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Based on records reviewed and interviews the Hospital failed to ensure, for one of seven patients (Patient #1) in a total sample of ten medical records reviewed, that Quality Assessment & Performance Improvement (QAPI) activities implemented performance improvement activities and evaluated those performance improvement activities for compliance after Patient #1 died.

Findings included:

The Physician Admission Note, dated 10/25/16, indicated the Hospital admitted Patient #1 to the Labor and Delivery Unit for an induction of labor and with a diagnosis of preeclampsia (commonly known as toxemia of pregnancy, a medical condition in pregnancy characterized by high blood pressure, swelling and protein in the urine). The Physician Note indicated Patient #1 had high blood pressures, swelling of both legs and thighs and protein in the urine.

The Death Certificate, dated 10/27/16, indicated Patient #1 died on 10/26/16 of hemorrhagic (bleeding) shock and severe preeclampsia.

The document titled, Action Planning, indicated corrective actions included the development of a Management of Preeclampsia/Eclampsia Guideline and an accompanying Preeclampsia Order-Set (preprinted doctor's orders) with an implementation date of mid-January 2017.

The Surveyor interviewed the Risk Manager at 12:45 P.M. on 2/1/17 and the Medical Chief of Obstetrics at 1:45 P.M. on 2/1/17. The Risk Manager and the Medical Chief of Obstetrics said that the Hospital had not finalized and fully implemented the Management of Preeclampsia/Eclampsia Guideline or Preeclampsia Order-Set.

The Hospital did not provide document(s) that indicated they implemented performance improvement activities or evaluated those performance improvement activities for compliance.

Based on records reviewed and interviews the Hospital failed to ensure, for one of seven patients (Patient #1) in a total sample of ten medical records reviewed, that Quality Assessment & Performance Improvement (QAPI) activities were implemented, after Patient #1 death, that included feedback and learning to Emergency Department Physicians and Hospitalists (physicians) that cared for pregnant and post-partum women throughout the Hospital.

Findings included:

The document titled, Action Planning, did not indicate corrective actions that included feedback and learning to Emergency Department (ED) Physicians and Hospitalists (physicians) that cared for pregnant and post-partum women throughout the Hospital.

The Surveyor interviewed the Medical Chief of Obstetrics at 9:30 A.M. on 2/3/17. The Medical Chief of Obstetrics said that he did not include the ED Physicians and the Hospitalists with learning information regarding preeclampsia, eclampsia, hypertension in pregnancy and postpartum.

A document and email, dated 2/3/17, indicated the Hospital distributed the Management of Preeclampsia/Eclampsia Guideline (learning information) to ED Physicians and other Hospital physicians that cared for pregnant and post-partum women throughout the Hospital during the Survey.