The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

STEWARD ROCKLEDGE HOSPITAL 110 LONGWOOD AVE ROCKLEDGE, FL 32955 May 18, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, interview and policy review, the facility failed to ensure 1 of 24 sampled emergency and obstetrical patients received a medical screening evaluation (MSE) prior to discharge, received treatment to stabilize a medical condition prior to discharge, and received an appropriate transfer to another hospital (#15).
Findings included:
1. Review of patient #15's medical record showed only minimal information related to the hospital visit of 04/13/2011. Patient #15, [AGE], (MDS) dated [DATE] with a chief complaint of pregnancy. Review of the obstetrical admission record was incomplete, with no information filled out for last menstrual period (LMP), expected date of confinement (EDC), or EDC per ultrasound examination. There was no documentation the patient received a MSE in the emergency department or in the obstetrical department, no documentation the patient received any treatment to stabilize a medical condition prior to discharge from the emergency department or in the obstetrical department, and there was no documentation of an appropriate transfer and any evidence of medical information sent to the receiving hospital.
2. During an interview on 05/17/2011 at 11:50 a.m., the Director of Obstetrical Services (Staff B) said she found out about patient #15 the following morning after it happened because she calls in for staffing daily. The nurse on duty told her a patient had (MDS) dated [DATE] and requested an induction at about 9 p.m. in the evening. The nurse said she told the patient they did not do inductions that late in the evening. Staff B said she asked the nurse "How is the baby?" The nurse told her she had called the physician and the physician said to send patient #15 back to another acute care hospital if she wanted an induction. Staff B said she questioned the nurse if she had given an SBAR (Situation-Background-Assessment Recommendation) report on the patient (which includes vital signs, baby information, prenatal information, and any other pertinent information) to the physician. The nurse told her no. Staff B said on the night of the event, 04/13/2011, there were no other patients in the Labor and Delivery Department.
During an interview on 05/18/2011 at 9 a.m., physician (staff C) said she remembered this case, because the following day she received numerous call related to the event. Staff C said patient #15 came to the hospital and gave the nurses a piece of paper saying she was at the hospital for an induction. Staff C said she could not verify what was on the paper, since she did not see it and said she told the nurse to tell the patient she did not know anything about the induction and would need to work the patient up prior to induction. Staff C said the patient told the nurse if no induction, she was not staying. Staff C said she had never seen the patient before. The patient was a health department patient, and typically she would not see these patients until delivery. The whole event was very short, maybe 10 minutes total time, and said this has never happened before and she did not tell the patient to leave.
3. Review of the facility policy titled "emergency room Scope of Care", dated as reviewed 10/19/2010, read the purpose of the policy as follows: "The Emergency Department is to provide adequate appraisal, initial treatment, stabilization, and/or advice to any patient with an illness or injury who presents to the department."
Review of the facility policy titled "Admission/Discharge Criteria of Maternity Undelivered and Delivered Patient", dated as reviewed 05/24/2010, read in part, "All FBP (Family Birth Place) patients get registered through ER (emergency room ) registration. All pre-maternity patients at greater than 20 weeks gestation and presenting to the hospital about an Obstetrical issue will be assigned to a FBP room. Patients are placed on a Max 23 status until it is determined that the patient is in labor or has another clinical condition that will require greater than 24 hour stay." Initial assessment and report on maternal/fetal status from the nurse to the care provider occurs by 30 minutes of arrival on the FBP department. Information provided to care provider includes basic identification including name, age, G/P (gravid/para-number of pregnancies/children), EDC/gestational age, pregnancy risk factors, pertinent vital signs and reason for call and/or patient's chief complaint. FHR (fetal heart rhythm) assessment data to include baseline FHR and determination of reactivity/non-reactive, periodic/non periodic acceleration/deceleration of contraction pattern."
Review of the facility policy titled "Admission to the Emergency Department", dated as reviewed 10/20/2010 read, "All patients admitted to the Emergency Department will have a complete chart and a Medical Screening Exam."
Review of the facility policy titled "Transfer Policy", dated as reviewed 10/21/2010, read, "No patient will be transferred without acceptance from the receiving facility."
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, interview and policy review, the facility failed to ensure 1 of 24 emergency and obstetrical patients sampled received a medical screening evaluation (MSE) prior to discharge (#15).
Findings included:
1. Review of patient #15's medical record showed only minimal information related to the hospital visit of 04/13/2011. Patient #15, [AGE], (MDS) dated [DATE] with a chief complaint of pregnancy. Review of the obstetrical admission record was incomplete, with no information filled out for last menstrual period (LMP), expected date of confinement (EDC), or EDC per ultrasound examination. There was no documentation the patient received a MSE in the emergency department or in the obstetrical department.
2. During an interview on 05/17/2011 at 11:50 a.m., the Director of Obstetrical Services (Staff B) said she found out about the patient #15 the following morning after it happened because she calls in for staffing daily. The nurse on duty told her a patient had (MDS) dated [DATE] and requested an induction at about 9 p.m. in the evening. The nurse said she told the patient they did not do inductions that late in the evening. Staff B said she asked the nurse "How is the baby?" The nurse told her she had called the physician and the physician said to send patient #15 back to another acute care hospital if she wanted an induction. Staff B said she questioned the nurse if she had given an SBAR report on the patient (which includes vital signs, baby information, prenatal information, and any other pertinent information) to the physician. The nurse told her no. Staff B said on the night of the event, 04/13/2011, there were no other patients in the Labor and Delivery Department.
During an interview on 05/18/2011 at 9 a.m., physician (staff C) said she remembered this case, because the following day she received numerous call related to the event. Staff C said patient #15 came to the hospital and gave the nurses a piece of paper saying she was at the hospital for an induction. Staff C said she could not verify what was on the paper, since she did not see it and said she told the nurse to tell the patient she did not know anything about the induction and would need to work the patient up prior to induction. Staff C said the patient told the nurse if no induction she was not staying. Staff C said she had never seen the patient before. The patient was a health department patient, and typically she would not see these patients until delivery. The whole event was very short, maybe 10 minutes total time, and said this has never happened before and she did not tell the patient to leave.
3. Review of the facility policy titled "Admission to the Emergency Department", dated as reviewed 10/20/2010 read, "All patients admitted to the Emergency Department will have a complete chart and a Medical Screening Exam."
Review of the facility policy titled "emergency room Scope of Care", dated as reviewed 10/19/2010 read, the purpose of the policy as follows: "The Emergency Department is to provide adequate appraisal, initial treatment, stabilization, and/or advice to any patient with an illness or injury who presents to the department."
Review of the facility policy titled "Admission/Discharge Criteria of Maternity Undelivered and Delivered Patient", dated as reviewed 05/24/2010, read in part, "All FBP (Family Birth Place) patients get registered through ER (emergency room ) registration. All pre-maternity patients at greater than 20 weeks gestation and presenting to the hospital about an Obstetrical issue will be assigned to a FBP room. Patients are placed on a Max 23 status until it is determined that the patient is in labor or has another clinical condition that will require greater than 24 hour stay. Initial assessment and report on maternal/fetal status from the nurse to the care provider occurs by 30 minutes of arrival on the FBP department. Information provided to care provider includes basic identification including name, age, G/P (gravid/para-number of pregnancies/children), EDC/gestational age, pregnancy risk factors, pertinent vital signs and reason for call and/or patient's chief complaint. FHR (fetal heart rhythm) assessment data to include baseline FHR and determination of reactivity/non-reactive, periodic/non periodic acceleration/deceleration of contraction pattern."
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, interview and policy review, the facility failed to ensure 1 of 24 sampled emergency and obstetrical patients received treatment to stabilize a medical condition prior to discharge (#15).
Findings included:
1. Review of patient #15's medical record showed only minimal information related to the hospital visit of 04/13/2011. Patient #15, [AGE], (MDS) dated [DATE] with a chief complaint of pregnancy. Review of the obstetrical admission record was incomplete, with no information filled out for last menstrual period (LMP), expected date of confinement (EDC), or EDC per ultrasound examination. There was no documentation the patient received any treatment to stabilize a medical condition prior to discharge from the emergency department or in the obstetrical department.
2. During an interview on 05/17/2011 at 11:50 a.m., the Director of Obstetrical Services (Staff B) said she found out about the patient #15 the following morning after it happened because she calls in for staffing daily. The nurse on duty told her a patient had (MDS) dated [DATE] and requested an induction at about 9 p.m. in the evening. The nurse said she told the patient they did not do inductions that late in the evening. Staff B said she asked the nurse "How is the baby?" The nurse told her she had called the physician and the physician said to send patient #15 back to another acute care hospital if she wanted an induction. Staff B said she questioned the nurse if she had given an SBAR report on the patient (which includes vital signs, baby information, prenatal information, and any other pertinent information) to the physician. The nurse told her no. checklist. Staff B said on the night of the event, 04/13/2011, there were no other patients in the Labor and Delivery Department.
During an interview on 05/18/2011 at 9 a.m., the physician (staff C) said she remembered this case because the following day she received numerous call related to the event. Staff C said patient #15 came to the hospital and gave the nurses a piece of paper saying she was at the hospital for an induction. Staff C said she cannot verify what was on the paper, since she did not see it and said she told the nurse to tell the patient she did not know anything about the induction and would need to work the patient up prior to induction. Staff C said the patient told the nurse if no induction she was not staying. Staff C said she had never seen the patient before. The patient was a health department patient, and typically she would not see these patients until delivery. The whole event was very short, maybe 10 minutes total time, and said this has never happened before and she did not tell the patient to leave.
3. Review of the facility policy titled "emergency room Scope of Care", dated as reviewed 10/19/2010, read the purpose of the policy as follows: "The Emergency Department is to provide adequate appraisal, initial treatment, stabilization, and/or advice to any patient with an illness or injury who presents to the department."
Review of the facility policy titled "Admission/Discharge Criteria of Maternity Undelivered and Delivered Patient", dated as reviewed 05/24/2010, read in part, "All FBP (Family Birth Place) patients get registered through ER (emergency room ) registration. All pre-maternity patients at greater than 20 weeks gestation and presenting to the hospital about an Obstetrical issue will be assigned to a FBP room. Patients are placed on a Max 23 status until it is determined that the patient is in labor or has another clinical condition that will require greater than 24 hour stay. Initial assessment and report on maternal/fetal status from the nurse to the care provider occurs by 30 minutes of arrival on the FBP department. Information provided to care provider includes basic identification including name, age, G/P (gravid/para-number of pregnancies/children), EDC/gestational age, pregnancy risk factors, pertinent vital signs and reason for call and/or patient's chief complaint. FHR (fetal heart rhythm) assessment data to include baseline FHR and determination of reactivity/non-reactive, periodic/non periodic acceleration/deceleration of contraction pattern."
Review of the facility policy titled "Admission to the Emergency Department", dated as reviewed 10/20/2010 read "All patients admitted to the Emergency Department will have a complete chart and a Medical Screening Exam."
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, interview, and policy review, the facility failed to ensure 1 of 24 sampled emergency and obstetrical patients received an appropriate transfer to another hospital (#15).
Findings included:
1. Review of patient #15's medical record showed only minimal information related to the hospital visit of 04/13/2011. Patient #15, [AGE], (MDS) dated [DATE] with a chief complaint of pregnancy. Review of the obstetrical admission record was incomplete, with no information filled out for last menstrual period (LMP), expected date of confinement (EDC), or EDC per ultrasound examination. There was no documentation of an appropriate transfer and any evidence of medical information sent to the receiving hospital.
2. During an interview on 05/17/2011 at 11:50 a.m., the Director of Obstetrical Services (Staff B) said she found out about the patient #15 the following morning after it happened because she calls in for staffing daily. The nurse on duty told her a patient had (MDS) dated [DATE] and requested an induction at about 9 p.m. in the evening. The nurse said she told the patient they did not do inductions that late in the evening. Staff B said she asked the nurse "How is the baby?" The nurse told her she had called the physician and the physician said to send patient #15 back to another acute care hospital if she wanted an induction. Staff B said she questioned the nurse if she had given an SBAR report on the patient (which includes vital signs, baby information, prenatal information, and any other pertinent information) to the physician. The nurse told her no. Staff B said on the night of the event, 04/13/2011, there were no other patients in the Labor and Delivery Department.
During an interview on 05/18/2011 at 9 a.m., the physician (staff C) said she remembered this case because the following day she received numerous call related to the event. Staff C said patient #15 came to the hospital and gave the nurses a piece of paper saying she was at the hospital for an induction. Staff C said she could not verify what was on the paper, since she did not see it and said she told the nurse to tell the patient she did not know anything about the induction and would need to work the patient up prior to induction. Staff C said the patient told the nurse if no induction she was not staying. Staff C said she had never seen the patient before. The patient was a health department patient, and typically she would not see these patients until delivery. The whole event was very short, maybe 10 minutes total time and said this has never happened before and she did not tell the patient to leave.
3. Review of the facility policy titled "Transfer Policy", dated as reviewed 10/21/2010, read, "No patient will be transferred without acceptance from the receiving facility."
Review of the facility policy titled "Admission to the Emergency Department", dated as reviewed 10/20/2010 read, "All patients admitted to the Emergency Department will have a complete chart and a Medical Screening Exam."