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Based on interview and record review, the hospital failed to implement its policy and procedure (P&P) titled, "Patient - Related Complaint and Grievance Management" for three of four sampled patients (Patient 19, Patient 20, Patient 21). This had the potential to result in unresolved grievances and/or patients now knowing the outcome of their grievances.

Findings:

During an interview on 3/5/25 at 9:20 a.m. with Risk and Regulatory Analyst (RRA), RRA stated she was responsible for coordinating the grievance process. RRA stated she recognized there were deficiencies in this process. RRA stated once a grievance was identified, the manager of the department should reach out to the patient involved in the grievance and document the investigation and outcome. RRA stated ideally a closure letter of the outcome would be sent to the patient within seven days.

During a concurrent interview and record review on 3/5/25 at 9:25 a.m. with RRA, the hospital's "Complaint/Grievance Log (CGL)" undated was reviewed. The "CGL" indicated, Patient 19 reported a grievance on 1/2/25. RRA stated the manager of the Emergency Department was assigned to call the patient, but this was not done. RRA stated this resulted in a delay in resolving the patient's grievance. RRA stated, the patient's complaint was not resolved in the required 7 days due to the delay of the patient contact which resulted in the final closure letter being sent to the patient on 2/27/25 (54 days later).

During a concurrent interview and record review on 3/5/25 at 9:42 a.m. with RRA, the hospitals "CGL" undated was reviewed. The "CGL" indicated, Patient 20 reported a grievance on 1/16/25. RRA stated, there was no final closure letter sent to the patient which should have been done (49 days had passed at the time of the interview).

During a concurrent interview and record review on 3/5/25 at 9:47 a.m. with RRA, the hospitals "CGL", undated was reviewed. The "CGL" indicated, Patient 21 reported a grievance on 2/3/25. RRA stated, there was no final closure letter sent to the patient which should have been done (30 days had passed at the time of the interview).

During a review of the hospitals P&P, titled "Patient - Related Complaint and Grievance Management" dated 7/27/22, the P&P indicated, "[Hospital] is committed to providing patients and the patient's legal representative a complaint and grievance mechanism within the facility designed to promptly resolve patient complaints and grievances regarding the care and service they have received. It is the goal that these complaints and grievances are thoroughly addressed in a timely manner and handled it a way that supports the patient's right to receive respectful and supportive care. . . C. Grievance Resolution Time Frames 1. Grievances are to be resolved within seven (7) days whenever possible. If the grievance cannot be resolved within the seven (7) days due to its complexity and the need for extensive follow up involving multiple staff members, the facility representative or appropriate department staff will maintain contact with the grievant, in writing if possible, and provide timely updates until a resolution/response can be achieved. Document all contacts with the grievant. The Grievance Committee shall issue a final determination regarding resolution at the conclusion of the investigation. A written notice of the facility's determination regarding the grievance shall be communicated to the patient or patient's legal representative in a language and manner that the patient or patient's legal representative understands."

Based on interview and record review, the hospital failed to ensure risks, benefits, and alternatives (RBAs) for elective procedures were documented as given prior to the procedure for eight of 11 sampled patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential for patients not knowing the procedure's risks, benefits, and alternatives, preventing the patients from making an informed decision.

Findings:

During a review of Patient 1's medical record, the History and Physical (H&P) dated 1/7/25, the H&P indicated Patient 1 was 39 weeks and four days pregnant (40 weeks is full term) and had begun leaking amniotic fluid (water breaking- Sac of liquid that surrounds and protects the developing fetus during pregnancy. Once the sac ruptures the risk of infection to the mother and fetus increases) on 1/6/25 at 10 p.m. The H&P indicated the plan was for induction (start) of labor (IOL) using Oxytocin (medication given through the vein to cause labor contractions).

During an interview on 3/4/25 at 8:10 a.m. with RN Regulatory Specialist (RNRS), RNRS stated after reviewing Patient 1's medical record, she was unable to find a physician order to consent for IOL, a signed consent for IOL, or documented RBAs for IOL.

During a review of Patient 1's nursing "Annotations" dated 1/7/25 at 11:24 a.m., the "Annotations" indicated IOL with Oxytocin was started.

During an interview on 3/4/25 at 8:39 a.m. with Registered Nurse (RN) 1, RN 1 stated she had taken care of Patient 1 the prior night shift (1/7/25 from 7 p.m. to 1/8/25 at 7:30 a.m.) and when she returned to work the night shift on 1/8/25 she was surprised that Patient 1 still had not delivered her baby. RN 1 stated she had a discussion with Charge Nurse (CN) about Patient 1 still being pregnant and that her amniotic fluid had been leaking for nearly 48 hours. RN 1 stated she did not document the discussion she had with CN regarding Patient 1 not delivering the baby.

During an interview on 3/4/25 at 1:34 p.m. with CN, CN stated that RN 1 discussed her concerns about Patient 1's slow labor progress. CN stated Physician 1 was at Patient 1's bedside around 8 p.m. CN stated Physician 1's decision was to allow Patient 1 to continue with IOL. CN stated she did not document the discussions she had with RN 1 or Physician 1.

During a review of Patient 1's nursing "Annotations" dated 1/8/25, at 8:01 p.m. the "Annotations" indicated, "OB [Obstetric- related to pregnancy and childbirth] provider [physician] at bedside."

During an interview on 3/5/25 at 8:56 a.m. with Physician 1, Physician 1 stated she discussed with Patient 1 the risks involved with continuing to allow Patient 1 to continue with her induction of labor. Physician 1 stated she did not document the discussion.

According to an article published by the National Institutes of Health (NIH), "Amniotic membranes are protective to the fetus, with anti-inflammatory [reduces redness and swelling], anti-bacterial [prevents the growth or spread of bacteria], and anti-viral [prevents the growth or spread of viruses] properties. Prolonged rupture of membranes (PROM) is considered when the duration is more than 18 h [hours] prior to delivery."

During a concurrent interview and record review on 3/5/25 at 9:38 a.m. with Interim Manager of Labor & Delivery (IMLD), Patient 3's medical record was reviewed. The H&P, dated 12/31/24, at 7:30 p.m. indicated, "patient [sic] scheduled for induction of labor." IMLD stated Patient 3 had an IOL on 12/31/24 and signed a consent for IOL on 12/31/24 at 8 p.m. IMLD stated she was unable to find documented RBAs for IOL.

During a concurrent interview and record review on 3/5/25 at 9:53 a.m. with IMLD, Patient 4's medical record was reviewed. The H&P dated 1/3/26 at 5:59 a.m. indicated Patient 4 came to the hospital for "leaking [amniotic] fluid" and labor. IMLD stated Patient 4 had an augmentation of labor (AOL- using Oxytocin to make labor contractions stronger and more regular) on 1/3/25 and signed a consent for AOL on 1/3/25 at 7:25 a.m. IMLD stated she was unable to find documented RBAs for AOL.

During a concurrent interview and record review on 3/5/25 at 10:32 a.m. with IMLD, Patient 5's medical record was reviewed. The H&P dated 1/6/25 at 9:31 p.m. indicated Patient 5 was "sent from [physician's] office for advanced dilatation of 5 cm [centimeters- cervix is measured from closed to 10 cm when the baby is ready to be delivered]." IMLD stated Patient 5 had an AOL on 1/6/25. IMLD stated she was unable to find a signed a consent for AOL or documented RBAs for AOL.

During a concurrent interview and record review on 3/5/25 at 10:39 a.m. with IMLD, Patient 6's medical record was reviewed. The H&P dated 1/7/25 at 12:22 a.m. indicated Patient 6 arrived at the hospital for a scheduled IOL. IMLD stated Patient 6 had an IOL on 1/6/25 and signed a consent for IOL on 1/6/25 at 10:10 a.m. IMLD stated she was unable to find documented RBAs for IOL.

During a concurrent interview and record review on 3/5/25 at 10:52 a.m. with IMLD, Patient 7's medical record was reviewed. The H&P dated 1/10/25 at 6:52 a.m. indicated Patient 7 was scheduled for IOL for "cholestasis of pregnancy [Condition that slows or stops the normal flow of bile in the gallbladder and can cause severe itching. Fetuses are at risk as the pregnancy advances, so patients are typically delivered at 37 weeks of pregnancy]." IMLD stated Patient 7 had an IOL on 1/10/25 and signed a consent for IOL on 1/10/25 at 10:30 a.m. IMLD stated she was unable to find documented RBAs for IOL.

During a concurrent interview and record review on 3/5/25 at 11:01 a.m. with IMLD, Patient 8's medical record was reviewed. The H&P dated 1/20/25 at 8:39 p.m. indicated Patient 8 went to the hospital for an "induction of labor." IMLD stated Patient 8 had an IOL on 1/20/25 and signed a consent for IOL on 1/20/25 at 10:14 a.m. IMLD stated she was unable to find documented RBAs for IOL.

During a concurrent interview and record review on 3/5/25 at 11:06 a.m. with IMLD, Patient 9's medical record was reviewed. The H&P dated 1/26/25 at 11:23 p.m. indicated Patient 9 presented to the hospital with leaking amniotic fluid. IMLD stated Patient 9 had an AOL on 1/26/25 and signed consent for AOL on 1/26/25 at 5:37 p.m. IMLD stated she was unable to find documented RBAs for IOL.

During a review of the hospital's policy and procedure (P&P) titled, "Oxytocin for Induction or Augmentation of Labor" dated 2/21/23, the P&P indicated, "C. Before Oxytocin Administration: 1. Verify that the physician has discussed the indications and the potential risks and benefits of induction or augmentation of labor with the patient and that maternal consent is documented."

During a review of the hospital's P&P titled, "Consent and Informed Consent" dated 5/4/22, the P&P indicated, "3. The topics that must be addressed in the informed consent discussion are: a. The nature of the operation or procedure, including other care, treatment, services or medication. B. Potential benefits, risks of the operation or procedure, including potential problems that might occur during recuperation. C. The likelihood of achieving the patient's goals. D. Reasonable alternatives and the relevant risks, benefits and side effects to such alternatives, including the possible results of not receiving the proposed care, treatment and services ... F. Documentation: 1. A document (H&P or progress note) shall be in the patient's permanent medical record prior to the procedure/treatment identifying that Procedures, Alternatives, Risks and Questions- (PARQ) have been discussed with the patient or the patient's legal representative ... 4. The nursing staff shall be responsible for verifying that the documentation has been included in the chart PRIOR to surgery/procedure and checking this off the surgical checklist. If these conditions are not met, the proceduralist performing the procedure must be contacted to obtain the required documentation. Non-emergency procedures will be delayed or cancelled [sic] until the informed consent process has been completed and fully documented."

Based on interview and record review, the hospital failed to:

1. Follow its policy and procedure titled, "Oxytocin [medication given through the vein to cause labor contractions] for Induction [to start] or Augmentation [make labor contractions stronger and more regular] of Labor" for eight of 11 sampled patients (Patient 1, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential for adverse outcomes for the mother and fetus [infant still in the womb].

2. Follow its policy and procedure titled, "NURSING ASSESSMENT AND REASSESSMENT FOR PATIENTS" for one of 11 sampled patients (Patient 1). This failure resulted in an inaccurate medical record and had the potential to negatively affect patient outcome.

Findings:

1. During an interview on 3/3/25 at 11:48 a.m. with Director of OB (Obstetrics- childbirth and the care of women giving birth) (DOB), DOB stated the obstetrics department follows standards and guidelines (National organization whose goal is to advance the nursing profession related to obstetric and newborn nursing).

During a concurrent interview and record review on 3/5/25 at 9:38 a.m. with Interim Manager of Labor & Delivery (IMLD), Patient 3's medical record was reviewed. The "History and Physical" (H&P) dated 12/31/24, at 7:30 p.m. indicated, "patient [sic] scheduled for induction of labor." IMLD stated Patient 3 had an induction of labor (IOL) using Oxytocin. IMLD stated nursing did complete maternal/fetal assessments (uterine activity, fetal heart rate, and any nursing interventions) every 15 minutes while Patient 3 was receiving Oxytocin. IMLD stated nursing did not assess Patient 3's pain every hour.

During a concurrent interview and record review on 3/5/25 at 9:53 a.m. with IMLD, Patient 4's medical record was reviewed. The H&P dated 1/3/26 at 5:59 a.m. indicated Patient 4 came to the hospital for "leaking [amniotic] fluid" and labor. IMLD stated Patient 4 had an augmentation of labor (AOL) on 1/3/25. IMLD stated nursing did not complete maternal/fetal assessments every 15 minutes while Patient 4 was receiving Oxytocin. IMLD stated nursing did assess Patient 4's pain every hour.

During a concurrent interview and record review on 3/5/25 at 10:32 a.m. with IMLD, Patient 5's medical record was reviewed. The H&P dated 1/6/25 at 9:31 p.m. indicated Patient 5 was "sent from [physician's] office for advanced dilatation of 5 cm [centimeters - cervix is measured from closed to 10 cm when the baby is ready to be delivered]." IMLD stated Patient 5 had an AOL on 1/6/25. IMLD stated nursing did not complete maternal/fetal assessments every 15 minutes while Patient 5 was receiving Oxytocin. IMLD stated nursing did not assess Patient 5's pain every hour.

During a concurrent interview and record review on 3/5/25 at 10:39 a.m. with IMLD, Patient 6's medical record was reviewed. The H&P dated 1/7/25 at 12:22 a.m. indicated Patient 6 arrived at the hospital for a scheduled IOL. IMLD stated Patient 6 had an IOL on 1/6/25. IMLD stated Patient 6 had an AOL on 1/6/25. IMLD stated nursing did not complete maternal/fetal assessments every 15 minutes while Patient 6 was receiving Oxytocin. IMLD stated nursing did not assess Patient 6's pain every hour.

During a concurrent interview and record review on 3/5/25 at 10:52 a.m. with IMLD, Patient 7's medical record was reviewed. The H&P dated 1/10/25 at 6:52 a.m. indicated Patient 7 was scheduled for IOL for "cholestasis of pregnancy [Condition that slows or stops the normal flow of bile in the gallbladder and can cause severe itching. Fetuses are at risk as the pregnancy advances, so patients are typically delivered at 37 weeks of pregnancy]." IMLD stated Patient 7 had an IOL on 1/10/25. IMLD stated nursing did not complete maternal/fetal assessments every 15 minutes while Patient 7 was receiving Oxytocin. IMLD stated nursing did not assess Patient 7's pain every hour.

During a concurrent interview and record review on 3/5/25 at 11:01 a.m. with IMLD, Patient 8's medical record was reviewed. The H&P dated 1/20/25 at 8:39 p.m. indicated Patient 8 went to the hospital for an "induction of labor." IMLD stated Patient 8 had an IOL on 1/20/25. IMLD stated nursing did not complete maternal/fetal assessments every 15 minutes while Patient 8 was receiving Oxytocin. IMLD stated nursing did not assess Patient 8's pain every hour.

During a concurrent interview and record review on 3/5/25 at 11:06 a.m. with IMLD, Patient 9's medical record was reviewed. The H&P dated 1/26/25 at 11:23 p.m. indicated Patient 9 presented to the hospital with leaking amniotic fluid. IMLD stated Patient 9 had an AOL on 1/26/25. IMLD stated nursing did not complete maternal/fetal assessments every 15 minutes while Patient 9 was receiving Oxytocin. IMLD stated nursing did not assess Patient 9's pain every hour.

During a review of the hospital's P&P titled, "Oxytocin for Induction or Augmentation of Labor" dated 2/21/23, the P&P indicated, "E. PERFORM MATERNAL/FETAL ASSESSMENT: 1. Perform a maternal fetal assessment every 15 minutes during the first stage of labor [from the onset of regular uterine contractions to when the cervix is completely dilated at 10 centimeters] ... 2. Assess maternal pain every one (1) hour and before and after all pain interventions."

A review of AWHONN's "Fetal Heart Monitoring Principles and Practices Sixth Edition" indicated documentation of fetal heart monitoring assessment with use of Oxytocin is every 15 minutes.

2. During a review of Patient 1's medical record, the H&P dated 1/7/25, the H&P indicated Patient 1 was 39 weeks and four days pregnant (40 weeks is full term) and had begun leaking amniotic fluid (water breaking- Sac of liquid that surrounds and protects the developing fetus during pregnancy. Once the sac ruptures the risk of infection to the mother and fetus increases) on 1/6/25 at 10 p.m. The H&P indicated the plan was for induction (start) of labor (IOL) using Oxytocin (medication given through the vein to cause labor contractions).

During a review of Patient 1's nursing "Annotations" dated 1/7/25 at 11:24 a.m. the "Annotations" indicated IOL with Oxytocin was started.

During an interview on 3/4/25 at 8:39 a.m. with Registered Nurse (RN) 1, RN 1 stated she took care of Patient 1 the prior night shift (1/7/25 from 7 p.m. to 1/8/25 at 7:30 a.m.) and when she returned to work the night shift on 1/8/25 she was surprised that Patient 1 still had not delivered her baby. RN 1 stated she had a discussion with Charge Nurse (CN) about Patient 1 still being pregnant and that her amniotic fluid had been leaking for nearly 48 hours. RN 1 stated she did not document the discussion she had with CN regarding Patient 1's baby not being delivered.

During an interview on 3/4/25 at 1:34 p.m. with CN, CN stated RN 1 discussed her concerns about Patient 1 making slow progress in labor. CN stated Physician 1 was at Patient 1's bedside around 8 p.m. CN stated Physician 1's decision was to allow Patient 1 to continue with IOL. CN stated she did not document the discussion she had with RN 1 or the discussion she had with Physician 1.

During a review of Patient 1's nursing "Annotations" dated 1/8/25, at 8:01 p.m. the "Annotations" indicated, "OB [Obstetric- related to pregnancy and childbirth] provider at bedside."

During an interview on 3/5/25 at 8:56 a.m. with Physician 1, Physician 1 stated she discussed the risks involved with continuing to allow Patient 1 to continue with her induction of labor, but she did not document the discussion.

According to an article published by the National Institutes of Health (NIH), "Amniotic membranes are protective to the fetus, with anti-inflammatory [reduces redness and swelling], anti-bacterial [prevents the growth or spread of bacteria], and anti-viral [prevents the growth or spread of viruses] properties. Prolonged rupture of membranes (PROM) is considered when the duration is more than 18 h [hours] prior to delivery."

During a review of the hospital's P&P titled, "NURSING ASSESSMENT AND REASSESSMENT FOR PATIENTS" dated 9/28/23, the P&P indicated, "I. DOCUMENTATION 1. Documentation should be timely, current and chronological - "chart as you go' is the preferred method ... Documentation is patient-centered and focused, collaborative, appropriate to the setting in which the care is provided and based on: a. A collaborative comprehensive plan of care that is individualized b. Professional intervention, observation and assessment c. The patient's current status and their preferences d. The patient's progress and response to treatment and care e. Collaborative plan-of-care discussions, consultations, and rationales for plan-of-care changes."