HospitalInspections.org

Based on document review and interviews conducted on March 20-21, 2013, it was determined that the hospital failed to provide stabilizing treatment within the capacity and capability of the critical access hospital prior to discharge of patients in active labor in two (2) of twenty-one (21) records.

The findings include:

1. A review of Records A and G was conducted. Both pregnant patients were in labor at the WIHCU (Women and Infants Health Care Unit) and were evaluated. It was documented that although they required hospitalization, both women were discharged to travel to other hospitals via private automobiles.

2. Patient A's medical record documented that Patient A's history was Gravida 2, Para 3 at 40+ weeks gestation. She was in active labor with contractions which were two (2) to six (6) minutes apart and the dilation was documented as five (5) to six (6) centimeters. The station was documented as -3 (minus three) and her cervix was noted to be "very posterior." The record also documented that Patient A preferred to deliver at another hospital if she was able to. Patient A's discharge instructions read "go to [receiving hospital] ASAP." Patient A's medical record at the receiving hospital documented that while her first stage of labor was "4 hours, 45 minutes," her second and third stages were two (2) minutes and six (6) minutes respectively. The record also documented: "patient delivered approximately 50 minutes after arrival."

3. Patient G's medical record documented that Patient G's history was Gravida 3, Para 2 at 37 weeks gestation. The record continued: "Pt [patient] arrived to unit with complaints of ctx's [contractions] for past 40min [minutes]... and is to deliver in Portland due to high risk pregnancy r/t [related to] previous c-section X2 [twice] one being lower transverse and one being classical incision, and has had to have half of uterus removed in past several years." Patient G was given a bolus of LR [lactated ringers] and an injection of terbutaline. Patient G's discharge instructions stated: "go directly to [receiving hospital] now, may be driven in own car."

4. The "Emergency Medical Treatment (EMTALA)" policy was reviewed. The policy refers the reader to the "Medical Screening Exam for Routine Labor Checks" policy and procedure. That policy then refers the reader to the "OB - Walk-In Obstetrical Patient" policy and procedure. All three policies were reviewed; none of them addressed documentation and communication requirements for patients which were discharged to travel directly to another hospital.

5. These findings were confirmed with the Director of Quality on March 20, 2013 as these policies and records were reviewed.

6. An interview with the physician on call for obstetrics on March 3, 2013 was conducted on March 20, 2013 at 1040. He confirmed that the registered nurse in WIHCU assessed Patient A and relayed the information to him telephonically. He made the determination that Patient A was stable for discharge based on the nurse ' s assessment. Additionally, he stated, " I clearly should have considered EMTALA laws in my decision making. "

7. On March 21, 2013, at 0945, Patient A's medical record from the receiving hospital was reviewed. Record A at the receiving hospital failed to contain documentation of any communication between the providers, or any indication that all medical records available at the time of discharge were provided by the sending hospital.

8. The potential outcome of the failure to provide stabilizing treatment to women in labor is that the health of the laboring patient and unborn child could be compromised resulting in possible permanent injury or death.

Based on document review and interviews conducted on March 20-21, 2013, it was determined that the hospital failed to provide stabilizing treatment within the capacity and capability of the critical access hospital prior to discharge of patients in active labor in two (2) of twenty-one (21) records.

The findings include:

1. A review of Records A and G was conducted. Both pregnant patients were in labor at the WIHCU (Women and Infants Health Care Unit) and were evaluated. It was documented that although they required hospitalization, both women were discharged to travel to other hospitals via private automobiles.

2. Patient A's medical record documented that Patient A's history was Gravida 2, Para 3 at 40+ weeks gestation. She was in active labor with contractions which were two (2) to six (6) minutes apart and the dilation was documented as five (5) to six (6) centimeters. The station was documented as -3 (minus three) and her cervix was noted to be "very posterior." The record also documented that Patient A preferred to deliver at another hospital if she was able to. Patient A's discharge instructions read "go to [receiving hospital] ASAP." Patient A's medical record at the receiving hospital documented that while her first stage of labor was "4 hours, 45 minutes," her second and third stages were two (2) minutes and six (6) minutes respectively. The record also documented: "patient delivered approximately 50 minutes after arrival."

3. Patient G's medical record documented that Patient G's history was Gravida 3, Para 2 at 37 weeks gestation. The record continued: "Pt [patient] arrived to unit with complaints of ctx's [contractions] for past 40min [minutes]... and is to deliver in Portland due to high risk pregnancy r/t [related to] previous c-section X2 [twice] one being lower transverse and one being classical incision, and has had to have half of uterus removed in past several years." Patient G was given a bolus of LR [lactated ringers] and an injection of terbutaline. Patient G's discharge instructions stated: "go directly to [receiving hospital] now, may be driven in own car."

4. The "Emergency Medical Treatment (EMTALA)" policy was reviewed. The policy refers the reader to the "Medical Screening Exam for Routine Labor Checks" policy and procedure. That policy then refers the reader to the "OB - Walk-In Obstetrical Patient" policy and procedure. All three policies were reviewed; none of them addressed documentation and communication requirements for patients which were discharged to travel directly to another hospital.

5. These findings were confirmed with the Director of Quality on March 20, 2013 as these policies and records were reviewed.

6. An interview with the physician on call for obstetrics on March 3, 2013 was conducted on March 20, 2013 at 1040. He confirmed that the registered nurse in WIHCU assessed Patient A and relayed the information to him telephonically. He made the determination that Patient A was stable for discharge based on the nurse ' s assessment. Additionally, he stated, " I clearly should have considered EMTALA laws in my decision making. "

7. On March 21, 2013, at 0945, Patient A's medical record from the receiving hospital was reviewed. Record A at the receiving hospital failed to contain documentation of any communication between the providers, or any indication that all medical records available at the time of discharge were provided by the sending hospital.

8. The potential outcome of the failure to provide stabilizing treatment to women in labor is that the health of the laboring patient and unborn child could be compromised resulting in possible permanent injury or death.