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Based on record review, interview and policy review, the facility failed to protect the emotional health of the mother by ensuring staff served this patient courteously and treated her with consideration and respect and failed to ensure staff performed every two hour checks to observe, assess, and document physical comforts.

See A144 and A167.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff served one patient courteously and treated that patient with consideration and respect. This affected one patient, Patient #1.

Findings include:

Review of the medical record of Patient #1 revealed the patient, beginning at 14 weeks gestation with her first pregnancy, presented to the facility's Emergency Department on 06/22/23, 06/25/23, and 06/29/23 with complaints of vaginal bleeding. An emergency physician's history and physical on 06/22/23 revealed the patient had a medical history of hypertension, morbid obesity, and type 2 diabetes mellitus. A note describing the medical decision making on this visit stated the patient's pregnancy was considered high risk given her comorbidities. A bedside ultrasound revealed there was fetal movement and a normal fetal heart rate of 154 beats per minute. A pelvic exam revealed no gross blood and a closed cervix. Although urinalysis revealed leukocytes, there were only rare bacteria, so the patient was not treated for a urinary tract infection. The patient and her significant other were counseled on the topic of a threatened miscarriage and discharged home with instructions on Emergency Department return precautions.

When the patient presented again on 06/25/23 with similar symptoms as three days prior, a urinalysis was grossly positive for infection. Although the patient denied any symptoms of a urinary tract infection, she was treated for an asymptomatic urinary tract infection given her early pregnancy. The first dose of Macrobid (antibiotic) was administered in the Emergency Department and the patient was discharged with a prescription to continue for one week. A repeat bedside ultrasound was deferred as the patient had a normal ultrasound performed during her previous visit. Again, she was discharged home with strict return precautions for worsening or new symptoms.

On 06/29/23, the patient, now 15 weeks gestation, presented to the Emergency Department for the third visit in two weeks for vaginal bleeding. The patient described the bleeding as a normal flow that she would have during a period. She also described some very small clots which all together may be dime-sized and a stabbing pain in her pelvic area that began as intermittent but now had worsened to constant. A bedside ultrasound revealed an intrauterine pregnancy with a fetal heart rate of 160 beats per minute. A physical exam also revealed the patient's cervix remained closed. An obstetric physician's medical decision making note stated the bleeding was likely secondary to subchorionic hemorrhage (a condition which most of the time does not harm the fetus where bleeding beneath the chorion membranes that enclose the embryo in the uterus occurs due to partial detachment of the chorion membranes from the wall of the uterus). The note stated there would be coordination with the patient to schedule a formal outpatient ultrasound and follow-up.

An emergency room nurse's note stated, prior to discharge, the patient called her to the bathroom with complaints of passing a large clot. A large amount of blood was noted in the toilet. Although no tissue was visible, a physician was made aware and a bedside ultrasound was performed prior to flushing the toilet, which revealed a fetal heart rate of 170 beats per minute. The patient was discharged home.

On 06/30/23 at 11:48 AM, the patient was sent to Obstetric Triage from an appointment at the clinic after a formal ultrasound performed by a maternal fetal medicine physician showed a significant clot in the cervix, which the physician suspected was a placental abruption (serious pregnancy complication in which the placenta detaches from the uterus). The fetal heart rate was normal at 161 beats per minute. The ultrasound also revealed the cervix was longer with dilation of one centimeter. The decision was made to admit the patient to the facility's High Risk Antepartum unit.

The maternal fetal medicine physician's admission note stated the abruption labs on admission were unremarkable and the patient's bleeding and cramping had improved. The patient was admitted for close observation. The note further stated: "We discussed that she may progress with further bleeding, dilation, and cramping which may signal an inevitable abortion." The physician stated if her bleeding or labs become concerning, she would be a candidate for a dilation and curettage (D&C: a surgical procedure in which the cervix is dilated so that the uterine lining can be scraped with a curette or spoon-shaped instrument to remove abnormal tissues)/dilation and evacuation (D&E: type of in-clinic procedure done with vacuum aspiration). The plan was to admit the patient overnight for observation and repeat the exam the next day.

A nurse's note stated the nurse instructed the patient to notify a staff member if she passed any clots. A second nurse's note on 07/01/23 at 6:33 AM stated the patient called out to notify the nurse that she had passed a half dollar sized clot. The nurse asked the patient if the clot was saved and the patient denied saving the clot. The note stated the nurse "educated the patient on the need to save any further clots." The patient verbalized understanding. The patient's vaginal bleeding had decreased to spotting on 07/01/23 and the patient declined a D&C/D&E, desiring expectant management. The patient was deemed stable for discharge and was provided discharge instructions that advised her to return with uncontrolled abdominal pain, fever greater than 100.3, uncontrolled nausea/vomiting, vaginal bleeding, decreased fetal movement, or any other concerning symptom. The patient was given a hat to place in the toilet to collect and/or measure urine output for a physician ordered 24-hour urine. The discharge instructions also advised the patient that her next appointment at the clinic was on 07/07/23.

The patient presented to Obstetric Triage on 07/05/23 at 7:00 PM with complaints of vaginal bleeding and the passing of a large clot. A provider's admission note stated the patient brought in the collection hat containing the clot, as she was concerned the clot was fetal tissue. However, a normal fetal heart rate was detected by bedside ultrasound at 143 beats per minute. The patient's cervix was now 2 centimeters dilated. The patient was counseled that she was experiencing an "inevitable miscarriage" and that given the gestational age of 16 weeks, the fetus was not viable. She was also counseled on management options including medical, surgical, and expectant management. The patient informed medical staff that this was a strongly desired pregnancy and declined surgical or medical management. A physician's discharge summary noted the patient was discharged home clinically and hemodynamically stable with stable vital signs.

The patient, now 16.2 weeks gestation, presented to the facility's clinic for a scheduled appointment on 07/07/23 at 8:00 AM with complaints of shortness of breath, sweating, chills that began at 2:00 AM, back pain, and cramping. A Certified Nurse Practitioner from the Diabetes and Pregnancy Program (Staff W) stated in a progress note that the patient's blood pressure was 116/43 mmHg, heart rate was 149 beats per minute, and temperature 99.3 degrees Fahrenheit. A fetal heart rate was noted at 202 beats per minute.

Staff W was interviewed on 08/16/23 at 4:15 PM. She stated the patient was transported to the examination room by wheelchair, as she didn't feel well enough to walk. Staff W revealed that the patient looked ill. She stated that the patient's face was red, she was diaphoretic, and tachycardic. She recalled that the patient reported having a fever, but had just taken a sip of water and her temperature only registered a low grade temperature. Staff W stated that the appointment with the patient lasted no longer than 30 minutes. She stated: "I was worried about sepsis with her." According to Staff W, the patient was escorted to the waiting room by a medical assistant as transportation was called to transport the patient to Obstetric Triage. Staff W was interviewed a second time on 08/17/23 at 12:27 PM and asked if she had notified staff in Obstetric Triage that the patient was being sent over and informed anyone of her symptoms. Staff W replied that she had "absolutely" spoken with an obstetric resident physician and a maternal fetal medicine physician and reported the patient's abnormal vital signs, that the patient appeared ill, and that she was worried for sepsis. Staff W also reported that she informed the physicians of the fetal heart rate of 202 beats per minute obtained via Doppler.

The transport tracking activity from 07/07/23 was reviewed on 08/17/23. The event history revealed a request was made to transport the patient with a high priority from the clinic at 9:01 AM. The transporter acknowledged the request at 9:15 AM and the patient was picked up eight minutes later, at 9:23 AM. The transport was completed at 9:33 AM.

Further review of the medical record of Patient #1 revealed the patient presented to Obstetric Triage at 9:50 AM. A nurse's note, composed by Staff X, stated heavy bleeding and clots were noted when the patient voided. The note further revealed the patient's temperature was 100.5 degrees Fahrenheit. An attending obstetric physician's progress note documented the following counseling provided to the patient on admission: "I informed the patient again of the diagnosis of an inevitable abortion. At this early of a gestational age, there is essentially no chance that she will remain pregnant until viability. In the meantime, though, there are significant risks to her health now that she is showing evidence of an intraamniotic infection. Although I voiced my condolences, I informed the patient that this baby will not survive regardless of her management but she is risking her own life by prolonging the pregnancy. Given this worsening clinical picture, she is amenable to proceeding with the delivery, requesting a D&E." A late entry nurse's note, composed by Staff X, on 07/14/23 for 07/07/23, stated: "Blood clots noted in toilet. Asked MD if she would like to assess blood clots prior to patient next door using bathroom. MD declined as she stated she is going into patient room to perform ultrasound at this time." An obstetric physician (Staff Y) scheduled to perform the D&E stated in a progress note that the patient had been counseled and consented to a D&E prior to her performing the ultrasound. The ultrasound, however, revealed there was no fetus. An operative report revealed a D&C was performed for concern of a septic abortion on the afternoon of 07/07/23.

An obstetric resident physician's progress note on 07/08/23 stated that it was believed that the patient delivered the fetus in the toilet since the ultrasound following heavy vaginal bleeding in the toilet revealed no intrauterine fetus. The note stated the patient was "understandably upset/angry that her fetus was not salvaged from the toilet, and I apologized for this today."

Staff H, the Assistant Nurse Manager of Labor and Delivery, was interviewed on 08/07/23 at 10:30 AM. According to Staff H, Labor and Delivery was busy on the morning of 07/07/23. She stated that it was so busy, she was pulled into staffing to care for patients in Obstetric Triage. She reported Obstetric Triage being full and Staff X, an Assistant Nurse Manager for High Risk Antepartum, offered to come to Obstetric Triage to help Staff H. Staff H informed this surveyor that Staff X had received a brief orientation to Obstetric Triage in order to be able to help out when the unit was busy. Staff H explained that there are six rooms in Obstetric Triage. Rooms #1 and #6 have a private bathroom. Room #2 shares a bathroom with Room #3 and Room #4 shares a bathroom with Room #5. Staff H explained that Patient #1 was placed in Room #5, which meant she was required to share a bathroom with the patient in Room #4. She also explained that she received no report that the patient was being transported from the clinic with symptoms of sepsis. Although she denied a written policy requiring staff to place a hat in the toilet of patients presenting to Obstetric Triage, staff nurses typically place a hat in the toilet prior to a patient using the restroom. Staff H was asked to provide a policy for management of preterm patients.

The facility policies titled Preterm Labor Management, Care of the Obstetrical Patient, and Admission, Transfer, Discharge Guidelines for L&D, OB, Recovery were reviewed. The policies revealed that patients less than 16 weeks are evaluated in the ED and patients greater than 16 weeks are evaluated in Obstetric Triage. Neither of these three policies directed staff to place hats in the toilet or provided any directions for staff in the event of delivery of a fetus in the toilet.

Staff Z, an attending obstetric physician, was interviewed via phone on 08/08/23 at 6:00 PM. According to Staff Z, Staff X did ask if she could flush the clots that were in the toilet because another patient needed to use the bathroom. Staff Z stated that she informed Staff X that she could flush the contents in the toilet. Staff Z was asked if she examined the contents prior to Staff X flushing the toilet and she replied that she did not.

Staff AA, an Emergency Department nurse, was interviewed on 08/16/23 at 11:20 AM. According to Staff AA, in the event a patient presents to the ED and it is suspected that they have delivered fetal tissue in the toilet, she would don gloves and assess the contents of the toilet.

The facility policy titled Patient Rights and Responsibilities, effective 11/01/92, was reviewed on 08/07/23 at 6:30 PM. According to the policy, patients have a right to be treated with consideration, respect, and served courteously.

Staff H and Staff BB were interviewed on 08/17/23 at 9:25 AM. It was confirmed that flushing fetal tissue down the toilet without examining the tissue and without a patient's knowledge is not treating the patient with consideration, respect, or serving a patient courteously.

Based on record review, interview and policy review, the facility failed to ensure a patient who was physically restrained was checked every two hours. This affected one (Patient #13) of ten patient records reviewed.

Findings include:

Review of the medical record of Patient #13 revealed the patient was transferred to the Emergency Department from an outside hospital on 07/25/23 at 1:27 PM with hypertensive emergency, altered mental status, and frank bleeding from tracheostomy. The patient's blood pressures on admission were 243/118 mmHg and 208/120 mmHg. According to a physician's history and physical, the patient was on hemodialysis but had refused hemodialysis on 07/24/23. An emergency department nurse's note on 07/26/23 at 12:10 AM stated the patient's bed alarm was going off and as the nurse entered the room, the patient was found attempting to climb out of the bed. The patient was in respiratory distress with an oxygen saturation of 85 percent. The decision was made to place the patient in non-violent self destructive restraints. According to the restraint flow sheet, bilateral upper extremity and right lower extremity restraints were applied. An emergency physician ordered the restraints at 12:30 AM. Although an initial restraint assessment was completed by a staff nurse at 12:30 AM, the medical record lacked documentation another assessment was completed by a staff nurse until 9:06 PM, more than eight hours later, after the patient was transferred to the unit, 8CCP.

On 07/27/23 at 3:17 AM and 5:00 AM, a nurse documented restraint assessments. A nursing note dated 07/27/23 at 5:24 AM revealed that when the nurse walked in the room, Patient #13 had pulled out his tracheostomy tube while still restrained. On 07/28/23 at 12:00 PM a restraint assessment was completed. There was no documentation another assessment was completed until 07/28.23 at 8:00 PM.

During interview on 08/18/23 at 10:15 AM., Staff FF confirmed Patient #13's restraints were not checked every two hours as required.

The facility policy titled "Restraint and or Seclusion: Non-Violent/Non-Self-Destructive Behavior and Violent/Self-Destructive Behavior", revised on 03/08/23, documented staff members are required to perform an assessment at a minimum of every two hours. Staff members are required to observe, assess, and document physical comforts including: nutrition/hydration, physical/psychological status, circulation, injury, range of motion, skin care, elimination, and hygiene.

Based on medical record review, facility policy review, and staff interview, the facility policy review, the facility failed to ensure staff followed the current facility policies related to performing RN to RN handoff and pain management. This affected Patient #14.

Findings include:

1. Review of the medical record of Patient #14 revealed the patient was directly admitted to the facility on 06/19/23 with a history of end stage liver disease secondary to presumed nonalcoholic steatohepatitis (fatty, inflamed liver not caused by heavy drinking). The patient was admitted for a liver transplant. The patient had a history of hypertension and type 2 diabetes. An operative note revealed the transplant was performed without complications on 06/20/23. The patient was hospitalized in the SICU until 06/23/23 when she was transferred to the 8CCP unit. The patient remained in this unit until discharge on 07/13/23.

Review of the RN to RN handoff flowsheet revealed on 06/19/23 at 3:38 PM, an RN gave a verbal handoff to an RN working the next shift. The medical record lacked documentation a verbal handoff was conducted from the RN working dayshift to the RN working nightshift. On 06/20/23 and 06/21/23, an RN to RN handoff was conducted on both dayshift and nightshift as required by facility policy. However, the medical record lacked documentation of another RN to RN handoff until 06/22/23 at 7:05 PM without evidence of a dayshift handoff. The next handoff occurred on 06/23/23 at 11:40 AM. The medical record lacked documentation of an RN to RN handoff from the nightshift nurse to the dayshift nurse on 06/25/23.

The facility policy titled Inpatient Nursing Documentation for the Permanent Medical Record, last reviewed/revised on 12/20/22, was reviewed on 08/18/23 at 11:50 AM. According to the policy, a RN to RN handoff should be performed and documented at the beginning of every shift. The handoff should confirm restraint orders and required documentation for restraint patients, allergies reviewed, admission history for completeness reviewed, and bedside verification of continuous IV infusions. Safety checks including clinical alarms, bed/chair alarms, and signed in and held orders should also be checked by the two RNs.

Staff C was interviewed on 08/18/23 at 12:00 PM. It was confirmed that the medical record lacked documentation of required RN to RN handoff.

2. The facility policy titled Pain Management, last reviewed/revised on 03/28/23, was reviewed on 08/17/23 at 2:30 PM. According to the policy, staff nurses are instructed that patients have the right to appropriate assessment and management of pain consistent with the total treatment plan. Patients are screened for pain upon initial assessment with outpatient, emergency, procedural or inpatient admission to the hospital with a licensed caregiver. Pain re-assessment are done to determine the effectiveness and safety of pain interventions. Pain score documentation upon re-assessment will occur within 45 minutes of administration of as needed IV/IM/ subcutaneous medications. For PO medications, pain should be re-assessed within 90 minutes.

Review of the Pain Flowsheet for Patient #14 revealed on 06/20/23 at 4:00 PM, the patient complained of abdominal incisional pain rating it a 7 on a 0-10 scale. The patient was medicated with Tylenol. The patient's pain wasn't reassessed until 8:00 PM. The patient rated her abdominal incisional pain a 9 on a 0-10 scale. The next pain assessment revealed the patient complained of abdominal incisional pain rating it a 6 on a 0-10 scale. The medical record lacked documentation the patient was medicated for pain. The patient's pain wasn't assess again until 8:58 AM on 06/21/23. The patient rated her abdominal incisional pain an 8 on a 0-10 scale. The patient was medicated with Tylenol. The reassessment did not occur until 12:00 PM. The patient continued to complain of pain rating it an 8 on a 0-10 scale.

Staff CC was interviewed on 08/17/23 at 2:45 PM. It was confirmed that the medical record lacked documentation the patient's pain was reassessed within 90 minutes after being medicated for complaints of severe pain after a liver transplant.