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MADISON HEALTH 210 NORTH MAIN STREET LONDON, OH 43140 July 3, 2012
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on medical record review, physician credentialing file review, staff interview, and unanswered request for policies and procedures related to obstetrical and neonatal emergencies, it was determined that the hospital failed to provide written policies, procedures, or protocols related to obstetrical and neonatal emergencies as requested. The hospital has 55 total beds including a Level One Nursery, licensed for seven maternal beds and nine infant beds. The census at the time of the survey was 17.

Findings include:

Interview of two maternity unit nurses, (staff D and E) on 07/03/12 revealed there were no written policies or procedures to direct maternity staff in obtaining help in the event of an obstetrical emergency. Both nurses stated the patient's obstetrician would be called first, but there were no defined protocols, or emergency call procedures such as, notifying an on call pediatrician, notifying a children's hospital neonatal support unit, or notifying the hospitals own emergency department.

Interview of a hospital emergency department (ED) physician (staff F) on 07/03/12 at 3:50 PM revealed that the ED physician responds to all hospital "Code Blues" (an emergency situation requiring rapid response in order to provide cardiopulmonary resuscitation), including those in the maternity department. The physician stated there is no policy to differentiate a "Code Blue" called for the mother or neonate.

Review of physician credentialing files revealed all ED physicians were certified in ACLS (advanced cardiac life support), BLS (basic life support), and PALS (pediatric advanced life support). Staff F was asked if ED physicians were certified in NRP (neonatal resuscitation program) and he stated, NRP certification had been optional, but the hospital, as of June 2012, has required all ED physicians to become NRP certified. No hospital policies were in place regarding NRP certification for ED physicians. When requested, the hospital failed to provide these policies.