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Based on hospital policy and procedure review, closed medical record review, EMS (Emergency Medical Services) trip report, grievance file review and staff and physician interviews, the hospital staff failed to comply with 42 CFR 489.24.

The findings include:

1. The hospital staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 1 of 17 sampled obstetrical patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patient#11).

~cross refer to 489.24(r) and 489.24(c) Medical Screening Exam , Tag A2406.

2. The hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 17 patients with an obstetrical emergent medical condition (Patient #11).

~ cross refer to 489.24(d)(1-3) Stabilizing Treatment, Tag A2407.

Based on hospital policy and procedure review, closed medical record review, EMS (Emergency Medical Services) trip report, grievance file review and staff and physician interviews, the hospital staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 1 of 17 sampled obstetrical patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patient#11).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 09/24/2012, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ...PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part. With respect to a pregnant woman having contractions, an 'emergency medical condition' means that there is inadequate time to effect a safe transfer to another hospital before delivery ...2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Name of Hospital). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition.... GUIDELINES: 1. Patients presenting to (Name of Hospital) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists. 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

Review of the hospital's policy, "Obstetrical Medical Screening, Examination, Stabilization and Transfer", revised 05/03/2013, revealed, "POLICY: Medical screening examinations are provided to obstetrical patients presenting in L&D (Labor and Delivery) to determine possible emergency medical conditions. BASIS: In compliance with the EMTALA law, (Name of Hospital) L&D provides a medical screening examination to individuals requesting care and if it is determined an emergency medical condition exists, provides treatment to stabilize the condition and/or transfer the patient to another facility. ...REQUISITES: Registered Nurses completing a Medical Screening Examination of the obstetrical patient are competent in the following: 1. Electronic fetal monitor application and interpretation 2. Performing Vaginal Examinations. 3. Recognition of Signs & Symptoms of labor. 4. Recognition of abnormal findings during the antepartum period. GUIDELINES: 1. The Emergency Medical Treatment and Active Labor Act (EMTALA) defines an emergency medical condition in the obstetrical patient when: a. The patient is having contractions. ...4. The initial OB Medical Screening exam, performed by the RN (Registered Nurse), includes: a. Maternal Vital Signs B. Fetal Heart Rate C. Uterine Contractions: frequency, intensity, duration and patient & fetal tolerance d. A vaginal/cervical exam is completed, if patient's condition allows. 5. If the Obstetrical Medical Screening exam is completed by the registered nurse, the findings are documented in OB Trace Vue. a. The registered nurse completing the OB medical screening examination notifies the patient's primary MD....or the on-call MD....of her assessment/findings and/or concerns. ...7. The MD... determines if the patient is to be admitted or stabilized and/or discharged/transferred. ...".

Review of the hospital's policy, "Observation in the Triage Unit and Admission to L & D (Labor and Delivery)", revised 01/03/2013, revealed, "PURPOSE: To provide care for the obstetrical patient while determining the need for admission. ...B. TRIAGE UNIT 1. Obstetrical patients equal to or greater than 20 weeks gestation are assessed in the triage area by a nurse with 2 years or greater L&D experience and a current completed Medical Screening Competency. ...6. Notify MD....of patient's status as indicated by patient's condition. 7. The pregnant woman may remain in the triage area for up to three (3) hours if indicated. ...DOCUMENTATION: Nursing documentation reflects: 1. Initial and ongoing maternal/fetal assessments: ...b. EFM (external fetal monitor) pattern c. Uterine contractions/activity ...f. Vaginal/cervical assessments. ...".

Closed medical record review for Patient #11 revealed a 25 year-old female who presented to the hospital's DED on 08/07/2013 at 2156 with a chief complaint of full-term pregnancy, having "uterine contractions and possible leaking fluid". Record review revealed Patient #11 was admitted to L&D Triage at 2202. Record review revealed Patient #11 was Gravida 5 (previous pregnancies) Para 4 (number of live births). Further review revealed Patient #11's estimated date of delivery as 08/09/2013. Further record review revealed Patient #11's previous delivery was on 06/18/2008 and she was in labor for 5 hours, delivering a 9 pound, 1 ounce female. Documentation by RN (Registered Nurse) #1 at 2203 revealed pain level as 8, on a scale of 1 to 10, with 10 being the most severe pain. Further documentation by RN #1 revealed an external fetal monitor was applied to the patient at 2208. Documentation by RN #1 revealed Patient #11's vital signs were obtained at 2209, with blood pressure 128/83, pulse 86, respiratory rate 20, temperature 98.5 degrees (Fahrenheit) orally and oxygen saturation as 99%. Documentation by RN #1 at 2212 revealed, "contractions noted, fetus active, bleeding - none noted...". Documentation by RN #1 further revealed a vaginal examination was completed at 2221 with cervical dilation: 2 cm (centimeters), cervical effacement: 30%, fetal station: -3, cervical consistency: medium, cervical position: posterior, membranes intact. Further documentation by RN #1 revealed a urine dipstick was completed at 2229 which was negative for glucose, bilirubin, ketones, blood, protein, nitrates and leukocytes. Further documentation by RN #1 revealed Physician A was called at 2252, "I'm calling about (Patient #11) 5 (gravida) P (para) 4, 39 5/7 (weeks gestation). She is here with C/O (complaints of) U/C (uterine contractions). U/C every 3-4 min (minutes), FHR (fetal heart rate) Category One. BP (blood pressure) 128/83. SVE (sterile vaginal exam) 2/30/3, Posterior. Orders Received and Readback". Record review revealed a telephone order from Physician A to RN #1 at 2252, "d/c (discharge) home". Further documentation revealed Patient #11 was discharged to home at 2255 , and only had one hour of monitoring. Record review revealed the patient's pain level at discharge was 4, on a scale of 1 to 10, with 10 being the most severe pain. Record review revealed no documentation that the cervix was reassessed by RN #1 for further dilation after the initial assessment at 2221 (41 minutes prior to discharge). Further record review revealed no available documentation of a manual exam by palpation for uterine contraction intensity.

Review of an EMS (Emergency Medical Services) dispatch report dated 08/08/2013 revealed a call was received by EMS personnel at 0021 (2 hours after Patient #11 was discharged from L&D). Review revealed the call was dispatched at 0023 as "pregnancy/childbirth". Review revealed EMS responded to a residence located at XYZ Street, 4.1 miles away from the hospital and arrived at Patient #11's home at 0030.

Review revealed, "Scene Information: mixed race F (female) sitting fowlers (upright) on toilet holding crying baby in arms with cord still attached being attended to by family and FD (fire department). Mom is c/a/o (conscious, alert and oriented) x 4 (times 4 - person, place, time, events) w/ (with) a normal work of breathing, no pallor/diaphoresis. Baby has good color and is actively crying loudly and moving all extremities well. Good general impressions. ...Pink body/pale extremities, pulse > (greater than) 100 and good respiratory effort. Pt will be transported to (Name of Hospital) w/ mother for eval (evaluation). ...Activity: 0029 Childbirth FD cut cord. Placenta delivered and placed in ziploc bag. APGAR=9 (measures infant's breathing, heart rate, muscle tone, reflex and skin color at birth-based on a score of 1-10, with 10 being the highest). 0037 Baby in mothers arms while being moved to unit for transport w/o (without) incident. 0047 Depart scene for (Name of Hospital), baby still actively crying in Mom's arms...0058 Arrive at (Name of Hospital)...".

Review of a grievance report dated 08/08/2013 revealed Patient #11 made a complaint to a hospital representative on 08/08/2013. Grievance file review revealed, "Patient, (Patient #11), indicates that she came to (Name of Hospital) L&D Triage on or about 08/07/13. (Patient #11) indicates that she was checked and was 2 cm dilated and in strong pains. According to (Patient #11), the RN called (Physician A) and informed him of the patient's dilation and pain level. According to (Patient #11), the RN stated that the doctor recommended she be discharged home. (Patient #11) states that she was not re-checked to see if there was further dilation and was sent home. Patient arrived at home and gave birth approximately one hour after being discharged. (Patient #11) alleges that was sitting at the toilet and 'almost gave birth on the toilet'. (Patient #11) feels that the doctor should've ordered her to stay at the hospital. Patient feels that the RN should've re-checked her cervix for dilation. When asked by Patient Relations representative what outcome she would like to see come of this grievance- (Patient #11) stated, 'I just don't want this to happen to anyone else nor to me again. (Patient #11) also wanted to bring awareness. (Patient #11) would like to be contacted by someone to address these issues with her".

Interview on 11/06/2013 at 1030 with RN #1 revealed the nurse triaged Patient #11 on 08/07/2013. Interview revealed, "she (Patient #11) came in complaining of uterine contractions. I put her on the external fetal monitor and was surprised at how close her contractions were compared to her demeanor. Her pain assessment on admission was 8 of 10. She was a gravida 5, para 4. I performed a vaginal exam at 2221. She was 2 centimeters, 30% effaced. The cervix was posterior and had medium consistency". Interview further revealed, "the fetal heart rate was Category 1, meaning it was running about 125 with accels (accelerations). She was having contractions initially every 2 to 3 minutes. After she rested a minute, they spaced out to every 3 to 4 minutes". Interview further revealed, "I called (Physician A) at 2252. I reported that she was 39 weeks, 5 days gestation with contractions every 3 to 4 minutes and reported on her cervix. He asked, 'Do you think she's in labor?' I said, "No, based on her demeanor and the condition of her cervix.". Interview revealed, "I don't remember her asking me to let her stay because she was in labor. She (Patient #11) was a bit disappointed that I was sending her home". Interview further revealed, "when she came back in after delivering at home, I was surprised". Interview further revealed, "I don't remember if I asked her how long she had been having contractions before coming in". Interview confirmed there was no documentation in the medical record noting how long Patient #11 had been having contractions prior to coming to the hospital on 08/07/2013 at 2156. Further interview revealed, "I didn't ask her and didn't review her history for her previous labor times". Interview while RN #1 reviewed Patient #11's external fetal monitor strip revealed, " she was having contractions every 2 to 3 minutes initially. They were lasting 60 to 90 seconds. After she rested off her feet, they spaced out to every 3 to 4 minutes, lasting 60 seconds". Interview revealed, "I don't rely solely on the monitor for quality of contractions". Interview further revealed, "I don't remember palpating her uterus to monitor her contractions". Interview confirmed Patient #11's cervical condition was not re-checked prior to discharge at 2302. Interview further revealed, "there is no minimum time to keep a patient to determine labor".

Interview on 11/06/2013 at 1120 with Labor and Delivery administrative nursing staff revealed, "I remember speaking with her (Patient #11) on August 8th. She and her mother were concerned that she was released prematurely and delivered at home. They wished she had been kept longer. I told her I would review her record and investigate the situation. I reviewed the record with (RN #1)". Interview revealed, "there was no documentation that the uterine contractions were actually palpated by the nurse. You can't rely on the external monitor to adequately monitor uterine contractions. The nurse should palpate the fundus (top of uterus)". Interview further revealed, "the history of her length of labor for other deliveries was automatically populated on the record from her previous visits in Labor and Delivery". Interview revealed, "there is no documentation of how long (Patient #11) has actually been in labor prior to presenting to Labor and Delivery on August 7th".

Interview on 11/06/2013 at 1100 with Physician A revealed the physician was covering for (Name of Physician) private patients on 08/07/2013. Interview revealed, "I remember being called about (Patient #11). The nurse (RN #1) told me the patient was a gravida 5, para 4, having contractions and her cervix was posterior and firm, -3 station, 2 cm dilated and 30% effaced". Interview further revealed, "with multiparas (patients who have had previous deliveries), it is difficult to predict a laboring cervix versus a non-laboring cervix. With an anterior cervix, the cervix will change quickly. It is unusual for a posterior cervix that is firm to deliver rapidly". Interview further revealed, "I asked the nurse if the patient appeared uncomfortable. She said, 'yes', she was uncomfortable but not in distress. I asked her how long she had been having contractions and she said, 'most of the evening'." Interview further revealed, "(Patient #11) had called me earlier in the evening, between 7 and 8 p.m. She (Patient #11) told me she had been having contractions since early evening. I told her to go to the hospital to be assessed". Interview with Physician A while reviewing the external fetal monitor strip revealed, "she was having regular contractions. They were every 3 minutes, lasting 60 to 90 seconds. The fetal heart rate was Category 1, running 110-160 with moderate variability". Interview revealed, "thinking she was in early labor and after confirming she lived in (Hospital's City Location), I told the nurse to let her go home with labor precautions. She was subsequently sent home by the nurse. With the information I was given, I did not think the patient was in active labor". Interview revealed, "I got a call from (Patient #11's ) cell phone at midnight. She hung up before I could answer. Three minutes later, the answering service paged me to call (Patient #11). At 1205 (0005), I called her back and the person answering the phone said they didn't mean to call me. I later presented to L&D to deliver another baby, about 1:15. (Patient #11) had presented to the hospital after delivering at home. I examined her (Patient #11). I found normal postpartum findings with no laceration. The full term baby was taken to the nursery". Interview further revealed, "there was no reason why this patient could not have been kept longer". Interview further revealed, "this was not a desirable outcome".

Based on hospital policy and procedure review, closed medical record review, EMS (Emergency Medical Services) trip report and staff and physician interviews, the hospital staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize 1 of 17 patients with an obstetrical emergent medical condition (Patient #11).

The findings include:

Review of the hospital's policy, "Medical Screening", revised 09/24/2012, revealed, "POLICY: (Name of Hospital) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment. (Name of Hospital) stabilizes patients who present with an emergency medical condition or are in labor. ...PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination, treatment, stabilization, and transfer of emergency medical conditions. DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part. With respect to a pregnant woman having contractions, an 'emergency medical condition' means that there is inadequate time to effect a safe transfer to another hospital before delivery ...GUIDELINES: ... 2. If the medical screening examination reveals that an emergency medical condition exists, (Name of Hospital) provides treatment and stabilization of the patient. 3. An unstable patient may not be discharged unless the patient or responsible party refuses treatment...."

Review of the hospital's policy, "Obstetrical Medical Screening, Examination, Stabilization and Transfer", revised 05/03/2013, revealed, "POLICY: Medical screening examinations are provided to obstetrical patients presenting in L&D (Labor and Delivery) to determine possible emergency medical conditions. BASIS: In compliance with the EMTALA law, (Name of Hospital) L&D provides a medical screening examination to individuals requesting care and if it is determined an emergency medical condition exists, provides treatment to stabilize the condition and/or transfer the patient to another facility. ...REQUISITES: Registered Nurses completing a Medical Screening Examination of the obstetrical patient are competent in the following: 1. Electronic fetal monitor application and interpretation 2. Performing Vaginal Examinations. 3. Recognition of Signs & Symptoms of labor. 4. Recognition of abnormal findings during the antepartum period. GUIDELINES: 1. The Emergency Medical Treatment and Active Labor Act (EMTALA) defines an emergency medical condition in the obstetrical patient when: a. The patient is having contractions. ...4. The initial OB Medical Screening exam, performed by the RN (Registered Nurse), includes: a. Maternal Vital Signs B. Fetal Heart Rate C. Uterine Contractions: frequency, intensity, duration and patient & fetal tolerance d. A vaginal/cervical exam is completed, if patient's condition allows. 5. If the Obstetrical Medical Screening exam is completed by the registered nurse, the findings are documented in OB Trace Vue. a. The registered nurse completing the OB medical screening examination notifies the patient's primary MD....or the on-call MD....of her assessment/findings and/or concerns. ...7. The MD... determines if the patient is to be admitted or stabilized and/or discharged/transferred. ...".

Review of the hospital's policy, "Observation in the Triage Unit and Admission to L & D (Labor and Delivery)", revised 01/03/2013, revealed, "PURPOSE: To provide care for the obstetrical patient while determining the need for admission. ...B. TRIAGE UNIT 1. Obstetrical patients equal to or greater than 20 weeks gestation are assessed in the triage area by a nurse with 2 years or greater L&D experience and a current completed Medical Screening Competency. ...6. Notify MD....of patient's status as indicated by patient's condition. 7. The pregnant woman may remain in the triage area for up to three (3) hours if indicated. ...DOCUMENTATION: Nursing documentation reflects: 1. Initial and ongoing maternal/fetal assessments: ...b. EFM (external fetal monitor) pattern c. Uterine contractions/activity ...f. Vaginal/cervical assessments. ...".

Closed medical record review for Patient #11 revealed a 25 year-old female who presented to the hospital's DED on 08/07/2013 at 2156 with a chief complaint of full-term pregnancy, having "uterine contractions and possible leaking fluid". Record review revealed Patient #11 was admitted to L&D Triage at 2201. Record review revealed Patient #11 was Gravida 5 (previous pregnancies) Para 4 (number of live births). Further review revealed Patient #11's estimated date of delivery as 08/09/2013. Further record review revealed Patient #11's previous delivery was on 06/18/2008 and she was in labor for 5 hours, delivering a 9 pound, 1 ounce female. Documentation by RN (Registered Nurse) #1 at 2203 revealed pain level as 8, on a scale of 1 to 10, with 10 being the most severe pain. Further documentation by RN #1 revealed an external fetal monitor was applied to the patient at 2208. Documentation by RN #1 revealed Patient #11's vital signs were obtained at 2209, with blood pressure 128/83, pulse 86, respiratory rate 20, temperature 98.5 degrees (Fahrenheit) orally and oxygen saturation as 99%. Documentation by RN #1 at 2212 revealed, "contractions noted, fetus active, bleeding - none noted...". Documentation by RN #1 further revealed a vaginal examination was completed at 2221 with cervical dilation: 2 cm (centimeters), cervical effacement: 30%, fetal station: -3, cervical consistency: medium, cervical position: posterior, membranes intact. Further documentation by RN #1 revealed a urine dipstick was completed at 2229 which was negative for glucose, bilirubin, ketones, blood, protein, nitrates and leukocytes. Further documentation by RN #1 revealed Physician A was called at 2252, "I'm calling about (Patient #11) 5 (gravida) P (para) 4, 39 5/7 (weeks gestation). She is here with C/O (complaints of) U/C (uterine contractions). U/C every 3-4 min (minutes), FHR (fetal heart rate) Category One. BP (blood pressure) 128/83. SVE (sterile vaginal exam) 2/30/3, Posterior. Orders Received and Readback". Record review revealed a telephone order from Physician A to RN #1 at 2252, "d/c (discharge) home". Further documentation revealed Patient #11 was discharged to home at 2302 (2 hours, 6 minutes after presenting to Labor and Delivery). Record review revealed the patient's pain level at discharge was 4, on a scale of 1 to 10, with 10 being the most severe pain. Record review revealed no documentation that the cervix was reassessed by RN #1 for further dilation after the initial assessment at 2221 (41 minutes prior to discharge). Further record review revealed no available documentation of a manual exam by palpation for uterine contraction intensity by RN #1.

Review of an EMS (Emergency Medical Services) dispatch report dated 08/08/2013 revealed a call was received by EMS personnel at 0021 (2 hours after Patient #11 was discharged from L&D). Review revealed the call was dispatched at 0023 as "pregnancy/childbirth". Review revealed EMS responded to a residence located at XYZ Street, 4.1 miles away from the hospital. Review revealed EMS arrived at Patient #11 at 0030. Review revealed, "Scene Information: mixed race F (female) sitting fowlers (upright) on toilet holding crying baby in arms with cord still attached being attended to by family and FD (fire department). Mom is c/a/o (conscious, alert and oriented) x 4 (times 4 - person, place, time, events) w/ (with) a normal work of breathing, no pallor/diaphoresis. Baby has good color and is actively crying loudly and moving all extremities well. Good general impressions. ...Pink body/pale extremities, pulse > (greater than) 100 and good respiratory effort. Pt will be transported to (Name of Hospital) w/ mother for eval (evaluation). ...Activity: 0029 Childbirth FD cut cord. Placenta delivered and placed in ziploc bag. APGAR=9 (measures infant's breathing, heart rate, muscle tone, reflex and skin color at birth-based on a score of 1-10, with 10 being the highest). 0037 Baby in mothers arms while being moved to unit for transport w/o (without) incident. 0047 Depart scene for (Name of Hospital), baby still actively crying in Mom's arms...0058 Arrive at (Name of Hospital)...".

Review of a grievance report dated 08/08/2013 revealed Patient #11 made a complaint to a hospital representative on 08/08/2013. Grievance file review revealed, "Patient, (Patient #11), indicates that she came to (Name of Hospital) L&D Triage on or about 08/07/13. (Patient #11) indicates that was checked and was 2 cm dilated and in strong pains. According to (Patient #11), the RN called (Physician A) and informed him of the patient's dilation and pain level. According to (Patient #11), the RN stated that the doctor recommended she be discharged home. (Patient #11) states that she was not re-checked to see if there was more dilation and was sent home. Patient arrived at home and gave birth at home only a few hours from being discharged. (Patient #11) alleges that was sitting at the toilet and 'almost gave birth on the toilet'. (Patient #11) feels that the doctor should've ordered for her to stay at the hospital. Patient feels that the RN should've re-checked her cervix for dilation. When asked by Patient Relations representative what outcome she would like to see come of this grievance- (Patient #11) stated, 'I just don't want this to happen to anyone else nor to me again. (Patient #11) also wanted to bring awareness. (Patient #11) would like to be contacted by someone to address these issues with her".

Interview on 11/06/2013 at 1030 with RN #1 revealed the nurse triaged Patient #11 on 08/07/2013. Interview revealed, "she (Patient #11) came in complaining of uterine contractions. I put her on the external fetal monitor and was surprised at how close her contractions were compared to her demeanor. Her pain assessment on admission was 8 of 10. She was a gravida 5, para 4. I performed a vaginal exam at 2221. She was 2 centimeters, 30% effaced. The cervix was posterior and had medium consistency". Interview further revealed, "the fetal heart rate was Category 1, meaning it was running about 125 with accels (accelerations). She was having contractions initially every 2 to 3 minutes. After she rested a minute, they spaced out to every 3 to 4 minutes". Interview further revealed, "I called (Physician A) at 2252. I reported that she was 39 weeks, 5 days gestation with contractions every 3 to 4 minutes and reported on her cervix. He asked, 'Do you think she's in labor?' I said, "No, based on her demeanor and the condition of her cervix.". Interview revealed, "I don't remember her asking me to let her stay because she was in labor. She (Patient #11) was a bit disappointed that I was sending her home". Interview further revealed, "when she came back in after delivering at home, I was surprised". Interview further revealed, "I don't remember if I asked her how long she had been having contractions before coming in". Interview confirmed there was no documentation in the medical record noting how long Patient #11 had been having contractions prior to coming to the hospital on 08/07/2013 at 2156. Further interview revealed, "I didn't ask her and didn't review her history for her previous labor times". Interview while RN #1 reviewed Patient #11's external fetal monitor strip revealed, " she was having contractions every 2 to 3 minutes initially. They were lasting 60 to 90 seconds. After she rested off her feet, they spaced out to every 3 to 4 minutes, lasting 60 seconds". Interview revealed, "I don't rely solely on the monitor for quality of contractions". Interview further revealed, "I don't remember palpating her uterus to monitor her contractions". Interview confirmed Patient #11's cervical condition was not re-checked prior to discharge at 2302. Interview further revealed, "there is no minimum time to keep a patient to determine labor".

Interview on 11/06/2013 at 1120 with Labor and Delivery administrative nursing staff revealed, "I remember speaking with her (Patient #11) on August 8th. She and her mother were concerned that she was released prematurely and delivered at home. They wished she had been kept longer. I told her I would review her record and investigate the situation. I reviewed the record with (RN #1)". Interview revealed, "there was no documentation that the uterine contractions were actually palpated by the nurse. You can't rely on the external monitor to adequately monitor uterine contractions. The nurse should palpate the fundus (top of uterus)". Interview further revealed, "the history of her length of labor for other deliveries was automatically populated on the record from her previous visits in Labor and Delivery". Interview revealed, "there is no documentation of how long (Patient #11) has actually been in labor prior to presenting to Labor and Delivery on August 7th".

Interview on 11/06/2013 at 1100 with Physician A revealed the physician was covering for (Name of Physician) private patients on 08/07/2013. Interview revealed, "I remember being called about (Patient #11). The nurse (RN #1) told me the patient was a gravida 5, para 4, having contractions and her cervix was posterior and firm, -3 station, 2 cm dilated and 30% effaced". Interview further revealed, "with multiparas (patients who have had previous deliveries), it is difficult to predict a laboring cervix versus a non-laboring cervix. With an anterior cervix, the cervix will change quickly. It is unusual for a posterior cervix that is firm to deliver rapidly". Interview further revealed, "I asked the nurse if the patient appeared uncomfortable. She said, 'yes', she was uncomfortable but not in distress. I asked her how long she had been having contractions and she said, 'most of the evening'." Interview further revealed, "(Patient #11) had called me earlier in the evening, between 7 and 8 p.m. She (Patient #11) told me she had been having contractions since early evening. I told her to go to the hospital to be assessed". Interview with Physician A while reviewing the external fetal monitor strip revealed, "she was having regular contractions. They were every 3 minutes, lasting 60 to 90 seconds. The fetal heart rate was Category 1, running 110-160 with moderate variability". Interview revealed, "thinking she was in early labor and after confirming she lived in (Hospital's City Location), I told the nurse to let her go home with labor precautions. She was subsequently sent home by the nurse. With the information I was given, I did not think the patient was in active labor". Interview revealed, "I got a call from (Patient #11's ) cell phone at midnight. She hung up before I could answer. Three minutes later, the answering service paged me to call (Patient #11). At 1205 (0005), I called her back and the person answering the phone said they didn't mean to call me. I later presented to L&D to deliver another baby, about 1:15. (Patient #11) had presented to the hospital after delivering at home. I examined her (Patient #11). I found normal postpartum findings with no laceration. The full term baby was taken to the nursery". Interview further revealed, "there was no reason why this patient could not have been kept longer". Interview further revealed, "this was not a desirable outcome".

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