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Based on record reviews and interviews, the facility failed to develop performance improvement indicators as a result of the incidents involving 2 of 3 sampled patients #13 and #14.

Findings:
Sample patient #13 came to the Emergency Department (ED) on 01/23/15 at 2:16 AM via Emergency Medical Services (EMS) for chest pain; she was also 8 months pregnant. The Physician Orders on 01/23/15 at 7:55 AM showed an Emergency room order to have first fetal non stress test done stat (now) by 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 ICU/CCU and on 01/23/15 at 7:55 AM and had an ordered non stress test for every shift. There was none completed on 01/23/2015 on the night shift and on 01/25/15 morning shift. On 01/25/15, the patient was transferred to telemetry, around 4pm- the patient reported no fetal movement. The Ultrasound U/S showed a fetal demise.
Sample patient #14 came to the ED on 2/3/15 at 3:10 PM via EMS for hyperglycemia; she was 33 weeks pregnant and had an internal insulin pump. She was sent straight to Antepartum and had an initial blood glucose (BG) of 268 at 3:24 PM. Pt was placed on continuous fetal monitoring at 3:40PM which showed moderate variability, late decelerations with contractions 1-2 minutes, fetal movement present, and heart rate within normal limits. MD (Medical Doctor) notified of BG, nausea, vomiting and diarrhea, gave orders to continue to monitor. Pt blood glucose BG continued to fluctuate between 237 and 308. Obstetric Gynecologist (OB/GYN) was on the unit and orders for 10 units of insulin were given at 5:55 PM. The fetal monitoring showed variable decelerations. A Stat ultrasound was ordered at 4:49 PM and completed at 5:35 PM. The Pt was taken to operating room (OR) for emergent cesarean section at 6:10 PM. A Still born infant delivered at 6:32 PM.
An analysis of the events was conducted as a result of the 2 sampled patients ' incidents. Review of the summary report showed that there are opportunities for improvement : assuring all physician orders are carried out, assure L&D R.N's (registered nurses) are competent in intermediate fetal monitoring, and assure pregnant patient receive NST (non-stress test) as appropriate.

As a result of the above sample patient ' s # 12, and #13 incidents, opportunities for improvement was identified and a plan of correction was submitted. The plan stated the Director of Clinical Quality Improvement further refined the Quality Assessment Performance Improvement program to specifically address how individual adverse events are addressed. When an adverse event occurs an intense analysis is conducted; corrective action is implemented and performance indicators are used to monitor the effectiveness of the corrective actions and sustainability of the actions implemented.
The plan further state, the Director of Clinical Quality Improvement/ Designee will attend 100% of all root cause/intense analysis to determine opportunities for improvement starting July 10, 2015. Once opportunities are identified, the Director of Clinical Quality Improvement along with the appropriate Department Director will develop performance improvement indicators. The department director will be responsible for collecting, maintaining, aggregating, analyzing and reporting of the data to the performance improvement council on a quarterly basis. The Director of Women Services and designees will monitor all fetal demises for tracking and trending purposes.
Review of the June 18th 2015 Performance Improvement Council minutes dated May 28, 2015 did not show any indicators being used to monitor the effectiveness of the corrective actions stated in the summary report.
On 07/27/2015 at 3:30 pm the Director of Clinical Quality Improvement stated that we do not currently have any performance indicators for fetal monitoring, non-stress tests, or for fetal demise. Moving forward we will do random audits of records of patients off the unit. We are not capturing those for fetal demise, fetal monitoring and non-stress test. It will be added to the August, 17, 2015 Performance Improvement Council agenda.
A copy of the agenda for the Performance Improvement Council meeting to be held on August 17, 2015 showed the Risk Management and the L/D (Labor/Delivery) report was added.
On 07/27/2015 at 5:30 pm the Compliance Officer confirmed the performance Risk Management and the L/D (Labor/Delivery) report was added to the August 17, 2015 agenda for the Performance Improvement Council meeting.




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