HospitalInspections.org

Based on document review, the hospital failed to ensure stabilized treatment for a labor patient, prior to discharge or transfer for 1 of 20 closed medical records reviewed (Patient # 4 A).

Findings include:

See findings cited at 489.24(d) Stabilizing Treatment A2407, 489.24(d).

Based on document review, the hospital failed to ensure stabilized treatment for a labor patient, prior to discharge or transfer for 1 of 20 closed medical records reviewed (Patient # 4 A).


Findings include:

1. Review of hospital policy entitled: "Transfer of Patient to Another Facility and Emergency Medical Treatment and Active Labor Act (EMTALA)", indicated under PROCEDURE, page 4, 4., "The Medical Screening Examination shall include both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to deternine the presence or absence of an Emergency Medical Condition"; 9. "A Medical Screening Examination is not an isolated event. It is on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred."; page 6, A. 1) "further medical examination and treatment, including Hospitalization, if necessary, as required to Stabilize the Emergency Medical Condition within the Capabilities of the staff and facilities available at the Hospital: or Transfer the patient to another more appropriate or specilized facility."; page 8, under STABILIZATION, B., "A patient will be deemed stabilized if the treating Physician attending to the patient in the Hospital has determined within reasonable clinical confidence that the Emergency Medical Condition has resolved." This policy was last approved in 2014.

2. Review of closed MR (medical record) for Patient # 4 A, from AH # 50 (acute care hospital), indicated the following:
A. Patient was a 18 y/o (year old) at 40 weeks/5 day gestation who presented to AH # 50's ER/ED (emergency department) at 7:28 am, on 8/2/2018, with patient then to OB (obstetrics) department for further assessment, screening, treatment at 7:34 am.
B. Patient noted as Gravida 1, Para 0, with "mild", "soft" contractions "every 2-5 minutes", and exam of 1 cm (centimeter) dilated, 60% effaced and -3 station, "membranes intact"; also noted by FR # 40 (Resident - OB) and MD # 31 (OB Physician) to be in "very early labor".
C. Vital signs/monitored noted B/P (blood pressure) readings 145/97, 138/95, 138/96, 140/100, 140/96 and 130/85. Lab (laboratory) tests were ordered, and noted by MD # 31 for "slight BP elevation", "no signs of pre-eclampsia".
D. Release of information for prenatal records from AH # 51 (acute care hospital), were signed by patient and sent to (faxed) AH # 51, with information not received back to AH # 50 until after patient was discharged.
E. Patient requested to be discharged to go to "patient's regular hospital for care"; and to go to "set appointment" that afternoon with patient's established OB Physician (MO # 61).
F. Patient was then discharged at 9:30 am, with discharge instructions and educational material. Discharge (activities) instructions included: "rest on your left side" and "go directly to" AH # 51.
G. MR documentation lacked communication with AH # 51 for patient's OB history, an accepting OB Physician or status for transfer; as patient was instructed to "go directly to" AH # 51, and was noted to be in early labor.

3. Review of closed MR for Patient # 4 B, from AH # 51, indicated the following:
A. Patient presented to AH # 51 at 1:00 pm, with patient to OB department and admitted at 1:17 pm to labor room 202.
B. Patient's OB prenatal records noted last prenatal visit on 7/26/2018, with EDD (estimated due date) of 7/28/2018, and next OB visit due in 1 week (8/2/2018).
C. Patient was noted to be 1-2 cm dilated, 50% effaced, -1 station. Patient stated "was told lost mucus plug".
D. Patient noted to be in "latent labor" by MO # 60 (OB Physician), with patient noted then at 7:19 pm to be "active labor at term", "transitioning to active labor", and "new onset gestational HTN (hypertension)".
E. Delivery record reflected onset of labor at 5:15 pm, complete dilation at 10:52 pm and "spontaneous delivery at 11:34 pm" (live birth).
F. Discharge summary completed by MO # 60, reflected transition to "active labor at term", "gestational hypertension", hospital course (vaginal delivery & postpartum care), and discharge with follow up care.

4. MR (Patient 4 A) lacked documentation for communication with Medical staff (OB physician) at AH # 51, in regards to patient's prenatal history, patient's status of 40 weeks/5 days ("early labor"), patient's request for discharge to go to "regular hospital for care", as well as an accepting Physician for same (for transfer: patient instructed to "go directly to" AH # 51).