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Based on record review, staff interview, physician interviews, facility policy reviews and internal investigation reports, the facility failed to ensure 1 of 6 sampled patients (Patient 3) received an adequate nursing assessment after a change in condition prior to discharge. Two (2) staff Registered Nurses failed to complete a nursing assessment of an adolescent patient (post-vaginal delivery 11/19/09) who exhibited symptoms of rapid pulse, chilling/shaking, diarrhea, nausea and fever of 103 degrees Fahrenheit orally on 11/21/09. The physician was contacted by the nurse regarding the increased temperature, but without doing a complete set of vital signs (i.e., temperature, pulse, respirations and blood pressure) and nursing assessment could not adequately report the patient's health status. An assumption was made without further assessment or testing that the patient had the flu and the patient was discharged. Interview with the patient's obstetrician, Medical Doctor (MD)-A, on 1/14/10 at 12:50 PM, revealed the patient was seen in physician's office two days post-discharge in critical condition. MD-A related the patient was immediately hospitalized in another local hospital and an emergent hysterectomy was performed on 11/25/09 as the uterus was the most likely source of infection. MD-A related the patient died of Group A Beta strep infection/sepsis with multiorgan system failure on 11/25/09.

The hospital did an internal review of Patient 3's care and a Root Cause Analysis with development of an Action Plan. However, hospital staff failed to develop or implement changes necessary to prevent further lack of adequate nursing assessment and nursing competency/critical thinking skills related to change in condition/vital signs which places all other obstetric patients in Immediate Jeopardy (IJ) - at risk of immediate threat to their health and safety - since 11/21/09. The facility identified they have an average of 200 obstetric deliveries per month.

The Interim Administrator for the hospital was notified on 1/14/10 at 3:42 PM that IJ conditions existed after consultation between staff at the State survey agency and the Centers for Medicare & Medicaid Services (CMS). The IJ was abated on 1/15/10 after the facility educated nursing staff and performed competency testing on all obstetric nursing staff to protect patients from harm. The findings were of such a serious nature that the facility was found to be out of compliance with the Condition of Participation for Nursing Services. See also A0395.

Based on record review, staff interviews, physician interviews, review of facility policies, review of facility internal review and review of physician office reports/documentation, the facility failed to ensure 1 of 6 sampled patients (Patient 3) received an adequate nursing assessment by a Registered Nurse after a change in condition that occurred prior to the patient's discharge drom the hospital. Two staff Registered Nurses (RNs) failed to complete a nursing assessment of an adolescent patient (post vaginal delivery 11/19/09) who exhibited symptoms of rapid pulse, chilling/shaking, diarrhea, nausea and fever of 103 orally on 11/21/09. The physician was contacted by the nurse but without doing a complete set of vital signs and nursing assessment could not adequately report the patient's health status. An assumption was made without further assessment or testing that the patient had the flu and was discharged. Interview with the patient's obstetrician, Medical Doctor (MD)-A, on 1/14/10 at 12:50 PM revealed the patient was seen in physician's office 2 days post-discharge in critical condition. MD-A related the patient was immediately hospitalized in another local hospital. The physician stated an emergent hysterectomy was performed on 11/25/09 as the uterus was the most likely source of infection. The MD related the patient died of Group B strep infection/sepsis with multiorgan system failure on 11/25/09.

The facility did an internal review of Patient 3's care and a Root Cause Analysis with development of an Action Plan. However, hospital staff failed to develop or implement changes necessary to prevent further lack of adequate nursing assessment and nursing competency/critical thinking skills related to change in condition/vital signs, placing all other obstetric patients in Immediate Jeopardy (IJ) - at risk of immediate threat to their health and safety since 11/21/09. Hospital staff identified they have an average of 200 obstetric deliveries per month. The Interim Administrator for the hospital was notified on 1/14/10 at 3:42 PM that IJ conditions existed after consultation between staff at the State survey agency and the Centers for Medicare & Medicaid Services (CMS). The IJ was abated on 1/15/10 after the facility educated nursing staff and performed competency testing on all obstetric nursing staff to protect patients from harm.

The total sample of 6 patients were selected from the Obstetric/Newborn Nursery area. The facility census was 171.

Findings are:

A. Medical record review revealed Patient 3, age 17, was admitted to the hospital on 11/19/09 at 8:00 AM for induction of labor. She was at 41 weeks gestation. She vaginally delivered a male at 5:42 PM with a third degree laceration (a tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the muscle that surrounds the anus). The patient had a normal recovery until the day of discharge 11/21/09. Record review of the "Vital Signs/Intake & Output Record" notes that the patient's vitals were taken for the first time on 11/21/09 at 8:00 AM. The oral temperature was documented as 98.9 (degrees Fahrenheit), pulse 128 (elevated), respirations at 18, blood pressure (BP) at 105/69. The Nurse Aide (NA)-E documented at 8:45 AM that the vital signs were "reported to [Name of RN C] ".

The patient's obstetrician, Medical Doctor (MD)-A was off on 11/21/09 so the patient was seen by obstetrician, MD-B, an associate of MD-A, at 9:20 AM. Documentation on "Progress Notes" by MD-B on 11/21/09 at 9:20 AM notes the patient's vital signs are stable and she is afebrile. The fundus (upper border of the uterus) was noted as firm and at the level of the umbilicus (normal findings for post delivery day 2). MD-B wrote an order at 9:30 AM for discharge to home with followup visit in 6 weeks. The physician also ordered on 11/21/09 Home Health Skilled Nursing Assessment for 1-2 home visits post-discharge. Review of the Discharge Planning/Case Manager notes at 11:04 AM on 11/21/09 document that the patient chose the hospital's Home Health Agency.

Documentation by RN-C on 11/21/09 at 3:05 PM notes the patient complained of nausea within the past hour and also reports the patient had two liquid stools and a headache. The nurse gave the patient Zofran, a medication ordered as needed for nausea, and one Narco, a pain medication with hydrocodone and 325 milligrams of acetaminophen, at 3:08 PM. Pain score was identified by the patient as "5" on a 10-point scale with 10 being the worst pain. The pain location was documented as "abdominal cramping" . RN-C documented the patient's temperature was 99.1 at 3:15 PM with no other vital signs (i.e., pulse, respirations or blood pressure - BP) recorded. RN-C documented the patient's temperature at 100.1 at 3:35 PM. No other vital signs were recorded.

RN-D took over the patient's care for the remainder of her stay on 11/21/09. RN-D documented at 4:00 PM that the patient's temperature orally was 103 degrees (normal oral temperature is 98.6). Elevated temperature is an indicator of possible infection and indicates the need for full vital signs and complete physical assessment by the RN to determine potential causes of the elevated temperature and enable the nurse to report to the physician the patient's symptoms and nursing assessment. The patient's pulse, respirations and BP were not documented since the 8:00 AM assessment. At 4:10 PM, RN-D documented the patient's fundus was "2" fingerbreadths below the umbilicus (normal) with "scant" amount of vaginal drainage (normal) but the patient "c/o [complained of] uterine tenderness with check - cramping with nursing [breastfeeding infant] uterus is not abnormally tender - lochia [vaginal drainage] is not foul smelling". Pain assessment at 4:10 PM notes the patient's pain score is 3 and described abdominal cramping. RN-D documented the patient stated she "is cramping with baby lying on her stomach". The nurse did not document any further nursing assessment of the patient's condition beyond obstetrical "checks". At 4:30 PM, RN-D documented calling MD-B and reported "Temp [temperature] is now 103 - aches all over - has vomited - had 2 diarrhea stools". The physician ordered Tamiflu and to discharge the patient to home. Review of physician telephone order notes the patient to "call dr [doctor] if difficulty in breathing or any problems drink lots of fluids". RN-D documented the patient was discharged from the hospital at 6:00 PM accompanied by the patient's parent with dismissal instructions and prescriptions.

B. According to "sepsis is a 3-stage syndrome starting with sepsis and progressing through severe sepsis to become septic shock. The goal is to treat sepsis during its mild stage before it becomes more dangerous. Sepsis - To be diagnosed with sepsis you must exhibit at least two of the following symptoms: Fever above 101.3 F or below 95 F; Heart rate higher than 90 beats per minute; Respiratory rate higher than 20 breaths a minute; Probable or confirmed infection."

Patient 3 was discharged from the hospital after having 2 symptoms of sepsis: elevated heart rate of 128 and a rising temperature of 103. The patient was identified at risk for infection in the plan of care. The genital tract is a common source of infection. The patient was at risk related to the laceration with delivery and uterine lining damage from release of the placenta. The patient did not receive further nursing assessment as would be expected to ensure she was stable for discharge.


C. Record review of facility policy titled "Documentation of Nursing Care", last reviewed 6/09, found it states, "It is required that a new nurse does a complete assessment of their patient at 0800, 1600 and 0000, and at the beginning of their shift if it varies with these times." However, nursing staff did not provide Patient 3 with a complete assessment including vital signs in accordance with facility policy.


D. Staff interview with RN-C on 1/13/10 at 11:10 AM related that Nursing Aide (NA)-E took the patient's vital signs the morning of 11/21/09, but does not recall the NA reporting the pulse of 128 to her. The nurse stated a pulse of 128 could be a concern the body is trying to compensate for something, but can sometimes be expected related to blood loss from delivery. RN-C reported that she was assigned 5 patients and by the afternoon two patients had gone home. The nurse stated that around 3:00 PM she found the patient chilling and took the patient's temperature which was 99.1. RN-C stated, "only temp [temperature] was taken." RN-C stated the patient was still chilling at 3:35 PM and took only the temperature for vital signs with the temperature at 100.1 orally. RN-C stated she told the patient she needed to wait to go home until they knew if the temperature was going to rise more and that they may need to call the doctor. RN-C related that the nurses call the physician when the temperature reaches 100.4. RN-C stated she then left the patient and gave report to RN-D; RN-C stated her last obstetric nursing assessment of the patient was that morning around 8:00 or 8:30 AM. RN-C stated she heard of Patient 3's death on 11/26/09 and called the Director of Perinatal Services to ensure the Director was aware the patient had died.


E. Staff interview with RN-D on 1/13/10 at 10:05 AM found RN-D recalled being told in report that Patient 3 had a temperature, loose stools on day shift and generalized aching. RN-D related the patient was seen at 3:45 PM and complained of aching all over and chilling. RN-D took the patient's temperature orally and it was 103. RN-D stated the patient told her it hurt to hold the baby. RN-D, who has many years of experience on obstetrics, stated that with a temperature the patient may have an infection. RN-D stated she "checked" the patient's fundus and the patient was not tender, an indicator of a uterine infection. She checked vaginal drainage and noted it had no odor. She did not check the patient's perineal area/laceration repair site visually. The nurse said the patient had no problems voiding and how she looked "was consistent with the flu". She related she was aware the patient had asthma but was breathing normally so did not listen to her lungs. RN-D said the patient was dressed and ready to go home. RN-D related she was unaware the patient was to go home on home health services.

RN-D called MD-B and "told him the patient had a slight temp earlier and was now 103", and that the patient complained of aching all over with flu-like symptoms including two loose stools. RN-D reported that the fundal check was normal with no abnormal tenderness and the vaginal flow was normal with no odor. MD-B told the RN to send the patient home on Tamiflu and to call in the prescription after checking with the lactation nurse to be sure the medication was not contraindicated with breastfeeding. RN-D stated he/she was "mostly comfortable with orders he [MD-B] gave but uncomfortable sending a patient home with a temp - never done that before. " RN-D stated she was the charge nurse on the evening shift 11/21/09. RN-D stated she was unaware the patient was going home with home health services and did not notify anyone from home health that the patient had a temperature. RN-D confirmed she did not include home health in the discharge instructions. The nurse related that "care conferences are coming up to discuss what we learned from this patient". The facility identified the case study titled "Anything Abnormal? A Case Study for Post Partum" was scheduled for 3/29/10.

F. Interview with MD-A on 1/14/10 at 12:50 PM revealed he saw the patient after discharge in his office on 11/23/09 (two days post discharge). MD-A stated the patient was brought to him in a wheelchair at 2:00 PM and was "lethargic, very fatigued and looked toxic". Patient 3's speech was garbled and the abdomen distended. The blood pressure was 70 (critically low). MD-A stated he felt she was septic. He took her to the Emergency Department of the adjacent local hospital "F" where she was admitted. MD-A stated the patient had Group A Beta Strep.

Record review of the Pathology Report from hospital F dated 11/23/09 identified "Group A Beta Streptococcus" from a blood culture taken 11/23/09. MD-A performed a hysterectomy on the patient on 11/25/09 for "post partum sepsis, possible endomyometritis, multiorgan failure with sepsis and adult respiratory syndrome". The operative report from hospital F, dated 11/25/09, states, "The uterus clearly looked like a source of significant infection." The patient died later that same day.

MD-A stated that the recorded pulse of 128 was abnormal and would have triggered a concern for him when she was normal prior to that. MD-A stated he "would expect nurses to take full set of vital signs especially if 1 vital sign was abnormal".

G. Interview with the Director of Risk Management on 1/13/10 at 4:10 PM revealed the facility did a Root Cause Analysis and determined that nursing assessments were not appropriate for the patient's condition and handoff communications from the NA to the RN of the vital signs (pulse 128) and the day nurse to the evening nurse regarding the Home Health orders and from the hospital to the Home Health nurse of the patient's condition change at discharge. At this point, the Director stated the facility had resolved the vital sign communication from the NA to the RNs on OB (obstetrics), but the remainder of the action plan was to be put in place in 30 days. The Director confirmed the facility's "short term action plan did not address professional nurse assessment with change of condition". The facility "planned to address the professional nurses' expectation for assessment with change of condition on 3/29/09 at the Case Study."

The facility's failure to address the re-education of nursing staff for assessment of OB patients with changes of condition/vital signs, and failure to ensure the OB staff are competent in decision making skills resulted in Immediate Jeopardy (IJ) conditions from 11/21/09 until 1/15/10. On 1/15/10 the IJ was abated when surveyors verified the facility had fully implemented an action plan which re-educated the nurses on OB and ensured their competency to render safe care.

Based on record review, facility policy review and staff interviews, the facility failed to ensure nursing staff kept current the patient's nursing care plan for 1 of 6 sampled patients (Patient 3). The total sample of 6 patients was selected from the Obstetric/Newborn Nursery area. The facility census was 171. See also A0395.

Findings are:

A. Medical record review revealed Patient 3, age 17, was admitted to the hospital on 11/19/09 at 8:00 AM for induction of labor. She was at 41 weeks gestation. She vaginally delivered a male at 5:42 PM with a third degree laceration (a tear in the vaginal tissue, perineal skin, and perineal muscles that extends into the muscle that surrounds the anus). The patient had a normal recovery until the day of discharge, 11/21/09, when the patient developed an elevated heart rate of 128 (normal heart rate would be approximately 60-80) and a rising fever of 103 degrees Fahrenheit (F.) when taken orally before discharge (normal temperature is considered 98.6 degrees F.). The patient also had chills, nausea, diarrhea, and complaint of abdominal pain when holding the baby on her abdomen. The physician orders dated 11/21/09 included an order for Home Health Care 1-2 skilled nursing visits to the home after discharge for patient assessment and teaching.

Record review of the facility documentation titled "Patient's Plan of Care" included, "Infection, Risk of R/T [Related To] Inadequate primary/secondary defenses," dated 11/19/09 with the goal that, "Patient will remain free of infection." Under the section titled "Additional Interventions", dated 11/20/09, it included, "Vital Signs were to be done daily at 8 AM and 1600 [4 PM]." The Plan of Care was not updated on 11/21/09 to reflect the patient's symptoms of infection and fever.

The patient's Discharge Plan was updated on 11/21/09 by RN-D, but failed to include that the patient was being discharged 11/21/09 with home health services. The patient's Discharge Instructions did not contain any identification of Home Health services to be provided or how to contact the Home Health service.

B. Staff interview with RN-D on 1/13/10 at 10:05 AM revealed RN-D was unaware of the plan for the patient to receive Home Health services after discharge and, therefore, did not include it in the patient's discharge instructions. RN-D related that Home Health was not notified of the patient's change in condition since she was unaware of the order for Home Health services after patient discharge.

Review of Discharge Planning/Case Management notes dated 11/21/09 at 11:04 AM revealed Home Health services had been set up for the patient through the facility's Home Health agency on 11/21/09. Failure to notify the Home Health agency of the patient's change in condition resulted in the patient's Home Health Nurse not seeing or contacting the patient until 11/22/09 at 2:30 PM.

C. Staff interview with the Director of Performance Improvement and Case Management on 1/13/10 at 12:20 PM revealed that in December of 2009 they found a "disconnect between the Social Workers and the Home Health Coordinators." The Director related that they fixed that problem, but have not connected the Home Health and Social Worker communication for OB (Obstetrics) to the nursing staff. Interview with the Case Management Team Coordinator on 1/13/09 at 2:30 PM revealed the facility has a computer program that "auto [automatically] populates" referrals for home health services to the nurses' shift report, but that program had not been turned on (activated) for OB yet.

D. Review of facility policy titled "Documentation of Nursing Care", last reviewed 6/09, found it states, "The plan of care is developed based on the admission assessment, individual patient needs and complements as well as supports the medical plan of care. Patient problems and/or needs are identified and are the foundation of the plan of care." The policy also states that, "The plan of care is reviewed and updated each shift and as the patient's condition changes by the RN [Registered Nurse]." However, the plan of care did not reflect Patient 3's change in condition identified by both the day and evening nurses on 11/21/09 and did not identify the patient's need and physician's order for home health services.