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Based on medical/facility record review and staff interviews, it was determined the facility failed to investigate and implement corrective action for two adverse incidents related to 2 of 10 sampled patients (SP #1 and #2). The facility did not include sampled patients #1 and #2 in their Quality Assurance and Performance Improvement program (QAPI). Patient #1 and #2's care and services was identified as adverse incidents by the facility, but they did not include data about the (2) fetal expirations and utilized the information to improve the health outcome for future expectant mothers and fetuses receiving services at the facility.

The findings:

Review of the 2015 Performance Improvement Plan revealed, the Quality Department identifies patients early in their hospital stay and continuously monitors their progress to ensure they are getting the right care. The Performance Improvement Teams are responsible for setting and prioritizing hospital-wide activities when an identified need exists. The methodology of the Performance Improvement Program includes determining the root causes and appropriate measures for problem solving and implementing solution/improvement, data collection and analysis.


1. During record review for sample patient #1, it was revealed, SP #1 came to the Emergency Department (ED) on 01/23/15 at 2:16AM via Emergency Medical Services (EMS) for chest pain, with mild contractions, and she was also 8 months pregnant. SP #1 revealed, she was having contractions 30-45mins apart. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room physician order to have the first fetal non stress test done stat now by a Labor and Delivery (L&D) nurse. Review of the patient's medical record did not show that the fetal non stress test was done, in the ED on 01/23/15, as ordered. The patient was admitted to Intensive Care Unit/Cardiac Care Unit (ICU/CCU) and on 01/23/15 at 7:55AM ordered to have a non-stress test every shift. The non-stress test was done on 01/24/15 on morning and night shift. There was no non stress test done on 01/23/15 night shift and on the 01/25/15 morning shift.

01/25/15 at 3:36PM, a fetal ultrasound with biophysical with/without non-stress test for decreased fetal movement, was ordered.

On 01/25/15, the patient was transferred to telemetry, around 4pm- the patient reported no fetal movement. The Ultrasound on 01/25/15 at 5:10PM showed a biophysical profile was 2/8 on a 35 week pregnancy. There was no fetal heart rate or motion. Fetal demise was concluded.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.

2. During record review for sample patient #2 it was revealed, SP #2 came to the ED on 2/3/15 at 3:10 PM via EMS for hyperglycemia, SP#2 was 33 weeks pregnant and had an internal insulin pump: basal rate 47 units and bolus 41 units a day. SP #2 was sent straight to Antepartum Unit and had initial blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart. Fetal movement was present, and the fetal heart rate was within normal limits. The medical doctor (MD) was notified of the BG, nausea, vomiting and diarrhea. The MD gave orders to continue to monitor. A Stat ultrasound was ordered at 4:49PM and completed at 5:35PM. SP#2 blood glucose (BG) continued to fluctuate between 237 and 308. An Obstetrician/Gynecologist #2(OB/GYN) was in the unit and gave orders for 10 units of insulin and the insulin was given at 5:55PM. The fetal monitoring showed variable decelerations. SP#2 was taken to the operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.


On 06/30/15 at 10:51AM, the Director of Risk Management reported that both SP#1 and SP#2 ' s cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient's medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


On 07/02/15 at 11:49PM, the Director of Medical Staff reported that none of the physicians have attended the Clinical Care Committee, which was recommended by the Peer Review.

During interview on 7/2/15 at 12:31 PM, the Director of Quality reported, she was not aware of the specific incidences with patients #1 and #2. It was reported, fetal death/stillborn are being tracked and trended monthly by the quality department.

Based on medical/facility record review and staff interviews, it was determined the facility failed to investigate and implement corrective action for two adverse incidents related to 2 of 10 sampled patients (SP #1 and #2). The facility did not include sampled patients #1 and #2 in their Quality Assurance and Performance Improvement program (QAPI). Patient #1 and #2's care and services was identified as adverse incidents by the facility, but they did not include data about the (2) fetal expirations and utilized the information to improve the health outcome for future expectant mothers and fetuses receiving services at the facility.

The findings:

Review of the 2015 Performance Improvement Plan revealed, the Quality Department identifies patients early in their hospital stay and continuously monitors their progress to ensure they are getting the right care. The Performance Improvement Teams are responsible for setting and prioritizing hospital-wide activities when an identified need exists. The methodology of the Performance Improvement Program includes determining the root causes and appropriate measures for problem solving and implementing solution/improvement, data collection and analysis.


1. During record review for sample patient #1, it was revealed, SP #1 came to the Emergency Department (ED) on 01/23/15 at 2:16AM via Emergency Medical Services (EMS) for chest pain, with mild contractions, and she was also 8 months pregnant. SP #1 revealed, she was having contractions 30-45mins apart. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room physician order to have the first fetal non stress test done stat now by a Labor and Delivery (L&D) nurse. Review of the patient's medical record did not show that the fetal non stress test was done, in the ED on 01/23/15, as ordered. The patient was admitted to Intensive Care Unit/Cardiac Care Unit (ICU/CCU) and on 01/23/15 at 7:55AM ordered to have a non-stress test every shift. The non-stress test was done on 01/24/15 on morning and night shift. There was no non stress test done on 01/23/15 night shift and on the 01/25/15 morning shift.

01/25/15 at 3:36PM, a fetal ultrasound with biophysical with/without non-stress test for decreased fetal movement, was ordered.

On 01/25/15, the patient was transferred to telemetry, around 4pm- the patient reported no fetal movement. The Ultrasound on 01/25/15 at 5:10PM showed a biophysical profile was 2/8 on a 35 week pregnancy. There was no fetal heart rate or motion. Fetal demise was concluded.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.

2. During record review for sample patient #2 it was revealed, SP #2 came to the ED on 2/3/15 at 3:10 PM via EMS for hyperglycemia, SP#2 was 33 weeks pregnant and had an internal insulin pump: basal rate 47 units and bolus 41 units a day. SP #2 was sent straight to Antepartum Unit and had initial blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart. Fetal movement was present, and the fetal heart rate was within normal limits. The medical doctor (MD) was notified of the BG, nausea, vomiting and diarrhea. The MD gave orders to continue to monitor. A Stat ultrasound was ordered at 4:49PM and completed at 5:35PM. SP#2 blood glucose (BG) continued to fluctuate between 237 and 308. An Obstetrician/Gynecologist #2(OB/GYN) was in the unit and gave orders for 10 units of insulin and the insulin was given at 5:55PM. The fetal monitoring showed variable decelerations. SP#2 was taken to the operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.


On 06/30/15 at 10:51AM, the Director of Risk Management reported that both SP#1 and SP#2 ' s cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient's medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


On 07/02/15 at 11:49PM, the Director of Medical Staff reported that none of the physicians have attended the Clinical Care Committee, which was recommended by the Peer Review.

During interview on 7/2/15 at 12:31 PM, the Director of Quality reported, she was not aware of the specific incidences with patients #1 and #2. It was reported, fetal death/stillborn are being tracked and trended monthly by the quality department.

Based on record reviews and interviews, the medial staff failed to implement timely care and services in one of 10 sampled patients (Patients #2).

The findings:

Review of facility's bylaws revealed, the medical staff has overall responsibility for the quality of services provided by professionals as well as the responsibility of accounting therefore to the governing body. To provide for a mechanism to assure that all professionals at the hospital provide services within the scope of their respective individual clinical privileges granted.

Sample patient #2 came to the emergency department (ED) on 2/3/15 at 3:10PM via emergency medical services (EMS) for hyperglycemia; she was 33 weeks pregnant and had an internal insulin pump. She was sent straight to Antepartum Unit and had initial an blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart, fetal movement was present, and the heart rate was within normal limits. The Obstetrician/Gynecologist (OB/GYN) was notified on 2/3/15 at 3:44PM of BG, nausea, vomiting and diarrhea, and gave orders to admit to Labor and Delivery. The patients blood glucose BG continued to fluctuate between 237 and 308. The OB/GYN was in the unit and orders were given for 10 units of insulin and the insulin was given at 5:55PM. There was no written order in the patient's medical record. Fetal monitoring from 3:40PM until 6:00PM showed variable decelerations. A Stat ultrasound was ordered at 4:49PM and the ultrasound was completed at 5:35PM. Review of the facility's documentation dated 5/15/15 revealed, after the ultrasound the fetal heart rate never returned to baseline, there were persistent late decelerations. At approximately 6:00PM, the labor and delivery (L&D) Charge Nurse contacted the Chief of the OB Group, OB/GYN #1 to discuss the results of the fetal monitoring strips and obtain new orders. At 6:09PM on 2/3/15 OB/GYN #1 ordered the patient to the operating room for a stat C-section. SP #2 was taken to operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.


During interview with OB/GYN #2 on 7/1/15 at 2:06PM, it was reported she was in the L&D unit all day when SP#2 was admitted. She stated that the patient had an insulin pump. Upon admission the patient was in diabetic ketoacidosis (DKA). The patient stated that she called her primary care physician who told her to adjust the pump up. OB/GYN #2 stated that she requested an ICU bed immediately because the labor and delivery nurse did not have the capacity to care for the DKA patient. The OB/GYN stated that the ICU bed was ready however, the patient was not moved right away because of the delay in having an ultrasound done. The OB/GYN #2 reported that she was not aware of this delay and the patient never made it to the ICU because she started having abdominal pain and the fetal monitoring was not reactive. She stated, the decision was made to perform a cesarean section (C-section). She stated that the patient was being monitored in the back and it is not known when the fetus died. When the fetus was removed from SP#2, the baby was not moving and was pronounced dead. OB/GYN #2 stated that due to SP#2's medical history and the fact that the baby was in distress, her aim was to try and save the mother's life.

On 06/30/15 at 10:51AM, the Director of Risk Management stated that both SP#1 and SP#2's cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient's medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


During interview on 07/02/15 at 9:30AM with Staff H, an RN( registered nurse) for SP#2, it was reported she was caring for SP#2 who arrived to L&D unit around 4:00PM (on February 3, 2015). Staff H stated, that SP#2 was put on continuous fetal monitoring and some decelerations were noted. She stated that the OB/GYN was in the unit and saw the patient. Staff H also stated that the patient was vomiting a lot and was given Zofran. She stated that the OB/GYN told SP#2 to inject three more units of insulin. Staff H stated that SP#2's blood sugar was 200 to 300. Around 5:00 PM, when the ultrasound was done, SP#2 was disconnected from the fetal monitor for about half an hour. She stated, when the patient was reconnected to the fetal monitor there were minimal variability and decelerations noted. She stated that the patient went to have the C-section around 6:00PM and when the baby came out, there was no movement. Staff H stated, that decelerations indicate uteral placental insufficiency in which the fetus is not getting enough oxygen. Decelerations also indicate cord compression.


On 07/02/15 at 11:30 AM, Staff J, an L&D Charge Nurse reviewed the fetal monitor strip for SP#2. She stated that upon placement of the fetal monitoring device on February 3, 2015 at 3:50PM, SP#2 had decelerations and late variability which could indicate cord compression. Staff J identified at least six episodes of late deceleration on SP#2 ' s fetal strip. She stated, after SP#2 ' s ultrasound which lasted from 5:00PM to 5:40PM, there were a lot of late decelerations. She stated that upon admission, patients who are not at term and who are having contractions would be given terbutaline to decrease the contractions. She stated that if the contractions persisted, then delivery would be necessary. Staff J stated that since SP#2 was a repeat C-section, she would not be given terbutaline, delivery should have be done immediately.

Review of the Policy Section: Medical Staff with subject: Peer Review Quality of Cares Issues (revised on 10/2012) the Peer review will complete a review referral form. The following peer review criteria should be used as a guide to initiate a review for referral: (a.) peri/post-operative mortalities (death within 30 days of procedure) ;( c.) And unexpected mortalities; (d) post-procedural complications/ injuries. An initial review will be done, if further review is warranted the case will be forwarded to the peer review committee.
The results of the peer review, conclusions and/or recommendations and actions will be recorded in the minutes of the committee or the department reviewing the case.
The committee will based on the findings of the reviewer, shall determine the appropriate disposition of the case and actions to be taken that may include: Care appropriate; potential opportunity for improvement.
All findings of closed cases will be presented to the peer review committee and to the medical executive committee for analysis and appropriate actions. These will then be presented to the governing body and final review and appropriate action.

On 07/02/15 at 11:49AM, the review of Peer Review Committee notes showed that SP#1's incident was reviewed by the committee on May 6, 2015 and SP#2's incident was reviewed by the committee in April 2015. The peer review committee recommended that the physicians involved in both cases attend the Clinical Care Committee.
On 07/02/15 at 11:49AM, the Director of Medical Staff stated that the physicians have not attended the Clinical Care Committee, to date.

Based on record reviews and interviews, the facility failed to implement timely care and services in one of 10 sampled patients. Patients #2.

The findings included:

Review of facility's bylaws revealed, the medical staff has overall responsibility for the quality of services provided by professionals as well as the responsibility of accounting therefore to the governing body. To provide for a mechanism to assure that all Professionals at the Hospital provide services within the scope of their respective individual clinical privileges granted.

During record review, it was revealed sample patient #2 came to the emergency department (ED) on 2/3/15 at 3:10PM via emergency medical services (EMS) for hyperglycemia; she was 33 weeks pregnant and had an internal insulin pump. She was sent straight to Antepartum Unit and had initial an blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart, fetal movement was present, and the heart rate was within normal limits. The Obstetrician/Gynecologist (OB/GYN) was notified on 2/3/15 at 3:44PM of BG, nausea, vomiting and diarrhea, and gave orders to admit to Labor and Delivery. The patients blood glucose BG continued to fluctuate between 237 and 308. The OB/GYN was in the unit and orders were given for 10 units of insulin and the insulin was given at 5:55PM. There was no written order in the patient's medical record. Fetal monitoring from 3:40PM until 6:00PM showed variable decelerations. A Stat ultrasound was ordered at 4:49PM and the ultrasound was completed at 5:35PM. Review of the facility's documentation dated 5/15/15 revealed, after the ultrasound the fetal heart rate never returned to baseline, there were persistent late decelerations. At approximately 6:00PM, the labor and delivery (L&D) Charge Nurse contacted the Chief of the OB Group, OB/GYN #1 to discuss the results of the fetal monitoring strips and obtain new orders. At 6:09PM on 2/3/15 OB/GYN #1 ordered the patient to the operating room for a stat C-section. SP #2 was taken to operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.


During interview with OB/GYN #2 on 7/1/15 at 2:06PM, it was reported she was in the L&D unit all day when SP#2 was admitted. She stated that the patient had an insulin pump. Upon admission the patient was in diabetic ketoacidosis (DKA). The patient stated that she called her primary care physician who told her to adjust the pump up. OB/GYN #2 stated that she requested an ICU immediately because the labor and delivery nurse did not have the capacity to care for the DKA patient. The OB/GYN stated that the ICU bed was ready however, the patient was not moved right away because of the delay in having an ultrasound done. OB/GYN #2 reported that she was not aware of this delay and the patient never made it to the ICU because she started having abdominal pain and the fetal monitoring was not reactive. She stated, the decision was made to perform a cesarean section (C-section). She stated that the patient was being monitored in the back and it is not known when the fetus died. When the fetus was removed from SP#2, the baby was not moving and was pronounced dead. OB/GYN #2 stated that due to SP#2 ' s medical history and the fact that the baby was in distress, her aim was to try and save the mother's life.

On 06/30/15 at 10:51AM, the Director of Risk Management stated that both SP#1 and SP#2's cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient ' s medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


During interview on 07/02/15 at 9:30AM with Staff H, an Registered Nurse for SP#2, it was reported she was caring for SP#2 who arrived to L&D unit around 4:00PM (on February 3, 2015). Staff H stated, that SP#2 was put on continuous fetal monitoring and some decelerations were noted. She stated that the OB/GYN was in the unit and saw the patient. Staff H stated that the patient was vomiting a lot and was given Zofran. She stated that the OB/GYN told SP#2 to inject three more units of insulin. Staff H stated that SP#2 ' s blood sugar was 200 to 300. Around 5:00PM, when the ultrasound was done, SP#2 was disconnected from the fetal monitor for about half an hour. She stated, when the patient was reconnected to the fetal monitor there were minimal variability and decelerations noted. She stated that the patient went to have the C-section around 6:00PM and when the baby came out, there was no movement. Staff H stated, that decelerations indicate uteral placental insufficiency in which the fetus is not getting enough oxygen. Decelerations also indicate cord compression.


On 07/02/15 at 11:30 AM, Staff J, an L&D Charge Nurse reviewed the fetal monitor strip for SP#2. She stated that upon placement of the fetal monitoring device on February 3, 2015 at 3:50PM, SP#2 had decelerations and late variability which could indicate cord compression. Staff J identified at least six episodes of late deceleration on SP#2 ' s fetal strip. She stated, after SP#2 ' s ultrasound which lasted from 5:00PM to 5:40PM, there were a lot of late decelerations. She stated that upon admission, patients who are not at term and who are having contractions would be given terbutaline to decrease the contractions. She stated that if the contractions persisted, then delivery would be necessary. Staff J stated that since SP#2 was a repeat C-section, she would not be given terbutaline, delivery should have be done immediately.

On 07/02/15 at 11:49AM, the review of Peer Review Committee notes showed that SP#1's incident was reviewed by the committee on May 6, 2015 and SP#2's incident was reviewed by the committee in April 2015. The peer review committee recommended that the physicians involved in both cases attend the Clinical Care Committee.
On 07/02/15 at 11:49AM, the Director of Medical Staff stated that the physicians have not attended the Clinical Care Committee, to date.

Based on medical record reviews, facility record review and interviews, it was determined the facility failed to 1) Administer medications per the physician orders for one of ten sampled patients, (SP #1), 2) Failed to document medication administration, per the facility's medication administration policy for one of ten sample patients, (SP #2), 3) Failed to complete non-stress tests, per the physicians order for one of ten sample patients. (SP #1)

The deficient practices lead to a Condition level deficiency.
Refer to A386, A392, A395, and A405.

The findings included:

Review of facility's Medication Administration Policy, dated 10/12 revealed, the patient's electronic Medication Administration Record (MAR) displays all medications ordered by the physician then either profiled or verified by the pharmacist. Once the pharmacist has verified the medication order, the same order must be confirmed by the nurse on the computer medication profile before the medication can be administered to the patient.

1) Review of sample patient (SP) #1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via emergency medical services (EMS). The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. The patient was eight months pregnant and also stated that she was having contractions at 30-45 minutes apart. Physician orders on 01/23/15 at 12:22PM showed an order for Betamethasone 12 milligrams (mg) intramuscular every 12 hours for two doses. Review of the Medication Administration Record (MAR) showed that the patient received betamethasone 12mg on 01/23/15 at 6:50PM. The MAR showed that on 01/23/15 at 10:41PM, betamethasone was documented not given-had to wait for pharmacy to dispense.


2) SP #2 presented to the Emergency Department via emergency medical services (EMS) on 02/03/15 at 2:42PM. The patient was 33 weeks pregnant with complaints of nausea, vomiting, diarrhea, abdominal pain and Hyperglycemia. The nursing note on 02/03/15 at 4:15PM documents the Obstetrician/Gynecologist (OB/GYN) #2 was at the bedside assessing the patient. On 02/03/15 at 4:17 PM, the note documented OB/GYN #2 ordered Zofran 4mg intravenous (IV) push, which was given at this time. There was no orders for Zofran written and the Zofran was not documented on the medication administration record. The nurse's note on 02/03/15 at 5:52PM documented the patient's blood sugar was 286 milligrams per deciliter (mg/dl). The nursing note on 02/03/15 at 5:55PM documented the OB/GYN #2 was notified and ordered regular insulin 10 units stat. The nurses on 02/03/15 at 6:00PM stated that the patient was given 10 units of regular insulin. There was no orders for regular insulin written and the administration of regular insulin was not documented on the medication administration record.

During interview on 06/30/15 at 3:30PM, Staff K reported, medications are given per a doctor's order.


3) Review of SP#1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via rescue. The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room order to have the first fetal non stress test done stat now by a L&D (labor and delivery) nurse. Review of the patient ' s medical record did not show that the fetal non stress test was done, in the ER on 01/23/15, as ordered.
The Admission Orders (entered by OB/GYN #1) on 01/23/15 included orders for a fetal non stress test every 12 hours, and to notify L&D nurses. The nurses note on 01/24/15 at 6:30AM stated, " at 2000 (8:00PM on 01/23/15), I called L&D (labor and delivery), the secretary took the msg (message) to her chg (charge) RN that we have a 31 wk (week) preg (pregnant) mom gravida 2 para 1 (two pregnancies, one live birth) with chest pain or resp (respiratory) problems, please come per protocol and check fetus. At 2400 (12:00AM on 01/24/15), I called, at 0530 (5:30AM on 01/24/15), I called and asked someone would see her before 7AM? And again the secretary took the msg. Sometime after 0100 (1:00AM on 01/24/15), someone called, I was put on hold and then I gave the patients name and room # (number). In addition L&D RNs visiting a friend also said they would relay the message. No fetal strip was done but the ladies did open the door and look in." Review of the medical record did not show the non stress test was completed on 01/23/15 and on 01/25/15.

During interview on 06/30/15 at 3:40PM with Staff D, the RN, stated that pregnant patients with chest pain go to the ER and the labor and delivery nurse goes to the ER to monitor the patients. She stated that if the pregnant patients are admitted to the medical units, the labor and delivery nurse goes to those units and complete a non-stress test (fetal movement monitoring strip) based on the physician orders. She stated a normal fetus heart rate is 110-160BPM (beats per minute). The baseline can be seen after the first two minutes of non-stress test monitoring. She stated that for a non-stress test to be reactive, the baby ' s heart rate should go up 15 beats above the baseline for 15 seconds, twice in a twenty minute strip. A heart rate that is ten beats above baseline for ten seconds, twice in a twenty minute strip is also reactive. She stated that if the non-stress test is not reactive, the physician is called to notify and the physician would most likely order prolonged monitoring. She stated that a biophysical profile that is eight out of eight (8/8) is considered normal.

On 07/01/15 at 10:15AM, Staff A, RN (for SP#1), stated that SP#1 was in the ICU (Intensive Care Unit). She stated that when she went to perform the non-stress test for SP#1, the patient was medicated with Nubain in the morning. However, the ICU nurse did not know what time the patient received the medication. She stated that it was the patient who told her that she was medicated with Nubain. She stated that Nubain causes sedation in fetuses. Staff A stated, that the patient was 36 weeks pregnant, per the patient's menstrual cycle. However, per ultrasound, the patient was 33 weeks pregnant. Staff A stated that a 36 week old fetus should have accelerations in heart rate of 15 BPM above baseline for 15 seconds. A fetus that is 33 weeks old should have acceleration in heart rate of 10 BPM above baseline for 10 seconds. She stated that a reactive non-stress test is six to ten BPM from baseline. She stated that SP#1 fetal heart rate was 120 beats per minutes (normal is 110 to 160 beats per minute) and accelerations were five to ten BPM above baseline with minimal variability (variability is the beat-to-beat changes in fetal heart rate as recorded on a graph). She stated that if the non-stress test was non-reactive, the physician would be called. However, because SP#1 was not having contractions and was already on intravenous (IV) fluids for hydration, the physician was not notified of SP#1 ' s minimal variability. Staff A stated that the non-stress test was not done for SP#1 on the morning of January 25, 2015 because it was busy in the labor and delivery unit. She stated that the labor and delivery unit was short staffed.

Based on record reviews and interviews, the facility failed to ensure that adequate staff was available to complete the fetal non-stress test for one (Patient #1) of ten sampled patients.

The findings included:

Review of SP#1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via rescue. The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room order to have the first fetal non stress test done stat now by a L&D (labor and delivery) nurse. Review of the patient ' s medical record did not show that the fetal non stress test was done, in the ER on 01/23/15, as ordered.
The Admission Orders (entered by OB/GYN #1) on 01/23/15 included orders for a fetal non stress test every 12 hours, and to notify L&D nurses. The nurses note on 01/24/15 at 6:30AM stated, " at 2000 (8:00PM on 01/23/15), I called L&D (labor and delivery), the secretary took the msg (message) to her chg (charge) RN that we have a 31 wk (week) preg (pregnant) mom gravida 2 para 1 (two pregnancies, one live birth) with chest pain or resp (respiratory) problems, please come per protocol and check fetus. At 2400 (12:00AM on 01/24/15), I called, at 0530 (5:30AM on 01/24/15), I called and asked someone would see her before 7AM? And again the secretary took the msg. Sometime after 0100 (1:00AM on 01/24/15), someone called, I was put on hold and then I gave the patients name and room # (number). In addition L&D RNs visiting a friend also said they would relay the message. No fetal strip was done but the ladies did open the door and look in." Review of the medical record did not show the non stress test was completed on 01/23/15 and on 01/25/15.

During interview on 06/30/15 at 3:40PM with Staff D, the RN, stated that pregnant patients with chest pain go to the ER and the labor and delivery nurse goes to the ER to monitor the patients. She stated that if the pregnant patients are admitted to the medical units, the labor and delivery nurse goes to those units and complete a non-stress test (fetal movement monitoring strip) based on the physician orders. She stated a normal fetus heart rate is 110-160BPM (beats per minute). The baseline can be seen after the first two minutes of non-stress test monitoring. She stated that for a non-stress test to be reactive, the baby ' s heart rate should go up 15 beats above the baseline for 15 seconds, twice in a twenty minute strip. A heart rate that is ten beats above baseline for ten seconds, twice in a twenty minute strip is also reactive. She stated that if the non-stress test is not reactive, the physician is called to notify and the physician would most likely order prolonged monitoring. She stated that a biophysical profile that is eight out of eight (8/8) is considered normal.

On 07/01/15 at 10:15AM, Staff A, RN (for SP#1), stated that SP#1 was in the ICU (Intensive Care Unit). She stated that when she went to perform the non-stress test for SP#1, the patient was medicated with Nubain in the morning. However, the ICU nurse did not know what time the patient received the medication. She stated that it was the patient who told her that she was medicated with Nubain. She stated that Nubain causes sedation in fetuses. Staff A stated, that the patient was 36 weeks pregnant, per the patient's menstrual cycle. However, per ultrasound, the patient was 33 weeks pregnant. Staff A stated that a 36 week old fetus should have accelerations in heart rate of 15 BPM above baseline for 15 seconds. A fetus that is 33 weeks old should have acceleration in heart rate of 10 BPM above baseline for 10 seconds. She stated that a reactive non-stress test is six to ten BPM from baseline. She stated that SP#1 fetal heart rate was 120 beats per minutes (normal is 110 to 160 beats per minute) and accelerations were five to ten BPM above baseline with minimal variability (variability is the beat-to-beat changes in fetal heart rate as recorded on a graph). She stated that if the non-stress test was non-reactive, the physician would be called. However, because SP#1 was not having contractions and was already on intravenous (IV) fluids for hydration, the physician was not notified of SP#1 ' s minimal variability. Staff A stated that the non-stress test was not done for SP#1 on the morning of January 25, 2015 because it was busy in the labor and delivery unit. She stated that the labor and delivery unit was short staffed.

Based on record reviews and interviews, the facility failed to complete the non-stress test for patients, per physician order for one (SP #1) of ten patients.

The findings included:

Review of SP#1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via rescue. The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room order to have the first fetal non stress test done stat now by a L&D (labor and delivery) nurse. Review of the patient ' s medical record did not show that the fetal non stress test was done, in the ER on 01/23/15, as ordered.
The Admission Orders (entered by OB/GYN #1) on 01/23/15 included orders for a fetal non stress test every 12 hours, and to notify L&D nurses. The nurses note on 01/24/15 at 6:30AM stated, " at 2000 (8:00PM on 01/23/15), I called L&D (labor and delivery), the secretary took the msg (message) to her chg (charge) RN that we have a 31 wk (week) preg (pregnant) mom gravida 2 para 1 (two pregnancies, one live birth) with chest pain or resp (respiratory) problems, please come per protocol and check fetus. At 2400 (12:00AM on 01/24/15), I called, at 0530 (5:30AM on 01/24/15), I called and asked someone would see her before 7AM? And again the secretary took the msg. Sometime after 0100 (1:00AM on 01/24/15), someone called, I was put on hold and then I gave the patients name and room # (number). In addition L&D RNs visiting a friend also said they would relay the message. No fetal strip was done but the ladies did open the door and look in." Review of the medical record did not show the non stress test was completed on 01/23/15 and on 01/25/15.

During interview on 06/30/15 at 3:40PM with Staff D, the RN, stated that pregnant patients with chest pain go to the ER and the labor and delivery nurse goes to the ER to monitor the patients. She stated that if the pregnant patients are admitted to the medical units, the labor and delivery nurse goes to those units and complete a non-stress test (fetal movement monitoring strip) based on the physician orders. She stated a normal fetus heart rate is 110-160BPM (beats per minute). The baseline can be seen after the first two minutes of non-stress test monitoring. She stated that for a non-stress test to be reactive, the baby ' s heart rate should go up 15 beats above the baseline for 15 seconds, twice in a twenty minute strip. A heart rate that is ten beats above baseline for ten seconds, twice in a twenty minute strip is also reactive. She stated that if the non-stress test is not reactive, the physician is called to notify and the physician would most likely order prolonged monitoring. She stated that a biophysical profile that is eight out of eight (8/8) is considered normal.

On 07/01/15 at 10:15AM, Staff A, RN (for SP#1), stated that SP#1 was in the ICU (Intensive Care Unit). She stated that when she went to perform the non-stress test for SP#1, the patient was medicated with Nubain in the morning. However, the ICU nurse did not know what time the patient received the medication. She stated that it was the patient who told her that she was medicated with Nubain. She stated that Nubain causes sedation in fetuses. Staff A stated, that the patient was 36 weeks pregnant, per the patient's menstrual cycle. However, per ultrasound, the patient was 33 weeks pregnant. Staff A stated that a 36 week old fetus should have accelerations in heart rate of 15 BPM above baseline for 15 seconds. A fetus that is 33 weeks old should have acceleration in heart rate of 10 BPM above baseline for 10 seconds. She stated that a reactive non-stress test is six to ten BPM from baseline. She stated that SP#1 fetal heart rate was 120 beats per minutes (normal is 110 to 160 beats per minute) and accelerations were five to ten BPM above baseline with minimal variability (variability is the beat-to-beat changes in fetal heart rate as recorded on a graph). She stated that if the non-stress test was non-reactive, the physician would be called. However, because SP#1 was not having contractions and was already on intravenous (IV) fluids for hydration, the physician was not notified of SP#1 ' s minimal variability. Staff A stated that the non-stress test was not done for SP#1 on the morning of January 25, 2015 because it was busy in the labor and delivery unit. She stated that the labor and delivery unit was short staffed.

Based on record review and interviews, the facility failed to 1) Administer medications per the physician orders for one of ten sampled patients, (SP #1), 2) Failed to document medication administration, per the facility's medication administration policy for one of ten sample patients, (SP #2).

The findings included:

Review of facility's Medication Administration Policy, dated 10/12 revealed, the patient's electronic Medication Administration Record (MAR) displays all medications ordered by the physician then either profiled or verified by the pharmacist. Once the pharmacist has verified the medication order, the same order must be confirmed by the nurse on the computer medication profile before the medication can be administered to the patient.

1) Review of sample patient (SP) #1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via emergency medical services (EMS). The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. The patient was eight months pregnant and also stated that she was having contractions at 30-45 minutes apart. Physician orders on 01/23/15 at 12:22PM showed an order for Betamethasone 12 milligrams (mg) intramuscular every 12 hours for two doses. Review of the Medication Administration Record (MAR) showed that the patient received betamethasone 12mg on 01/23/15 at 6:50PM. The MAR showed that on 01/23/15 at 10:41PM, betamethasone was documented not given-had to wait for pharmacy to dispense.


2) SP #2 presented to the Emergency Department via emergency medical services (EMS) on 02/03/15 at 2:42PM. The patient was 33 weeks pregnant with complaints of nausea, vomiting, diarrhea, abdominal pain and Hyperglycemia. The nursing note on 02/03/15 at 4:15PM documents the Obstetrician/Gynecologist (OB/GYN) #2 was at the bedside assessing the patient. On 02/03/15 at 4:17 PM, the note documented OB/GYN #2 ordered Zofran 4mg intravenous (IV) push, which was given at this time. There was no orders for Zofran written and the Zofran was not documented on the medication administration record. The nurse's note on 02/03/15 at 5:52PM documented the patient's blood sugar was 286 milligrams per deciliter (mg/dl). The nursing note on 02/03/15 at 5:55PM documented the OB/GYN #2 was notified and ordered regular insulin 10 units stat. The nurses on 02/03/15 at 6:00PM stated that the patient was given 10 units of regular insulin. There was no orders for regular insulin written and the administration of regular insulin was not documented on the medication administration record.

During interview on 06/30/15 at 3:30PM, Staff K reported, medications are given per a doctor's order.

Based on record review and interviews, the facility failed to 1) Administer medications per the physician orders for one of ten sampled patients, (SP #1), 2) Failed to document medication administration, per the facility's medication administration policy for one of ten sample patients, (SP #2).

The findings included:

Review of facility's Medication Administration Policy, dated 10/12 revealed, the patient's electronic Medication Administration Record (MAR) displays all medications ordered by the physician then either profiled or verified by the pharmacist. Once the pharmacist has verified the medication order, the same order must be confirmed by the nurse on the computer medication profile before the medication can be administered to the patient.

1) Review of sample patient (SP) #1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via emergency medical services (EMS). The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. The patient was eight months pregnant and also stated that she was having contractions at 30-45 minutes apart. Physician orders on 01/23/15 at 12:22PM showed an order for Betamethasone 12 milligrams (mg) intramuscular every 12 hours for two doses. Review of the Medication Administration Record (MAR) showed that the patient received betamethasone 12mg on 01/23/15 at 6:50PM. The MAR showed that on 01/23/15 at 10:41PM, betamethasone was documented not given-had to wait for pharmacy to dispense.


2) SP #2 presented to the Emergency Department via emergency medical services (EMS) on 02/03/15 at 2:42PM. The patient was 33 weeks pregnant with complaints of nausea, vomiting, diarrhea, abdominal pain and Hyperglycemia. The nursing note on 02/03/15 at 4:15PM documents the Obstetrician/Gynecologist (OB/GYN) #2 was at the bedside assessing the patient. On 02/03/15 at 4:17 PM, the note documented OB/GYN #2 ordered Zofran 4mg intravenous (IV) push, which was given at this time. There was no orders for Zofran written and the Zofran was not documented on the medication administration record. The nurse's note on 02/03/15 at 5:52PM documented the patient's blood sugar was 286 milligrams per deciliter (mg/dl). The nursing note on 02/03/15 at 5:55PM documented the OB/GYN #2 was notified and ordered regular insulin 10 units stat. The nurses on 02/03/15 at 6:00PM stated that the patient was given 10 units of regular insulin. There was no orders for regular insulin written and the administration of regular insulin was not documented on the medication administration record.

During interview on 06/30/15 at 3:30PM, Staff K reported, medications are given per a doctor's order.

Based on medical/facility record review and staff interviews, it was determined the facility failed to investigate and implement corrective action for two adverse incidents related to 2 of 10 sampled patients (SP #1 and #2). The facility did not include sampled patients #1 and #2 in their Quality Assurance and Performance Improvement program (QAPI). Patient #1 and #2's care and services was identified as adverse incidents by the facility, but they did not include data about the (2) fetal expirations and utilized the information to improve the health outcome for future expectant mothers and fetuses receiving services at the facility.

The findings:

Review of the 2015 Performance Improvement Plan revealed, the Quality Department identifies patients early in their hospital stay and continuously monitors their progress to ensure they are getting the right care. The Performance Improvement Teams are responsible for setting and prioritizing hospital-wide activities when an identified need exists. The methodology of the Performance Improvement Program includes determining the root causes and appropriate measures for problem solving and implementing solution/improvement, data collection and analysis.


1. During record review for sample patient #1, it was revealed, SP #1 came to the Emergency Department (ED) on 01/23/15 at 2:16AM via Emergency Medical Services (EMS) for chest pain, with mild contractions, and she was also 8 months pregnant. SP #1 revealed, she was having contractions 30-45mins apart. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room physician order to have the first fetal non stress test done stat now by a Labor and Delivery (L&D) nurse. Review of the patient's medical record did not show that the fetal non stress test was done, in the ED on 01/23/15, as ordered. The patient was admitted to Intensive Care Unit/Cardiac Care Unit (ICU/CCU) and on 01/23/15 at 7:55AM ordered to have a non-stress test every shift. The non-stress test was done on 01/24/15 on morning and night shift. There was no non stress test done on 01/23/15 night shift and on the 01/25/15 morning shift.

01/25/15 at 3:36PM, a fetal ultrasound with biophysical with/without non-stress test for decreased fetal movement, was ordered.

On 01/25/15, the patient was transferred to telemetry, around 4pm- the patient reported no fetal movement. The Ultrasound on 01/25/15 at 5:10PM showed a biophysical profile was 2/8 on a 35 week pregnancy. There was no fetal heart rate or motion. Fetal demise was concluded.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.

2. During record review for sample patient #2 it was revealed, SP #2 came to the ED on 2/3/15 at 3:10 PM via EMS for hyperglycemia, SP#2 was 33 weeks pregnant and had an internal insulin pump: basal rate 47 units and bolus 41 units a day. SP #2 was sent straight to Antepartum Unit and had initial blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart. Fetal movement was present, and the fetal heart rate was within normal limits. The medical doctor (MD) was notified of the BG, nausea, vomiting and diarrhea. The MD gave orders to continue to monitor. A Stat ultrasound was ordered at 4:49PM and completed at 5:35PM. SP#2 blood glucose (BG) continued to fluctuate between 237 and 308. An Obstetrician/Gynecologist #2(OB/GYN) was in the unit and gave orders for 10 units of insulin and the insulin was given at 5:55PM. The fetal monitoring showed variable decelerations. SP#2 was taken to the operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.


On 06/30/15 at 10:51AM, the Director of Risk Management reported that both SP#1 and SP#2 ' s cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient's medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


On 07/02/15 at 11:49PM, the Director of Medical Staff reported that none of the physicians have attended the Clinical Care Committee, which was recommended by the Peer Review.

During interview on 7/2/15 at 12:31 PM, the Director of Quality reported, she was not aware of the specific incidences with patients #1 and #2. It was reported, fetal death/stillborn are being tracked and trended monthly by the quality department.

Based on medical/facility record review and staff interviews, it was determined the facility failed to investigate and implement corrective action for two adverse incidents related to 2 of 10 sampled patients (SP #1 and #2). The facility did not include sampled patients #1 and #2 in their Quality Assurance and Performance Improvement program (QAPI). Patient #1 and #2's care and services was identified as adverse incidents by the facility, but they did not include data about the (2) fetal expirations and utilized the information to improve the health outcome for future expectant mothers and fetuses receiving services at the facility.

The findings:

Review of the 2015 Performance Improvement Plan revealed, the Quality Department identifies patients early in their hospital stay and continuously monitors their progress to ensure they are getting the right care. The Performance Improvement Teams are responsible for setting and prioritizing hospital-wide activities when an identified need exists. The methodology of the Performance Improvement Program includes determining the root causes and appropriate measures for problem solving and implementing solution/improvement, data collection and analysis.


1. During record review for sample patient #1, it was revealed, SP #1 came to the Emergency Department (ED) on 01/23/15 at 2:16AM via Emergency Medical Services (EMS) for chest pain, with mild contractions, and she was also 8 months pregnant. SP #1 revealed, she was having contractions 30-45mins apart. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room physician order to have the first fetal non stress test done stat now by a Labor and Delivery (L&D) nurse. Review of the patient's medical record did not show that the fetal non stress test was done, in the ED on 01/23/15, as ordered. The patient was admitted to Intensive Care Unit/Cardiac Care Unit (ICU/CCU) and on 01/23/15 at 7:55AM ordered to have a non-stress test every shift. The non-stress test was done on 01/24/15 on morning and night shift. There was no non stress test done on 01/23/15 night shift and on the 01/25/15 morning shift.

01/25/15 at 3:36PM, a fetal ultrasound with biophysical with/without non-stress test for decreased fetal movement, was ordered.

On 01/25/15, the patient was transferred to telemetry, around 4pm- the patient reported no fetal movement. The Ultrasound on 01/25/15 at 5:10PM showed a biophysical profile was 2/8 on a 35 week pregnancy. There was no fetal heart rate or motion. Fetal demise was concluded.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.

2. During record review for sample patient #2 it was revealed, SP #2 came to the ED on 2/3/15 at 3:10 PM via EMS for hyperglycemia, SP#2 was 33 weeks pregnant and had an internal insulin pump: basal rate 47 units and bolus 41 units a day. SP #2 was sent straight to Antepartum Unit and had initial blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart. Fetal movement was present, and the fetal heart rate was within normal limits. The medical doctor (MD) was notified of the BG, nausea, vomiting and diarrhea. The MD gave orders to continue to monitor. A Stat ultrasound was ordered at 4:49PM and completed at 5:35PM. SP#2 blood glucose (BG) continued to fluctuate between 237 and 308. An Obstetrician/Gynecologist #2(OB/GYN) was in the unit and gave orders for 10 units of insulin and the insulin was given at 5:55PM. The fetal monitoring showed variable decelerations. SP#2 was taken to the operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.

The facility's documentation report filed on 05/15/15 documented that no operational or hospital staff issues were identified after investigation and analysis by the Risk Manager. The incident was referred to Medical Staff Peer Review.


On 06/30/15 at 10:51AM, the Director of Risk Management reported that both SP#1 and SP#2 ' s cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient's medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


On 07/02/15 at 11:49PM, the Director of Medical Staff reported that none of the physicians have attended the Clinical Care Committee, which was recommended by the Peer Review.

During interview on 7/2/15 at 12:31 PM, the Director of Quality reported, she was not aware of the specific incidences with patients #1 and #2. It was reported, fetal death/stillborn are being tracked and trended monthly by the quality department.

Based on record reviews and interviews, the medial staff failed to implement timely care and services in one of 10 sampled patients (Patients #2).

The findings:

Review of facility's bylaws revealed, the medical staff has overall responsibility for the quality of services provided by professionals as well as the responsibility of accounting therefore to the governing body. To provide for a mechanism to assure that all professionals at the hospital provide services within the scope of their respective individual clinical privileges granted.

Sample patient #2 came to the emergency department (ED) on 2/3/15 at 3:10PM via emergency medical services (EMS) for hyperglycemia; she was 33 weeks pregnant and had an internal insulin pump. She was sent straight to Antepartum Unit and had initial an blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart, fetal movement was present, and the heart rate was within normal limits. The Obstetrician/Gynecologist (OB/GYN) was notified on 2/3/15 at 3:44PM of BG, nausea, vomiting and diarrhea, and gave orders to admit to Labor and Delivery. The patients blood glucose BG continued to fluctuate between 237 and 308. The OB/GYN was in the unit and orders were given for 10 units of insulin and the insulin was given at 5:55PM. There was no written order in the patient's medical record. Fetal monitoring from 3:40PM until 6:00PM showed variable decelerations. A Stat ultrasound was ordered at 4:49PM and the ultrasound was completed at 5:35PM. Review of the facility's documentation dated 5/15/15 revealed, after the ultrasound the fetal heart rate never returned to baseline, there were persistent late decelerations. At approximately 6:00PM, the labor and delivery (L&D) Charge Nurse contacted the Chief of the OB Group, OB/GYN #1 to discuss the results of the fetal monitoring strips and obtain new orders. At 6:09PM on 2/3/15 OB/GYN #1 ordered the patient to the operating room for a stat C-section. SP #2 was taken to operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.


During interview with OB/GYN #2 on 7/1/15 at 2:06PM, it was reported she was in the L&D unit all day when SP#2 was admitted. She stated that the patient had an insulin pump. Upon admission the patient was in diabetic ketoacidosis (DKA). The patient stated that she called her primary care physician who told her to adjust the pump up. OB/GYN #2 stated that she requested an ICU bed immediately because the labor and delivery nurse did not have the capacity to care for the DKA patient. The OB/GYN stated that the ICU bed was ready however, the patient was not moved right away because of the delay in having an ultrasound done. The OB/GYN #2 reported that she was not aware of this delay and the patient never made it to the ICU because she started having abdominal pain and the fetal monitoring was not reactive. She stated, the decision was made to perform a cesarean section (C-section). She stated that the patient was being monitored in the back and it is not known when the fetus died. When the fetus was removed from SP#2, the baby was not moving and was pronounced dead. OB/GYN #2 stated that due to SP#2's medical history and the fact that the baby was in distress, her aim was to try and save the mother's life.

On 06/30/15 at 10:51AM, the Director of Risk Management stated that both SP#1 and SP#2's cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient's medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


During interview on 07/02/15 at 9:30AM with Staff H, an RN( registered nurse) for SP#2, it was reported she was caring for SP#2 who arrived to L&D unit around 4:00PM (on February 3, 2015). Staff H stated, that SP#2 was put on continuous fetal monitoring and some decelerations were noted. She stated that the OB/GYN was in the unit and saw the patient. Staff H also stated that the patient was vomiting a lot and was given Zofran. She stated that the OB/GYN told SP#2 to inject three more units of insulin. Staff H stated that SP#2's blood sugar was 200 to 300. Around 5:00 PM, when the ultrasound was done, SP#2 was disconnected from the fetal monitor for about half an hour. She stated, when the patient was reconnected to the fetal monitor there were minimal variability and decelerations noted. She stated that the patient went to have the C-section around 6:00PM and when the baby came out, there was no movement. Staff H stated, that decelerations indicate uteral placental insufficiency in which the fetus is not getting enough oxygen. Decelerations also indicate cord compression.


On 07/02/15 at 11:30 AM, Staff J, an L&D Charge Nurse reviewed the fetal monitor strip for SP#2. She stated that upon placement of the fetal monitoring device on February 3, 2015 at 3:50PM, SP#2 had decelerations and late variability which could indicate cord compression. Staff J identified at least six episodes of late deceleration on SP#2 ' s fetal strip. She stated, after SP#2 ' s ultrasound which lasted from 5:00PM to 5:40PM, there were a lot of late decelerations. She stated that upon admission, patients who are not at term and who are having contractions would be given terbutaline to decrease the contractions. She stated that if the contractions persisted, then delivery would be necessary. Staff J stated that since SP#2 was a repeat C-section, she would not be given terbutaline, delivery should have be done immediately.

Review of the Policy Section: Medical Staff with subject: Peer Review Quality of Cares Issues (revised on 10/2012) the Peer review will complete a review referral form. The following peer review criteria should be used as a guide to initiate a review for referral: (a.) peri/post-operative mortalities (death within 30 days of procedure) ;( c.) And unexpected mortalities; (d) post-procedural complications/ injuries. An initial review will be done, if further review is warranted the case will be forwarded to the peer review committee.
The results of the peer review, conclusions and/or recommendations and actions will be recorded in the minutes of the committee or the department reviewing the case.
The committee will based on the findings of the reviewer, shall determine the appropriate disposition of the case and actions to be taken that may include: Care appropriate; potential opportunity for improvement.
All findings of closed cases will be presented to the peer review committee and to the medical executive committee for analysis and appropriate actions. These will then be presented to the governing body and final review and appropriate action.

On 07/02/15 at 11:49AM, the review of Peer Review Committee notes showed that SP#1's incident was reviewed by the committee on May 6, 2015 and SP#2's incident was reviewed by the committee in April 2015. The peer review committee recommended that the physicians involved in both cases attend the Clinical Care Committee.
On 07/02/15 at 11:49AM, the Director of Medical Staff stated that the physicians have not attended the Clinical Care Committee, to date.

Based on record reviews and interviews, the facility failed to implement timely care and services in one of 10 sampled patients. Patients #2.

The findings included:

Review of facility's bylaws revealed, the medical staff has overall responsibility for the quality of services provided by professionals as well as the responsibility of accounting therefore to the governing body. To provide for a mechanism to assure that all Professionals at the Hospital provide services within the scope of their respective individual clinical privileges granted.

During record review, it was revealed sample patient #2 came to the emergency department (ED) on 2/3/15 at 3:10PM via emergency medical services (EMS) for hyperglycemia; she was 33 weeks pregnant and had an internal insulin pump. She was sent straight to Antepartum Unit and had initial an blood glucose (BG) of 268 at 3:24PM. SP #2 was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes apart, fetal movement was present, and the heart rate was within normal limits. The Obstetrician/Gynecologist (OB/GYN) was notified on 2/3/15 at 3:44PM of BG, nausea, vomiting and diarrhea, and gave orders to admit to Labor and Delivery. The patients blood glucose BG continued to fluctuate between 237 and 308. The OB/GYN was in the unit and orders were given for 10 units of insulin and the insulin was given at 5:55PM. There was no written order in the patient's medical record. Fetal monitoring from 3:40PM until 6:00PM showed variable decelerations. A Stat ultrasound was ordered at 4:49PM and the ultrasound was completed at 5:35PM. Review of the facility's documentation dated 5/15/15 revealed, after the ultrasound the fetal heart rate never returned to baseline, there were persistent late decelerations. At approximately 6:00PM, the labor and delivery (L&D) Charge Nurse contacted the Chief of the OB Group, OB/GYN #1 to discuss the results of the fetal monitoring strips and obtain new orders. At 6:09PM on 2/3/15 OB/GYN #1 ordered the patient to the operating room for a stat C-section. SP #2 was taken to operating room (OR) for an emergent cesarean section at 6:10PM. A still born infant was delivered at 6:32PM.


During interview with OB/GYN #2 on 7/1/15 at 2:06PM, it was reported she was in the L&D unit all day when SP#2 was admitted. She stated that the patient had an insulin pump. Upon admission the patient was in diabetic ketoacidosis (DKA). The patient stated that she called her primary care physician who told her to adjust the pump up. OB/GYN #2 stated that she requested an ICU immediately because the labor and delivery nurse did not have the capacity to care for the DKA patient. The OB/GYN stated that the ICU bed was ready however, the patient was not moved right away because of the delay in having an ultrasound done. OB/GYN #2 reported that she was not aware of this delay and the patient never made it to the ICU because she started having abdominal pain and the fetal monitoring was not reactive. She stated, the decision was made to perform a cesarean section (C-section). She stated that the patient was being monitored in the back and it is not known when the fetus died. When the fetus was removed from SP#2, the baby was not moving and was pronounced dead. OB/GYN #2 stated that due to SP#2 ' s medical history and the fact that the baby was in distress, her aim was to try and save the mother's life.

On 06/30/15 at 10:51AM, the Director of Risk Management stated that both SP#1 and SP#2's cases were sent for peer review. She stated that peer review found that the physicians needed improvement. She stated that the two incidences were submitted late because initially, medical staff thought the incidences were related to the patient ' s medical condition. However, when medical staff reviewed the cases, they thought the physicians needed improvement. She stated that the nurses did a good job for both SP#1 and SP#2.


During interview on 07/02/15 at 9:30AM with Staff H, an Registered Nurse for SP#2, it was reported she was caring for SP#2 who arrived to L&D unit around 4:00PM (on February 3, 2015). Staff H stated, that SP#2 was put on continuous fetal monitoring and some decelerations were noted. She stated that the OB/GYN was in the unit and saw the patient. Staff H stated that the patient was vomiting a lot and was given Zofran. She stated that the OB/GYN told SP#2 to inject three more units of insulin. Staff H stated that SP#2 ' s blood sugar was 200 to 300. Around 5:00PM, when the ultrasound was done, SP#2 was disconnected from the fetal monitor for about half an hour. She stated, when the patient was reconnected to the fetal monitor there were minimal variability and decelerations noted. She stated that the patient went to have the C-section around 6:00PM and when the baby came out, there was no movement. Staff H stated, that decelerations indicate uteral placental insufficiency in which the fetus is not getting enough oxygen. Decelerations also indicate cord compression.


On 07/02/15 at 11:30 AM, Staff J, an L&D Charge Nurse reviewed the fetal monitor strip for SP#2. She stated that upon placement of the fetal monitoring device on February 3, 2015 at 3:50PM, SP#2 had decelerations and late variability which could indicate cord compression. Staff J identified at least six episodes of late deceleration on SP#2 ' s fetal strip. She stated, after SP#2 ' s ultrasound which lasted from 5:00PM to 5:40PM, there were a lot of late decelerations. She stated that upon admission, patients who are not at term and who are having contractions would be given terbutaline to decrease the contractions. She stated that if the contractions persisted, then delivery would be necessary. Staff J stated that since SP#2 was a repeat C-section, she would not be given terbutaline, delivery should have be done immediately.

On 07/02/15 at 11:49AM, the review of Peer Review Committee notes showed that SP#1's incident was reviewed by the committee on May 6, 2015 and SP#2's incident was reviewed by the committee in April 2015. The peer review committee recommended that the physicians involved in both cases attend the Clinical Care Committee.
On 07/02/15 at 11:49AM, the Director of Medical Staff stated that the physicians have not attended the Clinical Care Committee, to date.

Based on medical record reviews, facility record review and interviews, it was determined the facility failed to 1) Administer medications per the physician orders for one of ten sampled patients, (SP #1), 2) Failed to document medication administration, per the facility's medication administration policy for one of ten sample patients, (SP #2), 3) Failed to complete non-stress tests, per the physicians order for one of ten sample patients. (SP #1)

The deficient practices lead to a Condition level deficiency.
Refer to A386, A392, A395, and A405.

The findings included:

Review of facility's Medication Administration Policy, dated 10/12 revealed, the patient's electronic Medication Administration Record (MAR) displays all medications ordered by the physician then either profiled or verified by the pharmacist. Once the pharmacist has verified the medication order, the same order must be confirmed by the nurse on the computer medication profile before the medication can be administered to the patient.

1) Review of sample patient (SP) #1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via emergency medical services (EMS). The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. The patient was eight months pregnant and also stated that she was having contractions at 30-45 minutes apart. Physician orders on 01/23/15 at 12:22PM showed an order for Betamethasone 12 milligrams (mg) intramuscular every 12 hours for two doses. Review of the Medication Administration Record (MAR) showed that the patient received betamethasone 12mg on 01/23/15 at 6:50PM. The MAR showed that on 01/23/15 at 10:41PM, betamethasone was documented not given-had to wait for pharmacy to dispense.


2) SP #2 presented to the Emergency Department via emergency medical services (EMS) on 02/03/15 at 2:42PM. The patient was 33 weeks pregnant with complaints of nausea, vomiting, diarrhea, abdominal pain and Hyperglycemia. The nursing note on 02/03/15 at 4:15PM documents the Obstetrician/Gynecologist (OB/GYN) #2 was at the bedside assessing the patient. On 02/03/15 at 4:17 PM, the note documented OB/GYN #2 ordered Zofran 4mg intravenous (IV) push, which was given at this time. There was no orders for Zofran written and the Zofran was not documented on the medication administration record. The nurse's note on 02/03/15 at 5:52PM documented the patient's blood sugar was 286 milligrams per deciliter (mg/dl). The nursing note on 02/03/15 at 5:55PM documented the OB/GYN #2 was notified and ordered regular insulin 10 units stat. The nurses on 02/03/15 at 6:00PM stated that the patient was given 10 units of regular insulin. There was no orders for regular insulin written and the administration of regular insulin was not documented on the medication administration record.

During interview on 06/30/15 at 3:30PM, Staff K reported, medications are given per a doctor's order.


3) Review of SP#1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via rescue. The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room order to have the first fetal non stress test done stat now by a L&D (labor and delivery) nurse. Review of the patient ' s medical record did not show that the fetal non stress test was done, in the ER on 01/23/15, as ordered.
The Admission Orders (entered by OB/GYN #1) on 01/23/15 included orders for a fetal non stress test every 12 hours, and to notify L&D nurses. The nurses note on 01/24/15 at 6:30AM stated, " at 2000 (8:00PM on 01/23/15), I called L&D (labor and delivery), the secretary took the msg (message) to her chg (charge) RN that we have a 31 wk (week) preg (pregnant) mom gravida 2 para 1 (two pregnancies, one live birth) with chest pain or resp (respiratory) problems, please come per protocol and check fetus. At 2400 (12:00AM on 01/24/15), I called, at 0530 (5:30AM on 01/24/15), I called and asked someone would see her before 7AM? And again the secretary took the msg. Sometime after 0100 (1:00AM on 01/24/15), someone called, I was put on hold and then I gave the patients name and room # (number). In addition L&D RNs visiting a friend also said they would relay the message. No fetal strip was done but the ladies did open the door and look in." Review of the medical record did not show the non stress test was completed on 01/23/15 and on 01/25/15.

During interview on 06/30/15 at 3:40PM with Staff D, the RN, stated that pregnant patients with chest pain go to the ER and the labor and delivery nurse goes to the ER to monitor the patients. She stated that if the pregnant patients are admitted to the medical units, the labor and delivery nurse goes to those units and complete a non-stress test (fetal movement monitoring strip) based on the physician orders. She stated a normal fetus heart rate is 110-160BPM (beats per minute). The baseline can be seen after the first two minutes of non-stress test monitoring. She stated that for a non-stress test to be reactive, the baby ' s heart rate should go up 15 beats above the baseline for 15 seconds, twice in a twenty minute strip. A heart rate that is ten beats above baseline for ten seconds, twice in a twenty minute strip is also reactive. She stated that if the non-stress test is not reactive, the physician is called to notify and the physician would most likely order prolonged monitoring. She stated that a biophysical profile that is eight out of eight (8/8) is considered normal.

On 07/01/15 at 10:15AM, Staff A, RN (for SP#1), stated that SP#1 was in the ICU (Intensive Care Unit). She stated that when she went to perform the non-stress test for SP#1, the patient was medicated with Nubain in the morning. However, the ICU nurse did not know what time the patient received the medication. She stated that it was the patient who told her that she was medicated with Nubain. She stated that Nubain causes sedation in fetuses. Staff A stated, that the patient was 36 weeks pregnant, per the patient's menstrual cycle. However, per ultrasound, the patient was 33 weeks pregnant. Staff A stated that a 36 week old fetus should have accelerations in heart rate of 15 BPM above baseline for 15 seconds. A fetus that is 33 weeks old should have acceleration in heart rate of 10 BPM above baseline for 10 seconds. She stated that a reactive non-stress test is six to ten BPM from baseline. She stated that SP#1 fetal heart rate was 120 beats per minutes (normal is 110 to 160 beats per minute) and accelerations were five to ten BPM above baseline with minimal variability (variability is the beat-to-beat changes in fetal heart rate as recorded on a graph). She stated that if the non-stress test was non-reactive, the physician would be called. However, because SP#1 was not having contractions and was already on intravenous (IV) fluids for hydration, the physician was not notified of SP#1 ' s minimal variability. Staff A stated that the non-stress test was not done for SP#1 on the morning of January 25, 2015 because it was busy in the labor and delivery unit. She stated that the labor and delivery unit was short staffed.

Based on record reviews and interviews, the facility failed to ensure that adequate staff was available to complete the fetal non-stress test for one (Patient #1) of ten sampled patients.

The findings included:

Review of SP#1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via rescue. The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room order to have the first fetal non stress test done stat now by a L&D (labor and delivery) nurse. Review of the patient ' s medical record did not show that the fetal non stress test was done, in the ER on 01/23/15, as ordered.
The Admission Orders (entered by OB/GYN #1) on 01/23/15 included orders for a fetal non stress test every 12 hours, and to notify L&D nurses. The nurses note on 01/24/15 at 6:30AM stated, " at 2000 (8:00PM on 01/23/15), I called L&D (labor and delivery), the secretary took the msg (message) to her chg (charge) RN that we have a 31 wk (week) preg (pregnant) mom gravida 2 para 1 (two pregnancies, one live birth) with chest pain or resp (respiratory) problems, please come per protocol and check fetus. At 2400 (12:00AM on 01/24/15), I called, at 0530 (5:30AM on 01/24/15), I called and asked someone would see her before 7AM? And again the secretary took the msg. Sometime after 0100 (1:00AM on 01/24/15), someone called, I was put on hold and then I gave the patients name and room # (number). In addition L&D RNs visiting a friend also said they would relay the message. No fetal strip was done but the ladies did open the door and look in." Review of the medical record did not show the non stress test was completed on 01/23/15 and on 01/25/15.

During interview on 06/30/15 at 3:40PM with Staff D, the RN, stated that pregnant patients with chest pain go to the ER and the labor and delivery nurse goes to the ER to monitor the patients. She stated that if the pregnant patients are admitted to the medical units, the labor and delivery nurse goes to those units and complete a non-stress test (fetal movement monitoring strip) based on the physician orders. She stated a normal fetus heart rate is 110-160BPM (beats per minute). The baseline can be seen after the first two minutes of non-stress test monitoring. She stated that for a non-stress test to be reactive, the baby ' s heart rate should go up 15 beats above the baseline for 15 seconds, twice in a twenty minute strip. A heart rate that is ten beats above baseline for ten seconds, twice in a twenty minute strip is also reactive. She stated that if the non-stress test is not reactive, the physician is called to notify and the physician would most likely order prolonged monitoring. She stated that a biophysical profile that is eight out of eight (8/8) is considered normal.

On 07/01/15 at 10:15AM, Staff A, RN (for SP#1), stated that SP#1 was in the ICU (Intensive Care Unit). She stated that when she went to perform the non-stress test for SP#1, the patient was medicated with Nubain in the morning. However, the ICU nurse did not know what time the patient received the medication. She stated that it was the patient who told her that she was medicated with Nubain. She stated that Nubain causes sedation in fetuses. Staff A stated, that the patient was 36 weeks pregnant, per the patient's menstrual cycle. However, per ultrasound, the patient was 33 weeks pregnant. Staff A stated that a 36 week old fetus should have accelerations in heart rate of 15 BPM above baseline for 15 seconds. A fetus that is 33 weeks old should have acceleration in heart rate of 10 BPM above baseline for 10 seconds. She stated that a reactive non-stress test is six to ten BPM from baseline. She stated that SP#1 fetal heart rate was 120 beats per minutes (normal is 110 to 160 beats per minute) and accelerations were five to ten BPM above baseline with minimal variability (variability is the beat-to-beat changes in fetal heart rate as recorded on a graph). She stated that if the non-stress test was non-reactive, the physician would be called. However, because SP#1 was not having contractions and was already on intravenous (IV) fluids for hydration, the physician was not notified of SP#1 ' s minimal variability. Staff A stated that the non-stress test was not done for SP#1 on the morning of January 25, 2015 because it was busy in the labor and delivery unit. She stated that the labor and delivery unit was short staffed.

Based on record reviews and interviews, the facility failed to complete the non-stress test for patients, per physician order for one (SP #1) of ten patients.

The findings included:

Review of SP#1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via rescue. The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. Review of the Physician Orders on 01/23/15 at 7:55AM showed an Emergency room order to have the first fetal non stress test done stat now by a L&D (labor and delivery) nurse. Review of the patient ' s medical record did not show that the fetal non stress test was done, in the ER on 01/23/15, as ordered.
The Admission Orders (entered by OB/GYN #1) on 01/23/15 included orders for a fetal non stress test every 12 hours, and to notify L&D nurses. The nurses note on 01/24/15 at 6:30AM stated, " at 2000 (8:00PM on 01/23/15), I called L&D (labor and delivery), the secretary took the msg (message) to her chg (charge) RN that we have a 31 wk (week) preg (pregnant) mom gravida 2 para 1 (two pregnancies, one live birth) with chest pain or resp (respiratory) problems, please come per protocol and check fetus. At 2400 (12:00AM on 01/24/15), I called, at 0530 (5:30AM on 01/24/15), I called and asked someone would see her before 7AM? And again the secretary took the msg. Sometime after 0100 (1:00AM on 01/24/15), someone called, I was put on hold and then I gave the patients name and room # (number). In addition L&D RNs visiting a friend also said they would relay the message. No fetal strip was done but the ladies did open the door and look in." Review of the medical record did not show the non stress test was completed on 01/23/15 and on 01/25/15.

During interview on 06/30/15 at 3:40PM with Staff D, the RN, stated that pregnant patients with chest pain go to the ER and the labor and delivery nurse goes to the ER to monitor the patients. She stated that if the pregnant patients are admitted to the medical units, the labor and delivery nurse goes to those units and complete a non-stress test (fetal movement monitoring strip) based on the physician orders. She stated a normal fetus heart rate is 110-160BPM (beats per minute). The baseline can be seen after the first two minutes of non-stress test monitoring. She stated that for a non-stress test to be reactive, the baby ' s heart rate should go up 15 beats above the baseline for 15 seconds, twice in a twenty minute strip. A heart rate that is ten beats above baseline for ten seconds, twice in a twenty minute strip is also reactive. She stated that if the non-stress test is not reactive, the physician is called to notify and the physician would most likely order prolonged monitoring. She stated that a biophysical profile that is eight out of eight (8/8) is considered normal.

On 07/01/15 at 10:15AM, Staff A, RN (for SP#1), stated that SP#1 was in the ICU (Intensive Care Unit). She stated that when she went to perform the non-stress test for SP#1, the patient was medicated with Nubain in the morning. However, the ICU nurse did not know what time the patient received the medication. She stated that it was the patient who told her that she was medicated with Nubain. She stated that Nubain causes sedation in fetuses. Staff A stated, that the patient was 36 weeks pregnant, per the patient's menstrual cycle. However, per ultrasound, the patient was 33 weeks pregnant. Staff A stated that a 36 week old fetus should have accelerations in heart rate of 15 BPM above baseline for 15 seconds. A fetus that is 33 weeks old should have acceleration in heart rate of 10 BPM above baseline for 10 seconds. She stated that a reactive non-stress test is six to ten BPM from baseline. She stated that SP#1 fetal heart rate was 120 beats per minutes (normal is 110 to 160 beats per minute) and accelerations were five to ten BPM above baseline with minimal variability (variability is the beat-to-beat changes in fetal heart rate as recorded on a graph). She stated that if the non-stress test was non-reactive, the physician would be called. However, because SP#1 was not having contractions and was already on intravenous (IV) fluids for hydration, the physician was not notified of SP#1 ' s minimal variability. Staff A stated that the non-stress test was not done for SP#1 on the morning of January 25, 2015 because it was busy in the labor and delivery unit. She stated that the labor and delivery unit was short staffed.

Based on record review and interviews, the facility failed to 1) Administer medications per the physician orders for one of ten sampled patients, (SP #1), 2) Failed to document medication administration, per the facility's medication administration policy for one of ten sample patients, (SP #2).

The findings included:

Review of facility's Medication Administration Policy, dated 10/12 revealed, the patient's electronic Medication Administration Record (MAR) displays all medications ordered by the physician then either profiled or verified by the pharmacist. Once the pharmacist has verified the medication order, the same order must be confirmed by the nurse on the computer medication profile before the medication can be administered to the patient.

1) Review of sample patient (SP) #1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via emergency medical services (EMS). The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. The patient was eight months pregnant and also stated that she was having contractions at 30-45 minutes apart. Physician orders on 01/23/15 at 12:22PM showed an order for Betamethasone 12 milligrams (mg) intramuscular every 12 hours for two doses. Review of the Medication Administration Record (MAR) showed that the patient received betamethasone 12mg on 01/23/15 at 6:50PM. The MAR showed that on 01/23/15 at 10:41PM, betamethasone was documented not given-had to wait for pharmacy to dispense.


2) SP #2 presented to the Emergency Department via emergency medical services (EMS) on 02/03/15 at 2:42PM. The patient was 33 weeks pregnant with complaints of nausea, vomiting, diarrhea, abdominal pain and Hyperglycemia. The nursing note on 02/03/15 at 4:15PM documents the Obstetrician/Gynecologist (OB/GYN) #2 was at the bedside assessing the patient. On 02/03/15 at 4:17 PM, the note documented OB/GYN #2 ordered Zofran 4mg intravenous (IV) push, which was given at this time. There was no orders for Zofran written and the Zofran was not documented on the medication administration record. The nurse's note on 02/03/15 at 5:52PM documented the patient's blood sugar was 286 milligrams per deciliter (mg/dl). The nursing note on 02/03/15 at 5:55PM documented the OB/GYN #2 was notified and ordered regular insulin 10 units stat. The nurses on 02/03/15 at 6:00PM stated that the patient was given 10 units of regular insulin. There was no orders for regular insulin written and the administration of regular insulin was not documented on the medication administration record.

During interview on 06/30/15 at 3:30PM, Staff K reported, medications are given per a doctor's order.

Based on record review and interviews, the facility failed to 1) Administer medications per the physician orders for one of ten sampled patients, (SP #1), 2) Failed to document medication administration, per the facility's medication administration policy for one of ten sample patients, (SP #2).

The findings included:

Review of facility's Medication Administration Policy, dated 10/12 revealed, the patient's electronic Medication Administration Record (MAR) displays all medications ordered by the physician then either profiled or verified by the pharmacist. Once the pharmacist has verified the medication order, the same order must be confirmed by the nurse on the computer medication profile before the medication can be administered to the patient.

1) Review of sample patient (SP) #1 Emergency Room Nurses Notes showed that on 01/23/15 at 2:16AM, the patient presented to the Emergency Room (ER) via emergency medical services (EMS). The presenting complaint was chest pain. The patient ' s medical history included mitral valve prolapse, cardiac ablation and hypertension. The patient was eight months pregnant and also stated that she was having contractions at 30-45 minutes apart. Physician orders on 01/23/15 at 12:22PM showed an order for Betamethasone 12 milligrams (mg) intramuscular every 12 hours for two doses. Review of the Medication Administration Record (MAR) showed that the patient received betamethasone 12mg on 01/23/15 at 6:50PM. The MAR showed that on 01/23/15 at 10:41PM, betamethasone was documented not given-had to wait for pharmacy to dispense.


2) SP #2 presented to the Emergency Department via emergency medical services (EMS) on 02/03/15 at 2:42PM. The patient was 33 weeks pregnant with complaints of nausea, vomiting, diarrhea, abdominal pain and Hyperglycemia. The nursing note on 02/03/15 at 4:15PM documents the Obstetrician/Gynecologist (OB/GYN) #2 was at the bedside assessing the patient. On 02/03/15 at 4:17 PM, the note documented OB/GYN #2 ordered Zofran 4mg intravenous (IV) push, which was given at this time. There was no orders for Zofran written and the Zofran was not documented on the medication administration record. The nurse's note on 02/03/15 at 5:52PM documented the patient's blood sugar was 286 milligrams per deciliter (mg/dl). The nursing note on 02/03/15 at 5:55PM documented the OB/GYN #2 was notified and ordered regular insulin 10 units stat. The nurses on 02/03/15 at 6:00PM stated that the patient was given 10 units of regular insulin. There was no orders for regular insulin written and the administration of regular insulin was not documented on the medication administration record.

During interview on 06/30/15 at 3:30PM, Staff K reported, medications are given per a doctor's order.