Hospital Cited in Newborn Death

By Walter F. Roche Jr.

A newborn baby died within hours of delivery after staff at the Crozer Chester Medical Center failed to respond promptly to three calls for emergency assistance by a nurse caring for the baby.
"The medical staff failed to respond in a timely manner for a patient in distress," according to a recently released 15-page report from the state Health Department.
The report cites the hospital, located in Delaware County, for failure to have in place a clear escalation policy to be implemented in the event a health care provider does not timely repond to an urgent request for assistance.
The incident began on Feb. 3 when nurses noted the baby that had not yet been delivered had a rapid heartbeat and moments later no heartbeat at all.
According to the state report, the first call went to a resident (CF1) who was actively involved in a delivery.
Despite subsequent calls to the standby resident (CF2), no physician came to assess the patient and her mother for some 45 minutes. The nurse was told CF2 was unavailable.
According to the report the mother, who was in her 22 second week of pregnancy, was admitted to the 424-bed Crozer Chester facility on Jan. 17 with prolonged rupture of membranes.
On Feb. 3 at 21:22 (9:22 p.m.) a nurse monitoring the mother and baby reported the child's heart was racing and then no heartbeat could be detected. The nurse called the on-call resident but was told the physician was in the operating room.
She called for a resident a second time and the second resident ordered fluid initiation and said he would make an assessment when the ongoing delivery was complete.
"At 21:27 (9:27 p.m.)the nurse noted the loss of a fetal heartbeat," the report states, adding that she then escalated the patient's condition and a colleague suggested she get a doppler to perform a sonogram.
A code pink was called at 22:00 (10 p.m.)and the infant was delivered by cesarean section 10 minutes later by the first resident.
According to the report, nurses and employees told state surveyors that the second resident was not in the operating room and not delivering a baby when the nurse tried to reach him and was told he was unavailable.
"Employee seven confirmed CF2 (the second resident) was not in a delivery at the time.
"The whole thing went on for 45 minutes to an hour," the hospital employee told state Health Department officials.
The same employee told the surveyors that there was no written hospital protocol on an "escalation process."
Following the delivery the infant was taken to the neo-natal intensive care unit and the child's condition deteriorated overnight. Death occurred just before 09:00 a.m. Feb. 4.
The hospital did file a plan of correction which included escalation protocols and staff education, but when a surveyor returned on March 15, neither had been initiated.
Hospital officials did not respond to a series of questions about the report.
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