HospitalInspections.org

Based on review of Governing Bylaws. physician credential files, patient medical records and interview with staff, the hospital Governing Body failed to ensure criteria selection to the medical staff are competence, training, experience as evidenced by a Family Practice MD providing neonatal on-call coverage that was not trained in pre-term infant resuscitation. The hospital's Governing Body failed to identify through it's QA/PI program that there was a problem with preterm infant resuscitation as evidenced by no data collected following the delivery by Cesarean Section of a preterm infant that was not resuscitated.

Findings:

Review of the credentialing file for S9Family Practice Physician revealed he requested privileges for newborn resuscitation and was granted approval.

Review of the Progress Notes dated 1/11/13 at 4:25 a.m. for Patient #3 revealed the following entry: Fetus delivered via C-section (caesarian section) by S14Physician. Fetus 26 wks (weeks) by dates. P.E. fetus had no viability. CPR (cardiopulmonary resuscitation) via chest done for a few minutes while intubation unsuccessfully attempted by 3 people (2 CRNA's). Fetal death 26 wks. The entry was signed by S9Family Practice Physician.
Review of the medical record for Patient #3 revealed a document #1171 titled Labor and Delivery Record. In the section titled Apgar scores, the infant's scores at 1 minute and 5 minute were listed as 0. The spaces to document oxygen saturation, PPV (positive pressure ventilation) in minutes, chest compressions in minutes, intubation tube size, and medications were left blank. No additional notes were written on the page.
Further review of the medical record for Patient #3 revealed no other documentation about the resuscitation or assessment of her pre-term infant delivered on 1/11/13 at 4:25 a.m.

Interview with S9FamilyPractice Physician on 3/13/13 at 2:50 p.m. confirmed he had not received NRP (neonatal resuscitation program) certification; thereby was not trained for pre-term infant resuscitation.

Review of the Governing Body Bylaws reviewed and approved 12/20/2012 revealed the following: Article VI GOVERNING BOARD OPERATION Section 5. The Governing Body shall require the Medical Staff and staffs of the Hospital departments/services to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care, and for identifying and resolving problems.

Interview with S2Administrator on 3/14/13 at 4:40 p.m. confirmed the hospital's responsibility of ensuring medical staff's qualification to provide pre-term resuscitation through the credentialing process. S2 Administrator also confirmed the preterm infant that did not receive resuscitation was not evaluated through the PI program which resulted in the Governing Body not being aware that there was a problem with physician competency and training.

Based on interview and record review, the hospital failed to ensure the services provided were in accordance with appropriate written policies for neonatal resuscitation as evidenced by resuscitation efforts by the hospital staff on a premature infant not being performed according to hospital policy and Neonatal resuscitation guidelines by the American Academy of Pediatrics for 1 (#3) of 1 (#1) death records reviewed out of a total of 30 (#1- #30) patients sampled.

Findings:

Review of the Neonatal Resuscitation Textbook, 6th edition, by the American Academy of Pediatrics dated 2011 revealed the following principles of resuscitation of a neonate:
Assess the neonate to determine if he/she is term, breathing, and had good tone.
If not, provide warmth, clear the airway if necessary, dry, and stimulate. If after 30 seconds the heart rate is below 100 beats per minute, the infant is gasping or apneic (not breathing), then PPV (positive pressure ventilation) with a bag and mask should be initiated at a rate of 40 to 60 breaths per minute. If after 30 seconds of effective PPV the heart rate remains below 60 beats per minute, consider intubation, begin chest compressions, and coordinate with PPV. If after 30 seconds of chest compressions and PPV the heart rate remains below 60 beats per minute, administer Epinephrine. Further review revealed the correct ETT (endotracheal tube) size for a neonate below 28 weeks gestation is a 2.5 mm diameter tube.

Review of the hospital policy titled Special Newborn Procedures- Resuscitation in Delivery Room and in Newborn Nursery/ Oxygen Administration/ Cardiac Compression, Reviewed 2/17/13, revealed in part:
3. Follow NRP (Neonatal Resuscitation Guidelines). Manual kept in Labor and delivery and Newborn Nursery for reference.
At every delivery, there should be at least 1 person who is capable of performing a complete resuscitation, including endotracheal intubation or immediately available.

Medical record review revealed Patient #3 had been triaged in the emergency department on 1/10/13 at 9:35 p.m. with complaints of dizziness, headache, and new onset hypertension. Further review revealed at 9:46 p.m. physician ' s orders had been written to place Patient #3 on observation in Labor and Delivery because she was 26 weeks and 4 days pregnant. Review of the nursing notes revealed Patient #3 had decreased fetal heart tones, so she was taken to surgery for an emergency caesarian section which began at 4:15 a.m. on 1/11/13. Review of the birth record for Patient #3's infant revealed he had been delivered at 4:25 a.m. on 1/11/13.

Review of the Progress Notes dated 1/11/13 at 4:25 a.m. for Patient #3 revealed the following entry: Fetus delivered via C-section (caesarian section) by S14Physician. Fetus 26 wks (weeks) by dates. P.E. fetus had no viability. CPR via chest done for a few minutes while intubation unsuccessfully attempted by 3 people (2 CRNA's). Fetal death 26 wks. The entry was signed by S9Family Practice Physician.

Review of the medical record for Patient #3 revealed a document #1171 titled Labor and Delivery Record. In the section titled Apgar scores, the infant's scores at 1 minute and 5 minute were listed as 0. The spaces to document oxygen saturation, PPV (positive pressure ventilation) in minutes, chest compressions in minutes, intubation tube size, and medications were left blank. No additional notes were written on the page. Further review of the medical record for Patient #3 revealed no other documentation about the premature infant ' s resuscitation on 1/11/13.

In an interview on 3/13/13 at 10:50 a.m. with S10LPN, she stated she, S9Family Practice, and S11RRT (respiratory therapist) were at the radiant warmer when the preterm infant was born at 4:25 a.m. on 1/11/13. S10LPN stated no heart tones or breath sounds were auscultated by S9Family Practice. S10LPN said S9FamilyPractice shook his head no when he viewed the baby and said it was not viable. S10LPN said she stepped away from the radiant warmer and did not touch the infant. S10LPN said S9Family Practice then attempted to view the infant ' s vocal cords, but he said the blade on the laryngoscope was too large for baby so he could not see the vocal cords to intubate. She then said S11RRT and a CRNA attempted to intubate, but were unsuccessful. S10LPN also said no oxygen was administered to the infant at any time. S10LPN verified she had not documented any of the incidents on the Labor and Delivery record (Form # 1171) or in her nurse's notes. S10LPN said she should have charted about the resuscitation, but did not because the baby was dead. When asked if the documentation in the Progress notes by S9Family Practice was a complete and accurate description of the resuscitation, she replied, "no" . When asked if there was any more documentation of the events by another staff member, she replied, "no".


In an interview on 3/13/13 at 2:50 p.m. with S9Family Practice, he stated he had attended the delivery of Patient #3's infant on 1/11/13 at 4:25 a.m. S9Family Practice said he administered chest compressions for 2-3 minutes, but did not administer oxygen per blow-by or per ambu bag and mask. He said he attempted to intubate with a 3.0 ETT to check for viability of the infant, but could not get the endotracheal tube in the trachea. S9Family Practice also said 2 CRNAs attempted unsuccessful intubations. When asked who performed chest compressions while he attempted to intubate, S9Family Practice said no one. He also said he did not administer emergency medications. S9Family Practice said based on his documentation, it was difficult to tell what was done for the infant. S9Family Practice said, " I don't know how descriptive you would want me to be ".

In an interview on 3/14/13 at 8:30 a.m. with S11RRT, he stated he had attended the delivery of Patient #3's infant on 1/11/13 at 4:25 a.m. He stated he, S10LPN, and S9Family Practice were at the radiant warmer where the preterm infant was placed after delivery. He said S9Family Practice dried the infant after it was placed on the warmer and listened for heart tones, but then stood at the bedside doing nothing. S11RRT said S9Family Practice did not attempt to intubate or even view the vocal cords, but instead asked him to attempt intubation. S11RRT said he tried to intubate with a 3.0 ETT and a 2.5 ETT, but was unsuccessful. S11RRT said he and S10LPN both administered PPV (positive pressure ventilation) to the infant during the resuscitation. He also said he was not sure if S10LPN did chest compressions on the infant, but S9Family Practice did not perform chest compressions. He said S7CRNA attempted to intubate with a 3.0 ETT and a 2.5 ETT, but was also unsuccessful. S11RRT said the resuscitation process took approximately 10-15 minutes. He also said S9Family Practice was attempting to place lines in the baby's umbilicus for medication administration. S11RRT also stated he did not feel like the resuscitation went smoothly and S9Family Practice could have taken more of a leadership role. When asked if he documented any of the sequence of events, S11RRT replied, "no" . When asked if the team followed neonatal resuscitation guidelines, S11RRT replied "no" .

In an interview on 3/14/13 at 0900 with S12RN, she stated she had been working in labor and delivery on the morning of 1/11/13 when Patient #3 delivered. She said Patient #3 had to be taken for an emergency caesarian section because the fetal heart tones were decreased below an acceptable level. S12RN also stated at 3:41 a.m. on 1/11/13, the last set of recorded fetal heart tones were 110 beats per minute. She said the infant's delivery time was 4:24 a.m. She said no more heart tones had been taken, but it was not possible for the heart tones to have been absent for more than 30 minutes or so if even that long.

In an interview on 3/14/13 at 11:30 a.m. with S4RN Manager, she stated NRP guidelines had not been followed on 1/11/13 during the resuscitation of Patient #3's infant. S4RN Manager also stated the NRP guidelines should have been followed. In addition, S4RN Manager stated the only member of the resuscitation team that had a current NRP certification was S10LPN.

Based on interview and record review, the hospital failed to ensure drugs and biological were dispensed according to accepted pharmacy principles as evidenced by all prescriber ' s orders for first dose medications in non-emergent situations not being reviewed for appropriateness by a pharmacist before the first dose was dispensed.
Findings:

Review of the Nursing Service Policy and Procedure titled Pharmacy Responsibilities stated in part:
When the pharmacy is not open 24 hours a day 7 days a week, the pharmacist conducts a retrospective review of orders as soon as the pharmacist is available or the pharmacy opens.
b. The nursing supervisor will review each order for appropriateness of the drug dose, frequency, route, therapeutic duplication, real or potential allergies or sensitivities.

In an interview with S5Pharmacy Director, he stated the pharmacy was open from 7:30 a.m. - 6:00 p.m. Monday through Friday, and 7:00 a.m.- 4:00 p.m. on weekends and holidays.
He stated non emergent medications were not reviewed by a pharmacist before the first dose of the medication was dispensed and administered after pharmacy working hours or in the Emergency Department at any time. When asked if every medication administered in the Emergency Department was truly an emergency medication, S5Pharmacy Director replied no. S5Pharmacy Director said he did not think he had to review medications ordered in the Emergency Department because a physician was present.

Based on interview and record review, the hospital failed to ensure medical records were accurately documented as evidenced by incomplete charting by nurses and physicians of the neonatal resuscitation of a premature infant for 1 (#3) of 30 (#1- #30) patients sampled.
Findings:
Review of the policy presented by the hospital as current titled Medical Records Documentation, Revision date 2/19/13, revealed in part:
...The Medical record shall also contain sufficient information to identify the patient, support the diagnosis, to justify the treatment and document the patient's hospital course and the results of the patient's care as well as facilitate the continuity of care among all health care providers.

Review of the policy titled Labor and Delivery- Form #1171, reviewed 2/17/13, revealed in part:
4) Newborn Record
Fill in information on the following- Birth Weight, Apgar rating, O2 (oxygen) inhalation, Resuscitation, Ap, Pulse, Temperature, Observation of the newborn, Medications, ...Nurse's signature.

Medical record review revealed Patient #3 had been triaged in the emergency department on 1/10/13 at 9:35 p.m. with complaints of dizziness, headache, and new onset hypertension. Further review revealed at 9:46 p.m. physician's orders had been written to place Patient #3 on observation in Labor and Delivery because she was 26 weeks and 4 days pregnant. Review of the nursing notes revealed Patient #3 had decreased fetal heart tones, so she was taken to surgery for an emergency caesarian section which began at 4:15 a.m. on 1/11/13. Review of the birth record for Patient #3's infant revealed he had been delivered at 4:25 a.m. on 1/11/13.

Review of the Progress Notes dated 1/11/13 at 4:25 a.m. for Patient #3 revealed the following entry: Fetus delivered via C-section (caesarian section) by S14Physician. Fetus 26 wks (weeks) by dates. P.E. fetus had no viability. CPR (cardiopulmonary resuscitation) via chest done for a few minutes while intubation unsuccessfully attempted by 3 people (2 CRNA's). Fetal death 26 wks. The entry was signed by S9Family Practice Physician.

Review of the medical record for Patient #3 revealed a document #1171 titled Labor and Delivery Record. In the section titled Apgar scores, the infant's scores at 1 minute and 5 minute were listed as 0. The spaces to document oxygen saturation, PPV (positive pressure ventilation) in minutes, chest compressions in minutes, intubation tube size, and medications were left blank. No additional notes were written on the page.

Further review of the medical record for Patient #3 revealed no other documentation about the resuscitation or assessment of her preterm infant delivered on 1/11/13 at 4:25 a.m.

In an interview on 3/13/13 at 10:50 a.m. with S10LPN, she stated she, S9Family Practice, and S11RRT (registered respiratory therapist) were at the radiant warmer when the preterm infant was born at 4:25 a.m. on 1/11/13. S10LPN stated no heart tones or breath sounds were auscultated by S9Family Practice Physician. S10LPN said S9FamilyPractice Physician shook his head no when he viewed the baby and said it was not viable. S10LPN said she stepped away from the radiant warmer and did not touch the infant. S10LPN said S9Family Practice Physician then attempted to view the infant's vocal cords, but he said the blade on the laryngoscope was too large for baby so he could not see the vocal cords to intubate. She then said S11RRT and a CRNA (certified registered nurse anesthetist) attempted to intubate, but were unsuccessful. S10LPN also said no oxygen was administered to the infant at any time. S10LPN verified she had not documented any of the incidents on the Labor and Delivery record (Form # 1171) or in her nurse ' s notes. S10LPN said she should have charted about the resuscitation, but did not because the baby was dead. When asked if the documentation in the Progress notes by S9Family Practice Physician was a complete and accurate description of the resuscitation, she replied, "no" . When asked if there was any more documentation of the events by another staff member, she replied, "no".

In an interview on 3/13/13 at 2:50 p.m. with S9Family Practice Physician, he stated he had attended the delivery of Patient #3's infant on 1/11/13 at 4:25 a.m. He said he administered chest compressions for 2-3 minutes, but did not administer oxygen per blow-by or per ambu bag and mask. S9Family Practice Physician said he attempted to intubate with a 3.0 ETT (endotracheal tube) to check for viability of the infant, but could not get the endotracheal tube in the trachea. He also said 2 CRNAs attempted unsuccessful intubations. When asked who performed chest compressions while he attempted to intubate, he said no one. S9Family Practice Physician also said he did not administer emergency medications. S9Family Practice Physician said based on his documentation, it was difficult to tell what was done for the infant. He said, " I don't know how descriptive you would want me to be".

In an interview on 3/14/13 at 8:30 a.m. with S11RRT, he stated he had attended the delivery of Patient #3 ' s infant on 1/11/13 at 4:25 a.m. He stated he, S10LPN, and S9Family Practice Physician were at the radiant warmer where the preterm infant was placed after delivery. S11RRT said S9Family Practice Physician dried the infant after it was placed on the warmer and listened for heart tones, but then stood at the bedside doing nothing. S11RRT said S9Family Practice Physician did not attempt to intubate or even view the vocal cords, but instead asked him to attempt intubation. He said he tried to intubate with a 3.0 ETT and a 2.5 ETT, but was unsuccessful. S11RRT said he and S10LPN both administered PPV to the infant during the resuscitation. S11RRT also said he was not sure if S10LPN did chest compressions on the infant, but S9Family Practice Physician did not perform chest compressions. S11RRT said S7CRNA attempted to intubate with a 3.0 ETT and a 2.5 ETT, but was also unsuccessful. S11RRT said the resuscitation process took approximately 10-15 minutes. S11RRT also said S9Family Practice Physician was attempting to place lines in the baby's umbilicus for medication administration. When asked if he documented any of the sequence of events, S11RRT replied, "no".

In an interview on 3/14/13 at 11:30 a.m. with S4RNSupervisor, she verified the documentation in Patient #3's medical record on 1/11/13 about the infant resuscitation was not thorough. S4RNSupervisor also said S10LPN should have documented the events of the resuscitation in her nurse's notes or on Form 1171.

Based on record review and interview, the hospital failed to provide adequate supervision by anesthesiologists or operating practitioners to Certified Registered Nurse Anesthetists (CRNA). The hospital failed to specify in the privileges granted to individual practitioners, the type and complexity of procedures they may supervise during the administration of anesthesia by a CRNA. The hospital further failed to have an anesthesiologist who is immediately available on a 24-hour basis.
Findings:
Review of the practitioners' credentialing files revealed no specifications for privileges granted on the type and complexity of the type of procedures anesthesiologists or operating practitioners may supervise during the administration of anesthesia by a CRNA.
In an interview on 03/12/13 at 12:25 p.m., S6Director of Medical Staff Services indicated that no privileges had been granted to any surgeons or obstetricians regarding the supervision of Certified Registered Nurse Anesthetists during the administration of anesthesia. S6Director of Medical Staff Services further indicated that the hospital does not have an anesthesiologist in house 24 hours per day.

Based on review of medical records, Quality Assurance/Performance Improvement data and interview with staff, the hospital failed to ensure that all departments of the hospital reported data related to patient treatment outcomes to be evaluated through the Quality Assurance/Performance Improvement Program.

Findings:

During the survey process, the survey team requested information related to any deaths that occurred in the hospital during the past year. It was reported to the survey team there was an infant death on 1/13/13. Review of the birth record for Patient #3's premature (26 weeks 4 days) infant revealed he had been delivered at 4:25 a.m. on 1/11/13 with an undetected heart beat. Further review of the infant record revealed no documented evidence that the premature infant received full resuscitation. Review of Patient #3's Labor and Delivery Record revealed fetal heart tones were detected and monitored until the time an Emergency C-Section which was performed after prolonged fetal heart rate deceleration.

Interview with S10Director of Performance Improvement on 3/14/13 at 3:10 PM revealed each hospital department collected data related to patient care and treatment outcomes. S10 Director of PI stated each Director of all departments performed root cause analysis on problems identified and that she provided assistance to develop action plans when asked. S10Director of PI stated no data was presented by the Director of Obstetric/Newborn Services related to the death of Patient #3's preterm infant.

Review of QA data with S10Performance Improvement Director revealed data related to the infant death was not provided for evaluation by Performance Improvement.