HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure that nursing staff kept the nursing care plan current that reflected the ongoing nursing care provided by promptly documenting the ongoing assessments of the patient's needs, patient's response to interventions, and updating the nursing care plan promptly in accordance with the facility's policy for 1 of 1 patient reviewed (Patient #1).

Findings include:

Record review of the facility's "Assessment Timelines/ Reassessment Timelines" rev. 9/2014 states in part, that the nurse will monitor and document for Labor and Delivery "L&D: Phase 1- every hour; Phase 2 - every 15 minutes."

Review of complaint intake, TX00542458, received 5/8/25 alleges RN #1 "fabricated documentation" of Patient #1's medical records when the notes are dated and time-stamped between 7:37 AM and 9:40 AM on July 1, 2024; between 5 and 7 plus hours after Patient #1's son was born, not breathing at 2:36 AM. RN #1's shift ends at 07:30 AM, yet she stayed over 2 hours beyond her shift to document each patient encounter. RN #1 retroactively wrote very specific times in her notes, however she was not taking all those notes while she was instructing me to push.

Review of Patient #'1's Obstetric (OB) Nurses Notes Chronological Selection indicate that the patient delivered via cesarean section on 7/1/2025 at 2:36 AM.

OB NURSE NOTES (Chronological Selection):

Review of the OB Nurses notes dated 6/30/24 - 7/1/24 revealed the following patient care activities were documented anywhere from 5 hours and 50 minutes up to 9 hours and 35 minutes after the following treatment and assessments occurred by Primary care registered nurse (S#1):

At 07/01/24 07:32 AM, S#1 documents for 07/01/24 02:09AM, "monitors turned off for pt to be taken back to OR for urgent csection

At 07/01/24 07:37 AM, S#1 documents for 07/01/24 04:50 AM, SpO2 97% P 113 Comments: pt agrees to csection at this time and csection is called.

At 07/01/24 07:37 AM, S#1 documents for 07/01/24 01:47 AM, csection called at this time by Physician - A (S#2), pt questioning if there are any other choices stating she does not want a csection, S#2 explaining to pt that due to her tracing her babys heart tracing is nonreassuring with the deep variables and her pushing is not effective to bring baby down further into her pelvis, pt keeps saying she does not want a section, midwife & doula at bedside questioning if pt has to have csection, physician explains again about the nonreassuring fetal heart tones and she recommends urgent section

At 07/01/24 08:21 AM, S#1 documents for 06/30/24 23:59 PM, ISE applied, (S#2) at bedside; VE performed

At 7/01/24 08:22 AM, S#1 documents for 07/01/24 00:01 AM, S#2 at bedside explaining to pt for her to push with ctx for delivery of infant

At 07/01/24 08:25 AM, S#1 documents for 07/01/24 00:03 AM, Pt pushes with ctx but is ineffective with her pushing and breathing techniques

At 07/01/24 08:25 AM, S#1 documents for 07/01/24 00:04 AM, documents for Pt states she does not want to push

At 07/01/24 08:25 AM, S#1 documents for 07/01/24 00:05 AM, Pt requests epidural; SpO2 96%, P 83

At 07/01/24 08:26 AM, S#1 documents for 07/01/24 00:07 AM, 2 RN AT BEDSIDE EXPLAINING TO PT THE FETAL TRACING IS NONREASSURING AT THIS TIME, PHYSICIAN TO BEDSIDE EXPLAINING TO PT IF SHE CANNOT PUSH AND BABY DOES NOT RECOVER SHE WILL NEED AN EMERGENCY CSECTION

At 07/01/24 08:27 AM, S#1 documents for 07/01/24 00:04 AM Left lateral

At 07/01/24 08:27 AM, S#1 documents for 07/01/24 00:10 AM, BP 109/68 M 83 P 80 SpO2 96% P 83 Right Lateral

At 07/01/24 08:27 AM, S#1 documents for 07/01/24 00:12 AM, Hands-Knees

At 08:29 AM, S#1 documents for 07/01/24 00:13 AM, PT PLACED INTO STIRRUPS TO TRY PUSHING AGAIN WITHOUT EPIDURAL

At 07/01/24 08:31 AM, S#1 documents for 07/01/24 at 00:10, Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Decels A: Late, Variable, Category II, Provider rvw FMS: Yes, Comments Fetus A: in between pushing baseline noted to be 110, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 60-90

At 07/01/24 08:33 AM, S#1 documents for 07/01/24 00:20 AM SpO2 98% P80

At 07/01/24 08:33 AM, S#1 documents for 07/01/24 00:20, Continuous Fetal Monitoring, Mon Mode A: Internal Moderate 6-25bpm, Accels A: Absent, Decels A: Late, Variable, Category II, FHR Baseline Rate A: 110, Provider rvw FMS: Yes, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 60-80

At 07/01/24 08:34 AM, S#1 documents for 07/01/24 00:27 AM, Oxygen Amount: 10, Face Mask

At 07/01/24 08:34 AM, S#1 documents for 07/01/24 00:30 AM, SpO2 83% P 100 SpO2 97% P 85 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Prolonged, Category II, FHR Baseline Rate A: 110, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed. Contraction Freq: 2-3, Contraction Duration: 60-70

At 07/01/24 08:41 AM, S#1 documents for 07/01/24 00:29 AM, pt resting through this contraction, no pushing to allow fetus to recover, midwife at bedside talking to pt to just keep pushing, RN explained that pushing every ctx is not beneficial at this time as the fetus needs an opportunity to rest, pt verbalized understanding

At 07/01/24 08:46 AM, S#1 documents for 07/01/24 00:40 AM, SpO2 96% P 113 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate A: unable to determine baseline, Comments Fetus A: audible heart tones in between pushing 145s, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 60, Contraction Comments: pt pushing with ctx

At 07/01/24 08:47 AM, S#1 documents for 07/01/24 00:50 AM, SpO2 97% P 94 Continues Fetal Monitoring, Mon Mode A: Internal, Moderate 6-125 bpm, Accels A: Absent, Decels A: Late, Variable, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Duration: 60-70, Contraction Comments: pt pushing with ctx

At 07/01/24 08:48 AM, S#1 documents for 07/01/24 00:47 AM, RN asking pt if she wants an epidural for pain management, pt declines and does not want epidural


At 07/01/24 08:56 AM, S#1 documents for 07/01/24 00:55 AM, RN explaining to pt her fetal tracing remains nonreassuring with pushing, IV fluids continue blousing, oxygen face mask on pt, pt declines option for csection states she does not want a section, midwife @bedside asking if physician will do a vacuum delivery RN said she would ask, physician reviewed tracing no new orders received states to keep pushing at this time

At 07/01/24 08:59 AM, S#1 documents for 07/01/24 01:00 AM, Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate A: 150, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Greq: 2-3, Contraction Comments: pt pushing with ctx

At 07/01/24 09:03, S#1 documents for 07/01/24 01:10 AM, SpO2 98% P 89 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate 'A': indeterminate, Comments Fetus A: audible heart tones in between pushing in the 150s, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-60, Contraction Comments: pt pushing with ctx


At 07/01/24 09:04 AM, S#1 07/01/24 documents for 01:02 AM, documents for midwife at bedside having pt push while doing tug of war

At 07/01/24 09:04 AM, S#1 documents for 07/01/24 01:15 AM, SpO2 93% P 78 SpO2 97% P 89 RN explains to pt to rest with this ctx, no pushing, allow fetus to recover

At 07/01/24 09:06 AM, S#1 documents for 07/01/24 01:20 AM, SpO2 97% P 109 Continuous Fetal Monitoring, Mon Mode A: Internal, Moderate 6-25bpm, Accels A: Absent, Decels A: Late, Variable, Category II, FHR Baseline Rate 'A': indeterminate, Comments Fetus A: audible heart tones in the 155s between pushing, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-70

At 07/01/24 09:08 AM, S#1 documents for 07/01/24 01:19 AM, RN once again educating p on fetal tracing and also offers epidural, pt declines epidural, midwife asking again about vacuum delivery RN explaining that the baby has to be low enough in pelvis and at this time the baby is not low enough to perform a safe vacuum also with limited care with birth center physician might not, pt verbalized understanding and states that she wants to keep pushing and also declines a csection

At 07/01/24 09:10 AM, S#1 documents for 07/01/24 01:30 AM, SpO2 98% P 87 Continuous Fetal Monitoring, Mon Mode A: Internal, Minimal - Undetectable to <5bpm, Accels A: Absent, Decels A: Variable, Category II, FHR Baseline Rate 'A': indeterminate, Comments Fetus A: audible heart tones in 150s between pushing, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: Irregular, Contraction Duration: 40-60

At 07/01/24 09:12 AM, S#1 documents for 07/01/24 01:31 AM, S#2 reviewed fetal tracing and recommended pitocin, RN notified physician that strip does not meet criteria to start pitocin at this time

At 07/01/24 09:17 AM, S#1 documents for 07/01/24 00:50 AM, Iv Bolus, Oxygen

At 07/01/24 09:17 AM, S#1 documents for 07/01/24 01:30 AM, IV Bolus, Oxygen

At 07/01/24 09:19 AM, S#1 documents for 07/01/24 00:10 AM IV Bolus, Oxygen

07/01/24 09:23 AM, S#1 documents for 07/01/24 02:00 AM, Continuous Fetal Monitoring, Mon Mode A: Internal, Minimal - Undetectable to <5bpm, Accels A: Absent, Decels A: Variable, IV Bolus, Oxygen, Category II, FHR Baseline Rate 'A': 150, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-70

At 07/01/24 09:40 AM, S#1 documents for 07/01/24 01:45 AM, SpO2 97% P 75 Comments: S#2 at bedside assessing pts pushing efforts, midwife and pt asking to do vacuum delivery, physician explains to pt that is not an option at this point, the tracing is not reassuring and the station of the fetus is not low enough for safe vacuum, pt states she wants to keep pushing then and refuses csection

At 07/01/24 09:41 AM, S#1 documents for 07/01/24 01:30 AM, pt using squat bar to push with ctx

At 07/01/24 09:43 AM, S#1 documents for 07/01/24 00:08 AM, pt verbalized she refuses a csection

At 07/01/24 09:44 AM, S#1 documents for 07/01/24 01:21 AM, Left Lateral

At 07/01/24 09:44 AM, S#1 documents for 07/01/24 00:13 AM, Lithotomy

At 07/01/24 09:45 AM, S#1 documents for 07/01/24 01:29 AM, Squatting


07/01/24 09:30 AM, S#1 documents for 07/01/24 02:09 AM, Continuous Fetal Monitoring, Mon Mode A: Internal, Minimal - Undetectable to <5bpm, Accels A: Absent, Decels A: Variable, Prolonged, Category II, FHR Baseline Rate 'A': 150, Provider rvw FMS: Yes, Monitor Mode: Toco, Palpation, Cont Qual: Strong, Rest Tone Toco: Relaxed, Contraction Freq: 2-3, Contraction Duration: 40-80

Interview conducted with S# 1 6/26/2025 6:23 PM stated in part, that nurses have 24 hours to document in the patient's chart but document before going home. It is common practice to make quick notes on the monitor strip or scrubs or even an arm if needed until she can chart in the record. When surveyor requested to review the monitor strip S#1 stated "We don't keep them because it is kept electronically. The paper ones are shredded."

Interview conducted with S#4 at 6/24/2025 2:45 PM stated in part, staff has a 24 hour timeline to document in a patients record. IT provided the guideline or was provided during nurse training. Surveyor requested for documentation policy or education provided to staff with the 24hour timeline but none was provided.

Interview conducted with S#5 at 6/24/2025 3:40 PM with S #4 stated in part, staff has a 24 hour timeline to document in a patients record. Surveyor requested for documentation policy or education provided to staff with the 24hour timeline but none was provided.


Texas Board of Nursing-Title 22, Part 11, Chapter 217, Rule 217.11 in part states,
o The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted.
(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;

(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;
(iv) administration of medications and treatments;
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status;