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WEST BOCA MEDICAL CENTER 21644 STATE RD 7 BOCA RATON, FL 33428 Feb. 12, 2016
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, administrative and clinical record review, the facility failed to ensure that 1 of 10 sampled patients (Patient # 2) received quality medical care in a timely manner. As exemplified by the Obstetrical/Gynecological physician failure to medically evaluate and treat an emergency medical condition in a timely manner to ensure that the patient's emergency obstetrical medical condition did not deteriorate.

The Findings included:

The Medical Staff Rules and Regulations for OB (Obstetrical) Patients documented that "All patients presenting in the Emergency Department with obstetrical complaints will be triaged and directed to the Birthcare Pavilion for registration and have a medical screening examination accordingly. Obstetric patients presenting at the Birth Care Pavilion will be medically screened by a qualified Registered Nurse to determine if an emergency medical condition exists. If an emergency medical condition exists, i.e. the mother is in active labor, stabilizing treatment within the capability and capacity of the hospital will be provided and the patient's obstetrician will be notified. If the patient is found by the Labor and Delivery Registered Nurse to have an emergency medical condition, the patient will be admitted . Pregnant patients over 20 weeks with obstetrical problems will be admitted to the Obstetrician directly with the appropriate consultation to be provided in a timely manner from either the on call specialist or other necessary services."

Review of the clinical record for Patient # 2 revealed that the patient is a 35 week pregnant woman who presented to the facility's emergency room and was immediately transferred to the Labor and Delivery Unit. The patient (MDS) dated [DATE] at 2:07 AM with a chief complaint of Abdominal Pain since 11:00 PM. The Triage Nurse, Staff B, assessed the patient and applied a fetal monitor to evaluate the infant's heart rate. The fetal monitor provides information about how well the infant is doing and progressing. The nurse noted, abnormal results on the fetal monitoring with minimal variability (Persistently minimal or absent Fetal Heart Rate variability appears to be the most significant intrapartum sign of fetal compromise) and decelerations (decelerations are decreases noted in the infants heart rate in association with uterine contractions) and contacted the physician at 3:10 AM. The nurse documented, she informed the physician of the abnormal results noted on the fetal monitoring with minimal variability and decelerations. The physician prescribed via the telephone, orders for further assessment and treatment of the patient's condition which included laboratory and diagnostic (ultrasound with biophysical) testing, intravenous fluids and antibiotics. The Technician arrived on the unit to complete the ultrasound and biophysical testing to evaluate the status of the fetus at this time. The ultrasound tech's initial picture of the infant at 3:30 AM noted no fetal movement. So the technician gave the patient ice chips and had the patient to get out of bed and turn from side to side in an attempt to illicit fetal movement. The ultrasound (US) was completed at 4:22 AM and at 4:30 AM, the US tech informed the nurse that he had ambulated the patient, gave cold water and the fetus is still not moving. The technician also informed the nurse of the abnormal results noted on the Biophysical. The nurse documented, she contacted the physician at 4:40 AM to inform the physician of the abnormal biophysical ultrasound results of 2/8 (Biophysical measurement of fetal well-being has a desired score of 8/8. The test measures the fluid index, fetal tone, fetal breathing and the placenta. Two (2) points are given for each area, if present and viable). The test also measures the Amniotic fluid index (AFI). The patient's AFI was 7.4 (Amniotic fluid index, greater than 7 would be normal). The nurse also documented that she informed the physician that there was no breathing or movement noted from the infant. The Obstetric/Gynecology MD stated, she was coming in and for the patient not to have food or drink. At 5:30 AM (50 minutes from the notation of the 2nd call noting that the infant is not breathing and is not moving), patient #2 got out of bed to go to the bathroom. When the fetal monitor was replaced the infant was noted to have an extreme drop in his heart rate to 80 to 90's. The MD was called again and was informed of the drop in the fetal heart rate at 5:50 AM. The decision to prepare the patient for a caesarean section (c-section) was made (1 hour and 20 minutes after noting no movement and breathing from the fetus) and the nurse took the patient to the L & D (labor and delivery) operating room. At 5:58 AM, the physician was again called and the nurse expressed to the physician the urgent need of her presence immediately. The nurse noted, the MD informed her she was in route and another physician was also in route to assist with the c-section. The physician arrived at 6:12 AM (1 hour and 32 minutes after the nurse noted that she had informed the physician about the infant's low biophysical results and that the ultrasound noted that the infant was not moving or breathing). The infant was delivered promptly after the arrival of the physician. However upon delivery, the infant was not breathing and did not have a heartbeat (Apgar 0 and 0). Attempts to resuscitate the infant were unsuccessful. The complication noted at delivery was Placenta Abruption.
The US Fetal Biophysical Profile final results verified by the Radiologist on 11/25/15 at 5:09 AM. The findings included, "There is a single intrauterine pregnancy in cephalic presentation. The fetal heart rate is 140 beats per minute. The amniotic fluid index is 7.4 centimeters. The largest measured pocket is 3.3. The placenta is located fundal. Two points were obtained for qualitative amniotic fluid volume. Impression included Biophysical profile of 2/8. No sonographic demonstration of breathing, movement or tone."

An interview was conducted on 02/12/16 at 9:02 AM with Staff B, who confirmed she was the Triage nurse when Patient #2 arrived on 11/25/15. The nurse stated, that the patient presented to L & D with a chief complaint of abdominal pain for several hours. The pain was not classified as severe but around a 4 on a scale of 1 - 10. There was no bleeding evident and the patient did not complain of increasing pain. The initial fetal monitoring showed little variability. She stated, she showed the Charge Nurse (CN) the fetal monitoring strip and the CN stated to give the patient some juice. Staff B stated, she did note some improvement from the infant but she called the physician and informed her what was going on. The physician gave her some orders and she carried out the prescribed orders. The Ultrasound technician performed the biophysical with the patient for over an hour. The tech reported a score of 2/8 on the biophysical and there was no breathing and no movement from the infant noted, despite multiple interventions to induce movement. She stated, she contacted the physician immediately and informed her of the biophysical and informed the MD that the infant was not breathing and moving. The MD said she was coming in. When the patient returned from the bathroom the second time, it was difficult to get the heart rate on the fetus. She stated she again called the MD. The nurse stated, the physician response time varies but the physician is usually here within 30 minutes and will generally come in to see the patient when informed of abnormal biophysical results and that the infant is not breathing or does not have movement. The nurse also denied receiving an update on the official radiological results from the ultrasound/biophysical from the radiologist.

An interview was conducted on 02/12/16 at 1:25 PM with the physician, who confirmed she was contacted 4 times by the nurse but the last two calls made to her, she was already on her way to the facility. She stated, the initial call from the nurse was when the nurse informed her about the abnormal fetal monitoring strip. She stated she was aware of the flat line on the fetal monitoring (which indicated minimal variability) but felt that the nurse did not stress that she, the physician, needed to urgently come in or what the variability that was occurring. She also confirmed that she did not ask the nurse further questions to gain a better understanding of what was going on. She stated the second call she received from the nurse was to inform her about the 2/8 score on the biophysical. The physician denied being told that the infant was not moving or breathing. She stated, that had she known, she would have arrived earlier. Upon further questioning of the physician regarding the meaning of a 2/8 biophysical score and the need for urgent follow up, the physician confirmed that the testing is measuring the infant's breathing, tone, general movement and amniotic fluid and a score of 2/8 would indicate that the infant was compromised in 3 of the 4 areas being monitored. The physician further confirmed, though she felt what was occurring with the patient/infant was not clearly conveyed and it was puzzling to her, she admitted she did not question the nurse further about the patient's status to gain clarity. The physician stated, she felt it was the nurse's responsibility to inform the physician when a situation is stat (urgent). The MD stated, she lives 20 minutes away but she did not arrive until over 1 hour from when she stated she actually received the call (5:09 AM) and over 1 hour and 32 minutes from the time the nurse stated she called the MD. She denied being contacted by the radiologist regarding the abnormal biophysical results. She further confirmed, a physician stat arrival response is within 20-30 minutes.