HospitalInspections.org

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Based on interview and record review, the hospital failed to ensure that obstetric emergency care was managed and provided in accordance with professional practice recommendations or requirements.

Failure to manage and deliver obstetric emergency care in line with professional standards can lead to unsafe, incompetent, and low-quality obstetric emergency care.

Findings included:

1. Failure to integrate the obstetric emergency department (OB ED) with other services in the Family Birth Center.

Cross-reference A1103

2. Failure to ensure adequate numbers of qualified personnel are available to meet obstetric patient needs.

Cross-reference A1112
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Based on observation, interview, and record review, the hospital failed to integrate the obstetric emergency department (OB ED) with other services in the Family Birth Center by demonstrating the immediate availability of services, equipment, and personnel in 5 of 10 medical records reviewed (Patients #1401, #1406, #1408, #1414, & #1419).

Failure to integrate obstetric emergency services within the Family Birth Center can adversely affect the health and safety of patients who require obstetric emergency care.

Reference: Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). "Maternal Fetal Triage Index (MFTI)- Frequently Asked Questions for Nurses" (2020)- "The MFTI is a nurse's initial assessment performed to determine a pregnant woman's presenting acuity. This initial assessment doesn't include elements of a complete evaluation that are part of a medical screening examination (MSE). The purpose of the MSE is to determine if a patient has an emergency medical condition." "The MFTI is recommended to be used for the rapid, initial assessment of women presenting for care; therefore, the fetal heart rate parameters are based on auscultated findings. AWHONN suggests ten minutes as the time from the woman's arrival until the nurse has completed her assessment and assigned acuity."

Findings included:

1. Document review of the hospital's policy titled, "Obstetric Triage (MFTI)," policy number 5709077, last revised 02/2020, showed the following:

a. Obstetrical triage patients are to be screened immediately upon arrival to the OB ED.

b. The screening is to be completed by a triage nurse using the Maternal Fetal Triage Index (MFTI) to prioritize patient triage and allocation of resources.

c. Each OB ED triage patient is assigned a MFTI priority. Priority 1 requires an immediate room and emergency intervention, priority 2 requires an immediate room and evaluation, priority 3 requires a triage bed, priority 4 patients may wait in the waiting room while regularly reassessed by the registered nurse (RN).

2. Document review of the hospital's policy titled, "EMTALA- Examination, Treatment and transfer of Individuals in Need of Emergency Services," policy number 10992241, last approved 01/2022, showed the following that if the hospital cannot immediately complete an appropriate Medical Screening Examination (MSE), it still must assess the individual's condition upon arrival to ensure that the individual is appropriately prioritized for an MSE.

3. During review of a sample of medical records dated 03/30/22 to 04/30/22, Investigator #14 noted the following:

PATIENT #1401

Medical record review showed that on 03/30/22 at 9:45 AM, Patient #1401 arrived at the obstetric emergency department. Patient #1401 waited for an hour and 1 minute for a RN to evaluate and prioritize her MSE. Patient #1401 was a 23-year-old female who presented with a headache and abdominal tightness at 35 weeks and 4 days gestation. The patient's pregnancy was further complicated by uncontrolled type I diabetes mellitus (DMI), new onset hypertension (high blood pressure), and polyhydramnios (excessive amniotic fluid around the fetus). Patient #1401 fetal heart tones were briefly assessed at 128 beats per minute. The patient was classified as a MFTI 2 which required an immediate room equipped with fetal monitoring equipment. At 11:05 AM, the provider was notified of Patient #1401 waiting for triage and MSE, an hour and 20 minutes after arrival to the hospital. The triage RN (Staff #1402) documented that the patient was still waiting for triage and fetal monitoring at the time of provider notification.

At 1:15pm, 3 ½ hours after Patient #1401 arrived at the hospital, another triage nurse (Staff #1401) was assigned to triage and brought Patient #1401 to a triage room for a comprehensive triage assessment and fetal monitoring. When the patient was placed on the monitor, the nurse could no longer elicit fetal heart tones. The obstetrician was called to the bedside and an ultrasound revealed an agonal fetal heart rate of 40 beats per minute. An emergency cesarean section was done, and neonatal resuscitation performed. The resuscitative efforts were unsuccessful, and the near-term neonate died.

On 04/27/22 at 1:11 PM, Investigator #14 interviewed the triage RN (Staff #1402) about the triage process for Patient #1401. Staff #1402 stated that while the MFTI score indicated a higher acuity, the patient didn't appear to be in acute distress. Staff #1402 also explained that she didn't have a fetal monitor in the MFTI overflow area, and the triage beds were in use for other patients.

On 04/28/22 at 11:30 AM, Investigator #14 interviewed the charge nurse (Staff #1408) regarding the triage process for Patient #1401. Staff #1408 stated that she was not notified or aware that Patient #1401 was a MFTI 2 acuity and waiting in the overflow area without fetal monitoring. Staff #1408 also stated that the patients in the overflow area have to wait to get to triage to have access to staff and fetal monitoring and that the MFTI process was a work in progress and not well understood by triage staff yet.

On 04/27/22 at 10:15 AM, Investigator #14 observed the MFTI overflow waiting area. No continuous fetal monitoring equipment was observed to be located in the overflow waiting area.

On 04/27/22 at 10:15 AM, Investigator #14 interviewed the assistant manager (Staff #1404) regarding the assignment of the current MFTI nurse. Staff #1404 stated that the assigned MFTI nurse was currently in the operating room with a patient and that they would have to find another staff member if they needed to do a MFTI screening.

PATIENT #1414

Medical record review showed that on 04/08/22 at 12:28 AM, Patient #1414 arrived at the obstetric emergency department. Patient #1414 waited 1 hour and 52 minutes for a triage RN to evaluate and prioritize the patient's comprehensive triage and MSE. Patient #1414 was a 24-year-old female who presented with ruptured membranes without labor in a term pregnancy. Patient #1414 received a comprehensive triage assessment with fetal monitoring at 3:24 AM and an MSE at 4:06 AM.

The patient was subsequently admitted with the documented plan of inducing labor when a labor room became available. The provider ordered medications for inducing labor at 6:27 AM. The patient was transferred from triage to a labor room at 3:48 PM, over 12 hours after arriving to the hospital. The patient's medication for induction was given at 4:19 PM.

The patient experienced prolonged ruptured membranes without labor and was diagnosed with chorioamnionitis (infection surrounding baby in utero). The infant also required an admission to the neonatal intensive care unit for antibiotic treatment and monitoring for rule-out sepsis, respiratory distress, and temperature deregulation secondary to maternal chorioamnionitis diagnosis. Patient #1414 is not documented as refusing or delaying induction of labor. The medical record also showed that Patient #1414 expressed frustration to staff regarding the delay in her care in relation to her diagnosis of an infection.

On 05/02/22 at 2:00 PM, Investigator #14 interviewed a triage nurse (Staff #1412). Staff #1412 stated that Patient #1414 waited for an extended period of time without reassessment, monitoring or medical intervention due to the labor and triage beds being full. Staff #1412 also stated that she was unsure if the charge nurse was aware at the time.

PATIENT #1419

Medical record review showed that on 03/30/22 at 11:08 AM, Patient #1419 arrived at the obstetric emergency department with complaints of leaking amniotic fluid. The patient's MFTI score was not completed until 11:46 AM with a comprehensive triage and MSE beginning at 1:15 PM.

On 04/27/22 at 11:27 AM, the assistant manager (Staff #1404) confirmed the time lapses listed in the medical record for Patient #1419.

PATIENT #1406

Medical record review showed that on 04/08/22 at 11:06 AM, Patient #1406 arrived at the obstetric emergency department. Patient #1406 received a MFTI score of 2 at 12:08 PM, 1 hour and 2 minutes after arrival at the hospital, and a comprehensive triage occurred at 12:30 PM.

On 05/02/22 at 2:00 PM, Investigator #14 interviewed a triage nurse (Staff #1412) regarding patient care on 04/08/22. Staff #1412 stated that Patient #1406 had a triage and MSE outside of acceptable standards or hospital policy.

PATIENT #1408

Medical record review showed that on 04/11/22 at 12:37 PM, Patient #1408 arrived at the obstetric emergency room. Patient #1408 had a MFTI score completed at 12:42 PM. The patient's triage occurred at 2:30 PM, 1 hour and 48 minutes after initial MFTI score. No reassessment is documented during that time.

On 05/02/22 at 1:44 PM, Investigator #14 interviewed a triage nurse (Staff #1416) regarding patient care on 04/11/22. Staff #1416 stated that Patient #1408 waited a concerning amount of time to receive an initial MFTI score and triage due to lack of fetal monitors and staff.
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Based on interview and document review, the hospital failed to ensure obstetric triage personnel were trained and competent in the implementation of a new emergency triage process and in the related procedure for addressing patient needs beyond Family Birth Center capacity.

Failure to provide obstetric nursing personnel with adequate triage training puts patients at risk for harm from experiencing a delayed or inadequate emergency response.
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Findings included:

1. Document review of the hospital's policy titled, "Obstetric Triage (MFTI)," policy number 5709077, last revised 02/2020, showed the following:

a. Obstetrical triage patients are to be screened immediately upon arrival to the OB ED.

b. The screening is to be completed by a triage nurse using the Maternal Fetal Triage Index (MFTI) to prioritize patient triage and allocation of resources.

c. Each OB ED triage patient is assigned a MFTI priority. Priority 1 requires an immediate room and emergency intervention, priority 2 requires an immediate room and evaluation, priority 3 requires a triage bed, priority 4 patients may wait in the waiting room while regularly reassessed by the registered nurse (RN).

2. Document review of the hospital's policy titled, "EMTALA- Examination, Treatment and transfer of Individuals in Need of Emergency Services," policy number 10992241, last approved 01/2022, showed the following that if the hospital cannot immediately complete an appropriate Medical Screening Examination (MSE), it still must assess the individual's condition upon arrival to ensure that the individual is appropriately prioritized for an MSE.

3. Document review of the hospital's meeting minutes titled, "Family Birth Center Winter Staff Meetings," dated 02/2020, showed that the MFTI process was implemented and staff educated in February 2020.

4. On 04/26/22 at 7:30 PM, Investigator #14 interviewed a triage nurse (Staff #1401) regarding the triage and MFTI overflow process. Staff #1401 reported that there's not always a MFTI overflow nurse available and that patient's will often wait over an hour for a MFTI score to prioritize their triage and MSE. Staff #1401 also stated that an additional delay between a MFTI score and comprehensive triage is common as the purpose of the MFTI is not well understood by the triage staff. Staff #1401 was unsure if there was a guideline for reassessment of the MFTI or if there were fetal monitors that could be used in the MFTI overflow area. Staff #1401 stated that it was hard to communicate to the charge nurse regarding needs of patients in the MFTI overflow area because they only open that area when they don't have beds or staff.

5. On 04/27/22 at 1:11 PM, Investigator #14 interviewed the triage RN (Staff #1402) about the triage process. Staff #1402 stated that she was not aware that the hospital policy stated that a patient with a MFTI score of 1, 2, or 3 are to be triaged immediately while a MFTI 4 or 5 can remain in the waiting area with regular intervals of reassessment.

6. On 04/28/22 at 11:30 AM, Investigator #14 interviewed the charge nurse (Staff #1408) regarding the triage process. Staff #1408 also stated that the MFTI process isn't fully implemented yet and there's not a process for reassessment of MFTI because the patient should be having a comprehensive triage within 30 minutes of arrival. Staff #1408 also stated that the lack of beds, staff, and equipment has worsened in the past year and they aren't able to triage per policy at least several times each week.

7. On 04/27/22 at 11:30 AM, the assistant manager (Staff #1404) confirmed that 02/2020 was the last documented staff education on the MFTI process. Investigator #14 asked Staff #1404 how new staff are trained on the MFTI process. Staff #1404 stated that new staff training has not been updated to include the MFTI process.

8. On 05/02/22 at 1:44 PM, Investigator #14 interviewed a triage nurse (Staff #1416) regarding MFTI assessments and triage. Staff #1416 stated that she hadn't had training recently and she was unsure what the parameters were for MFTI timing and patient reassessment.

9. On 05/02/22 at 2:00 PM, Investigator #14 interviewed a triage nurse (Staff #1412). Staff #1412 stated that she was unsure how quickly a patient needed a MFTI score or reassessment and that it had been a long time since they had used MFTI scores or had training.

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