HospitalInspections.org

Based on interviews and document review the facility staff failed to ensure that a patient who arrived at the Antepartum desk was immediately assessed.

The findings include:

The triage nurse was notified twice by the administrative assistance, an untrained medical staff member, that a patient who was recently discharged was at the desk complaining of a headache and dizziness. The triage nurse did not come to the desk and assess the patient. The charge nurse did come to the desk, assessed the patient as needing care and left the patient in the care of the husband and the administrative assistant to determine if a bed was available to place the patient in.

Patient #7 arrived to L&D/Antepartum on 7/16/13 at approximately 17:55 with her husband complaining of a headache, high blood pressure and dizziness. The complainant alleges Patient #7's doctors' office instructed Patient #7 to go to L&D. Staff Members #5, 6, 7, 9 and 11 were interviewed on various days at various times and each stated the physician's office never called the L&D/Antepartum to alert the staff that Patient #7 was being sent to the hospital.
Staff Member #6 was interviewed on 8/6/13 and stated, "I did not register her (Patient #7) but I was there. The patient showed up at the desk and her husband told us their doctor's office told them to come here. (Name of another staff member) called the Triage nurse (Staff Member #5) who told (Name of another staff member) to tell them to go to the emergency room. The husband said he was told to bring his wife here. (Name of another staff member) again called the Triage nurse and informed the nurse the husband was told to bring his wife here (L&D/Antepartum). The Triage nurse said she would call back. The Charge nurse (Staff Member #7) then came out tried to speak with the husband and told (Name of another staff member) to register the patient while she found a room to put the patient in. During the time between talking to the Triage Nurse and the Charge Nurse the husband took breast milk over to the special care nursery. The patient looked fine at first but within 10 to 15 minutes she started looking upset and stressed."
Staff Member #7 was interviewed on 8/7/13 at 7:30 A.M. Staff Member #7 stated, "I usually work 7p to 7a on this day (7/16/13) I was working 7a to 7p. The patient (Patient #7) came to the front desk and the AA (administrative assistant) called the Triage nurse. I think they called her twice, I don't really know how many times. The front desk called me and I went out front. The patient (Patient #7) was sitting in a wheelchair and her husband was not there. He came back and grabbed the wheelchair and said he was taking his wife to the emergency room. I tried to stop him. I told him I was trying to find a room for his wife. He was yelling at me. I think he thought I was the nurse the front desk had called twice before. She (Patient #7) didn't look right and needed to be in a room. It was a busy day and we were rapidly turning rooms over so I went to see if the room was ready. The AA and husband wheeled her back to room #9. As soon as they got her (Patient #7) in the room she had a seizure. She was still in the wheelchair. I don't think I would have done anything different."
Staff Member #11 was interviewed on 8/7/13 at approximately 8:15 A.M. Staff Member #11 stated, "The patient (Patient #7) and her husband came to the front desk and said their doctor told them to come here because her (the patient's (Patient #7)) blood pressure was high and she (the patient (Patient #7)) was not feeling well. I called the triage nurse and she said they need to go to the emergency room. The husband said the triage nurse from the doctor's office told us to come here. I called the triage nurse again and she said let me talk to the resident. I was on hold and could hear their (the triage nurse and the resident)conversation. I heard the resident say to send them to the ER and he would go there and assess her (the patient (Patient #7)). The triage nurse said to me, "Did you hear that?" I said yes then the (Name of triage nurse) said you can call (Name of charge nurse) if you want. I called (Name of charge nurse) and she agreed with the triage nurse and the resident initially then said, "Wait I will call you back." After about 10 to 15 minutes (Name of charge nurse) came out to see the patient (Patient #7). She (Patient #7) didn't look well. (Name of charge nurse) told me to register her (Patient #7) and bring her back to room #9. The patient's husband and I escorted her back to room #9. As soon as we got her in the room I stepped out and yelled for (Name of charge nurse) and said, "Ya'll need to get in here." They (charge nurse, triage nurse and another tech) were there within seconds."
Staff Member #9 was interviewed on 8/7/13 at approximately 8:30 A.M. Staff Member #9 stated, "I did not check the patient in. I was sitting in the back room working. I overheard some of what was happening because the door was open. The husband got loud and was demanding his wife be seen. I did not interact with them. (Names of staff members #6 and 11) were at the front desk and were handling the situation."
The physician's progress notes dated 7/16/13 at 2225 state, "She was counseled on the risk of developing a seizure in the postpartum period."
Staff Member #2 was interviewed regarding the protocol of treating a patient who has recently delivered a baby but who is continuing to have symptoms of eclampsia. Staff Member #2 stated, "Our protocol is and has been for the patient to come to the Emergency Department to be assessed. If warranted a member of our staff (resident and or nurse) will go to the Emergency Department and assist with the patient's care. If a patient comes to our area our protocol is to triage the patient within 15 minutes and 30 minutes to decide where is the best place to treat the patient." Staff Member #2 provided a Triage of the Obstetric Patient chart.

Based on document review and interviews the facility staff failed to ensure the information from the physician's discharge summary was included on the patient's printed discharge instructions.
The findings include:
Patient #7's medical record was reviewed on 8/7-8/13 and revealed the following information.
The physician's discharge summary dated 7/20/13 at 6:11 P.M. stated, "After extensive discussion with the patient and her husband regarding admission, hospital course, and medical care, patient was discharged home on PPD7 with follow-up in 1 week for BP check. Counseling and strict precautions were given to patient. She was instructed to use her home BP check 3 times daily and if her BP's are trending upward or are > 160/100, she should return to the hospital for magnesium prophylaxis immediately." This information was not printed on the Postpartum Discharge Instructions dated 7/20/13. the printed discharge instructions state Patient #7 has a blood pressure check scheduled on 7/23/13. The printed instructions also state, "Please come to the Emergency Room at (Initials of facility) if you experience ANY prodromal symptoms of seizures."
Staff Member #2 stated, "I do not know why the physician's information from the discharge summary did not pull over to the printed discharge instructions."