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Based on observation, interview and record review, the hospital failed to ensure staff followed the facility policies and procedures for Patient Rights when:

1. Staff did not utilize interpreter services to seven out of 31 patients (Patient 1, Patient 13, Patient 14, Patient 15, Patient 19, Patient 22, and Patient 25) in their preferred language. (Refer A-0131)

2. Staff did not provide pain management interventions or pain medications to two out of ten patients (Patient 26 and Patient 4) complaining of severe pain. (Refer A-0144)

The cumulative effect of this systemic problem resulted in the hospital's failure to ensure patient rights were protected when interpreter services and timely pain management were not provided.

Based on observation, interview, and record review, the facility failed to ensure interpreter services were utilized for seven out of 31 patients (Patient 1, Patient 13, Patient 14, Patient 15, Patient 19, Patient 22, and Patient 25) Limited English Proficient (LEP) patients when:

1. Three Emergency Department (ED) staff (Registered Nurse [RN] 8, ED tech (EDT) and RN Shift Manager [RNSM]) did not utilize interpreter services with Patient 1, Patient 22 in the ED.

2. Patient 25 and Family Member (FM) 2 did not receive information by interpreter services prior to signing English language "PEDIATRIC UNIT [children's care unit] INFORMATION SHEET."

3. Five Patients (Patient 1, Patient 13, Patient 14, Patient 15, and Patient 19) did not receive information in their preferred language prior to signing procedure consent forms.

4. Patient 13 did not receive information by interpreter services prior to signing English language Conditions of Admission (COA - contract between the hospital and patient that outlines the patient's obligations with respect to services they receive) document.

These failures resulted in an incomplete assessment for Patient 1 and had the potential for Patient 25, Patient 13, Patient 14, Patient 15, and Patient 19 or other patients with LEP to be uninformed when making medical decisions affecting provision of treatment.

Findings:

1 a. During an interview on 9/15/22, at 12:06 PM, with RN 8, RN 8 stated, he knew Patient 1 had a previous cesarean section (baby delivered through an abdominal and uterine incision) because she had a "big scar" on her abdomen. RN 8 stated, he did not obtain the cesarean section history from Patient 1 because he (RN 8) "can't understand Spanish."

During an interview on 9/28/22, at 9:08 AM, with RN 8, RN 8 stated, Patient 1 arrived to ED triage (assessment of patient needs and determination of how quickly to be seen) on 8/26/22. RN 8 stated, he could not communicate with Patient 1 because she spoke Spanish. RN 8 stated, "I wasn't going to look for an interpreter." RN 8 stated, he knew an interpreter services telephone was available in the triage room. RN 8 stated, he chose to use RN 9 to provide language interpretation for Patient 1. RN 8 stated, RN 9 told him Patient 1 came to the ED due to abdominal (stomach area) pain. RN 8 stated, he did not assess Patient 1's level of pain because he did not speak Spanish.

During a review of Patient 1's Face sheet (FS-contains patient information including, physician, insurance, language information, etc ...), dated 8/26/22, the FS indicated, Patient 1's "Language: SPANISH" and "Interpreter Y."

1 b. During an observation and interview, on 9/27/22, at 11:08 AM, with Patient 22 and FM 1, in the ED waiting area, Patient 22 was in a wheelchair accompanied by FM 1. FM 1 stated, Patient 22 preferred to be spoken to in Spanish. A staff member transferred Patient 22 to the electrocardiogram room (EKG-records heart rhythm). FM 1 did not accompany Patient 22 to the EKG room.

During a concurrent observation and interview, on 9/27/22, at 11:20 AM, with Patient 22, FM 1, and EDT, in the ED waiting area, EDT and Patient 22 exited the EKG room. EDT stated, she performed the Patient 22's EKG because she (EDT) was able to speak Spanish and Patient 22 preferred Spanish. EDT stated, she did "not believe" she had interpreter services education but "my Spanish is good." EDT stated, she uses her Spanish to interpret for patients. EDT stated, she had worked at the facility for eight years and had never used the language line for interpreter services and does not know how to use the service.

During a concurrent observation and interview, on 9/27/22, at 11:25 AM, with Emergency Department Manager (EDM), in ED examination/treatment room 2, an interpreter service phone was on wall and a portable video interpreter machine was available in ED examination/treatment room 2. EDM stated, staff should use either interpreter services systems for interpreter services when needed.

During an interview, on 9/28/22, at 9:45 AM, with RNSM, RNSM stated, he spoke Spanish to Spanish speaking patients because he can relate to them and it is better to be face to face than using the interpreter services phone or video interpreter machine. RNSM stated, he spoke Spanish to new admits during assessments and when he explained consents because he was "fluent" (speaks Spanish well) in Spanish. RNSM stated, he had not had "formal" interpreter services education at the hospital.

2. During a concurrent interview and record review, on 9/28/22, at 9:20 AM, with RN 1, Patient 25's "FS", dated 9/26/22, was reviewed. Patient 25's "FS" indicated, "Language: SPANISH." RN 1 stated, both Patient 25 and FM 2 were Spanish speaking. RN 1 stated, she communicated with Patient 25 and FM 2 in Spanish when she cared for Patient 25. RN 1 stated, the hospital provided training on utilizing interpreter services for patients who do not speak English. RN 1 stated, she did not use interpreter services with Patient 25 because she (RN 1) spoke Spanish.

During a concurrent interview and record review, on 9/28/22, at 9:25 AM, with RN 1, Patient 25's "PEDIATRIC UNIT INFORMATION SHEET" (PUIS), undated, was reviewed. Patient 25's PUIS was printed in the English language. Patient 25's PUIS indicated, date of service 9/26/22, general information and safety rules for the Pediatric Department. FM 2 signed the PUIS. RN 1 stated, the facility did not have a PUIS sheet printed in Spanish language. RN 1 stated, she reviewed the PUIS with Patient 25 and her mother in Spanish and did not use interpreter services.

3a. During a concurrent interview and record review, on 9/28/22, at 11:15 AM, with Quality and Patient Safety Analyst (QPSA), Patient 1's "FS," dated 8/26/22, "CONSENT TO TRANSFUSION OF BLOOD AND/OR BLOOD PRODUCTS" (CB), dated 8/26/22, and "CONSENT FOR ANESTHESIA SERVICES" (CAS), dated 8/26/22, were reviewed. Patient 1's FS indicated, "Language: SPANISH." Patient 1's CB and CAS forms were printed in the English language. Patient 1 signed both the CB and CAS forms. Neither Patient 1's CB nor Patient 1's CAS indicated the use of interpreter services for Patient 1. QPSA stated, both of the forms signed by Patient 1were printed in English and Patient 1 preferred Spanish.


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3 b. During an interview on 9/27/22, at 11:12 AM, with RN 3, RN 3 stated, a patient's FS identified the patient's primary language and if they required an interpreter. RN 3 stated, the hospital provided interpreter services which could be accessed by phone or by video.

During a review of Patient 14's FS, dated 9/27/22, at 11:34 AM, the FS indicated, Patient 14's "Language: SPANISH" and "Interpreter Y" (yes).

During a concurrent interview and record review, on 9/28/22, at 2:30 PM, with RN 4, Patient 14's "Consentimiento para cirugia u procedimiento (Consent to surgery or procedure" (CSP), dated 9/26/22, was reviewed. The CSP indicated, Patient 14 signed his surgical consent on 9/26/22, at 8:49 AM, for a "Left Arm Fistula Thrombectomy [removal of blood clot in a fistula - connection of artery and vein for hemodialysis- cleans blood of waste products] possible revision, Fistulogram [x-ray to look at blood flow in fistula) with possible interventions." RN 4 was unable to provide documentation interpreter services were utilized prior to Patient 14 signing the CSP.

3 c. During a review of Patient 15's FS, dated 9/26/22, at 4:48 AM, the FS indicated, Patient 15's "Language: SPANISH" and "Interpreter Y."

During a concurrent interview and record review, on 9/28/22, at 2:30 PM, with RN 4, Patients 15's "Consentimiento Para Servicios de Anestesia" (CAS, consent for anesthesia), dated 9/26/22, at 6:45 AM, was reviewed. The CAS indicated, Patient 15 signed his anesthesia service consent on 9/26/22 at 6:45 AM; there was no documentation interpreter services were provided. RN 4 was unable to provide documentation interpreter services were utilized prior to Patient 15 signing the CAS.

3 d. During a review of Patient 19's FS, dated 9/20/22, at 8:13 PM, the FS indicated, Patient 19's "Language: ARABIC" and "Interpreter Y."

During a concurrent interview and record review, on 9/28/22, at 3:05 PM, with RN 4, Patient 19's "Consent to Transfusion of Blood And/Or Blood Products (CB)" dated 9/20/22, at 9:13 AM, and "Consent to Surgery (CTS)" dated 9/20/22, at 11:08 AM were reviewed. The CB and CTS indicated, Patient 19 signed CB and CTS on 9/20/22. RN 4 was unable to provide documentation interpreter services were utilized prior to Patient 19 signing the CB or CTS.

3 e. During a concurrent interview and record review, on 9/27/22, at 11:30 AM, with Patient Registration Representative (PRR), Patient 13's FS, dated 9/27/22, at 10:19 AM, and "COA", dated 9/27/22, at 10:23 AM, were reviewed. PRR stated, she asked Patient 13 her primary language which was Spanish. PRR stated, she documented Patient 13's preferred language on the FS and Patient 13's request for interpreter services. PRR stated, Patient 13's preferred language was Spanish and the FS indicated interpreter services requested. PRR stated, she had not utilized interpreter services when reviewing the COA and prior to Patient 13 signing the document. PRR stated, "I am not a qualified interpreter."

4. During an interview on 9/27/22, at 11:20 AM, with Patient 13 and FM 3. FM 3 stated, she preferred the hospital provided interpreter services for communication with hospital staff. FM 3 stated, interpreter services were not utilized by staff when Patient 13 was first admitted to hospital.

During an interview on 9/28/22, at 3:15 PM, with Quality Manager (QM), QM stated, interpreter services should be provided for all patients with LEP's.

During a review of the facility's Admission Packet Handout (APH) titled, "Patient Rights and Responsibilities," dated 9/2017, the APH indicated, "1. Considerate and respectful care. . . You have the right to respect for your culture. . . and preferences. . .To communicate effectively with your care team. Receive free and in a timely manner, aids and services if you have a disability or free language services if your primary language is not English. . .qualified interpreters and information written in other languages."

During a review of the facility's policy and procedure (P&P) titled, "Language Access for Limited English Proficient (LEP) Patients and Companions" dated 10/24/2018, the P&P indicated, "Guidelines A. Providing Interpreter Services for Meaningful Access. 1. Interpreter services, including a Qualified Medical Interpreter when needed to provide meaningful, equitable access to the Facility's services, are required for patient assessment, consent, education and discharge, including but not limited to the following circumstances: a. Determining a patient's history or description of ailment or injury; b. Obtaining informed consent or permission for treatment; c. Providing patient's rights; d. Explaining living wills or powers of attorney (or their availability); e. Explaining diagnosis or prognosis of ailments or injuries; f. Explaining procedures, tests, treatment, treatment options or surgery; g. Explaining the administration and side effects of medications, including side effects and food or drug interactions; h. Providing discharge instructions or discussing plans; i. Explaining and discussing advance directives; j. Explaining blood donations or apheresis [components of blood are removed and the rest of the blood is returned to patient]; k. Explaining follow-up treatment, test results, or recovery; l. Discussing billing and insurance issues."

Based on interview and record review, the hospital failed to provide effective pain management for two of 10 sampled patients (Patient 4 and Patient 26). This failure resulted in a violation of Patient 4 and Patient 26's right to be free from pain and had the potential to result in unrelieved pain and suffering.

Findings:

During a concurrent interview and record review on 9/28/22, at 10:52 AM, with Quality and Patient Safety Program Manager (QPSPM), Patient 26's electronic medical record (EMR) was reviewed. The EMR indicated, on 9/23/22, Patient 26 was admitted to Emergency Department (ED) for back pain. Patient 26's "Hemodynamic [dynamics of blood flow and circulatory system] and Vitals [measurements of basic body systems]" (HV), dated 9/23/22, HV indicated, at 1:32 PM, Patient 26 had a pain intensity of 9 out of 10 (Severe pain: score of 8-10 pain that interferes with activities of daily living, typically does not go away, and treatment needs to be continuous, Moderate pain: score 4-7, Mild pain: score 1-3) on the pain scale. QPSPM was unable to find documentation of pain-relieving interventions implemented including administration of medication and or physician notification to relieve Patient 1's pain. QPSPM stated, "No pain meds [medication] documented as given."

During a concurrent interview and record review on 9/28/22, at 12 PM, with QPSPM, Patient 4's EMR dated 9/23/22, was reviewed. The EMR indicated, Patient 4 was admitted on 9/23/22 with diagnoses of liver cirrhosis (late stage liver disease) and possible sepsis (body's extreme and life-threatening response to an infection). Patient 4's HV indicated, at 2:35 PM and at 6:35 PM, Patient 4 had a pain intensity of 10 out 10 on the pain scale. QPSPM was unable to find documentation of pain-relieving interventions implemented including administration of medication and or physician notification to relieve Patient 4's pain at 2:35 PM and 6:35 PM. QPSPM stated, "No [pain] meds given."

During a review of the facility's Admission Packet Handout (APH) titled, "Patient Rights and Responsibilities," dated 9/17, the APH indicated, "9. Appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions."

During a review of the hospital's policy and procedure (P&P) titled, "Pain Management," dated 2/23/22, the P&P indicated, "GUIDELINES/POLICY STATEMENT: It is the policy of . . . to ensure that all patients have access to effective and safe pain management consistent with respect for the sacredness of human life. . . 5 . . . pain-relieving interventions will be implemented, as appropriate with regular reassessment and follow-up. a. The physician will be notified when patient fails to achieve the comfort-function goal . . . 7. All members of clinical team are accountable to assist in managing the patient's pain . . . a. According to American Academy on Pain Management (2012), the patient's Bill of Rights on pain management should be an integral part of patient care approach . . . DEFINITIONS: 1. Pain Management: As a patient right, pain management extends beyond pain relief, encompassing the patient's quality of life.

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

1. The facility's policy and procedure titled "Fall Prevention and Management" was followed for three of ten patients (Patient 5, Patient 7 and Patient 10) when fall assessments were not completed every shift. This failure had the potential for Patient 5, Patient 7 and Patient 10 to have unmet care needs and risk of falls. (Refer A-0396)

2. The emergency department (ED) triage (assessment of patients to determine the level of care needed) and obstetrical (OB, care of women during and after pregnancy) emergency triage nursing staff were competent to assess, prioritize care, identify signs and symptoms of a potential obstetrical medical emergency for one of one (Patient 1) sampled patients. This failure resulted in a delay in the identification and care of Patient 1's medical emergency resulting in the death of Patient 1's baby. (Refer A-0397)

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure nursing care needs of patients were met and nursing competency in the triaging pregnant patients.

Based on interview and record review, the hospital failed to ensure nursing staff followed the facility's policy and procedure titled "Fall Prevention and Management" for three of ten patients (Patient 5, Patient 7 and Patient 10) when fall risks assessments not done each shift. This failure had the potential for Patient 5, Patient 7 and Patient 10 to have unmet care needs and risk of falls.

Findings:

During a concurrent interview and record review on 9/28/22, at 1:30 PM, with Quality Patient Safety Program Manager (QPSPM) and Quality Manager (QM), Patient 5's Electronic Medical Record (EMR - all patient records related to patient admission, medical history, assessments, care/treatments and discharge) Fall Risk Assessments were reviewed. QPSPM was unable to find a completed fall risk assessments for Patient 5 by the day shift nurse on 8/25/22, the day shift nurse on 8/26/22 and the night shift nurse on 8/26/22. QPSPM stated, "It's [fall risk assessment] not documented." QM stated, the day shift nurse did not complete Patient 5's fall risk assessment on 8/25/22, and both the day and night shift nurses did not complete Patient 5's fall risk assessment on 8/26/22.

During a concurrent interview and record review on 9/28/22, at 2:25 PM, with QPSPM, Patient 7's EMR Fall Risk Assessments were reviewed. QPSPM was unable to find a completed fall risk assessments for Patient 7, by the night shift nurse on 9/21/22. QPSPM stated, the night shift nurse did not complete Patient 7's fall risk assessment. QPSPM stated "It's [fall risk assessment] missed."

During a concurrent interview and record review on 9/28/22, at 4 PM, with QPSPM, Patient 10's EMR Fall Risk Assessments were reviewed. Patient 10's Fall Risk Assessment, dated 9/27/22, indicated, the night shift nurse did not complete Patient 10's fall risk assessment. QPSPM stated, "There's no [fall risk assessment] documentation."

During a review of the hospital's policy and procedure (P&P), titled "Fall Prevention and Management Policy and Procedure" dated 7/26/22, the P&P indicated, "PROCEDURE OR PROCESS: 1. Assessment and Reassessment a. The patient's fall risk will be assessed at the time of initial physical assessment, at the time of admission, every shift, upon transfer to another level of care, and after a patient fall per Core Standard of Practice."

Based on interview and record review the facility failed to ensure emergency department (ED) triage (assessment of patients to determine the level of care needed) nurses and obstetrical (OB, care of women during and after pregnancy) ED triage nurses provided complete and timely assessments, identify signs/symptoms of a potential obstetrical medical emergency and prioritize the care for one of one pregnant patients (Patient 1). This failure resulted in a delay in the identification and care of Patient 1's medical emergency resulting in the death of Patient 1's baby (Patient 31).

Findings:

During a concurrent interview and record review on 9/15/22, at 11:08 AM, with Registered Nurse (RN) 5 and Quality Manager (QM), RN 5 stated, Patient 1 arrived at the Obstetrical Emergency Department (OB ED) triage on 8/26/22, at 3:38 PM, via (by) wheelchair accompanied by the ED RN 8. RN 5 stated, RN 8 did not contact OB ED before he transferred Patient 1 to the OB ED. RN 5 stated, she interviewed Patient 1 in the OB ED waiting room because the examination room was being cleaned. RN 5 stated, Patient 1 had no outward signs of pain. RN 5 stated, Patient 1 spoke Spanish. RN 5 stated, she did not use interpreter services when she communicated with Patient 1. RN 5 stated, she did not complete a maternal and a fetal assessment when Patient 1 arrived to the OB ED.

During a concurrent interview and record review, on 9/15/22, at 11:15 AM, with Director of Obstetrics (DOB), and Quality Manager (QM), Patient 1's Electronic Medical Record (EMR) was reviewed. DOB stated, staff should perform a patient assessment "as soon as possible." QM was unable to provide documentation, in Patient 1's EMR, an OB nurse completed a maternal and a fetal assessment when Patient 1 arrived at the OB ED on 8/26/22. QM stated, Patient 1's EMR did not contain OB ED documentation for Patient 1 on 8/26/22 until 4:03 PM (Patient 1 arrived to OB ED 8/26/22 at 3:38 PM).

During a concurrent interview and record review, on 9/15/22, at 11:45 AM, with RN 5, RN 5 stated, she did not check for Patient 1's prenatal records (provides information regarding the past and present health of the patient and serves as a database) while she was in the OB ED. RN 5 stated, she did a "quick assessment" in the OB ED waiting room and took Patient 1 to the examination room at 4:03 PM. RN 5 stated, Patient 1's blood pressure was 78/39 (systolic/diastolic - Systolic blood pressure measures artery pressure when heart beats. Diastolic blood pressure measures artery pressure when heart rests between beats. Normal blood pressure 120/80 mm Hg. Hypotension [low blood pressure] is systolic 90 or less or diastolic of 60 or less. Symptoms may include blurred or fading vision, dizziness or lightheadedness, fainting, fatigue and nausea.) mmHg (millimeters of mercury - unit of measurement). RN 5 stated, she placed the tocodynamometer (toco - records the pressure force during uterine contractions) and fetal (baby) heart rate monitor on Patient 1's abdomen. RN 5 stated, Patient 1's fetal heart rate (FHR) was 58 beats per minute Patient 1's "FHR MHR [maternal heart rate] SPO2 [Saturation of Peripheral Oxygen - blood oxygen level] UA [measures uterine activity (hollow muscular organ where baby develops. The uterus contracts or squeezes during labor)]." Patient 1's Fetal heart rate document (FHRDOC), dated 8/26/22, was reviewed with RN 5. The FHRDOC indicated, at 4:04 PM, toco applied [data recorded], 4:05 PM, FHR data was recorded. RN 5 stated, Patient 1's FHR was 58 (bpm) (Fetal bradycardia [slow heart rate] less than 100 beats per minute, can indicate baby has inadequate oxygen supply.) RN 5 stated, she notified the OB hospitalist (OBH-physician who evaluates and provides medical screening examination [MSE]) and called an OB Alert (obstetrical emergency). RN 5 stated, Patient 1 was taken to the operating room for an emergency cesarean section (C/S, surgical delivery of baby) for possible uterine rupture (life threatening emergency resulting from tearing open of the uterine wall.)

During a review of Patient 1's "Event Notes," dated 8/26/22, at 16:15, Event Notes indicated, "Patient arrived via gurney [hospital bed on wheels] to ORA [operating room A], [anesthesiologist, provides pain control and sedation medications] paged overhead."

During an interview on 9/15/22, at 12 PM, with RN 8, RN 8 stated, Patient 1 was seen in the ED on 8/26/22. RN 8 stated, "I could not understand her (Patient 1) because she speaks Spanish." RN 8 stated, he documented in Patient 1's EMR the information obtained through the Spanish speaking interpretation by RN 9 and FM 5. RN 8 stated, RN 9 told him Patient 1 reported pelvic pain for two hours and weakness for one hour. RN 8 stated, Patient 1 would not sit still when he was trying to take her blood pressure. RN 8 stated, Patient 1 threw up and "still having pain it seemed." RN 8 stated, he took Patient 1 by wheelchair to the OB ED without calling report (indicates current situation, background and assessment) to the OB ED. RN 8 was unable to provide documentation he provided hand off communication/report (a transfer of patient information and acceptance of patient care responsibility achieved through effective communication) to OB RNs.

During a concurrent interview and record review on 9/15/22, at 12:06 PM, with RN 8, Patient 1's "General Information" form, dated 8/26/22, was reviewed. The General Information form entry by RN 8, at 3:19 PM indicated, "Arrival time [to ED] 3:12 PM. 3:15 PM Chief Complaint ED Pt (Patient 1) 33 weeks and c/o [complaint] of pelvic pain." RN 8 stated, he was aware Patient 1 had a previous cesarean section because she had a "big scar" on her abdomen. RN 8 stated, he did not obtain the cesarean section history from Patient 1 because he (RN 8) "can't understand Spanish." RN 8 stated, Patient 1's fetal heart rate was 157 beats per minute (bpm) and blood pressure was 85/45. RN 8 stated, Patient 1's low blood pressure indicated she was hypotensive. RN 8 stated, if a non-obstetrical patient with hypotension presented to the ED, he (RN 8) would contact the medical doctor (MD) or midlevel (Physician's assistant or Nurse practitioner) and the patient would not be considered stable. RN 8 stated, he did not notify the ED MD because Patient 1 was an OB patient and she would need to be seen by an OB doctor. RN 8 stated, he did not take another blood pressure prior to taking Patient 1 to OB ED. RN 8 stated, he did not assess or document Patient 1's pain level.

During an interview on 9/15/22, at 12:15 PM, with RN 8 and Emergency Department Director (EDD), EDD stated, it was not the hospital policy to use staff to provide interpretation for patients with limited English proficiency. EDD stated, abnormal vital signs should be reported to the MD or Midlevel by the RN. RN 8 stated, a pain level should be obtained, but he did not speak Spanish so he did not ask for Patient 1's pain level.

During an interview on 9/21/22, at 10 AM, with RN 7, RN 7 stated, OBH was present when Patient 1 presented to the OB ED, on 8/26/22, at 15:38 (3:38 PM). RN 7 stated, an OB assessment of the patient should be started upon arrival to the OB ED which would include history, chief complaint, application of EFM (external fetal monitor - monitor and records uterine contractions and fetal heart rate), vital signs, and urine sample. RN 7 stated, staff would obtain the patient's prenatal records. RN 7 stated, Patient 1 arrived to OB ED by wheelchair by RN 8 from the ED. Patient 1 stated, Patient 1 was not "thrashing" (moving wildly) or verbally expressing pain. RN 7 stated, she was within "earshot" of Patient 1's report and heard abdominal pain and fetal heart rate of 150 but did not "take" report from RN 8. RN 7 stated, there was no assignment of who would take Patient 1 upon arrival between RN 6 and RN 7 (OB ED triage nurses assigned to unit). RN 7 stated, she was admitting another patient and there were no beds available when Patient 1 arrived to OB ED. RN 7 stated, the room only needed the linen changed. RN 7 stated, later she changed the linen in the examination room to prepare for Patient 1. RN 7 stated, RN 8 took Patient 1 to the OB ED waiting room. RN 7 stated, she notified the charge nurse (RN 5) they (OB nurses) needed assistance in triage because they were busy. RN 7 was unable to provide documentation the charge nurse had been notified. RN 7 stated, Patient 1 "appeared stable" and based on the information provided by RN 8, the assumption was Patient 1 was stable therefore, there was no reason to call the OB manager. RN 7 stated, she did not know Patient 1 had prior cesarean sections because no one spoke with Patient 1. RN 7 stated, she did not check on Patient 1 while she was waiting the OB ED.

During an interview on 9/22/22, at 10 AM, with RN 6, RN 6 stated, RN 7 notified her Patient 1 was in the OB ED waiting room (no time provided). RN 6 stated, there was no determination of which triage RN (RN 6 or RN 7) nurse would be assigned to care for Patient 1. RN 6 stated, she did not review Patient 1's ED handoff tool in the EMR. RN 6 stated, Patient 1 was not put in a room because the room needed to be turned over (cleaned after patient use). RN 6 stated, she did not determine Patient 1's emergency severity index (ESI - determines frequency of patient reassessment, severity of condition and helps prioritize order to be seen by a Qualified Medical Professional). RN 6 stated, the patient's ESI should be determined throughout report including a visual examination and assessment of the patient.

During an interview on 9/22/22, at 1:09 PM, with Patient 1 and Family Member (FM) 4, FM 4 stated, Patient 1 said, she went to the hospital with her friend (FM 5) because she was having pain. FM 4 stated, Patient 1 said, when she was in the ED, she told RN 8 she was having pain in her stomach, nausea, blurry vision, and she felt like she was going to pass out. RN 8 told her these symptoms were normal. FM 4 stated, Patient 1 said, they tried different blood pressure machines because they could not get her blood pressure. FM 4 stated, Patient 1 said when she was in the OB ED, staff told her to wait in the waiting room because they did not have a room ready. FM 4 stated, Patient 1 said, she was told to walk from the waiting room to the examination room and they would not provide a wheelchair even though she was weak and in pain.

During an interview on 9/22/22, at 1:45 PM, with FM 5, FM 5 stated, she took Patient 1 to the ED on 8/26/22 because Patient 1 had "a lot of pain in her tummy" but not labor pain. FM 5 stated, she told the nurse, Patient 1 was scheduled for a C/S on 10/12/22. FM 5 stated, Patient 1's OB MD told her to go to the ED if she had pain. FM 5 stated, she told RN 9, Patient 1 had two prior C/S, baby had not been moving since pain started, and Patient 1 was weak. FM 5 stated, she was told Patient 1 had to register before she could be seen. FM 5 stated, RN 8 could not get Patient 1's blood pressure and she was not seen by an MD. RN 8 took Patient 1, in a wheelchair, to the OB ED front desk. FM 5 stated, there were three "nurses" at the desk and Patient 1 was told there were no rooms available. FM 5 stated, Patient 1 was told to get out of wheelchair and walk to the waiting room. FM 5 stated, she told the nurse, Patient 1 was thirsty, weak, sweating, and had more pain. FM 5 stated, no one came to the waiting room to check on Patient 1. FM 5 stated, Patient 1 waited for about "30 minutes" in the OB ED waiting room. FM 5 stated, she went up to the nurses' station to ask them to check on Patient 1 three times, but they did not come to the waiting room. FM 5 stated, RN 5 came to the waiting room when Patient 1's room was ready. FM 5 stated, she told them Patient 1 did not speak English. FM 5 stated, they used her to translate for Patient 1 and the staff. FM 5 stated, RN 5 made Patient 1 walk to the examination room when it was ready even though she asked for a wheelchair because she was weak and in more pain. FM 5 stated, RN 5 checked the baby's heart rate and "ran out" of the room. FM 5 stated, she was told Patient 1 would need an emergency C/S. FM 5 stated, "I told her and they didn't listen to me."

During a concurrent interview and record review, on 9/29/22, at 9 AM, with RN 8, Patient 1's ED to L&D (labor and delivery) Hand-Off Communication Tool" (EDHCT), dated 8/26/22, at 3:20 PM was reviewed. The EDHCT indicated, Patient 1's arrival time to the ED was on 8/26/22 at 3:15 PM, Time of evaluation (by RN 8) 3:19 PM, ED/MCH (maternal child health) transfer reason: Sent to OB for obstetric evaluation, Chief Complaint ED: pt. 33 weeks and c/o pelvic pain, Physician Name, Has patient been seen by ED physician: No, Is patient to be returned to ED: No. . .documented by RN 8, 8/26/22, at 3:19 PM. Patient 1's "OB Assessment of ED Patient > (greater than) 20 weeks" (OBA), was reviewed, OBA indicated, Chief complaint ED: Pelvic pain x 2 hrs (greater than 2 hours) weakness started 1 hour ago. Gravida Maternal: 3 Para: 2, Fetal Heart Rate Baseline: 157 bpm Uterine contractions: No Uterine Contraction, monitoring: N/A (not applicable) Fetal Movement: yes [amniotic, fluid surrounding baby] Leaking Fluid, Per Patient: No, Bleeding controlled: No. . . documented by RN 8 on 8/26/22, at 3:20 PM. RN 8 confirmed the information documented on the EDHCT.

During an interview on 9/29/22, at 9:08 AM, with RN 8 and EDM, RN 8 stated, he was unable to obtain Patient 1's blood pressure with the blood pressure machine, so he changed blood pressure cuffs. RN 8 stated, Patient 1's blood pressure was 85/45. EDM stated, Patient 1's blood pressure did not meet the parameters for activation of an OB Alert. EDM stated, the policy indicated an acute (sudden or severe change) or evolving systolic BP <90 (less than ) would be an indication to activate an OB Alert. The facility was unable to provide additional BP readings for Patient 1 in the ED.

During a review of Patient 1's "EN", dated 8/26/22, the EN indicated:
4:03 PM, "Pt in room 101, Pt presented at 33+5 weeks (33 weeks plus 5 days pregnant), G 3 P 2. Pt is a repeat c/s x 2 (2 prior cesarean sections). Pt denies uc's (uterine contractions) rom (rupture of membranes-water broke), or vaginal bleeding. Pt states her baby is measuring small, but denies any other problems of pregnancy. Pt states she has been having constant lower abd (abdominal) ..." Performed by RN 5.

4:08 PM indicated, "OBH notified of Pt BP 78/39, constant abdominal pain (repeat) c/s x 2, pt HR (heart rate) 83. OB Alert called. L and D (labor and delivery) called to open or (operating room) and call anesthesia (anesthesiologist), NICU (neonatal intensive care unit), and (Patient 1's) OBMD for emergency c/s ..." Performed by RN 5.

4:15 PM "pt arrived via gurney to ORA (operating room A), Anesthesiologist paged overhead ..." Performed by RN 10.

4:17 PM "late entry: OBMD to ORA, fetal heart tones attempted with Doppler (electronic device used to measure fetal heart rate), unable to obtain, EFM monitor applied, unable to obtain FHR, Informed OBMD and OBH unable to obtain FHTs ..." Performed by RN 11.

During review of Patient 1's "Physician Note," dated 8/26/22 at 7 PM, the Physician Note indicated, "History of Present Illness Fetal movement Last felt baby move at home prior to coming in. . .Patient presents to OBED with constant lower abdominal pain. History is limited as patient was found to be hypotensive with FHT in 50s. Previous cesarean section x 2." . . . Obstetric exam Singleton (one)/ Baby A fetal evaluation: heart tones [heart rate] (rate and rhythm fetal bradycardia (less than 110 bpm for 10 minutes or longer. FHT 50s. . .FHR Tracing reviewed ..." Documented by OBH.

During review of Patient 1's "History and Physical," dated 8/26/22, at 8:55 PM, the History and Physical indicated, "History of Present Illness Patient 1 is a 33 year old. . . She presented to OB ED with constant lower abdominal pain. History is limited as patient was found to be hypotensive with FHT in 50's. Previous cesarean section x 2. She was taken immediately to labor and delivery for emergent cesarean section. . .Hx (history) of CLASSICAL CESAREAN SECTION ..." Documented by OBMD.

During a review of Patient 31's "NEONATAL RESUSCITATION RECORD" (NRP), dated 8/26/22, the NRP indicated, "Date/time of birth 8-26-22/4:24 PM APGAR SCORE [a measure of the physical condition of a newborn infant. Obtained by adding points (2, 1, or 0) for heart rate, respiratory effort, muscle tone, response to stimulation, and skin coloration; a score of ten represents the best possible condition. A score of 0 indicates no heart rate, respiratory effort, muscle tone, response to stimulation, and blue skin coloration]"

Apgar at 1 minute and 5 minutes after birth:
color: 0 Blue/pale
Heart rate: 0 Absent
Reflex irritability: 0 No response
Muscle Tone: 0 Limp
Respiration: 0 Absent

Apgar at 10 minutes after birth:
color: 1 acrocyanotic (arms and legs blue)
Heart rate: 1 less than 100
Reflex irritability: 0 No response
Muscle Tone: 0 Limp
Respiration: 0 Absent

During review of Patient 31's History and Physical, dated 9/26/22, at 9:54 PM, the History and Physical indicated, "Admission diagnosis. 1. Severe hypoxic ischemic encephalopathy (type of brain injury that occurs when the brain experiences a decrease in oxygen or blood flow) 2. Uterine rupture (mother). . .history of 2 classical cesarean section deliveries. . .History of delivery. . .baby was resuscitated with elective oral intubation (tube to breath inserted into lungs),. . . cardiac compressions (pressure on chest above heart to mimic how the heart pumps to help keep blood flowing throughout the body). . . Following this this baby's heart rate initially stabilized and baby was transferred to the newborn intensive care unit. . . the baby once again deteriorated requiring full CPR [cardiac (heart) pulmonary (lung) resuscitation (attempt to revive a person) resuscitation. . .I explained baby's severe acidosis [high amounts of acid in baby's blood from decreased oxygen levels] extremely poor chance of survival. . .Father expressed a desire to not continue painful interventions." Documented by Neonatologist (NEOMD - MD specializing in newborn's critical care needs.)

During review of Patient 31's "Discharge Summary" (DC), dated 9/26/22, at 10:03 PM, the DC indicated, [Patient 31] Date and Time of death 8/26/22 at 5:42 PM ...Documented by NEOMD.

During a review of the facility's policy and procedure (P&P) titled, "Obstetrical," dated 2/11/21, the P&P indicated, "A medical record is created and maintained on every obstetrical patient seeking obstetrical emergency care ...The Labor and Delivery Obstetrical Emergency Department (OB ED) OB Hospitalist or provider on record and OB ED nursing (RN) are responsible for completing documentation in the electronic medical record (EHR) ...1. Obstetrical Emergency Department Nurse a. An OB ED nurse or designated licensed staff member will obtain initial vital signs on OB patient's arrival to OB ED. b. The OB patient will be assigned an emergency severity index (ESI) upon arrival to the OB emergency department. c. All OB patient arrival data including time of OB patient arrival, initial OB ED assessment, sepsis [life threatening response to infection] screening documentation, and fall risk screening will be documented in the electronic health record (EHR). . .e. Continuous OB patient care assessment includes physical reassessment and vital signs depending upon the OB patient's ESI level and severity of their OB medical condition. . .Pain level will be assessed with vital signs. . .Document pain level in the EHR."

During a review of the facility's P&P titled, "Chain of Command (COC): Communication of Patient Care Concerns," dated 2/2018, the P&P indicated, "All hospital and medical staff should take whatever action is necessary and appropriate to ensure that patients receive quality care. . .Do not delay care to the patient. There should be prompt progression through the chain of command. . . RN/clinician should provide patient care while the immediate supervisor escalates issue up the chain of command until it is resolved. . . Documentation should include: 1. care provided. . .3. Time of all notifications or attempted notifications 4. Individuals contacted."

During a review of the facility's P&P titled, "Obstetrical Patient Triage in the Emergency Department or Obstetrical Emergency Department," dated 2/2021, the P&P indicated, " 1. A Registered Nurse will determine the following for women who state they are pregnant and present to the Emergency Department (ED) or Obstetrical Emergency Department (OB ED): a) chief complaint. . .3. Obstetrical patients who present to the ED: a) Patients greater than or equal to 20 weeks with a life threatening condition or who are medically unstable (in association with or independent to their pregnancy) will remain in the ED and the OB ED RNs will be notified. . .b) Patients greater than or equal to 20 weeks with an OB related chief complaint that present to the ED will have vital signs taken. If the patient is without a life threatening condition, OB Ed is notified and the patient will be transferred to OB ED."

During a review of the facility's P&P titled, "Triage in the Emergency Department", dated 3/20, the P&P indicated, "A triage qualified Registered Nurse (RN) will perform a brief, focused assessment and assign the triage acuity level, as soon as possible after the patient's arrival to the ED. Based on the acuity and patient flow the triage trained RN will prioritize treatment based on the patient's Emergency Severity Index (ESI) acuity level. . .1. Walk in patients will be assessed by the Quick Look RN to determine the patient's acuity. If the patient is deemed to be a medical emergency then they will be seen by a provider as soon as possible and the charge RN notified. . .ALL pregnant patients, who present to the ED with a life threatening emergency will remain in the ED for their MSE. In these cases, the OB hospitalist will respond to the ED. Patients > = [greater than or equal] to 20 weeks and do not have a life threatening condition will be transferred to labor and delivery (L&D) department. The MSE will be initiated in L&D. Prior to transfer the ED triage nurse will: a. Obtain a full set of VS [Vital Signs, Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure] b. Obtain fetal heart tones. . . Call the L&D and give report e. Make arrangements for transportation to L&D 3. In event of . . .OB emergency then the ED staff will call an OB alert and place the patient in an ED room for treatment. Attachment B. . .Severe pain/distress is determined by clinical observation and/or rating of greater than or equal to 7 on 0-10 pain scale [tool use to help assess a person's pain indicating pain level with 0 as no pain to 10 severe pain."

During a review of the facility's P&P titled, "OB Alert," dated 10/21, the P&P indicated, "The purpose of this policy is to provide guidelines for the effective assessment and early intervention of patients with impending or actual Obstetrical Emergencies and conditions warrants additional resources. An OB alert should be initiated when an Obstetric Emergency occurs within the Emergency Department, Labor and Delivery. . .1. [Facility name] has an OB alert policy to prevent delays and increase efficiency and resources in an Obstetric Emergency 2. The role of the OB Alert team is to assess and act accordingly to an Obstetric Emergency . . . DEFINITIONS: An Obstetric Emergency is defined and an OB Alert may be called but is not limited to the following situations for pregnant patients greater than or equal to 20 weeks gestation. . . 9. Acute changes in: b. Systolic blood pressure less than 90. . .Procedure. . .Dial 77 and report an "OB Alert". . .ASSIGNMENT OF DUTIES 1. Primary RN (either OB triage RN. . .or ER RN. . .) a. Responsible for initial assessment and recognition of Emergency Situation. . .Notify Charge RN of situation monitor patient appropriately. d. Initiates OB Alert. . .3. Ensures IV access (i.e. . .patient is medically unstable [hypotension is a sign of unstable blood flow])."