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ADVENTHEALTH OCALA 1500 SW 1ST AVE OCALA, FL 34474 May 12, 2016
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on medical record review, and interview revealed that the facility failed to have patient medical record information for 1 of 10 patients (patient #1, such as assessments in the patient's medical record in order to be available to the physician and other care providers to use in making assessments of the patient's condition, to describe the patient's progress, and to describe the patient's response to medications, interventions, and services, on the provision of care to the patient.

Findings:

Interview on 05/12/16 at 11:15 AM ,with Staff A stated " I was patient #1-baby mothers nurse on 03/24/16 during labor and delivery, which patient #1 was delivered vaginally at 4:03 AM on 03/25/16. The mother was not following instructions during childbirth and panicking the hole time. The mother kept saying that she was a big baby and could not handle pain. Baby #1 head was delivered with tight nuchal cord wrapped around his head and body. I instructed the mother to continue to push and she started screaming and dropped her legs and refused to push. I was with the mother the entire delivery and never left her side. I noticed a deceleration of the FHR ( Fetal Heart Rate) in the 60's at 2:45 AM, and I felt that it is up to the provider, the CNW ( Certified MidWife)to call the physician if a C-section was needed. I did all nursing intervention to improve oxygenation and to increase FHR by repositioning the patient to alleviate possible cord compression or increased utero placental perfusion, administered oxygen ()2) at 10 liters (L), increased Intravenous (I.V.) fluids, and the CMW was encouraging the patient to have a natural childbirth. "

Interview on 05/12/16 at 11:00 AM, Nurse Manager of Women ' s Surgery and Post-Partum stated that when she was asked if she was familiar and have seen the Code Blue Neonatal Resuscitation worksheet, she stated "No I am not."

Interview on 05/12/16 at 12:15 AM, Charge Nurse, Staff C stated that when she was asked if she knew what the Code Blue Neonatal Resuscitation worksheet was, she stated "No I do not."

Interview on 05/13/16 at 6:05 PM, Nursery Nurse, Staff D stated that when she was asked if she knew what the Code Blue Neonatal Resuscitation worksheet was, and if she had documented with the staff present on 03/25/16 during the Code Blue neonatal Resuscitation, she stated, "I'm not familiar with the form, and wasn't aware of anyone doing documentation of Code Blue for patient #1 that day."

Review of the nurse's notes in the medical record of patient #1 revealed that on 03/25/16 at 03:52 AM the Nursery registered Nurse (RN) Staff D was at bedside and discussed calling the physician due to poor maternal effort and FHR pattern. Urged mother to push harder. The baby's mother was crying and saying I can't push. At 04:05 AM the decision was made to call the physician to aid in the delivery. At 04:07 the physician was called for delivery. at 04:09 AM the head of the infant delivered with tight nuchal. The Certified Nurse Midwife (CNM) reduced the nuchal and shouted for the mother to push. The mother stated screaming and dropped her legs and refused to push. The CNM lifted the mothers head up to aid in moving the infant down. At 04:12 AM the mother was still screaming for others to pushed the infant out, called for more staff and the neonatologist to attend. canceled the call to the delivery physician to delivery of the infant's head. The infant was delivered at 4:13 AM, limp and blue. Cords clamped and infant to the warmer where nursery staff tended to the infant. APGAR scores were 0/0/0, meaning no heart rate, no respiratory effort, and no muscle tone. (APGAR score -evaluation of an infant ' s physical condition, usually performed one minute and five minutes after birth. A low one minute score requires an immediate intervention, including giving oxygen, clearing the nasopharynx, and usually transfer to an intensive care nursery. A baby with a low score that persists at five minutes requires expert care, which may include assisted ventilation, umbilical catheterization, cardiac massage, blood gas evaluation, medication to correct acid-base deficit, or medication to reverse the effects of maternal medication.)

A Neonatal Code Blue was called for respiratory arrest of a newborn, on 03/25/16 at 4:17 AM.
Record review did not reveal a Neonatal Code Blue Record for patient #1 on 03/25/2016 that showed documentation that Respiratory Therapy, neonatologist, Nursery RN's, or any physicians were present or any documentation of their role in the resuscitation.


Review of the facility's Code Blue Policy and Procedure's for Emergency Response Team Code ABC, Code Blue revealed the following:

Personnel- The following personnel will respond to " Code ABC " .
Neonatal Resuscitation team:
Respiratory Therapist
Emergency Department (ED) physician
Certified Nurse Midwife (when available)
Anesthesia (when available)
Neonatologist or any Pediatrician when available
Nurse Manager (days)/administrative Supervisor (nights)
Registered Nurse (RN) Labor and Delivery (L&D)
RN Nursery

Responsibilities of Neonatal Team Responders
In effect when the Neonatal Code Team arrives- the Administrative Supervisor (7 PM-7 AM) or the RN Nursery Team Leader is the recorder and assists in Code Blue Protocols

DOCUMENTATION
RN assigned to patient:
Complete the Neonatal Resuscitation worksheet
a. White copy-Mom ' s chart
b. Yellow copy-Nursery
c. Pink copy-manager



After review of patient #1's medical record it did not reveal a Code Blue resuscitation work sheet completed by staff that were present on the Code Blue on 03/25/16.

Patient #1 was stabilized and sent to another hospital with a higher level of care after acceptance from that physician at approximately 8:10 AM on 03/25/16.