Phs Indian Hospital at Rosebud

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 26629 Based on the complaint investigation survey; interview, record review and policy review, the hospital failed to meet emergency care standards, violating 42 CFR 482.55 Condition of Participation: Emergency Services. Adequate protocols were not available to meet the emergency needs of obstetric (OB; pregnancy, labor and childbirth) patients, and protocols lacked nationally recognized, evidence-based guidelines for emergency and obstetrical care. This failure affected two patients (#13, #18) and posed a continuing risk to future patients. Please refer to A-1114 and A-1115 for further details.”

“EMERGENCY SERVICES READINESS CFR(s): Effective July 1, 2025, in accordance with the complexity and scope of services offered, there must be adequate provisions and protocols to meet the emergency needs of patients. This Standard is not met as evidenced by: 26629 Based on interview, record review and policy review, the hospital failed to ensure emergency services readiness in accordance with the complexity and scope of services provided. Adequate provisions and protocols were not available to meet the emergency needs of two patients (#13 and #18) of six obstetric (OB; pregnancy, labor and childbirth) patients who presented to the emergency department (ED) for emergency obstetric care. This failure had the potential to affect all OB patients presenting to the ED with time-sensitive conditions and placed both mothers and babies at risk for serious adverse outcomes, including death. Findings included: During an interview on 05/05/2026 at 09:00 am, Staff C (ED Supervising Physician) stated “this hospital’s ED did not provide obstetric and gynecological (OB/GYN) services except on an emergency basis, because the hospital did not have a physician on staff to provide specialized OB/GYN care, and the hospital did not have a dedicated OB or neonatal (newborn baby) unit to provide post-partum (after care for the mother after the birth of child) or newborn care. In addition, due to the hospital’s unique physical location, air transportation is often not available. Air transportation must be via a fixed wing plane and not rotary (a helicopter). The amount of fuel that’s necessary to complete the transport is too much for a helicopter to carry, and the location is often affected by high winds which can delay or ground air transportation. When this occurs, the only transportation available is ground transportation to hospitals which are one to three-to-four hours away.” During an interview on 05/07/2026 at 1:00 pm, Staff C (ED Supervising Physician) stated that “laboring Indian OB patients would come to the hospital for deliveries so that their children would have tribal birth rights.” Review of the hospital’s three policies related to OB care in the ED showed there was no policy or procedure for the augmentation of labor (to speed up the labor and delivery process) and no policy or procedure for amniotomies (a medical procedure where a medical professional intentionally breaks the protective water sac surrounding the baby). Review of the hospital’s “ObRED Manual” clinical protocols showed there were no protocols for augmentation of labor or amniotomies. Patient #13 Review of Patient 13’s medical record showed she presented to the ED on 03/04/2026 at 5:24 pm, with a chief complaint of 35 Weeks Gestational Age (WGA, how far along the pregnancy is) and abdominal/hip pain every 15 minutes. The patient was examined and found to be in active labor, however, the patient’s contractions (uterine muscle tightening associated with labor) were slowing down instead of increasing (may indicate false or stalled labor). Documentation showed at 5:39 pm, Staff E (medical doctor) implemented active labor standing orders, and the patient was placed on a fetal heart monitoring system (a system which monitors the baby’s heart rate during maternal contractions when in labor). At 6:29 pm Staff E documented the patient was fully dilated (the cervix was completely open), fully effaced (the cervix had completely thinned which allows a baby to pass into the birth canal), +2 station (the baby has moved down into the birth canal), with contractions every three minutes. At 7:00 pm contractions were three minutes apart with good variability (normal fetal heartbeat changes). At 7:25 pm contractions were five minutes apart with no fetal heart rate decelerations (slowing of the baby’s heartbeat that may indicate distress). At 7:39 pm contractions were six minutes apart with no fetal heart rate decelerations. At 8:20 pm Staff E gave report to Staff F (medical doctor) due to shift change. Staff F reevaluated the patient; patient was effaced 100%, 10 centimeters (cm) dilated (fully dilated), vertex (baby is in the ideal head-down position for delivery) and at +2 station with contractions every three minutes. At 8:48 pm the patient began pushing and continued to push on 60 separate occasions (every 1-4 minutes) through 11:21 pm. An offsite provider was consulted and recommended starting oxytocin (intravenous medication administered to the mother for labor augmentation). At 10:19 pm oxytocin was initiated. At 02:44 am, the patient was transferred to hospital B for OB care. Oxytocin was initiated to augment the patient’s labor, even though the hospital did not offer OB services or have a protocol for augmentation of labor. Review of the patient’s medical records from Hospital B showed that upon arrival, the OB specialist examined the patient and found the patient was only 2.5 cm dilated, was not in active labor, and was discharged home. The patient did not deliver her baby until four weeks later. During an interview with Staff F (medical doctor) at 10:00 am on 05/07/2026, he stated he assumed care of the patient from Staff E (medical doctor) and “the patient was 100% effaced, and 10 cm dilated with the baby positioned at 2+ station and had active contractions every two to four minutes.” In speaking to hospital B’s OB specialist, he was “shocked to learn that the patient’s cervix (lower part of the woman’s reproductive organ that opens to allow a baby to pass into the birth canal) was only 2 cm dilated,” because his evaluation showed 10 cm dilation and active effacement and two other ED staff members’, an OB nurse and Staff E (medical doctor), evaluations resulted in the same findings. Patient #18 Review of Patient 18’s medical record showed she presented to the ED via ambulance on 04/02/2026 at 06:33 am, with a chief complaint of abdominal pain at 21 WGA. At 06:33 am a vaginal examination showed the patient’s cervix was fully dilated to 10 cm, the amniotic membrane (protective layer that surrounds a developing baby) was still intact and bulging. The patient was experiencing significant bleeding with blood clots, with an estimated blood loss of approximately 500 milliliters (slightly more than two cups). A bedside ultrasound confirmed positive fetal movement and fetal heart tones (heartbeat) were recorded as 180 beats per minute (bpm). Documentation indicated a threatened preterm delivery. Staff G (medical doctor) consulted three offsite providers for transfer acceptance and treatment guidance. At 06:50 am documentation showed the amniotic membrane was ruptured. At 07:19 am, Staff G attempted to deliver what was protruding from the vaginal canal. The medical record showed conflicting documentation regarding fetal status. At 07:30 am, a bedside ultrasound confirmed no fetal (baby) movement and no fetal heart tones (heartbeat), however at 07:37 am fetal heart tones were 170 bpm. At 09:08 am the patient was transferred via ground transportation to a higher level of care as air transport was not accessible due to weather issues. Review of the medical records from Hospital B showed that upon arrival, the OB specialist examined the patient and found no evidence of active bleeding, no placenta previa (the organ that nourishes the baby attaches too low in the uterus, partially or completely blocking the cervix), and no fetal heart tones. A sterile speculum exam was performed which revealed a closed-appearing cervix with only membranes protruding from the opening of the cervix, and the patient was not having regular contractions. Shortly after 10:25 am, the patient began to experience increased pain and the patient delivered a stillborn infant at 10:47 am. The patient was then transferred via air transportation to a higher level of care at hospital C During an interview on 05/14/2026 at 11:00 am, Staff B (Hospital Medical Director) stated that he was unaware the Condition of Participation for Emergency Services required OB protocols, regardless of whether the hospital offered OB services. Due to the hospital’s unique rural location, difficulty when transferring to a higher level of care and known need for laboring women to deliver infants at this hospital, the hospital failed to identify, develop and implement policies and/or clinical protocols that address obstetric emergencies.”

“PROTOCOLS CFR(s): Protocols must be consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical emergencies, complications, and immediate post-delivery care. This Standard is not met as evidenced by: 26629 Based on interview, record review and policy review, the hospital failed to ensure protocols were consistent with nationally recognized standards and evidence based guidelines. This failure had the potential to affect all OB patients presenting to the emergency department (ED) with time-sensitive conditions and placed both mothers and babies at risk for serious adverse outcomes, including death. FINDINGS Patient #13 Review of Patient 13’s medical record showed she presented to the ED on 03/04/2026 at 5:24 pm, with a chief complaint of 35 Weeks Gestational Age (WGA, how far along the pregnancy is) and abdominal/hip pain every 15 minutes. The patient was examined and found to be in active labor, however, the patient’s contractions (uterine muscle tightening associated with labor) were slowing down instead of increasing (may indicate false or stalled labor). Documentation showed at 5:39 pm Staff E (medical doctor) implemented active labor standing orders, and the patient was placed on a fetal heart monitoring system (a system which monitors the baby’s heart rate during maternal contractions when in labor). At 6:29 pm Staff E documented the patient was fully dilated (the cervix was completely open), fully effaced (the cervix had completely thinned which allows a baby to pass into the birth canal), +2 station (the baby has moved down into the birth canal), with contractions every three minutes. At 7:00 pm contractions were three minutes apart with good variability (normal fetal heartbeat changes). At 7:25 pm contractions were five minutes apart with no fetal heart rate decelerations (slowing of the baby’s heartbeat that may indicate distress). At 7:39 pm contractions were six minutes apart with no fetal heart rate decelerations. At 8:20 pm Staff E gave report to Staff F (medical doctor) due to shift change. Staff F reevaluated the patient; patient was effaced 100%, 10 cm dilated, vertex (baby is in the ideal head-down position for delivery) and at +2 station with contractions every three minutes. At 8:48 pm showed the patient began pushing and continued to push on 60 separate occasions (every 1-4 minutes) through 11:21 pm. An offsite provider was consulted and recommended starting oxytocin (intravenous medication administered to the mother for labor augmentation). At 10:19 pm oxytocin was initiated. At 10:19 pm Staff K (registered nurse) started an oxytocin infusion containing 10 units in 1,000 milliliters (mL) at a rate of 999 mL per hour. This differed from the confusing physician’s order recorded at 8:33 pm which directed that oxytocin 10 units be mixed in 1,000 mL of normal saline and started at a rate of 6 mL per hour. The physician’s order specified a total volume of 500 mL to be administered immediately. This was an amended order from 8:30 pm which dosed the oxytocin differently. During an interview on 05/13/2026 with Staff K, he stated “I ran it [oxytocin] wide open.” However, later amended his statement to reflect “I put it [oxytocin] on a pump, I enter the patient’s weight, and the pump automatically calculates the drip rate.” Neither of these stated rates were ordered from the provider. Staff K was unaware of any protocols or procedures regarding the administration of oxytocin. Staff K stated he performs tasks, such as medication administration based upon verbal orders given by the ED provider, he did not have access to the medical record in the ED obstetric room and relies on a third-party documentation system to record events. During an interview on 05/07/2026 with Staff F, he stated “the fetal monitoring system showed active contractions every two-to-four minute and we were there for several hours; with Mom pushing, trying to deliver the baby, and we decided to give her oxytocin. I consulted with an OB specialist at a different hospital (not hospital B, the receiving hospital) who recommended the administration of oxytocin if she didn’t deliver. After three-to-four hours, we decided she wasn’t going to deliver and that we needed help maybe there was something we were missing, maybe the oxytocin.” At 02:44 am, the patient was transferred to hospital B for OB care. Records from the fetal heart monitoring system were not available for review, although requested Because the ED record did not contain evidence from the fetal monitoring system, the effectiveness of oxytocin administration and accurate dosing were unable to be determined, which may have resulted in uterine hyperstimulation (where contractions come to fast and can impact the well-being of the unborn child), as evidenced by multiple pushing efforts (60 occasions) over a period of approximately two hours. The hospital lacked a specific protocol regarding augmentation of labor that was consistent with nationally recognized standards. Patient #18 Review of Patient 18’s medical record showed she presented to the ED via ambulance on 04/02/2026 at 06:33 am, with a chief complaint of abdominal pain at 21 WGA. At 06:33 am a vaginal examination showed the patient’s cervix was fully dilated to 10 cm, the amniotic membrane (protective layer that surrounds a developing baby) was still intact and bulging. The patient was experiencing significant bleeding with blood clots, with an estimated blood loss of approximately 500 mL (slightly more than two cups. A bedside ultrasound confirmed positive fetal movement and fetal heart tones (heartbeat) were recorded as 180 beats per minute (bpm). Documentation indicated a threatened preterm delivery. Staff G (medical doctor) consulted three offsite providers for transfer acceptance and treatment guidance. At 06:50 am documentation showed the amniotic bag was ruptured. At 07:19 am, Staff G attempted to deliver what was protruding from the vaginal canal. The medical record showed conflicting documentation regarding the fetal status. At 07:30 am, a bedside ultrasound confirmed no fetal (baby) movement and no fetal heart tones (heartbeat), however at 07:37 am fetal heart tones were 170 bpm. At 09:08 am the patient was transferred via ground transportation to a higher level of care as air transport was not accessible due to weather issues. Review of the medical records from Hospital B showed that upon arrival, the OB specialist examined the patient and found no evidence of active bleeding, no placenta previa (the organ that nourishes the baby attaches too low in the uterus, partially or completely blocking the cervix), and no fetal heart tones were found. A sterile speculum exam was performed which revealed a closed-appearing cervix (indicating the patient was not dilated) with only membranes protruding from the opening of the cervix, and the patient was not having regular contractions. Shortly after 10:25 am, the patient began to experience increased pain and the patient delivered a stillborn infant at 10:47 am. The patient was then transferred via air transportation to a higher level of care at hospital C. Records from the fetal heart monitoring system were not available for review, although requested. During an interview on 05/07/2026 at 10:20 am, Staff G he stated “the patient presented to the ED with an amniotic sac prolapse (when the sac surrounding the baby protrudes through the cervix) with hemorrhage associated with it; with amniotic sac prolapse , there was a chance the baby was in the sac. Due to the hemorrhage, it was important to remove the products from the vaginal canal. Although, there was a 99% mortality (death) rate for the infant at this gestational age and with the mother bleeding, in order to offer the best chance at survival, I made the decision to perform the amniotomy. The hemorrhaging slowed down after that and the mom stabilized. The fact that the amniotic sac didn’t break was reflective of the 21 WGA and in fact, only the membrane was delivered, no fetus (baby) was inside. The OB specialists at 3 different hospitals, including the receiving hospital B, were contacted and concurred with my decision.” The hospital lacked a protocol or an evidence-based approach for the performance of an amniotomy. Review of the ED’s only (three) OB related policies titled: Emergency Department Deliveries and Precipitous Deliveries; Management of Hypertension in Pregnancy and Post-Partum Hemorrhage Guidelines showed one incomplete policy and multiple outdated references. An example: the policy titled “Emergency Department Deliveries and Precipitous Deliveries” (Last Approved 05/2025), identified the purpose, policy and procedure as: Purpose: To provide guidelines for nursing care of patients presenting with delivery in the ED or with precipitous delivery in an obstetrics care unit. Emergency room delivery occurs as a result of a rapid labor making transfer to an obstetrics care unit unsafe or untenable.... Policy: The patient who presents in active labor with imminent delivery will be cared for in a safe manner. Nurses are expected to quickly provide complex patient care and collaborate with health team members to provide proficient nursing care to both mother and newborn. Procedure: Blank The policy’s section titled “Procedure” was left blank. Reference review by surveyors revealed multiple pertinent nationally recognized and evidence-based guidelines including, American College of Obstetricians and Gynecologist (ACOG) Clinical Practice Guideline No. 8, First and Second Stage Labor Management, which addresses oxytocin indications, dosing, and monitoring protocols for augmentation of labor and American College of Obstetricians and Gynecologists (SACOG) Practice Bulletin No. 200 Early Pregnancy Loss, which address management of hemorrhage in the setting of pregnancy loss or pre-viable pregnancy. Review of the Clinical Protocols outlined in the ObRED Manual showed there were no protocols for augmentation of labor or amniotomies.”