that is neither reassuring nor non-reassuring) a few times. RN 2 stated the expectation was for nurses to intervene first, then notify MD, and try to document as we (nurse) go. RN 2 stated she did not speak with MD 2 about every single Category 2. RN 2 stated, according to the facility policy she should have spoken to MD 2 every time Patient 1 had a Category 2 tracing. RN 1 stated the importance of notifying MD 2 of these category changes was for MD 2 to make a change to the plan of care if needed.

During a concurrent interview and record review on 10/28/24 at 3:59 p.m. with NMLD Patient 1's Clinician Notification "Flowsheet Print Request" (FPR) was reviewed. The FPD indicated there were no clinician notifications from 8:04 a.m. to 4:29 p.m. NMLD stated during a review of the medical record there is no documentation that RN 1 or RN 2 contacted the MD. NMLD stated the nurses should always communicate and document category 2s to the MD and MD's responses.

During a review of the facility's policy and procedures (P&P) titled "Assessment and Documentation, Nursing: Acute Patient Care," the P&P indicated, "Procedure: II. Principles of Documentation. . . Nursing documentation reflects communications, observations, decisions, actions, and outcomes related to patient-centered care. Information reflecting the nursing process, patient plan of care and other pertinent information are documented in the individual patient record in an ongoing, accurate, timely and legible manner. . . B. What to Chart. . . 6. Contacts with and outcomes of interactions with primary care providers. . . II. Documentation Elements. . . B. Documentation includes the status of the identified problems until they are resolved in the medical record or become inactive."