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Based on document review, policy review, record review and interview, the hospital failed to assess and treat pain for 1 of 3 postpartum patients (Patient #1) and the hospital failed to have an organized nursing service which provided ongoing assessments of patients' needs and ensure they provided the services to meet those needs for 1 of 3 postpartum patients (Patient #1).

The findings included:

Patient #1 presented to the hospital's emergency department (ED) on 2/16/2021 in active labor. Patient #1 was of advanced maternal of an age of 39 years old and 36.6 weeks pregnant.

Review of the postpartum nursing pain assessments revealed no pain assessments were documented on Patient #1 for approximately 12 hours. Patient #1 stated she was in pain postpartum without relief for hours. There was no documentation of Patient #1's complaints of pain during those 12 hours.

Review of Patient #1's medical record revealed no documentation of breastfeeding or hydration education.

Review of Patient #1 and Baby #1's medical record revealed the documentation regarding maternal assessments for the fundus and lochia were incomplete for Patient #1, and infant glucose monitoring was not completed according to hospital policy for Baby #1.

Refer to A392 and A395

Based on policy review, medical record review, and interview, the hospital failed to have an organized nursing service which ensured patients' needs were met regarding maternal and infant assessments, breastfeeding and hydration for 1 of 3 postpartum patients (Patient #1), and 1 of 3 infants (Baby #1).

The findings included:

1. Review of the Hospital's Policy Glucose Screening in the Newborn revealed, "...The infant will maintain normal levels of blood glucose (40-120 mg/dl [milligrams per deciliter]...Identify patients at risk for hypoglycemia...Late preterm infants (35-36 weeks gestation)...Asymptomatic Newborns at Risk for Hypoglycemia...Phase 1: Birth to 4 hours of age...Initial POC [Point of Care glucose screening] < 40 then feed and repeat POC in 1 hour...Continue feeding q 2 to 3 hr. POC glucose screening prior to each feed...monitor until 2 consecutive POC > 45. Then may discontinue routine glucose measurements..."

Review of the Hospital's policy Recovery Phase of Birth Protocol revealed, "...The recovery phase after birth is a critical time of physiological adjustment and initial recovery from the stress of labor...Monitor every 15 minutes X [times] 1 hour...the following...Fundus [top of the uterus] - location and tone...Lochia [afterbirth bleeding] - Color, amount, odor...Pain...monitor every 30 minutes X 2, and every hour X 2 the following...Fundus...Lochia...Pain...Initiate breastfeeding according to the patient's preference...A complete report should be given by an RN [Registered Nurse] with the transfer of care or the transfer of the patient to another unit...Record all assessments and interventions..."

Review of the Hospital's policy Care of the Postpartum Patient revealed, "...The postpartum phase is a time of physiological and psychological change...Postpartum women should be assessed for...emotional adjustment to motherhood...Adequate hydration should be maintained...Maternal emotional status should be assessed...Encourage breastfeeding..."

1. Medical record review revealed Patient #1 was transported via ambulance during a winter blizzard on 2/16/2021 and was unable to be transported to the requested hospital. The ambulance crew was able to transport Patient #1 to the nearest hospital (Hospital #1). Patient #1 presented to the Emergency Department on 2/16/2021 at 3:28 AM in active labor. Patient
#1 was of advanced maternal age (age 39), and 36 weeks 6 days pregnant.

Patient #1 delivered Baby #1 on 2/16/21 at 5:42 AM.

Review of the maternal assessment form postpartum revealed Patient #1's fundus was checked on 2/16/21 post delivery at 6:00 AM, 6:15 AM, 6:35 AM, 7:07 AM (every 15 minutes for 1 hour). There was no documentation her fundus was checked at 7:30 AM per hospital policy. Her fundus was was checked at 8:00 AM. (every 30 minutes times 2). The fundus was not checked at 9:00 AM or 10:00 AM (every 1 hour times 2) per hospital policy.

During a telephone interview with Patient #1 on 6/21/21 at 9:07 AM, Patient #1 stated her fundus and lochia were not checked regularly. Patient #1 stated she felt as though she was not taken care of at this hospital. Patient #1 stated on the late afternoon of 2/16/21 when Nurse #1 called her back using the intercom, she asked Nurse #1 if she could come and take the baby to the nursery so Patient #1 could take a shower. Patient #1 stated Nurse #1 told her to bring the baby's crib over to the door of the bathroom and I could watch her while I took a shower. Patient #1 stated she was very upset about that and felt it was dangerous because there was no family in the room with her. Patient #1 stated she rang the call bell 3 times and asked for the water pitcher to be filled with ice and water. Patient #1 stated the lady answered by saying "I will let your nurse know". Patient #1 stated the water pitcher remained in the packaging unopened until Nurse #2 came in with pain medication on 2/16/21 at 8:33 PM. Patient #1 stated she remained thirsty during the day shift. Patient #1 stated the first 12 hours after delivery was traumatic for her. She revealed after she was discharged home, she continued to feel very anxious and sad about her stay at (Named Hospital).

2. Medical record review revealed Baby #1 revealed the following:
The admission assessment form dated 2/16/21 at 6:34 AM revealed the plans to feed Baby #1 was "Exclusive Breast Milk".
Baby #1's initial glucose was 39 mg/dl on 2/16/21 at 6:41 AM and was immediately fed formula.
There was no documentation in Baby #1's medical record that a POC blood glucose was repeated 1 hour after this feeding.
Baby #1's glucose was checked at 9:15 AM prior to feeding. The result was 62 mg/dL. Baby #1 was then fed formula.
Baby #1 was fed formula at 12:00 PM. No glucose was checked prior to this feeding per hospital policy.
Baby #1 was fed formula at 3:00 PM. No glucose was checked prior to this feeding.
Baby #1's glucose was checked at 6:38 PM prior to feeding. The result was 48 mg/dL. Baby #1 was then fed formula.

Baby #1's glucose was not repeated in 1 hour after the initial feeding. Baby #1's glucose was not repeated prior to 2 consecutive feedings to establish a POC glucose > 45 mg/dL which would have given Patient #1 ability to breast feed earlier in the day. Patient #1 was relying on Nursing for direction when it was safe to breastfeed.

During an interview with Nurse #1 on 6/17/21 at 11:00 AM, Nurse #1 was asked about checking Patient #1's fundus and lochia. Nurse #1 stated, "...I assessed her fundus and bleeding at 7:07 and 8:00 AM when I cleaned her up. Every shift is how often we check it or PRN [as needed] if bleeding heavy or passing clots..."
Nurse #1 was asked if Patient #1 asked about taking a shower and taking the baby to the nursery and Nurse #1 stated, "I told her normally you bring the bassinet close to the door and have the bassinet right in her view...She didn't seem upset or anything..."

During an interview with Nurse #3 on 6/17/21 at 11:15 AM, Nurse #3 was asked if a patient asks to have the baby taken to the nursery while she takes a shower, is that something that would be done and Nurse #3 stated, "We can do that as a personal request, yes we can. We stress bonding time...If the postpartum nurse is asked she should call the nursery to see if it's ok or just do it. They can bring the babies to the nursery too...if the mother asks we should go get the baby..."
Nurse #3 confirmed a blood glucose should have been checked prior to the 12:00 PM feeding and again at 3:00 PM. Nurse #3 stated, "...It must have been a very busy day."

During a telephone interview with Nurse #2 on 6/17/21 at 12:16 PM, Nurse #2 confirmed the patient's water pitcher was still in the package laying on the shelf. Nurse #2 confirmed [Named Registered Nurse] opened it and filled it with ice and water. Nurse #2 confirmed Patient #1 voiced several concerns she had from the previous shift, breastfeeding, and the baby's blood sugar wasn't checked. Nurse #2 stated Patient #1 stated she couldn't get any assistance. Nurse #2 stated the manager at the time was in the building and came to the unit. Nurse #2 stated she talked to [Named Nurse Manager] about Patient #1's concerns and she went down the hall to speak to the patient.

During an interview with Patient #1 on 6/21/21 at 9:07 AM, Patient #1 stated Nurse #2 explained that the baby's glucose was low and had to be fed formula until a glucose above 50 mg/dL was achieved 2 times consecutively before she could breastfeed. Patient #1 stated she was very upset that no one came to check her baby's glucose between the 9:00 AM feeding and the 6:00 PM feeding. She stated she was distressed because she wanted to begin breast feeding as soon as she could. Patient #1 stated she felt all alone and felt that no one would give her the information she needed to be able to take care of her new baby.

Based on policy review, record review and interview, the hospital failed to ensure nursing services performed assessment, reassessments and took steps to manage patient's pain for 1 of 3 (Patient #1) postpartum patients.

The findings included:

1. Review of the Hospital's Pain Assessment Policy revealed, "...All patients will be assessed for pain based upon their clinical presentation, services sought, and in accordance with the care, treatment, and services provided...The identification and treatment of pain is an important part of the plan of care because unrelieved pain has adverse physical and psychological effects...Pain scales used are...Numeric Rating Scale...0 (no pain) to 10 (worst pain)...Pain Assessment Frequency...Inpatients...Upon admission and reassessed twice daily and as needed (PRN)...If pain medication is administered, patients will be reassessed for intensity of pain or sleeping within 2 hours...Breakthrough pain: a transient episode of increased pain experienced by patients between normal doses of medication that generally controls or palliates such pain. Medications ordered to treat breakthrough pain should be administered at least 1 hour after any previous pain medications...Pain assessment and interventions are documented in the medical record..."

2. Medical record review revealed Patient #1 was transported via ambulance during a winter blizzard on 2/16/2021 and was unable to be transported to the requested hospital. The ambulance crew was able to transport Patient #1 to the nearest hospital (Hospital #1). Patient #1 presented to the Emergency Department on 2/16/2021 at 3:28 AM in active labor. Patient
#1 was of advanced maternal age (age 39), and 36 weeks 6 days pregnant.
Patient #1 was transferred to Labor and Delivery on 2/16/2021 at 3:37 AM.
Patient #1 gave birth to Baby #1 on 2/16/2021 at 5:42 AM.
Patient #1 was transferred to a postpartum room on 2/16/2021 at 9:20 AM.

Review of Physician orders dated 2/16/2021 at 7:13 AM revealed, "...Naproxen 500 mg [milligrams]...1 tab [tablet], PO [by mouth], q [every] 12h [hours] PRN [as needed]...for uterine cramps..."

Review of Physician orders dated 2/16/2021 at 7:13 AM revealed, "...acetaminophen-HYDROcodone 325 mg-5 mg oral tablet...1 tab PO, q4h, PRN Pain, Moderate (4-7)..."

Review of Physician orders dated 2/16/2021 at 7:13 AM revealed, "...acetaminophen-HYDROcodone 325 mg-5 mg oral tablet...2 tab PO, q4h, PRN Pain, Severe (8-10)..."

Review of Patient #1's Medication Administration Record (MAR) revealed Naproxen 500 mg. was administered PO (by mouth) to Patient #1 at 7:43 AM. A reassessment was completed at 8:43 AM with a pain rating of 0 (no pain).

There was no documentation Patient #1 was assessed for pain from 8:43 AM - 8:33 PM. Patient #1 had no pain assessments performed for 11 hours and 50 minutes the first day post partum.

There was no documentation Patient #1 received any pain medications from 7:43 until 8:33 PM. Patient #1 had no pain medication administered for 12 hours and 50 minutes during the first day postpartum.

On 2/16/2021 at 8:33 PM, a pain assessment was performed on Patient #1 at which time Patient #1 rated her pain at a level of 6 or moderate pain.

Review of Patient #1's MAR revealed Patient #1 received Naproxen 500 mg. PO at 8:33 PM. A reassessment was completed at 9:33 PM with a pain rating of 0 (no pain).

During an interview with Nurse #1 on 6/17/2021 at 11:00 AM, Nurse #1 was asked about Patient #1's requests for pain medication and Nurse #1 stated, "No, I don't recall that, it was so long ago...I remember talking to [Named Clinical Director of Perinatal Services] a few days later, but I don't remember her asking..."

During a telephone interview with Nurse #2 on 6/17/2021 at 12:16 PM, Nurse #2 stated Patient
#1 had complained that she couldn't get any assistance. Nurse #2 stated Patient #1 complained about not getting pain medicine when she had asked for it. Nurse #2 stated she got her some pain medicine after she did a pain assessment. Nurse #2 stated the manager at the time was in the building and came to the unit. Nurse #2 stated she talked to [Named Clinical Director of Perinatal Services] about Patient #1's concerns and she went down the hall to speak to the patient.

During an interview with the Clinical Director of Perinatal Services on 6/17/2021 at 1:50 PM, the Clinical Director stated she talked with Nurse #1 about administering pain medications. The Clinical Director stated Nurse #1 told her it was busy the day Patient #1 was at the hospital. The Clinical Director confirmed Nurse #1 had said that Patient #1 had asked for pain medication and Nurse #1 had told Patient #1 that it was not time to administer the pain medication. The Clinical Director confirmed she did not do a verbal or a written corrective action plan for Nurse #1. There was no documentation of this discussion between Nurse #1 and the Clinical Director.

During a telephone interview with Patient #1 on 6/21/21 at 9:07 AM, Patient #1 stated she asked for pain medication three (3) times during the day shift from 7:00 AM to 7:00 PM using the call light. Patient #1 stated she told the person answering the call light she needed something for pain. Patient #1 stated the person responded each time saying, "I'll let your nurse know." Patient #1 stated she did not hear from her nurse (Nurse #1). Patient #1 stated after the 3rd call for pain medication, Nurse #1 responded via the call light intercom stating, "It's not time for your medicine yet." There was no documentation the nurse performed a pain assessment. Patient #1 stated when the next shift began [night shift 7:00 PM -7:00 AM], the night shift nurse (Nurse #2) performed a pain assessment at 8:33 PM. Patient #1 confirmed she did receive pain medication on 2/16/2021 at 8:33 PM.

Patient #1 had orders for Naproxen every 12 hours and for HYDROcodone every 4 hours for pain. Patient #1 received pain medications at 7:43 AM and was reassessed at 8:43 AM. There were no more pain assessments for Patient #1 until 8:33 PM which was 11 hours and 50 minutes post partum the first day. When Patient #1 was assessed for pain at 8:33 PM, the patient's pain level was a 6 on a scale of 1 - 10. The patient was in moderate pain. The hospital failed to ensure each patients' pain needs were assessed, reassessed and interventions were implemented to manage all patients' pain.