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Based on interviews, a review of a complaint allegation and a tour of the hospital, the hospital failed to provide, within its licensed capability and capacity, a medical screening examination for one of 39 sampled patients (Patient 1). Cross Reference A2406.

The hospital failed to provide, within its licensed capability and capacity, further stabilizing treatment for one of 39 sampled patients (Patient 1). Cross Reference A2407.

The hospital failed to provide, within its licensed capability and capacity, an appropriate transfer for one of 39 sampled patients (Patient1) who presented to the hospital with an emergency medical condition.
Cross Reference A2409.

Based on interviews and a tour of the hospital conducted at 0930 hours on 9/1/10, the hospital failed to maintain a list of physicians who were on-call for duty for two specialities to provide further evaluation and treatment for individuals presenting to the hospital with an emergency medical condition. This could potentially result in medical staff not available to provide consultation services, when required, to meet the needs of patients.

Findings:

A review of the on-call back specialty list for August, 2010 revealed that for the specialties of Cardiology and Ophthalmology, the call list failed to contain the name and contact information for the physician on-call. Instead, the name of a medical group had been placed on the on-call list. The Emergency Department Nursing Director, interviewed on 9/1/10, seemed unaware that the name of the individual physician was required to provide instant information to hospital staff, in the event emergency back up on-call specialty coverage would be required.

Based on interviews, a review of a complaint allegation and a review of medical records, the hospital failed to provide, within its licensed capability and capacity, a medical screening examination for one of 39 sampled patients (Patient 1). This could potentially result in emergency medical conditions going unrecognized and treated.

Findings:

Patient 1 came to the labor and delivery unit of the Hoag Hospital at 0107 hours on 8/13/10, complaining of vaginal spotting and possible uterine contractions. Patient 1 was assessed as not in labor and discharged from the hospital.

Patient 1 returned to Hoag Hospital on 8/19/10 at approximately 1605 hours complaining of abdominal pain, thought to be the onset of labor. Patient 1 was assessed in "OB Triage" at 1620 hours. Assessment revealed abdominal pain of 8/10 associated with uterine contractions. An external fetal monitoring strip demonstrated evidence of contractions every 2-4 minutes. The contractions were assessed as "mild" and lasting 60-80 seconds in duration. Marked variability was noted on the fetal monitoring strip (variation of the fetal heart rate greater than 25 bpm (beats per minute) during and after each contraction).

At 1621 hours, an assessment by nursing revealed the cervix to be 3.0 cm. (centimeters) dilated, effacement 90% (thinness and softness of the cervix)and station -2 (the position of the baby's head during labor).

According to the nursing notes, at 1720 hours, MD X was "at bedside, plan of care discussed with patient, verbalized understanding, consents signed."

The "Outpatient Antepartum Discharge Orders" included check off boxes for "Discharge" and included a check off box that stated "Based on the information provided, the patient is not in labor or is in false labor." The boxes were left blank.

According to interviews with RN U, Patient 1 was discharged from the Labor and Delivery (L&D) area of the hospital at 1745 hours on 8/19/10, and instructed to go to a different hospital for delivery of the baby, since the hospital does not provide services for patients 15 years of age and younger. Review of the external fetal monitoring strip with RN U confirmed the presence of uterine contractions, via the strip.

MD X failed to provide any written documentation of the encounter with Patient 1, or to record any examination to document any progression of labor and/or assessment of the cervix dilatation prior to the discharge of the patient.

A review of the closed medical record for Patient 1 failed to demonstrate evidence of a nursing assessment to document any progression or change in the status of the patient prior to discharge.

The hospital failed to notify the receiving hospital of the discharge or status of Patient 1. The hospital failed to obtain verification that the capability or capacity of the hospital was consistent with the arrival of Patient 1 and that the receiving hospital could provide care within its licensed capability and capacity.

According to the complaint, Patient 1 went, by private car, to the receiving hospital and arrived at the facility at approximately 1815 hours, approximately 45 minutes after leaving Hoag Hospital. Patient 1 told the staff at the receiving hospital that the membranes of pregnancy had ruptured en route to the receiving hospital. According to the medical record from the receiving hospital, Patient A was assessed at 1817 hours. A "Vaginal exam" revealed the cervix was 4-5 cm dilated and 70% effaced. Station was -1. Patient A delivered a viable infant at 2352 hours.

An interview was conducted with MD X on 9/2/10 at approximately 1130 hours. MD X stated he evaluated Patient 1 in the L&D unit 8/18/10 at approximately 1720 hours. MD X stated that, in his opinion, Patient 1 was not in labor. MD X stated that, in his opinion, it was safe to transport Patient 1 to the receiving hospital for delivery. MD X stated that hospital rules and regulations prevented delivery of Patient 1 at the hospital because of her age. He stated that the patient understood the situation and was agreeable to the treatment plan for discharge, and to go the receiving hospital for delivery. MD X agreed that the medical record contained no written documentation of his encounter with Patient 1, no written documentation of a medical examination and no statement that, in his opinion, Patient 1 was not in labor.

Based on interviews, a review of a complaint allegation and a review of the closed medical record for Patient 1, the hospital failed to provide, within its licensed capability and capacity, further stabilizing treatment for one of 39 sampled patients (Patient 1). This resulted in the patient being discharged in active labor (an emergency medical condition for both the mother and the unborn baby) via a private vehicle.

Findings:

Patient 1 came to the labor and delivery unit of Hoag Hospital at 0107 hours on 8/13/10, complaining of vaginal spotting and possible uterine contractions. Patient 1 was assessed as not in labor and discharged from the hospital.

Patient 1 returned to Hoag Hospital on 8/19/10 at approximately 1605 hours complaining of abdominal pain, thought to be the onset of labor. Patient 1 was assessed in "OB Triage" at 1620 hours. Assessment revealed abdominal pain of 8/10 associated with uterine contractions. An external fetal monitoring strip demonstrated evidence of contractions every 2-4 minutes. The contractions were assessed as "mild" and lasting 60-80 seconds in duration. Marked variability was noted on the fetal monitoring strip (variation of the fetal heart rate greater than 25 bpm (beats per minute) during and after each contraction).

At 1621 hours, an assessment by nursing revealed the cervix to be 3.0 cm. (centimeters) dilated, effacement 90% (thinness and softness of the cervix)and station -2 (the position of the baby's head during labor).

According to the nursing notes, at 1720 hours, MD X was "at bedside, plan of care discussed with patient, verbalized understanding, consents signed."

The "Outpatient Antepartum Discharge Orders" included check off boxes for "Discharge" and included a check off box that stated "Based on the information provided, the patient is not in labor or is in false labor." The boxes were left blank.

According to interviews with RN U, Patient 1 was discharged from the Labor and Delivery (L&D) area of the hospital at 1745 hours on 8/19/10, and instructed to go to a different hospital for delivery of the baby, since the hospital does not provide services for patients 15 years of age and younger. Review of the external fetal monitoring strip with RN U confirmed the presence of uterine contractions, via the strip.

MD X failed to provide any written documentation of the encounter with Patient 1, or to record any examination to document any progression of labor and/or assessment of the cervix dilatation prior to the discharge of the patient.

A review of the closed medical record for Patient 1 failed to demonstrate evidence of a nursing assessment to document any progression or change in the status of the patient prior to discharge.

The hospital failed to notify the receiving hospital of the discharge or status of Patient 1. The hospital failed to obtain verification that the capability or capacity of the hospital was consistent with the arrival of Patient 1 and that the receiving hospital could provide care within its licensed capability and capacity.

According to the complaint, Patient 1 went, by private car, to the receiving hospital and arrived at the facility at approximately 1815 hours, approximately 45 minutes after leaving Hoag Hospital. Patient 1 told the staff at the receiving that the membranes of pregnancy had ruptured en route to the receiving hospital. According to the medical record from the receiving hospital, Patient A was assessed at 1817 hours. A "Vaginal exam" revealed the cervix was 4-5 cm dilated and 70% effaced. Station was -1. Patient A delivered a viable infant at 2352 hours.

An interview was conducted with MD X on 9/2/10 at approximately 1130 hours. MD X stated he evaluated Patient 1 in the L&D unit 8/18/10 at approximately 1720 hours. MD X stated that, in his opinion, Patient 1 was not in labor. MD X stated that, in his opinion, it was safe to transport Patient 1 to the receiving hospital for delivery. MD X stated that hospital rules and regulations prevented delivery of Patient 1 at the hospital because of her age. He stated that the patient understood the situation and was agreeable to the treatment plan for discharge, and to go the receiving hospital for delivery. MD X agreed that the medical record contained no written documentation of his encounter with Patient 1, no written documentation of a medical examination and no statement that, in his opinion, Patient 1 was not in labor.

The hospital thus failed to provide further stabilizing treatment, within its licensed capability and capacity for Patient 1 who presented to the hospital with possible signs and symptoms of active labor.

Based on interviews, a review of a complaint allegation and a review of 39 open and closed medical records, the hospital failed to provide an appropriate transfer for one of 39 sampled patients presenting to the hospital with an emergency medical condition (Patients 1). This resulted in the patient being sent to another hospital by private auto. The hospital receiving Patient 1 was not notified in advance that the patient was being sent to the hospital and no medical record information was sent with the patient.

Findings:

Patient 1 came to Hoag Hospital on 8/19/10 at approximately 1605 hours complaining of abdominal pain, thought to be the onset of labor. Patient 1 was assessed in the "OB Triage" at 1620 hours. Assessment revealed abdominal pain of 8/10 associated with uterine contractions. An external fetal monitoring strip demonstrated evidence of contractions every 2-4 minutes. The contractions were assessed as " mild" and lasting 60-80 seconds in duration. Marked variability was noted on the fetal monitoring strip (variation of the fetal heart rate greater than 25 bpm during and after each contraction).

At 1621 hours, an assessment by nursing revealed the cervix to be 3.0 cm. dilated, effacement 90% and station -2.

According to the nursing notes, at 1720 hours, MD X was "at bedside, plan of care discussed with patient, verbalized understanding, consents signed."

The "Outpatient Antepartum Discharge Orders" included check off boxes for "Discharge" and included a check off box that stated "Based on the information provided, the patient is not in labor or is in false labor." The boxes were left blank.

According to interviews with RN U, Patient 1 was discharged from the Labor and Delivery (L&D) area of the hospital at 1745 hours on 8/19/10, and instructed to go to a receiving hospital for delivery of the baby, since the hospital does not provide services for patients 15 years of age and younger. Review of the external fetal monitoring strip with RN U confirmed the presence of uterine contractions, via the strip.

MD X failed to provide any written documentation of the encounter with Patient 1, or to record any examination to document any progression of labor and/or assessment of the cervix dilatation prior to the discharge of the patient. A review of the closed medical record for Patient 1 failed to demonstrate evidence of a repeat assessment for Patient 1, to document any progression or change in the status of the patient prior to discharge.

The hospital failed to notify the receiving hospital of the discharge or status of Patient 1. The hospital failed to obtain verification that the capability or capacity of the hospital was consistent with the arrival of Patient 1 and that the receiving hospital could provide care within its licensed capability and capacity. The hospital failed to send any medical record information with the patient.

According to the complaint, Patient 1 went by private car to the receiving hospital. Patient 1 arrived at the facility at approximately 1815 hours, approximately 45 minutes after leaving Hoag Hospital. Patient 1 told the staff at the receiving hospital that the membranes of pregnancy had ruptured en route to the receiving hospital. According to the medical record from the receiving hospital, Patient 1 was assessed at 1817 hours. A " Vaginal exam" revealed the cervix was 4-5 cm dilated and 70% effaced. Station was -1. Patient A delivered a viable infant at 2352 hours.

According to interviews conducted with MD X and RN U at approximately 1130 hours on 9/2/10, MD X spoke with an associate at the receiving hospital to arrange for a transfer of care for Patient 1. However, there was no written documentation that Hoag Hospital notified the receiving hospital to confirm that the receiving hospital had the capability and capacity to accept Patient 1 for care.

A review of the closed medical record for Patient 1 revealed no documentation that the transferring physician and hospital had obtained a signed consent for transfer that explained the risks, benefits and alternatives for transfer of a patient with an emergency medical condition.

Hoag Hospital failed to provide appropriate transportation for Patient 1, who had presented with the possible onset of labor, an emergency medical condition.