513112 of ?sh: 32:52:; cap? DEPARTMENT OF HEALTH PO BOX 367 TRENTON. NJ. 08625-0367 CHRIS CHRISTIE Governor KIM GUADAGNO MARY E. MP Lt. Governor December 18. 2012 Frank Vozos Chief Executive Of?cer Monmouth Medical Center 300 Second Avenue Long Branch, NJ 07740 Re: Complaints and Dear Dr. Vozos: Thank you for your courtesy and cooperation extended during the complaint investigations conducted on September 26, 2012 by a surveyor from the Department of Health. Enclosed is the statement of de?ciencies; please reply to each de?ciency on an item-by-item basis with your Plan of Correction The must include: 1. How you will correct the speci?c findings cited for each de?ciency. 2. What systemic changes will be implemented to ensure that each de?cient practice does not recur. 3. How the facility will monitor its corrective actions to ensure that the de?cient practice is being corrected and will not recur, i.e. what program will be put into place to monitor the continued effectiveness of the systemic changes. The plan must identify the individual responsible for monitoring, how and when the monitoring will be conducted, and to whom the results will be reported. Monmouth Medical Center Page 2 4. The date on which each item addressed on the P00 will be corrected. All responses should be numbered to correspond with the number of your de?ciency statements. Please sign and date the ?rst page of the de?ciency statement with your plan of correction. Return these forms to this of?ce within ten (10) calendar days of receipt of this letter, to the attention of Sophie Xyloportas, RN. Any delay or lack of response may jeopardize the licensure of your facility. Please be advised that some or all of the de?ciencies cited in the enclosed survey report may be referred to the Of?ce of Program Compliance for imposition of enforcement remedies. including civil penalties. OPC will advise you, at a later date and under separate cover, of any enforcement actions and your appeal rights. Please do not hesitate to contact me. if you have any questions regarding the de?ciencies at (609) 292-9900. Sincerely, J44 Sophie Xyloportas Assessment and Survey Encl. New Jersev Department of Health PRINTED: 12/1Bl2012 FORM APPROVED STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 11304 WING Ixzi MULTIPLE CONSTRUCTION DATE SURVEY A. BUILDING COMPLETED 09126l201 2 NAME OF PROVIDER OR SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH. NJ 07740 ID SUMMARY STATEMENT OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION {st CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE 000 INITIAL COMMENTS The facility is in substantiai compliance with N.J.A.C. Title 8 Chapter 43 G- Hospital Licensing . Standards for this Complaint Investigation: NJ00053395. The facility is not in compliance with N.J.A.C. TItle. 8 Chapter 43 (3- Hospital Licensing Standards for this Complaint Investigation: NJ00056972. 03957 NURSING CARE: POLICIES BI PROCEDURES The hospital shall have written policies and procedures for the nursing care service that guide I nursing practices in the hospital. These policies shall be reviewed at least once every three years. revised more frequently as needed. and implemented. These policies and procedures shall conform with the Nurse Practice Act. N.J.S.A. 45:11?23 and N.J.A.C. 13:37-14. 6.1. 6.2. 13.1 and 13.2. This REQUIREMENT is not met as evidenced by: Based on medical record review. staff interview. review of facility inservices and policies. it was determined that the facility failed to ensure that recommended obstetrics guidelines are adhered to by staff. Findings include: Reference Facility Policy #640-044-130. titled "Care of the Patient; Post Partum" refers to the following reference as to the procedure that the facility adheres to. Mattson, 8., Smith, J.E., (1997) AWHONN: Core 000 03957 LABORATORY OR REPRESENTATIVES SIGNATURE STATE FORM WEE LDOF11 TITLE (X6) DATE If continuation sheet 1 of 14 . PRINTED: 12l18!2012 FORM APPROVED New JerseY Department of Health STATEMENT OF DEFICIENCIES x1 PROVIDERISUPPLIERICLIA x2 TIPLE CON 0?31 DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: UL 0 COMPLETED A. BUILDING 3. mm; 11304 09I261201 2 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE MONMOUTI-I MEDICAL CENTER LONG BRANCH. NJ 07740 9(4) .9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (XS) PREFIX DEFICIENCY MUST BE PRECEDED eY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING INPORMAT ION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 0395? Continued From page 1 0395? Curriculum for Maternal-Newborn Nursing. Second Edition. Philadelphia. W.B. Saunders Company. p. 393 Chapter 21; Hypertension in Pregnancy: Objectives: 3. Identify factors that place women at greater risk for preeclampsia 4. Correlate history and physical findings with signs and of preeclarnpsia. eclampsia and HELLP [Hemolysis. Elevated Liver enzymes. Low Platelets] 5. Predict maternal and fetal complications 6. Formulate nursing interventions to alleviate or prevent potential problems identified in the nursing assessment 7. Summarize the treatment of preeclampsia, eclampsia and HELLP Introduction: A. Introduction: Hypertensive disorders of pregnancy can result in life-threatening complications 3. Hypertension during pregnancy is one of the leading causes of maternal morbidity and mortality 4. Therapy is aimed at controlling hypertension and seizures. preventing long-term morbidity and preventing maternal. fetal or neonatal death E. Differentiation of hypertensive disorders 1. [Pregnancy Induced Hypertension] a. Preeclampsia (1 Hypertension Systolic pressure is at least 140 mm Hg Diastolic pressure is at least 90 mm Hg At least two elevated values 6 or more hours apart Relative hypertension may be identi?ed with a systolic increase Of 30 mm STATE FORM fcontinuation sheet 2 of 14 PRINTED: FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES PROVIDERISUPPLIEWCLIA (x2) MULTIPLE DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A BUILDING WING 11304 0926,2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE on AVENUE MONMOUTH MEDICAL CENTER EONg?gg?ch. NJ 07740 {my ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (st PREHX DEFICIENCY MUST BE PRECEDED BY FULL PREHX CORRECTIVE ACTION SHOULD BE COMPLETE m3 REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCEO To THE APPROPRIATE DATE DEFICIENCY) 0395? Continued From page 2 03957 Hg and a diastolic increase of 15 mm Hg above baselines 120/90 compared with 90/60 at first prenatal visit) Relative hypertension should alert health care providers to the need for further evaluation and close surveillance Severe preeclarnpsia is de?ned as one of the following (1) Blood pressure Systolic pressure is at least 160 mm Hg Diastolic pressure is at least 110 mm Hg (7) Epigastric or right upper quadrant pain Eclampsia Other risks include cerebrovascular accident (OVA). cerebral edema, anoxia, coma and maternal death 2. Eclampsia should be preventable if preeclampsia is recognized in its early stages. surveillance is adequate and therapy is appropriate Reference The facility's policy #640-044-130. titled "Care of the Patient; Post Partum? stipulates: TO determine care through assessment/reassessment of patient care needs. Decisions regarding patient care are based on analysis Of date obtained by the members of the multidisciplinary health care team and the patient's response/progress identify potential complications and take appropriate action to minimize risk to both mother and baby. POLICY: 3. All abnormal ?ndings, potential complications. and lack of progress toward care goals will be communicated to the physicianslmidwife for clinical assessment/intervention. PROCEDURE: 5. Assessment. Reassessment. Care and Education: i. Pain/Discomfort: Assess for verbal and nonverbal signs of discomfort pain STATE FORM LDQF11 fcontinuation sheet 3 of 14 PRINTED: 12l?l?l20?l 2 . FORM APPROVED New Jersey Department of Health STATEMENT OF DEF ICIENCIES Ixn PROVIDERISUPPLIERICLIA Ixzi MULTIPLE CONSTRUCTION 0?3) DATE SURVEY AND PLAN OF CORRECWN IDENTIFICATION NUMBER: COMPLETED A. BUILDING a. Mime 11304 09126I201 2 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. STATE. ZIP CODE 300 SECOND AVENUE MONMOUTH MEDICAL CENTER LONG BRANCH. NJ 077 40 out; In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION {x5} pnepix (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX IEACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 0395? Continued From page 3 03957 medication/analgesics as ordered by physician and evaluate effectiveness. ii. REFERENCES: Core Curriculum for Maternal-Newborn Nursing, 1997. Reference Facility Policy #640-084-110. titled "High Risk Criteria: Obstetric Patient,? stipulates: PURPOSE: To Identify the obstetric patient who may present a higher risk for a safe pregnancy and delivery. POLICY: it is the philosophy of Monmouth Medical Center identification and treatment of "high risk" patients that patients will receive the appropriate level of care in the appropriate setting thereby decreasing the risk for preterm delivery and maternal/infant morbiditylmortality. Reference Facility ln-Services: Titled "Hypertensive Disorders of Pregnancy? "Risk Factors for Development of Preeclampsia" Criteria Mild-moderate BIP [Blood Pressure] 140190 or higher. or a rise of 30 mm HG systolic and 15 mm Hg diastolic from baseline Severe BIP 1601110 or above "Postpartum Management" Delivery of baby does not immediately reverse the pathOphysiologic Changes of preeclampsia therapy and monitoring to be alert for early signs of preeclampsia complications such -increased intracranial pressure, -intracranial hemorrhage Most common physical complaints; epigastric or RUQ [right upper quadrant] pain. [nausea and vomiting] "Complications" hematoma. Reference Department of Pathology: Chemistry Reference Range: [Alanine aminotransferase] ALT 10-43, [Aspartate aminotransferase] AST STATE FORM WP LDOP11 If continuation sheet 4 Of 14 New Jersev Department of Health PRINTED: 12/18/2012 FORM APPROVED STATEMENT OF DEFICIENCIES {x1} AND PLAN OF CORRECNON IDENTIFICATION NUMBER: 11304 (X2) MULTIPLE CONSTRUCTION A. BUILDING WING DATE SURVEY COMPLETED 09/26/2012 MONMOUTH MEDICAL CENTER NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH. NJ 07740 (x4, ?3 SUMMARY STATEMENT OF DEFICIENCIES FREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY on LSC IDENTIFYING ID PLAN OF CORRECTION 0?5) PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 03957 Continued From page 4 13-41 . [Lactate dehydrogenase] 116-243. [Blood urea nitrogen] BUN 5-21. Alkaline phosphate 42-119. Blood Glucose 70-110. Total Protein 6.4-8.3. Creatinine 0.40-1.10. Albumin 3.5-5.0. Amylase 28-118 Findings include: 1. On 9/26/12 a review of Medical Record in the presence of Staff #2 revealed the following: a. The AntEpartum Record (office prenatal visits) for Patient #2 indicates the following blood pressures: 3/10/11-108/64. 6/14/11-110168. 5/2/11-108/60. 5/31/11-120/64. 6/28/11-106/68. 7/25/11-112/70. 8/8/11-112/70. 8/24/11-118/72. 9/6/11-120/70. 9/15/11-108/72. 9/21/11-120/70. b. Review of the LED [Labor and Delivery] Admission Assessment dated 9/30/11 at 1941 indicated: Admission Vital Signs; 147/99. This was signi?cantly higher than the baseline (Antepartum) blood pressures. stated above. C. There is no evidence that the nurse notified the primary care physician (PCP) of the elevated admission blood pressure. d. The above was con?rmed by Staff #2 and 2. A review of the Physician Orders dated 9/30/11 at 2000 indicated: Vital signs every 15 minutes for the first hour. then every 30 minutes 2, then every 4 hours 12 hours. a. The Admission Assessment dated 9/30/11 03957 STATE FORM 6m LDOF11 If continuation sheet 5 of 14 PRINTED: 12/1312012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1; (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A BUILDING B. WING 11304 0912612012 NAME OF PROVIDER OR SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH. NJ 07740 revealed a blood pressure of 147199 at 2008. b. There is no evidence in the medical record of a blood pressure between at 2008 and 1011/11 at 0402. Seven hours and 56 minutes lapsed between the ?rst and the second blood pressure. c. The above was con?rmed by Staff #2 and 3. Review of the Maternal Flow Sheet indicated the following: a. From admission on 9I30111 at 2008 to at 1826. 21 systolic blood pressures were at or above 140 mm Hg. ranging from 140-162 mm Hg. and 13 diastolic blood pressures were at or above 90 mm Hg. ranging from 90-106. These numbers are indicative of hypertension as per reference b. There was no indication in the medical record that the Registered Nurse (RN) noti?ed the health care providerIObstetrics Gynecologist (OBGYN), of the elevated blood pressures of Patient prior to delivery. c. There was no evidence in the medical record of further evaluation and surveillance of Patient from the health care providerlOBGYN. prior to delivery. (1. The above was confirmed by Staff #2 and 4. Review of the Delivery Summary: GYN [Gynecological] HISTORY (per Patient or Prenatal Record); Denies having any complications. Delivery Date: 1010011. 1849 Outcome: Liveborn out} It) SUMMARY STATEMENT OF DEFICIENCIES .D PRovloER's PLAN OF CORRECTION {x5} DEFICIENCY MUST BE PRECEDED av FULL pagnx (EACH CORRECTIVE ACTION SHOULD BE COMPLETE m3 REGULATORY OR IDENTIFYING INFORMATION) m3 CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0395? Continued From page 5 03957 STATE FORM 8399 LDQF11 ll continuation sheet 6 of 14 PRINTED: 12/18/2012 FORM APPROVED New Jersev Department of Health STATEMENT OF DEFICIENCIES (XI) PROVIDERJSUPPUEWCUA (x2, MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED A. BUILDING WING 11304 09261201 2 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH. NJ 07T40 9(4) ID SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION p.15] PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING TAG TO THE APPROPRIATE DATE MONMOUTH MEDICAL CENTER 03957 Continued From page 6 03957 5. Review of the Vaginal Delivery- Recovery sheet indicated: a. Blood pressures: 10/1/10: Time - 1856 - 136/83 1911 - 154/97 1926 - 161/93 1937 - 141/90 1941 - 154/97 1956 - 160/95 2011 - 161/96 2020 - 152/102 2026 - 158/97 2041 - 184/103 2056 - 169/108 No BIP taken for 1 hour and 29 minutes 2225 - 175/100 No taken for 1 hour and 44 minutes 10/2/11: 0009 -174/101 0013 - 184/119 0014 - 197/117 0018 - 191/115 0024 - Attempt made to take 0031 - 138/101 0032 - Attempt made to take 0049 - 146/97 0053 - 155/102 0054 - 148/102 b. Review of the Vaginal Delivery Recovery sheet indicated that the patient's pain was as follows: 2030-Mid-epigastric was rated at 7/10 (on a pain scale of 1/10, 10 being the worst pain). Intervention; Bicitra 30 ml. Pain relief was STATE FORM 559? LDQF11 II continuation sheet 7 of 14 PRINTED: 12/18/2012 FORM APPROVED New Jersev Department of Health STATEMENT OF Ixzi MULTIPLE CONSTRUCTION 9?31 DATE SURVEY AND PLAN OF CORRECTIDN IDENTIFICATION NUMBER: A BUILDING COMPLETED a. WING 11304 09/26/2012 NAME OF PRov OER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH, NJ 07740 ?3 SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECTION (x51 PREFIX (EACH DEFICIENCY MUST BE PRECEOED BY FULL PREFIX IEACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) MONMOUTH MEDICAL CENTER 0395? Continued From page 7 03957 documented at 7/10. 2041-Pain was:10/10. 2050-Pain was rated at 10/10. 2150-Pain was 8/10. 2200-Pain was 10/10. Interventions indicated that a GI [Gastroenterologist] Consult was ordered and Dilaudid 2mg IV was administered. 2200-Pain was rated 10/10. C. There was no evidence in the medical record that the elevated blood pressures were addressed by the primary health care provider/OBGYN. 6. Review of the Nursing Notes indicated the following: 10/1/11 - 2030: Patient complained of severe mid-epigastric pains and burning radiating up her Chest. MD at bedside. Patient evaluated. active bowel sounds present all 4 quadrants, Bicitra orders received. 2032 - Orders received for IV Dilaudid 0.5 mgs. patient requests V2 2041 - MD aware of patient's Preeclampsia labs unable to stay still. bending over in pain. Patient vomiting. 2050 - Preectampsia labs remains in pain. 2100 - Patient pain status remains the same. MD made aware. MD at bedside. STATE FORM 0899 LDOF11 II continuation sheet 3 of 14 New Jersey Department of Health PRINTED: 1211812012 FORM APPROVED STATEMENT OF DEFICIENCIES (x1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 11304 MULTIPLE CONSTRUCTION A. BUILDING B. WING DATE SURVEY COMPLETED 0912612012 NAME OF PROVIDER OR SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH. NJ 07740 0(4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING ID PROVIDERS PLAN OF CORRECTION {x5} PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0395? Continued From page 8 Dilaudid 0.5 mg given IV push. 2120 - Lab results back from lab. MD made aware. No abnormal labs 2130 - Patient states relief from pain. "l'm feeling much better." 214? - Patient in pain 2200 - pain present. Patient and husband made aware a GI consult is in 2215 - consult via phone to OBGYN. Plan of care discussed. Orders received for upper abdominal X-ray. amylase and lipase levels. Maalox 30 ml now. 2216 - Unable to give Maalox at this time. 2220 - Dilaudid 2 mg administered IV push. 2225 - Patient unable to remain 2255 - Maalox 30 ml given PO. 2300 - 40 mg Protonix given IV. 2315 - Patient to Emergency Department (ED) for continues to appear in pain 10l10 localized mid-epigastric pain. Patient vomiting. OBGYN made aware of patient status and X-ray results. General Surgery consult requested. 2345 -.Surgery Resident at bedside. Patient evaluated. 2355 -.Patient states "do anything to stOp this pain." OBGYN at for morphine 2 03957 STATE FORM 55?? LDOF11 It continuation sheet 9 of 14 New Jersev Department of Health PRINTED: 1211819012 FORM APPROVED AND PLAN OF CORRECTION IDENTIFICATION NUMBER: B. WING 11304 STATEMENT 0" DEFICIENCIES {x1} PROVIDERJSUPPLIERJCLIA (x2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED 0912612012 LONG BRANCH, NJ NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER SECOND AVENUE 07740 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES IO PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG PLAN OF CORRECTION (XS) CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) D3957 Continued From page 9 0395? mg 10I2I11 - 0005 Morphine 2 mg IV push 0009 - Pulse Ox applied. patient extremely 0010 - OBGYN at Bedside. patient cognitively intact. lethargic. 001B - OBGYN assessing patient. Left side facial drooping noted. Patient unable to lift left arm. Code Stroke called. 0028 - Code Stroke team at bedside 0035 - Magnesium Sulfate initiated. 4 gm loading dose. 115 Blood Sugar ?nger 0045 - Patient 7. Review of the Physicians Progress Notes by the OBGYN revealed the following: Admit Note: 9/30/11 at 2015. Cervidel started. No mention of elevated admission BIP. 10/1111 at 2230; no mention of elevated BIP. 1240 - Vital signs stable 1650 - Patient without complaints. BIP 132(68. 1800 - Patient with out any complaint. no complaint of epigastric pain mentioned. 10/1l11 Delivery note pt delivered female at 1012/11 - 0210 Addendum by the health care providerlOBGYN at 1011/11 2030; STATE FORM seen LDOF1 1 It continuation sheet 10 of 14 Lin.? 1?1. PRINTED: 1211812012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERJSUPPLIERJCUA MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 11304 09I26I2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE MONMOUTH MEDICAL CENTER LONG BRANCH, NJ 07740 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION 1x5) paemx (EACH DEFICIENCY MUST BE PRECEDED BY FULL pREpIx (EACH CORRECTIVE ACTION SHOULD BE COMPLETE ?mg REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0395? Continued From page 10 0395? Patient complained mid-epigastric pain with nausea. given Bictra with no relief. ..severe mid~epigastric pain GI and lipase ordered WNL [within normal limits]. Surgery consult ordered..Given Dilaudid for pain. Pain not mg Morphine exhibits facial droop on left . side. Code Stroke called. BIP 137/102. magnesium sulfate paralysis went to [Intensive Care Unit]. 8. Review of the History and Physical Form in the medical record. from the PCPIOBGYN indicated: I 10I2112 at 0200; Code Stroke I ICU transfer note: Code stroke was called around 12:24 am to Patient had delivered 4 hours "when she started to complain of epigastric pain she was given V2 mg Dilaudid 2. then 2 mg Dilaudid and later 2 morphine IV. which eased her pain." A surgical consult was requested and patient was being evaluated by a surgical resident. It was noticed patient had right I facial droop and left sided weakness around 1200 [1012111] at this point code stroke was called. When I saw the patient she had right sided facial droop and unable to move left upper and lower . extremities. Stat CT of head without contrast I ordered 1230 with labs work including PTIINR. Patient started vomiting and anesthesia needed to intubate to secure airway. CT scan done at 0100 and revealed right and subarachnoid bleed with 5 mm mm shift. The patient was brought to the ICU. being evaluated by neurologist and neurosurgeon. Patient started on Mannitol 50 gm lV BP 175/122235 CNS: Unable to assess as patient under the If continuation sheet 11 of 1 PRINTED: 12f18l'2012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) X2 MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING a. WING 11304 0912612012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER (x41 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION 1x5] DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 0395? Continued From page 11 03957 effect of paralyzing agent. Abdomen; soft Bowel Sounds AIP (Assessment and plan) Code Stroke with right facial droop and left hemiparesis. I Likely secondary to arterial venous malformation (AVM) vs. HELLP vasculitis. Patient admitted to ICU. 9. Review of the Discharge Summary in the medical record written by the OBGYN. indicated: . a. Hospital Course: weeks. 6 days presented in for elective induction of labor. Vitals were stable I b. Assessment and Plan: 10/1111 at 0830 no complaints. no nausea or vomiting, vitals stable. I 1245 - status post epidural patient had complained of some tenderness. ..resotved over a period of time. 1650 - no nausea or vomiting, BIP 137/68. no complaints at this time. 1800 - no complaints. 1915 - delivery note written. female infant APGAR 9 at 1 minute. 9 at 5 minute at 1849. Patient with out complaints. 5 c. 1012/11. at 0210 Addendum written by the . health care providerIOBGYN which notes: at . approximately 2030 patient complained of - mild-epigastric pain with nausea. Given Bicitra with no of severe mid-epigastric pain. Patient husband requested GI consult. GI MD called. Maalox 30 ml given. Amylase and STATE FORM LDOF11 It continuation sheet 12 of 14 PRINTED: 121139012 FORM APPROVED New Jersev Department of Health STATEMENT OF DEFICIENCIES x1 PROVIDERISUPPLIEFUCLIA X2 MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A BUILDING WING 11304 091261201 2 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE monmoum MEDICAL CENTER LONG BRANCH. NJ 07740 9(4) lD SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION {x5} PREFIX DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 0395? Continued From page 12 03957 Lipase ordered along with pre-eclamptic labs. . Patient had a surgical consult. An upright AP film I ordered. showed possible dilated loops of bowel. Dilaudid given for pain. no response. 2 mg Morphine IV given within 5 minutes. Patient ex facial droop on left side. Code stroke called. BIP . 137I102. Magnesium Sulfate loading dose given for seizure prophylaxis anesthesia intubated patient. Patient sent to CT scan. Neurosurgeon . called. Patient to Intensive Care Unit . Patient 5 initial blood work on 10! 1f 11 at 2050 were; ALT-18. AST-40. Alkaline. Phosphate-59. . Amylase-47. Lipase 26. Blood Glucose 90. BUN 10 Creatinine-O.77 Uric Acid-7.5. Total Protein 5.6. Albumin 3.2. Labs discussed with husband. were sent immediately upon presentation of mid-epigastric tenderness. At time of stroke labs drawn again. ALT had now jumped to 490. AST-718 and Alkaline Phosphates-241. By 1:30 in the morning. the ALT had gone to 509 and AST 791. By 2:59 the ALT was 717 and AST 1303. By 5:32 AM. ALT-795. AST 1688 and LDH 2938. Neurosurgeon spoke to husband over the phone i at home re; results of CT (OBGYN) was I called to the ICU as patient?s BP continued to I drop. Patient was started on Levophed drip. Second CT scan reviewed by radiology. showed . worsening swelling in brain. questionable whether I or not patient was herniating. Neurosurgeon . made aware. Patient taken to the Operating Room (OR). CT scan and abnormal liver US were . discussed with husband. As per radiologist there was no hematoma or sub capsular hemorrhage of the liver. LFTs continue to rise, platelets down to 41 team attempting to place femoral line and platelets were being hung. On 10I2111 at approximately 1310 after patient was taken to OR by neurosurgeon, a deceleration of death by Neurologic criteria was filled out. ..apnea test done. patient failed to have STATE FORM LDQF 11 If continuation sheet 13 of 1 PRINTED: 12!18!2012 FORM APPROVED New Jersey Department Of Health STATEMENT OF DEFICIENCIES x1 PROVIDEFUSUPPLIERICLIA (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 0(2) MULTIPLE CONSTRUCTION COMPLETED A. BUILDING WING 11304 2 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. STATE. ZIP CODE ECO VENU MONMOUTH MEDICAL CENTER 33242 NJ 57740 044, .0 SUMMARY 0F DEFICIENCIES In PLAN OF CORRECTION 1x5, (EACH DEFICIENCY MUST BE PRECEDED BY FULL pagnx CORRECTWE ACTION SHOULD BE COMPLETE m3 REGULATORY OR LSC IDENTIFYING INFORMATION) m; CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 0395? Continued From page 13 03957 spontaneous breathing. no gag re?ex. no corneal met criteria for brain death. Patient extubated. The patient lost cardiac activity at 1507 on the monitor. Patient pronounced dead 1012! 11 1508 with family at permission not granted by husband and family. The cause of death was intracranial hemorrhage secondary to unknown etiology, possibly HELLP d. There was no evidence in the medical record that the elevated blood pressures were addressed by the health care provider/OBGYN until after Code Stroke was called. e. The above was confirmed by Staff #2 and STATE FORM 6399 LDOF11 If continuation sheet 14 of 14 I ,5 with? '53: . (State of ?sh 321-521;; DEPARTMENT OF HEALTH PO BOX 367 TRENTON. NJ. 08625-0367 CHRIS CHRISTIE Governor KIM GUADAGNO MARY E. O'Dowo, MPH Lt Governor Commissioner December 28. 2012 Re: Monmouth Medical Center Complaint NJ00056972 A representative rrom Assessment and Survey conducted an investigation of your complaint concerning patient care at Monmouth Medical Center. The investigation included medical record review. review of facility documentation. staff interviews and review of facility policies and procedures. Please be advised that this facility will be cited for violation of regulations of Hospital/Ambulatory Licensing Standards. A correction plan will be submitted by this facility for this de?cient area. It will then be evaluated by this of?ce for compliance with state licensure regulations. The complaint speci?cs and the investigation results were presented to and reviewed with administrative staff for continued monitoring of patient care. Thank you for forwarding your concerns to this of?ce. Sincerely, r} 7 f; LA Sophie Xyloporta?sTf-QN Hcsa?? Assessment and Survey PRINTED: 12113I2012 NOT n-cc?pTE-b FORM APPROVED New Jersey Department of Health (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY STATEMENT OF (x1) PROVIDERISUPPLIERICLIA A. BUILDING COMPLETED DEFICIENCIES IDENTIFICATION NUMBER AND PLAN OF CORRECTION B. WING 09:25:2012 11304 NAME OF PROVIDER OR SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH NJ 07740 004) ID SUMMARY OF OEFICIENCIEs ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEOEO BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR IDENTIFYING INFORMATION TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 000 8:436 INITIAL COMMENTS 000 The facility is in substantial compliance with N.J.A.C. Title 8 Chapter 43 6? Hospital Licensing Standards for this Complaint Investigation: I NJ00053395. . 03957 03957 I The facility is not in compliance with N.J.A.C. or TitIe r: 3 Chapter 43 6- Hospital Licensing Standards for this Complaint investigation: 8:436- 18.2(3) NURSING CARE: POLICIES PROCEDURES The hospital shall have written policies and procedures for the nursing care service that guide nursing practices in the hospital. These policies shall be reviewed at least once every three years. revised more frequently as needed. and implemented. These policies and procedures shall conform with the Nurse Practice Act. N.J.S.A. 45:11-23 and N.J.A.C. 6.1. 6.2. 13.1 and 13.2. This REQUIREMENT is not met as evidenced by: Based on medical record review. staff interview. review of facility in-services and policies. it was determined that the facility failed to ensure that recommended obstetrics guidelines are adhered to by staff. Findings include: Reference Facility Policy #640-044-130, titled "Care of the Patient; Post Partum? refers to the following reference as to the procedure that the facility adheres to: Mattson. S.. Smith. J.E.. (1997) AHONN: Core . 11' I i a a . 03957 2012 Mandatory Educational Program for all Labor and Delivery Staff Nurses; content of the program included: 1. Risk Factors. signs and of pre-eclampsia 2. Risk Factors, signs and of eciam psia LABORATORY DIRECTOR SI TU DATE For Monmouth Medical Center 5213:4; STATE FORM WI 6899 II continuaugi sheet 1 of 14 PRINTED: 12I18f2012 FORM APPROVED New Jersey Department of Health STATEMENT OF (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION DATE SURVEY DEFICIENCIES IDENTIFICATION NUMBER A. BUILDING COMPLETED AND PLAN OF CORRECTION 11304 B. WING 09I26I2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 Ox (x4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE it: MPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) . 4i . 0395? Continued from page 1 3. Risk Factors. signs and of HELLP Curriculum for Maternal-Newborn Nursing, Second Edition, Philadelphia, W. B. Saunders Company. P. 393 Chapter 21; Hypertension in Pregnancy: Objectives: 3. Identify factors that place women at greater risk for pre-eclampsia 4. Correlate history and physical ?ndings with signs and of pre-eclampsia, eclampsia and HELLP (Hemolysis. Elevated Liver Enzymes. Low Platelets) 5. Predict maternal and fetal complications 6. Formulate nursing interventions to alleviate or prevent potential problems identi?ed in the nursing assessment 7. Summarize the treatment of pre-eclampsia. eclampsia and HELLP Introduction: A. Introduction: Hypertensive disorders of pregnancy can result in life-threatening 3. Hypertension during pregnancy is one of the leading causes of maternal morbidity and 4. Therapy is aimed at controlling hypertension and seizures, preventing long- term morbidity. and preventing maternal. fetal or neonatal death E. Differentiation of hypertensive disorders 1. PIH (Pregnancy induced Hypertension) a. Pre-eclampsia (1) Hypertension Systolic pressure is at least 140 mm Hg Diastolic pressure is at least 90 mm Hg At least two elevated values 6 or more hours apart Relative hypertension may be identi?ed with a systolic increase of 30mm 4. Risk Factors. signs and of PIH (Pregnancy Induced Hypertension) 5. Treatment Modalities for patients exhibiting signs and of pre-eclampsia. eclampsia. HELLP and PIH (Pregnancy Induced Hypertension) 100% of RN staff completed this mandatory education 2012) The educational program has been added to the staff orientation program (2012) W30 charts per month 3 months were reviewed for. a. variance in pre-natal to admission blood pressure suggestive of pre- eclampsia. eclampsia or PIH. b. If variance was suggestive of pre-eclampsia. eclampsia or nurse documented physician noti?cation c. identi?cation of signs and suggestive of the HELLP d. If patient exhibited signs and indicative of HELLP nurse documents physician noti?cation. Monitoring Compliance: BP Variance: 90% Monitoring Compliance HELLP 6. ALSO (Advanced Life Support Obstetrics) staff training program: staff training began in 2009 and is offered twice yearly; currently 25% of staff RN's have completed the course; additional staff will attend until 100% of staff receive training. . ALSO is a course that is offered by AAFP (American Academy of Family Physicians); the course is structured. evidenced based and multidisciplinary 7. The organization will be offering a Critical Care Obstetrics Course in 2013; the course is available for Labor and Delivery RN's and ICU this course will be repeated annually 8. The facility has created a new policy: this policy will address the care of the ?intrapartum? patient. This policy is based on AWHONN's Standards for Professional Nursing Practice (Association of Women's Health. Obstetrics and Neonatal Nursing) All staff will be required to review and attest to reviewing this policy. Education time frame: 2115-3112013 Implementation date: 3I2I2013 A (If LA) L05 {rt/on +0 a. Rf Monmouth Medical Center STATE FORM 6399 lf continuation sheet 2 of 14 PRINTED: 2 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING 09l26f2012 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) D3957 Continued from page 2 03957 Continued from page 2 Hg and a diastolic increase of 15 mm Hg above baselines (9.9. compared . with 90.60 at ?rst prenatal visit.) Relative hypertension should alert health care providers to the need for further evaluation and close surveillance. \t Severe eclampsia is de?ned as one of the following (1) Blood pressure Systolic pressure is at least 160 mm Hg Diastolic pressure is at least 110 mm Hg (7) Epigastric or right upper quadrant pain Eclampsia Other risks include cerebrovascular accident (CVA). cerebral edema. anoxia. coma and maternal death 2. Eclampsia should be preventable if pre- eclampsia is recognized in its early stages, surveillance is adequate and therapy is appropriate. Initiation of Team STEPPS Training I) Referfnce #23 The Program in March 2012. This program titled Care of the Patient; Post Partum . was developed by the AHRQ (Agency ., {attrpulalt?es TO dftim'pe care for Healthcare Research and Quality) to . I mug assessme?.? reassessfme" 9 pa improve patient safety. The program care needs. Decrsrons regarding patient care are bl? based on analysis of date obtained by the was attended by ?3?0 RN Staff and ?3?0 members of the multidisciplinary health care team OPIGYN staff. The program teaches and the patient?s responselprogress. To identify evidence based methods that address potential complications and take appropriate optimizing assessment and action to minimize risk to both mother and baby. communication skills for healthcare POLICY: 3- abnormal ??dingsu potential providers. Aspects of training include: I, complications. and lack of progress toward care a. SBAR: Situation. Background. goals will 3e cgmmunicated to the Assessment and . ph sician mi wife for clinica . It) asgessmentlintervention. Recommendatroanequest PROCEDURE: 5. Assessment. Reassessment. b' Situation Monltorlng Care and Education: c. Mutual .4 i. PainlDiscomfort: Assess for verbal and d. Communlcatron r~ nonverbal signs of discomfort. Provide pain staff conduct intra-multidisciplinary huddles at the beginning of each shift and as needed. i.e. with change in patient presentation throughout the shift Monmouth Medical Center STATE FORM 6899 LDOF11 If continuation sheet 3 of 14 PRINTED: 12i18f2012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING 09f26f2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) R) 0395? Continued from page 3 D3957 All laboring patients are monitored and managed in by the nursing staff medicationianalgesics as ordered by physician and physicians. with additional consultation m' and evaluate effectiveness. ii. REFERENCES: AWHONN: Core Curriculum for MatemaI-Newbom Nursing. 1997. Reference Facility Policy #640?084-110. titled ?High Risk Criteria: Obstetric Patient?. stipulates: PURPOSE: To identify the obstetric patient who may present a higher risk for a safe pregnancy and delivery. POLICY: It is the philosophy of Monmouth Medical identi?cation and treatment of ?high risk? patients that patients will receive the appropriate level of care in the appropriate setting thereby decreasing the risk for preterm delivery and maternal?nfant morbidity/mortality. Reference Facility ln-Services: Titled ?Hypertensive Disorders of Pregnancy? ?Risk Factors for Development of Pre-eclampsia" Criteria Mild-moderate BP (Blood Pressure) 140190 or higher. or a rise of 30 mm Hg systolic and 15 mm Hg diastolic from baseline. Severe BIP 1601110 or Management? Delivery of baby does not immediately reverse the pathophysiologic changes of therapy and monitoring ..Continue to be alert for early signs of pre-eclampsia complications such as: -HELLP -increased intracranial pressure, - intracranial hemorrhage. Most common physical complaints; Epigastric or RUQ (right upper quadrant) pain, (nausea and vomiting) ?Complications? .subcapsular hematoma. Reference Department of Pathology: Chemistry Reference Range: (Alanine amniotransferase) ALT 10-43. (Aspartate amniotransferase) AST with other specialties as appropriate. If a patient is pregnant and is admitted for a condition other than labor and the patient requires services that can not be provided in or whose care requirements are outside of the expected practice of the LED staff the patient will be transferred to the ICU. A nurse will be in constant attendance during the patient's admission and will perform matemal and fetal monitoring in that location. 2012 Mandatory Educational Program for all Labor and Delivery Staff Nurses; content of the program included: 1.Ris < Factors, signs and of pre-eclampsia 2.Risk Factors, signs and of eclampsia 3. Risk Factors, signs and of HELLP 4. Risk Factors. signs and of PIH (Pregnancy Induced Hypertension) 5. Treatment modalities for patients exhibiting signs and of pre- eclampsia, eclampsia, HELLP and PIH (Pregnancy Induced Hypertension) 100% of RN staff completed this mandatory education (2012) The educational program has been added to the staff orientation program (2012) Monitoring: 30 charts per month 3 months were reviewed for: a. variance in pro-natal to admission blood pressure suggestive of pre- eclampsia. eclampsia or PIH. b. If variance was suggestive of pre-eclampsia. eclampsia or PIH nurse documented physician noti?cation c. identification of signs and suggestive of the HELLP d. If patient exhibited signs and indicative of HELLP nurse documents physician notification. Monitoring Compliance: BP Variance: 90% Monitoring Compliance HELLP Monmouth Medical Center STATE FORM 6899 If continuation sheet 4 of 14 PRINTED: 131812012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING 09f26f2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) 6. ALSO (Advanced Life Support Obstetrics) 03957 Continued from page 4 03957 staff training program: staff training began in 13-41. (Lactate dehydrogenase) 116-243. (Blood urea nitrogen) BUN 5-21. Alkaline phosphate 42-119. Blood Glucose 70-110. Total Protein 6.4-8.3. Creatinine 0.40-1.1. Albumin 3.5-5.0. Amylase 26-116 Findings include: 1. 0n 9f25r'12 a review of Medical Record in the presence of Staff #2 revealed the following: a. The Antepartum Record (of?ce prenatal visits) for Patient #2 indicates the following blood pressures: 3110/1 1-108164. 6f14f11-110I68. 5l2f11-108l60. 513111 1-1 20164. 6112611 1-106166 7f25l11-112170. 816f11-112l70. 8124? 1-1 18172 916111420170. 9f15!11?106I72. 9f21f11-120170. b. Review of the LED (Labor and Delivery) Admission Assessment dated 9f30111 at 1941 indicated: Admission Vital Signs; 147I99. This was signi?cantly higher than the baseline (Antepartum) blood pressures. stated above. c. There is no evidence that the Lil-D nurse noti?ed the primary care physician (PCP) of the elevated admission blood pressure. (1. The above was con?rmed by Staff #2 and 2. A review of the Physician Orders dated 9/30/11 at 2000 indicated: Vital signs every 15 minutes for the first hour. then every 30 minutes X2. then every 4 hours X12 hours. a. The Admission Assessment dated 9I30111 2009 and is offered twice yeariy; currently 25% of staff RN's have completed the course; additional staff will attend until 100% of staff receive training. . ALSO is a course that is offered by AAFP (American Academy of Family Physicians); the course is structured. evidenced based and multidisciplinary. One of MMC Attending OBIGYN physicians will be attending training to achieve instructor certi?cation in this course. This will enhance staff codi?cation. 7. The organization will be offering a Critical Care Obstetrics Course in 2013; the course is available for Labor and Delivery and ICU this course will be repeated annually 8. The facility has created a new policy; this policy will address the care of the ?intrapartum" patient. This policy is based on AWHONN's Standards for Professional Nursing Practice (Association of Women's Health, Obstetrics and Neonatal Nursing) All staff RN's will be required to review and attest to reviewing this policy. Education time frame: 2I15f2013-3f112013 Implementation date1312r'2013 1 In 2012.8taff nurses were educated regarding the necessity of reviewing. when available. or obtaining the patients pre-natal record. Education identi?ed that they must make a comparison of the pre-natal blood pressure against the initial admission blood pressure. Note:'The physician order dated 913012011 at 1941 was a standing order for postpartum nursing care. 2. The Clinical Documentation system. Centricity has been amended to include the following requirements: Staff will attest to review of the patients pre- natal record or they will indicate that the record was not available at the time of admission (call to PMD to obtain) If the initial systolic blood pressure is =to or> than 140 andlor the diastolic blood pressure is =to or than 90 the physician will be notified and a repeat blood pressure will be taken within one hour. Implementation date: 1f18f2013 to?? Monmouth Medical Center STATE FORM 6399 LDQF11 If continuation sheet 5 of 14 PRINTED: 1211812012 FORM APPROVED New Jersey Department of Health STATEMENT OF (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY DEFICIENCIES IDENTIFICATION NUMBER A. BUILDING COMPLETED AND PLAN OF CORRECTION 11304 e. WING 0912012012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETIN TAG FULL TAG CROSS-REFERENCED TO THE APPROPRIATE DATE REGULARTORY OR LSC IDENTIFYING DEFICIENCY) .- INFORMATION . If 3 The Iacility has created a new policy; this policy will address 0395? Continued from page 5 D3957 the care of the ?intrapartum' patient. This policy is based on Standards for Professional Nursing Practice Revealed a blood pressure of 147199 at 2008. (Association 01W0men?s Health. Obstetrics and Neonatal Nursing) - b. There is no evidence in the medical record of All staff RN's will be required to review and attest to reviewing a blood pressure between 9130111 at 2008 and this policy. 1011111 at 0402. Seven hours and 56 minutes Education timetrame: 211531112013 lapsed between the ?rst and second blood Implementation date.31212013 pressure. Baseline vital signs are obtained on all patients at the time of c. The above was con?rmed by Staff #2 and admission to frequency oi repeat vital signs is based on the patient condition and plan of care. Repeat vital signs will be 3. Review of the Maternal Flow Sheet indicated obtained every 4 hours at a minimum. the following: 2012 Mandatory Educational Program for all Labor and Delivery a. From admission on 9130111 at 2008 to Staff Nurses: content 01 the program included: 1011111 at 1826. 21 systolic blood pressures 1.Risk Factors. signs and of pre-eclampsia were at or above 140 mm Hg. ranging from 2.Risk Factors. signs and of eclampsia 140-162 mm 3. Risk Factors. signs and 01 HELLP Hg. and 13 diastolic blood pressures were at or 4. Risk Factors. signs and 01 PIH (Pregnancy above 90 mm Hg. ranging from 90-106. These Induced Hypertension) numbers are indicative of hypertension as per 5. Treatment Modalities for patients exhibiting signs and - reference of pre-eclampsia. eclampsia. HELLP and PIH (Pregnancy Induced Hypertension) b. There is no evidence in the medical record 100% of RN staff completed this mandatory education 2012) that the Registered Nurse (RN) noti?ed the The educational program has been added to the LED staii health orientation program (2012) care providerIObstetrics Gynecologist M30 charts per month it 3 months were reviewed for: (OBGYN). of the elevated blood pressures of a. variance in pre-natal to admission blood pressure suggestive patient #1 of pre-eclampsia. eclampsia 0r PIH. b. It variance was prior to delivery suggestive of ore-eclampsia. eclampsia or PIH nurse documented physician noti?cation c. identi?cation of signs and c. There is no evidence in the medical record of suggestive of the HELLP d. If patient further evaluation and surveillance of Patient exhibited signs and indicative oi HELLP #1 . from the health care providerIOBGYN. prior nurse documents physician noti?cation. to delivery. Monitoring Compliance: 8P Variance: 90% Monitoring Compliance HELLP d. The above was con?rmed by Staff #2 and 4. Review of the Delivery Summary: GYN The medical record has OBIGYN Physician notes as follows: (Gynecological) HISTORY (per patient or 913012011 at 2015: Admission Progress Note Prenatal Record): Denies having any 101112011 at 0630: Physician Progress note complications. 101112011 at 1245: Physician Progress Note Delivery Date: 10101111. 1849 101112011 at 1400: Physician Progress Note Outcome: Liveborn 101112011 at 1650: Physician Progress Note 101112011 at 1800: Physician Progress Note 101112011 at 1915: Physician Delivery Note Monmouth Medical Center STATE FORM 6899 LDOF11 If continuation sheet 6 of 14 PRINTED: 1211812012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING 0912612012 NAME OF PROVIDER OR SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID PREFIX TAG SUMMARY OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULARTORY OR LSC IDENTIFYING INFORMATION ID PREFIX TAG PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 03957 Continued from page 6 5. Review of the Vaginal Delivery- Recovery sheet indicated: a. Blood pressures: 1011110 (sic): Time - BIP 1856 - 136183 1911 154197 1926 - 161193 1937 141190 1941 - 154197 1956 160195 2011 - 161196 2020 1521102 2026 - 158197 2041 - 1841103 2056 1691106 No BIP taken for 1 hour and 29 minutes 2225 - 1751100 No B1P taken for 1 hour and 44 minutes 1012111: 0009 1741101 0013 1841119 0014 - 1971117 0018 1911115 0024 Attempt made to take BIP 0031 1381101 0032 - Attempt made to take 0049 - 146197 0053 - 1551102 0054 1481102 13. Review of the Vaginal Delivery Recovery sheet indicated that the patient?s pain was as follows: 2030-Mid-epigastric was rated at 7110 (on a pain scale of 1110. 10 being the worst pain). Intervention: Bicitra 30 ml. Pain relief was 03957 Continued from page 6 z?w Monmouth Medical Center STATE FORM 6899 LDQF11 If continuation sheet 7 of 14 PRINTED: 12/18/2012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11 304 B. WING 09126I201 2 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG RE GULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) Continued from page 7 XL 0395? Continued from page 7 0395? 0k; I documented at 7/10. (L 2041-Pain was; 10/10. 2050-Pain was rated at 10110. 2150-Pain was 8/10 2200-Pain was 10/10. Interventions indicated that a GI (Gastroenterologist) Consult was ordered and DiIaudid 2mg IV was administered. 2200-Pain was rated 10110. c. There was no evidence in the medical record The Medical Chairman of the OBIGYN that the elevated blood pressures were department provided professional addressed by the primary health care remediation for the identi?ed physician in provider/OBGYN. 2011. Monitoring of 100% of records for physician of record per month 3 months. Records were assessed for compliance of timely physician intervention for elevated blood pressures/pain assessment and management 6. Review of the Nursing Notes indicated the Monitoring Compliance: 100% following 1011/11-2030: Patient complained of severe mid-epigastn?c pains and burning radiating up her chest. MD (OBGYN) at bedside. Patient evaluated. active bowel sounds present In all 4 quadrants. Bicitra orders received. 2032- Orders received for IV Diiaudid 0.5mgs. Patient requests dose.. 2041? MD (OBGYN) aware of patient's BIP. Pre- eclampsia labs Patient unable to stay still, bending over in pain. Patient vomiting. 2050 Pre-ecIampsia labs drawn.. . Patient remains in pain. 2100 - Patient pain status remains the same. MD (OBGYN) made aware. MD (OBGYN) at bedside. donmouth Medical Center STATE FORM 6899 LDOF11 If continuation sheet 8 of 14 I PRINTED: 1211812012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING 09I26i2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) Continued from page D3957 Continued from page D3957 Dilaudid 0.5 mg given IV push. 2120 Lab results back from lab. MD (OBGYN) made aware. No abnormal labs 2130 - Patient states relief from pain. ?I'm feeling much better.? 2147 Patient in pain again..Patient 2200 - pain present. Patient and husband made aware a GI consult is in place 2215 consult via phone to OBGYN. Plan of care discussed. Orders received for upper abdominal X-ray, amylase and lipase levels. Maalox 30 ml now. 2216 Unable to give Maalox at this time, 2220 Dilaudid 2 mg administered IV push. 2225 Patient unable to remain 2255 Maalox 30 ml given PO. 2300 40 mg Protonix given IV. 2315 ?Patient to Emergency Department (ED) for continues to appear in pain 10(10 localized mid-epigastn?c pain. Patient vomiting. OBGYN made aware of patient status and X-ray results. General Surgery consult requested. 2345 Surgery Resident at bedside. Patient evaluated. 2355 Patient states ?do anything to stop this pain." OBGYN at bedside..orders for morphine 2 Monmouth Medical Center STATE FORM 6899 Ii continuation sheet 9 of 14 - A?u. h? . g. PRINTED: 12/180012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) Continued from page 9 I 0395? Continued from page 9 D3957 mg 1012l11 - 0005 Morphine 2 mg IV push 0009 Pulse Ox applied. patient extremely 0010 OBGYN at Bedside, patient cognitively intact. lethargic 0018 - OBGYN assessing patient. Left side facial drooping noted. Patient unable to lift left arm. Code Stroke called. 0026 Code Stroke team at bedside. 0035 Magnesium Sulfate initiated. 4 gm loading dose. 115 Blood Sugar ?nger stick. 0045 - Patient intubated. .. 7. Review of the Physicians Progress Notes by the OBGYN revealed the following: Admit note: 9/30/11 at 2015, Cervidel started. No mention of elevated admission BIP. 10I1l11 at 2230: no mention of elevated BIP. 1240 Vital signs 1650 Patient without complaints; BIP 132168. 1800 Patient without any complaint. no complaint of epigastric pain mentioned. 10/1l11 Delivery note patient delivered female at 10(2111 0210 Addendum by the heath care provider OBGYN at 1OI1I11 2030 . I Kid? Monmouth Medical Center STATE FORM 6899 LDOF11 If continuation sheet 10 of 14 Irma?.- PRINTED: 1211812012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING 09l26l2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07T40 (x4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) 0395? Continued from page 10 0395? Continued from page 10 Patient complained mid-epigastric pain with nausea. given Bictra (sic) with no mid-epigastn?c pain. GI called. . . Maalox and lipase ordered WNL (within normal limits). Surgery consult ordered..Given Dilaudid for pain. Pain not mg Morphine IV..patient exhibits facial droop on left side. Code Stroke called. BIP 137/102. magnesium sulfate paralysis went to CT-Scan..to ICU (Intensive Care Unit). 8. Review of the History and Physical Form in the medical record. from the PCPIOBGYN indicated: 10/2/12 (sic) at 0200: Code StrokelICU transfer note: Code Stroke was called around 12:24am to L&D..Patient had delivered 4 hours ?when she started to complain of epigastn?c pain she was given V: mg Dilaudid x2. then 2mg Dilaudid and Iater2 morphine IV. which eased her pain." A surgical consult was requested and patient was being evaluated by a surgical resident. It was noticed that patient had n'ght facial droop and lelt sided weakness around 1200 (10(2111) at this point code stroke was called. When I saw the patient she had right sided facial droop and unable to move lett upper and lower extremities. Stat(sic) CT of head without contrast ordered 1230 with labs (sic) work including PTIINR. Patient started vomiting and anesthesia needed to intubate to secure airway. CT scan done at 0100 and revealed right and subarachnoid bleed with 5mm shift. The patient was brought to the ICU. being evaluated by neurologist and neurosurgeon. Patient started on Mannitol 50 gm IV BP 175/122235 CNS: Unable to assess as patient under the Monmouth Medical Center STATE FORM 6899 LDQF11 If continuation sheet 11 of 14 . - PRINTED: 12/18/2012 FORM APPROVED New Jerse De-artment of Health STATEMENT OF OEFICIENCIES (x1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER (X3) DATE SURVEY A. BUILDING COMPLETED 11304 B. WING 091'261'2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 SUMMARY OF DEFICIENCIES PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION REGULARTORY 0R LSC IDENTIFYING CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY Continued from page 11 Continued from page 11 effect of paralyzing agent. Abdomen soft Bowel Sounds MP (A 9. Review of the Discharge Summary in the medical record Written by the OBGYN, indicated: a. Hospital Course: weeks, 6 days presented in MD for elective induction of labor. Vitals were b. Assessment and Plan: 10/1/11 at 0830 no complaints. no nausea or vomiting. Vitals stable. 1245 - status post epidural patient had Complained of some tendemess. over a period of time. 1650 - no nausea or vomiting, BIP 137/68, no complaints at this time. 1800 no complaints. nmouth Medical Center ATE FORM 6399 LDQF11 ll continuation sheet 12 of 14 - PRINTED: 1211812012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) 0395? Continued from page 12 0395? Continued from page 12 Lipase ordered along with pre-eclamptic labs. Patient had a surgical consult. An upn'ght AP ?lm ordered. showed possible dilated loops of bowel. Dilaudid given for pain. no response, 2mg Morphine IV given within 5 minutes. Patient ex facial droop on left side. Code stroke called. BIP 1371102. Magnesium Sulfate loading dose given for seizure prophylaxis anesthesia intubated patient. Patient sent to CT scan. Neurosurgeon called. Patient to Intensive Care Unit (ICU). Patient?s initial blood work on 10/1/11 at 2050 were: ALT-1B. Alkaline. Phosphate-59. Amylase-47. Lipase 26. Blood Glucose 90. BUN 10 Creatinine-0.77 Uric Acid-7.5. Total Protein 5.8. Albumin3.2. Labs discussed with husband. were sent immediately upon presentation of mid- epigastric tenderness. At time of stroke labs drawn again. ALT had now jumped to 490. AST-718 and Alkaline Phosphates -241. By 1:30 in the morning the ALT had gone to 509 and AST 791. By 2:59 the ALT was 717 and AST 1303. By 5:32 AM. ALT-795. AST 1888 and LDH 2988. Neurosurgeon Spoke to husband over the phone at home re: results of CT (OBYN) was called to the ICU as patient's BP continued to drop. Patient was started on Levophed drip. Second CT scan reviewed by radiology. showed worsening swelling in brain. questionable whether or not patient was hemiating. Neurosurgeon made aware. Patient taken to the Operating Room (OR). CT scan and abnormal liver US were discussed with husband. As per radiologist there was no hematoma or sub capsular hemorrhage of the liver. LFTs continue to rise. platelets down to team attempting to place femoral line and platelets were being hung. On 1012l11 at approximately 1310 after patient was taken to OR by neurosurgeon. a Declaration of Death by Neurologic Criteria was ?lled out..apnea test done. patient failed to have Monmouth Medical Center STATE FORM 6399 LDQF11 If continuation sheet 13 of 14 PRINTED: 12/18/2012 FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES {x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES lD PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETIO TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE I INFORMATION DEFICIENCY) Br? 0395? Continued from page 13 03957 spontaneous breathing. no gag re?ex, no corneal reflex..Patient met the criteria for brain death. Patient extubated. The patient lost cardiac activity at 1507 on the monitor. Patient pronounced dead 10!2l11 1503 with family at bedside. .Autopsy permission was not granted by husband and family. The cause of death was intracranial hemorrhage secondary to unknown etiology. possibly HELLP (1. There was no evidence in the medical record that the elevated blood pressures were addressed by the health care provider/OBGYN until a?er Code Stroke was called. e. The above was con?rmed by Staff #2 and Continued from page 13 XIIN 1. The Medical Chairman of the OBIGYN department provided professional remediation for the identi?ed physician in 2011. Monitoringz12/201 1-212012 Monitoring of 100% of records for physician of record per month it 3 months. Records were assessed for compliance of timely physician intervention for elevated blood pressureslpain assessment and management Monitoring Compliance: 100% Monmouth Medical Center STATE FORM 6399 If continuation sheet 14 of 14 FEB-24-2613 D3142 - New Jersey Department of Health MED I CPIL CENTER TATEMENT OF PROVIDEWSUPPLIERICLIA EFICIENCIES IDENTIFICATION NUMBER ND PLAN OF CORRECTION 11304 (X2) CONSTRUCTON A. BUILDING B. WING . [32/23 PRINTED: 121812012 FORM APPROVED (X3) DATE SURVEY COMPLETED 099M201 2 OF PROVIDER OR SUPPLIER IONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. STATE, ZIP CODE 300 SECOND AVENUE LONG BRANCH NJ 07740 X4) ID FIX TAG SUMMARY OF (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULARTORY OR IDENTIFYING INFORMATION ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-RE FERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETION DATE 000 )3957 3:436 INITIAL COMMENTS The facility Is in substantial compliance with N.J.A.C. Title 8 Chapter 43 6- Hospital Licensing Standards for this Complaint investigation: 0# . NJ00053395. The facility is not in compliance with Title 8 Chapter 43 G- Hospital Licensing Standards for this Complaint investigation: 182(3) NURSING CARE: POLICIES 8: PROCEDURES The hospital shall have written policies and procedures for the nursing care service that guide nursing practices in the hospital. These policies shall be reviewed at least once every three years. revised more frequently as needed, and implemented. These policies and procedures shall conform with the Nurse Practice Act. N.J.S.A. 45:11-23 and N.J.A.C. 6.1. 6.2. 13.1 and 13.2. This REQUIREMENT is not met as evidenced by: Based on medical record review. staff Interview. review of facility In-servlces and policies. it was determined that the facility failed to ensure that recommended obstetrics guidelines are adhered to by staff. Findings include: Reference Facility Policy #640-044-130, titled 'Care of the Patient: Post Partum" refers to the following reference as to the procedure that the facility adheres to: Mattson. 8., Smith. J.E.. (199?) AHONN: Core 03957 D3957 NV 2012 Mandatory Educational Program for all Labor and Delivery Staff Nurses: content of the program included; 1. Risk Factors. signs and of pre-eclampsia 2. Risk Factors. signs and of eclampsia LABORATORY 5 OR PROVIDE RSISUPPLIER REPRESENTATIVE SIGNATURE TITLE For Monmouth Medical Center (X6) DATE STATE FORM 6899 LDQF11 if continuation sheet 1 of 14 FEB-24-2813 B3: 42 New Jersey Department of Health MEDICRL CENTER PRINTED: 12l18!2012 FORM APPROVED OF (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER A. BUILDING (X3) 33$:ng IND PLAN OF CORRECTION 3- WW3 OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MEDICAL CENTER sou SECOND AVENUE LONG BRANCH NJ 07740 mi ID SUMMARY orE DEFICIENCIES ID PLAN OF (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE common TAG REGULARTORY OR IOEN11 FYING TAG CROSS-REFERENCED To THE APPROPRIATE DATE INFORMATION DEFICIENCY) )3957 Continued from page 1 3. Risk Factors. signs and of HELLP Curriculum for Maternal-Newborn Nursing. Second Edition. Philadelphia, W. B. Saunders Company. P. 393 Chapter 21; Hypertension in Pregnancy: Objectives: 3. Identify factors that place women at greater risk for pre-eoiarnpsia 4. Correlate history and physical ?ndings with signs and of pre-eclampsia. eclampsia and HELLP (Hemolysis. Elevated Liver Enzymes. Low Platelets) 5. Predict maternal and fetal complications 6. Formulate nursing interventions to alleviate or prevent potential problems identi?ed in the nursing assessment 7. Summarize the treatment of pre-eolampsia. eclampsia and HELLP Introduction: A. Introduction: Hypertensive disorders of pregnancy can result in life-threatening 3. Hypertension during pregnancy is one of the leading causes of maternal morbidity and 4. Therapy is aimed at controlling hypertension and seizures. preventing long- term morbidity, and preventing maternal. fetal or neonatal death E. Differentiation of hypertensive disorders 1. PIH (Pregnancy Induced Hypertension) a. Pre-eclampsia 1) Hypertension Systolic pressure is at least 140 mm Diastolic pressure is at least 00 mm H9 (C) At least two elevated values 6 or more hours apart Relative hypertension may be identified with a systolic increase of 30mm 4. Risk Factors, signs and of PIH (Pregnancy induced Hypertension) 5. Treatment Modalities for patients exhibiting signs and of pre-eclampsla. eclampsia. HELLP and PIH (Pregnancy Induced Hypertension) 100% of RN stalf completed this mandatory education 2012) The educational program has been added to the LED stair orientation program (2012) Monitorim 30 charts per month at 3 months (December 201 1-Febmary 2012) were reviewed by the Pl Coordinator for. a. variance in pro-natal to admission blood pressure suggestive of pre- eclampsia. eciarnpsia or PIH. b. If variance was suggestive of pre-ecIampsia. eciampsia or PIH nurse documented physician noti?cation C. identi?cation of signs and suggestive of the HELLP If patient exhibited signs and indicative of HELLP nurse documents physician noti?cation. Monitoring Compliance: BP Variance: 90% Monitoring Compliance HELLP 6. ALSO (Advanced Life Support Obstetrics) staff training program staff training began in 2009 and is offered twice yearty; currently 25% of start? RN's have completed the course; additional staff will attend until 100% of staff receive training. Most recent course was provided on October 21- October 22 2012. ALSO is a course that is offered by AAFP (American Academy of Family the course is structured. evidenced based and multidisciplinary 7. The organization will be offering a Critical Care Obstetrics Course on April 26. 2013: the course is available for Labor and Delivery RN's and ICU this course will be repeated annually. The review course will be provided by the OB and Critical Care Educators and the Director of the Education Department who Is a Certi?ed OB Clinical Nurse Specialist 8. The facility has created a new policy; this policy will address the care of the 'intrapartum? patient. This policy is based on Standards for Professional Nursing Practice (Association of Women's Health. Obstetrics and FEB-24-2813 B31 42 MDNMUUTH MEDICFIL CENTER 1 P.64K2B Neonatal Nursing) All staff will be required to review and attest to reviewing this policy. (signed attestation form that will be placed Into their unit personnel Monitoring will be performed by the Clinical Director of Labor and Delivery: 5 charts per day or 100% of records is 5 patients admitted to the unit for a 24 hour period. Monitoring will be performed over a 3 month period. 31320136132013) Education time frame: 211531112013 Implementation date: 3121'2013 tonmouti'l Medical Center FORM 3899 LDOF11 If continuation sheet 2 of 14 I. FEB-24-2913 B3 3 42 MUNMEIUTH MEDICFIL CENTER . @5326 PRINTED. 131812012 New Jersey Department of Health FORM APPROVED STATEMENT OF DEFICIENCIES (an I (x2) MULTIPLE CONSTRU ON 3 AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING 0? 11304 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMDUTI-I MEDICAL CENTER son SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PREOEDED FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE ON TAG OR IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) 03957 Continued from page 2 0395? Continued from page 2 Hg and a diastolic Increase of 15 mm Hg above baselines 120:!90 compared with 90(60 at first prenatal visit.) Relative hypertension should alert health care providers to the need for further evaluation and close surveillance. Severe edampsia is de?ned as one of the following (1) Blood pressure Systolic pressure is at least 160 mm Hg Diastolic pressure is at least 110 mm Hg (7) Eplgastn?c or right upper quadrant pain Eclampsia Other risks include cerebrovascular accident (OVA), cerebral edema. anoxia. coma and maternal death 2. Eclampsia should be preventable if pre- eclampsla is recognized in its early stages. surveillance is adequate and therapy is appropriate. Reference The facility?s policy #640-044-130. titled ?Care of the Patient; Post Partum" stipulates: PURPOSEIGOAL: To determine care through assessmentireassessmant of patient care needs. Decisions regarding patient care are based on analysis of data obtained by the members of the multidisciplinary health care team and the patient?s responseiprogress. To identify potential complications and take appropriate action to minimize risk to both mother and baby. POLICY: 3. All abnormal ?ndings. potential complications. and lack of progress toward are goals will be communicated to the physicianslmidwiie for clinical assessment/intervention. PROCEDURE: 5. Assessment. Reassessment. Care and Education: i. Assess for verbal and nonverbal signs of discomfort. Provide pain Initiation of Team STEPPS Training Program in March 2012.This program was presented on 3/26/2012. This program was developed by the AHRQ (Agency for Healthcare Research and Quality) to Improve patient safety. The program was attended by RN Staff and um OBIGYN staff. The program teaches evidence based methods that address optimizing assessment and communication skills for healthcare providers. Aspects of training include: a. SEAR: Situation, Background, Assessment and RecommendationfRequest b. Situation Monitoring c. Mutual Support d. Communication LED staff conduct mire-multidisciplinary huddles at the beginning of each shift and as needed. is. with change in patient presentation throughout the shift Monitoring was performed by the Assistant Clinical Directors of Labor and Delivery from Monitoring identified 100% compliance with performing a daily brie?ng at the start of the shift. debrie?ngs post 'compiicated" deliveries. huddles .m FEB-24-2913 :33: 43 MDNMUUTH MEDICPIL CENTER 2'3 performed during the course of the shift to discuss current stains of patients. and evidence of mutual support among caregivers. lonmouth Medical Center TATE FORM 3899 LDQF11 If continuation sheet 3 of 14 FEB-24-2813 33: 43 MUNMDUTH MEDICFIL CENTER . B7929 PRINTED: 1218/2012 medicationlanalgesics as ordered by physician and evaluate effectiveness. ii. REFERENCES: AWHONN: Core Curriculum for Maternal-Newborn Nursing. 1997. Reference Facility Policy #640?084-110. titled 'High Risk Criteria: Obstetric Patient?. stipulates: PURPOSE: To identify the obstetric patient who may present a higher risk for a safe pregnancy and delivery. POLICY: It is the philosophy of Monmouth Medical Center. ..aarly Identi?cation and treatment at ?high risk? patients that patients will receive the appropriate level of care In the appropriate setting thereby decreasing the risk tor preterm delivery and Reference Facility In-Sarvlces: Titled ?Hypertensive Disorders of Pregnancy' ?Risk Factors for Development of Pre-eciampsia" Criteria Mild-moderate BP (Blood Pressure) 140190 or higher. or a rise of 30 mm Hg systolic and 15 mm Hg diastolic from baseline. Severe BIP 100M 10 or Management? Delivery of baby does not immediately reverse the pathophysiologic changes of therapy and monitoring ..Continue to be alert for early signs of pre-eclampsia complications such as: -HELLP -incraased Intracranial pressure. - lntracranial hemorrhage. Most common physical compiaints; Epigastric or RUQ (right upper quadrant) pain. Ivsv (nausea and vomiting) ?Complications? hematoma. Reference Department of Pathology: Chemistry Reference Range: (Alanine amniotransterase) ALT 10-43. (Aspartate amniotransferase) AST managed in by the nursing staff and physicians, with additional consuttation with other specialties as appropriate. If a patient Is pregnant and is admitted for a condition other than labor and the patient requires services that can not be provided in or whose care requirements are outside of the expected practice of the LED staff the patient will be transferred to the ICU. A nurse will be in constant attendance during the patients admission and will perform maternal and fetal monitoring in that location. 2012 Mandatory Educational Program for all Labor and Delivery Staff Nurses; content-of the program included: 1.Risk Factors. signs and of pre-eclampsia 2.Risk Factors. signs and of eclampsia 3. Risk Factors. signs and of HELLP 4. Risk Factors. signs and of PIH (Pregnancy Induced Hypertension) 5. Treatment modalities for patients exhibiting signs and of pre- eclampsia. eclampsia. HELLP and PIH (Pregnancy Induced Hypertension) 100% of RN staff completed this mandatory education (2012) The educational program has been added to the LED staff orientation program (201 2) charts per month it 3 months (December 2011-February 2012) were reviewediby the PI Coordinator for. a. variance in pre-natal to admission blood pressure suggestive of pre-eciampsia. eclampsia or PIH. b. If variance was suggestive of pre-eciampsla. aclampsia or PIH nurse documented physician noti?cation c. identi?cation of signs and suggestive of the HELLP d. If patient exhibited signs and indicative of HELLP nurse documents physician notification. Monitoring Compliance: BP Variance: 90% Monitoring Compliance HELLP FORM APPROVED New Jersey Department of Health STATEMENT OF DE FICIENCIES (x1 I PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 B. WING. 0912612012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE INFORMATION DEFICIENCY) D3957 Continued from page 3 03957 All laboring patients are monitored and FEB-24-2813 B3143 MEDICFIL CENTER P.98f28 _l . I 1 donrnouth Medical Center ETATE FORM 8899 LDOF11 ll continuation sheet 4 of 14 FEB-24-2613 B3: 43 MONMEIUTH MEDICFIL CENTER P. BSFEI PRINTED: 12118f2012 FORM APP New Jersey Department of Health ROVED STATEMENT OF DEFICIENCIES (a1) PROVIDERISUPPLIERICLIA X2 MULTIPLE CONSTRUCTI AND PLAN OF CORRECTION IDENTIFICATION NUMBER 5i. ON (X3) 331$ng 11304 B. WING magenta NAME OF PROVIDER OR SUPPLIER REEF ADDRESS. CI . STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID SUMMARY OF DEFICIENCIES ID PROVI PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR LSC IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 6. ALSO (Advanced Life Support Obstetrics) 03957 Continued from page 4 03957 sta?' training program: sta? training began in 13-41, (Lactate dehydrogenase) 118-243. (Blood urea nitrogen) BUN 5-21. Alkaline phosphate 42-119. Blood Glucose 70-110. Total Protein 6.4-8.3. Creatinine GAO-1.1, Albumin 3.5-5.0. Amylase 23-113 Findings Include: 1. On 9125! 12 a review of Medical Record in the presence of Staff #2 revealed the following; a. The Antepartum Record (of?ce prenatal visits] for Patient #2 indicates the following blood pressures: 3110(11-108164. 512f11-108f30. 5131111-120i64. 63311140638 818111412170. W24I11-11BI72 915? 1420170, 911511408172. b. Review of the (Labor and Delivery) Admission Assessment dated 9130111 at 1941 indicated: Admission Vital Signs: 147(99. This was signi?cantly higher than the baseline (Antepertum) blood pressures. stated above. c. There is no evidence that the Lit-D nurse noti?ed the primary care physician (PCP) of the elevated admission blood pressure. d. The above was confirmed by Stall #2 and 2. A review of the Physician Orders dated 9f30!11 at 2000 indicated: Vital signs every 15 minutes for the ?rst hour. then every 30 minutes x2. then every 4 hours X12 hours. a. The Admission Assessment dated sraom 2009 and is altered twice yearly; currently 25% of staff have completed the course: additional staff will attend until 100% of staff receive training. Most recent course was provided on October 21-October 22 2012. ALSO is a course that is offered by AAFP (American Academy of Family Physicians); the course is structured. evidenced based and multidisciplinary. One of MMC Attending OBIGYN physicians will be attending training to achieve instructor certification in this course. This will enhance staff certification. 7. The organization will be offering a Critical Care Obstetrics Course on April 26. 2013; the course is available for Labor and Delivery RN's and ICU :this course will be repeated annually. The review course will be provided by the OB and Critical Care Educators and the Director of the Education Department who is a Certi?ed OB Clinical Nurse Specialist. 8. The facility has created a new policy: this policy will address the are of the ?intrapartum' patient. This policy is based on AWHONN's Standards for Professional Nursing Practice (Association of Women's Health. Obstetrics and Neonatal Nursing) All staff will be required to review and attest to reviewing this policy. (signed attestation form that will be placed into their unit personnel Monitoring will be performed by the Clinical Director of Labor and Delivery: 5 charts per day or 100% of records is 5 patients admitted to the unit for a 24 hour period. Monitoring will be performed over a 3 month period. Monitoring will be performed over a 3 month period. Education time frame: Implementation date:3!212013 1. In 2012.8ta?' nurses were educated regarding the necessity of reviewing. when available. or obtaining the patients pro-natal record. Education identi?ed that they must make a comparison of the pro-natal blood pressure against the initial admission blood pressure. Note:'The physician order dated B3: 43 MUNMCIUTH MEDICFIL CENTER P. 13?26 9i3til2011 at 1941 was a standing order for postpartum nursing care. 2. The Clinical Documentation system. Centriclty has been amended to include the following requirements: Staff will attest to review of the patients pre- natal record or they will indicate that the record was not available at the time of admission (mil to PMD to obtain) If the initial systolicblood pressure is =to or> than 140 andfor the diastolic blood pressure is =to or then 90 the physician will be noti?ed and a repeat blood pressure will be taken within one hour. Monitoring will be performed by the Clinical Director of Labor and Delivery; 5 charts per day or 100% of records is 5 patients admitted to the unit for a 24 hour-period. Monitoring will be perfom'led over a 3 month period. Implementation date: 11134201 3 ilonmouth Medical Center FORM 6899 LDQF11 If continuation sheet 5 of 14 D3: 44 MED I CENTER . 1 U26 PRINTED: 1218(2012 FORM APPROVED Iilew Jersey Department of Health TATEMENT OF PROVIDERISUPPLIEFUCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY EFICIENCIES IDENTIFICATION NUMBER A. BUILDING COMPLETED ND PLAN OF CORRECTION 11304 3. Wing . 09:23:2012 AME 0F PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 on ID summer OF DEFICIENCIES ID Paomoee's PLAN OF oonnec?ion (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG FULL TAG CROSS-REFERENCED TO 11-lE APPROPRIATE DATE REGULARTORY OR LSC IDENTIFYING DEFICIENCY) INFORMATION 3. The facility has created a new policy; this policy will 3395? Continued from page 5 03957 address the care of the ?Intrapartum' patient. This policy il til I i' . I (OBGYN). of the elevated blood pressures of Revealed a blood pressure of 147(99 at 2008. b. There is no evidence In the medical record of a blood pressure between 9130(11 at 2008 and 10I1I11 at 0402. Seven hours and 56 minutes lapsed between the ?rst and second blood pressure. c. The above was con?rmed by Staff #2 and 3. Review of the Maternal Flow Sheet indicated the following: a. From admission on 91:30:11 at 2008 to 1011(11 at 1826. 21 systolic blood pressures were at or above 140 mm Hg. ranging from 140-162 mm Hg. and 13 diastolic blood pressures were at or above 90 mm Hg. ranging from 00-106. These numbers are Indicative of hypertension as per reterence b. There is no evidence in the medical record that the Registered Nurse (RN) noti?ed the health is based on Standards for Professional Nursing Practice (Association of Women's Health. Obstetrics and Neonatal Nursing] All staff will be required to review and attest to reviewing this policy. (signed attestation form that will be placed into their unit personnel file}. Monitoring will be performed by the Clinical Director of Labor and Delivery; 5 charts per day or 100% of records Is 5 patients admitted to the unit for a 24 hour period. Monitoring will be performed over a 3 month period. Education time frame: 2/15-3/1/2013 Implementation date:3/2I2013 Baseline vital signs are obtained on all patients at the time of admission to frequency of repeat vital signs is based on the patient condition and plan of care. Repeat vital signs will be obtained every 4 hours at a minimum. 2012 Mandatory Educational Program for all Labor and Delivery Staff Nurses: content of the program Included: 1.ltisk Factors, signs and of pre-eclampsia 2.Ris t Factors, and of eclampsia 3. Risk Factors, signs and of HELLP patient #1 prior to delivery c. There is no evidence In the medical record of further evaluation and surveillance of Patient from the health care providerIOBGYN, prior to delivery. d. The above was con?rmed by Steii #2 and 4. Review of the Delivery Summary: GYN (Gynecological) HISTORY (per patient or Prenatal Record): Denies having any complications. Delivery Date: 10(01111, 1849 Outcome: Livehom 4. Risk Factors, signs and of PIH (Pregnancy Induced Hypertension) 5. Treatment Modalities for patients exhibiting signs and of pre-eclampsia. eclampsia, HELLP and PIH (Pregnancy Induced Hypertension] 10056 of RN staff completed this mandatory educatlon 2012) The educational program has been added to the Leo staff orientation program (2012] Monitoring: 30-charts per month it 3 months (December mil-February 2012) were reviewed by the Pl Coordinator; charts were reviewed for: a. variance in ore-natal to admission blood pressure suggestive of pre- eclampsia, eclampsla or PIH. b. If variance was suggestive of pro-eciampsia. eclampsia or Pit-l nurse documented physician noti?cation c. identification of signs and suggestive of the HELLP d. If patient exhibited signs and Indicative of HELLP nurse documents physician notification. Monitoring Compliance: BP Variance: 90% Monitoring Compliance HELLP The medical record has OBIGYN Physician notes as FEB-24-2813 B33 44 MUNMUUTH MED ICFIL CENTER . 12x28 follows: 9/30/2011 at 2015: Admission Progress Note 10/1/2011 at 0330: Physician Progress note 10/1/2011 at 1245: Physician Progress Note 10/1/2011 at1400. Physician Progress Note 10/1/2011 at 1650: Physician Progress Note 10/1/2011 at 1300: Physician Progress Note 10/1/2011 at 1915: Physician Delivery Note mmouth Medical Center FORM 6899 LDOF11 If con?nuation sheet 6 of 14 FEB-24-2813 B3 44 dew Jersey Department of Health CENTER P. 13:29 PRINTED: 1211812012 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER 11304 (x1) PROVIDERISUPPLIERICUA (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 0912612012 PROVIDE 0R SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS, 6111'. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH NJ 071'40 (X4) ID PREFIX TAG SUMMARY OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULARTORY OR LSC IDENTIFYING INFORMATION ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1X5) COMPLETION DATE 03957 1012111: Continued from page 6 5. Review of the Vaginal Dellve ry? Recovery sheet indicated: a. Blood pressures: 1011110 (sic): Time - BIP 1356 - 136183 1911 154197 1926 101193 1937 141190 1941 -154197 1056 - 160195 2011 - 161196 2020 1521102 2020 - 158197 2041? 1041103 2056 - 1691103 No BIP taken for 1 hour and 29 minutes 2225 1751100 No BIP taken for 1 hour and 44 minutes 0009 1741101 0013 - 1041119 0014 -1971117 0018 - 1011115 0024 Attempt made to take BIP 0031 - 1381101 0032 - Attempt made to take BIP 0049 146197 0053 - 1551102 0054 1431102 b. Review of the Vaginal Delivery Recovery sheet indicated that the patients pain was as follows: 2030-Mid-epigasl?c was rated at 7110 (on a pain scale of 1110. 10 being the worst pain). Intervention: Bicitra 30 ml. Pain relief was D3957 Continued 1mm page 6 Vonrnouth Media-I Center STATE FORM LDOF1 1 If continuation sheet '1 of 14 B3: 44 MDNMULITH MED I Iill-IL CENTER P. 14:28 PRINTED: 12/1812012 FORM APPROVED 'ew Jersey Department of Health STATEMENT OF DE FICIENCIES (x1) PROVIDERJSUPPUERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED _r 11304 a. WING oorzerzm NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE MONMOUTH MEDICAL CENTER 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID RT OF i'cie' NCIES Io PROVIDERS PLAN OF com (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULARTORY OR IDENTIFYING TAG CROSS-REFERENCED To THE APPROPRIATE DATE INFORMATION DEFICIENCY) Continued from page 7 D3957 Continued from page 7 D3957 documented at 7/10. 2041-Pain was: 10110. 2050-F'aln was rated at 10110. 2150-Pain was 8110 . 2200-Pain was 10110. Interventions Indicated that a GI (Gastroentemlogist) Consult was ordered 'le and Dilaudid 2mg Iv was administered. . ii 2200-Pain was rated 10110. c. There was no evidence In the medical record The Medical Chairman of the OBIGYN [Rf-"i I that the elevated blood pressures were department provided professional addressed by the primary health care remediation for the Identi?ed physician In providerIOBGYN. 201 1 . Monitoring of 100% of records for physician of record per month It 3 months was performed by the PI Coordinator. Records were assessed for compliance of timely physician intervention for elevated blood pressuresipain assessment and 6. Review of the Nursing Notes Indicated the management following Monitoring Compliance: 100% Patient complained of severe pains and bumlng radiating up her chest. MD (OBGYN) at bedside. Patient evaluated. active bowel sounds present In all 4 quadrants. Bicitra orders received. 2032? Orders received icr IV Diiaudid 0.5mgs. Patient requests dose. 2041- MD (OBGYN) aware of patients DIP. Pre- eciampsia labs Pedant unable to stay still. bending over In pain. Pedant vomiting. 2050 - Pre-eclampsia tabs drawn. ..Patient remains in pain. 2100 - Patient pain status remains the same. MD (OBGYN) made aware. MD (OBGYN) at bedside. donmouth Medical Center FORM 0099 LDQF11 Ii continuation sheet a of 14 B33 44 Jew Jersey Department of Health MONMOUTH NEDICFIL CENTER P. 1.5326 PRINTED. 13182012 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER 11304 (at?l) PROVI A. BUILDING B. WING (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 091233012 NAME OF PROVIDER OR SUPPLIER MONMOUTH MEDICAL CENTER (X4) lD PREFIX TAG STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH NJ 07740 SUMMARY OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL OR LSC IDENTIFYING INFORMATION ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION (X5) DATE D3957 Continued from page Dilaudid 0.5 mg given iv push. 2120 Lab results back from lab. MD (OBGYN) made aware. No abnormal labs 2130 - Patient states relief from pain. "l'm feeling much better.? 214? - Patient in pain again..Patlent 2200 - .. .Epigaatric pain present. Patient and husband made aware a GI consult is In place 2215 consult via phone to OBGYN. Plan of sore discussed. Orders received for upper abdominal X-ray. amylase and lipase levels. Maatox 30 ml new. 2216 - Unable to give Maalox at this time. 2220 Diiaudid 2 mg administered IV push. 2225 Patient unable to remain 22 55 Maalox 30 ml given PO. 2300 - 40 mg Protonix given N. 2315 ?Patient to Emergency Department (ED) for continues to appear in pain 10110 localized mid-splgastrio pain. Patient vomiting. OBGYN made aware of patient steals and X?ray results. General Surgery consult requested. 2345 - Surgery Resident at bedside. Patient evaluated. 2355 Patient states ?do anything to stop this pain." OBGYN at bedside..orders for morphine 2 Continued from page 8 vlonmouth Medical Center STATE FORM 8899 LDOF1 1 If oonlinuation sheet 9 of 14 FEB-24-2O 13 B3: 44 view Jersey Department of Health MEDI CPIL CENTER PRINTED: 1211812012 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER IDENTIFICATION NUMBER 11304 (x1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION A. BUILDING. B. WING MONMOUTH MEDICAL CENTER (X3) DATE SURVEY COMPLETED STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH NJ 01740 (x43?) PREFIX TAG SUMMARY OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULARTORY OR LSC IDENTIFYING INFORMATION ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE -- ru-u-q-I . 0395? Continued from page 9 mg 1orzm - 0005 Morphine 2 mg IV push 0009 - Pulse 0x applied . patient extremely D3957 Continued from page 9 0010 - OBGYN at Bedside. patient cognitively intact. lethargic 0018 OBGYN assessing patient. Left side facial dropping noted. Patient unable to li? Ie?: arm. Code Stroke called. 0028 Code Stroke team at bedside. 0035 - Magnesium Sulfate Initiated. 4 gm loading dose. 115 Blood Sugar linger stick" 0045 Patient intubated. .. 7. Review of the Physicians Progress Notes by the OBGYN revealed the following: Admit note: at 2015, Cervidel started. No mention of elevated admission BIP. at 2230: no mention of elevated BIP. 1240 - Vital signs 1650 Patient wlthout complaints; HIP 13%5. 1800 - Patient without any complaint. no complaint of epigastn'c pain mentioned. 10l1l11 Delivery note patient delivered female at - 0210 Addendum by the heath care provider OBGYN at 10I1I11 2030 donmouth Medical Center FORM LDQF11 It continuation sheet 10 of 14 D3: 45 low Jersey Department of Health CENTER PRINTED: 1211812012 FORM APPROVED P. 17/28 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (x1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER 11:04 (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 09126I2012 NAME OF PROVIDER 0R SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. ST ATE. ZIP CODE 300 LONG BRANCH NJ 07740 SUMMARY OF 3 (EACH DEFICIENCY MUST BE PRECEDED av FULL (X4) ID PREFIX INFORMATION ID PREFIX TAG REGULARTORY OR LSC IDENTIFYING TAG PROVIDERS PLAN OF CORRECTION (x5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 0395? Continued from page 10 Patient complained mld-epigastric pain with nausea. given Bictra (sic) with no mld-epigastric pain. GI and lipase ordered WNL (within normal limits). Surgery consult ordered..Given Dilaudid for pain. Pain not mg Morphine IV..patient exhibits facial droop on left side. Code Stroite called. BIP 1371102. magnesium sulfate initiated. .After paralysis went to (ST-Sounds ICU (intensive Care Unit). 8. Review of the History and Physical Form in the medical record, from the PCPIOBGYN Indicated: 10:2!12 (sic) at 0200; Code StrokeiICU transfer note: Code Stroke was Called around 12:24am to L&D..Patiant had delivered 4 hours ?when she started to complain of eplgastrio pain she was given mg Dliaudld x2. then 2mg Dilaudid and later? morphine N, which eased her pain A surgical consult was requested and patient was being evaluated by a surgical resident. It was noticed that patient had right facial droop and left sided weakness around 1200 (101211) at this point code stroke was called When I saw the patient she had right sided facial droop and unable to move left upper and lower extr'emities. Stat(sic) CT of head without contrast ordered 1230 with labs (sic) work including PTIINR. Patient started vomiting and anesthesia needed to intubate to secure airway. CT scan done at 0100 and revealed right and subarachnold bleed with 5mm shift The patient was brought to the ICU. being evaluated by neurologist and neurosurgeon. Patient started on Mannitol 50 gm IV BP 1751122. RR 10 AST - 791 ALT 235 CNS: Unable to assess as patient under the 0395? Continued from page 10 Monmouth Medical Center STATE FORM 6899 LDOF11 If continuation sheet 11 of 1 4 Hm FEB-24-2D 13 D3: 45 low Jereegir Department of Health CENTER P. 18/26 PRINTED: 12I1812012 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER 11304 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED B. WING NAME OF PROVIDER on MEDICAL CENTER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECONDIAVENIJE LONG BRANCH NJ 07740 (X4) ID PREFIX TAG SUMMARY OF DEFICIENCIES DEFICIENCY MUST BE PRECEDED BY FULL REGULARTORY OR LSC IDENTIFYING INFORMATION ID PLAN or CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (XS) COMPLETION DATE 03957 Continued from page 11 effect of paralyzing agent. Abdomen so? Bowel Sounds NP (Assessment and plan) Code Stroke with right facial droop and left hemlparesis. Likely secondary to arterial venous malformation (AVM) vs. HELLP vasculitis. Patient admitted to ICU. 9. Review at the Discharge Summary In the medical record written by the OBGYN. Indicated: a. Hospital Course: weeks. 6 days presented in for elective Induction of labor. Vitals were b. Assessment and Plan: 1011111 at 0830 no complaints. no nausea or vomiting. Vitals stable. 1245 - status post epidural patient had Complained of some tenderness. over a period of time. 1650 - no nausea or vomiting. BIP 137I68. no complaints at this time. 1000 - no complaints. 191 5 - delivery note written, lemete infant APGAR 9 at 1 minute. 9 at 5 minute at 1849. Patient with out complaints. 0. 1012111. at 0210 Addendum written by the heatth care providerJOBGYN which notes: at approximately 2030 patient oomplelned of mild-epigast?c (sic) pain with nausea. Given Bicitia with no of severe mid- epigastric pain. Patients husband requested GI consult. GI MD called. Maalox 30 ml given. Amylase and D3957 Continued from page 11 Monmouth Medical Center STATE FORM 6899 LDOF11 Ii continuation attest 12 of 14 FEB-24-2613 D33 45 Jew Jersey Department of Health I CRL CENTER P. 19/29 PRINTED: 121180012 FORM APPROVED STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION IDENTIFICATION NUMBER 11304 PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING (X3) DATE SURVEY COMPLETED 0912612012 NAME OF PROVIDER OR SUPPLIER MONMOUTH MEDICAL CENTER STREET ADDRESS. CITY. STATE. ZIP CODE 300 SECOND AVENUE LONG BRANCH NJ 07740 (X4) ID PREFIX TAG SUMMARY OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULARTORY OR LSC IDENTIFYING INFORMATION ID PREFIX TAG PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TO THE APPROPRIATE DATE DEFICIENCY) D3957 Continued from page 12 Lipase ordered along with pre-eclernptic labs. Patient had a surgical consult An upright AP tilrn ordered. showed possible dilated loops at bowel. Dilaudid given for pain. no response. 2mg Morphine IV given within 5 minutes. Pedant ex facial droop on left side. Code stroke called. BIP 1371102. Magnesium Sulfate loading dose given for seizure prophylaxis anesthesia intubatad patient. Patient sent to CT scan. Neurosurgeon called. Patient to Intensive Care Unit (ICU). Patients initial blood work on 1011:11 st 2050 were: ALT-1B. Alkaline. Phosphate-59. Amylase-47. Lipase 26. Blood Glucose 90. BUN 1O Creatinine?O.77 Urlc Acid-7.5. Total Protein 5.6. Albumin3.2. Labs discussed with husband. were sent immediately upon presentation of mid- epigastric tenderness. At time of stroke labs drawn again. ALT had now jumped to 490. AST-718 and Alkaline Phosphates -241. By 1:30 in the morning the ALT had gene to 509 and AST 791. By 2:59 the ALT was 717 and AST 1303. By 5:32 AM. ALT-795. AST 1688 and LDH 2988. Neurosurgeon spoke to husband over the phone at home re: results of CT (OBYN) was called to the ICU as patient's BP continued to drop. Patient was started on Levophed drip. Second CT scan reviewed by radiology. showed worsening swelling in brain. questionable whether or not patient was hemiating. Neurosurgeon made aware. Patient taken to the Operating Room (OR). CT scan and abnormal liver US were diswssed with husband. As per radiologist there was no hematonta or sub capsular hemon'hage of the liver. LFTs continue to rise. platelets down to 41 lean-i to place femoral line and platelets were being hung. 0n 1012(11 at approximately 1310 a?er patient was taken to OR by neurosurgem. a Declaration of Death by Neurologic Criteria was ?lled out..apnea test done. patient failed to have Continued from page 12 donrnouth Medical Center STATE FORM LDOF11 Ii continuation sheet 13 of 14 try Lila?I?m." FEB-24-2B 13 D3 45 MED I CENTER P. 26:26 PRINTED 12118;:012 FORM APPROVED lew Jersey Department of Health STATEMENT OF DEFICIENCIES PROVIDERISUPPLIERICLIA (x2) MULTIPLE (N3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING COMPLETED 11304 EMS NAME OF PROVIDER OR SUPPLIER STREET CITY. STATE. 21? CODE MONMOUTH MEDICAL CENTER sou SECOND-AVENUE LONG BRANCH NJ 07740 (X4) Io SUMMARY OF DEFICIENCIES ID PLAN OF CORRECTION Ix5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD as COMPLETION TAG REGULARTORY OR LSC IDENDFYING TAG CROSS-REFERENCED To THE APPROPRIATE DATE INFORMATION DEFICIENCY) Continued from page 13 0395? Continued from page 13 0395? spontaneous breathing. no gag re?ex. no corneal re?exPatient met the cn'teria?for brain death. Patient extubated. The patient lost cardiac activity at 1507 on the monitor. Patient pronounced dead 1012/11 1508 with family at permission was not granted by husband and family. The cause of death was intraCIaniai hemorrhage secondary to unknown etiology. possibly HELLP d. There was no evidence in the medical record that the elevated blood pressures were addressed by the health care providerI'OBGYN until alter Code Stroke was called. e. The above was con?rmed by Staff #2 and 2011. management The Medical Chairman of the OBIGYN department provided professional remediation for the identi?ed physician in Monitoringz1212011?2l2012 Monitoring of 100% of records for physician of record per month I: 3 months. The Pi Coordinator performed the review. Records were assessed for compliance of timely physician intervention for elevated blood pressureslpain assessment and Monitoring Compilance: 100% Monmouth Medical Center STATE FORM 8399 LDOF1 1 if continuation sheet 14 of 14 25?5- y?i' is"? 3, nl-I- . . .. G$1.2m: of gain DEPARTMENT OF HEALTH PO BOX 367 TRENTON. 03625-0360 CHRIS CHRISTIE Governor KIM GUADAGNO MARY DOWD Lt Governor Commissroner March 6, 2013 Frank Vozos Chief Executive Officer Monmouth Medical Center 300 Second Avenue Long Branch. NJ 07740 Re: Complaint Dear Dr- Vozos: Thank you for providing the Assessment and Survey Program with a Plan of Correction for the de?ciency found during the Complaint Investigation at your facility on September 26, 2012. Your Plan of Correction has been reviewed. found to be complete and approved by this of?ce. Enclosed is a form indicating that all deficiencies have been corrected- Continued compliance with State Licensure will be required by your facility. You are advised that this letter does not preclude a revisit from Assessment and Survey staff at a later date. to ensure that all elements of the P00 have been implemented. Should you have further concerns regarding this survey/investigation, please direct them to me at (609) 292-9900. v/ SOphie Xyloportas. RN HCSE Assessment and Survey AH Form Approved 3/4/2013 (Y1) Provider 1 Supplier i Identification Number 11 304 Name of Facility MON MOUTH MEDICAL CENTER State Form: Revisit Report (Y2) Multiple Construction A Buniding Wing (Y3) Date of Revisit Slit/201 3 Street Address. City. State. Zip Code 300 SECOND AVENUE LONG BRANCH. NJ 07740 This report is completed by a State surveyor to show those de?Ciencies previously reported that have been corrected and the date such corrective actIOn was accomplished Each deficiency shOuid be fully Identified using either the regulation or LSC provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each f?QUeri'l'lel'it on the survey report form) (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) item we Date Correction Correction Correction Completed Completed Completed ID Prefix D3957 03:02:2013 ID Pre?x ID Prefix Reg. Reg it Reg LSC LSC LSC Correction Correction Correction Completed Completed Completed ID Prefix ID Prefix ID Pre?x Reg. Reg it! Reg it LSC LSC LSC Correct.on Correction Correction Completed Completed Completed ID Prefix ID Prefix lD Prefix Reg. Reg it Reg LSC LSC LSC Correction Correction Correction Completed Completed Completed ID Pre?x tD Prefix ID Prefix Reg. ii! Reg it Reg it LSC LSC LSC Correction Correction Correctton Completed Comp'eted Completed ID Prefix ID Prefix ID Pre?x Reg. it Reg it Reg it LSC LSC LSC Reviewed BY Date: Signature of Su eyor: r" Date: i' ii State Agency 0-) ?#?qufr 5 g, . t, Reviewed By Reviewed By Date; Signature of Surveyor: If Date: CMS R0 Followup to Survey Completed on: 9/26/2012 STATE FORM REVISIT REPORT [5i'99J Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (OMS-2567) Sent to the Facility? YES NO Page 1 of 1 Event ID LDOF12 PRINTED: FORM APPROVED New Jersey Department of Health STATEMENT OF DEFICIENCIES Ixu PROVIDERISUPPLIERICLIA Isz MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A COMPLETED R-C 11304 9 WING 031041201 3 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY STATE ZIP CODE 300 SECOND AVENUE MONMOUTH MEDICAL CENTER LONG BR ANCH, NJ 07,740 0(4) .0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER-S PLAN OF CORRECTION (x5, FREFIX DEFICIENCY MUST BE PRECEDED SY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) {0 000} 8:436 INITIAL COMMENTS {0 000} The facility is in substantial compliance based on an acceptable plan Of correction with N. J. A. C. Title 8 Chapter 43 G- Hospital Licensing Standards for complaint investigation: 00* NJ00056972. TITLE DATE LABORATORY OR REPRESENTATIVE SIGNATURE STATE FORM LDQF12 Itconunuauon sheet 1 ol 1 3'5? '23, . staged State of $523.1 Earsrg DEPARTMENT OF HEALTH PO BOX 367 TRENTON. NJ. 08625-0367 CHRIS CHRISTIE Governor KIM GUADAGNO MARY O'Dowo P.H Lt Gavemor Commissioner January 28. 2013 ivingston. NJ 07039 Complaint Dear? This is a follow up to the letter sent to you on December 28, 2012. Upon further review it was decided that some of the issues in your complaint do not fall within our jurisdiction. therefore, we have referred your complaint to the Board of Medical Examiners and the New Jersey Board of Nursing. Should you have questions or concerns regarding the physician complaint, please contact the Board of Medical Examiners at (609) 826-7100. Should you have questions or concerns regarding the nursing complaint, please contact the New Jersey Board of Nursing at (973) 504-6430. Thank you for bringing this matter to our attention. Sincerel fk Sophie Xyloportas. RN HCSE Assessment and Survey