The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GULF COAST MEDICAL CENTER LEE HEALTH 13681 DOCTORS WAY FORT MYERS, FL 33912 Oct. 7, 2014
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
Based on a review of discharge records and interview with clinical and management staff, the hospital failed to ensure discharge instructions were given to patients in an language they were able to understand for 3 (Patients #6, #7, and #8) of 3 patients reviewed whose primary language was Spanish.


The findings include:


1. Review of the clinical records for Patients #6, #7, and #8 documented they were primarily Spanish-speaking. According to their nursing evaluations, they needed their instructions in Spanish. In Patient # 6, #7, and #8's record, the discharge instructions were given to the patient in English. There was no documentation in the record to indicate the discharging nurse provided the instruction to the patient in Spanish.

The nurse educator confirmed this in an interview during each record review done on 10/6/14 between 10:30 a.m. and 1:00 p.m.


2. During an interview on 10/7/14 at 11:33 a.m., the risk manager said there was no way for the nurse to provide these instructions in Spanish to the patients. The computer has other information that was translated to Spanish to give to patients (in fact multiple different languages including: Japanese, Italian, and German, plus others) such as consents and instruction sheets. They do not provide the discharge instruction to the patient in any other languages than English. There was no documentation the other instruction sheets were utilized in patient teaching.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on a review of the adverse incident report and interview with the risk management and administrative staff, the hospital failed to ensure there were quality assurance activities performed as a part of the plan of correction.


The findings included:


1. The adverse incident report, including a plan of correction, dated 9/5/14 was reviewed. There was no quality assurance monitoring included in the plan of correction. When the director of the obstetrics (OB) unit was questioned on 10/7/14 at 1:00 p.m., she said she had performed in-service education for her staff except for the ones who were on leave.


2. During an interview on 10/7/14 at 1:00 p.m., the risk manager and the director of the OB unit confirmed they have not been performing any monitoring of the staff after the in-service education was provided. They were unsure the education provided was effective and sustained.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure patient's needs were met by qualified nursing personnel, for one (Patient #2) of 10 patients reviewed for labor and delivery care.


The finding included:


Review of the medical record for Patient #2, documented the obstetrics patient entered the hospital on [DATE] at 10:27 a.m. The rupture occurred (water broke) at 12:35 p.m. Active labor started at 2:00 p.m. Patient#2 delivered Patient #11 at 10:12 p.m. on 8/15/14.

Patient #2 was started on a Pitocin intravenous drip (to induce labor) at 11:30 a.m. and was given an epidural anesthetic at 2:45 p.m. (local pain relief).

At 7:41 p.m., Staff B was noted to be at the bedside to evaluate the patient. A manual cervical exam was done at this time (by Staff B) with dilation noted as 7. Another manual cervical exam was done by Staff B at 8:45 p.m., with dilation noted as complete.

Staff D nurse's note, at 8:44 p.m., documented Staff B was notified by Staff F, regarding "late decels (decelerations of fetal heart tone) and that Pt. was complete (ready for delivery), asked to attend delivery."

Review of a policy/procedure entitled "Certified Nurse Midwife (CNM)Clinical Privileges," dated June 2014, documented "It is recommended that the CNM seek consultation with the supervising physician regarding the disposition of women who present with the following conditions. These lists are adjunct to good clinical judgment and are not inclusive of all possible complications. Obstetrical complications including: Known significant fetal (baby) anomalies."

Upon interview of Staff B, Staff D and Staff F, on 10/7/14, it was said "deceleration of fetal heart tone" represents a significant fetal anomalie (abnormality) that requires physician notification.

During an interview at 9:30 a.m., Staff B stated "I was not notified regarding the deceleration until the patient was complete (fully dilated)." When asked if she had reviewed the fetal heart tone monitoring records, at any time during Patient #2's labor (8 hours and 45 minutes); she stated "No, I rely on the nurses to notify me if anything is wrong. It was busy that day, I was delivering 4 or 5 other babies. I suppose I should have looked (at the fetal heart tone monitoring records)."

During an interview on 10/7/14 at 10:30 a.m., Staff D stated "this was my first week out of orientation (assignment to Patient #2) and that is why I had my charge nurse involved in this care." Staff D acknowledged that fetal heart tones had some decelerations at 7:30 p.m., but said Staff B examined the patient at 7:40 p.m. This examination was documented in the medical record.

During an interview on 10/7/14 at 11:00 a.m., Staff F said she had no special training to be a charge nurse and she had a patient assignment the evening of 8/15/14 and she had troubleshooting responsibilities. She stated (referring to Patient #2) "would want the baby to be delivered sooner rather than later."

Staff C and Staff E, during interview on 10/7/14, acknowledged the physician should have been notified regarding the baby's heart rate abnormality. Staff C at 9:30 a.m., said the physician is not in the hospital, but can be reached immediately via telephone. Staff C said this service is for patients on Medicaid.

During an interview on 10/7/14 at 9:30 a.m., Staff B stated Patient #2 "had a thick band that the baby kept hitting" after she was fully dilated at 8:45 p.m. The medical record noted an episiotomy (surgical laceration) was performed at approximately 10:12 p.m., and the infant was subsequently delivered. When asked why the episiotomy (done after full dilation for 87 minutes) was not done earlier, Staff B did not respond. It was noted, in the medical record, the baby had tachycardia (rapid heart rate) prior to delivery.

Upon delivery, there was documentation of a neonatal consult on 8/15/14 at 10:33 p.m., "the infant was born without respiratory effort. Bag and mask ventilation was given. Infant was profoundly hypotonic and IV (intravenous fluid) was being inserted. The infant was assessed to have severe [DIAGNOSES REDACTED] (brain damage). Diagnoses: Full-term, appropriate for gestational age infant; severe perinatal hypoxic [DIAGNOSIS REDACTED]; severe metabolic acidosis; respiratory failure secondary to hypoxic [DIAGNOSIS REDACTED]."
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
Based on an interview and review of discharge records, the hospital failed to ensure the discharge summary was complete and contained an accurate and complete summary of the care provided for 6 (Patients #1, #2, #3, #6, #7, and #8) of 10 sampled patients.


The findings included:


1. Patients #1, #2, #3, #6, #7, and #8 were discharged from the hospital following delivery of a baby. Review of the discharge summary form in each of these patients records documented admission and discharge date s, the attending physician, the reason for admission. No final diagnoses was documented.
Problems addressed during the the hospital stay were noted as one line sentences including the following type statements: "postpartum care and examination immediately after delivery," "pregnancy," "indication for care or intervention in labor or delivery."

Under hospital course, it indicated the patient's age and she had a normal vaginal delivery. There was no mention the patient was inducted. There was no mention if the mother and baby went home together.

Under consultants, it does not mention if consults were obtained.

Under labs, it directs to see the computer, with no mention if any labs were done during the hospital stay. It does indicate the diagnostic tests performed was labor checks and there was no co-morbidities and complications.

The condition at discharge was identified as stable without a description of what was the patient's appearance.

A medication list was documented with the medications started and stopped.

The discharge instructions were not documented in this report; it does indicate the nurse was to review and give written copy prior to discharge. It did indicate to follow-up with the doctor, but no specific timeframes were noted.


2. During an interview on 10/7/14 at 9:30 a.m., the nurse midwife said they do these when the patient is discharged . The form is already preloaded into the computer and they only "click" on things that are included. They do no personalize it for each patient. They do not write any additionally documentation about the particular patient.


3. An e-mail provided by the risk manager from the hospital system medical director included the following information: "Upon discharge, a discharge summary shall be completed and signed by the attending physician for all patients hospitalized for over 48 hours except for normal newborns and uncomplicated obstetric deliveries. In these case, a final progress note including the final diagnosis(es), procedures, patient's condition at discharge, discharge instructions, and follow-up may be substituted for the summary."

This was not being done in the 6 discharge charts reviewed. The discharge summary written by the nurse midwives did not contain all of this information.