Maternity ward nurses working for Kaiser Permanente San Francisco Medical Center have declared their own workplace unsafe for mothers and babies, according to a complaint filed with the state Department of Public Health by the California Nurses Association earlier this month.
Understaffing has led expectant mothers to be left unmonitored despite the potential for life-threatening complications, the complaint reads, and nurses regularly manage more patients than recommended in national nursing guidelines, opening the door for errors nurses allege may decide the life or death of a mother, or their child.
Kaiser Permanente of Northern California denied the allegations in a statement. “The claims being made about staffing in our San Francisco Maternal Child Health department are not true. We are proud of the care our highly skilled teams of physicians and nurses provide to mothers and newborns.”
The complaints come at a time of record operating income for Kaiser Permanente, which posted an operating gain of a “record” $1 billion just last year, according to the industry trade site Modern Healthcare, bringing Kaiser to a total revenue of $18.1 billion. Those complaints also arrive during a widely reported swelling of patient enrollment in recent years due to the Affordable Care Act.
It should also be noted that the nurses are not in contract negotiations with Kaiser right now. CNA and Kaiser agreed to a five-year contract replete with raises for the union’s 19,000 nurses in April, according to the union.
Despite official assurances from Kaiser, nurses working in that maternity ward who spoke to me on the agreement of anonymity, for feal of reprisal from Kaiser, described the conditions for expectant mothers in one word: “Unsafe.”
One nurse told me, “I remember when I was at my very first birth, I was crying tears of joy and wonder.” Now, however, short staffing levels, and being forced to care for too many patients, prompts her to worry every day that she may have missed a vital warning sign that may have signaled an unhealthy mother or child. One nurse told me the staffing levels are unsafe for half of the shifts she has worked in the last year.
“I’ve been having nightmares,” another said.
In one staffing infraction detailed in the complaint from May this year, one Kaiser nurse assumed the care of four simultaneously laboring mothers. In another case in May, nurses were assigned three laboring mothers simultaneously, according to the complaint. Both of these instances violated recommended guidelines for patient safety, the CNA alleged.
Nurses giving care to expectant mothers in the antepartum department also had insufficient staffing to cover breaks. “This has caused one antepartum nurse to assume the care of six antepartum patients simultaneously,” the complaint reads, despite state regulations enshrined in California Code of Regulations Title 22 requiring no more than four patients assigned to an antepartum nurse. In another case detailed in the complaint, a recovering Labor and Delivery department patient and casesarean section patient, each of whom are required to receive one-to-one nursing care, were taken care of by the same nurse.
Nurses from Kaiser SF have also filed among the highest number of on-the-job “objection” forms in their recent history, according to data provided by CNA.
Maternity ward nurses at Kaiser SF filed 41 Assignment Despite Objection forms, known as ADOs, from April 23 to June 29. As many as 89 individual nurses signed the ADOs, which I verified by viewing them myself at the behest of the CNA, who redacted portions of those ADOs to legally preserve patient privacy. Nurses file these forms at the start of a shift when they see staffing levels may lead to unsafe conditions — its essentially a legal mechanism for nurses to legally object to work conditions.
In their complaint to the California Department of Public Health, nurses allege babies are delivered with only one nurse present, a violation of policy, and that babies are delivered in “triage rooms where there is little room for resuscitation and intervention,” among other allegations.
Again, Kaiser Permanente Northern California objected to the nurses’ allegations.
“Our staffing ratios meet all state requirements and we routinely adjust staffing levels to meet the needs of our patients,” a spokesperson wrote, in a statement. “We have investigated each complaint made and our findings do not support the broad claims.”
Following up those complaints I spoke to a number of nurses through their union, CNA, who described dangerous conditions for expectant mothers in all levels of Kaiser SF’s maternity ward: The antepartrum departments, labor & delivery department, neo-natal intensive care unit, and the postpartum department. Those nurses were careful to describe their experiences generally, as specifically detailing a patient experience would violate HIPAA, the Health Insurance Portability and Accountability Act, which would hold them legally liable.
“We want to make sure the moms coming into our facility are aware there’s a great concern among the staff that we cannot safely provide them the care they deserve,” one nurse told me.
Sometimes staffing is insufficient to put expectant mothers on fetal monitors right away, they said. “Moms come in sometimes for decreased fetal movement,” one nurse said, making the monitors vital because “that movement is the only way to tell a baby is okay.” Yet right now mothers can expect waiting times in the thirty to forty minute range.
“It can be life or death for that baby,” in the meantime, one nurse said.
Emergencies in the labor and delivery department are especially problematic, they said, as sometimes patients are left “without a nurse” as nurses rush to a patient in immediate need. “Then we’ve got two, four, five patients no one is watching,” these nurses said, meaning one of those patients could meet an emergency that “no one is attending to.”
Nurses are also expected to answer the phones for mothers-to-be who know they will be admitted to Kaiser SF soon. Often, they told me, no nurse is available to answer those calls.
“It rings, and rings, and rings,” they said.
This alleged understaffing has led to a number of management gymnastics from Kaiser, the nurses alleged. Management has sometimes adjusted the “acuity” of patients based on their own discretion, but not the nurses’ discretion, downgrading patients the nurses said were more severe, and needed more care, to less severe, dictating the need for fewer nurses.
The alleged understaffing also leads to some high-risk patients to go unmonitored after birth, one nurse familiar with postpartum practices told me.
Mothers with high blood presure who are at risk of seizures may recieve magnesium sulfate, that nurse told me, a particularly high risk medication.
If the worst happens, one nurse told me, “They can get fluid in their lungs … their breathing can get much lower. They can get magnesium toxic. They’ll start to not urinate … They get a brain fog. Their consciousness is diminished. Eventually they could stop breathing.”
Though legally in the clear, nursing ratios recommended in community guidelines from the Association of Women’s Health, Obstetric and Neonatal Nurses describes a safe “ratio” of one patient on the sulfate drip, and one other patient, each monitored by one nurse. Yet now nurses are often watching three other patients and one sulfate patient.
“It’s very unsafe, super unsafe,” one nurse said.
When I asked perhaps the ultimate question — if a child had died due to understaffing — the nurses grew silent, and stepped outside our meeting to privately discuss how much detail they could reveal both legally and ethically. Ultimately they answered, “We feel if we had safe staffing, safe staffing would save lives.”
One of the nurses who was herself pregnant perhaps painted the picture of Kaiser SF most starkly.
“I am not planning on giving birth at Kaiser San Francisco,” she said.
On Guard prints the news and raises hell each week. Email Fitz at firstname.lastname@example.org, follow him on Twitter and Instagram @FitztheReporter, and Facebook at facebook.com/FitztheReporter.