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.

WOODHULL MEDICAL & MENTAL HEALTH CENTER 760 BROADWAY BROOKLYN, NY 11206 Aug. 24, 2020
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, medical record review and interview, in seven (7) of 11 incident reports reviewed, the facility's governing body failed to ensure that medical staff is held accountable for the quality of care provided to patients (Patient #s 1, 13, 14, 15, 16, 18, and 19).

Findings include:

Review of the facility's Medical Staff Bylaws revised January 2018 and current as of April 2019; Section B - Procedures for Membership states: "During the first six (6) months of appointment to the Medical and Dental Staff, each member will undergo review of their privileges or competencies granted by the governing body. This is called a Focused Professional Practice Evaluation (FPPE). It allows the chairperson to evaluate the providers performance on patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. A FPPE may be initiated by the Medical Director or Chairperson when the following are met: A significant adverse patient event or occurrence in which the provider's practice may have been contributory; An unexpected deviation from peers identified through ongoing professional practice evaluation; Quality issues relating to the provider's performance identified through PI and/or morbidity and mortality review.

Review of adverse incidents for 2018, 2019 and 2020, revealed seven cases where patients in labor suffered adverse outcomes related to the administration of anesthesia by medical staff.

Patient #13: On 5/31/18 at 7:50 PM, this [AGE]-year-old patient G3P0020 (G5-number of pregnancies; P4 - Term deliveries; 0 - Preterm deliveries; A0 - numbers of abortion/miscarriage; L5 - living children) at 40 weeks gestation, presented to the labor and delivery triage with a complaint of decreased fetal movement all day. Her expected delivery was 5/31/18. At 10:23 PM, decision made to deliver via c-section. At 11:15 PM, the anesthesiology on duty was informed of the plan. The anesthesiologist obtained the anesthesia consent from the patient and left the unit stating, "I need 20 minutes." The nurse and obstetrician were not aware that the anesthesiologist did not return to the unit. The nurse paged for the anesthesiologist who did not return until approximately one hour later, on 6/1/20 at 00:15 AM. At 00:25 AM, the patient received a combined spinal epidural. (a spinal injection combined with the insertion of an epidural catheter for ongoing pain medication) Following delivery, the infant was intubated and transferred to the Neonatal Intensive Care Unit (NICU). Later that same day, the infant was transferred to another hospital for head cooling and the mother was transferred to be with the infant.

Medical Record #14: On 8/21/18 at 7:30 AM, a [AGE]-year-old G5P4004 at 39 weeks gestation with no previous medical history presented to Labor and Delivery triage for induction of labor due to gestational diabetes mellitus. On 8/25/18, the patient was in pain and requested an epidural. Following the placement of the epidural by Staff A, her blood pressure dropped, and the patient became unresponsive. The patient recovered and was subsequently rushed to the Operating Room (OR) for a stat c-section under general anesthesia.

On 11/20/18 at 4:16 PM, MR #15, a [AGE]-year-old G1P0000 at 38 weeks and 3days gestation with an expected date of delivery 12/1/18 presented to the labor and delivery triage for induction of labor due to chronic hypertension and new onset headache.
On 11/22/18, at 6:15 PM, the patient received an epidural for pain management. Shortly after receiving the epidural, the patient complained of loss of feeling. She became hypotensive (low blood pressure). The fetal heart rate also dropped to the 60s (Normal fetal heart rate per minute: 110-160). The patient received emergency treatment, and at 7:45 PM, she was taken to the OR for a stat c-section.

On 1/2/19, MR #16, a [AGE]-year-old G4P1021 at 39 weeks and 4 days gestation (estimated date of delivery 1/5/19) was sent to the labor and delivery triage from the clinic for elevated blood pressure. She was admitted for induction of labor due to preeclampsia (high blood pressure in pregnancy) and abdominal pain. The patient received Cooks balloon and Pitocin (medications used to induce labor) with an anticipated vaginal birth.
On 1/4/19 shortly after the placement of epidural by Staff A, the patient experienced a loss of consciousness, maternal tachycardia, and hypoxia. A stat c-section was performed with delivery at 2:00 PM.

On 5/22/20, MR #18, a [AGE]-year-old G2P1001 at 37 weeks and 2 days gestation was sent to the labor and delivery unit from the non-stress testing (NST-a test of the heart rate of the fetus with movement) for induction of labor secondary to oligohydramnios (low amniotic fluid). The patient requested an epidural anesthesia for pain relief. After placement of the epidural by Staff A, the patient stated: "I am not feeling anything, there is numbness in my legs." Followed by "Give me air." The patient later became unresponsive requiring intubation and a stat c-section.

On 6/19/20, MR #19 submitted a complaint that she had an epidural anesthesia that took over an hour. She experienced heavy bleeding from the epidural site and had a lot of pain in her back, neck, shoulder and she was unable to walk straight following the procedure. She requested to speak to the anesthesia chair.

On 7/2/20, Patient #1, a 26- year- old G4P0030 (G4-number of pregnancies; P0 - Term deliveries; 0 - Preterm deliveries; A3 - numbers of abortion/miscarriage; L0 - living children) with and estimated gestational age (EGA) 40+ weeks, was sent to the labor and delivery unit to rule out Gestational Hypertension/Pre-eclampsia -refers to high blood pressure beginning in pregnancy. While the patient was undergoing labor induction, an epidural catheter was placed and a test dose administered at 9:37 PM by Staff A, Anesthesiologist. Two minutes after, at 9:39 PM, the patient became unresponsive and pulseless after saying "I can't breathe." A stat c-section was performed, and the baby was delivered at 9:45 PM. The patient expired on [DATE] at 11:55 PM after several resuscitation attempts.

Review of Staff A's personnel file who was involved in six (6) of the seven (7) cases revealed no documented evidence that five (5) past adverse events and occurrences involving the staff were identified through ongoing professional practice evaluation, and that his performance on patient care was monitored and actions were taken to improve patients' safety.

At telephone interview on 7/28/20 at 11:00 AM, Staff P, Attending and past Interim Chief of Anesthesiology, stated: "He (Staff A) had a previous case where the patient was given the top off (given the full dose of medication) without giving a test dose (MR # 14 on 8/25/18). He had given the medication without given the test dose. The patient had a high spinal incident (a potential life-threatening complication to mother and fetus). I interviewed him. I told him that he had to be prepared to do the rapid recognition and management of the patient. I was monitoring him constantly while I was in charge. Once the new chairman came and took over in May 2019, I handed over all the responsibilities."

During telephone interview on 7/28/20 at 12:08 PM, Staff Q, Chief of Anesthesia Service stated: "I started here in June 2019. I was not aware of any issues with this anesthesiologist. There was no sign of issues till he left in October 2019. He left voluntarily not because of any issues. He said his family was relocating to Oklahoma. He contacted us in late January and asked if he could come back. We took him back. His privileges were still active. He returned in February of 2020. There were issues in the operating room (OR) in March and April that he was part of, but did not have to do with high spinals, just OR events ...Staff P never informed me that this doctor was having a history. It is only as this issue occurred (Death of a patient on ---after receiving epidural on ---) that I became aware of the other incidents ...It gets reported if an incident is anesthesia or procedure related, then reviewed by Anesthesia Operative and Invasive Procedures Committee (AOIP). The review includes risk management ...any procedure even a gastrointestinal (GI) administering his own anesthesia. If no reporting of the event, it doesn't go to AOIPC. It is possible that the other events were not reported. It is my understanding that a few of these high spinals were not reported."
VIOLATION: QAPI Tag No: A0263
.
Based on medical record review, document review and interview, the facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program. Specifically, incidents and adverse events related to the administration of anesthesia in the Obstetrics and Gynecology (OB/GYN) Department were not reported, tracked, analyzed and plans of correction implemented to ensure patient safety and improve health outcomes. This failure was identified in eight (8) of 11 incidents related to the care of women in labor
(Patient #s 1, 13, 14, 15, 16, 17, 18, and 19).

The facility failure to report and conduct investigation of anesthesia incidents in the OBGYN Department and implement corrective action resulted in adverse patient outcomes to Patient #s 13,14, 15, 16, 17, 18, 19, and death of Patient #1.

See Tag 0283
.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review and interview, in eight (8) of 11 incidents reviewed related to the administration of anesthesia to obstetric (OB) patients, the facility failed to ensure that adverse events are analyzed, and corrective actions implemented, including the monitoring of physician performance to improve the overall safety of patients (Patient #s 1, 13, 14, 15, 16, 17, 18 and 19).

Findings include:

Review of anesthesia incidents for three years; 2018, 2019, and 2020 identified eight (8) adverse incidents related to the administration of anesthesia to OB patients.

On 7/2/20, Patient #1, a 26- year- old G4P0030 (G4-number of pregnancies; P0 - Term deliveries; 0 - Preterm deliveries; A3 - numbers of abortion/miscarriage; L0 - living children) with and estimated gestational age (EGA) 40+ weeks, was sent to the labor and delivery unit to rule out GHTN/PEC (Gestational Hypertension/Pre-eclampsia-refers to high blood pressure beginning in pregnancy)." Her expected date of confinement (EDC) was 6/27/20. The patient was placed on the external fetal monitor, she received two doses of Cytotec (medication used induce labor) and was started on oxytocin (Pitocin, a medication used to augment labor) on 7/3/20 at 4:00 PM. On 7/3/20 at 9:23 PM, the midwife assuming care of the patient documented that the patient's preeclampsia labs were negative, Pitocin infusing at 13 mu/hour, no complaints and plans to repeat preeclampsia labs, epidural for pain management. Anticipate vaginal delivery. The patient had an epidural catheter placed and a test dose administered at 9:37 PM by Staff A. At 9:39 PM, the patient became unresponsive and pulseless after saying "I can't breathe." A Code Blue was called, and the patient was transferred to the operating room (OR) for a stat c-section. Baby was delivered at 9:45 PM and the patient started to hemorrhage from the nose, mouth and eye. The patient expired after on 7/3/20 at 11:55 PM after several resuscitation attempts. The case was accepted by the Medical Examiner (ME).

The facility's RCA submitted for review on 7/31/20 identified two problems with the care of this patient; 1) The knowledge deficits and the resuscitations skills did not adhere to hospital policies and they may have contributed to the poor outcome; 2) ln the absence of staff/providers notifying / escalating clinical issues to Risk Management, the investigation of the clinical practice of this provider was delayed.

The proposed corrective action plan: Continue Code Blue simulation for maternal health staff; Revised policy for responding to maternal cardiac arrest based on American Heart Association recommendation for cardiac arrest in pregnancy; Create an extra layer of support if there is a delay in the backup team responding; Respiratory Therapist will be competence to intubate; The Assistant Director of Nursing and the Code Blue committee members would evaluate Code Blues in Labor and Delivery; Evaluate possibility of Code Blue teams having elevator keys to expedite code team response to Labor and Delivery; Implement new occurrence reporting system and educate all staff on the new system as well as the escalation process.

There was no documented evidence that these proposed correction action plans have been fully implemented during the start of the survey on 7/20/20.

Patient #13: On 5/31/18 at 7:50 PM this [AGE]-year-old patient G3P0020 at 40 weeks gestation, presented to the labor and delivery triage with a complaint of decreased fetal movement all day. Her expected delivery was 5/31/18. At 10:23 PM, decision made to deliver via c-section. At 11:15 PM, the anesthesiology on duty was informed of the plan. The anesthesiologist obtained the anesthesia consent from the patient and left the unit stating, "I need 20 minutes." The nurse and obstetrician were not aware that the anesthesiologist did not return to the unit. The nurse paged for the anesthesiologist who did not return until approximately one hour later, on 6/1/20 at 00:15 AM. At 00:25 AM, the patient received a combined spinal epidural. (a spinal injection combined with the insertion of an epidural catheter for ongoing pain medication) Following delivery, the infant was intubated and transferred to the Neonatal Intensive Care Unit (NICU). Later that same day, the infant was transferred to Bellevue Hospital for head cooling and the mother was transferred to be with the infant.

Facility's Root Cause Analysis indicated the following corrective action plan: Just culture algorithm will be used to determine course of action to follow regarding behavior of anesthesiologist (Staff A); Inservice with obstetric, nursing and anesthesia staff to enforce the importance of huddles so that communication about plan of care for patients are clear.

There was no documented evidence of the implementation of the corrective action plan proposed to correct identified problems with miscommunication and timely care.

Medical Record #14: On 8/24/18 at 7:30 AM, a [AGE]-year-old G5P4004 at 39 weeks gestation with no previous medical history presented to the Emergency Department (ED) for scheduled induction of labor (IOL) due to gestational diabetes mellitus (Diabetes in pregnancy) on metformin and glyburide (medications to stabilize blood glucose). She was admitted .

On 8/25/20 the patient was in pain and requested an epidural. Following the placement of the epidural by Staff A, her blood pressure dropped, and the patient became unresponsive. A Rapid Response Team (RRT a team proficient in resuscitation) was called then escalated to a Code Blue (a team for cardiac arrest). The patient had a pulse so no ACLS (Advance Cardiac Life Support) was done. The patient was subsequently rushed to the OR for a stat c-section under general anesthesia and intubated.

There was no documented evidence that this incident was investigated, and corrective actions implemented.

On 11/20/18 at 4:16 PM, MR #15, a [AGE]-year-old G1P0000 at 38 weeks and 3days gestation with an expected date of delivery 12/1/18 presented to the labor and delivery triage for induction of labor. She was sent for induction from the high-risk clinic for chronic hypertension and new onset headache. On 11/22/18, at 6:15 PM, the patient received an epidural for pain management. Shortly after receiving the epidural, the patient complained of loss of feeling. She became hypotensive (low blood pressure). The fetal heart rate also dropped to the 60s (normal is between 110-160). The patient was placed on her left side. The fetal heart recovered to baseline for several minutes then dropped again to the 60s. The patient was given a dose of Terbutaline (a medication used to slow contractions) for contractions once every minute. At 7:45 PM, the patient was taken to the OR for a stat c-section.

There was no documented evidence that this incident was investigated, and corrective actions implemented.

On 1/2/19, MR #16, a [AGE]-year-old G4P1021 at 39 weeks and 4 days gestation (estimated date of delivery 1/5/19) was sent to the labor and delivery triage from the clinic for elevated blood pressure. She was admitted for induction of labor due to preeclampsia (high blood pressure in pregnancy) and abdominal pain. The patient received Cooks balloon and Pitocin (medications used to induce labor) with an anticipated vaginal birth. On 1/4/19, shortly after the placement of epidural by Staff A, the patient experienced a loss of consciousness, maternal tachycardia, and hypoxia. A stat c-section was performed with delivery at 2:00 PM.

There was no documented evidence that this incident was investigated, and corrective actions implemented.

Medical Record # 17: On 4/14/19 at 00:40 AM, [AGE]-year-old G4P2203, at 32 weeks gestation arrived by ambulance to the labor and delivery with a complaint of vaginal bleeding and clots. At 00:45 AM, the patient was taken to the OR for a stat c-section. A decision was made to do the procedure using local anesthesia. The anesthesiologist arrived during the procedure, induced general anesthesia and intubated the patient.

The facility's RCA indicated corrective action: It is the expectation that the anesthesiologist assigned to the obstetrical unit should be available immediately. This was imprecise. The new expectation will be that the anesthesiologist on duty would always be on the unit. If they need to leave this must be communicated to the head nurse/charge nurse. Educate anesthesia and nursing staff on the new process.

There was no documented evidence that the facility implemented their proposed corrective action plan.

On 5/22/20, MR #18, a [AGE]-year-old G2P1001 at 37 weeks and 2 days gestation was sent to the labor and delivery unit from the non-stress testing (NST-a test of the heart rate of the fetus with movement) for induction of labor secondary to oligohydramnios (low amniotic fluid). The patient requested an epidural anesthesia for pain relief. After placement of the epidural by Staff A. Shortly after the epidural placement, the patient stated: "I am not feeling anything and numbness in my legs." Followed by "Give me air." The patient was given oxygen via non-rebreather mask at 10 liters per minute. At 4:00 AM the patient became unresponsive and a rapid response team (RRT) was called. The patient was intubated in the room by Staff A. The patient was transferred to the OR for a stat c-section.

There was no documented evidence that the facility investigated or proposed a plan of correction for this incident.

On 6/19/20, MR #19 submitted a complaint that she had an epidural anesthesia that took over an hour. She experienced heavy bleeding from the epidural site and had a lot of pain in her back, neck, shoulder and she was unable to walk straight following the procedure. She requested to speak to the anesthesia chair.

The facility investigated the complaint and the action plan proposed noted that Staff A, would be
advised to request assistance after three (3) unsuccessful attempts at epidural placement.

Review of Staff A' credential file on 7/22/20 revealed no evidence of the communication with the staff and the monitoring of his job performance.

At telephone interview on 7/28/20 at 11:00 AM, Staff P, Attending and past Interim Chief of Anesthesiology, stated: "He (Staff A) had a previous case where the patient was given the top off (given the full dose of medication) without giving a test dose (8/25/18 MR # 14). He had given the medication without given the test dose. The patient had a high spinal incident (a potential life-threatening complication to mother and fetus). I interviewed him. I told him that he had to be prepared to do the rapid recognition and management of the patient. I was monitoring him constantly while I was in charge. Once the new chairman came and took over in May 2019, I handed over all the responsibilities."

During telephone interview on 7/28/20 at 12:08 PM, Staff Q, Chief of Anesthesia Service stated: "I started here in June 2019. I was not aware of any issues with this anesthesiologist. There was no sign of issues till he left in October 2019. He left voluntarily not because of any issues. He said his family was relocating to Oklahoma. He contacted us in late January and asked if he could come back. We took him back. His privileges were still active. He returned in February of 2020. There were issues in the operating room (OR) in March and April that he was only one part of but did not have to do with high spinals just OR events ...Staff P never informed me that this doctor was having a history. It is only as this issue (Patient #1) occurred that I became aware of the other incidents ...It gets reported if an incident is anesthesia or procedure related, then it is reviewed by Anesthesia Operative and Invasive Procedures Committee (AOIPC). The review includes risk management ...any procedure even a gastrointestinal (GI) administering his own anesthesia. If no reporting of the event it doesn't go to AOIPC. It is possible that the other events were not reported. It is my understanding that a few of these high spinals were not reported."

There was no documentation evidence that all incidents were reviewed by AOIPC and corrective actions plans proposed, implemented and evaluated.
.
VIOLATION: ANESTHESIA SERVICES Tag No: A1000
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, document review, and interview, in eight (8) of eleven (11) medical records (MR) reviewed, it was determined that the facility failed to provide anesthesia services in accordance with generally accepted standards (MR #s 1, 13, 14, 15, 16, 17, 18, and 19).

These failures resulted in harm to obstetric patients who received anesthesia services.

Findings include:

Medical Record # 1: On 7/2/20 [AGE]-year-old G4P0030 (G4-number of pregnancies; P0 - Term deliveries; 0 - Preterm deliveries; A3 - numbers of abortion/miscarriage; L0 - living children) with and estimated gestational age (EGA) 40+ weeks, was sent to the labor and delivery unit to rule out GHTN/PEC (Gestational Hypertension/Pre-eclampsia-refers to high blood pressure beginning in pregnancy)." Her expected date of confinement (EDC) was 6/27/20. The patient was placed on the external fetal monitor and received one dose of Cytotec (medication used induce labor). On 7/3/20 she received a second dose of Cytotec, a Cervical Ripening Balloon (CRB, a medication used during the induction of labor), and was started on oxytocin (Pitocin, a medication used to augment labor).
At 9:23 PM the midwife assuming care of the patient documented that the patient's preeclampsia labs were negative, Pitocin infusing at 13 mu/hour, no complaints and plans to repeat preeclampsia labs, epidural for pain management. Anticipate vaginal delivery. The patient received an epidural (a small tube inserted between the spinal spaces) placement at 9:37 PM by Staff A and became unresponsive and pulseless after saying "I can't breathe." A Code Blue was called, and the patient was transferred to the operating room (OR) for a stat c-section. Baby was delivered at 9:45 PM and the patient started to hemorrhage from the nose, mouth and eye. The patient Coded several times and was taken to the intensive care unit (ICU). Within minutes of her arrival in the ICU she became unresponsive again. Another Code Blue was called. The physician spoke with the family who agreed to stop the resuscitative efforts. The patient was pronounced at 11:55 PM. The facility is doing a root cause analysis (RCA) however, it is not completed yet. The case was accepted by the Medical Examiner (ME).

During interview on 7/22/20 at 10:00 15 AM, Staff B Attending on the labor and delivery unit stated: "While Staff A was performing his task, I was in the nurse's station. Staff L RN, called for me to come in. I ran in. Staff A was just standing at the patient's bedside. The patient was supine, not responsive. I screamed at him (Staff A) "What happened? I can't believe this is happening again. What did you do?" I think he was probably stuttering. I said to him is this another high spinal (an epidural given too high on the spine). His response was "could be." There was another incident in 2018 involving a multipara. (multipara, a patient with more than one delivery) here to have her 5th baby. I was with Staff A. She requested epidural and became unresponsive and had a stat section. Mother and baby survived." Surveyor asked what Staff A was doing during this occurrence. Staff B responded: "He was just standing there. That's what I remember. Next I called for a stat section. I told the nurse to unhook her. I screamed at him intubate her. I started getting dressed. Staff L also screamed at Staff A to intubate her. "

On 7/29/20 at 10:00 AM, Staff L, RN stated: "I attempted to give her oxygen, she is not conscious, I called a Code Blue. Staff A was doing nothing. Staff B was the first to present to the room. Still Staff A stood there frozen as I am on the bed giving chest compressions. He didn't get involved with the chest compressions. I screamed at him to intubate her. He intubated her but did not give ongoing ventilation to the patient. He did sometimes and sometimes not ...He was not properly ventilating the patient. When the code team arrived. Staff O (emergency room Attending Physician) ended up taking control of the head (patient's head."

At telephone interview on 7/28/20 at 11:00 AM, Staff P, Attending and past Interim Chief of Anesthesiology, stated: "He (Staff A) had a previous case where the patient was given the top off (given the full dose of medication) without giving a test dose (8/25/18 MR # 14). He had given the medication without given the test dose. The patient had a high spinal incident (a potential life-threatening complication to mother and fetus). I interviewed him. I told him that he had to be prepared to do the rapid recognition and management of the patient. I was monitoring him constantly while I was in charge. Once the new chairman came and took over in May 2019, I handed over all the responsibilities."

During telephone interview on 7/28/20 at 12:08 PM, Staff Q, Chief of Anesthesia Service stated: "I started here in June 2019. I was not aware of any issues with this anesthesiologist. There was no sign of issues till he left in October 2019. He left voluntarily not because of any issues. He said his family was relocating to Oklahoma. He contacted us in late January and asked if he could come back. We took him back. His privileges were still active. He returned in February of 2020. There were issues in the operating room (OR) in March and April that he was only one part of but did not have to do with high spinals just OR events ...Staff P never informed me that this doctor was having a history. It is only as this issue occurred that I became aware of the other incidents ...It gets reported if an incident is anesthesia or procedure related, then reviewed by Anesthesia Operative and Invasive Procedures Committee (AOIP). The review includes risk management ...any procedure even a gastrointestinal (GI) administering his own anesthesia. If no reporting of the event it doesn't go to AOIPC. It is possible that the other events were not reported. It is my understanding that a few of these high spinals were not reported."

The review of anesthesia incidents identified seven (7) other cases where the standard of care for anesthesia services were not met.

Patient #13: On 5/31/18 at 7:50 PM this [AGE]-year-old patient G3P0020 at 40 weeks gestation, presented to the labor and delivery triage with a complaint of decreased fetal movement all day. Her expected delivery was 5/31/18.
At 10:23 PM, decision made to deliver via c-section. At 11:15 PM, the anesthesiology on duty was informed of the plan. The anesthesiologist obtained the anesthesia consent from the patient and left the unit stating, "I need 20 minutes." The nurse and obstetrician were not aware that the anesthesiologist did not return to the unit. The nurse paged for the anesthesiologist who did not return until approximately one hour later, on 6/1/20 at 00:15 AM. At 00:25 AM, the patient received a combined spinal epidural (a spinal injection combined with the insertion of an epidural catheter for ongoing pain medication) Following delivery, the infant was intubated and transferred to the Neonatal Intensive Care Unit (NICU). Later that same day, the infant was transferred to Bellevue Hospital for head cooling and the mother was transferred to be with the infant

Medical Record #14: On 8/24/18 at 7:30 AM, a [AGE]-year-old G5P4004 at 39 weeks gestation with no previous medical history presented to the Emergency Department (ED) for scheduled induction of labor (IOL) due to gestational diabetes mellitus (Diabetes in pregnancy) on metformin and glyburide (medications to stabilize blood glucose). She was admitted .
On 8/25/20 the patient was in pain and requested an epidural. Following the placement of the epidural by Staff A, her blood pressure dropped, and the patient became unresponsive. A Rapid Response Team (RRT a team proficient in resuscitation) was called then escalated to a Code Blue (a team for cardiac arrest). The patient had a pulse so no ACLS (Advance Cardiac Life Support) was done. The patient was subsequently rushed to the OR for a stat c-section under general anesthesia and intubated.

On 11/20/18 at 4:16 PM, MR #15, a [AGE]-year-old G1P0000 at 38 weeks and 3days gestation with an expected date of delivery 12/1/18 presented to the labor and delivery triage for induction of labor. She was sent for induction from the high-risk clinic for chronic hypertension and new onset headache.
On 11/22/20, at 6:15 PM, the patient received an epidural for pain management. Shortly after receiving the epidural, the patient complained of loss of feeling. She became hypotensive (low blood pressure). The fetal heart rate also dropped to the 60s (normal is between 110-160). The patient was placed on her left side. The fetal heart recovered to baseline for several minutes then dropped again to the 60s. The patient was given a dose of Terbutaline (a medication used to slow contractions) for contractions once every minute. At 7:45 PM, the patient was taken to the OR for a stat c-section.

On 1/2/19, MR #16, a [AGE]-year-old G4P1021 at 39 weeks and 4 days gestation (estimated date of delivery 1/5/19) was sent to the labor and delivery triage from the clinic for elevated blood pressure. She was admitted for induction of labor due to preeclampsia (high blood pressure in pregnancy) and abdominal pain. The patient received Cooks balloon and Pitocin (medications used to induce labor) with an anticipated vaginal birth. On 1/4/19 shortly after the placement of epidural by Staff A, the patient experienced a loss of consciousness, maternal tachycardia, and hypoxia. A stat c-section was performed with delivery at 2:00 PM.

Medical Record # 17: On 4/14/19 at 00:40 AM, [AGE]-year-old G4P2203, at 32 weeks gestation arrived by ambulance to the labor and delivery with a complaint of vaginal bleeding and clots. At 00:45 AM, the patient was taken to the OR for a stat c-section. A decision was made to do the procedure using local anesthesia. The anesthesiologist arrived during the procedure, induced general anesthesia and intubated the patient.

The facility's RCA indicated that it was the expectation that the anesthesiologist assigned to the obstetrical unit should be available immediately.

On 5/22/20, MR #18, a [AGE]-year-old G2P1001 at 37 weeks and 2 days gestation was sent to the labor and delivery unit from the non-stress testing (NST-a test of the heart rate of the fetus with movement) for induction of labor secondary to oligohydramnios (low amniotic fluid). The patient requested an epidural anesthesia for pain relief. After placement of the epidural by Staff A. Shortly after the epidural placement, the patient stated: "I am not feeling anything and numbness in my legs." Followed by "Give me air." The patient was given air via non-rebreather mask at 10 liters per minute. At 4:00 AM the patient became unresponsive and a rapid response team (RRT) was called. The patient was intubated in the room by Staff A. The patient was transferred to the OR for a stat c-section.

On 6/19/20, MR #19 submitted a complaint that she had an epidural anesthesia that took over an hour. She experienced heavy bleeding from the epidural site and had a lot of pain in her back, neck, shoulder and she was unable to walk straight following the procedure.

These findings were brought to the attention of Staff T, Chief Executive Officer on 8/20/20 at 11:53 AM.