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Based on record review and interview, the hospital failed to ensure accountability of the medical staff for the quality of care provided to patients. The deficient practice is evidenced by failure of the facility to ensure all cesarean sections for non-reassuring fetal status were performed within 30 minutes as per Fetal Heart Rate Management and Notification Guidelines.
Findings:

A review of the hospital guidelines titled, "Fetal Heart Rate Management and Notification Guidelines," dated 06/2020, revealed in part: "Decision to incision should not exceed 30 minutes."

A review of Patient #1's medical record revealed Patient #1 was admitted on 01/24/2024 at 3:08 AM with an admit diagnosis: Induction, Elective.
Decision to take Patient #1 for Cesarean Delivery was made by S7MD on 01/24/2024 at 5:15 PM.

A review of the Nurse Delivery record on 01/24/2024 at 6:16 PM revealed the following:
Operative Indications: Arrest of Descent, Non-Reassuring FHR
Operative Status: Urgent
To OR: 5:51 PM (01/24/2024)
In Room: 5:52 PM (01/24/2024)
Full Dilation Date/Time: 01/24/2024 at 1:30 PM
OR Prep Completed: 01/24/2024 at 6:09 PM
C-Section Incision Date/Time: 01/24/2024 at 6:13 PM
Delivery Date/Time: 01/24/2024 at 6:19 PM
Delivery Type: C-Section
Placenta: Expressed/Intact
Placenta Date/Time: 01/24/2024 at 6:21 PM
Birth Status: Living
Delivery Infant Weight: 8 lb 2 oz
Newborn Outcome: In the care of NICU

Delivering Personnel:
MD Date/Time In: 01/24/2024 at 6:10 PM (S7MD)
Assistant Date/Time In: 01/24/2024 at 6:11 PM (S14MD)

C-Section End Date/Time: 01/24/2024 at 7:13 PM
Delivering Personnel
MD Date/Time Out: 01/24/2024 at 7:13 PM (S7MD)
Assistant Date/Time Out: 01/24/2024 at 7:05 PM (S14MD)

A review of Apgar scores revealed the following:
Total=1 at 1 minute (Heart Rate=1, Respiratory Effort=0, Tone=0, Reflex=0, Color=0)
Total=6 at 5 minutes (Heart Rate=2, Respiratory Effort=1, Tone=1, Reflex=1, Color=1)
Total=7 at 10 minutes (Heart Rate=2, Respiratory Effort=2, Tone=1, Reflex=1, Color=1)

A review of the Cord pH revealed the following:
01/24/2024 at 6:33 PM
Cord pH= 7.156 Low (normal 7.21-7.37)
Cord Base Excess= -10.1 Low (normal -3.7-2.7)

On 01/25/2024 at 3:39 AM the baby expired.

In an interview on 03/11/2025 at 1:35 PM, S1CNO verified that documentation revealed the decision for an urgent cesarean section was made on 01/24/2024 at 5:15 PM with an incision time of 6:13 PM. At this time S1CNO confirmed decision to incision time for the cesarean section was 58 minutes.

In an interview on 03/11/2025 at 1:47 PM, S1CNO reviewed the fetal monitoring strip. At this time S1CNO confirmed that the fetal monitoring strip from 01/24/2024 starting at 3:47 PM was concerning.

In an interview on 03/11/2025 at 3:55 PM, S1CNO confirmed the facility has 4 operating rooms that are used for cesarean deliveries. Per review of operating room schedule for deliveries on 01/24/2024, S1CNO confirmed that 2 operating rooms were in use, 1 room was being cleaned post procedure, and 1 operating room was open at the time a decision was made to take Patient #1 for cesarean delivery.

Based on policy review, record review, and interview, the hospital failed to provide the patient with a written notice of its decision regarding the resolution of a grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion. This deficient practice was evidenced by the failure to provide a written letter describing the steps taken to investigate the patient's claims for 1 (#1) of 1 reviewed patient records with an associated grievance.
Findings:

A review of hospital policy No. 103 titled, "Patient Rights," last revised 08/2024, revealed in part: "N. Right to File a Complaint or Grievance: 1. The patient has the right to file a complaint or grievance regarding any concern, dissatisfaction, or disagreement with any treatment or service they receive, including premature discharge or any patient safety concerns. (See Patient Complaint or Grievance Policy No. 158 - General Administrative)."

A review of hospital policy No. 158 titled, "Patient Complaint or Grievance," last revised 08/2024, revealed in part: "D. Written Notification of Resolution of Grievance: 1. Any written notification provided to a complainant shall contain the name of the hospital contact person, the steps taken to investigate the grievance, the results of the grievance process, and the date on which the Grievance Committee determined that the grievance was resolved."

A review of Patient #1 grievance revealed Patient #1 had complaints about not being updated on the status of the morbidity and mortality conference concerning her labor and delivery case, and that Patient #1 was having issues obtaining medical records from the hospital.

A review of the written grievance letter provided to Patient #1 failed to reveal the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

In an interview on 03/10/2025 at 3:04 PM, C1CNO and C5ACNO confirmed the written grievance letter did not state the steps taken to investigate the grievance, the results of the grievance process, or the date of completion for the grievance.

Based on record review and interview, the director of nursing services failed to ensure intrapartum nursing care was provided according to hospital policy. The deficient practice is evidenced by failure of nursing staff to initiate resuscitative measures for non-reassuring fetal status per hospital policy for 1(#1) of 3 (#1-#3) medical records reviewed.
Findings:

A review of the hospital guidelines titled, "Fetal Heart Rate Management and Notification Guidelines," dated 06/2020, revealed in part: "Decision to incision should not exceed 30 minutes. Labor Intervention Measures: Measures for Variable Decelerations: Change maternal position to where FHR is most improved; IV bolus; Cervical exam- check for cord prolapse or imminent delivery; decrease or discontinue uterine stimulation; Consider therapeutic amnioinfusion; Consider terbutaline to treat tachysystole or tetanic contraction. Measures for Late Decelerations, Minimal or Absent Variability, or Tachycardia: Place patient on left side; Correct maternal hypotension with IV fluids and/or pressors; Decrease or discontinue uterine stimulation; Consider terbutaline to treat tachysystole or tetanic contraction; Evaluate for infection and consider recommending antibiotics. "

A review of the hospital guidelines titled, "Lippincott Procedures- Oxytocin administration during Labor and Delivery," last revised 08/18/2024, revealed in part: "Clinical Alerts: To manage tachysystole with an abnormal FHR pattern (category II or III), discontinue the oxytocin infusion, place the patient on the side, administer oxygen (as prescribed), increase the rate of primary IV solution, and notify practitioner. Special Considerations: If the practitioner plans cesarean delivery, discontinue the oxytocin infusion."

A review of the hospital guidelines titled, "Lippincott Procedures- Fetal Monitoring, external," last revised 11/17/2024, revealed in part: "A normal baseline FHR ranges from 110 to 160 beats/minute. A baseline FHR of less than 110 beats/minute for at least 10 minutes is called bradycardia; a baseline greater than 160 beats/minute for at least 10 minutes is called tachycardia. Clinical significance: Tachycardia is an ominous sign when associated with late decelerations, severe variable decelerations, or minimal or absent variability.
Nursing Interventions: Intervene to alleviate the cause of fetal tachycardia. Provide supplemental oxygen, as ordered. Administer IV fluids, as prescribed. Decrease or discontinue the oxytocin infusion, as ordered, to reduce uterine activity. Turn the patient into lateral position to maximize placental perfusion. Continue to observe the FHR. Document interventions and outcomes. Notify practitioner because further medical intervention may be needed."

A review of Patient #1's medical record revealed Patient #1 was admitted on 01/24/2024 at 3:08 AM with an admit diagnosis: Induction, Elective. Decision to take Patient #1 for Cesarean Delivery was made by S7MD on 01/24/2024 at 5:15 PM.

A review of Patient #1's medical record revealed the following physician orders for Patient #1:
-Fetal Heart Rate Management entered 01/24/2024 at 3:29 AM
Instructions: For Fetal Heart Rate Management: Refer to FHR Management and Notification Guidelines algorithm: May apply Internal Fetal Scalp Electrode (IFSE) in the presence of non-reassuring fetal heart rate pattern if the membranes are ruptured, the patient is greater than 37 weeks gestation, and the patient is free from active infection which precludes the use of internal monitoring. Notify the physician ASAP. Administer IV fluid bolus of 500 ml Lactated Ringers.
-General Care Admission Physician instructions: entered 01/24/2024 at 3:29 AM
Notify MD ASAP: If IFSE is applied as ordered for non-reassuring fetal heart rate pattern.
-Entered on 01/24/2024 at 3:29 AM; Terbutaline Injection (Brethine Equiv), Dose 0.25 mg, Route: SC, Frequency: PRN x1 dose, PRN Reason: Tachysystole or Tetanic Contractions
Dose Instructions: Give if pulse less than or equal to 120 bpm.
Label Comments: In the presence of tachysystole and if category 2 or 3 fetal monitor tracing discontinue Oxytocin give IV bolus of 500 ml lactated ringers and administer terbutaline 0.25mg subcutaneously x1 dose for tachysystole or tetanic contractions. Notify MD ASAP. See MD orders for Oxytocin Infusion resumption.

A review of the nursing obstetrical flowsheet revealed the following:
01/24/2024 at 2:30 PM
Contractions:
-Monitoring Mode: Toco Transducer
Fetal Assessment:
-Monitor Mode: External Fetal Monitor
-Baseline: 145
-Variability: Moderate
-Accelerations: Yes
-Decelerations: Prolonged, Variable
-Decel Pattern: Recurrent
-Baseline Changes: Return to baseline
-FHR Category: Category II
Second Stage Labor:
-Fetal Station: +1
-Induction Medication: Oxytocin (Pitocin) at 3 milliunits/min
-Fetal Uterine Interventions: Continuing to Monitor

01/24/2024 at 3:30 PM
Contractions:
-Monitoring Mode: Toco Transducer
-Frequency (Minutes): 2-4
-Uterus Relaxed between Contractions: Yes
Fetal Assessment:
-Monitor Mode: External Fetal Monitor
-Baseline: 155
-Variability: Moderate
-Accelerations: Yes
-Decelerations: Late, Prolonged, Variable
-Decel Pattern: Recurrent
-Baseline Changes: Return to baseline
-FHR Category: Category II
Second Stage Labor:
-Fetal Station: +1, patient pushing
-Induction Medication: Oxytocin (Pitocin) at 3 milliunits/min
-Fetal Uterine Interventions: Continuing to Monitor; repositioned
Maternal Assessment:
-Position: Left/right lateral, supine, Semi Fowler's

01/24/2024 at 4:00 PM
Contractions:
-Monitoring Mode: Toco Transducer
-Frequency (Minutes): 1.5-6
-Uterus Relaxed between Contractions: Yes
Fetal Assessment:
-Monitor Mode: External Fetal Monitor
-Baseline: 170
-Variability: Moderate
-Accelerations: Yes
-Decelerations: Variable
-Decel Pattern: Recurrent
-Baseline Changes: Tachycardia >= 10 min
-FHR Category: Category II
Second Stage Labor:
-Fetal Station: +1
-Induction Medication: Oxytocin (Pitocin) at 3 milliunits/min
-Fetal Uterine Interventions: Continuing to Monitor; Repositioned

01/24/2024 at 4:30 PM
Contractions:
-Monitoring Mode: Toco Transducer
-Frequency (Minutes): 1-4
-Uterus Relaxed between Contractions: Yes
Fetal Assessment:
-Monitor Mode: External Fetal Monitor
-Baseline: 145
-Variability: Moderate
-Accelerations: Yes
-Decelerations: Variable
-Decel Pattern: Recurrent
-Baseline Changes: Return to baseline
-FHR Category: Category II
Second Stage Labor:
-Fetal Station: +1
-Induction Medication: Oxytocin (Pitocin) at 3 milliunits/min
-Fetal Uterine Interventions: Continuing to Monitor; repositioned patient

01/24/2024 at 5:00 PM
Contractions:
-Monitoring Mode: Toco Transducer; Palpation
-Uterus Relaxed between Contractions: Yes; toco adjusted
Fetal Assessment:
-Monitor Mode: External Fetal Monitor
-Baseline: 175
-Variability: Moderate
-Accelerations: Yes
-Decelerations: Prolonged, Variable
-Baseline Changes: Tachycardia >= 10 min
Second Stage Labor:
-Fetal Station: +1
-Induction Medication: Oxytocin (Pitocin) at 3 milliunits/min
-Fetal Uterine Interventions: Continuing to Monitor

01/24/2024 at 5:30 PM
Contractions:
-Monitoring Mode: Toco Transducer; Palpation; toco adjusted
-Uterus Relaxed between Contractions: Yes
Fetal Assessment:
-Monitor Mode: External Fetal Monitor
-Baseline: 175
-Variability: Moderate
-Accelerations: Yes
-Decelerations: Late, Variable
-Decel Pattern: Recurrent
-Baseline Changes: Return to baseline
-FHR Category: Category II
-Induction Medication: Oxytocin (Pitocin) at 3 milliunits/min
-Fetal Uterine Interventions: Continuing to Monitor; repositioned Patient. MD Notified, Prepare patient for Delivery

01/24/2024 at 5:52 PM
Contractions:
-Monitoring Mode: Toco Transducer, toco adjusted
Fetal Assessment:
-Monitor Mode: External Fetal Monitor
-Baseline: 180
-Variability: Moderate
-Accelerations: Yes
-Decelerations: Variable
-Decel Pattern: Recurrent
-Baseline Changes: Return to baseline
-FHR Category: Category II
-Fetal Uterine Interventions: Continuing to Monitor, Pitocin off, Prepare patient for delivery

A review of the Nurse Delivery record on 01/24/2024 at 6:16 PM revealed the following:
Operative Indications: Arrest of Descent, Non-Reassuring FHR
Operative Status: Urgent
To OR: 5:51 PM (01/24/2024)
In Room: 5:52 PM (01/24/2024)
Full Dilation Date/Time: 01/24/2024 at 1:30 PM
OR Prep Completed: 01/24/2024 at 6:09 PM
C-Section Incision Date/Time: 01/24/2024 at 6:13 PM
Delivery Date/Time: 01/24/2024 at 6:19 PM
Delivery Type: C-Section
Placenta: Expressed/Intact
Placenta Date/Time: 01/24/2024 at 6:21 PM
Birth Status: Living
Delivery Infant Weight: 8 lb 2 oz
Newborn Outcome: In the care of NICU
Delivering Personnel:
MD Date/Time In: 01/24/2024 at 6:10 PM (S7MD)
Assistant Date/Time In: 01/24/2024 at 6:11 PM (S14MD)
C-Section End Date/Time: 01/24/2024 at 7:13 PM
Delivering Personnel
MD Date/Time Out: 01/24/2024 at 7:13 PM (S7MD)
Assistant Date/Time Out: 01/24/2024 at 7:05 PM (S14MD)

A review of Operative report on 01/24/2024 by S7MD revealed the following:
Surgery/Delivery Date: January 24, 2024
PREOPERATIVE DIAGNOSIS:
1. 39-4/7ths weeks by date.
2. Arrest of descent.
3. Terminal meconium.
4. Terminal fetal tachycardia with decelerations.
POSTOPERATIVE DIAGNOSIS: Probable fetal meconium aspiration.
PROCEDURE: Primary low transverse C-section under epidural.
SURGEON: S7MD
ASSISTANT: S14MD
PACKS AND DRAINS: Foley catheterization
OPERATIVE FINDINGS: Viable baby boy, weighing 8 pounds 2 ounces. Cord pH 7.156 with base excess at -10.
ESTIMATED BLOOD LOSS: 511 ccs
BRIEF CLINICAL HISTORY:
The patient was admitted for elective induction of labor. She was fingertip and 60%. She progressed over 8 hours with Pitocin induction to complete cervical dilation. She was seated for approximately 30 minutes or more just to enhance fetal descent from the cervix at 9-10 with a posterior lip. Once the lip was verified as diminished and the fetus was in the OA position, the patient intermittently pushed over the course of 3 hours with rest phases in between. She had a generous amount of room posteriorly in her pelvis. The category two strip was present with primarily variable decelerations with return to baseline and marked variability as reported to me by nursing. She was able to bring the fetal vertex to +1 station, but no further thereafter. She was reassessed by me when the nurse called me for arrest of descent and was nearly +2. The patient and spouse were comfortable with cesarean as we had predicted the baby to be approximately 8 pounds.
Terminal meconium was evident when I attended the bedside for my final assessment and I was informed of this as well as her fetal tachycardia at that time. Marked variability was still present with a category two tracing. Decelerations persisted. We made the decision for urgent cesarean delivery and prepared the patient accordingly. Following delivery of the infant, who was deeply impacted in the pelvis, a vaginal hand by the nurse was used to assist with gentle upward placement of the fetal head so I could place my left hand below the vertex. My partner gently moved the right shoulders up and tucked in the right arm which was wanting to deliver and the fetal vertex was scooped out of the lower pelvis.

In an interview on 03/11/2025 at 9:15 PM, S1CNO confirmed that the Pitocin was not documented as being discontinued until 01/24/2024 at 5:52 PM although there was fetal distress noted in documentation.

In an interview on 03/11/2025 at 12:20 PM, S15CE confirmed that S10RN had only been trained on assisting with placement of an IFSE. In an interview on 03/11/2025 at 3:55 PM, S1CNO and S2DQ verified that there were multiple staff working on 01/24/2024 who could have placed and internal fetal scalp electrode.

In an interview on 03/11/2025 at 1:45 PM, S1CNO confirmed that per medical record review Patient #1 was not given any IV fluid boluses as a resuscitation measure for non-reassuring fetal heart rate.

In an interview on 03/11/2025 at 1:47 PM, S1CNO reviewed the fetal monitoring strip. During review of fetal monitoring strip S1CNO confirmed that the fetal monitoring strip from 01/24/2024 starting at 3:47 PM was concerning. S1CNO confirmed that an Internal Fetal Scalp Electrode was not applied per order to monitor non-reassuring fetal heart rate pattern.

In an interview on 03/11/2025 at 1:55 PM, S1CNO confirmed that the Pitocin was not documented as being discontinued until 01/24/2024 at 5:52 PM.

In an interview on 03/11/2025 at 3:55 PM, S1CNO confirmed that there were staff working who could have placed and internal fetal scalp electrode to monitor the non-reassuring fetal heart rate.