HospitalInspections.org

Based on medical record review, document review and interview, in three (3) of seven (7) medical records reviewed, medical screening examinations to rule out labor were performed by nursing staff who were not approved as Qualified Medical Personnel (QMP). (Patients #s 2, 3, and 4).

This finding may have placed the mothers and their unborn babies at risk for harm.

Findings include:

During an interview conducted on 8/29/19 at 11:40 AM, Staff E, the Director of Maternity Services stated that the Labor and Delivery nurses assess patients to rule out labor and delivery.

Review of the medical records identified these nurses were conducting evaluations and assessments of pregnant patients who are in possible labor.

Medical record for Patient #2 identified the following: This pregnant patient presented to the facility on 8/3/19 at 8:59 PM with a complaint of decreased fetal (unborn offspring) movement. The gestational age (age of the pregnancy) was 33 weeks and 3 days. The nursing staff monitored the patient for uterine (relating to the womb) contractions and the fetal heart rate. A physician gave a telephone order to discharge the patient on 8/04/19. The patient was discharged from the facility on 8/4/19 at 12:55 AM.

Medical record for Patient #3 identified the following: This 33 year old patient presented to the facility on 8/4/19 at 11:50 PM for a labor assessment. The gestational age was 37.4 weeks. The nursing staff performed a vaginal examination, monitored and assessed the fetal heart rate and assessed the patient's contractions and vital signs. The patient was discharged on 8/05/19 at 2:30 AM with a diagnosis of false labor.

Medical record for Patient #4 identified the following: This 26 year old patient presented to the Labor and Delivery Unit on 8/05/19 at 4:15 PM for a labor assessment because she had contractions. The nursing staff monitored the fetal heart rate and assessed uterine contraction. The patient was given intravenous fluid and was discharged from the facility on 8/05/19 at 8:15 PM.

Review of the facility's policy and procedures and medical staff bylaws determined that Labor and Delivery Nurses were not authorized or designated as Qualified Medical Personnel to perform medical screening examinations on pregnant patients.

During an interview conducted on 8/29/19 at 11:40 AM, Staff E, the Director of Maternity Services acknowledged the findings. She stated the Labor and Delivery nurses perform the role of Qualified Medical Personnel (QMP) and confirmed that the medical staff did not approve this privilege and this privilege is not documented in the medical staff bylaws.