Morton Plant Hospital

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48190 Based on the facility’s policy and protocol, medical record review and interviews, the facility failed to ensure care was provided in a safe setting. The facility did not adhere to their protocol administration of Pitocin (medication used by medical professionals to induce labor, strengthen weak contractions, manage miscarriages, or control heavy bleeding immediately after childbirth) and recognize fatal changes in fetal heart monitoring for 1 (Patient #1) of 1 patient sampled, resulting in the demise of Patient #2. Findings included: Review of facility policy, “Labor and Birth, care of the Patient During” last revised 09/2025 revealed: Expected Outcome: 1. Maternal/ fetal well- being is optimized during labor and birth 2. Parent’s birth experience is reflective of their personnel goals and individual 3. Fetal well-being is assessed, and any fetal compromise is identified. Potential Complications: 1. Category 2 (It indicates that the fetus might be experiencing stress or a temporary lack of oxygen, requiring close monitoring and potential, though not immediate, intervention) or Category 3 (is an abnormal intrapartum tracing. It indicates significant fetal stress, risk of fetal acidemia (low pH), and potential for hypoxic-ischemic encephalopathy. These patterns require immediate clinical evaluation and interventions) FHR pattern. 2. Tachysystole (greater than 5 contractions in a 10-minute window averaged over 30 minutes) ... Safety Care: Use continuous fetal monitoring in the following situations: Category 2 or Category 3 pattern and administration of any medication which may affect FHR pattern (induction/augmentation agents). Category 2: minimal variability (it may point to fetal stress, oxygen deprivation, or the effects of medication), absent variability with no decelerations (indicates the heart rate stays completely flat, typically lacking both natural fluctuations and drops), accelerations (temporary, abrupt increases in the baby’s heart rate above the baseline), variable decelerations with minimal variability (minimal variability may suggest fetal stress or hypoxia, requiring close monitoring and immediate in-utero resuscitation by your healthcare team), recurrent late decelerations with moderate variability (fetus is experiencing placental insufficiency; reduced blood/oxygen flow) Category 3: absent variability recurrent late decelerations (placental insufficiency causing fetal hypoxia and acidosis. This finding requires immediate, urgent medical intervention to resuscitate the fetus and assess the need for expedited delivery), recurrent variable decelerations (abrupt decreases in a baby’s heart rate that limit the baby’s oxygen supply. When frequent, they are considered a concerning pattern that requires careful monitoring and immediate clinical intervention) Review of the Pitocin protocol revealed: 1. Titration instructions: a. Starting rate 2 milliunits/minute b. titrate by 2 milliunits/minute every 30 minutes until adequate uterine activity (contractions 3 to 5 minutes apart, palpate matter moderate or 50/60 MMHG above resting tone by uterine pressure catheter intensity) c. contact provider if the rate of 20 milliunits/minute is reached. d. Maximum dose 42 milliunits/minute. 2. Uterine tachysystole or unresolved category 2 fetal tracing: a. decrease Pitocin to half of the current rate for 15 minutes. b. If uterine tachysystole or category 2 tracing is not resolved discontinue Oxytocin (Pitocin). c. Notify physician. 3. Category 3 fetal tracing or prolonged deceleration: a. discontinue Pitocin b. notify physician 4. if fetal tracing resolves: a. if Pitocin infusion held less than or equal to 30 minutes restart oxytocin at half of the previous rate b. if Pitocin infusion held greater than 30 minutes restart at the initial order rate. Review of Patient #1’s medical record showed that Patient #1 was admitted on 04/20/2026 at 6:39 PM for a scheduled induction of labor. Pitocin was initiated on 04/21/2026 at 10:00 PM and intermittently stopped overnight due to late fetal heart rate decelerations. On 04/22/2026 at 11:37 AM, the patient was noted to be fully dilated, 100% effaced, and +1 station, and pushing began. Intermittent variable and late decelerations occurred during pushing but resolved with maternal repositioning, with baseline FHR remaining approximately 150 bpm. The physician discussed vacuum assisted delivery multiple times, including at 12:44 PM, but determined at that time that fetal descent was insufficient for safe vacuum use. At approximately 14:00, decelerations reached nadirs in the 40-50’s for the first time, and the fetus was at +3 station with crowning. Due to significant caput but adequate ability to place the vacuum safely, the physician proceeded with vacuum assisted vaginal delivery as the most expeditious option. Vacuum assistance occurred over four contractions. The infant was delivered but was nonresponsive with no cry at birth; the cord was immediately clamped and cut, and the infant was transferred to the NICU (Neonatal Intensive Care Unit) team, who had been present during the final pushing efforts. The baby expired after resuscitative efforts failed. During review of the fetal heart monitoring strips for Patient #1 on 5/11/2026 at 12:00 PM, the Evidence Based Quality Coordinator (EBQC) stated regarding 04/22/2026 at 10:00 AM, the fetal heart monitoring strip showed minimal variability with no accelerations (abrupt, temporary increases in the baby’s heart rate above the baseline considered a reassuring sign that the fetus is healthy, well-oxygenated, and has a properly functioning nervous system), and the Pitocin was increased from 8 units to 10 units. At 10:30 AM, the fetal heart monitoring strip showed minimal variability, accelerations were absent, late and variable decelerations (specific patterns in a baby’s heart rate observed during electronic fetal monitoring during labor. They represent different underlying issues and require specific medical interventions) are present, and the Pitocin was increased from 10 units to 12 units. At 11:00 AM, the fetal heart monitoring strip showed minimal variability, accelerations are absent, late and variable decelerations are present, and the Pitocin was increased from 12 units to 14 units. At 12:00 PM, the fetal heart monitoring strip showed absent variability, accelerations are absent, late and variable decelerations are present; the Pitocin is still infusing. The EBQC stated that the nurses charting was not appropriate, and the use of Pitocin was not appropriate. The bedside nurse had fetal monitoring education and should be competent in reading an electronic fetal monitoring strip. She should be able to tell if a baby is in distress. Based on review of the strip, they did not follow the protocol. During an interview on 05/11/2026 at 9:36 AM, the Risk Manager stated no one identified the strip (fetal heart monitoring) looked bad, the strip prior looked ok. There were some variability (fluctuations in the baseline heart rate) and some variables (decelerations). Not repetitive late decelerations variability during pushing more repetitive variable (how well the baby is tolerating the physical stress of delivery). The MD (Medical Doctor) was at the bedside the whole time. The patient was not listening to be able to pause and check heart rate; that’s where the problem was. The patient was pushing with and without contractions so they could not make sense of the pattern due to her pushing constantly. The MD told me she felt the pattern was not unusual and often returned to baseline. The MD found it hard to define a moment where she would change the management of the patient. The case was sent for per review, and opportunities were identified and are being addressed. During an interview on 05/11/2026 at 1:34 PM, Patient #1’s beside RN (Registered Nurse) stated the MD ordered to start a low dose Pitocin and she said I’ll be back in two hour; there was a couple times baby heart rate went down, and we repositioned mom then baby heart rate came right back up. Mom was complete and MD said let’s start pushing, so we started pushing. The babies’ heart rate kept going down and the patient was getting erratic. After an hour, I asked the MD if she was progressing and the MD said yes to continue pushing. The MD educated mom on using the vacuum (a procedure used during the second stage of labor. A doctor attaches a soft, plastic suction cup to the baby’s head to gently guide the baby through the birth canal while the mother pushes) to assist with the delivery. I’ve never had a provider use the vacuum that long. The patient was just screaming. There are a lot of things I forgot to document looking back on the incident. At one point, the MD said to continue pushing and she was stepping out to check on another patient. I was not comfortable with that, so I went to get her and to tell her to come back and she needs to stay. My charge nurse was aware of the situation; she was there at that point. A lot of people were in the room because the fetal heart strip (continuous visual record of a baby’s heart rate alongside the mother’s uterine contractions) looked bad meaning the baby’s heart rate kept dropping to the 90’s. Looking back on the situation, I should have gone to get another MD to help after the 1st hour of pushing and the frequent decelerations that were occurring. During an interview on 05/11/2026 at 2:12 PM, the MD stated when I did my morning rounds, Patient #1 was still 6 centimeters and I said increase her Pitocin and if she’s not able to progress then I plan on doing a C section (a surgical procedure used to deliver a baby through incisions in the mother’s abdomen and uterus). She made progress and she had some intermittent (stops and starts at irregular intervals) decelerations throughout the day but always responded when we put her in different positions. I think the patient was completely dilated (cervix opened to 10 centimeters, allowing enough room for the baby’s head and shoulders to pass through the birth canal.) at 11:30 am and started pushing. There was a period when she requested I help her while she pushed. There was a brief period when I was out of the room, and I checked on the other laborers. She was pushing well and then she had a very deep variable that went to the 40’s and then the heart rate came immediately back up to the 150’s but without much variability at all, very minimal. When it did that again it was down for 30 seconds or less. Then the next one was similar maybe 30 to a minute. The patient kept saying can you please help me? Can you do something to help me get this baby out faster? The MD stated it was not worth the risks of a vacuum at that point at which she was requesting help. Then, she had that really deep variable (deceleration) and if I had tried to do a section (surgical birth), I was really concerned the baby would be wedged down the pelvis and I would have a very difficult extraction, or it would take longer like getting to the OR (operating room). I have never used a vacuum in my career. There were times when the baby had late decelerations but felt the baby was safe to be delivered vaginally. She stated she thought it was more cord compression during that time. The Pitocin was not turned off because she was progressing, the baby was responding to position changes, and the baby did not show signs of distress for longer than 1 minute. We have a meeting coming up for women’s clinical institution and category 2 algorithms will be discussed. I’m not sure if we are discussing that because of the incident. During an interview on 05/11/2026 at 2:39 PM while reviewing the fetal heart monitoring strips, the Director of Women’s Services, who is certified in electronic fetal monitoring, stated based on the protocols I would not have increased the Pitocin. The charting does not look accurate. The Pitocin should have been turned off. During an interview on 05/11/2026 at 3:39 PM, the CMO (Chief Medical Officer) stated during the peer review, it was identified that there were opportunities for strip interpretation and interventions that were not done. Until more discussions, the MD will not be able to practice here or at [another hospital name] until more discussions can take place.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 48190 Based on medical record review, facility policy/protocols and interviews, the physician failed to identify and act upon a possible fatal fetal heart rate and follow hospital protocols for Pitocin administration in 1 (Patient #1) of 1 patient sampled, associated with the death of Patient #2. Findings included: Review of facility policy, “Labor and Birth, care of the Patient During” last revised 09/2025 revealed: Expected Outcome: 1. Maternal/ fetal well- being is optimized during labor and birth 2. Parent’s birth experience is reflective of their personnel goals and individual 3. Fetal well-being is assessed, and any fetal compromised is identified. Potential Complications: 1. Category 2 (It indicates that the fetus might be experiencing stress or a temporary lack of oxygen, requiring close monitoring and potential, though not immediate, intervention) or Category 3 (is an abnormal intrapartum tracing. It indicates significant fetal stress, risk of fetal acidemia (low pH), and potential for hypoxic-ischemic encephalopathy. These patterns require immediate clinical evaluation and interventions) FHR pattern 2. Tachysystole (greater than 5 contractions in a 10-minute window averaged over 30 minutes) ... Safety Care: Use continuous fetal monitoring in the following situations: Category 2 or Category 3 pattern and administration of any medication which may affect FHR pattern (induction/augmentation agents). Category 2: minimal variability (it may point to fetal stress, oxygen deprivation, or the effects of medication), absent variability with no decelerations (indicates the heart rate stays completely flat, typically lacking both natural fluctuations and drops), accelerations (temporary, abrupt increases in the baby’s heart rate above the baseline), variable decelerations with minimal variability (minimal variability may suggest fetal stress or hypoxia, requiring close monitoring and immediate in-utero resuscitation by your healthcare team), recurrent late decelerations with moderate variability (fetus is experiencing placental insufficiency; reduced blood/oxygen flow) Category 3: absent variability recurrent late decelerations (placental insufficiency causing fetal hypoxia and acidosis. This finding requires immediate, urgent medical intervention to resuscitate the fetus and assess the need for expedited delivery), recurrent variable decelerations (abrupt decreases in a baby’s heart rate that limit the baby’s oxygen supply. When frequent, they are considered a concerning pattern that requires careful monitoring and immediate clinical intervention) Review of the Pitocin protocol revealed: 1. Titration instructions: a. Starting rate 2 milliunits/minute b. titrate by 2 milliunits/minute every 30 minutes until adequate uterine activity (contractions 3 to 5 minutes apart, palpate matter moderate or 50/60 MMHG above resting tone by uterine pressure catheter intensity) c. contact provider if the rate of 20 milliunits/minute is reached. d. Maximum dose 42 milliunits/minute. 2. Uterine tachysystole or unresolved category 2 fetal tracing: a. decrease Pitocin to half of the current rate for 15 minutes. b. If uterine tachysystole or category 2 tracing is not resolved discontinue oxytocin. c. Notify physician. 3. Category 3 fetal tracing or prolonged deceleration: a. discontinue Pitocin b. notify physician 4. if fetal tracing resolves: a. if Pitocin infusion held less than or equal to 30 minutes restart oxytocin at half of the previous rate b. if Pitocin infusion held greater than 30 minutes restart at the initial order rate. Review of Patient #1’s medical record showed that Patient #1 was admitted on 04/20/2026 at 6:39 PM for a scheduled induction of labor. Pitocin was initiated on 04/21/2026 at 10:00 PM and intermittently stopped overnight due to late fetal heart rate decelerations. On 04/22/2026 at 11:37 AM, the patient was noted to be fully dilated, 100% effaced, and +1 station, and pushing began. Intermittent variable and late decelerations occurred during pushing but resolved with maternal repositioning, with baseline FHR remaining approximately 150 bpm. The physician discussed vacuum assisted delivery multiple times, including at 12:44 PM, but determined at that time that fetal descent was insufficient for safe vacuum use. At approximately 14:00, decelerations reached nadirs in the 40-50’s for the first time, and the fetus was at +3 station with crowning. Due to significant caput but adequate ability to place the vacuum safely, the physician proceeded with vacuum assisted vaginal delivery as the most expeditious option. Vacuum assistance occurred over four contractions. The infant was delivered but was nonresponsive with no cry at birth; the cord was immediately clamped and cut, and the infant was transferred to the NICU team, who had been present during the final pushing efforts. The baby expired after resuscitative efforts failed. During review of the fetal heart monitoring strips for Patient #1 on 5/11/2026 at 12:00 PM, the Evidence Based Quality Coordinator (EBQC) stated regarding 04/22/2026 at 10:00 AM, the fetal heart monitoring strip showed minimal variability with no accelerations (abrupt, temporary increases in the baby’s heart rate above the baseline considered a reassuring sign that the fetus is healthy, well-oxygenated, and has a properly functioning nervous system), and the Pitocin was increased from 8 units to 10 units. At 10:30 AM, the fetal heart monitoring strip showed minimal variability, accelerations were absent, late and variable decelerations (specific patterns in a baby’s heart rate observed during electronic fetal monitoring during labor. They represent different underlying issues and require specific medical interventions) are present, and the Pitocin was increased from 10 units to 12 units. At 11:00 AM, the fetal heart monitoring strip showed minimal variability, accelerations are absent, late and variable decelerations are present, and the Pitocin was increased from 12 units to 14 units. At 12:00 PM, the fetal heart monitoring strip showed absent variability, accelerations are absent, late and variable decelerations are present; the Pitocin is still infusing. The EBQC stated that the nurses charting was not appropriate, and the use of Pitocin was not appropriate. The bedside nurse had fetal monitoring education and should be competent in reading an electronic fetal monitoring strip. She should be able to tell if a baby is in distress. Based on review of the strip, they did not follow the protocol. During an interview on 05/11/2026 at 9:36 AM, the Risk Manager stated no one identified the strip (fetal heart monitoring) looked bad, the strip prior looked ok. There were some variability (fluctuations in the baseline heart rate) and some variables (decelerations). Not repetitive late decelerations variability during pushing more repetitive variable (how well the baby is tolerating the physical stress of delivery). The MD (Medical Doctor) was at the bedside the whole time. The patient was not listening to be able to pause and check heart rate; that’s where the problem was. The patient was pushing with and without contractions so they could not make sense of the pattern due to her pushing constantly. The MD told me she felt the pattern was not unusual and often returned to baseline. The MD found it hard to define a moment where she would change the management of the patient. The case was sent for per review, and opportunities were identified and are being addressed. During an interview on 05/11/2026 at 1:34 PM, Patient #1’s beside RN (Registered Nurse) stated the MD ordered to start a low dose Pitocin and she said I’ll be back in two hour; there was a couple times baby heart rate went down, and we repositioned mom then baby heart rate came right back up. Patient #1 began pushing. The babies’ heart rate kept going down and the patient was getting erratic. The MD educated mom on using the vacuum (a procedure used during the second stage of labor. A doctor attaches a soft, plastic suction cup to the baby’s head to gently guide the baby through the birth canal while the mother pushes) to assist with the delivery. I’ve never had a provider use the vacuum that long. The patient was just screaming. At one point, the MD said to continue pushing and she was stepping out to check on another patient. I was not comfortable with that, so I went to get her and to tell her to come back and she needs to stay. A lot of people were in the room because the fetal heart strip (continuous visual record of a baby’s heart rate alongside the mother’s uterine contractions) looked bad meaning the baby’s heart rate kept dropping to the 90’s. Looking back on the situation, I should have gone to get another MD to help after the 1st hour of pushing and the frequent decelerations that were occurring. During an interview on 05/11/2026 at 2:12 PM, the MD stated when I did my morning rounds Patient #1 was still 6 centimeters and I said OK let’s increase her Pitocin and if she’s not able to progress then I plan on doing a section (a surgical procedure used to deliver a baby through incisions in the mother’s abdomen and uterus). She did progress and she had some intermittent (stops and starts at irregular intervals) decelerations throughout the day but always responded when we put her in different positions. I think the patient was completely dilated (your cervix has opened to 10 centimeters, allowing enough room for the baby’s head and shoulders to pass through the birth canal.) at 11:30 am and started pushing. There was a period when she requested I help her while she pushes. There was a brief period when I was out of the room, and I checked on the other laborers. She was pushing well and then she had a very deep variable that went to the 40’s and then the heart rate came immediately back up to the 150’s but without much variability at all, very minimal. When it did that again, it was down for 30 seconds or less. Then the next one was similar maybe 30 to a minute. I said “OK, I think we need to get the vacuum out.” The patient kept saying can you please help me? Can you do something to help me get this baby out faster? I was like it is not worth the risks of a vacuum at the point at which she was requesting help. Then at the point she had that really deep variable and if I had tried to do a section I was really concerned the baby would be wedged down the pelvis and I would have a very difficult extraction, or it would take longer like getting to the OR (operating room). I have never used a vacuum in my career. There were times when the baby had late decelerations but felt the baby was safe to be delivered vaginally. I think it was more cord compression during that time. The strip was category but able to do position change and the baby target rate would come back up. The Pitocin was not turned off because she was progressing, the baby was responding to position changes, and the baby did not show signs of distress for longer than 1 minute. We have a meeting coming up for women’s clinical institution and category 2 algorithm will be discussed. I’m not sure if we are discussing that because of the incident. During an interview on 05/11/2026 at 2:39 PM while reviewing the fetal heart monitoring strips, the Director of Women’s Services, who is certified in electronic fetal monitoring, stated based on the protocols, she would not have increased the Pitocin. The charting does not look accurate. The Pitocin should have been turned off. During an interview on 05/11/2026 at 3:39 PM, the CMO (Chief Medical Officer) stated during the peer review, it was identified that there were opportunities for strip interpretation and interventions that were not done. Until more discussions, the MD will not be able to practice here or at [another hospital name] until more discussions can take place.”