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Based on record review and interview, the facility's Governing Body failed to ensure the medical staff provided quality of care for 1 (Patient #5) of 11 patients the hospital serves.

The findings include:

On 8/10/11, review of the clinical record for Patient #5 revealed the patient was admitted to the Emergency Care Center (ECC) on 7/1/11 at 9:45 a.m., with a diagnosis of 13 wk's pregnant, vaginal bleeding, and abdominal pain. The patient was documented as being a diabetic with an insulin pump (Humalog Insulin - fast acting) in place. Review of the clinical record for this patient failed to include any baseline glucose testing ordered or performed by either the registered nurse and/or the laboratory.

Interview with the attending emergency center physician on 8/10/11 at 4:09 p.m. revealed the following: The physician reported the patient was NPO (nothing by mouth) and he did not know where the patient was going with the pregnancy. Normally a Chemistry (a laboratory test for electrolytes, glucose, etc) is not performed for a young person. He stated, "I rely on staff when hypo/hyperglycemia (low/high blood sugar) was showing up." However, the patient's record documented that other laboratory tests were performed upon admission to the ECC at 10:30 a.m. on 7/1/11. Those tests included a Hemogram, Platelet, Differential (test used to determine blood values for hemoglobin and hematocrit, clotting, etc.), Hcg Beta Subunit Quant (used to determine pregnancy), Rh(D) Antigen Typing (blood Rh factor), Blood Bank Clot, and Urinalysis w/Culture Refined (determining the presence of a urinary tract infection). No chemistry test was ordered which would have included a glucose level.

The patient was kept NPO. There was no physician order to discontinue/maintain either the insulin pump and/or receive an infusion of IV Dextrose to utilize the insulin being infused via insulin pump with continuous glucose monitoring. The patient only received one liter of IV 0.9% Normal Saline as a one time bolus of fluids at 10:00 a.m. to infuse as "wide open." There were no orders to monitor the patient's blood sugars from 9:45 a.m. to 4:00 p.m. and/or any additional IV fluid infusions.

The first obstetric ultrasound was performed at approximately 11:15 a.m. and had documented the following impression: "1. Dichorionic twin intrauterine pregnancy of about 12 weeks 3/4 days; 2. normal fetal heart rates both fetuses; 3. Cervical os now appears open with foreshortened cervical segment of 1.6 cm Some debris or clot appears to be present within the cervical segment..." Findings discussed with the ECC (sic) doctor at 11:45 a.m. The nurse documented the patient was bleeding significantly from the vagina and the ECC was informed at 11:40 a.m. The patient was in obvious labor and the ECC physician failed to initiate any immediate response to the ultrasound report, the patient's continued labor pains and profuse bleeding.

At 12:25 p.m. the ECC physician performed a pelvic exam with suction assisted by the patient's assigned registered nurse #1. There was no documentation in the record the patient had signed any informed consent as to the procedure being performed and was apprised of any untoward outcome of this exam. Documentation revealed the patient was passing big clots and spontaneously aborted one of the fetuses during the procedure.

At 2:00 p.m. the patient returned from the second obstetric ultrasound with the following impression: "There is a single remaining intrauterine pregnancy with normal fetal rate of 167 beats per minute. An ovoid fluid examination seen adjacent to this gestational sac made of remnants? of prior twin gestation. No additional intrauterine abnormality is otherwise observed. Represents...Cervix has resumed normal length but there is extensive endocervical debris. The cervical os now appears closed." There was no documentation in the clinical record the ECC physician ordered any interventions to maintain the second twin pregnancy. The clinical record does not contain any physicians orders to attempt to stop labor.

Documentation in the record revealed the blood sugar was first taken manually at 4:00 p.m. by fingerstick with a result of 45 (hypoglycemia - low blood sugar). This result was considered critical and required an intervention of orange juice orally and an immediate dose of Dextrose 50% 12.5 Gram IV (1/2 amp) at 4: 10 p.m. with a subsequent infusion of D5W 0.45 normal saline infusion at 1000 ml/hour. The physician now ordered Blood sugar fingersticks.

At 5:30 p.m. the patient's attending obstetrical physician was in to perform a pelvic exam. with no new orders initiated at that time. At 6:15 p.m., documentation revealed the mother of the patient came out and stated the patient passed the other fetus.

Review of the Emergency Room Report dated 7/3/11 and dictated at 9:14 a.m. contained the following entries: "During the time of the first pelvic exam, there was a large amount of clots, which we wanted to see removed from the cervical area. Some suction was used, and I believe it was during that the patient patient expelled the first fetus after returning back from the ultrasound."

Documentation in the clinical record reports the first fetus was expelled during the pelvic exam with suction prior to the performed ultrasound. Also the Emergency Room report documented that the second ultrasound "Said that the fetus that was left, I guess fetus B, was still with an inactive heartbeat." This documentation was inconsistent with the radiologist's report: "There is a single remaining intrauterine pregnancy with normal fetal rate of 167 beats per minute."

The facility's governing body failed to ensure the ECC physician had provided the quality of care necessary for Patient #5 as follows:
1. Order Blood Chemistry test at onset of admission to ECC to establish baseline blood glucose level.
2. Monitor blood sugar levels as patient was receiving continuous subcutaneous insulin via an infusion pump.
3. Initiate orders in response to increased clotting with abdominal/labor pains.
4. Document that the patient had informed consent to all eventualities/sequale for the Pelvic Exam with Suction. The only documentation was in the Emergency Room Report dated 7/3/11 and dictated at 9:14 a.m. with the following entry: "I did explain to the patient that if the pregnancies were trying to remove themselves that there was really nothing that could be done." There was no documentation that any of the fetuses could be suctioned/removed as a result of this exam.
5. There are no documented interventions to stop labor.

This Condition of Participation is not met based on the facility failure to ensure all patients entering through the emergency room/department are free of neglect.

This systemic failure has the potential to affect the health, safety and well-being of all the patients the hospital serves.

The findings include:

On 8/8/11 and 8/10/11, record reviews and interviews were conducted. The facility failed to ensure all patients were free from neglect for 8 (Patients #1, #2, #3, #4, #5, #7, #8 and #10) of 11 patient 's reviewed. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Please refer to A-0145 and A-0385 for detailed information.

Based on record reviews and interviews, the facility failed to ensure all patients were free from neglect for 8 (Patients #1, #2, #3, #4, #5, #7, #8 and #10) of 11 patient's reviewed. Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

The findings include:


1. The facility's governing body failed to ensure the ECC physician had provided the quality of care necessary for Patient #5 as follows:

Order Blood Chemistry test at onset of admission to ECC to establish baseline blood glucose level;

Monitor blood sugar levels as patient was receiving continuous subcutaneous insulin infusion via pump;


Initiate orders in response to increased clotting with abdominal/labor pains, and

Document that the patient had informed consent to all eventualities/sequale for the Pelvic Exam with Suction. The only documentation was in the Emergency Room Report dated 7/3/11 and dictated at 9:14 a.m. with the following entry: "I did explain to the patient that if the pregnancies were trying to remove themselves that there was really nothing that could be done." There was no documentation that any of the fetuses could be suctioned/removed as a result of this exam.

There are no documented interventions to stop labor.

2. Review of the records on 8/10/11 for these 8 (Patients #1, #2, #3, #4, #5, #7, #8 and #10) patients, who were admitted with vaginal bleeding, revealed nursing failed to document the amount of blood lost at each entry including how many unerpads had been changed/used in the Documents Review Report. At each encounter there was a space for the nurse to enter any narrative notes not included in the electronic system with no documentation of the patients' estimated blood loss and pad count, vital signs, peri care and lacked complete assessment of all the body systems.

3. Patient #5 was admitted to the ECC with pelvic pain and vaginal bleeding. This patient was approximately 13 weeks pregnant, NPO (nothing by mouth), a diabetic and had a continuous subcutaneous infusion device continuously infusing Humalog (rapid-acting) insulin. The Documents Review Report written by Nurse #1 who was assigned to the patient contained the following:
a. There was no documentation the nurse obtained a baseline blood sugar and assessed the need for the insulin pump use versus possible discontinuation.
b. There was no documentation the nurse assessed the patient's genitourinary system. The assessment of the bladder would be crucial in determining where the uterus was in the pelvis during pregnancy.
c. There was no documentation the nurse and/or "multi skilled" tech offered the bedpan to the patient since the patient was not able to ambulate to the bathroom..
d. There was no documentation the nurse obtained the "STAT" (at once) urine specimen ordered at 10:00 a.m. until the specimen was collected at approximately 3:35 p.m. (5 1/2 hour delay)
e. The nurse documented a Foley Cath was put into place at 3:35 p.m. with the nurse failing to document what size Foley and balloon was used, the color and amount of the urine immediately returned and that a urine specimen was sent to laboratory as ordered.
f. The nurse failed to document the patient's actual psychosocial/behavioral assessment with the following: "Behavior appropriate to situation/age; cooperative. The patient lost one fetus at 12:25 p.m. with no psychosocial assessment at that time." There was no documentation of any abnormal findings until 4:15 p.m. with the following entry: "Anxious, crying with sudden outbursts from family." (entered by Nurse #2)
g. At 6:55 p.m. the nurse wrote patient transported to pre-op services. Foley catheter had 1800 output. There was no documentation in the nursing notes demonstrating that the nurse discussed with the patient/family prior to ECC discharge/in-patient admission what would be occurring with the patient/family and their verbalized understanding.

In an interview with the Director and Clinical Manager of the ECC on 8/10/11 at 11:00 a.m., it was reported that the expectation of the ECC as a "Standard of Care" would be to take the blood sugar for a diabetic patient upon admission and assess the patient as needed. They also stated the nurse to patient ratio is 4:1.

In an interview with one of the ECC Triage Nurses (#3) on 8/10/11 at 11:30 a.m., it was reported that often patients were immediately sent back and triaged in the rooms. Bloods sugars were mostly done out front and down-loaded into the interface. Patient #5 did not have one done even though the patient had an insulin pump. There was no explanation for why the blood sugar check had not been performed.

In an interview with the Medical Director of the ECC on 8/10/11 at 11:50 a.m., it was shared that the clinical record had many ultrasound tests cancelled and then reordered an hour later thereby delaying any crucial test results. He reported that the irregularity for ultrasound testing was because the wrong tests were ordered (e.g. Transvaginal versus Obstetric) and the Radiology Department automatically cancelled the wrong test for ECC reorder. He did not offer any explanation as to why the ECC staff were ordering the inappropriate tests and were not updated on the correct tests to be ordered.

In an interview with the nurse (#1) assigned to Patient #5 on 8/10/11 at 12:10 p.m., it was reported the nurse did not change the "Chux" (under pad). It was also reported that a Chemistry 7 blood test had been completed with "139" blood sugar level as a result (Documentation is the clinical record failed to corroborate this test result). "The patient and family were complaining about the blood sugar being low and I was unable to complete the accucheck (fingerstick blood sugar) before the patient went to ultrasound." At 3:30 p.m., I received a heart patient and was unable to get the tech to do the fingerstick until 4:00 p.m. The lack of critical thinking skills demonstrated nurse (#1) failed to get the charge nurse to help with the two critical patients and say "I need help!"

The nurses in the ECC failed to exercise critical thinking skills essential to providing well-organized nursing care and utilize the nursing process of assessment, planning, intervention and evaluation for the provision of quality nursing care and services.

This Condition of Participation is not met based on record reviews and interviews, the facility failed to ensure the nursing process of assessment, planning, intervention and evaluation was completed and/or documented for 8 (Patients #1, #2, #3, #4, #5, #7, #8 and #10) of 11 patient records reviewed from admission through discharge in the Emergency Care Center (ECC).

The Nurse Practice Act, Chapter 464.003 defines the "Professional Practice of Nursing" as the performance of those acts requiring substantial specialized knowledge, judgment and nursing skill based upon applied principles of psychological, biological, physical and social sciences which shall include, but not be limited to: the administration of medication and treatments as prescribed or authorized by a duly licensed practitioner authorized by laws of this state to prescribe such medication and treatment and the "Practice of practical nursing" as the performance of selected acts, including the administration or treatments and medications in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist.

Professional Standard of Care is defined in Chapter 766.102 as,"The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers."

This was evidenced by failure to assess fetal distress, failure to monitor and assess increased diabetic distress, failure to evaluate underlying pathophysiology and co-morbidity, physical assessments not being done, follow the nursing process and poor/inadequate documentation.

Findings: 8 (Patients #1, #2, #3, #4, #5, #7, #8 and #10) of 11 medical records failed to have a systemic collection and review of patient-specific data, including vital signs, eight of eleven medical records (Patients #1, #2, #3, #4, #5, #7, #8 and #10) reviewed failed to document the nurse assessed the estimated amount of blood loss during vaginal bleeding including the counting of under pads; 1 (Nurse #5) of 8 medical records reviewed failed to ensure nursing monitored and assessed blood sugar levels according to hospital policy, failed to ensure nursing evaluated the underlying pathophysiology (Diabetes) and genitourinary system for Patient #5, failed to monitor urine output for 1 (Patient #5) of 8 and failed to ensure the nursing process of assessment, planning, intervention and evaluation was completed and/or documented in the clinical record for all eight patients.


The findings include:

1. Review of the records on 8/10/11 for 8 (Patients #1, #2, #3, #4, #5, #7, #8 and #10) patients, who were admitted with vaginal bleeding, revealed nursing failed to document the amount of blood lost at each entry including how many unerpads had been changed/used in the Documents Review Report. At each encounter there was a space for the nurse to enter any narrative notes not included in the electronic system with no documentation of the patients' estimated blood loss and pad count, vital signs, peri care and lacked complete assessment of all the body systems.

2. Patient #5 was admitted to the ECC with pelvic pain and vaginal bleeding. This patient was approximately 13 weeks pregnant, NPO (nothing by mouth), a diabetic and had a continuous subcutaneous infusion device continuously infusing Humalog (rapid-acting) insulin. The Documents Review Report written by Nurse #1 who was assigned to the patient contained the following:
a. There was no documentation the nurse obtained a baseline blood sugar and assessed the need for the insulin pump use versus possible discontinuation.
b. There was no documentation the nurse assessed the patient's genitourinary system. The assessment of the bladder would be crucial in determining where the uterus was in the pelvis during pregnancy.
c. There was no documentation the nurse and/or "multi skilled" tech offered the bedpan to the patient since the patient was not able to ambulate to the bathroom.
d. There was no documentation the nurse obtained the "STAT" (at once) urine specimen ordered at 10:00 a.m. until the specimen was collected at approximately 3:35 p.m. (5 1/2 hour delay).
e. The nurse documented a Foley Cath was put into place at 3:35 p.m. with the nurse failing to document what size Foley and balloon was used, the color and amount of the urine immediately returned and that a urine specimen was sent to laboratory as ordered.
f. The nurse failed to document the patient's actual psychosocial/behavioral assessment with the following: "Behavior appropriate to situation/age; cooperative." The patient lost one fetus at 12:25 p.m. with no psychosocial assessment at that time. There was no documentation of any abnormal findings until 4:15 p.m. with the following entry: "Anxious, crying with sudden outbursts from family." (entered by Nurse #2)
g. At 6:55 p.m. the nurse wrote Patient transported to pre-op services. Foley catheter had 1800 output. There was no documentation in the nursing notes demonstrating that the nurse discussed with the patient/family prior to ECC discharge/in-patient admission what would be occurring with the patient/family and their verbalized understanding.

In an interview with the Director and Clinical Manager of the ECC on 8/10/11 at 11:00 a.m., it was reported that the expectation of the ECC as a "Standard of Care" would be to take the blood sugar for a diabetic patient upon admission and assess the patient as needed. They also stated the nurse to patient ratio is 4:1.

In an interview with one of the ECC Triage Nurses (#3) on 8/10/11 at 11:30 a.m., it was reported that often patients were immediately sent back and triaged in the rooms. Bloods sugars were mostly done out front and down-loaded into the interface. Patient #5 did not have one done even though the patient had an insulin pump. There was no explanation for why the blood sugar check had not been performed.

In an interview with the Medical Director of the ECC on 8/10/11 at 11:50 a.m., it was shared that the clinical record had many ultrasound tests cancelled and then reordered an hour later thereby delaying any crucial test results. He reported that the irregularity for ultrasound testing was because the wrong tests were ordered (e.g. Transvaginal versus Obstetric) and the Radiology Department automatically cancelled the wrong test for ECC reorder. He did not offer any explanation as to why the ECC staff were ordering the inappropriate tests and were not updated on the correct tests to be ordered.

In an interview with the nurse (#1) assigned to Patient #5 on 8/10/11 at 12:10 p.m., it was reported the nurse did not change the "Chux" (under pad). It was also reported that a Chemistry 7 blood test had been completed with "139" blood sugar level as a result (Documentation is the clinical record failed to corroborate this test result). "The patient and family were complaining about the blood sugar being low and I was unable to complete the accucheck (fingerstick blood sugar) before the patient went to ultrasound." At 3:30 p.m., I received a heart patient and was unable to get the tech to do the fingerstick until 4:00 p.m. The lack of critical thinking skills demonstrated nurse (#1) failed to get the charge nurse to help with the two critical patients and say "I need help!"

The nurses in the ECC failed to exercise critical thinking skills essential to providing well-organized nursing care and utilize the nursing process of assessment, planning, intervention and evaluation for the provision of quality nursing care and services.

Therefore, the cumulative effect of this lack of oversight and systemic issues resulted in the Nursing Service's inability to ensure the facility maintained the provision of quality health care in a safe environment and assured that the patients' rights to quality of care, treatment, and services had not been compromised. This has the potential to affect the health, safety, and well-being of all the patients the hospital serves.

This Condition of Participation is not met based on failure of the facility to ensure the right of all patients seen in the emergency room to be free of neglect. The facility failed to meet the needs of patients in accordance with acceptable standards of practice.

This systemic failure has the potential to affect the health, safety and well-being of all the patients the hospital serves.

The findings include:

1. During record review and interview on 8/8/11 and 8/10/11, the facility failed to ensure the medical staff provided quality of care for 1 (Patient #5) of 11 patients the hospital serves in the Emergency Department.

2. On 8/8/11 and 8/10/11 during record reviews and interviews, it was determined the facility failed to ensure the nursing process of assessment, planning, intervention and evaluation was completed and/or documented for 8 (Patients #1, #2, #3, #4, #5, #7, #8 and #10) of 11 patients records reviewed from admission through discharge in the Emergency Care Center (ECC).

Please refer to A-0049 and A-0385 for detailed information.